May Mars Reports

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. 270

Aborted Berthing: Mars 201519

A small general cargo vessel in ballast was to enter a port to load logs with drafts fore and aft at 3.5 and 4 metres respectively, with winds from the north at Beaufort force 7. At 10:30, after the pilot boarded, there was a short conversation on the berthing manoeuvre and the vessel headed inbound. The pilot requested the stern line to be secured first to hold the stern. About six minutes later, the master asked the pilot to repeat the details of the berthing manoeuvre. He also asked if a tug was necessary. The pilot repeated how he intended to back in and pivot and also replied a tug would take six hours to arrive.

At 10:40 the bow thruster was put to full port and three minutes later the main engine to full astern. The vessel soon started to go astern. As the vessel approached the berth, the pilot shouted to send the heaving line. The line was sent and a mooring line set on the berth, but the mooring winch could not hold the stern, which was drifting south away from the berth. At 10:54 the pilot ordered to let go and full ahead in an abort manoeuvre. Hard to port helm was also ordered and applied, but a grinding noise was heard at about this time.

The vessel was manoeuvred out of the port without further incident and anchored. Divers attended later and found a large bundle of rope fender in the propeller, which itself was slightly damaged.

As it turned out, the master had only recently been promoted to captain.

Some of the actions taken and lessons learned by the company:

• Proper training for the ship’s masters/crew was scheduled with reference to proper passage planning, bridge resource management and seamanship.
• The procedures of promotion of seafarers, evaluation of seafarers and office visits by seafarers was to be reviewed. Feedback/findings (verbal or in writing) from office departments have to be incorporated in these procedures.

Editor’s comment: By any measure, this berthing was attempted on a wing and a prayer. With a strong wind pushing south, away from the berth, no tug assistance, and a flotilla of small boats and buoys just south of the berth, the bridge team appears to have given little forethought to the manoeuvre. Given the conditions, the consequences could have been much worse. An inexperienced master and an apparently impatient pilot met at the wrong time in the wrong place.

Towing Vessel Becomes the Towed: Mars 201520

As edited from official Maib report no 29/2014

A multi-purpose cargo ship was making way in a busy TSS at about 15 knots at night and with a sole OOW on the bridge. The vessel was gaining on a tug towing an unmanned crane barge about 6 nm ahead. The tug and tow were proceeding at 6 knots and keeping to the northern edge of the traffic lane to enable other vessels to pass down its port side. The length of the towline was 250 metres.

When the cargo ship was almost at the level of the tow, the OOW adjusted the autopilot to port in order to overtake the tug on its port side. Seconds later, the vessel collided with the unmanned crane barge; then continued to pass between the crane barge and the tug, catching on the towline on the way through. The OOW on the cargo ship quickly reduced the ahead pitch on the CPP, but his vessel continued to overtake the tug. On the tug, the lead of the towline moved from astern to ahead, which pulled the tug through 180° and now saw the tug being towed stern-first by the cargo ship.

The tug’s OOW immediately took the main engine out of gear and shouted down to the accommodation to warn the rest of the tug’s crew of the situation. Seconds later, the bitter end of the towline broke free from the towing drum; the tug stopped in the water with the unmanned barge off its starboard side. The barge’s wheelhouse had been set forward in the collision and crushed. The jib of its crane was buckled, guardrails bent, the tow’s hydraulic winch motor seriously damaged and several hydraulic connections ruptured. The cargo vessel suffered a gash in the forecastle.

Some of the analysis and findings of the official report, as edited, are:

• For nearly 55 minutes before the collision, the radar targets associated with the tug and barge were clearly visible on the X-band radar of the cargo vessel. Additionally, the aft lights on the tow would have been visible from the cargo vessel for at least twenty minutes before the collision. The OOW had ample time to detect, assess and take avoiding action.
• The OOW had not been keeping a proper lookout and had only seen the tug just before he altered to port; he failed to see the unmanned barge at all.
• It is almost certain, as deducted from the sequence of events, that the cargo vessel’s OOW was relying solely on Ais information as shown on the Ecdis, but the tug and barge were not transmitting Ais information.

