An independent and confidential Issue 74

MARITIME FEEDBACK reporting system for the Maritime industry Spring 2024

CONFIDENTIALITY SUBMIT A REPORT

CHIRP always protects the identity of our reporters. Reports can be submitted easily through All photos are stock library images. Persons, places our encrypted online form or vessels shown are not associated with the www.chirp.co.uk or via our app accompanying report unless otherwise stated.

The human cost of maritime incidents According to British anthropologist Robin Dunbar, Adam Parnell the average person maintains relationships with Director (Maritime) approximately 150 friends and family. The true cost of a safety incident therefore goes far beyond those immediately involved; the injuries and incidents that occur in our industry literally touch millions of lives.

O rganisations often state that they put safety first. Regrettably however, commercial and reputational realities often obstructs the realisation CHIRP is aware of several cases where those reporting safety concerns through their organisation’s reporting channels have faced redundancy or of this lofty ambition: rather than view incidents reprisals. Such suppression only serves to ensure that as an opportunity to learn from experience, some safety issues are not addressed, and the risk of repeat companies go to great lengths to present themselves incidents remains stubbornly high. as being 100% safe, 100% of the time. But in an CHIRP’s independent, impartial and confidential industry known to be more ‘dangerous’ than many reporting system allows individuals and companies others, this simply can’t be correct. to raise safety concerns and issues without the risk The sad news of Captain Oguz Kok, who recently of reprisal, or loss of reputation. The following reports died during a night pilot transfer in the Bosphorus were sent to CHIRP to raise awareness of risks across reminds us of the dangers inherent in the maritime the industry, or to share best practice, or to get an industry. And while many, including ourselves, were issue addressed. In many of these reports, you will quick to express condolences and offer thoughts for read that CHIRP advocated for the reporter by raising his family and friends, the collective maritime industry the issues with the company or Flag State while needs to do more to improve safety. protecting our reporters’ identities.

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 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 74 | Spring 2024

M2194

Unsafe tug/barge operations Initial Report Our reporter was very concerned about the operational practices used in their tug and barge operations: “As a new employee and apprentice in the industry, my onboard experience has raised serious doubts about the overall safety culture and protocols in place. While on the tug, I observed a significant need for more familiarisation and the absence of buddy support. Instead of being paired with a qualified deckhand for essential on-the-job learning, I was left to navigate tasks independently. This absence of mentorship has resulted in a notable gap in my understanding of crucial safety procedures. More alarmingly, I suffered a severe injury due to exposure to an unlabelled chemical referred to as “carbon remover.” The lack of proper labelling and informed usage resulted in severe eye burns. This incident raises concerns about the company’s safety protocols for handling hazardous substances. In addition to these safety issues, I observed unsatisfactory conditions on board, particularly regarding cleanliness. Coupled with the lack of training, this paints a concerning picture of the overall working environment.”

CHIRP Comments CHIRP has raised the reporter’s concerns with the Flag State Authority, who have informed CHIRP that they are investigating the claims. The ISM Code implicitly requires familiarisation and training (6.3, 6.5). This must be done to identify all hazards and reduce the associated risks to avoid significant safety incidents on board the vessel. The reporter has dared to report the company’s inadequacies to CHIRP, which is commendable.

The reporter has dared to report the company’s inadequacies to CHIRP, which is commendable Human Factors Capability – The company’s management appears to lack the necessary resource capability to ensure that the crew employed is provided with basic safety familiarisation. Does this situation, as described, apply to you? If so, please get in touch with CHIRP.

Teamwork – According to the reporter, more cooperation is needed to help new joiners in the industry. Does your company operate a mentoring system for new joiners or have a” buddy” system?

Culture – The company’s management needs to demonstrate a safety culture. Taking on a contract to tow a damaged barge, which is not fit to be on the water, is a clear example of safety being given a very low priority.

M2205 dangers if you have carried it, especially on a cruise liner or superyacht? Did you know that it is classified as a

Asphyxiation hazard dangerous goods cargo? Have you received training in the handling of dry ice?

