An independent and confidential Issue 76

MARITIME FEEDBACK reporting system for the Maritime industry Autumn 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.

Arrogance, or Ignorance? they see an unsafe situation developing, but it is Adam Parnell apparent that there are still many companies where Director (Maritime) a robust safety culture is lacking. We feel honoured that people in such situations contact CHIRP Maritime when they feel unable to deal with situations through their own organisation, and we continue to support

T his edition of Maritime FEEDBACK contains a wide variety of interesting and often alarming reports, and we are extremely grateful to our reporters for them to the best of our ability, without ever revealing their identities. Fortunately, this edition also contains reports sharing them with us. on how good teamwork averted a potential disaster We begin with an account of a company Head of and how crew members felt empowered to stop Safety who led potential purchasers into an enclosed work and call a safety meeting when they saw an space without taking any precautions, and we ask unsafe situation developing. We applaud everyone whether this was arrogance or ignorance. We define involved in those cases, which contrast sharply arrogance as a result of people underestimating risk with another ship where the crew were unpaid and and overestimating their own abilities. inadequately provisioned. Arrogance may also have been present in reports Our final report concerns a senior officer who about a master who ignored contractual requirements was repeatedly observed to be asleep on watch. during a dynamic positioning incident despite the DPA We suspect this was a severe case of fatigue, and advising against his actions and another master who if one officer was suffering, then it is highly likely opted to sail from a port despite a warning from the pilot. others were also affected. If the company ran other Another worrying trend which emerges is that ships with similar manning on similar routes then the so many reporters did not feel comfortable reporting problem could be widespread. We hope the relevant to their managers or senior officers, and came to us authorities will take action and crack down hard if our instead. The best companies strive for kind leadership suspicions prove to be accurate because mariners and a just culture which ensures that all crew deserve better. members feel empowered to speak up whenever 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 76 | Autumn 2024

M2276 Factors related to this report Communication – In this case, actions speak louder

Unauthorized entry into an than words. The manager’s actions destroyed any safety messaging the company may have communicated to its fleet.

enclosed space Local practices – An enclosed space entry operation requires a significant number of crew members to be in Initial report attendance. Make sure that everyone knows that enclosed The company’s Head of Safety was conducting a tour of a space entry is taking place. The permit to work must be vessel which had been laid up for over a year, accompanied distributed to all parts of the ship: the bridge, engine room, by potential purchasers. They were witnessed opening and the master, and the entrance to the enclosed space. Is this entering a void space, which was correctly labelled as an what happens on your ship? How well are enclosed space enclosed space, despite not having a permit to work to do entry work activities communicated? so. They were not carrying an atmospheric gas analyser. They had not completed pre-entry activities, e.g., venting Alerting – If you see a safety breach, even by a senior the compartment, having crew and emergency equipment manager, speak up! It is better that they are embarrassed standing by, and an enclosed space entry checklist than dead! thoroughly completed and signed off by the master. The reporters approached CHIRP about this matter because Pressure – Be aware that real or perceived pressure can any report raised through their company system would lead anyone to deviate from procedures if they think it will have gone directly to the Head of Safety, and they feared save them time. If you feel under pressure, pause for a reprisals. They did not speak up at the time because they did moment, and re-evaluate the risks. If you see others taking not want to embarrass a senior company member. shortcuts, call it out.

Complacency (under-estimation of risk) – Enclosed spaces can be lethal if incorrectly entered.

Culture – Managers’ actions set the tone and standard of a company’s safety culture. In this incident, the reporter did not feel safe raising this issue through the company’s reporting system. CHIRP exists to capture these reports and advocate for improved safety while protecting the reporter’s identity.

