Since we publish a summer issue of SWZ Maritime for both July and August and the Mars Reports are published monthly, you can read an extra edition of Mars Reports here.
Expect the Unexpected: Mars 201745
An inbound tanker was proceeding under pilotage in a restricted waterway. There was an outbound container vessel in the channel ahead of the tanker.
The bridge team observed a fishing trawler four points on the port bow at a distance of 1.0 nm. The trawler was not engaged in trawling and was making 8 knots over ground. Initially it was ascertained that the trawler would cross astern of the tanker with a clearance of about 0.5 miles, so no action was taken by the Master and pilot.
At the point where the container vessel had approached to within approximately 0.6 nm of the tanker, the fishing trawler altered course to port without notice. It was now attempting to cross ahead of the inbound tanker.
The pilot on the tanker cautioned the trawler over VHF and repeatedly sounded the ship’s whistle to attract attention. On seeing no change in the aspect of the fishing trawler, the Master, in consultation with the pilot, altered ship’s course to starboard and reduced speed to half ahead.
The pilot on the outbound container vessel was also concerned with the conduct of the trawler and sounded several short blasts on his ship’s whistle. At the last minute the fishing trawler turned to port to avoid collision, but it came close enough to the tanker to cause a minor contact.
Lessons Learned
- Never assume a situation is ‘set in stone’. Be alert and expect the unexpected.
- Remain engaged with the pilot, as did the bridge team on the tanker in this report.
Automatic Shutdown of Main Engine: Mars 201746
An outbound tanker was transiting a restricted area at the port entrance. Suddenly, the main engine shut down. The Master quickly ordered the forward manoeuvring station to let go the starboard anchor. Meanwhile, the pilot ordered the escort tug to assist the ship while the Master ordered the port anchor dropped in sequence.
In spite of the actions of the crew and pilot, the vessel made contact with several channel markers before the main engine could be restarted and the tug made fast.
An investigation of the incident revealed that the oil mist detector had shut down the main engine due to a false detection of oil mist in the crankcase. The system was configured to allow only one second between the detection of oil mist (or other anomaly) and a shutdown. No human intervention was possible.
Lessons Learned
- While automation is desirable for safety, so too is the possibility of human intervention if needed.
- Current class rules allow automation systems to be manually overridden (except in cases where manual intervention will result in a total failure of the main engine, for example in case of over speed), given a manned engine room and alarms advising of the override.
- Certain models of oil mist detectors can be programmed with varying delays for shutdown such that when navigating in restricted waters the delay before shutdown is longer than when in open sea, thus giving time for emergency action.
Earth Fault Means Trouble: Mars 201747
In the early evening hours the fire alarm sounded showing an alarm on B deck. Smoke was also reported on the port side of B deck. The fire source was localised in a cabin and first attempts to extinguish it with portable extinguishers were inconclusive. Meantime, emergency teams were mustered. Crew donned fire suits and breathing apparatus (BA) sets to attack the fire, while boundary cooling was started from outside the cabin bulkhead. The fire was extinguished, but thick smoke was still prevalent.
Boundary cooling was continued for the next 30-45 minutes while bulkhead temperatures were continuously monitored. It was observed that the ceiling tube light in the cabin along with all fittings appeared to be the most severely burnt area, so was possibly the origin of the fire.
Upon closer inspection it was found that molten plastic from the ceiling light had probably ignited the chair and other objects below the light.
Further investigation found the alarm logs in the engine room had recorded a low insulation alarm 10 minutes before the fire had started. This earth fault was probably the first indicator of the light fixture deficiency that started the fire.
Lessons Learned
- Earth fault alarms should be investigated as they occur and the ship searched for any unusual activity.
Mooring Rope Caught in Thruster: Mars 201748
A chemical tanker in ballast was unmooring from a river berth with a strong current. The forward breast lines had been simultaneously let go ashore but were still in the water and being winched on board.
Suddenly the bow thruster stopped functioning. This event did not affect the manoeuvre and the unmooring was safely completed.
It was discovered that one of the forward breast lines floating on the water surface had become caught in the thruster’s propeller. This caused an overload on the thruster which then ceased functioning. The mooring rope was successfully removed some days later by divers.
Lessons Learned
- Always be aware of mooring ropes in the water and their proximity to thrusters.
- If possible, single up lines first so that the number of lines to be retrieved from the water at the moment of leaving the berth is reduced.