The damage to the cargo vessel and barge.

• The radar targets directly ahead and closing should have prompted the OOW to look out of the window and attempt to correlate the targets with visual information. As he took neither of these actions, and the targets were on the radar for almost one hour, it is likely the OOW was not monitoring this instrument at all.
• The level of arousal of the cargo vessel’s OOW was low. Consequently, he was not proactive in maintaining his situational awareness or reactive to changing circumstances. This is supported by his failure to use radar or Arpa and to keep an effective visual lookout.
• It is impossible to determine whether a lookout’s presence on the bridge would have assisted the OOW in making a more accurate assessment before altering towards the barge. However, it would have increased the probability of the tow as well as the tug being seen. A lookout’s presence would also have probably helped keep the OOW alert.

Lessons Learned

For collision avoidance, a balance needs to be struck between overreliance and effective use of Ais. In this case, the OOW’s apparent exclusive use of Ais information displayed on Ecdis indicates he was not aware that many vessels, such as small fishing vessels, leisure craft, warships and vessels under 300 gt, might not be displayed.

Faulty Interlock + Faulty Training = Uncontrolled Descent: Mars 201521

As edited from official ATSB report No. 275 MO-2010-004

The crew of an LNG tanker were in the process of lowering the fast rescue boat (FRB). The FRB was nearly 6.5 metres in length, weighed 2200 kg and could be launched from a remote control unit (as below) or from inside the boat, using a winch brake release wire. As one crew was about to release the brake to lower the FRB, another crew reached across and pressed the “wave compensator” button on the remote control unit. His understanding was it must be activated before the boat reached the water. As soon as this button was pressed, the FRB descended at high speed hitting the water about 18 metres below.

Several of the FRB crew were seriously injured and had to be evacuated.

The wave compensation feature was designed to ensure there was continuous tension on the fall wire when the FRB was riding the sea swell. When active, the lifting capacity of the davit was reduced by approximately ninety per cent to around 300 kg; the davit winch would continuously tension the fall wire, but would have insufficient power to lift the FRB.

The manufacturer’s instruction stated that the wave compensation feature should only be activated when the FRB was waterborne. As an additional safety measure, to prevent the wave compensation unit from activating if the wave compensator button was pressed before the FRB was waterborne, the system was fitted with a safety interlock. In this case, the safety interlock did not function correctly.

The wave compensator was activated before the FRB hit the water.

Lessons Learned

• The FRB davit wave compensator safety interlock did not operate as designed to prevent the fast rescue boat from free falling to the water. It was found the safety interlocks on the wave compensator systems on board this vessel and two sister ships had been electrically by-passed thereby preventing them from functioning. As a result, the wave compensators on board all three ships could be engaged regardless of whether the FRB were waterborne or suspended from the fall wire.
• The maintenance and testing of the FRB davit by approved service agents had not identified that the wave compensator safety interlock was not correctly functioning on board the vessel.
• The training provided to the crew did not ensure they were sufficiently familiar with the function or operation of the wave compensator or its safety interlock.
• The FRB manual, as supplied by the manufacturer, did not provide sufficient guidance for the crew in the operation of the wave compensator and its safety interlock.
• The job hazard analysis for the operation of the FRB was incomplete and did not include an assessment of the hazards associated with the operation of the wave compensator.

Short Training Proves Insufficient: Mars 201522

As edited from official TSB report M13L0067

A new mate joined a small inland passenger vessel for his first day of work. That same day, with the new mate (OOW) at the wheel and the master guiding him, the vessel was navigated on a typical day cruise that lasted 1.5 hours. Later that same day, the vessel embarked on an evening cruise, following a different route than the afternoon cruise. Under the master’s guidance, the OOW was at the helm again for most of the two hour cruise, all the while learning the various courses and alterations.

