Cement Carrier and Crew Lost in Heavy Weather

SWZ Maritime's January issue is about to come out, which means it is time for a new Mars Report. Read it here.

Mars (Marine Accident Reporting Scheme) Report is one of the regular sections of SWZ Maritime. We will publish all the reports we receive 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, accidents with rescue boats and so on.

Incinerator Exhaust Plugged: Mars 201665

The incinerator was fired up by an engineer. When the temperature of the secondary chamber had reached 400°C, the primary burner was lit. About five minutes later, when the primary burner was at about 300°C, garbage was fed into the incinerator. After about one hour of operation the incinerator was stopped to allow a period of cooling down. About 20 minutes later, the incinerator was again fired up and fed garbage, although the primary burner was only at a temperature of about 250°C.

After about three minutes of operation the incinerator vacuum broke and smoke started to come out of the burner air inlets. Smoke continued to exit the burner blowers for another 10 minutes until the garbage inside the incinerator was completely burnt. In the meantime, the incinerator main blower had been tripped as a result of excessive back pressure. Although the fire alarm had been sounded, the water mist system did not activate because there was no flame. Once the smoke had cleared and the incinerator stopped an investigation was carried out.

Among other things, the incinerator funnel flame screen was found to be completely clogged with unburnt paper and soot, which prevented proper exhaust flow (see photos below: before and after cleaning).
Feeding garbage into the incinerator when the primary chamber temperature is below 600°C can result in unburnt light materials blocking the flame screen at the funnel.

Lessons Learned

• Deviations from procedures can cause accidents. In this case, each deviation led further down the casualty path.
• Feeding material into the incinerator when the primary burner temperature is lower than 600°C can cause unburnt garbage to collect at the incinerator funnel flame screen.
• The funnel flame screen was allowed to become clogged, setting in motion the subsequent sequence of events.

Wrong Helm Applied and Vessel Grounds: Mars 201666

Edited from official Transportation Safety Board of Canada (TSB) report M14C0219

A small tanker was making way in restricted waters and in darkness, proceeding full ahead at speeds sometimes greater than 19 knots (SOG) as a result of a following tidal current close to 3 or 4 knots. The officer of the watch monitored the vessel using the starboard radar and the ECS, and the master was on the bridge. The vessel was approximately 2.6nm from the next course change of 071°T, through a channel that is 0.3nm at its narrowest.

The OOW, who had the con for the first time in this area, requested that the master take over before the large alteration to port at Island A (see below), approximately 0.7nm before the next course change waypoint. The master took over the con and the OOW went to the chart table and began preparing the next chart. The helmsman was manually steering a course of about 140°G and the vessel was now proceeding at 16.7 knots. The master was monitoring the vessel’s progress on the starboard radar; he had set up a parallel index to determine when to commence the port turn. A parallel index line was also set up on a course of 071°T to maintain a distance of 0.22nm off the northernmost point of Island A.

At the planned wheel-over position, the master ordered the helmsman to apply 10° port rudder to initiate the turn. The helmsman acknowledged the order by repeating it, but instead put the helm 10° to starboard. Within seconds, the master ordered the helmsman to apply 15°. The helmsman looked at the rudder angle indicator and repeated the order, but put the helm to 15° to starboard. Then, the helmsman asked for clarification about the direction of the order. The master ordered the helm be applied faster without indicating the direction.

The helmsman then stated that the helm was at starboard 15°. The master ordered the helm hard to port. The helmsman acknowledged by repeating the order and applying maximum port helm (35°). The vessel’s speed was now about 15 knots.
Over the next three minutes, the master continued to monitor the vessel on the radar as it swung back to port while querying information being provided by the OOW. At some point during this time the master applied astern propulsion. Nonetheless, the vessel made bottom contact west of Island A on a heading of 012°G.

