New Mars Reports

Although SWZ Maritime's April issue will not appear until 22 April, you can already read the latest, complete Mars Reports on SWZonline.

Marine Accident Reporting Scheme (Mars) Report No. 281

CPP Control Transfer Causes Berthing Incident: Mars 201612

Edited from official Maritime Safety Awareness Bulletin Issue 2, Australian Maritime Safety Authority

With berthing almost complete, control of the ship’s controllable-pitch propeller (CPP) was transferred from the bridge to the engine room. Unknown to anyone, the engine room pitch lever was not aligned with the bridge lever, which was at zero. The engine room pitch lever
was not at zero pitch.

As a result, when control was accepted in the engine room, the propeller pitch moved to the ahead position and the vessel began to move forward. This placed considerable load on the mooring lines, causing one of the forward lines to part. Another line that was being tended by a crew member came under tension, slipped off the winch drum and struck the crew member on the leg. The ship was quickly brought to a halt and the berthing was completed without further incident.

The injured crew member sustained bruising to the leg and was declared unfit to work for five days. This incident clearly demonstrates how the smallest of lapses, even those far removed from the mooring deck, can have significant consequences during mooring operations.

Lessons Learned

• When transferring CPP pitch control from the wheelhouse to the engine room, best practice is to call beforehand and confirm ‘pitch to zero’ – ‘transferring to engine room’.
• When tending mooring lines, keep your situational awareness at maximum and watch for any unexpected ship movements, among others.

One Small Valve Causes Grounding, Sinking and Channel Closure: Mars 201613

Edited from the Swedish Accident Investigation Authority official report RS 2015:07

A small general cargo vessel lost steering in a restricted waterway and ran hard aground against the edge of the channel. The cargo hold filled with water and the vessel listed heavily to port. Shortly afterwards, the vessel came away from the channel edge and floated free.

The crew pumped ballast with the intention of reducing the list while the vessel slowly manoeuvred against the fenders of a nearby bridge on the opposite side of the channel. The vessel managed to moor alongside the fenders, and then sank to the bottom of the channel without capsizing.

The vessel was evacuated and the navigation channel was closed to all commercial shipping for about four days. Once the vessel had temporarily been made watertight, it departed to a nearby port to unload the cargo and continued to a shipyard for permanent repairs.

The accident investigation found that the vessel initially lost steerage and went aground due to a reduction in speed. This was caused by the unintentional operation of a shut-off valve that acted on the main engine speed-governor.

Lessons Learned

• The placement and protection of critical valves and buttons should be carefully considered so as to avoid accidental activation or de-activation.

Snap-back Slip-up: Mars 201614

Edited from the OCIMF official bulletin The Hazards of Snap-back, Sept 2015

A large LNG carrier was being warped into position by tensioning the forward back springs. The deck officer in charge of the forward mooring party was standing aft of the fairlead through which the spring lines passed. He was directing operations by signalling to a seaman who was located forward. From this position the seaman was able to relay the signals to the winch operator, who could not see the deck officer.

While under tension, the mooring line parted inboard from a pedestal fairlead. The section of the line between the break and the port shoulder roller fairlead struck the deck officer on the head as it whipped back before going overboard through the fairlead. The deck officer was found lying unconscious forward of the roller fairlead. He had sustained
multiple skull fractures.

The mooring line that failed was a 44-millimetre-diameter sheathed ultra-high-modulus polyethylene line. The line was fitted with a 22-metre-long polyester/polyethylene tail. The section of line in use between the winch and the connection with the tail was approximately
68 metres long.

