An independent and confidential Issue 68

MARITIME FEEDBACK reporting system for the Maritime industry Summer 2022

SUBMIT A REPORT ONLINE

CHIRP always protects the identity of our reporters. Reports can be submitted easily through All personal details are deleted from our system once our encrypted online form a report is completed. www.chirp.co.uk

Safety. By design! Adam Parnell Director (Maritime) maritime authorities to take a closer look at tug training and associated topics, including the requirements for

S adly, this edition of FEEDBACK contains several reports involving loss of life. They remind us that we cannot relax our vigilance, even for a moment, shipmasters with pilotage exemptions to be familiar with modern tug capabilities and limitations? Poor design is another feature which appears in because the consequences can be fatal. Every death several of our reports, but all too often we accept what or serious injury at sea has repercussions far beyond we are given and try to make the best of it, rather the ship itself, not least for the family and friends than pointing out the deficiencies and demanding that whose lives are also irrevocably affected. So, please, something be done about them. remain alert and do your best to ensure you get home Good companies will always welcome feedback safely to your family. from the fleet, although some of our reports suggest There are a number of themes running through there are still companies which are reluctant to listen this edition, and many of them will be depressingly to their crews or spend any money on safety. This familiar to our regular readers. The dangers of is disappointing because many other industries working at height are well known, yet accidents and recognise that safety and efficiency go hand-in-hand. fatalities still occur frequently, as we highlight in the A safe company is a more efficient and profitable following pages. Similarly, the importance of ensuring company, and it is high time more shipping operators watertight integrity during towing may seem obvious, realised this. yet we have received two reports where the danger Finally, we have some reports where the officer was overlooked, and evidence from a regulatory body who should probably have been supervising a that the problem is quite widespread. job was doing the work personally. Removing the Tugs are becoming more powerful and oversight in this way leaves an obvious gap. Do sophisticated but there is ample evidence that you have sufficient manpower to provide adequate training in the towage sector is not keeping up with supervision on your ship? the advances in technology. Is it time for national Until next time, be careful out there!

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.

Are you interested in becoming a CHIRP Maritime Ambassador? CHIRP and the Nautical Institute who also share your passion for to improve safety outcomes. The have an established ambassador safety, and you will quickly gain key attributes of a successful scheme to raise awareness of a broad knowledge of current ambassador is a passion for safety our incident reporting schemes safety issues. These are great and a willingness to speak up for and encourage the submission additions to your CV and increase CHIRP among your colleagues of incident, accident and your employability. and contacts. near-miss reports. Together we can promote the If this sounds like you, please contact As an ambassador you will join an development of a ‘just’ reporting us to discuss this opportunity at international network of seafarers culture across the maritime sector mail@chirp.co.uk

YOU REPORT IT WE HELP SORT IT

You can report on the go using our App, scan the QR codes to download Apple: Android: www.chirp.co.uk

www.chirpmaritime.org MFB 68 | Summer 2022

M1987 onto the deck. However, grease and loose overshoes significantly increase the likelihood of slipping and falling,

Danger! Working at height! and you should carefully consider the risks if you use them. The crew member in white overalls appears to be wearing only a harness around the waist, not a full-body Initial report harness. An incorrect or badly fitted harness increases the Our reporter sent us this picture of two seafarers working risk of internal injuries when coming to a sudden stop at the on a crane at height while the vessel was underway at sea end of the lanyard. in poor weather conditions. They appear to be re-greasing Fall arrestors reduce this shock but need you to fall the sloping wires of a crane. Their lifelines are attached to another 2-4m to work correctly. If there is insufficient the same wires. Nothing would stop them from falling to the clearance to fall this distance without hitting an object or the bottom if they slipped and fell. deck, the wearer could hit these objects at full speed and They are not wearing safety helmets or lifejackets be seriously injured. In the photograph, the crew members despite being close to the edge of the vessel. This activity would likely fall onto the crane arms before their safety took place in full view of the bridge team, but they were harnesses could work. neither challenged nor stopped. Hanging motionless in a harness restricts blood circulation and can cause breathing difficulties (this is often called ‘suspension trauma’) if you are not rescued within 15 minutes. If you are sent aloft wearing a harness, make sure there is a rescue plan in place. A rescue plan is a pre- planned procedure to safely retrieve someone suspended at height in a harness. It should also be regularly practised to ensure it can be done safely and quickly. If your ship uses safety harnesses for working aloft, make sure there is a rescue plan in place. CHIRP questions why this task could not have been delayed until the weather had improved and wonders if this is an indicator that the ship’s programme was too full to allow maintenance to be properly and safely completed.