The engines and the bow thrusters were used to manoeuvre the vessel back into the channel, and the vessel continued its voyage while the crew sounded the tanks and checked for damage. A crack approximately 0.6m long was found in No. 3 port water ballast tank that was allowing water ingress.

The official investigation found, among other things, that:

• At the time of the occurrence, three of six fatigue risk factors were present for the master and for the helmsman: acute sleep disruptions, chronic sleep disruptions, and desynchronisation of the circadian rhythm. Both exhibited performance decrements consistent with fatigue, contributing to the bottom contact.
• The officer of the watch ceased participating in the monitoring of the vessel’s progress after the master took over the con so was not in a position to readily detect the helm error or to assist the master in responding to it.

Editor’s note: Many of us have experienced helm error and often it is corrected quickly and without serious consequences. In restricted waterways like this example, the margin for error is slim. One technique to help mitigate the consequences of helm error in restricted waterways is for the officer who has the con to closely monitor the helm order as executed via the helm angle indicator or by sighting the helmsman during the manoeuvre. In this case, since fatigue was involved, even these techniques may not have been sufficient to avoid the grounding, as being fatigued is the equivalent to being drunk. Avoiding fatigue is every mariner’s responsibility and not just a paper exercise.

Capsize and Loss of All Crew: Mars 201667

Edited from official UK Marine Accident Investigation Branch (MAIB) report 8-2016

A small cement carrier with a crew of eight was loaded with cement and underway across the North Sea on a passage plan that brought the vessel through the Pentland Firth. Having spent 24 hours heading into deteriorating weather and increasingly heavy seas, the master first reported that there would be a two-hour delay to the arrival time at Liverpool bar buoy. The next day, in consequence of increasingly bad weather, his report stated that there would be a further 10 hours delay As the vessel entered Pentland Firth (figure below), it was on a heading of 270° (COG of 272°) and SOG of 10.6kt. Once inside the Pentland Firth, the vessel was sighted by the crew of a nearby ferry.

The cement carrier appeared to be upright and making slow headway, pitching heavily into the large waves. Later that afternoon the vessel’s AIS transmissions ceased. The data from the last received transmission showed a heading of 239°, a COG of 276° and SOG of 6.3kt. Such a SOG, however, would have meant a speed through the water of less than one knot, rendering the vessel unmanageable and at the mercy of the ferocious oncoming waves.

The hull of the capsized cement carrier was spotted and reported to the local coastguard 25 hours later. The damaged vessel soon sank. Search and rescue (SAR) activities were undertaken, but no surviving crew members were found.

The official accident report found, among other things, that:

• On one past occasion when the vessel entered the Firth with an opposing flood tide, the same master held position by stemming the stream, and waited for it to ease. From this it can be deduced that the master understood the tidal risks and actions were normally taken to abort or avoid the unfavourable tidal conditions in the Firth.
• On another occasion of rough weather in Pentland Firth, during the alteration of course across the sea, the vessel had heeled excessively and suffered a cargo shift, resulting in a significant list to port. The vessel was brought back upright using the ballast tanks. The master’s decision to proceed into the Firth on this (final) occasion, with very unfavourable conditions, was inconsistent with his previous actions.
• The extraordinarily violent sea conditions were created by gale force winds opposing a strong ebb tidal stream. Such conditions were predictable and passage through the Pentland Firth should not have been attempted.
• The cement carrier was loaded to its draught marks, but the density of its bulk cargo was not properly considered. As a result it is likely that its stability did not meet the minimum criteria set by the IMO. Potential reductions in its righting levers would have made the cement carrier more vulnerable to capsize in a heeling situation.

Lessons Learned

• Always adopt a conservative approach to weather – your life depends on it.
• Never bring your vessel to a point where manoeuvrability is lost.

Containers Overboard: Mars 201668

Edited from UK P&I Club bulletin 1096 – 05/16

Changes to the SOLAS Convention now require shippers to ensure containers are weighed before being loaded on vessels. A recent incident highlights the importance of this amendment.

