New Mars Reports

SWZ Maritime’s October issue (to appear 18 October) contains a selection of reports from Mars report no. 251. The full report can now be read 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.

Weather Terminology Rains Confusion: Mars 201351

Official report edited from MAIB 8/2013

A small coastal cargo vessel had been loading limestone at an exposed, tide-constrained berth when the weather, as predicted, continued to worsen. The master, after listening to the weatherpredictions, decided to finish loading and then put to sea. However, strong winds and large waves overwhelmed the vessel while it was manoeuvring away from the jetty, causing it to be driven onto the shore. The vessel was later declared a constructive total loss.

Although several contributing factors were at play in this casualty, one of particular interest was the Met Office’s use of qualifying terms in describing the arrival of weather patterns and winds in their weather forecasts (see below). Although these terms are defined, quantitatively, in Admiralty List of Radio Signals they are not part of the international meteorological lexicon. This accident demonstrates that they have the potential to cause misunderstanding; in this case the master, a non-English mother tongue speaker, although aware that the weather was likely to deteriorate, was confused by the terminology used in UK maritime weather forecasts. He did not appreciate the meaning of the term ‘imminent’ and, as a consequence, did not fully comprehend how quickly the bad weather was forecast to arrive.

MET Office terms used for approaching weather systems and their corresponding meaning

• Imminent: Expected within six hours of time of issue
• Soon: Expected within six to 12 hours of time of issue
• Later: Expected more than 12 hours from time of issue

Lesson Learned

• The official MAIB report states that it would be beneficial to make warnings about severe weather explicit and self-explanatory.
• Watchkeepers should not be left in doubt or need to look up definitions.

Weather Tightness of Hatch Covers: Mars 201352

Even on new ships hatch covers are only truly weather tight in the static condition; weather tightness can’t be guaranteed in dynamic conditions such as at sea and especially in rough weather. When water does enter the hatch cover, by design it goes into the drain channel, through a non-return valve, and then passes on to the deck. The nonreturn valve ensures water can only go from the drain channel to the deck and not vice versa.
Unfortunately, inspections have revealed missing, blocked or otherwise plugged non-return valves and drain channels. Some nonreturn valves have even been found capped. These conditions mean that water which enters the hatch cover is not able to pass out from the hatch cover drain channel and instead goes into the hold, resulting in cargo damage.
Inspections have also revealed hatch cover rubber packing that is missing or damaged. Where repairs have been effected, they sometimes appear to have been made too localised to the damage (six to twelve inches, whereas manufacturer’s instructions normally require a minimum of twenty four inches to be changed.) The ends of the repair packing should be cut at a 45 degree angle, not vertically, and the packing should be hammered from the centre towards the sides.
Another deficiency noticed during inspections is with the rubber washers of cleats. Often, these washers are either too hard (due to age) or covered by thick layer of paint which makes the rubber washer ineffective.

Hatch Covers and Cranes: Mars 201353

Edited from official report of the Dutch Safety Board

While closing the hold a hatch fell out of the hatch crane and into the hold. This then caused the hatch crane to come off its rails on the starboard side. The first mate, who was operating the hatch crane alone from the operating platform, fell approximately eight metres into the hold; he was not wearing personal anti-fall protection (safety harness).

He suffered serious injuries as a result of this fall and was admitted to hospital in a critical state The hatch crane and hatch arrangement are similar to those in many small ocean going and inland vessels. The hatch crane rides on both sides of the hold over rails which are fitted to the hatchway coaming. The crane consists of two vertical uprights and a yoke, placed athwartships [across the width of the vessel] and fitted with hooks from which the hatches are hung during hatch movement. The hatches are fitted with attachment points, referred to as ‘pockets’. There are markings on both the hatches and the hatch crane to indicate the correct position of a hooked-up hatch relative to the hooks of the hatch crane. The person who operates the crane stands on the hatch crane, either on one side or on top, and rides along with the hatch crane while the hatch is moved.
Because the hatch was being transported in a high position, not only was its centre of gravity higher than need be, but also there was little chance of it coming to rest on the hatchway coaming when it fell. The investigation also determined that the hooks of the hatch crane yoke on the starboard side did not connect to the hatch attachment points but to the rounded (outer) side of the attachment points. Contrary to the vessel’s procedures, this was not checked by a second person at the time of the manoeuvre.

The hatch crane with hatch in hooked position 

Hooks used with blunt end

Since 1992, a total of 15 incidents involving hatch cranes on board Dutch flagged ships have been reported to the authorities. These have resulted in three deaths and 13 serious injuries.
Investigations have revealed two categories of incidents/accidents. On the one hand, many occurrences involved contacts between the crane and people on or near the rails. On the other hand, eight other occurrences involved hatches falling out of the crane hooks, potentially causing the hatch crane to topple or shift, and then the operator to fall. Dutch authorities made a number of recommendations to limit this type of accident. They can serve as a list of lessons learned.

Recommendations

1. Use claws on the hatch crane which grip the rails so that the crane cannot topple or shift off the rails.
2. Use sharp ended hooks and pockets, so that the hook cannot lift the hatch if it is not properly connected.