- Clear, concise communication between the bridge team and the mooring crew is a necessary component in safe berthing and de-berthing operations.
Classic Foggy Collision: Mars 201749
As edited from the Republic of Cyprus report 115-2014
A loaded bulk carrier, vessel A, was heading 022° in very restricted visibility. The Master and Chief Officer (CO) were in the wheelhouse with a helmsman and lookout. The engine was put on stand-by and the vessel speed was reduced from 13 to about 11 knots. The bridge team noticed a vessel (B) on the radar at a distance of about six nm on a near reciprocal course approaching at a speed of six knots. The Master ordered a course alteration from 022° to 050°. The distance to vessel B was now 3 nm with a CPA of only 490m. Once on a heading of 050° the Master ordered ‘Steady’. About this time the CO called vessel B on VHF radio and agreed to a port-to-port meeting, although the communication was hampered by language difficulties and ambiguous statements. Soon after the Master of vessel A ordered a course of 060°.
A few minutes later vessel B started turning to port, instead of turning to starboard as was expected for a port-to-port passing. The Master on vessel A ordered 070° and then 080°. Shortly thereafter a green light was spotted ahead and they felt the vibration of an impact. The engine was stopped and the alarm sounded. Once the vessels disengaged, vessel B sank while vessel A had water ingress into its forepeak tank.
Since the vessels were close to shore the local coast guard rendered assistance to the crew of vessel B who had abandoned into a life raft.
Lessons Learned
- As per the Colregs, in restricted visibility (Rule 19) avoid altering course to port when there is a vessel forward of the beam.
- Use clear and unambiguous communication when making meeting arrangements with other vessels, especially in restricted visibility.
- When altering course for collision avoidance use bold course alterations instead of a series of relatively small course changes. This will make your actions more apparent to the other vessel’s bridge team.
Simple Repair Becomes Deadly: Mars 201750
As edited from UK MAIB report 17-2016
A dredger was on site and in the process of dredging when the engineer of the watch (EOW) smelt diesel oil in the engine room. He found a small leak in the low pressure diesel oil supply line to the main engine. Physical evidence indicates that he was attempting to make a temporary repair while the main engine remained running, without informing the bridge team or the chief engineer.
It would appear that during the repair process the engineer’s overalls became soaked in fuel. When he subsequently used a portable angle grinder, sparks from the grinding disc probably ignited the atomised fuel from the leak as well as his diesel soaked clothing. This resulted in his overalls catching fire and igniting a fire in the engine room. The EOW was nonetheless able to exit the engine room and reach medical assistance.
The fire in the engine room was extinguished using the fixed CO2 smothering system. The EOW’s burns were so severe that he ultimately succumbed and was later pronounced dead.
Some of the findings of the official report were:
- The EOW informed neither the chief engineer nor the bridge OOW of the fuel leak and his apparent intention to repair it. His reason for not doing so is likely to have been influenced by the onboard culture of routine lone working and absence of regular and frequent communication.
- The fact that sparks generated by using fixed and portable angle grinders produce a hot work hazard is not currently acknowledged in marine industry guidance.
- The EOW would have been aware that isolating the fuel system would have involved stopping the main engine which, in turn, would have interrupted the loading programme. It might have been his professional pride and confidence in his ability to successfully complete the repair that drove him to carry on with the task.
Lessons Learned
- Safety should be a personal and company value that takes precedence over commercial activities or professional pride. Undertaking a repair on the fuel system while the vessel continued to work and without informing other crew or the bridge team was a major failing that ultimately cost the EOW his life.
- Sparks from an angle grinder can be sufficient to ignite a fire given the right conditions.
Reporting of Close Calls – Some Examples: Mars 201751
Reports of accidents and incidents received by the editor of MARS are then edited and formatted for Seaways. Our hope is that our readers can learn the lessons of these events and hence increase their own safety awareness and risk appreciation. From time to time we receive summaries of close calls that, taken individually, are not conducive to a single MARS report, but are nonetheless very good indicators of a healthy safety culture. We would like to reproduce here a sample of these summaries with the view of displaying what a robust reporting culture looks like.
Editor’s note: Weight training equipment is a great addition to on-board amenities but free weights can be a problem if not properly stowed after each use – not to mention the possibility of injury while using the equipment due to vessel motion at sea. Rack-based weights would appear to be a better and safer alternative for ships.
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.