The next day in the ebbing tide, the vessel left for a harbour cruise following the same route as that of the previous afternoon; the OOW was at the helm and the master remained on the bridge, but was doing paperwork and making phone calls. As the OOW continued to steer the vessel, the master turned periodically and looked out the window. At one point, the OOW asked the master if the alteration to port could be initiated. The master looked out, then agreed; the OOW then altered to port.

Over the next four to five minutes, as the vessel crossed the channel in a north-easterly direction, the OOW searched in vain for the leading lights, normally between two anchorage buoys, indicating the secondary channel. He was navigating visually, not utilising the bridge navigational equipment or charts. While still looking for the leading lights, the OOW glanced at the echo sounder and noticed the water depth was decreasing. The vessel was making approximately 10 knots and a course over ground of approximately 027°. He then glanced at the ECS and alerted the master, who quickly ordered the rudder hard to port. The OOW put the helm to port, but at the same time the vessel struck the river bottom and remained grounded.

Some of the findings and lessons learned from the official report were:

• The OOW focused on finding a visual reference and did not utilise the bridge navigational equipment to effectively monitor the vessel’s progress as it proceeded off the intended course and went aground.
• During this time, the master was not participating in or supervising the navigation of the vessel, and there was no communication between the master and the OOW. As a result, the deck watch was effectively composed of a single person who was expected to fulfil all of the tasks of navigation, maintaining a lookout and steering.
• The master did not assess the OOW’s understanding of the navigational requirements for the intended voyage following the familiarisation trip on the previous day, and there was no documented plan for the OOW to use for guidance.

The master did not supervise the navigation and the vessel became stuck on the river bottom.

Tight Coil/Slow Rescue: Mars 201523

When I was a cadet, one of my friends drowned after he fell from the gangway into the water. Since that time, I have taken particular interest in lifebuoys with lifelines. Now, when I visit ships as a marine safety inspector and auditor, I often find the lifebuoy line coiled as a tight “sausage” (see the left of the picture below). When coiled in this manner, it takes, on average, two minutes to unravel before the buoy can be thrown into the water.

The proper way to coil a rope for quick and easy use is illustrated in the pictures 1 through 5 below.

The wrong and right way to coil a rope on a life buoy.

Hand Injury During Mooring Operations: Mars 201524

A bunker barge was approaching the port side of a Platform Supply/Multi-Purpose Vessel (PSV) at anchor, for bunkering operations. The crew of the bunker barge passed the “messenger line” to a crewman on the PSV, along with two mooring ropes. The crewman took the ropes and put the eyes of the two mooring ropes on each of the twin aft bollards and returned the messenger line to the bunker barge crew. The crewman on the PSV, assuming the mooring operation was over, started to walk away. As he reached amidships, the master of the bunker barge got his attention and indicated he should go aft again and shift one of the mooring ropes to a different bollard. As the barge crew slackened the mooring rope a little, the PSV crewman tried to remove the rope.

At that moment, there was sudden tension on the rope, due to relative movement between the vessel and bunker barge, and his left palm got stuck between the rope eye and bollard.

The PSV crewman suffered severe laceration injuries to his left hand. First aid was given and the victim was taken to the ship’s hospital for further checks before going ashore for further treatment.

Lessons Learned

• The mooring rope was handled without insisting on it being sufficiently slackened.
• The PSV crewman failed to take into account the relative movement of the vessels, which led to his hand getting stuck between the eye of the rope and the bollard.
• There was no very high frequency (VHF) communication established between the bridge of PSV and the bunker barge. The injured person was not in VHF communication with the duty officer and was taking instructions directly from the bunker barge master and crew.
• The PSV crewman was attending to the moorings alone which was contrary to the existing job hazard analysis which required attendance in pairs.

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.