An independent and confidential Issue 70

MARITIME FEEDBACK reporting system for the Maritime industry Spring 2023

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Single Points of Failure Adam Parnell As ever, CHIRP publishes these reports to raise Director (Maritime) awareness of the safety learning that arises from these incidents, and where possible, we always try to highlight simple and practical safety measures Welcome to the Spring edition of FEEDBACK, our free that you can implement in your daily routines. In safety newsletter for the global maritime community. this edition, we encourage you to adopt the PACE We’re delighted to report that we’re now publishing in (Probe, Alert, Challenge, Emergency) system, which Arabic as well as the other seven existing languages, improves group decision-making. You can also read all of which can be found on our website or via our a fuller description in our Making Critical Decisions at mobile app, which you can download using the QR Sea publication (available on our website under the codes printed on the back page of this newsletter. ‘Resources’ tab). Let us know what you think about Readers will detect that all of the reports in this system - we’d be delighted to hear if this helps this edition share a common theme: single points you and your teams on board. And we’re always keen of [safety] failure. Whether it is the pilot who to receive your incident and near-miss reports that undertakes the burden of night navigation unaided, help others learn from your experiences too. the rope through which every fender on the ship’s Until the next edition – stay safe! side is secured, or the single safe walkway to the forecastle which gets blocked by the timber cargo Recognising and addressing stored on deck, recognising and addressing potential ‘single points of failure’ greatly reduces the risk of an potential ‘single points of failure’ incident occurring. greatly reduces the risk of an incident

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.

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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

www.chirp.co.uk/maritime MFB 70 | Spring 2023

M2100 to push onto the vessel’s port quarter. With this assistance, the ship safely manoeuvred off the shallow patch at 0506

Vessel grounding and subsequently berthed without further incident after extensive checks on the hull’s watertight integrity.

in harbour CHIRP Comment Maintaining situational awareness at night is challenging. Ri Visual references are difficult to make out, particularly ve r against background lights, and they can change over Vessel 400m LOA Wind time due to development ashore. IMO SOLAS Chapter V Draft 15m Tide 90 minutes after high water regulation 13,

City Establishment and operation of aids to River navigation should be reviewed for each port as the volume of traffic justifies and Port the degree of risk required

As part of the assessment, port authorities must consider whether their navigation aids are sufficient to enable safe navigation, including appropriate lit aids to navigation Open sea if the port is open at night. To determine which aids are required, countries and port authorities must conduct risk assessments of their ports. IALA guidance (G1124) provides Initial Report a guide to safety assessment. The pilot boarded a very large container ship at 0200 before The briefing between the pilot and crew was hampered it navigated into harbour. The wind was NNE 10 knots, the by language difficulties. The pilot became the ‘single point tidal current was to the SE, and visibility was good. The pilot of failure’ as a result. A sketch or other visual aid would have noted after the incident that language difficulties reduced helped develop a common understanding, making it easier the effectiveness of spoken communication. to identify when the pilot needed assistance and to prompt At about 0350 (1 hr and 30 mins after high water), the constructively or question, e.g. “Are you aware that we are container ship commenced her swing to port off the berth. drifting towards the shallow patch?” This did not happen. By 0405, with the swing completed, the vessel appeared to As the vessel moved close to the jetty and other objects, be setting south under the influence of wind and tide. the pilot’s workload focus increased, and they lost overall The vessel’s stern swung towards the quay and got close situational awareness. to one of the jetty cranes, so the pilot manoeuvred the vessel CHIRP strongly encourages teams to adopt the PACE to avoid contact. They needed someone to report distances (Probe, Alert, Challenge, and Emergency) described in some to the quay and other infrastructure as it was less than depth in the CHIRP publication ‘Making critical decisions at 10m from the jetty and a mooring dolphin. Three tugs were Sea’, which is available on our website. Good communication directed to pull the container ship away from the jetty, but it and attention are essential, particularly at night when our became apparent that the vessel had drifted due to wind and circadian rhythms are often at their lowest. tide and had grounded on a charted shallow patch. The port CHIRP draws your attention to the enormous forces authorities were informed, and a fourth tug was despatched acting on the underwater hull of very large vessels. Masters