Lessons Learned

• Snap-back zones can be complex and sometimes counter-intuitive. In this case, computer modelling was used after the accident to assess the dynamic trajectory of the entire length of the rope from its point of failure. The modelling indicated that it was highly probable that the rope would go aft of the roller fairlead and wrap around it before finally going outboard.
• Synthetic tails provide additional elasticity in the mooring system and serve to reduce peak dynamic loads. As a result of the tail’s elasticity, the elongation of the total mooring line under tension is increased; this introduces considerable stored energy that will be released if the mooring line fails. The snap-back characteristics of this type of mooring line (ultra-high-modulus polyethylene), initially considered to be relatively benign, will be heavily influenced by the addition of the synthetic tail.
• The length of tail fitted to the mooring line will influence the amount of stored energy in the system. The longer the tail, the greater the elasticity and stored energy, and the greater the likelihood of recoil and snap-back should the mooring line fail.
• Depending on where the line breaks, there can be snap-back zones in multiple locations. Actual mooring arrangements on board require specific analysis to determine the most likely snap-back zones.
• The best protection during mooring operations is not to have line ruptures. Careful inspection, use and well-considered modifications, such as adding synthetic tails, are the best guarantee of safe operation

Backdraught Injures Ten: Mars 201615

Edited from UK Marine Accident Investigation Board (MAIB) official report 20-2015

While approaching port, a ro-ro ferry experienced a fire alarm. A smoke detector in the port boiler room had been activated. A pulse of smoke could be seen emanating from the jointing surfaces at the top of the furnace. The boiler room ventilation was stopped from the bridge, and the ship’s fire teams were instructed to don fire-fighting outfits.

An uncontrolled fire in the port thermal oil heater furnace was confirmed; the unit was shut down at the local control panel and isolated. The Master advised the port and made a safety announcement to the passengers.

A 15kg dry powder fixed fire-extinguishing system for the oil heater furnace was activated on the chief engineer’s instruction. A few minutes later the ferry berthed and passengers were disembarked. Monitoring of the oil heater furnace exhaust temperature over a 15-minute period showed it had risen from 280°C to 340°C.

Soon, shore fire-fighters joined the effort to extinguish the fire, coordinating with the ship’s crew. At one point the port boiler room access door was opened. This resulted in an unexpected fireball, which swept across the deck with considerable force, and knocked a number of personnel to the deck. First-aid treatment for burns was administered on board the ship while ambulances, including an air ambulance, were called to the jetty.

Soon afterwards all members of ship’s crew who were not involved in fire-fighting were mustered and accounted for. The Master indicated to the crew that there was a fire that required them to proceed to emergency stations. At the same time, the fourth engineer manually operated the hi-fog fixed fire-extinguishing system covering the oil heater burner unit, and the ship’s crew began boundary cooling.

After further discussions between ship’s crew and shore fire-fighters, it was decided to inject foam directly into the oil heater furnace using the dry powder fixed fire-extinguishing system pipework. This took more than three hours, due to delays in planning and approval among other things. It was not initially successful. Shore fire-fighters also deployed their combined water-jet cutting and fog nozzle fire-fighting equipment (COBRA) to assist in cooling the port boiler room. Finally, more than 12 hours after the initial smoke detector had operated, the fire was confirmed extinguished. Temperature monitoring of the furnace then continued throughout the night.

As a consequence of the fire, six members of ship’s crew and four shore fire-fighters suffered burn injuries, three of which were serious. All of the injuries resulted from the backdraught.

Some of the findings of the official report were:

• The coil in the port thermal oil heater failed as a result of stress caused by a securing weld. The section of coil that failed was particularly difficult to inspect visually because of the refractory insulation in the vicinity. In such circumstances it would have been more appropriate to pressure-test the coil.
• The absence of a standard operating procedure for dealing with a fire on the thermal oil heating system installation meant that such a scenario had not been exercised as part of the training programme on board the ferry.
• Had fire-fighters conducted a thorough situational risk assessment, the risk of backdraught conditions ought to have been identified and a revised entry plan devised.
• The failure of the retrofitted furnace dry powder fixed fireextinguishing system to extinguish the fire inside the port thermal oil heater furnace demonstrates the unsuitability of dry powder as a fire-extinguishing medium for this purpose.

Lessons Learned

When fighting a fire, backdraught is a particularly dangerous event. In this occurrence, the observations of smoke intermittently pulsing from the furnace joints were an indication of the risk of backdraught conditions developing within the compartment.

