An independent and confidential Issue 75

MARITIME FEEDBACK reporting system for the Maritime industry Summer 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.

It’s good to talk! you are discouraged from voicing your concerns then Adam Parnell it may be wise to look for a company where safety is Director (Maritime) taken more seriously. Teamwork and the benefits of mutual support also feature prominently, especially when people must work alone. Does anybody oversee the

O nce again we feature a wide selection of different incidents, and we are grateful to all our reporters for sending them to us. Without them, Maritime crew handling mooring ropes on your vessel, and does the electrician get the support he needs? Do management and local agents ensure you have the FEEDBACK would not exist. details you need to stow and carry cargoes safely? In this edition we have three different types Do your officers receive the support they need from of fire, two hand injuries and a variety of other shore management when they face pressure from unfortunate events but there are some common external sources to cut corners? threads running through them. Perhaps the most In this edition we use the word ‘escalate’, obvious is the need for better communication, which means passing your concerns up the chain whether it is between crew members or with shore of command. If you see a potential problem, inform personnel or the vessel’s management. This is a a senior officer who can escalate your report to the theme we see very often in our reports, and by now master. The master can then escalate it to the DPA it should be obvious that good communication is vital if necessary. Good officers will always take you to safe operations. If you see something which is not seriously and deal with your concerns. right, you should feel empowered to speak up. And if Until next time, stay safe.

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 75 | Summer 2024

M2216 Teamwork – The organisation is pulling in different directions, compromising safety. Reading this report, do you

Inappropriate pressure feel that this sometimes happens to you?

placed on the master Local Practices – Follow the correct legal requirements as Master and put in writing your concerns. Contact the DPA. The financial consequences of using an anchor that cannot Intial report function and then discovering that the situation has not The master of a large vessel received unusual instructions from been disclosed in the port arrival information will be many charterers concerning pre-arrival reporting to the authorities. times higher than the tug escort fees. The reputational The vessel had sailed with both anchors damaged, one damage to the company will be even higher. more so than the other. A dispensation to sail was granted, and a condition of class was imposed on the vessel. New anchors would be supplied to the vessel at the next portThe M2183 master was advised not to mention the dispensation letter to the port authorities at the next port, as revealing the state of the anchors would require a tug escort to the berth. Fire in the laundry room CHIRP Comments Intial report A dispensation letter is usually a one-off temporary permit Directly after some tea towels had been in the tumble dryer, to sail to the next port, where spare parts or replacements they were put in a plastic garbage bag and placed on top of it. for technical problems can be rectified. The authorities After some time, the fire/smoke detector in the laundry room granting the dispensation letter, usually from the class was activated, and the crew was alerted. When entering the society, do so based on a risk assessment. As such, it must laundry room, they noticed smoke from the plastic bag. They be conveyed to the next port during the port pre-arrival managed to put out the smouldering fire with an extinguisher. information exchange. The dispensation letter is a lifeline, granting temporary reprieve amidst technical challenges. CHIRP’s comments The Master must exert their overriding authority to Placing hot towels or boilersuits that have not cooled down mitigate the risks. This is a legal requirement, and pressure sufficiently and may still contain oil /grease residues in the to do anything other than act safely must be refused. CHIRP fabric in a plastic bag on top of a tumble dryer creates the advocates that when such requests are received, the master conditions for spontaneous combustion, which is a common consults them to the ship’s DPA in writing. cause of shipboard laundry fires. Given the complete loss of anchoring efficiency for Spontaneous combustion occurs when a combustible one of the anchors, employing an escort tug is the correct material with traces of oil/grease in the fibre heats up and mitigation measure in a higher-risk port area to ensure safe reaches its ignition temperature, involving oxygen in the air passage to the berth. (oxidation). The oxidation of the flammable material creates Additionally, failure to follow the dispensation the heat. requirements can invalidate the vessel’s insurance cover It is essential to ensure that the tea towels are properly in the event of an incident. Cutting corners has severe hot washed to remove the grease and oily residues on the consequences—a single misstep can unravel insurance cloth before drying them in a tumble dryer. The appropriate coverage, leaving the vessel vulnerable to legal issues. type of detergent should be used to ensure they are clean Ultimately, in an incident where the anchors are of oily residues. required but they cannot function, and the port has not The tumble dryer should be set appropriately to been informed, the company can be prosecuted for failure ensure that the towels go through a proper cycle, to notify. including the cooling cycle, so they are not hot when the When in doubt, escalate. The master’s duty is not just cycle is completed. The filters in the tumble dryers should to navigate the vessel; it is to navigate through a maze of be cleaned before each cycle. Blocked filters prevent regulations, ensuring every decision is a commitment to good airflow and prevent drying of the clothes during the safety. Commercial costs for providing an escort tug must cycle. They should then be separated, placed in the never interfere with the vessel’s safety. drying room on completion, and never placed on top of the There is no compromise in maritime operations: safety drying machines. must always come first. Laundry rooms are particularly high-risk environments for fire, and the cleanliness of the machinery is essential Human factors to prevent fires. Detector heads, ventilation fans, FFA, and Pressure – Excess pressure to ensure that commercial suitable door-closing arrangements must be adequately costs and operational deadlines are met is a dangerous maintained to mitigate the fire risk. Regular fire drills should human factor that creates unnecessary doubt and can cloud be carried out in this area to train the crew to be alert to the the judgement of those making critical safety decisions. potential for fire. Given their high use, the equipment should be considered Culture – The chartering team’s connection with safety for replacement every five years during a docking period. was poor, and the ship management team did not support the master’s openness in reporting the dispensation with Human Factors the port authorities and sharing the risks outlined by the Local practices – Follow well-established laundry cleaning dispensation letter. procedures and do not adhere to unsafe practices. If you see

