Tag: lessons learned

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 ...

Corrective / preventative actions A small gas tanker was on a loaded coastal voyage. Prior to arrival at the discharge port, the chief engineer and a company superintendent who was on board to carry out an inspection of the vessel, planned to test the operation of QCVs in the fuel oil (FO) and diesel oil (DO) tanks. At about 11:30, both the chief engineer and superintendent positioned themselves near the FO service tank and ordered the tripping of the tank's QCV from the remote emergency control station.After confirming proper closing, the QCV was manually opened and reset. It was then decided to break for lunch. At about 12:40 hrs, when one hour's notice of arrival had been given by the bridge, the Chief Engineer returned to the engine room. At the time, the vessel was proceeding along the traffic separation scheme in the outer approaches to the destination port. At 12:55 hrs, No. 1 generator engine suddenly stopped, causing a blackout and loss of propulsion and steering. The Master broadcast a safety message on VHF and arranged to display Not Under Control (NUC) signals. Immediately, No. 2 generator engine was started manually and was taken on load, but after about ...

It is suspected that the use of the starboard anchor accelerated the turning movement An oil tanker under our management was approaching an anchored 'mother vessel' on her starboard side in order to perform a STS operation. The weather conditions were ideal and adequate fendering was deployed by both vessels. The mother vessel was riding to her starboard (same side as her 'working' side) anchor, which is contrary to OCIMF STS guidelines.During the approach, the mother vessel suddenly began to yaw. It is suspected that the use of the starboard anchor accelerated this turning movement. An urgent order was given to the tug to pull the vessels apart, but this sudden stressing of the towline resulted in it parting and the vessels coming into contact.The tug was made fast and again ordered to pull our vessel clear, but, due to high tensile loads, the towline parted for a second time, resulting in multiple contacts between the two vessels. Both vessels suffered minor damages. Subsequently, a fresh approach was successfully made and the STS operation was performed without further incident.Root cause / contributory factors1. Non-compliance with OCIMF STS guidelines2. Unexpected yaw by anchored mother vessel;3. Inadequate planning and misjudgment by the ...

Hong Kong Merchant Shipping Information Note Hong Kong Marine Department issues Merchant Shipping Information Note regarding Crew Fatality while working at Deck Log Cargo as follows:A fatal accident occurred on a Hong Kong registered cargo ship at anchor loading log cargo.An Ordinary Seaman fell overboard and disappeared into the water while he was working deck log cargo near the ship's side. 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 cargo ship was at anchor loading logs. When the loading in No. 1 cargo hatch was completed, the ship's crew were tasked to tighten the lashings over the deck log cargoes while loading continued in other hatches. The Ordinary Seaman (OS) who was assigned to work on the deck cargoes near the ship's side fell overboard and disappeared into the water.2. At the time of the accident, the weather was fine. The wind was southwesterly with force 3. The sea state was smooth but the water was muddy with current setting northeast at a speed of about 1 knot. Despite search and rescue operation being conducted for 7 days, the missing ...

Corrective and preventative actions One vessel was to move from her berth (port side alongside) and tie up at another berth (starboard side alongside) further up the dock. A pilot and two harbour tugs arrived at the designated time and Master - Pilot information was exchanged before commencing the movement. The pilot requested that the port accommodation ladder be hoisted by only a few metres and retained there, as he intended to use it for disembarking from the 'sea' side at the next berth. Due to the ship's draught, height of the pier and the state of tide, in this 'raised' position, the gangway was only about a metre clear of the jetty.During the unmooring operation, there was a strong off-shore wind and moderate rain, and due to the latter, both the Master and the Pilot remained inside the wheelhouse throughout. On the pilot's advice, all headlines and sternline(s) were first let go, retaining only the backsprings fore and aft. After the sternline(s) had been retrieved on board, the deck officer in charge of the aft mooring station went over to the backspring winch, which was situated on the starboard main deck, forward of the accommodation. He engaged the gear ...

Experience Feedback Tanker was proceeding with a Pilot on board to anchor in the designated area for bunkering in a large Asian port. While she approached on a southeasterly heading, a large multi-tug tow was observed right ahead on a reciprocal course.The Pilot informed the VTS of his intention to pass red to red with the tow, and after passing, to adjust the planned track to arrive at the designated spot in the anchorage area. He then ordered starboard ten in order to pass the tow to port and reduced the speed quickly from harbour full ahead to dead slow ahead.A short while later, the rudder was ordered back to midship. By then, the vessel had already attained a considerable rate of turn to starboard, so the Pilot ordered the rudder to port ten, followed immediately by port twenty and finally hard to port. However, the vessel continued her rapid swing to starboard, forcing the Pilot to order increased ahead speeds in an attempt to arrest the starboard swing.Despite these actions - putting the rudder hard to port and increasing the speed to full ahead - the vessel continued her starboard swing. Simultaneously, the vessel was closing rapidly with an ...