• Be aware of the signs of backdraught conditions:
• Fire in a compartment with limited ventilation;
• Fire has been burning for some time;
• Fire gases being pushed out under pressure from gaps;
• Windows blackened with no visible sign of flame;
• Fire gases pulsing out from gaps.

Underway at Anchor: Mars 201616

Edited from Australian Transport Safety Bureau (ATSB) official report 308-MO-2014-003

Several ships were at anchorage awaiting berthing space in port. In the early morning, squalls and rain passed across the anchorage and the weather was otherwise stormy with a west-northwest wind at 20+ knots. As a squall with wind gusts up to 56 knots moved across the anchorage, the increased noise from the wind and rain woke the Master of vessel A. He called the bridge and the OOW confirmed they were maintaining position.

At about the same time the OOW on the vessel at anchorage B observed on radar that ship A was moving towards his ship. His calls to ship A on VHF went unanswered. He next attempted to attract the attention of the OOW on ship A by sounding his ship’s whistle. The OOW on ship B then phoned the Master and sounded the ship’s general alarm.

Meanwhile, ship A’s OOW now realised that they were moving eastwards. He phoned the Master and reported that the ship was dragging its anchor and moving at 1.5 knots. Ship A’s deck crew were mustered on the forecastle but saw, to their surprise, that the port anchor cable was missing. The Master instructed them to let go the starboard anchor. Meanwhile, ship B began to veer more cable to try and avoid contact with ship A.

Ship B’s main engine was started as the deck party continued to veer more cable. The Master used the main engine in an attempt to manoeuvre the ship’s bow to port, away from the closing ship A. With collision imminent, ship B’s deck crew retreated from the forecastle; ship A’s starboard quarter then collided with ship B’s bow.

Shortly thereafter, ship A’s main engine was started and run at slow ahead. The Master began to dredge the starboard anchor and move clear of Ship B.

Some of the findings of the official investigation were as follows:

• In adverse weather conditions, the securing pin from ship A’s port anchor chain cable stopper bar worked free. As a result, the guillotine bar opened and the cable’s load came on to the windlass brake, which did not hold. The anchor cable ran out to its bitter end and the entire cable was lost into the sea.

• The poor condition of ship A’s anchoring equipment was indicative of inadequate maintenance. The shipboard management team was not aware of the equipment’s maintenance history, nor was it able to provide relevant documents from the ship’s planned maintenance system.
• As the sole watchkeeper, ship A’s OOW remained on the navigation bridge during the anchor watch. As such, routine rounds of the forecastle deck were not undertaken and no one detected that the cable stopper’s securing pin was working free.
• Ship A’s main engine was not in an appropriate state of readiness for the adverse weather conditions forecast and the warnings issued.

Lessons Learned

• The windlass is an essential piece of equipment that should be kept in top notch condition.
• At anchor, rounds to the forecastle deck to check the condition of the anchor and associated gear should be considered best practice.
• While at anchor in adverse weather conditions, the main engine should be on standby.

Catch of the Day: Mars 201617

Edited from US Coast Guard (USCG) Safety Alert 12-15

A vessel was preparing to depart the port. The forward mooring line messenger was secured to the tow hitch of a pick-up truck to assist in the task. When the line was thrown off the bollard, the ship began to haul it in with the messenger still attached to the truck. The pick-up truck was subsequently dragged into the harbour. The shore-side line handler in the truck narrowly escaped dire consequences by quickly jumping out before it was dragged off the berth.

Line handlers often use the assistance of powered machinery such as trucks, forklifts and golf carts to help handle mooring lines. The extreme weights of the mooring lines involved and the lack of adequate personnel to accomplish this task safely lead to the unconventional line handling practices.

Lessons Learned

• Ship’s crew should use caution and remain vigilant when hauling in, ensuring that lines and cables are clear and free of attachments. Special attention should be given to the mooring lines as they are coming off the dock and being hauled aboard.

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

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