April’s Mars Reports Now Online

by | Apr 25, 2013 | News

MARS April 2013

In addition to the selection of Mars reports, which will appear in SWZ Maritime's April issue, we publish the entire 245 Report here on SWZonline.

Mars (Marine Accident Reporting Scheme) Reports is one of the regular sections of SWZ Maritime Reports. We will publish all the reports we receive online, as they may prevent other accidents from happening. Mars Reports cover all kinds of maritime incidents such as (near) collisions and groundings, accidents with tools, falling objects injuring crew and accidents with rescue boats.

Expert Advice Can Avoid Reefer Cargo Damage: Mars 201310

(Edited from Skuld P&I Club bulletin Apr 2011)
 Damage to refrigerated cargoes during sea transport can arise due to:

  • Insufficient pre-cooling.
  • Improper stowage that could restrict air circulation or lead to shifting/ crushing.
  • Improper ventilation.
  • Improper packaging.
  • Malfunction of the reefer machinery.
  • Deviation from the required cooling temperature.
  • Contamination or taint.

Many importing countries have strict health and sanitary regulations that prohibit damaged cargo from being landed, making it very difficult and costly to dispose of a spoilt consignment.

Recommended Precautions

  1. Written instructions should always be obtained from the shipper prior to loading refrigerated cargo. These instructions should include details of pre-cooling, carriage temperature, ventilation and stowage requirements.
  2. The vessel should obtain a certificate from a class surveyor or other competent expert prior to loading, stating the condition and suitability of the refrigeration machinery and reefer compartments for the carriage of the specific cargo in question. For containers, pretrip inspections should be carried out.
  3. Any confirmation, doubt or ambiguity must be queried and resolved in writing.
  4. The vessel should never accept carriage instructions that the vessel will not be able to comply with.
  5. Temperature ranges must be strictly adhered to, and in case of unavoidable deviation, the vessel’s P&I insurer must be immediately notified.
  6. For controlled atmosphere (CA) shipments, the carriage instructions should include recommended concentration of oxygen (O2) and carbon dioxide (CO2) and, if relevant, other gases (eg hydrocarbons).
  7. Whether loaded inside containers or the ship’s hold, proper stowage with sufficient horizontal and vertical air gaps or channels must be ensured.
  8. The floor/deck must be dry, clean and the drains must be clear.
  9. Pre-cooling may take up to 24 hours before the set or desired carrying temperature can be maintained.
  10. For containers, the air vent must be set or controlled as per shipper’s instructions.

Case Study

A container ship encountered a storm during her voyage. The heavy seas washing over the deck rendered about 130 reefer containers without electrical power. The cargoes comprised perishable, frozen and chilled cargoes. The owners immediately contacted the P&I Club.
Information regarding the nature of the cargo in all the containers, their set and monitored temperatures and the carriage instructions were passed to an expert. He recommended a prioritised sequence of repair, ensuring that the units with the most susceptible cargo were powered up first. All the affected reefer power sockets and circuit breakers were repaired or changed by the crew as soon as the weather improved over the next few days, but by following the recommended sequence, there was no cargo damage or claim.

Inadequate Maintenance Caused Partial Release of Bulk CO2: Mars 201311

A vessel was preparing to sail from port after completing discharge when multiple alarms sounded. It was observed that the automatic emergency stop system for the engine room supply fans had already tripped the blowers and the fixed CO2 gas release alarm had been activated. The generator engines automatically shut down, resulting in a total blackout of the vessel. The crew evacuated the machinery space and mustered, after which the C/E, 1/E and electrician went to the CO2 room to investigate. From the condensation and frosting on them, it was evident that eleven cylinders making up one of the several banks of gas for the protection of the E/R had discharged into the main distribution manifold. Fortunately, the main directional dump valve for the E/R remained shut, averting the flooding of the protected machinery spaces and the risk of asphyxiating many of the crew. Later, the residual manifold pressure of about 10 bar was carefully vented via a hose to the atmosphere outside the CO2 room.
(MARS 200778 shows that such temporary or improvised modifications to a high-pressure system can have grave consequences, including multiple fatalities – Ed)

A joint investigation conducted by Port State Control Officer (PSCO) and Classification Society surveyor found that:

  1. The set screw designed to regulate the check stem valve operation was not torqued to the required setting, causing it to lift at a much lower pressure than designed.
  2. A revised maintenance instruction issued by the makers two years before the incident, containing the procedure and the special tool required for adjusting the torque on each cylinder’s set screw had not been made available to the vessel or to the service contractor which had recently completed the annual servicing of the system. It was later found that the service contractor was not licensed by the maker.
  3. The ambient temperature inside the CO2 room had reached 50°C, causing abnormally high pressure to build in the cylinders, eventually resulting in the check stem valve lifting.

