An independent and confidential Issue 72

MARITIME FEEDBACK reporting system for the Maritime industry Autumn 2023

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Teamwork saves lives

Adam Parnell compliance with the International Maritime Dangerous Director (Maritime) Goods Code and the Code of Safe Practice for Cargo Stowage and Securing is necessary to prevent accidents and protect crew, vessels, and the environment. CHIRP has recently received reports from across the Sub-aqua diving safety comes under scrutiny maritime sector, and we reflect this in the variety of following an incident in which a diver was seriously incidents published in this edition. Although each injured by a propeller. We explain why the use of incident is unique, they all agree that a proactive Surface Marker Buoys (SMBs) and shot lines are approach to safety, adherence to guidelines, effective recommended to improve visibility and coordination communication and continuous training are essential during diving operations. to preventing incidents. A vessel’s response to an engine failure We start with a potentially hazardous situation highlights the need for timely assessment and that was averted by the quick response of a vigilant familiarity with emergency controls. Effective and alert crew. The incident also raises questions collaboration between bridge and engine teams and the adequacy of berth assessments, and underlines the importance of experienced decision-making the significance of proper mooring system design during emergencies is underscored. and maintenance. Finally, a lucky rescue of a single-handed fisher CHIRP was contacted by a shore-based contractor who had fallen overboard reveals several good safety who frequently participates in lengthy sea trials. lessons, including the importance of wearing flotation Concerned that fatigue could lead safety incidents, they devices and personal locator beacons (PLBs), carrying sought CHIRPs intervention to resolve the situation. means of communication, and implementing self- Lithium-ion batteries (LIBs) fires in containers rescue measures such as ladders. pose serious risks. We report on one incident that Remember - your feedback on our FEEDBACK reinforces the need for accurate cargo declaration, is vital! And keep those reports coming! Sharing your proper packaging, and adherence to guidelines for the experiences with us directly helps improve maritime safe carriage of dangerous goods. safety for others who learn from your incidents. More generally, improper stowage practices can Sail Safe, lead to cargo damage and hazards, and we discuss why CHIRP Maritime Team

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 seafarers (see map) who also share to improve safety outcomes. The have an established ambassador your passion for safety, and you key attributes of a successful scheme to raise awareness of will quickly gain a broad knowledge ambassador is a passion for safety our incident reporting schemes of current safety issues. These and a willingness to speak up for and encourage the submission are great additions to your CV and CHIRP among your colleagues of incident, accident and increase 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 over 50 culture across the maritime sector mail@chirp.co.uk

YOU REPORT IT WE HELP SORT IT

www.chirp.co.uk/maritime MFB 72 | Autumn 2023

M2150 Factors identified in this report Communications – Are such design shortcomings fed back

Imminent mooring failure to naval architects to ensure that future vessels have these hazards removed?

averted by vigilant crew Fit for purpose – Was the berth fit for purpose in the prevailing weather conditions? Did the charterer’s local Initial Report agent confirm this was the case? Had they raised concerns Whilst the vessel was alongside at our terminal, long-period with the terminal operator? low amplitude swell waves (groundswell) caused a large bulk carrier to yaw and roll. This motion caused the edge of Teamwork – This report is a good example of effective the roller fairlead to saw through one of the forward spring monitoring by the ship’s crew. lines. Fortunately, this was detected by the crew before it was cut all the way through, and they were able to replace Design – Naval architects should avoid designing sharp the line before it parted. edges over which lines are likely to be run. Crews: does your vessel have this issue? If so – report it! CHIRP Comment The crew’s response to the potentially dangerous situation was highly commendable; their alertness and quick action M2155 ultimately prevented the parting of mooring lines and potential further complications. CHIRP wonders whether the charterer’s agent properly assessed the berth for suitability in the prevailing weather Fire in Container conditions? Unsafe berth claims go against the charterer, Initial Report not the owner, so they should have a local agent on site to During a voyage, a 20ft container loaded with cargo satisfy themselves that the berth was suitable and to raise installed with lithium-ion batteries caught fire. The cargo concerns with the terminal’s operator. had been mis-declared as non-DG (dangerous goods). The design of the mounting block on which the pairs of Despite the difficulty and safety risk when gaining access roller fairleads are mounted requires review. The 90-degree to an above-deck container in a confined space, the crew edges act as a blade on surging ropes. Naval architects are punctured the container and flooded the burning cargo with reminded that the edges of these should be considered water. This action controlled the fire until the vessel got to during the design phase of a new vessel. By eliminating the next port, where the container was discharged for an such hazards at this stage can significantly decrease the investigation by the terminal authorities. chances of lines abrading or parting during the vessel’s lifetime. OCIMF’s Mooring Equipment Guidelines (MEG4) CHIRP Comments (https://www.ocimf.org/publications/books/mooring- The crew’s actions in containing the fire until the vessel equipment-guidelines-meg4) provide further guidance on reached port are commended, as is the decision by the port to the design and construction of the mooring system. accept the vessel – many ports turn away vessels if there is a Properly installed moorings are not only essential for fire of any description on board. However, these fires require the safety of the crew but also for maintaining the ship’s specialist equipment and techniques to extinguish, which are structural integrity. The risks associated with inadequately only available in port. Both ports and vessel managers need installed moorings—including the potential for fatalities, to develop and exercise robust emergency procedures for LIB injuries, damage, and increased costs—can be effectively fires: traditional equipment and training is insufficient. minimised by giving importance to mooring design and It is critical that shippers declare LIB and other construction quality. dangerous goods correctly. Failure to do so potentially puts Vessel owners remain responsible for maintenance the lives of crews in danger because they will not have in most cases, and they should ensure that such hidden taken this factor into consideration when loading the cargo, hazards are removed as soon as possible, or at the latest, nor be prepared to tackle a LIB fire. Regrettably, cargo during the vessel’s next maintenance period. misdeclaration occurs frequently. The Cargo Incident Notification System and Network (CINS) has released a comprehensive guidance document (CSAR-101A) which is an invaluable reference document for stakeholders transporting LIBs, and provides guidelines for their safe carriage in containers. Shippers must strictly comply with all relevant national and international safety, health, and environmental regulations when transporting goods containing LIBs. They must thoroughly evaluate the anticipated transport conditions, including factors like manufacturers and customers involved, and conduct a comprehensive assessment of the risks inherent in the supply chain. The selection of appropriate containers, and following proper packing procedures, is especially important when shipping LIBs. Use temperature-controlled cargo units or

