Tag: lessons learned

Experience feedback A deep draught tanker arrived at a port to discharge her oil cargo and temporarily anchored in the exposed roadstead in order to await her turn. Expecting to berth the followingday, the Master paid out a scope of 6 shackles of chain on the port anchor in gale conditions. The next morning, the weather was unchanged and the vessel received instructions to proceed to the pilot boarding ground to embark pilot. The engine was readied and the vessel began weighing anchor.When 4 shackles had been heaved in, the windlass hydraulic motor suddenly failed and the entire 11 shackles of chain ran out at such speed that the brake was damaged as the crew tried desperately to check the cable. Fortunately, there was no injury and the bitter end securing of the cable in the chain locker did not part. Ship's staff temporarily exchanged the damaged port windlass hydraulic motor with the operational starboard unit, and after a short delay, the ship weighed anchor and proceeded to her designated berth. The managers arranged for a classification society surveyor to attend the ship at berth and survey the damage, after which a condition of class was imposed.Root cause/contributory factors1. Lack ...

Root cause/contributory factors An offshore installation was undergoing major refit works at a repair yard. There were a large number of sub-contractors working at many locations, including fitting a new detachable electrical power supply system to the temporary living quarters (TLQ).However, when it was observed that there was no power supply, the ship's electrician was asked to investigate. He saw that the main power supply lead cable, terminating at a 4-pin-male plug, was disconnected from the socket/isolator.Without ascertaining that the terminals were not live, he grabbed the plug in an attempt to push it into the female socket and immediately received a 440 Volt electric shock, sustaining an electric burn on the left middle finger and an abrasion on the right palm. He was attended to by medical personnel onboard the vessel and an ECG (electrocardiograph) was recorded. He was admitted to hospital for 24 hours and subsequently placed on light duties for a few days.Root cause/contributory factors1. The TLQ's wiring system was fitted with female sockets which resulted in the extension supply lead cable having live male ends; 2. The 440 Volt power supply was not isolated from the main switchboard prior to the re-connection attempt. 3. The importance ...

Experience Feedback Just after sunset on a calm evening, a large inbound container ship was approaching the pilot boarding position about a mile NE of the harbour's breakwater entrance. As the pilot was to transfer from an outbound coastal tanker, he instructed the container ship to move to the starboard side (west) of the recommended track to avoid the tanker and maintain minimum speed, which, for this vessel was 7 knots.As soon as the tanker had exited the breakwater, the pilot's launch transferred him to the container ship. This operation lasted nearly eight minutes, by which time the vessel was very close to the breakwater and nearly parallel with it.Immediately on reaching the bridge, the pilot realised the unfavourable situation but instead of consulting the master or aborting the approach, he ordered half ahead and hard-astarboard, with the intention of steering the ship around the breakwater head. The intended track now involved a very sharp starboard turn of almost 130º at minimum steerage way, keeping close to the breakwater head.The bridge team did not appreciate that this manoeuvre was beyond the ship's turning ability. The bridge team's vision was blinded by the bright city lights to the south, which were ...

Corrective/preventative action The crew had only recently taken delivery of a very modern anchor handling, towing and supply ship (AHTS). The hydraulic power pack unit on this vessel, comprising five electric motor-driven hydraulic pumps that powered the windlass and multiple winches, was equipped with a touch screen control panel located on the navigating bridge. A notice pasted on top of the panel stated 'For windlass or tugger winches, use No 3 or No 4 pump'.The deck officer was instructed by the Master to start the pumps for the windlass in preparation for anchoring. After reading the notice on the panel, the officer duly started only pump no. 3. In view of the charted and measured depth in excess of 40 metres below the keel, the Master decided to walk out the anchor under power to 6 shackles.As the 4th shackle was passing through the hawse pipe, with the ship making slight sternway, the cable suddenly began to run freely, despite the dog clutch being fully engaged and the windlass control lever being held in the full hoist position.Fortunately, the crew quickly tightened the brake and the cable, which had run out to 8 shackles, was checked and prevented from running ...