M2258

Incorrect enclosed space entry can be lethal (Stock image for illustrative purposes only) Good teamwork averts a serious incident CHIRP Comments Initial report Entering an enclosed space without completing the pre- Two pilots boarded an LNG carrier before making an entry activities is exceptionally hazardous. Last year, 16 approach along a fairway to an offshore LNG terminal. The seafarers were killed because they entered enclosed spaces weather was rough, with a long swell. Four tugs were made where the air was not breathable. fast before proceeding at approximately 5kts. Even if the Head of Safety did not have a seagoing As the chief pilot prepared to make a planned alteration maritime background, they ought to have been aware of course, both engines of the tug attached to the centre of these hazards and the safety protocols that should lead forward failed within minutes of each other, and the be followed. tug was overtaken and pulled hard against the LNG carrier’s We will not speculate on the reasons that led to this bow by the towing line. specific incident, but people generally deviate from safety Because of the risk of damaging or capsizing the tug, protocols for one of several reasons. One is that they the chief pilot could not conduct the planned turn while the underestimate or are unaware of the risks or overestimate stalled tug was still attached, but through a combination of their abilities (arrogance). Another is that they feel (real or good bridge teamwork and skilful control of the remaining imagined) pressure to complete a task quickly or without the three tugs, the LNG vessel was slowly manoeuvred right resources (lack of time or equipment). alongside without further incident. Officers and managers have a special responsibility Throughout the incident, the co-pilot liaised with the to lead by example in safety. They set the standards for a stalled tug for regular updates and with two standby tugs company’s safety culture. in the vicinity, directing one to assist the disabled tug in When CHIRP contacted the company, they immediately detaching its towing line and pulling it to safety. At the same understood the seriousness of the incident and responded time, the second tug assisted in manoeuvring the LNG vessel. immediately to ensure that it could not happen again. The pilots also provided regular updates to the port authority.

A combination of the sea state and the tug’s ballast Factors related to this report arrangement was found to have caused the sea chest to Situational Awareness – Tug crews should be alert to the become starved of cooling water for the generators, which changing dynamics operating on the tug hull, especially were automatically shut down to preserve the equipment. in open waters. A simple checklist for the type of towing arrangement would ensure an adequate draft for all tow CHIRP Comment stages, and that equipment is correctly configured. CHIRP is aware of 3 similar tug events published in 2024, and readers may be aware of the case in 2019 in which a Teamwork – The pilots and the bridge team worked large passenger ship lost propulsion and nearly foundered excellently to manage the situation, highlighting the effect of because the ship’s motion in rough weather caused the oil adequate resources and training. pressure to drop, shutting down the engines. In Bow Tug Operations, a manual by Henk Hensen, he Alerting – From a technical perspective, there appeared to writes, “Bow tug operations of a ship having headway are be insufficient warning concerning the generators shutting very risky.” The International Harbour Masters Association down. Temperatures would have risen quickly once the recommends a 6-knot speed limit for such operations. cooling water could not reach the generators. Tugs sometimes undertake bow-to-bow (reverse) towing because it keeps their propellors further away from Design – Given the nature of towing operations and the the pressure fields around the towed vessel’s bow. This increasing use of ASD tugs in narrow channels, towing method also ensures that if the tug propulsion fails (as in this from the bow has considerable benefits concerning incident), it is pulled alongside the towed vessel by its bow, performance and girting safety. The change in trim that which reduces the risk of capsizing. results if ballast is not correctly applied needs to be However, when reverse-towing (as in this incident), factored into design considerations. there is a risk that the tug becomes trimmed by the bow, lifting the stern (and sea-chest water intake) out of the water and starving the sea chest of cooling water to the M2286 generators. This risk is lessened by towing more slowly, adjusting the vessel’s trim, and ensuring that the sea chest vents are open so that any air trapped inside can be expelled to allow it to re-fill. OOW asleep on watch! The automatic shut-down system protects the Initial report equipment from overheating and being damaged or CHIRP received a report about an officer who regularly even catching fire. However, many systems do not have slept on the bridge during solo morning watches (0400- a manual override for use in emergencies. Tug vessel 0800) and relied on automated navigational alarms. Several operators are advised to investigate how their equipment crewmembers witnessed this behaviour over the course of would react in a similar scenario, whether it would alert a week. the operators before shutting down, and then develop emergency procedures accordingly. A checklist that CHIRP Comments includes the operating area (open water, sheltered water), Sleeping while on a watch is a severe breach of the draft and trim, ballast arrangement, and type of towing international collision regulations, and CHIRP contacted the for the job will ensure that the risks of a blackout vessel’s Flag State, which is investigating. are mitigated. Normally, no officer deliberately sleeps on a watch, This incident was successfully mitigated without injury especially a solo watch. In many cases, the onset of fatigue or damage because of the close integration of the pilots, creates this desire to close one’s eyes on watch and go effective bridge team management, and close coordination into a deep sleep. CHIRP suspects that the individual is between the vessels and port authority. Everyone suffering from exhaustion to the point that their judgement understood their role and responsibilities, and information is impaired, causing them to take unacceptable risks during exchanges were clear and effective. The speed of response their bridge watches. of all parties demonstrated their readiness to respond to an CHIRP questions what working practices are taking unplanned incident. place on the vessel operating without a dedicated lookout to create such a state of tiredness. Or is the officer deliberately ignoring their safety responsibilities and breaking the rules? Either way, the safety of the ship is severely compromised.

