NTSB: Safer Seas Digest 2021

Safer Seas Digest 2021 detailed the lessons learned from 31 maritime tragedies involving capsizings, contact, collisions, fires, flooding and groundings.

Among the investigations included in the report are the sinking of Scandies Rose, where five lives were lost, and the capsizing of Golden Ray, one of the most expensive marine accidents in history.

Lessons Learned

#1 Vessel Stability

A vessel’s stability instructions must be accurate, and the crew must use the instructions correctly when determining stability to ensure a vessel is loaded such that it meets the stability criteria intended by the vessel designers and approved by regulators.

#2 Containing Engine Room Fires

Engine rooms contain multiple fuel sources and are especially vulnerable to rapidly spreading fires. Following the initiation of an engine room fire, it is imperative to remove the source(s) of available fuel to a fire. Designers and operators should evaluate fire hazards and provide effective means to mitigate them. Vessel owners should encourage crews to familiarize themselves and train frequently on machinery, fuel oil, lube oil, and engine room ventilation shutoff systems.

#3 Icing and Severe Weather

Marine operating companies should develop and continuously evaluate severe weather plans to prepare for challenges accompanied by severe weather, and mariners should take caution when operating in conditions where sea spray icing can occur.

#4 Risk Management and Project Planning

A formal risk assessment, which involves identifying hazards and estimating the risk they pose, is a critical component of casualty prevention. By considering the likelihood and severity of each risk, risk matrices increase the visibility of risks and help managers select controls commensurate with the risk level. With such information, a hazard control plan can be developed and implemented.

#5 Cargo Preparation and Securement

It is important for cargo planners to have tools and procedures, such as stow plans, calculations, and preparation instruction, to assist with determining proper stowage and the sufficiency of securing arrangements for cargo loaded aboard vessels. These tools and procedures must consider the type of cargo and the design of the vessel, as well as the potential hazards presented by the cargo.  Operators must ensure that these procedures are followed during the loading of the vessels.

#6 Teamwork

Safe and effective operations are not one person’s job. Teamwork is an essential defense against human error, and a good team should anticipate dangerous situations and recognize the development of an error chain. If in doubt, team members should speak up or notify a higher authority. Sharing information among crew, pilots, and facility operators and providing a thorough turnover are also critical components of effective teamwork.

#7 Effective Communication

Early and effective communication is critical to avoiding close-quarters situations. The use of VHF radio can help dispel assumptions and provide bridge teams and vessel operators with the necessary information to adequately assess other vessels’ intentions. In situations where a casualty cannot be avoided, early and effective communication can mitigate the effects, reducing damage, injuries, or loss of life

#8 Standard Operating Procedures

Safety of vessel operations and compliance with mandatory rules and regulations can be achieved, in part, by establishing clear standard operating and emergency procedures. In conjunction, regularly training crews and personnel involved in operations in standard operating procedures can prepare for and mitigate the risk of emergency situations.

#9 Transiting in Narrow Channels

Narrow channels can be particularly challenging to navigate due to the hydrodynamic effects on a vessel and the substantial amount of traffic in the waterway. Larger, deeper draft vessels are even more prone to the hydrodynamic forces created by the channel banks and passing vessels. Transiting a narrow channel, like the Houston Ship Channel, at sea speed, in which the vessel is at or near its maximum speed while the engine is less responsive, provides little room for error and should be avoided.

#10 Distress Communications and Preparations for Abandonment

A successful emergency response is contingent on early distress notification and clear, effective communication. Additionally, preparing to abandon ship by donning survival suits or personal flotation devices increases the likelihood of survival when experiencing significant flooding, fire, or other emergencies.

#11 Identifying Navigational Hazards

Situational awareness demands a mariner should be alert for new hazards that can appear along their intended route. It is important to check the Coast Pilot and navigational charts when developing voyage plans to improve knowledge of an area and prepare for a safe passage.

#12 AIS Data Input for Towing Operations

To enhance others’ situational awareness and alleviate possible misinterpretation, the combined dimensions of a vessel and its tow, reflecting the overall area covered by the tow, should be entered into AIS and broadcasted while under way.

#13 Continuous Monitoring of Unmanned Vessels

Fire and flooding are risks not only for crewed vessels, but those unattended as well. To protect personnel, property, and the environment, it is good marine practice for owners, operators, and shipyard managers to coordinate and implement some form of continuous monitoring for vessels undergoing maintenance in a shipyard, in lay-up, or in some other inactive period without regular crews aboard. Continuous monitoring can consist of scheduled security rounds and/or active monitoring with sensing and alarm systems.

#14 Sufficient Handover Period

Fatigue is a longstanding issue that continues to adversely affect the safety of marine operations. Failing to get adequate sleep is a high-risk practice that leads to casualties. When joining vessels, crewmembers must often travel long distances, including internationally, and may have little time for rest. It is critical that vessel operating companies ensure that joining crewmembers have the opportunity to obtain adequate rest and allow for a sufficient handover period before they take over critical shipboard duties.

EXPLORE MORE AT ntsb’S safer seas digest 2021