New Mars Reports Online

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. The latest reports are now posted online.

Mars (Marine Accident Reporting Scheme) Report is one of the regular sections of SWZ Maritime. The reports are also published online, as they may prevent other accidents from happening.

Mars Report No. 269

Serious Injury While Greasing: Mars 201513

The deck team undertook the greasing of the aft mooring winches. Using a grease gun, an O/S began greasing a winch. The O/S was holding the hose of the grease gun with his right hand while resting his left hand on the groove where the winch gear is engaged.

The bosun, unaware that the O/S was resting his left hand on the groove of the winch engagement, ordered another seaman to turn the winch slowly to maximise the greasing effect. Suddenly, the O/S using the grease gun shouted ‘Stop, stop, stop’. The winch was stopped immediately, but not before the gear had seriously wounded his hand. The victim was treated for deep lacerations in the hospital and repatriated, being declared unfit for work for fourteen days.

The bosun was unaware that the O/S was resting his left hand on the groove of the winch engagement.

Lessons Learned

1. While there was certainly inadequate supervision during this job, miscommunication and a lack of situational awareness among team members also played a large role in the outcome.
2. Although the team had experience with this relatively mundane task, they failed to appreciate the hazards present in such an activity.

Editor’s note: Mundane, everyday jobs can, in some ways, be considered more hazardous than unusual or special tasks. With the latter, we usually take the time to analyse risks, communicate efficiently as a team, and retain high situational awareness. Everyday jobs can find us slipping into complacent behaviour, and when we become complacent, bad things happen.

Risky Behaviour: Mars 201514

As edited from the Confidential Hazardous Incident Reporting Programme (Chirp)

A manager has sent several reports of incidents regarding pilotage in different parts of the world. In the first, the master was concerned that the pilot was making excessive use of his mobile phone while piloting the vessel. This was compounded by the pilot’s refusal to take advice on his behaviour from the master.

In a second report, the master of another vessel was concerned that the pilot was apparently under such time pressure that he did not initially wish to spend time discussing the proposed plan for departure from the port. The pilot was initially reluctant to order the tug to make fast to the ship – ‘There is no time for that!’ The vessel then passed too close to another moored ship. Finally, the pilot disembarked before the vessel was clear of the port entrance.

In both cases, the masters, with the full support of the manager, had reported the incidents to the appropriate local authorities. On subsequent visits to the ports, significant improvements have been noted.

Lessons Learned

• Mobile phones and proper conning/vessel navigation do not mix well.
• A review and discussion of the proposed passage plan is essential. ‘Poor planning produces poor performance.’
• There should always be ‘time’ for safety.

Safe Haven Not Safe: Mars 201515

Edited from the Marine Safety Forum – Safety Flash 14-34

An anchor handling tug (AHTS) was deploying a 15 ton anchor during a pre-lay operation. Deck personnel were using tugger wires with an endless chain sling connected through the anchor D-shackle to move the anchor along the deck and over the stern roller. During the operation, the rigging assembly (endless chain) parted and both tugger wires recoiled around the cargo barrier. Even though the deck crew were positioned in so-called safe havens, a crew member was struck on the head by a tugger wire and suffered a fractured skull and jaw as well as lacerations to the neck. The victim was provided with medical treatment on board the vessel and transferred to hospital for surgery.

Schematic overview of the accident showing where the chain sling parted.

Lessons Learned

• Snapback zones were not adequately identified during the job planning.
• The safe haven for deck crew was not adequately assessed.
• Procedures did not incorporate calculation of expected loads, sizing/ selection and use of rigging and its limitations.
• Small wire and loose rigging equipment failure has become “accepted practice” on many AHTS vessels.
• Chain slings are not to be used in configurations such as in this accident due to reductions in Minimum Breaking Load (MBL) as a result of a non-linear pull and rigging around sharp edges. In these circumstances it is possible to have a reduction in MBL of up to fifty per cent.
• When wires and equipment are under tension, no personnel should be located aft of a line extending between the most forward tugger winches on both sides of the cargo rail. The only exception being to take control of anchor handling safety systems such as check of shark jaws.

NB. The use of a higher grade of chain (120 for example), designed specifically for extreme conditions, should be investigated to improve the factor of safety during such operations.