practices that differ from what you have been trained to do, the necessary support, and did they feel they were part of speak up. the team?

Alerting – Alert those responsible when you see something Distractions – How often do you become distracted from that is not safe. How often have you visited the laundry your current intentions to go to a place or do a job of work? room and seen unsafe conditions? Did you report them? Would you alert someone if you were going to make a change of plan and do something different?

M2234 Situational Awareness – The refrigeration provision plant runs continually throughout the ship’s working life. Its machinery operates periodically in an idle state and can start Fingers amputated in without notice. Working in this area demands a high level of awareness, and work should not be undertaken unless rotating machinery signed off by another supervising senior officer.

Initial Report At about 14:50 hrs LT, the electrician left the engine control M2254 room, went to the electrician’s workshop to leave his tools, and then went for his work break. While passing the refrigerant provision plant, he saw dust in the idle No. 2 electric motor compressor. The ETO Fire – Resin in a container used a rag to clean the motor’s axis and turn the belt. Initial Report Also, dust was found on the No. 1 electric-motor The fire was discovered as the vessel lay anchored off compressor. The No. 1 unit was in “auto” mode, and the a port. Following the activation of the vessel’s fire alarm, motor was stopped then. The ETO used the rag again to assistance from the shore authorities was sought. Fireboats clean the axis, and at that time, the motor started to operate. from the maritime authorities were dispatched. Water The rag got tangled between the motor and the compressor. cannons were employed to engulf the burning deck In an effort to pull out the rag, the electrician’s right container stacks. After several hours, the fire was reported to hand became caught in the motor’s belts. The electrician felt be under control. great pain as three last fingers were partially amputated. The operation involved firefighting in a restricted space The vessel was in port, so the electrician was taken to and resulted in damage to the containers on fire and to hospital, where the last three fingers ( middle, ring, little) adjacent containers. were amputated, about 1/3 of each finger. The injury caused permanent incapacity for employment at sea.

CHIRP Comments The report highlights the importance of maintaining mindfulness in our actions and surroundings, especially when individuals work independently. Despite being aware of the risks involved, the electrician’s decision to conduct unscheduled cleaning resulted in a tragic oversight of essential safety measures. It emphasises the need for a systematic approach, such as Stop, Look, Think, Assess, and Look Again, to ensure thorough assessment and awareness before undertaking tasks. Operating autonomously, ships’ electricians may only sometimes have direct oversight, potentially leading to neglect of vital safety procedures. Therefore, it is crucial to regularly remind the ship’s Electro-Technical Officers Shoreside firefighters assist the crew in tackling the fire. (ETOs) to seek assistance if they deviate from planned work, typically assessed at daily work planning meetings. CHIRP Comments The incident underscores the dangers of machinery CHIRP commends the crew and shore authorities for their operating in automatic mode, which may remain inactive swift action in containing the fire, which posed a significant until triggered by specific signals. Implementing robust safety threat to the vessel. The incident underscores the difficulty of measures like the Tag Out-Lock Out-Try Out (TOLOTO) combating fires in confined spaces like those found on ships. system is essential to address such risks. This system ensures Understanding the contents of containers is crucial for equipment is adequately secured against unintended operation crew safety and vessel integrity. Mis-declared containers, during maintenance or cleaning activities. Additionally, a common issue, can significantly endanger crew lives. In installing protective guards on equipment adds another layer of this case, the containers involved contained resin, which defence against lapses in attention or mindfulness. can be transported in various forms, such as bags, drums, containers, or bulk, and may fall under IMDG Class 3 or 4, Human Factors depending on their state. Teamwork – Considering your last ship, how well did Liquid resins, classified as IMDG Class 3, are highly you communicate with the electrician? Were they provided flammable and can form explosive vapours in the air.