Intial report Communication – How well are you aware of the carriage A crewmember entered a freezer compartment for routine of dry ice in the galley fridges of other compartments where duties where, unknown to them, dry ice was being stored. it may be stored? Are these spaces labelled as enclosed The crewmember quickly lost consciousness because spaces?How is this communicated to everyone on board? of the high CO2 levels produced by the dry ice. Luckily, another crewmember quickly raised the alarm, and they Alerting – A crew member nearly died because of a lack of were rescued and given first aid. They were then sent to the knowledge of dry ice and its hazards. Does your company hospital for a confirmatory check-up. provide extra information on dry ice carriage? Have you seen dry ice’s material safety data sheets (MSDS)? Have CHIRP Comments they been explained to you? The decision to transport dry ice for culinary presentation carries significant risks, and management is responsible for them. The management team must thoroughly evaluate the M2208 associated risks at the organisational level before approving the procurement of dry ice. Strict adherence to regulations and guidelines is essential when dealing with dry ice, considering its inherent Bunker station design hazards. Key considerations involve recognising dry ice Initial Report as a dangerous good (UN 1845) and understanding the The reporter sent a concise video highlighting the poor specific risks it poses during transportation. Compliance with design of the bunkering station on a very large yacht. regulations becomes vital for ensuring the cargo’s safety The reporter informs CHIRP that super yachts use a and the well-being of the individuals involved in its handling. variety of bunkering facilities, and it is very rare to connect Emphasis must be placed on proper handling, packaging, with a Marpol flange. and ventilation to mitigate the risks of transporting dry ice. Most bunkering hoses have camlock fittings, and A thorough risk assessment must be conducted to because of poor design issues at the bunkering station and ensure that all potential hazards are explored. poor maintenance of the camlocks, many connections leak, Since the dry ice is sourced from a franchisee/ creating pollution, health hazards, and fire hazards. sub-contractor, it is imperative to communicate detailed information regarding its hazards, proper handling, and safe storage to various stakeholders, including management, the master, the chief officer, the chief engineer, and all ship’s staff. The storage compartment for dry ice immediately falls under the classification of an enclosed space, requiring an enclosed space permit for entry. Solid dry ice must be packaged in non-airtight containers to allow the safe release of carbon dioxide gas produced during sublimation (change from a solid to a gas without becoming a liquid), thereby preventing container overpressure and the associated risk of an explosion. Adequate ventilation becomes crucial, avoiding the accumulation of carbon dioxide gas in enclosed spaces and mitigating the potential for asphyxiation for anyone working in the compartment. Entry into a fridge space containing dry ice necessitates a permit to work. Comprehensive training for crew members handling dry ice is a management responsibility. It covers hazards such as explosion, suffocation, and tissue damage due to extremely low temperatures. Training programs must highlight the importance of proper ventilation and avoiding unventilated compartments. Management should establish robust mitigation strategies and emergency response procedures, including incorporating personal gas detectors and enforcing appropriate PPE to prevent skin contact damage.

Human factors Capability – Dry ice, or solid CO2, demands good knowledge to mitigate the risks. Does your shore management team have the necessary skills to manage the risks for the crew? Have you been aware of the

www.chirp.co.uk/maritime MFB 74 | Spring 2024

CHIRP Comments fuel exceeding the 0.5% limit should be required to Design issues with bunkering connections often need to be demonstrate how they intend to reduce sulphur levels, thoroughly thought out. Bunker connections are frequently either through a scrubber system or another method. positioned in tight spaces, making it difficult to connect the The exhaust gas cleaning system should only be hose. Once connected, the connecting flanges can often considered a temporary measure, and ultimately, all come under much stress due to poor alignment, making a ships should be converted to using low-sulphur- tight seal difficult to achieve. compliant fuel. CHIRP requests owners reconsider their bunkering design and, during the next drydock or lay-up period, Human factors consider changing the pipework to ensure connections are Culture – The vessel’s organisation does not appear to positioned to allow better alignment and a tighter seal to be invested in environmental compliance. This is perhaps prevent leakages while bunkering. unsurprising given that the vessel is involved in ‘sanction CHIRP strongly believes persistent leakages when busting”. The requirement to burn cleaner fuels or have bunkering are unacceptable and indicate a normalisation of scrubbers fitted has been in force for three years. Is your deviance, where this practice is accepted as the new norm. vessel following the rules?

Human factors Pressure – The company uses economic pressure to conceal Design – The design needs to be improved for secure the vessel’s non-compliance with Marpol, but if caught, the bunkering. The workspace for hose connections needs to monetary fines will outweigh any short-term savings. provide adequate space to allow alignment for the camlock. Does your bunker station have sufficient clearance to obtain Local Practice – The practice of a company operating ships good alignment when bunkering? which are not fitted with an exhaust gas cleaning system must be ended. If you are operating on a vessel with a Alerting- Alerting management to the fact that buckets must similar operation, please get in touch with CHIRP. not be used to control leakage from a bunker connection and should not be tolerated. Management should also be advised of the remedial action required to be taken. M2206

