Tag: lessons learned

MAIB- Safety Digest 1/2012 MAIB issues Safety Digest 1/2012 regarding Lessons from Marine Accident Reports.This Safety Digest draws the attention of the marine community to some of the lessons arising from investigations into recent accidents and incidents. It contains information which has been determined up to the time of issue.This information is published to inform the shipping and fishing industries, the pleasure craft community and the public of the general circumstances of marine accidents and to draw out the lessons to be learned. The sole purpose of the Safety Digest is to prevent similar accidents happening again.The content must necessarily be regarded as tentative and subject to alteration or correction if additional evidence becomes available. The articles do not assign fault or blame nor do they determine liability. The lessons often extend beyond the events of the incidents themselves to ensure the maximum value can be achieved.You may view MAIB- Safety Digest 1/2012 by clicking hereSource: MAIB

Experience Feedback While loading at a terminal, the ship listed heavily to port during shifting of ballast. She finally became stable at about 16 degrees list whilst touching the bottom. At the time of the accident, the ship was approximately at even keel with a draft of about 9m. The owner's office and DNV ERS (Emergency Response Service) were immediately informed of the situation by the Master. They communicated by telephone whilst stability and strength calculations were carried out. Ballast was carefully shifted to starboard and after about five hours, the ship was reported to be back in an upright position.Extent of damageThere was no damage to the hull but cargo operations had to be stopped for a few hours. Fortunately, no cargo hoses were connected to the terminal at the time of the accident, otherwise they would have been damaged and might have resulted in pollution.Probable CauseThe ship is a double hull tanker. The cargo tanks are built without longitudinal centre line bulkhead and the wing ballast tanks are "L" shaped. Partially filled cargo tanks with no longitudinal bulkheads may cause large free surface effects to the extent that the initial metacentric height (GM) becomes negative. This creates initial ...

Experience Feedback In a recent case an entered vessel pressed up its ballast tanks in order to optimise trim and to satisfy mandatory stability criteria. The operation resulted in the unexpected flooding of a cargo hold causing extensive damage to cargo. An entered containership was carrying out ballast exchange operations mid voyage and pressed up one set of double bottom ballast tanks. On arrival it was observed that one of her holds had significant water inside and considerable damage to bottom stow cargo.The vessel had recently opened up several manhole covers for routine inspection of her ballast tanks.After the incident it was noted that the high level bilge alarms in the hold were not functioning.Whilst investigations are still continuing into this particular case it maybe timely to remind Members that poorly secured manhole covers are still a frequent cause of water ingress into holds, many, but not all, arising after drydocking where shore staff have not secured covers properly.If double bottom manhole covers are removed for whatever purpose it is recommended a note be made of where and when, this not only acts as an aide memoire but also helps in defending claims should water ingress occur Good maintenance should ...

Experience Feedback An offshore support vessel sailed from her shore base on a routine supply run to her designated oilfield. Her deck was loaded with a variety of tubing, casings, pallets, tool boxes, food containers and one large unpacked wooden cable reel, weighing about 11 tonnes. The reel was stowed with its axis fore-and-aft and was pre-slung with an extralong 12 mm steel wire sling passed through the very narrow central hole, which precluded threading any other securing rope or chain through the coil.The sling was unsuitable for securing, so the ship's crew secured the reel by pushing wooden wedges under it and tightening a chain around its girth. Additionally, the vessel's tugger wire was tensioned at the reel's mid-height. Soon after sailing, the ship rolled and pitched heavily in a gale, and the accelerations imposed large forces on the lashings. Suddenly, a link in the chain parted and the tugger wire instantly became slack. Subsequent movements displaced the wedges and the bridge watch observed the reel moving freely on the deck.The Master was called, speed reduced to minimum and heading altered into the sea and swell. With the ship now pitching gently, the crew managed to throw some square ...

It is not that simple anymore Until recently, a carrier could place heavy reliance on the "on deck cargo" exclusion clauses contained in the contracts of carriage. Quite justifiably, so one might say, bearing in mind that there has been a long chain of case law (The Danah, The Imvros, The Darya Tara) upholding the position that a carrier would be adequately sheltered in case of deck cargo lost overboard, as long as an exemption clause was in place in the bill of lading.The wind started to change after The Imvros which was a case heavily criticised in an article by Simon Baughen, Scholar, Reader at the University of Bristol, in 2000. This was a case of cargo loaded, stowed and lashed by the crew acting as servants of the charterers, who were responsible for loading, stowage and lashing under an un-amended NYPE clause 8. The Panel of Arbitrators found that the effective cause of the loss was the insufficiency of lashings which rendered the vessel unseaworthy. It weighted heavily on the mind of the Tribunal that it was charterers who were the ones contractually responsible for lashing, and hence owners won the argument. Charterers appealed on the basis that ...

