Tag: lessons learned

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 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 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

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, ...