MARITIME

Issue 67 June 2022

An independent and confidential reporting system for the maritime industry

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The CHIRP editorial

Risk acceptance – have we got the balance right? tender ran aground at speed Adam Parnell because nothing untoward Director (Maritime) had occurred on previous transits of a similar route. Welcome to the latest But we also report on edition of FEEDBACK. We occasions when crews did aim to improve safety for all speak up, as in the case of seafarers, so I am pleased an LNG tanker which that this issue contains sounded a fire alarm reports about bulk cargo when they were unsure vessels, gas and oil tankers, whether they saw steam container carriers, fishing or smoke coming out of vessels and super yachts. the compressor room. And Although the reports might at we also report on a port first appear not to share many operator who realised that similarities, there is a common an emergency command had theme that runs through them been missed and spoke up. all: risk acceptance. Regular readers will know It is well understood that that we often report on pilot maritime operations are ladder shortcomings. To help more hazardous than many avert future incidents, we other occupations, but have encourage ships to adopt the we as seafarers become so ‘pilot ladder permit to work’ accepting of risks that we form that we have published no longer see them? Have at the end of this newsletter. mariners become numbed to railings to get from one part Have we as seafarers Don’t forget! CHIRP is dangers because they don’t of the vessel to another. In here to receive your safety believe they can challenge another, we examine why a become so accepting concerns in confidence. It them – or that nothing will ship undocked even though of risks that we no welcomes reports of incidents, change if they speak up? the weather conditions longer see them? accidents and near misses In our first report were unsuitable. Sometimes from commercial seafarers, concerning a timber carrier, we accept risks through recreational mariners or we investigate why the crew repetition, which was the those working ashore in the had to walk on the ship’s case when a superyacht maritime industry.

Please note all reports received by CHIRP are accepted in good faith. Whilst every effort is made to ensure the accuracy of any editorials, analyses and comments that are published in FEEDBACK, please remember that CHIRP does not possess any executive authority.

MARITIME

Are you interested in becoming a CHIRP Maritime Ambassador? CHIRP and the Nautical Institute have an Together we can promote the development of a established ambassador scheme to raise ‘just’ reporting culture across the maritime sector to awareness of our incident reporting schemes and improve safety outcomes. The key attributes of a encourage the submission of incident, accident successful ambassador is a passion for safety and and near-miss reports. a willingness to speak up for CHIRP among your colleagues and contacts. We seek additional volunteer ambassadors around the world, especially in China, Cyprus, Indonesia, If this sounds like you, please contact us to discuss the Philippines, Spain and the USA. this opportunity at mail@chirp.co.uk

As an ambassador you will join an international network of seafarers who also share your passion for safety, and you will quickly gain a broad knowledge of current safety issues. These are great additions to your CV and increase your employability.

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M1852 Factors relating to this report