MFB 72 | Autumn 2023 www.chirp.co.uk/maritime

protective stowage locations if the expected temperatures M2163 within a container are likely to exceed 40 degrees Celsius during the voyage. By following the CINS guidelines, stakeholders can Fatigue issues for Contractors who work significantly reduce the risk of incidents such as thermal runaway, which can be challenging to contain and

on ships extinguish. It is essential to mention that a thermal runaway event creates very high temperatures, toxic gases and can be inextinguishable. Traditional fire-fighting techniques are inadequate for Initial Report these fires, and there is an urgent need for both training A shore-based contractor who often embarks on ships for and equipment to evolve to meet the hazards of an LIB sea trials contacted CHIRP with concerns that their working fire. In particular, CHIRP is concerned that many ports have routines were leading to them becoming fatigued, and not established procedures for tackling such fires on board they were anxious that this could result in a safety incident vessels, nor have yet designated a safe anchorage or berth or accident. At sea they regularly worked 12-hour days, for such an eventuality. sometimes switching between day and night shifts mid-trial. Sea trials typically lasted for 2-3 weeks with no rest days (except when they switched from day to night shift), and fatigue has been a factor. The reporter asked CHIRP to advise on safe working limits in such circumstances, so that they could have an informed conversation with their employer.

CHIRP Comment The Maritime Labour Convention defines a seafarer as: “Any person, including a master, who is employed, or engaged, or works in any capacity on board a ship and whose normal place of work is on a ship.” Under the Convention, seafarers are entitled to a minimum of 77 hours of rest in any 7-day period and at least 10 hours of rest within any 24-hour period. The schedule of working hours must be recorded and posted for all seafarers to see. If a person’s normal workplace is ashore, they are categorised as a ‘worker’ and their working hours are regulated by the vessel’s Flag State or local regulations. These commonly (but not always) limits the working week to an average of 48 hours, with the working day an average of 8 hours, with one day a week as a rest day. The contractors’ employer is responsible for the health, safety and wellbeing of their employees and should set working limits accordingly. However, it is good practice for masters to ask for copies of the contractors’ fatigue management plans so that they can satisfy themselves Shippers must strictly comply with that their working routines have properly taken fatigue into account. Ultimately, masters are responsible for the safety of all relevant national and international all persons on board and have the authority to grant additional safety, health, and environmental rest periods to ensure that the hazard of fatigue has been controlled to a level that is “as low as reasonably practicable”. regulations when transporting goods Other practical steps include the buddy-buddy system containing LIBs where pairs of workers monitor each other for signs of fatigue and bring this to their partner’s attention. Scheduled rest days at regular intervals and shorter shifts can also help Factors identified in this report mitigate fatigue-related risks. Capability – Cargo misdeclaration happens too frequently. CHIRP is pleased to report that in this case, the Owners, charterers and shippers should ensure their employer listened to the reporter’s concerns and took action organizations have good document management skills and to address their fatigue concerns. processes in place. Similarly, vessels and ports should have a plan and the equipment to tackle a LIB fire. How often are Factors identified in these reports they practiced? Alerting – Alerting the company to high workloads is an essential first step in solving fatigue issues for shore Situational Awareness – Understanding everyone’s role contractors. Does your company empower you to in the supply chain is the most effective way to transport report fatigue concerns, and are you aware of their DG’s safely. reporting procedure?