Factors related to this report Fatigue – The incident report highlights the officer’s lack of concern about the severe lapse in navigational safety. Clearly, the officer is suffering from sleep deprivation and has reduced mental capability and decision-making. Fatigue kills: the company must take steps to manage it.

Alerting – CHIRP was alerted to the issue, but why was the master not alerted? This serious safety situation affects Figure 1: Likely response of a tug to engine failure everyone on board - speak up or contact CHIRP. The officer

www.chirp.co.uk/maritime MFB 76 | Autumn 2024

should be able to speak with the master and inform them Another crew member stopped work, and a safety of their fatigued state. This may likely apply to other officers meeting was convened to remind the crew members about and crew on the same ship. the hazards and to wear hard hats.

Culture – There appears to be a very poor safety culture CHIRP Comments on the ship, which may be reflected within the company. The rotating tail shaft poses a lethal entrapment or Does anyone care about safety? This issue would not have snagging hazard, even if wire guards are present. Better happened if the company operated a just culture and senior planning would have eliminated this hazard by ensuring officers demonstrated kind leadership. that maintenance was only carried out when the shaft was stopped, i.e., in port. However, for commercial reasons, Teamwork – Good teamwork by the officers and crew can there is a move across the industry to conduct as much assist everyone in challenging, unsafe situations. Looking maintenance at sea as possible to reduce time spent out for each other and feeling confident about reporting alongside. Engineers are already fully tasked with other roles personal well-being issues is a sign of good teamwork. This when in port. takes time to achieve and is driven by a good company Was this incident the unintended consequence of a safety culture. management decision? CHIRP applauds the crewmember who alerted others to the danger and stopped the work from progressing until M2267 a safety briefing was held. We encourage all companies to empower their crews with similar ‘Stop Work’ authority when safety is in doubt. Rotating shafts create a Factors related to this report lethal hazard Alerting and Teamwork – Both were demonstrated in this incident: alerting others to the danger and calling a halt on Initial report safety grounds is good teamwork. While on passage, the crew was tasked to clean and paint the engine room tank top. One crewmember was seen Situational Awareness – Consider all aspects of the working near the vicinity of the tail shaft and narrowly work, including your proximity to hazards, and consider avoided hitting their head on the revolving shaft. the consequences.

Befrienders Worldwide (BW) is an The people who run the centres Befrienders Worldwide has a emotional support charity whose – Befrienders – are volunteers who dedicated seafarers’ page recognising mission is global suicide prevention. have all been specially trained. The the emotional challenges seafarers BW has operated for 50 years work is non-political and non-religious; face while working at sea. and has over 400 centres in volunteers do not try to impose their 48 countries. convictions on anyone. They listen. Please look at the website. The main aim of the centres is to Contact with a centre can be by www.befriender.org give confidential emotional support telephone, letter, email, internet chat, to people when they are suicidal. SMS text message, or face-to-face If you need to contact a dedicated The centres also alleviate misery, meeting. It is strictly confidential, as seafarers’ centre, please click on the loneliness, despair and depression by is everything that the person tells link: https://befriender.org/befrienders- listening to anyone who feels they a Befriender. Some callers prefer to worldwide-seafarers/ which will take have nowhere else to turn. remain anonymous, and that’s fine. you to the seafarers’ page. Thank you.

M2266 Satellite System (DGNSS) and either a laser or microwave system capable of ‘Follow Target’ functionality. These

Rationed food systems are essential for FPSO operations. They ensure that a specified distance is maintained between the vessel and the FPSO and adjust the angle between their longitudinal Initial report axes to match any horizontal rotation of the FPSO. A vessel was provisioned with a month’s supplies for a two- Under pressure from the client’s schedule, the master month passage and planned anchorage, and the crew was proceeded with the operation despite his vessel not having instructed to ration its provisions. Since they had not been the required ‘Follow Target’ function. This decision led to paid for three months, they could not purchase additional potentially unsafe conditions, requiring the crew to manually provisions, so they approached CHIRP for assistance. adjust the vessel’s position against visual references for a 12-hour fuel oil transfer. The Designated Person Ashore CHIRP Comments (DPA) cautioned against operating under such precarious The shore management company claimed they did not circumstances, but the master continued anyway. The have enough money to provide sufficient provisions. CHIRP crew realised safety was being compromised to meet client contacted the vessel’s Flag State, which immediately demands and reported