New Mars Reports

The number of reports the Nautical Institute receives is still declining, with the Mars editor barely able to create a substantial monthly report. Save Mars and submit your report! Below the full March report, a selection of which will also appear in SWZ Maritime's February issue, to appear Friday 20 March.

Mars Report No. 268

Small and Manoeuvrable, But Still out of Control: Mars 201507

On a clear night, a small feeder ship with controllable pitch power (CAP) was brought out of a restricted port in order to shift berth from port to starboard side. It was to be turned around and brought back in.

A passage plan was presented and discussed during the master/pilot exchange prior to leaving the berth. The passage down river to the sea was uneventful. The vessel turned outside the port and began the approach to re-enter.

While passing the breakwaters, the vessel’s speed was approximately 8.5 knots (forty per cent pitch). As they progressed in, the gyro was checked against leading lights and found to be out by up to 8°. The pilot suggested that another bearing be taken on the inner harbour leading line. During this phase of the transit, verifying the gyro occupied the bridge team to a great extent.

On approaching the jetty, the pilot ordered a reduction of speed to minimal ahead. The pitch was subsequently reduced from forty to ten per cent, but this sudden reduction caused a large swing to port. The pilot ordered starboard helm and more propeller pitch to aid steerage. Now at about 2-3 cables from the terminal berth, the pitch was put to zero per cent and then full astern, which swung the bow to starboard. This resulted in the vessel grounding south of the terminal berth at about 3 knots.

Coming full astern brought the vessel off the ground very quickly, but caused the stern to swing rapidly to port. The vessel then made heavy contact with the south jetty on the opposite side of the river. At this point, control of the vessel was regained and the vessel completed berthing starboard side to at the terminal berth.

Map of the area.

Lessons Learned

• The gyro error distracted the bridge team during a critical period of the berth approach.
• Background lights and darkness made visual observation of the berth, and the closing distance, more difficult to judge.
• The master was unaware of the pilot’s contingency plan, which was to overshoot the berth (go further up-river). This was not communicated during the master/pilot exchange.
• As is common with CP power vessels, the abrupt decrease of speed caused the vessel to lose steering and take a shear.
• The master played a passive role during the manoeuvres and could have been more aware and involved in the handling of the ship and its movements.

Expired Flare Improperly Discarded: Mars 201508

Marine Safety Forum – Safety Flash 14-32

A discarded marine flare ignited on the picking line at a depot where ship’s garbage is sorted. Fortunately, there was no injury to personnel, but some damage was done to the conveyor belt.

Flares and other special wastes should not be disposed of within the waste receptacles provided by the port for the use of ships. Disposal of expired ship’s flares or any marine pyrotechnic should only be arranged through an approved provider for such services.

Flares and other special wastes should not be disposed of within the waste receptacles provided by the port for the use of ships.

Being Tough May Not Be Enough: Mars 201509

Edited from Marine Accident Casebook

There are concerns that freefall lifeboats being installed in vessels currently under construction may not be compliant with the Life Saving Appliance (LSA) Code. Despite type-approval and acceptance by a major classification society the design does not comply with the LSA Code (Chapter IV 4.7.2.2), which calls for at least 650 mm free clearance in front of the backrest. In this design, the distance is only about 150 mm. Under certain circumstances, such a limited distance can be dangerous or even fatal to any person sitting in that seat. In addition to the personal injury hazard, the non-compliance could put the vessel at risk of detention in the event of a port state control inspection.

Efforts are underway to resolve the situation with the lifeboat manufacturer in question. However, the same issue may arise with other lifeboat designs, and crew should be aware of the issue.

Lessons Learned

1. Even classification societies and the class inspector on board during the vessel construction can make mistakes or miss something. Mariners should remain vigilant as ultimately, they will be the ones using the equipment.
2. Ship owners, masters and mates should ensure that lifeboats aboard their vessels are compliant with the LSA Code and, in the event of non-compliance, advise their owners and class society.

Gangway to Heaven: Mars 201510

Edited from UK P&I Club Technical Bulletin 42-2014

Many serious injuries (or deaths) are caused by falls from gangways or embarkation ladders. Vessel risk assessors frequently see gangways that are badly rigged or otherwise in a poor condition and witness dangerous working practices.

Often, accidents occur while the gangway is being rigged. Rigging the stanchions and the side ropes is inherently dangerous as there can be little for crew members to hold on to until this is completed. On the other hand, many ships are now fitted with a gangway safety wire to which the safety harness line can be attached or even fall inertia blocks which allow for greater freedom of movement.

No lifejacket or safety harness.

Consider how best to rig stanchions and safety chains. In the photo below on the left, it is clearly difficult to step onto the bottom platform from the bow of the launch, while on the right, access from a launch to the gangway or vice versa is much easier.

The picture on the left shows it is clearly difficult to step onto the bottom platform from the bow of the launch. On the right, access from a launch to the gangway or vice versa is much easier.   

The bottom platform is not horizontal.

Other common faults with gangways include incorrectly rigged safety nets, slack sidelines, slippery steps and loose or missing stanchions.

