Read the August Mars Reports

Since SWZ Maritime publishes a 7/8 issue this month, we were unable to include the August Mars report in the magazine. However, you can read the full report right here on SWZ online.

Mars (Marine Accident Reporting Scheme) Report is one of the regular sections of SWZ Maritime. 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.

Stopper Pin – When Two Is One Too Many: Mars 201338

While the vessel was in dock, the bosun and an assistant carried out adjustment work on the windlass. After completing the job they intended to disengage the clutch by shifting the clutch lever. The bosun removed the stopper pin for the lever and instructed his assistant to shift the lever, which the assistant did (after first confirming all was clear and getting a confirmation back). However, the bosun’s finger was still positioned between the edge of the clutch lever and the stopper plate.
As the assistant swung the clutch lever the bosun’s finger was crushed as the lever approached its end position. The victim sustained several superficial lacerations, a distal edge nail laceration and a fractured finger joint. He was treated with sutures and application of a prosthetic nail after surgical nail-bed repair.
 

The accident occurred at the end of a hard day’s work so fatigue may have played a part. Neither the bosun nor his assistant were aware the bosun’s fingers were in harm’s way.

Editor’s note: This seemingly simple task still resulted in an unfortunate and rather serious accident – surgical nail bed repair is nothing to joke about. The two crew seemed to be communicating well enough, but they both had less than adequate situational awareness. This company should be praised for identifying fatigue as a possible contributing factor – fatigue should always be considered until it can be shown not to have been a factor. It may be of interest, however, that from a formal investigative standpoint, fatigue is usually identified by documenting work and rest over a period of 72 hours or more, not just one day.
More importantly, had the bosun or his assistant accomplished this task alone, no injury could have occurred. If the same person first removes the pin and then throws the clutch lever, their fingers cannot be in harm’s way. Of course, hindsight is 20/20, but this nonetheless highlights the advantages of carefully evaluating each task to be accomplished before acting.

Emergency Air Compressor Fights Back: Mars 201339

An engineer was carrying out routine inspection and maintenance on the emergency air compressor including a start test. When starting the compressor by manually cranking, the engineer failed to remove the handle before the engine reached its self-ignition RPM speed. As a result, the handle was thrown off the crank engagement nub when the compressor began turning over on its own, hitting him in the face. The engineer suffered two chipped teeth and lacerations of his lip.
 

The vessel’s investigation determined that the engineer was not fatigued at the time of the task. Additionally, he had carried out the same starting operation a number of times in the past.
The compressor starting procedure was apparently followed during start-up, covering items such as leaving the compressor drain valve opened and operating the engine decompression lever at the time of testing.

Action Taken

• Suitable caution notice should be displayed near the unit to remind the operator of the danger.
• The operator should receive specific training and be made aware of this danger when joining the vessel and before he/she carries out this test for the first time.
• The operator should be positioned suitably and firmly and pay full attention at the time of crank-starting the compressor.

Editor’s note: If all procedures were truly followed during this task, yet this accident still occurred, the residual risk would appear to be somewhat high. In that case, it may require a re-evaluation of the fundamental design or of the PPE necessary to accomplish this task, such as requiring a full face mask much like wood cutters in the forest industry.

Risks of Dropping the Anchor Underway: Mars 201340

Official report edited from The Dutch Safety Board

In calm weather and good visibility, a cargo vessel under pilotage while departing port was overtaking a tug towing a pontoon. The cargo vessel’s electrical needs at the time were being supplied via the shaft generator. Both of the ship’s service generators were shut down to save on fuel.
While overtaking the pontoon, the cargo vessel’s main engine suddenly failed. Since the electrical systems on board the vessel were linked to the main engine via the shaft generator, the electricity failed as well and for a short period of time the vessel suffered a blackout. During the blackout, the rudder unexpectedly turned to port, causing the vessel to deviate sharply from its course and toward the tug and tow. In order to prevent a collision, the captain, on VHF radio, ordered the anchor let go. As there were crew on deck at the time, the anchor was let go very quickly after the order – within fifteen seconds. At the time the anchor was let go, the cargo vessel still had a speed over ground (SOG) of 7.5 knots.
Despite the attempts by the AB to secure the winch brake, the anchor chain continued to run out. The last length of chain had broken loose from the chain locker, and the AB was hit and fatally injured by the bitter end.
The cargo vessel collided with the pontoon almost simultaneously with the breaking free of the anchor chain. Both vessels sustained limited damage as a result of the collision.