Factors relating to this report Alerting – Our reporter may have sent this to us because they did not feel able to alert the master or OOW. If you saw this happen on board your vessel, would you be listened to, or is this usual practice? Tell us about your experiences.

Teamwork – Why didn’t the bridge team intervene? They are all part of the same team.

Supervision/Local practices – Did this incident occur because supervision was lacking, or was it an acceptable local practice to balance on the wires?

Capability – Are the individuals correctly trained to wear a CHIRP Comment safety harness? Does the ship have a rescue plan? Are you Good equipment design can eliminate operating and sent aloft in a harness when no rescue plan exists? What maintenance hazards. In this case, it could have been happens on your vessel? possible to design the crane to be lowered to the deck to allow maintenance to take place without ever sending Pressure – Was inappropriate time pressure put on the someone aloft. If that were not possible, the designer could officers and crew to take risks to keep the vessel running to have added hand-holds and connection points for safety a timetable? Is profit put above safety? If so, why? This task harnesses to be attached so that the crew had safe access. is probably not time-critical and could have been delayed When accepted into service by the Flag State and until the weather conditions were more appropriate. Classification Society, did either organisation audit the maintenance routines to ensure they were safe? It is unlikely that either body would agree that sending people aloft by M1912 balancing on greasy wires is a safe system of work. Is this then a poor local practice? If so, it is sadly a common practice that occurs on many ships. CHIRP questions why the wire cannot be run out onto the deck and Fatality by drowning grease added as the wire is rewound in? Initial report The maintainers are wearing loose plastic overshoes – A bulk carrier was loading a timber deck cargo at anchor. this is a common (but unsafe) way of keeping your footwear While lashing down the timber, an Ordinary Seaman (OS) clean and avoiding transferring the grease from the wires fell overboard into the sea. Another crew member jumped

MFB 68 | Summer 2022 www.chirpmaritime.org

in to search for them but was unsuccessful, and despite an “While working on the cargo, there should be provisions extensive search over several days, the victim was never found. to attach a safety harness. (TDC Code)” What caused the OS to fall into the water could not be determined as there were no witnesses. The OS was Working on top of logs to carry out lashings is hazardous inexperienced yet had not been trained or briefed on the and requires experience and training to do the work safely. risks of working on timber. He wore coveralls, gloves, a The average height of a completed stack of logs varies from safety helmet, and studded overshoes. Still, the ship’s 5 to 8 meters above the main deck; a fall either overboard or SMS manual did not mention the rigging of safety lines to the deck can be fatal. or wearing safety harnesses when working on top of the timber, nor did it require the crew to wear lifejackets or Factors relating to this report buoyancy aids. Capability – This job was beyond the capability of the crew member because he had no experience performing this work. Does your company consider the experience required for log carriers; are the crews staggered so that experience can be passed down? Does your company provide practical training courses for the officers and crew to understand the hazards of carrying timber deck cargo?

Situational Awareness – Being alert to your position on the logs is crucial to maintaining good situational awareness. A constant check is required. This can be impaired if you are tired or fatigued.

Teamwork – A vital component for a successful lashing operation. The team working on the logs should be working as a cohesive unit and looking out for each other.

Culture – Does your SMS have information and procedures for a bulk carrier carrying logs? Does the company provide sufficient details for carrying logs, especially if this is not a regular cargo? Does the marine manager actively engage with the master to advise on the safety requirements for log carriage?

M1908

Fatality – Falling from height [Note: CHIRP received this report from a company who were happy to share their safety learning. CHIRP applauds their transparency and commitment to safety and welcomes reports from other similarly-minded organisations.]

CHIRP Comments Initial Report This report raises several organisational safety concerns. A three-person crew had been tasked to replace the wire There was nothing in the company SMS about working at rope of a cargo crane grab stowed on the main deck in its height on logs, nor any guidance on the rigging of safety designated storage position. The weather was fair, and lines or the wearing of safety harnesses. It would be working at height precautions, including completing a impractical to rig a lifeline over the timber because it would Permit to Work, had been taken. interfere with the timber being loaded or unloaded by crane, The work started in the morning and was completed in but alternatives should have been considered. On board, the the evening. Two seafarers first descended from the grab. operational leadership knew of his inexperience, but did not The senior crew member then unclipped his safety harness provide a safety briefing or assign the person a ‘buddy’ or as he prepared to descend. Tragically he lost his footing and supervisor to ensure his and others’ safety. fell about 5 metres onto the platform railing and a further 1 Was safety compromised because of poor safety culture metre onto the deck below. He suffered a head injury and on board, or because the operational programme set by the was taken to the ship’s hospital. The ship’s master sought company could not be achieved without reducing safety? radio medical advice, but the crewman died of his injuries In a similar previous report (M1979, see FEEDBACK about an hour after the accident. edition 67), CHIRP referenced the IMO’s Timber Deck Cargo The grab’s shape, size and position meant poor hand Code (the TDC Code), and the reader’s attention is drawn to and footholds, although it was concluded that the crew section A2.22, which states that member probably perceived the risk involved as acceptable