Missing stanchions.

The gangway safe weight limit (SWL) is often unrealistically large, sometimes as much as one person per step. Although the physical static strength of the gangway and wire could probably bear this number of persons, the dynamic load (bouncing effect) should be considered.

Unrealistic SWL.

Lessons Learned

1. Crew should always wear a safety harness and lifejacket while rigging a gangway. Even though installing a safety harness line can sometimes be difficult and movement restricted by the length of the harness line, a life saved is well worth the effort.
2. Gangways should be inspected regularly. Particular attention should be paid to areas where there are aluminium alloy to steel connections. The absence or deterioration of the insulating gasket can lead to electrolytic corrosion, which will cause wastage and hence weakening.
3. Ensure a proper and realistic SWL is indicated on the gangway. Strictly enforce this limit, even when stevedores, agents, inspectors and chandlers want to board “en masse” as soon as they are able.
4. Gangways should never be raised or lowered when personnel are on them.
5. In certain situations, the use of pilot ladders may be the safest, or only, option. However, as their name infers, these are mainly for the use of pilots who are specifically trained in their use.

A Small Defect Leads to a Large Collision: Mars 201511

Edited from official BSU accident report 417-13 (Germany)

A small container vessel was making way in a restricted waterway under pilotage. Earlier that day, there had been intermittent main engine problems due to a drop in lubricating oil pressure, but the exact cause of the reduced oil pressure was not yet known. The vessel decided to overtake a much larger container vessel. As it was overtaking, the lubricating oil problem occurred again, and main propulsion on the small container vessel automatically shut down.

Hard starboard rudder was quickly applied, but the vessel became un-manoeuvrable and was drawn to port towards the larger vessel due to hydrodynamic interactions. The forecastle of the smaller ship rammed into the starboard side of the larger vessel’s aft section at an angle of about 60°. The force of the collision caused fifteen containers on the smaller vessel to fall overboard. Due to the ebb current and the loss of manoeuvrability, the smaller vessel then ran aground outside the fairway. Both ships sustained material damage above the waterline and the fairway had to be temporarily closed to transiting shipping.

Fifteen containers fell overboard.

Lessons Learned

1. The loss of main propulsion on the smaller container vessel caused a reduction in speed, among other things, and made the vessel un-manoeuvrable. Hydrodynamic effects then took over and caused the smaller vessel to move unavoidably towards the larger.
2. Even after extensive investigations it was not possible to conclude, with absolute certainty, the cause of the oil pressure drop of the main engine. However, seizure marks were found on the discharge piston of the pressure control valve of the lubricating oil system. The most probable theory is that this valve became blocked in the fully open condition from time to time enabling a disproportionately large amount of lubricating oil to flow back into the retention tank.
3. Considering the vessel had several episodes of main engine problems during the day, it would appear that insufficient attention was given to the risk of an accident due to this anomaly during the time the vessel was in the restricted waterway.
4. VDR data for the time of the accident on the small container vessel was not available for the investigation. No technical faults were found on the VDR; it is likely that the data backup button was not pressed as per the manufacturer’s specifications. It may have been held down for either less than the two seconds specified by the manufacturer, or longer than the maximum five seconds.

Pressure control valve as installed.

Editor’s note:  Since the introduction of VDRs, accident investigation and hence root cause analysis has made great strides. However, a lack of VDR data subsequent to an accident, as in this case, is still all too common. Owners and operators that value safety should consider regular testing of this equipment and ensure clear, vessel-specific procedures on how to operate the VDR. Test procedures can even include the use of the VDR “test data” for navigational audit purposes, thus accomplishing two important tasks at once.

Broken Gear Deals a KO Blow: Mars 201512

Stevedores were securing containers on board a vessel with chain slings. During the securing of one container, the chain broke at the hook and hit a stevedore on the head. The stevedore’s helmet took the brunt of the impact and was cracked in the process. The victim was treated with stitches and had to take eleven days medical leave.

During the investigation, the master was asked to show the schedule of inspection/ maintenance of the lashing equipment, but none was available.

The broken hook.

Lessons Learned

• Although inspecting chains and lashing equipment is an arduous task, it must be done and proper records have to be kept on board.
• Fortunately, the stevedore had his protective helmet on, yet still received stitches and many days of recuperative leave. Imagine the injury and lost time had he not had his helmet.
• The contributor of this report suggests that one way inspection and maintenance of such gear on busy vessels can be adequately carried out is by leaving it to properly trained personnel at a shore workshop. Readers with experience in this area who would like to share their best practices with others are invited to send their comments to mars@nautinst.org.

From the Editor

Last year, the Mars editor made a heartfelt plea for more reports from readers; Mars was clearly at risk as the number of reports was sinking below sustainable levels. Mars appears to be highly appreciated by a great number of readers, but it can only continue with your support and contributions. A few paragraphs is all that is needed, and preferably a few photos too. No names will appear nor identities be revealed. Reports can simply be e-mailed as text or you can use our simple reporting form to help guide you. Both e-mail address and reporting form can be found on the Mars web page.

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.