Corrective and preventative actions
A cargo vessel berthed during the evening and began discharging steel cargo alongside a wharf. According to the discharging plan, it was intended to discharge cargo from hold nos. 2, 4 and 6 initially. During this sequence, sea water ballast was to be pumped into Nos. 1, 4 and 6 (port and starboard) wing tanks. At times, due to the uneven distribution of cargo in the holds, the vessel took a list to one side, and the ballast tank valves were appropriately controlled to keep the ship close to upright.
Soon after midnight, the valves of Nos 1 and 4 wing tanks were shut and ballasting of No 6 wing tanks commenced. Tank soundings were not monitored during the ballasting operations, and the quantity of sea water in the tanks was not estimated either. At about 0130 hrs, a ‘440 V Insulation Fail’ alarm activated at No. 1 deck crane power distribution panel on the main switchboard. The power cables to the deck cranes passed through the port side passageway. Suspecting moisture in the junction boxes, the electrician opened the access to the passageway, and was shocked to find that it was flooded with ballast water
. Portable pumps were used to discharge this water. When the space was sufficiently dry by early afternoon, it was observed that No. 1 P wing tank manhole cover had not been closed, and water was continuing to pour out into the passageway. The tank was deballasted to bring the water level below the manhole opening and the lid was secured tightly. After the electrical junction boxes in the passageway had been cleaned and dried, the insulation readings returned to normal and power supply was restored to the deck machinery. During a precautionary check, it was noticed that two more wing tank manholes were open and these were properly secured.
Investigations revealed that after internal inspection by the Chief Officer on the previous day, the fitter who was assigned the task of securing the manhole lids had forgotten to carry out the work. The Chief Officer had also failed to verify that the job had been properly completed.
Root cause/contributory factors
1. Failure to follow basic seamanship in securing tank lids after completion of inspection;
2. Failure to closely monitor progress of ballasting operations and tank soundings;
3. Inadequate work planning and execution;
4. Defective high level bilge alarm in the passageway (fault known to crew);
5. No risk assessment carried out and appropriate control measures not taken;
6. Inadequate leadership and supervision;
7. Inadequate maintenance.
Corrective and preventative actions
1. A Safety Meeting was immediately held by the attending superintendent and the serious lapses and failures on the part of the crew were discussed;
2. Instructions issued to ship’s staff to ensure careful planning and continuous monitoring and recording of all ballasting operations, including regular appraisal of quantities in each tank based on tank and pump capacities.
Editor’s note: This incident is of concern on many counts, and points to possible serious deficiencies in the safety management system (SMS), operational and maintenance procedures and crew’s observance of basic seamanship. Where such bilge wells are fitted, the onboard procedures and planned maintenance systems (PMS) should incorporate the regular testing and recording of the functioning of the bilge alarm andthe draining/pumping arrangements and also ensure a reasonable stock of spare parts.
Source: Mars/Nautical Institute