Simulation of A/B attempting to secure the brake as the chain ran out
 

Lessons Learned

• The use of the anchor to slow down the ship in an emergency: IACS stipulates that an anchor must be constructed in such a way that it is suitable to anchor a ship temporarily in "moderate" ambient conditions. The anchor gear is not designed to stop a ship. Anchoring at high speed is an extremely risky operation that may result in fatal injuries to crew members and serious damage to the ship. Such a manoeuvre should only be considered in an extreme emergency. The captain, in consultation with the bridge team, should assess whether the potential benefits of such a manoeuvre outweighs the substantial risks to the crew and ship.
• The need for uninterrupted power supply when sailing in confined waters: Sailing in narrow waters entails increased risks of collision or grounding. Therefore, prior to commencing a passage in confined waters, a risk analysis should be carried out (or consulted) as part of the SMS in order to verify that back-up systems are instantly available. Uninterrupted power supply in confined waters is essential in order to guarantee a ship’s manoeuvrability and should be considered a best practice.
   

Steering Failure? Think NFU: Mars 201341

Official Report edited from TSB (Canada) M11L0160

The vessel, under pilotage, departed port in ballast and was down bound in a restricted waterway. The engine control was set to bridge control and a helmsman was using manual full follow-up (FFU) steering.
At one point a port alteration was requested; however, the rudder angle indicator showed 10˚ to starboard. Several port and starboard helm inputs were attempted with the FFU, but no rudder movement could be observed on the rudder angle indicator. The pilot then ordered the engine to be stopped and that the anchor be readied.
 

The master arrived on the bridge just as the vessel was leaving the buoyed channel. He went directly to the steering stand and transferred the steering system actuator switch from the port system to starboard system. This action restored control to the steering, but it was too late. The vessel ran aground at an estimated speed of 8 knots over the ground.
The vessel is fitted with a very typical steering control system where a control mode selector switch is used to select one of three different means of steering the vessel: autopilot, hand (FFU) or non-follow-up (NFU). The helm order data signal to the steering gear telemotors is provided by two potentiometers that are mechanically linked to the helm wheel and electrically linked to each telemotor: one potentiometer per telemotor. It was later discovered the port system helm follow-up potentiometer had failed, rendering the FFU useless until the starboard system was belatedly selected by the master.
Typically, when the NFU mode is selected, the NFU controller becomes operational and the helm wheel is deactivated. Additionally, on this vessel, once the NFU controller is used, it overrides all other steering controllers without the need to set the steering mode selector switch to NFU. The NFU controller is a spring-loaded lever that must be held to one side or the other for a signal to be sent to the steering gear telemotors.

Alternative Steering Methods

Subsequent to this accident the TSB conducted a review of vessels from different owners and flag states to determine the general knowledge and use of the NFU mode by bridge crew members. Although from a statistically small group, it was nonetheless found that 75 per cent of crew surveyed were not fully familiar with the use of the NFU mode.
Generally, familiarisation for helmsmen on joining the vessel included brief explanations of the different steering stand components and their use, including the NFU mode. Furthermore, the procedures for dealing with situations involving steering failures refer primarily to the local emergency steering in the steering gear compartment. Use of the NFU mode, if it is referred to, is usually listed as a secondary or tertiary method to regain control.
When the bridge team became aware that the rudder was not responding, three options were available on the bridge to rectify the situation:

1. taking over the steering control with the non-follow-up (NFU) mode,
2. changing over from the port to the starboard steering system to also regain steering control, or
3. stopping the vessel.

Stopping the vessel, however, was not a viable option because of the vessel’s proximity to the shore and the length of time required to put the engine at full astern and stop the vessel and or anchor effectively. Thus, while in this case the engine was ordered full astern, the engine went astern only after the vessel had grounded and before the anchor could be deployed.
The other two options in this situation involved regaining control of steering. There was no attempt made by the OOW or the helmsman nor order by the pilot to use the NFU mode or to switch from the port to the starboard steering system. By the time the master returned to the bridge and switched the steering system selector switch from port to starboard, restoring control of rudder movement, it was too late to prevent the grounding.

Some of the Findings of the Official Report

1. Without the regular replacement of potentiometers, there is an increased risk that they will fail in service.
2. Crew may be unfamiliar with the steering control methods of the non-follow-up mode or switching steering systems in cases of steering failure if this information is not incorporated into technical manuals, familiarisation, and drills, or adequately described and posted near the steering stand.