Corrective and preventative actions A deep draught tanker arrived at a port to discharge her oil cargo and temporarily anchored in the exposed roadstead in order to await her turn. Expecting to berth the following day, the Master paid out a scope of 6 shackles of chain on the port anchor in gale conditions. The next morning, the weather was unchanged and the vessel received instructions to proceed to the pilot boarding ground to embark pilot. The engine was readied and the vessel began weighing anchor.When 4 shackles had been heaved in, the windlass hydraulic motor suddenly failed and the entire 11 shackles of chain ran out at such speed that the brake was damaged as the crew tried desperately to check the cable. Fortunately, there was no injury and the bitter end securing of the cable in the chain locker did not part. Ship's staff temporarily exchanged the damaged port windlass hydraulic motor with the operational starboard unit, and after a short delay, the ship weighed anchor and proceeded to her designated berth. The managers arranged for a classification society surveyor to attend the ship at berth and survey the damage, after which a condition of class was imposed.Root ...

Resulting in the breaching of five of her ballast tanks - experience feedback A large container ship was on a coastal passage in the South China Sea, an area well known for dense concentrations of fishing vessels. In the evening, in order to adjust the ETA at the destination port the following morning, the Master decided to stop and drift for an hour in open water before resuming passage at full speed.When the chief officer came on watch at 0400, accompanied by a lookout, he reviewed the charts to be used and noted the potential danger areas, including an isolated, unmarked reef, and highlighted it on the paper chart.The planned track avoided the reef by means of two sharp course alterations. By 0600, about an hour before these waypoints, a large concentration of randomly-moving fishing vessels was encountered, causing the chief officer to make a number of course alterations over the next hour.By this time, the vessel was approaching the most navigationally constrained part of the passage, in the vicinity of the off-lying islands and reef. The ship was making 21 knots and she was well off her intended track.The vessel's position had been plotted only twice between 0600 and ...

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 ...

Corrective and preventative actions A crewmember engaged in fabrication work went to the pipe storage rack to select and remove a length of pipe. Having selected the pipe, he grabbed it by the partially projecting end and pulled with all his strength. As it was held in place between other pipes in the rack by compressive and frictional forces, his initial effort failed to dislodge it.In a fresh attempt to move the pipe, the crewmember pulled on it with a violent jerk, causing the pipe to suddenly slide out freely. The worker lost his balance and fell backwards, hitting his back on the bulkhead behind him, resulting in a contusion injury.Root cause/contributory factors1. Lack of proper risk assessment and work planning;2. Failure to seek assistance from co-worker when in difficulty.Corrective/preventative actionsIncident report circulated to all vessels in the fleet with instructions to:1. Discuss the incident at their next safety meeting and refer to Section 3 Chapter 19.4 of The Code of Safe Working Practice (COSWP) - Manual Handling - Advice to seafarers;2. Carefully assess any load that is to be lifted or moved and plan for the best way to apply the effort;3. Request assistance from other crew in case ...

Corrective and preventative action In preparation for arrival in port, two seamen were assigned to bring out mooring ropes from the forward rope store and coil them on the forecastle deck. The OS was operating the windlass/mooring winch control lever, which was at about chest-level for a person of average height, and the AB was handling the rope on the warping barrel, situated about 4 metres outboard.Presumably in order to adopt a more ergonomically efficient stance for holding the control lever in its operating position, the OS placed his right foot on a welded pad eye on the supporting bracket for winch shaft bearing. Inadvertently, he pushed his foot into the gap between this bracket and the circumferential guard of the main driven gear wheel and into the path of the rotating spokes. Instantly, his foot was trapped and crushed. He was given first aid and was hospitalised soon after arrival in port the following day.Lessons learnt 1. While operating the mooring winch/windlass, the operator must concentrate on what he is doing and must not be distracted;2. A winch operator must stand only on the designated area for a safe and effective operating position;3. All body parts (hands, feet, etc.) ...

When Water Ballast Tank was discharged, an oily sheen was observed on the sea surface A double-hulled oil tanker with segregated ballast tanks (SBT) was standing by off-limits at a loading port in good weather. In accordance with the pre-arrival schedule and loading plan, extra ballast was being pumped out. When 2S Water Ballast Tank (WBT) was discharged, an oily sheen was observed on the sea surface. Deballasting was immediately stopped and investigations detected an oil layer (innage) of about 15 cm on top of the ballast water in the tank.Shore management was informed, the oily mixture from tank 2S WBT was skimmed off with a portable salvage pump and transferred to 3S cargo oil tank (COT) and from there, to the slop tank. Thereafter, No. 2S WBT was superficially washed and gas freed to make the tank safe for human entry. After complying with all safety procedures, the inspection team entered the tank.They discovered that during the previous loaded voyage, oil from the adjacent cargo tank had leaked into the ballast tank through a crack on a weld seam approximately 3.5 metres below the deckhead, at the intersection of the longitudinal bulkhead and first stringer flat.Corrective actions1. With approval ...