Situational Awareness (SA) – Collective situational Machinery breakdown awareness is based upon formal Risk Assessment and the adoption of agreed Standing Operating Procedures. It results in allision also relies on everyone understanding the plan and their part in it and knowing what to do if things go wrong (the Initial Report emergency response plan). The vessel was undocking following a successful survey in dry-dock. The plan was to move to an inner anchorage Capability – The crew in this incident did not have recent to conduct sea trials before her scheduled departure. The experience of undocking a vessel and had to rely on the vessel was in a very light condition with a draft of 5m and a three dock masters. Did the difference in experience and freeboard of 17m. capability make it difficult for the crew to raise questions or The deck and engine room teams completed their pre- concerns? When writing the risk assessments for uncommon departure procedures, but the main engine was not tested. or infrequent tasks, do you consider’ capability’? How does A passage plan had been prepared, and this was given to your ship empower a ‘challenge’ culture? the pilot by the master. Three dock masters were also in attendance. Strong winds were forecast (27 knots with gusts Pressure – The undocking went ahead even though the of up to 35 knots) from the port side. weather conditions were unsuitable. Dry docks usually are Five tugs were in attendance, with two attached to the fully booked, and overstaying can be financially costly. Did bow, one attached to the stern and two others standing by. the master and crew feel under pressure to undock even The main engine was set to ‘Stand By’, and the vessel was though the conditions were unsafe? pulled out of the dock by the tugs. As the vessel exited the Teamwork is situational: crews who perform strongly in dock, the two tugs at the bow were released and the bridge familiar situations may not do well when facing unfamiliar ordered ‘Dead Slow Astern’ on the telegraph. The engine challenges. This takes time, leadership and open failed to respond, and the vessel started to drift to starboard communication. How does your company ensure that your because of the strong winds. team is ready to face its next task? One of the tugs was directed to make fast on the port side and pull the vessel to port. The tug attached Training – The crew did not respond appropriately to the to the stern was not directed to do anything, so it did machinery breakdown. Do you regularly conduct machinery not assist. breakdown drills on your vessel? The vessel drifted onto a newly-built moored vessel which was extensively damaged, as were some of the nearby shore facilities. Fortunately, there were no casualties Manoeuvring into and out of a dry dock or pollution. Shortly afterwards, a third tug was made fast would be an unfamiliar operation for most on the port side, and the pilot was able to manoeuvre the vessel to the allocated anchorage. An investigation ship crews. Our maritime advisors questioned undertaken by the authorities, owners and the engine why the vessel was allowed to undock, given manufacturers found the exhaust valves had not been the very strong winds, and asked if this was properly calibrated whilst in dry-dock. due to commercial pressure? CHIRP Comment Manoeuvring into and out of a dry dock would be an unfamiliar operation for most ship crews. Our maritime advisors questioned why the vessel was allowed to undock, M1979 given the very strong winds, and asked if this was due to commercial pressure? The presence of three dock masters and five tugs Unsafe access! suggests that a plan had been developed. Still, the lack of Initial report a coordinated response to a reasonably foreseeable event A pilot embarked on a loaded log-carrying vessel which was (the engine failure) indicates that the emergency response about to depart. There was no safe walkway over or around plan was missing or inadequate. Most tugs can push more the logs. The only way the crew could access the forecastle powerfully than they can pull, but the three available tugs was either by balancing on the railings around the ship’s side were not ordered to ‘push on’ to arrest the drift caused by or by climbing over the logs. None of the crew wore the right the strong wind. PPE to climb safely over the logs, and those balancing on the The fact that the main engine was not tested before ship’s side were at risk of falling overboard. departure, despite undergoing significant repairs, is a major The pilot raised the matter with the master and alerted failing concerning risk mitigation and reflects poorly on the the authorities to these significant safety breaches. management, supervision, and the organisation. Given the proximity of nearby vessels immediately outside the dry-dock and the prevailing onshore wind conditions, the risk assessment, including the consequences for loss of control, was not considered. Nor was emergency anchoring considered. The dry dock pilot should have insisted that the main engine be tested before departure. Was this raised during the master-pilot information exchange?

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CHIRP Comment members from pointing this out? Did they feel empowered The IMO’s Code of Safe Practice for Ships Carrying Timber to raise the alarm, or were they afraid of the consequences? Deck Cargoes (the 2011 TDC Code) applies to timber- Would you raise the alarm if you saw this on your vessel? carrying vessels over 24m. Although it is not mandatory, it provides safety guidance that says: Pressure – When working under pressure, we often prioritise completing the task over keeping ourselves safe. (2.8.2) “Special measures may be needed to ensure safe access to the top of and across the cargo” and Seafarers: Do you ever feel pressured to carry out an unsafe act? Do you ever discuss pressure workloads (2.8.5) “A safe walking surface not less than 600mm during safety committee meetings? What can you do to wide should be fitted over the cargo” alongside a reduce workload pressure? wire lifeline. DPAs: is there inadvertent or deliberate pressure on the The suggested PPE is a safety harness and lifeline and onboard managers (Captains & Chief Engineers) to cut suitable safety footwear. (It is recommended that ankle corners to save time? How do you know? boots and spiked overshoes are used to prevent slipping and ankle injuries). Local practices – Loading and securing timber cargo Because ships are under commercial pressure to sail as is a high-risk operation. If you are not provided with the soon as their cargo is loaded, there might not be time to correct PPE, would you raise the matter with your head of install a safe walkway to the forecastle. This should have department or through a company hotline? been considered part of the vessel’s risk assessment for unberthing and alternative safety measures, such as a temporary walkway, should have been provided. CHIRP has previously received reports of serious injury occurring in M1794 similar situations.

Factors relating to this report Fire in LNG carrier Culture – A good safety culture is one in which all reasonable compressor room? steps are taken to remove or reduce risks. If these steps are difficult to implement or take time to put into place, there is a Initial report real danger of ‘safety apathy’, and we no longer ‘see’ the risks. The Dual Fuel Diesel Electric (DFDE) LNG carrier was on We tell ourselves that “the risks are the risks” or convince passage at sea at night. At around 0400, the reporter was ourselves that the risks we are taking are ‘acceptable’. Where woken by a fire alarm and a PA announcement that there is your company on the Hudson Safety Ladder? was a fire in the compressor room, which is an unmanned space (UMS). Alerting – The crew would have known that walking on Fearing an explosion, the reporter donned PPE and met a bulwark rail is dangerous, so what stopped the crew the senior engineer outside the compressor room. It took both

