The June Mars Reports

A selection of the 259 Mars Report will appear in SWZ Maritime’s June issue, to appear 20 June. Read the full report here on SWZonline.

Mars (Marine Accident Reporting Scheme) Report is one of the regular sections of SWZ Maritime and features a selection of Mars reports. The complete reports are published 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.

Emergency Exit Cuts Like a Knife: Mars 201424

During an engine room fire drill, the crew practised an evacuation through the emergency escapes. After successfully exiting via the escape hatchway, the team leader instructed a rating to operate the external hand-wheel to ensure the free opening of the hatch lid for emergency entry purposes. The rating attempted to rotate the handwheel with all his strength in order to overcome the residual resistance of the securing dogs below. The dogs released with a jerk causing the wheel to turn freely. Due to the sudden absence of resistance, the rating’s right hand shot past the sharp bottom edge of the housing lid, which inflicted a deep gash near the knuckle.

Crew members immediately gave first aid, applying pressure on the wound to stop the bleeding. The victim was escorted to the ship’s hospital where the wound was cleaned, dressed with antibiotic powder and tightly bandaged.

Contributing Factors

• The faulty design of the hand-wheel housing lid, with its sharp edges and wheel rim located very close to edge of housing cover.
• The hasty and vigorous operation of hand-wheel under the prevailing pressure of an ongoing emergency drill.
• The sudden release of securing dogs.
• The absence of gloves (normally not a requirement for emergencies or drills).

Corrective Actions

The incident was discussed at a special stand-down safety meeting held after the incident. An injury report was sent to management with a corrective action plan; a rubber strip was permanently glued to the sharp bottom edge of hand-wheel housing lid and a warning note was stencilled on the underside of lid.

Trapped in a Tank: Mars 201425

The vessel was en route, with a couple of ship surveyors onboard to perform steel condition assessments. One area of interest was the aft peak ballast tank. This tank was drained to allow the surveyors inside. The stern shaft, which passed through the lower aft peak ballast tank, was rotating throughout and the chief engineer was keen to re-flood the tank as quickly as possible to ensure shaft temperatures did not increase beyond specified limits. It was a tight space and required a lot of wiggling and squeezing through small holes and around bends to get to the furthest reaches of the tank.

A rating had been posted at the access hatch of the ballast tank; his task was to stand by at the entrance and advise the bosun once the surveyors were out of the tank. Unknown to the surveyors or the bosun, the rating left the tank entrance for a brief period.

The bosun arrived back at the tank access hatch to find the rating had left. He assumed the surveyors had finished their work and were out of the tank. As he started securing the hatch back on, the surveyors heard the rattling of the air-gun as the bolts were being fastened. The surveyors scrambled back through the confines of the tank to the access hatch, yelling all the way. They began hammering on the bulkhead hatch with their fists and chipping hammers to warn of their presence in the tank. Fortunately, the bosun heard the banging in time; all but two of the 20 bolts remaining had been secured.

Lessons Learned

The rating posted at the tank entrance was not aware of the importance of his task. He was essentially the lifeline for the surveyors deep inside the ballast tank. By leaving his post, even for a short while, he had put their lives in danger.

In assuming the surveyors had exited the tank, the bosun committed an error. Always follow procedures for enclosed spaces, which should include positive verification that the tank is indeed vacant of personnel before closing up. If no procedure is in place, one should be made.

Improvisation Leads to Fall: Mars 201426

The main engine crankshaft deflection was to be measured and recorded at the anchorage, a routine job completed every three months. A risk assessment was prepared by the second engineer the day before the job and was approved by the chief engineer. In preparation for entry the main engine crankcase doors were opened and the space ventilated. Prior to entry, a tool box meeting was held including a review of the risk assessment and the enclosed space entry requirement. All personnel involved in this job had been given adequate rest and there was no pressure to complete the job in a hurry.

The plan, as improvised, was to position the crank shaft in such a way that the crank web was in the horizontal position. This would allow crew to cross directly from one side of the crank case to the other. An engine cadet was assigned to note down the readings and the fourth engineer was to operate the main engine turning gear remote control.
Once ready, and wearing a work suit, helmet and rubber boots, but not using gloves, the second engineer entered the crankcase. Inspection and measurements of units number one and two went without incident.

However, while crossing from port to starboard on the horizontal crank web in unit number three, he lost his balance, tried gripping the hand rails/steps, and fell on to his left arm with all his weight. He was later diagnosed with a fracture.