Corrective/Preventative Actions

  1. All vessels had their systems checked by authorised service contractors and a number of deficiencies were noted and rectified.
  2. The incident was shared with the makers of the fixed fireextinguishing systems fitted on company-managed vessels, their authorised representatives / servicing agents and it was ensured that correct and appropriate maintenance information, instructions and equipment were provided to all vessels.

Hydraulic Oil Leak Starts Fire in Engine Room: Mars 201312

On a tanker on passage, the fire alarm suddenly sounded. At the same time, the engine room crew saw small flames and smoke rising from the after exhaust manifold and cylinder heads of the running main engine. After extinguishing the localised fire, it was discovered that hydraulic oil from the cargo pump system had leaked from a flange connection in the vent/overflow line situated directly above the main engine cylinder head platform.

Result of Investigation

  1. At the previous discharge port, a submerged cargo pump hydraulic motor had malfunctioned. In preparation for carrying out repairs, an engineer had closed the vent-cum-overflow line valve located before the service/header tank without draining the line.
  2. Due to the residual pressure in the line, the flange connection (later found to have loose fasteners) leaked and a fine spray of hydraulic oil began falling on the hot surfaces on the top of the exhaust manifold and ignited after attaining self-ignition temperature.

Root Cause/Contributory Factors

  1. Inadequate work planning – line was not depressurized/drained before closing of valve before header tank.
  2. Inadequate management of change – the hydraulic piping had been modified some years ago to tap off a new branch line before the header tank leading to an offline oil filtering system. A stop valve was fitted before the branch without properly assessing risks.
  3. Inadequate communication – the engineer who closed the valve failed to inform other members of this fact.

Corrective/Preventative Actions

  1. Ship’s staff removed the stop valve from the vent line, and the piping was re-modified to ensure that the offline filtration circuit was independent of the vent/overflow line.
  2. All joints in the hydraulic system lines were inspected for proper condition and tightness.
  3. Sister vessels fitted with the same filtration plant were advised to check the lines to ensure that the overflow line could not be inadvertently shut. All vessels were instructed to thoroughly inspect all nuts and bolts on flange joints and tighten them.

Inadvertent Release of Senhouse Slip Caused Fall and Injury: Mars 201313

Official report edited from Marine Safety Forum Safety Flash 12-46
A crewmember was engaged in spot chipping/descaling of the platform where a fast rescue craft (FRC) was stowed. At the aft end of the platform, there was very limited access space between the outboard motors of the FRC and the two removable safety chains strung across and secured by senhouse slips.
As the seaman was attempting to move between the FRC and the safety chains to sweep up the debris from the platform, he unknowingly leaned heavily on the upper chain and inadvertently released the senhouse slip. The safety chain suddenly dropped and the seaman lost his balance and fell over the lower safety chain and into an empty halfheight open top container located below.
This incident could have had very serious consequences, but fortunately the injured person fell only a short distance and landed on a stack of empty pallets inside the container, sustaining only minor cuts
and bruises.

Result of Investigation

  1. No task-specific risk assessment was conducted for the assigned work – especially to consider the difficulty in accessing, working and moving in the area.
  2. The two safety chains were excessively slack.
  3. The two senhouse slips did not have a ‘lip’ on the end of the arm to prevent unintentional release.


View of after end of platform showing restricted room between FRC and safety chains    


Straight arm of the senhouse slip aided its unintended release

Editor’s Note
Senhouse slips meant for emergency applications should preferably be oriented vertically so that gravity assists in keeping the locking oval link in a safe position until a deliberate operator action is initiated to manually release the device. For added safety, the arm must incorporate a curved end or a raised ‘lip’ or a ‘bump’ at its end. For rigging horizontal safety chains, snap hooks are more convenient and efficient. See illustrations below.


Senhouse slips incorporating a curve, raised lip or hook at the end of the lever arm are safer


Carabiner-type snap hooks with spring gates are more efficient for securing safety chains

Foot Injury: Mars 201314

At the end of the day on a vessel at sea, two crewmembers were engaged in securing the grit blasting equipment on deck for the night. While moving the machine to its intended stowing position, the trailing grit hose snagged on an obstruction. As one person went to free the hose, the other seaman found it impossible to hold the top-heavy, wheel-mounted unit. As the unit toppled over, the seaman let go and tried to jump clear, but the equipment fell on his left foot. Despite his steel toed-safety boots, the impact inflicted a serious crush and cut injury. He was stretchered to the ship’s hospital, and was given first aid and treatment according to radio medical advice.

Root Cause/Contributory Factors

  1. Lack of proper risk assessment and situational awareness.
  2. Insufficient manpower to safely control the movement of heavywheeled equipment.