   

    

3. Operate the hatch crane only if there is a person on each side to check whether the hooks are connected properly.
4. Appply markings to the hatch crane and the hatches so that it is clear whether the crane is correctly positioned in relation to the hatch.
5. Move the hatch crane only when the pontoon is in the lowest possible position to keep the crane’s centre of gravity as low as possible.
6. Use ‘brushes’ in front of the wheels, so that fingers can be pushed away instead of becoming trapped.
7. The installation and maintenance of audiovisual warning signals in order to warn bystanders of the driving crane.

Working at Height without Restraining Gear: Mars 201354

Edited from official MAIB report 25/2012

As part of a drill, the outboard lifeboats and tenders of a passenger ship were lowered and held alongside deck nine by their tricing pennants. The lifeboat’s bowsing tackles were rigged, tensioned from the coach roof and secured to bitts welded to the bowsing tackle blocks fitted to the lifeboat lifting plates.
On the order to release the tricing pennants, the forward crewman was unable to remove the tricing pennant hook release lever pin while at the same time holding the bowsing tackle on the bitts. The overseeing officer went to assist. As the officer removed the pin and operated the release lever, the crew member stepped to one side, which caused the bowsing rope that he was holding to come free from the bitts. Without tension on the bowsing tackle, the lifeboat swung violently away from the ship’s side and heeled to port. The officer and crew member, who were not wearing any form of personal restraint, slipped from the smooth coach roof and fell 22 metres into the water below. They were quickly recovered by other members of the crew.
Luckily, the two men sustained only minor injuries.

Lesson Learned
While other factors contributed to this accident, had the men been wearing proper fall restraint equipment they wouldn’t have taken a 22 metre plunge into the harbour waters. When working where risk of falling is present, fall restraint PPE is your last line of defence.

Foundering at Night: Mars 201355

Edited from official MAIB report 12/2013

In darkness and heavy seas, a small general cargo ship began to founder. Although a Mayday message was broadcast on VHF radio channel 16, Digital Selective Calling (DSC) was not used. The voice Mayday call was short and incomplete.
After the general alarm was sounded, the crew assembled on the bridge and donned immersion suits collected from two decks below.
These were a mix of different types – some of the suits were required to be donned with lifejackets, others were not. As the vessel’s freeboard reduced, the master realised that the vessel was sinking and ordered the crew to prepare to launch the liferafts. At about the same time, the second officer collected the two search and rescue transponders (SART).
However, he had difficulty activating them because of the design of the gloves integral to his immersion suit (see picture below), and eventually had to use his teeth to operate them.
Less than 20 minutes after suffering a catastrophic structural failure, the vessel foundered. Two crew survived, climbing into a liferaft that had inflated after the vessel sunk beneath them. The master and five crew perished. About an hour after the vessel foundered, a rescue helicopter arrived on scene and spotted the two survivors in the liferaft, winching them to safety.

Safety Lessons

Abandoning ship in the middle of the night in rough seas is a situation no seafarer wants to experience. Unfortunately, many do, and although SOLAS requirements place a great deal of emphasis on the importance of life saving appliances (LSA) and abandon ship drills, tragically lives continue to be lost. To improve the likelihood of all crew surviving should the need to abandon ship arise, vessel owners, managers and crews are strongly advised to take into account the lessons to be learned from this accident. In particular:

• The importance of ensuring that all crew are fully briefed on mustering procedures and that they are able to properly don the immersion suits and lifejackets available through regular and realistic abandon ship drills.
• The benefits of transmitting distress messages in the recommended and internationally recognised format. This can quickly and accurately be achieved via digital selective calling (DSC), but in situations in which the use of voice procedures is preferred, a simple aide-mémoire, showing the format and information required, is a straightfoward and cost-free option.
• Having several different types of immersion suit and lifejackets on board is potentially confusing and increases the risk of the equipment either being donned incorrectly or not quickly enough.
• It is commonsense that all of the immersion suits provided on board a vessel should be of the same type; i.e. either they all have in-built buoyancy, or they all need to be worn with a compatible lifejacket, but not a mix of the two designs. Even in large fleets that carry many types of suits and lifejackets, this can usually be arranged through good planning.
• The provision of life saving apparatus (LSA) should be goal-based and holistic in order to ensure that the components are compatible and that the ‘system’ is fit for purpose. The compatibility of individual items of equipment cannot be taken for granted, even where the LSA provided meets the required performance standards.

Vessel Strikes Island: Mars 201356

Recently we handled a damaged vessel which had a head on  collision with a small unlit island during the night. The vessel’s course line passed directly over this small island, a fact that was overlooked by the navigation team. Point to note is that the vessel was using a chart with no colour tints. In modern charts, shallow patches are more easily visible due to the use of contrasting colours, as recommended in the current chart specifications of the International Hydrographic Organization.
All officers must check the sounding for 10-20 miles on each side of the course track in their watch and be aware of any other dangers.
Besides this, the officer who prepares the courses must check the soundings for all the charts and mark the dangers very clearly on the chart.
Editor’s note: When establishing and especially when checking the vessel’s passage plan, charts of the largest scale should always be used. Small unlit islands can be anywhere and a course drawn across seemingly empty ocean on small scale charts is just the formula for a grounding that could have easily been avoided. Of course, keeping a sharp lookout is also a watchkeeping task that may have helped avoid this accident.

Acknowledgement

Through the kind intermediary of The Nautical Institute we gratefully acknowledge sponsorship provided by:

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.