Contributory Factors

• The second engineer was not wearing proper PPE. For example, he was not wearing correct safety shoes/boots nor an antiskid protective cover for the footwear. Nor was he wearing gloves such as dotted cotton gloves that enhances grip on slippery surfaces.
• Proper procedures were not followed during the inspection. Crew should not be crossing over from one side to the other through the crank web. Rather, the procedure calls for climbing down and passing underneath the crank web, then climbing up the other side to continue the inspection.
• Inadequate safety leadership as demonstrated by not following the procedure and not wearing the correct PPE.
• The risk assessment prepared for this task was not effective as it did not adequately list the risk control measures for preventing slips and falls. The risk assessment sheet lacks imagination and seems to be a copy of the standard risk assessment sample sheets provided to the vessel. Consequently the tool box meeting was ineffective and there was a lack of awareness of hazards and possible consequences.

Corrective Action

• Staff must be familiarised with procedures. The safety briefing conducted with senior officers prior to their joining the vessel has to be reviewed. This briefing should focus on raising standards of safety leadership on board. Senior officers shall be briefed on carrying out realistic risk assessments and the briefing shall include a video on risk assessments.
• Anti-skid covers for safety shoes are necessary PPE when working in slippery work spaces. The company shall provide all fleet vessels with antiskid covers for safety shoes. The PPE matrix will be amended in the appropriate manual.
• All ship’s staff shall be encouraged to prepare realistic risk assessments and conduct effective tool box meetings that discuss the actual conduct of a job in explicit detail. It has to be reiterated to the crew that a tool box meeting is the opportune time to review the process of work and discuss any preoccupations.
• The second engineer should attend the in-house risk assessment course/safety officer course prior to his next employment on board a fleet vessel.

Editor’s note: The company investigation quite rightly found that safety leadership was lacking. When company leaders do not follow procedures or lack proper training in risk assessments and hazard identification, accidents and incidents are bound to happen with greater frequency and consequence than is reasonably acceptable.

Good BRM Saves the Day: Mars 201427

The vessel was proceeding to an anchorage area under pilotage on a heading of 025º. At the time, there were many ships anchored on the vessel’s port side, the closest only about one cable away. At a point where the vessel was to alter course to port to enter the anchorage, the pilot ordered 315º. The Master, who was present and monitoring the pilot’s actions as well as all rudder and engine movements, immediately realised the order was incorrect. He countermanded the course order and instructed the helmsman to remain, for the time being, on 025º.
A short discussion with the pilot ensued. The pilot admitted the error and corrected the course to steer, ordering 015º.

Lessons Learned

Under pilotage, the vessel’s crew have a duty to closely monitor and interact with the pilot. Anyone can make a mistake. Good BRM means mistakes by one member of the team are spotted and stopped early and consequences are reduced.2

If You Are Tired, Do Not Sit Down: Mars 201428

Edited version of official Marine Accident Investigation Branch (UK) report 26/2013

After loading, the vessel left port at 2300. The Master decided that the AB assigned to the 0000-0400 watch would not be required for lookout duties. Near midnight, the second officer arrived on the bridge to relieve the Master. After plotting the vessel’s midnight position on the chart, the Master handed the watch to the second officer but remained on the bridge to complete some paperwork and to monitor the vessel’s transit through some restricted waters. Once in more open water, the second officer engaged the autopilot and the Master left the bridge for some rest.

At 0256, the vessel reached a waypoint and the second officer adjusted the vessel’s course to 311º. He then went out to the starboard bridge wing to get some fresh air. When he returned to the wheelhouse, he secured the starboard bridge door in the fully open position and sat in the port bridge chair. Shortly afterwards he fell asleep. The vessel passed the next planned waypoint and maintained her course for just over 2½ miles, at about 10.5 knots. The OOW woke up and, sensing something was wrong, he immediately moved the engine control to neutral, and then full astern, but the vessel grounded nonetheless.

At the time of the accident, the wind was south-westerly force 3, the sea was calm and the visibility was good.

Some of the Findings of the Official MAIB Report

• While ergonomically efficient, the bridge design encouraged the OOW to sit down, which increased the potential for him to fall asleep.
• The OOW’s method of navigation provided little stimulation and allowed him to remain inactive for extended periods of time which further increased the potential for him to fall asleep.
• Although the OOW had gone out to the starboard bridge wing to get some fresh air, and had then secured the starboard bridge door in the fully open position, his actions were insufficient to prevent him from falling asleep.
• The lack of a lookout removed a valuable control measure in that his interaction with the OOW might have prevented the latter from falling asleep. Additionally, if a lookout had been present on the bridge, he would have been in a position to immediately wake the OOW.
• Routine absence of a lookout on watch at night without incident would have reinforced a belief that it was safe to operate the vessel in that way, and would have influenced the Master’s decision not to employ a lookout on this occasion.
• The OOW was possibly fatigued when he arrived on the bridge for his watch. The bridge navigation watchkeeping alarm system (BNWAS) was probably not switched on during the period leading up to the grounding, and the ECS and GPS audible alarms were insufficiently loud to wake the sleeping second officer.
   