www.chirp.co.uk/maritime MFB 72 | Autumn 2023

Culture – Employers of shore contractors should have pressure, fatigue, wrong signal cues from the crew, and wellbeing policies and fatigue management plans. Masters overconfidence can cause this. are strongly encouraged to ask for sight of these when embarking contractors. Alerting – given the severity of the incident, medical attention is required immediately. This did not happen, Local practices – The buddy-buddy system is a useful tool according to the reporter. What are your medical emergency to spot the early signs of fatigue. This is most beneficial when plans in similar circumstances in your company? crew and workers are empowered to report such concerns, and there are well-understood procedures in place to do so. M2154

Dredging a ship’s anchor M2152

Personal injury while diving to reach a temporary Initial Report During a recreational wreck dive off a chartered dive anchorage vessel, a diver was hit by the turning blades of the dive boat’s propeller, sustaining significant injuries. The diver Initial Reportt was transferred to the local hospital and had their wounds During a daylight approach to a buoyed channel, the main stitched. Coastguard assistance was not requested. engine of a loaded tanker was stopped to allow more time The wreck is best dived while there is still a weak for congestion at the berth to clear. tide over the site, ie close to slack water. The divers had On passing the harbour’s outer entrance, the main therefore to be dropped up-tide of the wreck to counter the engine was requested to Dead Slow Ahead but failed to effect of tide while they descended from the surface to the start. Several minutes elapsed without explicit information wreck. Once the skipper was satisfied that they were in the from the engine room as to the nature of the problem, which right position, the engine was put into neutral to stop the eventually appeared to be a control issue with fuses. propellor spinning, and the divers entered the water as a The engineers, on request by the master and pilot, could group. They swiftly conducted last minute checks before not establish local control of the main engine immediately, so making themselves negatively buoyant and it was decided to dredge the starboard anchor to a temporary leaving surface. anchorage close to the safe water area. On the dive boat, the engine is only put back into A tug was requested at the location to assist in gear once is it visually confirmed that all divers have left relocating the vessel to a designated anchorage area. surface. CCTV coverage of blind spots under the hull provide The engineers eventually provided local control of additional assurance. However in this instance, when the main engine. Approx. 2 hours later, the tug arrived on forward propulsion was engaged, it collided with the diver location and was made fast forward before commencing who sustained serious injuries. weighing anchor. The vessel was towed to the designated anchorage using the local control of the main engine as CHIRP Comment required. The vessel remained anchored for three days while The effect of tide on the boat meant that it drifted back repairs involved the Class surveyor’s attendance. over the location where the divers had entered the water. The reporter’s concern was the excessive time to Although it was visually confirmed that they had all left assess the mechanical problem necessitating the immediate surface, the crew on board had no way of knowing that at need to anchor and the need for more familiarity with the least one diver remained at a shallow depth, with whom emergency side controls. they then collided when the engine was put back into gear. The use of Surface Marker Buoys (SMB), or the laying CHIRP Comments of a shot line for the divers to hold while they descend The report highlights that accurate assessment skills and would have provided the dive boat a visual clue to the familiarity with maritime emergency equipment are crucial divers’ locations. in ensuring the safety and effectiveness of maritime This injury was potentially fatal, and CHIRP has operations. The importance of experience in identifying the contacted the reporter for additional information to causes of engineering problems is highlighted, emphasising determine what happened. With the reporter’s permission, the need for the engine team to engage in collective thinking CHIRP has also contacted the relevant Flag and the to enable effective collaboration with the bridge team for appropriate Accident Investigation Authority because of the anticipating and planning necessary actions. seriousness of the incident. However, infrastructure support and assistance availability can vary depending on the vessel’s location, Factors identified in this report adding extra complexity to emergencies. Situational Awareness – It is very difficult to determine the In terms of training engineers to collectively address depth of a diver once they have left surface. This was not engineering problems, the Short Term Strategy (STS) adequately taken into account by the dive boat’s helm. approach is recommended, especially when no predefined rules or procedures are available. Conducting meetings in Distractions – The boat was manoeuvre before the the Engine control room to discuss the problem, assess vessel was clear from the diver. Many stimuli, commercial risks, and evaluate available time can significantly enhance

MFB 72 | Autumn 2023 www.chirp.co.uk/maritime

teamwork, establish a shared mental model, and improve When fishing single-handed, CHIRP advises that a communication between the engine and bridge teams. This ladder is rigged to aid self-rescue or a floating messenger collaborative approach helps ensure a coordinated response line attached to a lifebuoy streamed from the stern and next to challenges. to the ladder. Fishers are also strongly encouraged to wear a The report also suggests that engineers should be waterproof hand-held VHF radio or (even better) a Personal well-versed in