www.chirp.co.uk/maritime MFB 75 | Summer 2024

Some resins may polymerise explosively when exposed The master and crew failed to give adequate attention to heat or fire. to provisioning, a critical aspect of ensuring the vessel’s Both liquid and solid resin spillages can trigger seaworthiness. The amount of food required must be exothermic reactions when they come into contact with assessed based on crew size, trading pattern, and the other substances in the container. It is essential to exercise availability of suitable victualing companies. Neglecting this due diligence with shippers to ensure proper packaging, assessment can result in severe consequences for crew stowing, and labelling of goods. health and morale. CHIRP recommends providing a photograph of the Purchasing expired, or reduced-price food indicates stowed dangerous goods (DG) container before sealing the that the food budget is driven by cost-saving measures doors. This allows the crew to understand the cargo behind rather than prioritising the crew’s well-being. This practice the doors, enhancing their awareness of the challenges in is unacceptable and compromises the safety and welfare of combating fires involving such cargoes. those onboard.

Human factors Human factors Capability 1 – Do your ship and shore staff properly know Capability – The master usually has the responsibility of the IMDG code to understand the risks? Have you been given checking the quality and quantity of food on board. This a training course on transporting dangerous goods by sea? requires close attention to the requirements and working closely with the cook. How well do you manage this job? Capability 2 – Does your ship have the necessary Do you feel your provision budget is too tight to order good firefighting equipment to fight different types of fire in quality food? restricted spaces? Capability – Does the cook on your vessel hold the Communications – How diligently does your company appropriate cooking certificates? Are there regular engage with shippers who ship dangerous goods? refresher cooking courses that can be taken? How varied are your meals? CHIRP recommends providing a Alerting – If you felt that your food quality and quantity photograph of the stowed dangerous were insufficient, would you contact your DPA? goods (DG) container before sealing Culture – Having the right type of food available creates the doors an excellent social atmosphere and is part of good onboard social culture. Please see The Social Integration Matters (SIM) project, which was carried out by The International M2255 Seafarers Welfare Assistance Network (ISWAN).

Shortage of provisions M2246

on board Initial Report Grounding The reporter informed CHIRP that a bulk carrier crew Initial Report was out of food. When some crew members visited the A reporter recounted an incident to CHIRP involving seaman’s mission, they received expired food supplies a grounding that resulted in the loss of jobs for the from a local supermarket at a reduced cost to the crew. reporter and another officer. The incident caused minor The reporter indicated that the crew was starving as no damage to the vessel’s hull bottom but no physical provisions were on board. injuries. Contributing factors were distractions and The report requested that CHIRP intervene and inform poor preparation. the authorities to check the food status on board. On the day of departure, the master was preoccupied CHIRP contacted the Port State Control, and an with obtaining a crew visa and addressing engineering investigation was carried out. problems. Due to the visa requirements, the vessel was already a few days late setting sail for the 10-day passage CHIRP Comments to return to its home port. Despite these challenges, the All Flag States mandate a minimum requirement for crew daily passage plan was completed by mid-afternoon. However, food provisions, which must be reflected in the company’s a critical issue arose with the primary ECDIS system, budget. This includes allocating a reserve allowance for displaying incorrect charts for the planned route. Despite essential provisions when there may be uncertainty in the this, the decision was made to depart using information vessel’s port rotation and access to good providers. from other sources, including paper charts and a secondary The provision of poor-quality, inexpensive food not only ECDIS display, and knowing there would be a pilot onboard. leads to higher wastage but also poses long-term health During the vessel’s unmooring, the pilot’s apparent risks to the crew, including increased rates of diabetes, distraction with their phone hindered communication and obesity, and heart problems. Running out of food for the coordination. Despite the very brief master pilot exchange crew is totally unacceptable and should only occur in for the outbound passage, there appeared to be no overall exceptional circumstances. control over the vessel’s navigation. Concerning the pilot’s

action, there was a