Lessons Learnt

  1. Crewmembers must jointly conduct a proper appraisal and risk assessment, ensuring sufficient manpower is deployed for safe conduct of every task.
  2. If an unsafe situation arises, the work should be immediately stopped and the situation corrected with all the appropriate safeguards put in place prior to resuming the work.
  3. All team members must maintain a high level of situational awareness at all times.

Hull Projections Can Damage Fenders: Mars 201315

A cargo ship of a novel design called at our terminal recently on her maiden voyage. She had all her deck cranes fitted along the ship’s port side and the pedestals extended beyond the shell plating like vertical sponson or blister tanks. As such hull protuberances can potentially damage the fenders on the berth, it is important that vessels provide this information well before the ship’s arrival. Indeed, the Master of the vessel did admit that a port had filed a claim for fender damage against another sister ship. Accordingly, it may be prudent for shipowners, naval architects and shipbuilders to avoid designs that involve projections beyond the side shell of vessels.


Closer views of hull projection showing risk of fouling and damaging fenders at wharf


View from astern showing two vertical projections on port side shell

Surveyor Fractured Wrist after Fall on Deck: Mars 201316

While inspecting cargo tanks after completion of discharge at an oil terminal, the accompanying surveyor tripped over a longitudinal on the main deck. He fell heavily on his right wrist, fracturing it. It was observed that the injured person had not worn proper safety footwear, although the fall could not be directly attributed to this omission

Lessons Learnt

  1. Proper PPE must always be worn by all personnel on board ship, regardless of whether they are ship’s crew or shore-based personnel/visitors.
  2. Persons must move with caution in areas that may have obstructions, especially under low lighting conditions.
  3. Clothing must allow free and unrestricted movement of limbs.

Seaman Injured During Hold Washing: Mars 201317

An A/B on a bulk carrier at sea was instructed to remove cargo residue adhering to the forward Australian ladder of the hold while the deck crew was carrying out hold washing operations. The seaman descended to the top platform, bringing with him a fully pressurized fire hose fitted with a jet nozzle. Having cleaned the upper platform and first section of the vertical ladder, he directed the water jet downwards at the middle landing for several minutes, but was unable to dislodge a lump of cargo still sticking to the landing. Instead of turning off the water temporarily while he lowered the hose to the next level, he decided to jam the running hose’s nozzle in a gap between the rods at the bottom of the upper landing. Then, without seeking assistance from other crewmembers, he began descending the middle section of the vertical ladder, intending to physically remove the cargo. As his
head came level with the nozzle, it suddenly jerked clear and whipped violently, hitting him on the face. The whipping hose could have struck the seaman repeatedly and could have even knocked him unconscious/off the ladder with fatal consequences, but fortunately, he quicklymoved away from the danger zone, sustaining only a laceration and bruise above his right eye. Fortunately, the C/O who was in the vicinity of the hold entrance trunk on the main deck, heard the seaman’s shouts.
After shutting off the hydrant, he assisted the injured person to the ship’s hospital, where he was administered first aid.

Root Cause/Contributory Factors

  1. No risk assessment was conducted before commencing the hold washing operation.
  2. Inadequate work planning, briefing and supervision – a pressurised fire hose must always be handled by at least two persons, with another person to supervise and to assist from the deck.
  3. Dangerous practice of assigning an inexperienced seaman to handle a high-pressure hose at height without assistance.
  4. Failure on the part of the injured person to identify the hazards from an unsecured, unattended, pressurised fire hose.

Corrective/Preventative Actions

  1. The hold washing operation was immediately suspended and a safety meeting was held to review the task, past working experience of each crewmember, and safe working procedures were communicated to all involved.
  2. In future, a responsible officer or team leader will ensure that all work teams will be under the charge of an appropriately experienced crewmember, and that a ‘buddy’ system will ensure that every crewmember is monitored and can avail themself of immediate assistance at all times.
  3. The incident was circulated to all vessels in the fleet to prevent recurrence.

Acknowledgement

Through the kind intermediary of The Nautical Institute we gratefully acknowledge sponsorship provided by:
American Bureau of Shipping, AR Brink & Associates, Britannia P&I Club, Cargill, Class NK, Consult ISM, DNV, Gard, International Institute of Marine Surveying, Lairdside Maritime Centre, London Offshore Consultants, Lloyd’s Register-Fairplay Safety at Sea International, MOL Tankship Management (Europe) Ltd, Noble Denton, North of England P&I Club, Port of Tyne, Sail Training International, Shipowners Club, The Marine Society and Sea Cadets, The Swedish Club, UK Hydrographic Office, UK P&I Club

Submit a Mars Report

More reports are needed to keep the scheme interesting and informative. All reports are read only by the Mars coordinator and are treated in the strictest confidence. To submit a report please use the Mars report form and send it to mars@nautinst.org.