www.chirpmaritime.org MFB 68 | Summer 2022

and within his control. The fall prevention equipment on Alerting – If you see a team member’s performance dip due board was not ideal for vertical movements, so using to fatigue, do you feel empowered to point it out and take a equipment such as a double-legged energy-absorbing short break? lanyard would have been more appropriate. The equipment was of a type that necessitated unclipping the safety Fatigue – The task started early morning and finished early harness lanyard to ascend or descend at the work site. evening. Regular breaks should be incorporated into lengthy The ship’s SMS procedures did not refer to hazards tasks and, if necessary, the task should be broken into smaller related to access/egress from a worksite at height, and it tasks spread over several days. Team members should also could not be determined if the risk of going up and down be monitored for signs of fatigue. Fatigue management from the grab had been assessed. planning should take these factors into account.

Fit for purpose (equipment) – CHIRP recommends that safety harnesses have two lifeline lanyards (also known as double-lanyard harnesses) so that at least one can always be connected when climbing up or down a ladder. For wearers of harnesses fitted with only one lanyard, the ascent or descent to a task is the most hazardous time.

M1893

Main Engine failure exposes maintenance deficiencies Initial Report A vessel was approaching a mooring to perform Ship to Ship CHIRP Comments (STS) loading operations. As they approached the mooring, The task was lengthy and required concentration the pilot ordered an increase of the revolutions from slow throughout, which can bring about fatigue. When we finish ahead to half ahead. The main engine failed to respond a job, particularly one that is challenging or difficult, our correctly and an investigation revealed that the number one brains release dopamine which causes positive feelings but cylinder had a very low exhaust gas temperature. The main can also impair decision-making, including when assessing engine slow-down function was overridden, but the problem risks. In combination, these factors would make the descent persisted and the mooring was aborted. The vessel went to from this task perhaps the riskiest part of the job. a nearby anchorage for a fuller investigation and repair. A fatigue management plan is useful in these Number one cylinder exhaust valve required circumstances: if a task can be broken into smaller parts, and replacement. There were three spares on board but none either sufficient rest breaks or crew rotations are provided, could be used immediately, and each needed an overhaul then concentration and decision-making can be protected. before use. The overhaul created a 12-hour delay before the The company have suggested that a double-legged vessel could return to service. energy-absorbing harness would have been appropriate. The removed exhaust valve had only been serviced CHIRP agrees, because a single-leg harness must be 4,700 hours previously. The maintenance interval for this unclipped when climbing, descending, or navigating equipment is 16,000 hours which suggests that the previous obstacles, thus removing the benefit of wearing a harness. maintenance was neither properly completed nor adequately And in this incident, a fall arrestor would not have worked assured by the senior engineer afterwards. This prompted the because the crewman would hit the grab or the deck before company to order a fleet-wide review of critical spare parts to it functioned. ensure they were ready for immediate use. Were the placement of hand-holds or other safe means of access and work considered at the equipment’s CHIRP Comment design stage? If not, why not? Some vessels have fold- The pilot made the right decision to abort the planned away temporary scaffolding that can be quickly erected manoeuvre in restricted waters because he did not have around equipment. This takes up minimal deck space and is confidence in the main engine. Luckily the incident relatively cheap. occurred in an area where tugs and shore assistance were readily available. Factors relating to this report The exhaust valve failure so soon after the previous Teamwork – Supporting one another is crucial during high- maintenance interval could indicate poor engineering risk work which is long and physically demanding. Is this the standards. These can result from insufficient training, case on board your vessel or in your company? Do you feel supervision or time to adequately maintain the spares. It could supported by your ship workmates, or do you operate like also result from inappropriate procurement choices: cheap an individual with everyone doing their own thing? and poor-quality parts may not last as long as expected.

MFB 68 | Summer 2022 www.chirpmaritime.org

Items identified as critical spares should be in a good the alternative lane to the east but ignored the pilot’s advice enough condition to be used when needed. None of the to do so and entered the lane to the south, against the three spares carried was in this condition, which could be general direction of traffic flow for that lane. bad luck or an indication that they were listed as a critical CHIRP could not determine whether the container spare for documentary, inspection and audit purposes only. vessel’s Standard Operating Procedures empowered the The company had concerns because they ordered a fleet- OOW to amend their speed (i.e.