MFB 70 | Spring 2023 www.chirp.co.uk/maritime

responsible for safely navigating very large vessels should Factors identified in this report be provided with adequate training in handling these large Overconfidence – The operator may be too overconfident vessels so that they can, with enhanced knowledge, assist in the ability of the fender to provide a secure arrangement the pilots in safely berthing the vessel. for both vessels, given the environmental conditions. There are a number of manned-model courses which train masters and pilots in understanding the dynamic forces Local practices – This may be a local practice. However, in acting on the hull of all types of vessels. all ship-to-ship operations, both masters are responsible for ensuring that the mooring is secure throughout the loading/ Factors identified in this report discharge operation. Would you challenge this fendering Communications – The bridge team should have affirmed arrangement? Would you abort the berthing? the pilot’s actions when requested. A drawing of the intended plan would have provided a visual interpretation of Alerting – Would you alert the master of the export the stages of the turn with safe clearing distances applied to ship with the fenders that the securing arrangement is the radar for cross-checking. inadequate?

Alerting – Only the pilot appeared concerned about the vessel’s movement towards the corner of the jetty. The pilot M2095 stated he was acting alone- does this happen on your ship? Do you provide the support the pilot needs?

Fatigue/Situational Awareness – It’s possible, given Loss of steering the time of day, that elements of fatigue were apparent. Berthing or unberthing at night requires enhanced control on a bulk carrier situational awareness of yourself and your surroundings. Actively seek input from others. approaching a berth Initial report M2099 The master-pilot exchange was completed with no defects or limitations recorded. A tug was made fast aft on the centre line before arrival at the harbour entrance. Unsafe fendering The pilot altered to starboard at the entrance to the harbour in accordance with the passage plan, but no arrangement for Ship to counter helm was applied, and the ship continued to swing to starboard. The pilot gave a positive order of hard to port, Ship Operations and at this point, the helm indication was showing hard to starboard. The bridge team reported to the pilot that the ship had lost control of the steering. There was no audible alarm Initial Report on the bridge to indicate any defect or loss of control of the Our reporter sent a photo of a storage ship with incorrectly steering control system. rigged fenders, noting that a failure of any of the fender’s The engine was immediately stopped, and the tug was securing lines will lead to a failure of the complete fender ordered to pull back easily to arrest the ship’s headway protection system. which was reduced from 4.2kn to 0.4kn. The master re-established control of the rudder in Storage mother ship Non-Follow Up (NFU) mode, and the rudder was bought Original photo Fenders secured by single line back to midships. With the ship in a safe position in the harbour, the master and engineers reported that the defect had been rectified. The pilot instructed the master to thoroughly test the steering gear system before proceeding to the berth. When completed, the vessel was berthed safely.

CHIRP Comment This report is an example of a good safety culture in action. As a result of a comprehensive risk assessment that included contingency planning, the tug was ordered and made fast astern. The master-pilot exchange allowed the pilot to integrate quickly into the bridge team, and they acted as one team during the incident. CHIRP Comment Depending on the nature of the breakdown, an audible The rope is a single point of failure – if it breaks, the entire alarm may not sound, and the rudder indication is the most fender arrangement is compromised. Good seamanship reliable indicator of a breakdown occurring. This was quickly demands that each fender is individually secured in position detected by an alert bridge team, and the pilot could reduce since the relative motion of vessels can cause the securing speed by ordering the stern tug to take action. Once the lines to part. engineering team reported that the problem was fixed, the

www.chirp.co.uk/maritime MFB 70 | Spring 2023

bridge team carried out confirmatory checks, and the vessel Our usual procedure is to have a minimum of two people continued safely alongside astern and constant communications. We were ten days into a charter, and everyone was very fatigued. The captain was Factors identified in this report well over his hours. The fault lay on both sides: I should have Culture – Are you confident that the safety culture on board radioed the captain and said I was sorting the fenders first. He your vessel is similar to the one demonstrated here? assumed I was standing by but didn’t confirm or ask if it was okay to come astern. We were fortunate! Communications – Because the communications were so good, even the outstations (engine room, tug, and parts of Our usual procedure is to have a minimum ship) were aware of what was going on and what they had to do. This is an excellent example to follow. of two people astern and constant communications. We were ten days into a Teamwork – The pilot, master, bridge team, engineers and charter, and everyone was very fatigued. tug crew all operated in harmony because they had a shared mental model of the issue and the actions required. The pilot’s The captain was well over his hours insistence that the entire steering control system is tested before berthing was correct. The port authority should be commended CHIRP Comment for adopting this thorough approach to risk mitigation. A work operation such as this is risky at any time, especially in the early morning. A toolbox talk beforehand would have The master-pilot exchange allowed the ensured that everyone understood the plan. A risk assessment and comprehensive brief were pilot to integrate quickly into the bridge required for this work, and all underwater equipment and team, and they acted as one team during inlets/outlets were correctly and appropriately isolated with the incident a LOTOTO system. Carrying out work in darkness and in the early hours when everyone is tired increases the risk of a mistake. Getting rest before carrying out this work in daylight with M2082 all crew available to assist if anything goes wrong is a much safer alternative.