Experience Feedback In heavy weather, in the course of routine rounds in his watch, the 4/E noticed that steel plates stowed in a storage rack against a bulkhead were inadequately secured and were beginning to move. Without considering the hazards or informing the senior watchkeeping engineer (2/E), he decided to re-stow the plates and re-secure the rack unassisted. During this process, the vessel suddenly rolled heavily.The plates toppled, trapping and crushing the 4/E's left leg. The 2/E, who was in the workshop at the time, heard the noise of the falling plates and a cry from the trapped 4/E. He immediately rushed to the location and sounded the emergency alarm. The Emergency Team assembled and rescued the 4/E, who was immediately given first aid. Due to the serious injury, and under radio medical advice, the vessel deviated to the nearest port, from where the injured crewmember was flown to Singapore in an air ambulance, for further medical treatment to his broken leg.Root cause/contributory factors1. Failure to inform other personnel of a hazardous situation and failure to seek assistance;2. Lack of experience and awareness - the young 4/E did not understand the risks in attempting to re-stow and re-secure the steel ...

Experience Feedback An offshore support vessel planned a routine launch of the rescue boat whilst at sea. A risk assessment was conducted and a permit to work was issued. The 2/O then left the bridge to brief the deck launching team (ABs 1& 2), and the boat's crew (deck cadets 1 & 2) on the procedures. The conditions were ideal with a light breeze, near-calm sea state and no traffic. Prior to launching, the 2/O held a toolbox meeting, reviewed the procedures and completed all pre-launch checks. It was visually confirmed that the painter was secure and that the painter release mechanism was locked.However, the outboard motor was not started prior to launching, as it had been been tested on muffs (a portable cooling water connection) the previous day. The 2/O gave clear instructions to deck cadet 2 that he was to stand by the painter and operate the release only after the engine was started in the water and the fall wire was unhooked. The vessel was on autopilot on a steady course of about 2.5 knots, and after ensuring a good lee, the Master ordered the boat to be launched. However, as the boat entered the water, the ...

Experience Feedback Two aframax tankers had just completed an offshore shipto- ship (STS) transfer of diesel oil. As the last lines were slipped, the quarters of the two vessels began to close. In order to check this movement, the STS superintendent on board the designated manoeuvring vessel (on the right hand side) ordered dead slow ahead and 10 port rudder. However, the vessel's diesel engine failed to start.This information was relayed to the superintendent after a slight delay, by which time he had ordered slow ahead and a larger port rudder angle. He immediately broadcast a hurried and incomplete VHF safety warning but did not sound an alarm on the whistle, so the other tanker was not aware of the emergency.As the manoeuvring vessel's bow began to swing very slowly to port towards the other vessel, the superintendent ordered slow astern. This time, the engine started and the superintendent immediately ordered full astern followed by a series of engine and helm orders given in rapid succession. Seconds later, the manoeuvring vessel's port anchor struck the starboard lifeboat on the other vessel. It was later established that the engine failed to start due to a dirty air start pilot valve that ...

Experience Feedback A team of seamen was transporting a newly-supplied garbage compactor from the upper deck to a higher deck aft of the galley area. When changing the lifting arrangement from above the work area, they requested assistance from a passing crewmember, who was not part of the assigned work team. As he approached the work area, a shackle was accidentally dropped from above, hitting him on the head. Fortunately, there was no injury.Lessons learnt1. The team failed to review the operation when the additional person was called to assist. In this case, the operation should have been stopped and the new team member properly briefed, in accordance with safe working practices;2. Any additional personnel inducted into a task should wear appropriate PPE before entering the work area. Corrective/preventative actions Fleet circular issued to all vessels, instructing crew to:1. Conduct proper risk assessments before commencing a task. In case of change in circumstances or personnel, the job must be stopped, risks re-assessed and only allowed to continue once appropriate control measures are in place;2. Observe the 'Take 5' rule at various stages during the task;3. Comply with the PPE matrix at all times;4. Plan the work carefully, allocating sufficient manpower ...

Experience Feedback At a river port in West Africa, a bulk carrier under pilotage and with tugs assisting was to double-bank with a bulk cement storage vessel that was moored to a berth located on a sharp bend in the estuary. The cement vessel had several large pneumatic rubber fenders deployed on her offshore side. The bulk carrier had lowered both her bower anchors to just outside the hawsepipes for letting go.During the final approach, she encountered a strong cross-current which canted her bow sharply to starboard on to the cement vessel. The overhanging starboard anchor struck the cement vessel before the fenders on the waterline could cushion the impact and caused extensive damage to the cement vessel's side shell and internals. The accident was analysed and the underlying causes were identified as incorrect estimation of ebb current and lack of knowledge and skills on the part of the bridge team.Corrective/preventative actionsThe company decided to implement the following steps immediately: 1. Leadership training for key bridge team personnel; 2. Analysis of all critical operations and tasks; 3. Immediate investigation of all accidents/incidents and communication of findings and recommendations; 4. Improve emergency preparedness.Source: Mars/Nautical Institute