MED LY INFOR R E ASING Figure 1: The Hudson IN C Safety Ladder Generative safety is how we do Proactive business round here we work on the Calculative problems that we we have systems still find

Reactive in place to manage safety is important, all hazards

www.chirpmaritime.org Pathological we do a lot every time who cares as long we have an accident as we’re not caught T TRUS SING IN CREA

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of them to open the door against the positive air pressure Training – Responding to an emergency at night is

in the compartment. From the doorway, they could see no more challenging than during the day. Do you conduct sign of fire or smoke but did not enter immediately because emergency drills at night? neither had remembered to collect portable gas detectors. They sent for them, and once these had arrived and they confirmed that there was no gas present, the three-person fire team entered the compartment wearing breathing apparatus. M1977 A thorough search confirmed that there was no fire. The bridge team were convinced that they had seen flames coming out of the compressor room. The three- Collision between a tanker person team checked the adjacent motor room and and fishing vessel confirmed no fire. The emergency party went to the bridge, and the bridge Initial report team told them that they had seen a big cloud coming from A laden tanker was sailing in an area well known for high the compressor room ventilation shaft. This was inspected levels of commercial and fishing vessel traffic. The sea state and found warm, so the team concluded that the bridge was moderate with Beaufort wind force 5, although visibility team had mistaken a steam cloud for flames and smoke in was good. The ARPA radars were set at 6nm and 12nm for the darkness. the X and S-band, respectively, linked to the ECDIS. Further investigation revealed that there had been a loss At 0449, an AIS target appeared at a range of 1nm. of electrical power throughout the ship, which had been Neither the OOW nor lookout could see anything through restored only a few moments before the fire alarm sounded. their binoculars, but a bright light was switched on from the The ship continued sailing, but it was discovered that the fishing boat shortly afterwards. fire detection panel was faulty, and the gas detection mode The OOW detected the fishing boat on the port bow switched off, so there was no way to identify a fire or gas leak. and assessed that there was a risk of collision as the CPA was 0.01nm. CHIRP Comment The OOW repeatedly flashed the fishing boat with an Aldis LNG carriers use an inert nitrogen gas system in the motor lamp but observed no response or action by the fishing vessel. room and compressor room to keep out air/oxygen and At 0504, the OOW judged that the fishing vessel was not taking water vapour, which could freeze and damage critical action to avoid collision and ordered hard starboard rudder. equipment. It also serves to reduce the risk of fire. At 0506, the fishing boat hit the tanker’s port side. The fishing Excess nitrogen gas is vented through a small vessel maintained its course and speed until it collided with the gooseneck vent on the compressor room roof, which can tanker. There was no evidence that it was engaged in fishing. be seen from the bridge. Usually, the quantity released is After the collision, the fishing vessel briefly slowed and very small and almost unnoticeable, but in a power failure, then resumed its original course and speed. the system will expel a greater amount in a sudden burst. At 0520, the duty officer reported the collision to the The gas is super-cooled, and when it meets the atmosphere master. The master immediately proceeded to the bridge, over the compressor room roof, it causes water vapour to ordered the engine to standby and started investigating the condense into a steam cloud which can look like smoke. condition of the fishing boat and the vessel. The vessel had suffered a loss of electrical power At 0525, the master took over the watch from the OOW because the uninterruptable power supply (UPS) had not and called the chief officer to check for damage. worked. The loss of power triggered the fire alarm, further The master observed the fishing boat for about 30 minutes reinforcing the perception of a fire in the compressor room. to determine whether she was damaged and needed any Because the vessel was newly built (around a year old) help. Attempts to communicate with the fishing vessel through and had only recently entered service, the UPS defect likely VHF were unsuccessful. The fishing boat appeared to be existed since she was built but had not been previously without serious damage, and she resumed her voyage. detected. A review of the existing UPS test and inspection At 0543 the master called the operating company using regime would be beneficial, as would raising the bridge the emergency contact number and reported the incident. team’s awareness of the effects of a loss of power on the The VDR data were saved and ECDIS screenshots were nitrogen gas system and the likelihood that a temporary taken as well. The lookout and OOW were tested for alcohol burst of steam may be seen shortly afterwards. in accordance with company policy, and both had negative (alcohol free) results. Factors relating to this report Both vessels resumed their passages after the incident, Situational Awareness – People awakened from deep and the master of the tanker reported the incident to local sleep can feel groggy and disoriented for several minutes port authorities. When the tanker reached port, there was after they wake up. This hampers our ability to build attendance by the local P&I and Class, and the marine situational awareness and explains why the portable gas superintendent for the management company. detectors were not collected initially. Written aide memoir Findings were