Fouled Towing Line Bridle Factors identified in this report Fatigue- Early morning activities are always difficult, Initial report especially if crews are already fatigued, and decision- Our reporter stated they were on a tug, towing a 47ft making can be affected. Could this operation have been tender and approaching the anchorage in the early timed for daylight when the crew could be better rested? morning (0130 hrs). “There were just three crew on duty: me, the master, Communications- Establishing communications before and the engineer. About a mile offshore, the master reduced the activity commences is essential, and for safety-critical speed to prepare for unhooking the tender. He directed me tasks such as this, closed-loop communications are the to the aft deck and to stand by. I started to put out fenders, safest method. ready for the tender to come alongside after anchoring. As I was doing this, I heard the engines go astern. The tender Teamwork- Teamwork in small teams usually works very was only about 40m astern using a 75m tow line, and the well, but in this case, it broke down. This is a reminder that tow line was slack. I radioed the bridge to say disengage/ from time to time, even on very well-run vessels, we all neutral, but it was too late. need to check on each other to ensure everyone knows The port end of the tow bridle got wrapped in the what is happening. starboard propellor, and the engine shut down. We were drifting away from land, which was too deep to anchor. I put a mask on with a dive light and entered the water M2088 to assess what had happened. The tow line had gone through the middle of the rudders and, fortunately, had not damaged the propeller shaft or rudder. The towing bridle was, however, bar-tight and had to be cut off. I alerted the Pressurised to make a other dive master to assist me, and we went under the hull and cut the line off the propeller. This took about 10 fatal decision minutes to complete. Initial report Once we had re-positioned and anchored, I spoke with The superyacht was anchored in a bay where jet skis the captain about what had happened. He said he looked had been prohibited due to the density of traffic in the into the stern-facing camera when he was in neutral. He anchorage and a spate of previous incidents. saw the tender approaching and thought that we were The owner was on board with a fellow guest who pulling it in, so he gave the tug a kick astern to assist with drank heavily. They requested that the jet ski be launched. retrieval. He was unaware that the bridle was already slack The captain explained that using jet skis was prohibited in the water. None of this was communicated until after I and ill-advised when inebriated. The owner and his guest shouted to go into neutral. were insistent, and this conversation escalated until the

MFB 70 | Spring 2023 www.chirp.co.uk/maritime

captain was given the ultimatum of either launching the Pressure/culture: The owner bullied the captain into jet-ski or being dismissed. going against their professional judgement. On board, such The captain yielded to this pressure, and the jet ski behaviour was reflected in the safety culture (and probably launched. Shortly after, the owner’s guest had a high- the welfare culture). speed collision with a nearby vessel. The casualty was recovered from the water, unconscious and severely injured; the crew found he was not breathing and M2101 commenced CPR, but the casualty died before emergency services arrived. The result was one death, a traumatised crew and owner, and the captain losing his job. He remained out of Unsafe access for work for the following two years while under investigation and under the threat of criminal prosecution. the crew on a logger In my experience, Superyacht owners are often Initial Report unreasonably demanding and need to respect the captain’s Our reporter sent photos of a vessel loading timber cargo command. Being told “no” is unfamiliar to them and seen over alternate deck hatches. The timber extended right as an insult. Captains who stand their ground risk being across the width of the deck, and the crew had to either side-lined for their professional conduct, and those that walk on the narrow tops of the bulwarks or swing outboard do yield to such demands potentially face even more dire of the log stanchions and hang over the side of the vessel. consequences. Both methods are unsafe. The pictures show the height of the “log face.” CHIRP Comment This is a lethal accident waiting to happen. The drink had clouded the judgement of the guest and the owner, but the captain knew that jet-skiing in the bay was prohibited. Even if the owner had sacked the captain on the spot, once they had sobered up, they would most likely have realised that the captain was speaking objectively, not subjectively. However, even when it could place others in danger, it can still be hard to refuse a request or order by