Position of grounding

Editor’s note: If you are tired, or even you are not, at such early hours anyone can fall asleep if in a comfortable position. The best remedy is to occupy oneself with watch keeping duties of position fixing, radio watch, and lookout, including effective use of radar by regularly changing scales. If you feel yourself very tired, get some help. Also, never work alone at night; have an effective lookout posted at all times in darkness and in reduced visibility.

A Senseless Close Call: Mars 201429

As edited from official Transportation Safety Board (Canada) report M12L0098

A tug pushing a loaded barge had left port and was outbound. The weather was clear and winds were from the west-southwest at 10 to 15 knots with 1.5 metre seas. The tug and barge were abeam and clearing Pointe à la Chasse and the only immediate traffic in the vicinity, as reported by vessel traffic, was a cargo vessel that was heading for a port further west. At this point the Master on the tug handed the con over to the OOW and left the bridge; the vessel’s course was 216° and speed was 6.5 knots.

Soon afterward, the OOW detected a target on the radar; the target was on the tug’s port side at about 12 nm. The OOW acquired the target with the automatic radar plotter and also verified the information on the automatic identification systems (AIS). The AIS identified the target as the cargo vessel mentioned by vessel traffic and indicated the closest point of approach (CPA) to be approximately 0.3 nm. The automatic radar plotter confirmed the CPA and indicated the cargo vessel would cross ahead of the tug.

Tug and barge

Cargo vessel

Since the tug was the stand-on vessel, the OOW maintained course and speed and continued to monitor the cargo vessel. About 40 minutes later the cargo vessel was within 4.6 nm and had not yet altered course. The OOW, concerned about the developing close quarters situation, attempted to call the vessel on VHF, but was unsuccessful.

Only when the vessels were about 3.3 nm from each other, with a CPA of approximately 0.25 nm, did the OOW on the tug finally make contact with the OOW of the cargo vessel. The tug OOW asked the cargo vessel’s OOW his intentions and if he would alter to starboard to pass astern of the tug. The request was rejected by the cargo vessel’s OOW. He made an alternative proposal that both vessels should alter course a little to port in order to increase the CPA. This proposal was justifiably rejected by the tug’s OOW based on the collision regulations.

Tug and barge and cargo vessel track

Soon, both OOWs had called their respective Masters to the bridge for assistance. When the Master of the cargo vessel arrived on the bridge and saw the tug and barge close on the starboard side, he ordered to reduce speed to half ahead on the telegraph. VTS also advised him that the tug and barge was requesting their vessel alter course to starboard in order to pass astern. The cargo vessel’s Master responded that they would try; the vessels were about 2 nm from each other with a CPA of approximately 0.25 nm. Unclear as to the cargo vessel’s intentions, the Master of the tug sounded one short and one long blast on the whistle to alert his crew, then reversed engines to stop and let the cargo vessel cross ahead. No manoeuvring or warning whistle signals were sounded; however, the Master broadcast the manoeuvre astern on VHF radio.

Shortly after, vessel traffic advised the Master of the cargo vessel that the tug was reversing engines. The cargo vessel acknowledged the call and replied that they would maintain course and speed and pass ahead of the tug and barge.

Findings of the Official Report

• The cargo vessel maintained course to pass across the bow of the tug without taking action to avoid the close quarters situation, resulting in a risk of collision.
• Following VHF radiotelephone communications, the tug remained unclear as to the cargo vessel’s intentions and did not sound the appropriate whistle signals to indicate their doubts. The tug maintained course and speed until it became apparent that the cargo vessel was not taking action.
• Upon arriving on the bridge, the Master on the cargo vessel reduced the vessel’s speed prior to assessing the situation, further reducing the CPA.

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, DNV, Gard, IHS Fairplay Safety at Sea International, International Institute of Marine Surveying, Lairdside Maritime Centre, London Offshore Consultants, MOL Tankship Management (Europe) Ltd, Noble Denton, North of England P&I Club, Sail Training International, Shipowners Club, The Marine Society and Sea Cadets, The Swedish Club, UK Hydrographic Office, West of England 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.