Six containers had apparently gone missing while en route. The stack in question was located at the bow of the vessel on the very edge and had clearly been lost overboard during the voyage. Apparently, neither the Captain nor chief officer or crew were aware of what had occurred at the time.

It transpired that the stowage plan had been created using weights provided at the initial time of booking. While the final bills corrected the weights, this was never picked up by the planners, which resulted in the vessel being stacked incorrectly. The top four containers, all loaded with cement, were 28 tonnes each. The two bottom containers were only 5 and 3 tonnes respectively. This meant that the total weight for that stack was 143 tonnes, as opposed to the 50 tonnes permitted by the Cargo Securing Manual, as well as being top-heavy and unstable.

Lessons Learned

• The new legislation will go a long way in preventing such accidents as the terminal and planners will be notified of the correct weights before the container is placed on board.

Dangerous Wave on Deck Astern: Mars 201669

Edited from the Marine Safety Forum’s Safety Alert 16-13

A platform supply vessel was carrying out deck cargo and fuel operations alongside an offshore platform. Winds were 25 knots and the swell 3m. With the starboard stern quarter of the vessel against the weather/sea, suddenly the stern was hit by one larger wave and water flooded the stern deck. Two unsecured small containers were shifted/capsized by the force of the water on deck.

No people were injured – the deck crew were working at the forward end of the deck at the time of the incident.

Lessons Learned

• The risk of abnormal waves must be taken into consideration in the risk assessment and toolbox talk for work with the stern positioned against the weather.
• For this vessel and those of similar build trading in a harsh environment a higher aft bulwark should be fitted.

Cargo Hook Safety Latches: Mars 201670

A port captain has reported several instances of poorly maintained, incorrectly installed or even missing safety latches on cargo hooks. Mariners should be advised that a cargo hook safety latch is a simple but critical safety measure that should always be in perfect order.

On the Bridge But Not on the Job: Mars 201671

Edited from Transport Malta Marine Safety Investigation Unit report 07/2016

A car carrier in ballast was making way at about 20 knots in good visibility (approximately 12nm) and light winds. As the vessel approached a major shipping lane it was observed that the traffic density was getting heavier. Two radars were set in relative motion on the 12nm range scale with an off-centred display. As a consequence, both radars were scanning approximately 18nm ahead. Another radar, also off-centred, was on the 6nm range scale. Apparently, no collision warning alarms were programmed on the ARPA sets.

In the afternoon, the OOW was alone on the bridge and immersed in the task of planning the next voyage on paper charts. Several vessels were within visual and radar range, including Vessel A. At one point, the OOW interrupted his chart work to make a minor course alteration of 3° to starboard on the autopilot. He then returned to his chart work, apparently unaware of vessel A approaching on his starboard side.

About 17 minutes after making the minor course alteration, the noise of the collision with Vessel A brought him to his senses.

The official investigation found, among other things:

• A single lookout during daytime is the norm at sea and does not contravene international requirements. However, a number of factors need to be kept into perspective before deciding on the minimum number of lookouts on the bridge. In particular, consider the need to keep a proper lookout by sight and hearing at all time, and that the OOW is not to undertake any duties that would interfere with the safe navigation of the ship.
• All three ARPA sets had been set up off-centred, displaying a longer range in the ahead position. However, this mode carries an important disadvantage: the reduction in the scanning range on the vessel’s beams and abaft the beams.
• Although the chart preparation area was part of the open-style bridge, its location was not ideal for visibility forward and quite inappropriate for visibility abeam.
• Neither vessel apparently took any action before the collision.

Lessons Learned

• It is prudent to have a dedicated lookout at all times when in congested waters .
• As an OOW on a vessel underway, your primary job is to navigate that vessel in a safe and efficient manner. Accomplishing extra duties, as in this case, or allowing yourself to be distracted by mobile phones or irrelevant conversations with crewmates while navigating, will eventually lead to no good.

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.