No Rest for the Weary: Mars 201516

A master has sent Mars the following real-life example of the difficulties of getting enough sleep on certain vessels, in this case a livestock carrier:

• 0500: Crew called for stations for picking up anchor and berthing.
• 0600: Pilot on board.
• 0730: Vessel alongside and all made fast.
• 0800: Authorities including PSC and quarantine board vessel.
• 1000: Quarantine inspection of the vessel and cargo spaces completed.
• 1030: Port state authority preload inspection commences as is required prior to loading livestock.
• 1900: Vessel inspection completed. A few deficiencies were identified during the inspection which required class attendance.
• 2000: Class surveyor attends vessel.
• 2200: All deficiencies closed and vessel cleared for loading.

In the meantime, crew are also busy attending other activities such as fodder loading, receiving stores, spares and provisions. While the inspection is in progress, the entire deck crew, master, chief officer, cadets and duty officer along with engine room personnel are attending the inspection. After the vessel is cleared for loading, the chief officer and his team are busy preparing the vessel to receive the livestock. The master is busy with e-mails, communicating to all parties the results of the inspection and forwarding all relevant documents.

Readers will understand the problems in complying with STCW and MLC regulations on work and rest hours.

Lessons Learned and Recommendations

• Commercial managers, including exporters should be informed/educated about shipboard work/rest requirements.
• If we are to comply with hours of work/rest, there has to be a shore-driven effort to ensure this can be done.
• Suggest allowing a “cooling off” period for at least four hours after completion of cargo work prior to commencement, allowing ship’s crew to take some rest, meals et cetera.

Editor’s note: STCW gives a regulatory framework for work/rest, which admittedly is hard to adhere to under certain commercial conditions; yet within this convention is what can be considered a fatal flaw. It specifies that the hours of rest ‘may be divided into no more than two periods, one of which will be at least six hours in length.’ Since the minimum standard is set by this convention, natural commercial pressures push operators to that level – hence the often maligned “6 on/6 off” system. Scientific studies have shown that restorative sleep is only acquired after seven to eight hours of rest.

Coast Assisted Collision: Mars 201517

Edited from Maib official report 25/2014

A general cargo vessel was making way in a busy traffic separation scheme (TSS). A bulk carrier was abaft the vessel’s starboard beam at a distance of 1.7 nm and slowly overtaking.

Positions of the general cargo vessel and the bulk carrier.

The OOW of the general cargo saw another vessel forward, 20° off his starboard bow at 3.9 nm and with a CPA of 0.1 nm. He did not acquire the vessel on the Arpa or use the AIS data to determine the vessel’s name or status. However, he assessed that the vessel was crossing their bow from starboard to port so he judged his vessel was the give way vessel.

As it turned out, this was a fishing vessel engaged in fishing, not a crossing vessel. The fishing vessel began to manoeuvre to port to stay away from the commercial traffic, but the OOW on the general cargo vessel did not immediately notice this. When he did notice the change of course, he was confused as this did not match his mental picture of a vessel crossing the traffic lane. His response was to continue to alter to starboard, putting the fishing vessel about 30° off his port bow. By now he was becoming unsure of what to do – and in the following two minutes he made several alterations of course to both port and starboard. He was still unaware that this vessel was a fishing vessel that was manoeuvring out of his way.

Within seconds, the bulk carrier’s OOW noticed the cargo vessel was turning quickly towards him and a collision could not be averted.

The coast guard TSS services, seeing the movements on radar, became aware that an ambiguous situation was developing and called the OOW of the general cargo vessel. A short conversation ensued and the TSS services inquired if the general cargo vessel was executing a 360° turn. Although this was not the OOW’s plan, he replied in the affirmative to TSS services; immediately after this conversation, the OOW selected hand steering and applied 35° starboard helm. Since the vessel was equipped with a high lift rudder the rate of turn increased rapidly. He did not realise that the bulk carrier was now about 500 m off his starboard beam.

Meanwhile, the bulk carrier’s OOW had also been contacted by the TSS services and after a short conversation, this OOW ordered hard port helm. Although he had been monitoring and was now aware that the general cargo was to do a 360° turn, he did not think this manoeuvre was already underway. He assumed that the general cargo would pass ahead before starting the 360° turn. But within seconds he noticed that the cargo vessel was turning quickly towards him so he immediately ordered hard starboard helm. Nonetheless, soon afterwards the two vessels collided.

The damage on one of the two vessels resulting from the collision.