Editor’s Note: A steering malfunction in the middle of the ocean is not a problem – you have lots of time and there are no hazards. But typically, in restricted waterways you only have a minute or two to resolve the steering issue before unwanted consequences are suffered.
Many reports and surveys have shown that crew are not instinctively switching to NFU when a steering failure in FFU mode occurs – yet this should be their first reaction. Switching steering systems (port to starboard or vice versa) is also a procedure that takes only a few seconds and could save the situation.
 

Some Surge Protection Devices Unfit for Vessels: Mars 201342

Official Safety Alert from United States Coast Guard: Alert 03-13b

Most commercially available surge protection devices (SPDs) are designed for use ashore and will interrupt only the hot conductor when a surge occurs. What does that mean for the ship owner/operator? It means that while these devices may provide protection in our homes and offices, these same devices may be a fire risk on board vessels.
A marine casualty investigation of two separate stateroom fires revealed that the sources of the fires were attributed to the use of SPDs plugged into a lighting circuit. It was discovered that a ground had developed on another circuit that was connected to the same distribution panel providing power to the staterooms. This ground created an imbalance of voltage between the two power conductors supplying the SPDs which caused excessive currents, overheating, and subsequently, a fire.

Typical home SPD
 

In this instance, even if the SPDs automatically tripped as designed, only one power conductor would have been secured while the other would continue to provide power, possibly shorting to the device’s ground wire and the structure of the vessel.
For shipboard applications, it is critical for a device to interrupt both power conductors.
Vessels should have defined procedures for checking the condition and grounding capabilities of personal/portable electrical equipment, and trained shipboard personnel should be assigned to check and approve all SPDs in use or brought on board for compatibility with the vessel’s electrical distribution system prior to use.

Additional Technical Information

• This safety alert only applies to vessels with alternating current power systems.
• There is no official Underwriters Laboratory standard for Marine Surge Protective Devices despite numerous retailers advertising "UL Marine 1449".

An SPD should be:

• only permitted for use on board once approved by a trained crewmember;
• removed from service if it is hot to touch;
• unplugged when not in use;
• regularly inspected for damage or wear;
• limited to one SPD per single duplex receptacle outlet and never daisy chained;
• prevented from use in excessively humid or moist environments;
• provided air circulation and not covered with carpet or other items, and
• checked to ensure that all plugs are fully engaged.
   

Get a Good Grip: Mars 201343

Official Report edited from BSU 415/10

During operations, an O/S climbed onto the 2.2 metre hatch coaming and used the guard rail for foot support. Presumably, as there were no direct witnesses, he lost his footing and/or handhold, fell backward onto the deck and struck the guard rail with his head causing fatal injuries. He was wearing size 10 mixed fabric (cotton/rubber) gloves and a protective helmet. An examination of the work rest schedule of the victim did not reveal fatigue as a factor.
No ladder was located in the immediate vicinity of the accident; there were only three permanently installed ladders along the whole of the hatch coaming. It would have been possible to safely stand on the hatch coaming with such a ladder as an additional handhold and backfall preventer is offered by the rail above each ladder.
 

Scene of the accident (simulation)
 

The official BSU report found that the accident was the result of structural defects and inappropriate protective equipment, amongst others. Had more ladders been installed on the hatch coaming then it is very likely that the accident would not have happened because controlled operation with additional protection (in this case, a backrest on the coaming) would then have been possible.
 

Permanent ladder with backfall protection
 

Additionally, it is possible that the accident was facilitated by gloves which were too big and inappropriate for the intended use. When assessing the gloves, the BSU found that the size 10 was a very large fit and that hands could easily slip out. The gloves were also without a nonslip coating such as provided by "gripper dots".
A protective glove suitable for all activities on board does not exist because the spectrum of applications is too wide. In this case, it was noted that only one glove type had been made available, and only in size 10, for all the shipboard activities. Gloves should be fit for service and be supplied in the right size so as to provide a snug fit.

A protective glove suitable for all activities on board does not exist
 

Editor’s note: Although the BSU report specifies that the victim was wearing a protective helmet at the time of the accident, the report remains silent on whether the helmet had been secured with a chinstrap to keep it firmly in place. Unfortunately, in my experience, chinstraps are rarely used. Yet, in order to help prevent injuries such as the one in this accident, the helmet must be held firmly on the head at impact. This can only be done by both correctly adjusting the head size ring to be snug and using a firmly cinched chin strap.

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.