M2209 Personal injury due to not Marpol contravention following a permit to work Intial report for working aloft. Several reporters informed CHIRP that their tanker was burning Intermediate Fuel Oil (IFO) with a sulphur content Initial Report of 2.4% even though the vessel was not fitted with an The OOW spotted a faulty navigation masthead light exhaust gas cleaning system (scrubber) to reduce the warning on the bridge’s navigation light control alarm sulphur content to below 0.5% as required by Marpol VI system while the vessel was at sea. The issue was reported reg 14. The ship trades worldwide and is not fitted with to the chief engineer and master, but due to the sea state, an exhaust gas cleaning system (scrubber) to reduce the the decision was made to wait until the vessel was alongside sulphur content below 0.5%. (Marpol VI reg 14). To avoid before going aloft. detection, they knew the vessel switched to burning Immediately upon coming alongside, while the rest marine diesel fuel when operating in ports or emission of the crew were busy rigging the gangway, the chief control areas (ECA). engineer climbed up the mast without completing the The reporters were highly concerned about reporting permit to work for working aloft or wearing a safety this matter because the vessel is part of the ‘dark fleet’ of harness. While the CE was up the mast, the wake of a vessels breaking international sanctions. They were fearful passing vessel caused the vessel to roll violently, causing of potential reprisals should their identity become known. the CE to fall and break their arm.

CHIRP Comments CHIRP’s comments Following extensive communication with the reporters, The decision to delay attending to the light while underway CHIRP raised these concerns to the Flag State, the at sea was correct. Once alongside, vessel motion can still designated person ashore (DPA), and the Hull and be affected on both large and small ships, especially as Machinery Insurers. the ship’s stability can change significantly during cargo, This report illustrates the lengths to which some bunkering and ballasting operations. irresponsible vessel owners will go to circumvent regulations Contacting the port authority to check on vessel movement designed to protect the environment. This is likely because for the time the work is carried out is standard practice. the cleaner fuel is more expensive, and the company puts The fact that the Chief Engineer went aloft so swiftly profit over safety. indicates a self-imposed time pressure to get the task The incident also suggests that Flag and Port State done as soon as possible. Similarly, not following safety inspections should be reviewed to ensure that such procedures before going aloft suggests that the chief behaviours can be detected. Vessels admitting to carrying engineer succumbed to optimism bias (also known as the

“It won’t happen to me” syndrome). More concerningly, The reporter is confident that similar practices are taking it points to poor safety culture and safety leadership: place on other ships with elevators and wanted to draw our if others see the chief engineer (who is very often the attention to this. Although nothing happened in this case, ship’s safety officer) taking safety shortcuts, how does there have been incidents where people have been crushed this incentivise the more junior crewmembers to follow to death when working on the top of an elevator that wasn’t safety procedures? properly isolated.

Human Factors CHIRP Comments Culture – When it comes to safety culture, senior officers CHIRP contacted the Flag State to find out more information must lead by example and model the safety behaviours concerning this incident. They readily assisted CHIRP by they want their team to adopt. As the saying goes, it is better recounting the details that led to the severe injury. to set an example than to be one! This work is the same as working at height and must be treated accordingly. A permit to work must be Alerting – Making sure that the master/safety officerand part of the process and form part of the risk assessment. crew were aware that the light was going to be fixed would Crucially, a Lock Out - Tag Out - Try Out (LOTOTO) must have alerted everyone to the requirement to use the permit be implemented and cross-checked before any work is to work for going aloft. Does your vessel operate a permit- performed. The Try-Out for the acronym LOTOTO is an to-work system when going aloft? evolution of the original term LOTO and shows further safety enhancement of the hierarchy of controls. Situational awareness – Being aware that even in The report highlights that this incident was categorised a port where conditions are not affected so much by as an “optimising violation”, where the engineer tried to make environmental factors, you can sometimes overlook the the work easier by not fully isolating the main power to the lift. dynamic action on your vessel by passing vessels. For most companies, lift maintenance is carried out by the original equipment manufacturer (OEM). However, the Pressure – here appeared to be pressure to get the ship always has a duty of care to ensure that shipboard safety work done. This work should have been allocated to crew controls cover the maintenance contractor. It must be applied members who are more used to working aloft. The permit to even if the contractor has its own safety requirements. work for going aloft could have been supervised by the chief CHIRP notes that the engineer was working alone, engineer. How do you control your permits to work? Do you so there was no one to cross-check or challenge any know the rank of your safety officer? unsafe behaviour. Given the increasing number of elevators used in commercial shipping, CHIRP questions whether an M2207 introductory safety maintenance training course should be offered for all ship’s officers.

Potentially lethal near Human Factors Culture – Capability for this work could be improved, given miss: elevator maintenance the high risk associated with lift operations. Initial Report Complacency – A casual attitude to the work was Our reporter stated that they were asked to open a vessel’s displayed, which has probably been evident in the past elevator doors so that a cleaning crew could ride to the top and has been accepted as the norm. Does your SMS have of the