Lessons Learned

Although the fishing vessel had started to alter course in order to clear the traffic lane and avoid impeding the safe passage of the two larger vessels, this alteration was not seen by the general cargo vessel’s OOW for over five minutes. This implies that the general cargo vessel’s OOW was neither keeping a proper visual lookout, nor effectively using the electronic aids available.

The intervention on VHF radio by the coast watch officer was timely, appropriate and well-intended. However, because of the language used, it unintentionally influenced the decision-making of the general cargo vessel’s OOW and prompted him to improvise a 360° turn, unwittingly turning towards the bulk carrier.
The general cargo vessel’s OOW suffered a complete loss of situational awareness. He was unaware of the proximity of the bulk carrier until the vessels collided.
The general cargo vessel’s OOW was very inexperienced, as shown by his inability to make sense of the fishing vessel’s actions and his total loss (or lack) of situational awareness. He had not yet developed sufficient competency to keep a bridge watch in a busy TSS at night by himself.

As it turned out, the general cargo vessel’s OOW had been in charge of only ten bridge watches before the accident and the master had only known him for about two weeks. It is not known why the master was sufficiently confident of the OOW’s abilities to entrust him with the bridge watch in such a congested area at night.
The general cargo vessel’s OOW was the sole lookout notwithstanding darkness. An additional lookout was rarely, if ever, employed on board the vessel.

Editor’s note: The Mars archive contains many incidents and accidents where the OOW is the sole lookout in darkness. Yet it is an implicit requirement within STCW to keep a separate dedicated lookout on the bridge, in addition to the watchkeeper, during the hours of darkness and in busy shipping areas while underway. The editor is curious to know how any company that is ISM certified (or simply values safety and quality) can escape this requirement given the plethora of port state inspections, internal and external ISM audits – not to mention common sense, risk management and best practices.

Caught in a Bight: Mars 201518

Edited from official Australian Transportation Safety Bureau 2014-005

A vessel that had been assisted by a tug was preparing to let go the tow. In preparation for letting go, seaman 1 ran the messenger line over the drum end of the mooring winch, while seaman 2 operated the winch to pull about two metres of tow line in board. The second mate wrapped the rope stopper around the main tow line while the messenger line was taken off the drum end and the eye of the tow line taken off the mooring bitts. The messenger line was then put around the forward post of the mooring bits to assist with the controlled lowering of the tow line.

On board the tug, a crew member was standing on deck near the winch, ready to guide the tow line onto the winch drum. Another crew member was at the remote winch controls inside at the port bridge console. The crewmember controlling the winch waited until he saw the tow line being lowered before he started heaving in. As the tow line was retrieved, seaman 2’s right leg somehow became entangled in the messenger line. He was then dragged about four metres across the deck and into the rollers of the fairlead. When his legs entered the fairlead, the messenger line came under tension and it severed the seaman’s right foot.

Positions of the crew members and the messenger line.

Both crew on the tug had seen the messenger line go tight and the crew member at the winch control stopped heaving. The assisted vessel’s second mate ran to the ship’s rail and signalled to slacken the line. Medical assistance from ashore was quickly requested and the victim was transported to hospital for treatment.

Findings from the Official Report

From his position at the port bridge console, the crew member controlling the winch could see the tow line, the winch and the signalling crew member on the tug’s deck. However, due to the freeboard of the assisted ship, no one on board the tug could see past the ship’s main deck hand rails. As is usual, the tug’s crew had no direct radio communications with the ship’s aft mooring team, and were therefore reliant on visual contact with the mooring team for all communications.
By assisting the two seamen with releasing the tug’s line from the bitts, the officer was not at the ship’s side where he would have had a clear line of sight of the tug; he had thus relinquished his supervisory role. When the seaman became entangled in the messenger line, there was no one on the assisted vessel in a position to quickly signal the tug’s crew to stop heaving or slacken the line.

Lessons Learned

Mooring operations are often seen as a routine task, but contain dangers that are often not realised until it is too late. As the forces that can be exerted on mooring and towing line cannot be directly observed, they are often underestimated by those working around them.
Serious injury is likely when there is an incident during tug and mooring operations, but the likelihood of such an occurrence can be managed through effective risk assessment, training, supervision, communications and good housekeeping – both prior to and during berthing operations.

View of assisted ship from tug bridge console.

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.