Tag: lessons learned

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

Hong Kong Merchant Shipping Information Note Hong Kong Marine Department issues Merchant Shipping Information Note regarding Fatal Accident while boarding vessel by pilot ladder as follows:The relieving Chief Engineer of a Hong Kong registered bulk carrier fell into the water and drowned while he was boarding the vessel by means of the pilot ladder. This information note draws the attention of Shipowners, Ship Managers, Ship Operators, Masters, Officers and Crew to the lessons learnt from this accident.The Accident1. A Hong Kong registered bulk carrier was at anchor in light ship condition with high freeboard for crew repatriation. The relieving Chief Engineer (C/E), who had injected a dose of insulin about 1 hour before the accident and arrived at the ship's side after about 14 hours of transportation, fell into the water when he was climbing the pilot ladder to board the vessel. He was retrieved from the water to the service launch by the joint effort of the launch attendant and the ship's crew in about 10 minutes. Despite first aid treatment and cardiopulmonary resuscitation applied to him on the launch as well as emergency treatment in the hospital, he was certified dead afterwards.2. At the time of the accident, ...

Experience Feedback During self-discharging of a dry bulk cargo, the engine room rating on watch informed the cargo control room by portable radio that he was proceeding to the conveyor belt tunnels located beneath the cargo holds on his routine rounds. About 45 minutes later, the Chief Officer also went down to the tunnels to carry out his routine inspection and monitoring of the self-discharging system. When he reached the after end of the port side conveyor belt, he found the rating's body between the conveyor belt roller and a supporting beam.The Chief Officer immediately activated the emergency conveyor belt stop system and called for help. Although the emergency services were quickly on the scene, the rating had already died of severe injuries. The rating had not been instructed to carry out any maintenance work on watch and the self-discharging machinery was operating normally during the incident. The reason for the rating becoming caught in the system is unknown. There were no witnesses.Lessons learnt1. The machinery at the end of the conveyor belt system was guarded by only a waist-high hand rail. Therefore, it was easy for a crew member to intentionally or unintentionally bypass the rail and come into ...

Experience Feedback On board a coastal vessel at sea, the Chief Engineer instructed the motorman to go to the steering gear flat and mop up a small quantity of accumulated leaked hydraulic fluid. The steering gear machinery was enclosed by a perimeter railing and as the motorman entered this enclosure, his clothing snagged on the flange coupling of the linkage that connected the rams on opposite sides of the tiller.Simultaneously, a hard-over rudder movement was executed from the bridge, and the large axial movement of the linkage resulted in him being dragged into the narrow gap under the raised walkway frame, trapping and seriously injuring him.A short while later, the Chief Engineer went to the steering gear flat to check on the work and found the injured motorman lying motionless and unable to extricate himself. After he was evacuated from the steering gear space, the motorman was airlifted to the nearest hospital, where he received medical treatment for crush injuries to his vertebrae and pelvic region.Lessons learnt1. Areas around moving machinery should be securely guarded to prevent such accidents;2. Personnel should never enter or remain alone in any unmanned machinery space unless they have advised a responsible person / control ...

Experience Feedback During routine maintenance of a fixed tank cleaning machine on a tanker, a crewmember removed all the nuts on the base studs, lifted the drive unit slightly and inserted the end of an open spanner (wrench) between the base flange and the drive unit to visually examine the working parts through the narrow gap.During this operation, he had inadvertently placed his left middle finger near the wrench, under the base mounting of the drive unit. Suddenly, the spanner slipped out and the drive unit dropped on his finger, badly crushing it. The injured person was given immediate first aid and was off work for the next three days and was given shore medical treatment at the next port.Root cause/contributory factors1. Inappropriate tool used as temporary stopper device;2. The task was not planned or assigned by the Chief Officer;3. The crewmember decided to carry out this task on his own initiative and he did not conduct any risk assessment;4. Crewmember did not follow the correct method of inspection as recommended in the maker's service manual;5. Lack of skills and overconfidence on part of the worker in his ability to undertake the task.

Experience Feedback A large container ship was on a fixed trans-continental service, regularly crossing the ocean on a tight schedule. Every month, at the turnaround port, it was a routine for the engine crew to isolate, cool down and open the economiser (also known as waste heat or exhaust gas boiler) to clean out the accumulated soot and unburnt carbon particles. (Being very corrosive, these deposits can cause rapid wastage of the water tubes in the economiser and their eventual rupture. - Ed)When sailing from this port, the first few starts of the very large marine diesel engine would eject clouds of soot from the main engine exhaust uptake. These particles would rain down on the bridge wings and external decks, often ruining the clothing of the unwary. Subsequently, after the outward pilot had disembarked and the engine was rung up on the sea passage (Full Away), the volume, temperature and velocity of exhaust gases would increase. By day, the soot particles would now appear like a continuous plume of smoke, (burning embers not visible) and, by night, it would appear as if there was a prolonged fireworks display atop the funnel. On many occasions, with a cross wind blowing, ...

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 ...

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 ...