Ask Yourself: ‘What Can Go Wrong?’

Redouble your vigilance when something new presents itself. Ask yourself: ‘What can go wrong?’

Improvements meant to make a situation safer, can sometimes have unwanted results. Read the latest Mars Reports below, including one about a new channel resulting in several groundings.

New Channel, New Risks: Mars 201807

Edited from UK P&I Club Circular 003/2017

A new channel was dredged and buoyed in a river waterway, allowing a straighter route to a commercial port. However, several groundings in the new channel over a short period of time revealed that there were risks that were apparently unaccounted for.
Initial investigations found some possible contributing factors including:

• Charts did not correctly reflect the new channel;
• The navigation aids initially installed were not sufficient to cover the new area;
• The strength of the current, which is considerable;
• Pilots lacked experience of the new channel.

After consultation it was decided to decrease risks by adding three additional green side buoys in the new channel.

Lessons Learned
New configurations, new ways of working, or changes in the status quo bring new risks that need to be carefully evaluated.
Redouble your vigilance when something new presents itself. Ask yourself, what can go wrong?

Illusion of Safety: Mars 201808

Edited from CHIRP Maritime Feedback Issue No49 12/2017

The crew were rigging the gangway, using inertia wire rope safety lanyards clipped to the webbing straps of their life jackets as fall protection. They believed they were acting safely. However, objective observations show that safety, in this case, was an illusion:

• The lifejacket was not of a type designed for fall arrest. (The lanyard was clipped around the lifejacket strap and the strap around the torso.)
• The inertia wire rope unit was not directly above the worker. If a crew member had fallen, they would have suffered a pendulum effect.
• The wire was passed over a sharp coaming.
• The inertia unit was secured to handrails that were in poor condition.

Lessons Learned

• The design of gangways and associated areas is often less than adequate to allow crew to safely rig or stow the gangway. Evaluate your gangway arrangements to see if there are improvements to be made.
• If the lifejacket is not designed for fall arrest – and few are – then ensure the safety line is attached to a proper fall arrest harness. These will typically have specific ‘D’ clips on strong points either in front, in back or both, and have leg anchor straps.
• A false sense of security, as in this case, is a dangerous situation. It is an accident waiting to happen.

Defective Lifejacket Lights: Mars 201809

Edited from US Coast Guard Safety Alert 09-17

Several sources have indicated that the water activated flashing lifejacket light on Alcares models Jack A1-ALK and Jack ARH-ALK may have operational problems before their advertised expiration dates. Inspections have discovered over 3,000 such lights with leaky batteries (see photo). Additionally, some had incorrect battery expiration labels. The US Coast Guard recommends that lifejackets with lights, especially those with automatic lights, be stored in environments where temperature and humidity are controlled. Visual inspections and tests must be conducted in accordance with vessel carriage requirements and manufacturer manuals. Vessel owners/operators should check their lifejacket lights to verify that they are operational at the nearest opportunity.

Lessons Learned

• Check your lifesaving equipment as if your life depended on it. It does.
• Correct storage conditions for lifesaving equipment are crucial to ensure longevity and operational readiness.

Heave up? Not So Fast: Mars 201810

The vessel, a regular caller at the port, was slipping mooring lines. The usual procedure for the release of lines had the Officer in Charge (OIC) standing at a vantage point or close to the rails to ensure proper visual contact with the shore and his crew. The OIC and crew communicated directly with the shore linesmen with visual signals.

The crew lowered the forward breast lines for release by the shore linesmen. The OIC, assuming that the lines had been released, gave the signal to the winch operator to heave in. The winch operator commenced heaving, but the OIC then realised that one of the mooring lines was in fact still on the shore mooring post. He signalled to the winch operator to stop heaving and to release the tension. The line was then released by the linesmen and the un-mooring operation continued.

An analysis of the close call found that the OlC was not standing at the proper location for the task, nor was he acting in a supervisory role. He had become personally involved with retrieving the lines on deck. Because he could not properly see what was going on, he did not have positive assurance that all lines were released. Instead, he made an assumption that the lines had been released from shore, based on the elapsed time. Another aggravating factor was that the winch was operating at high speed instead of the standard practice of starting at slow speed. As a result, when the signal to stop was given the winch drum took longer to stop.

Lessons Learned

• Before giving winch orders, ensure the action is indeed appropriate. Never assume.
• As an extra precaution when letting go, always wait for the linesmen to leave the immediate vicinity of the bitts before heaving in.
• If you are overseeing an operation, resist the temptation to get involved yourself. You will lose your overall appreciation of the situation.

Editor’s note: In this incident, no one was injured or killed and no machinery was damaged, yet it was reported as a close call and important lessons were learned. This illustrates the importance of a strong reporting culture; we should not have to wait for dire consequences in order to learn lessons from the events. For more insight, readers are invited to read the following URL: https://safeship.ca/uploads/3/4/4/9/34499158/creating_a_reporting.culture.pdf    

Knee Cap Injury Due to High Localised Winds: Mars 201811

A crewmember was doing his rounds on deck on an LNG vessel underway. Although winds were relatively strong at 40 knots (43 knots relative on deck), the crewmember felt safe as rolling was minimal and, with a high freeboard, water was not washing on deck. However, the decks were somewhat wet from rain.

As he made his way past the juncture between two LNG tanks he met localised winds that were so strong he was blown uncontrollably between the tanks. He was forcefully slammed into the ship’s structure and his knee hit the steel, breaking his kneecap.

After first aid the crewmember was evacuated to a shore hospital. A steel pin had to be inserted in his kneecap.

After analysis of this incident it was decided to apply non-slip paint on the upper deck passageways between the tanks. It was also agreed to increase the ‘eye-catching’ yellow markings of various structural elements that could be tripping or impact hazards. Finally, it was decided to conduct a hazard analysis on the strength of localised wind between the tanks with a view to risk reduction.

Lessons Learned

• Outside decks should be covered in non-slip paint, even areas not regularly used.
• Every incident is an opportunity to reduce risks by analysing what went wrong and why it happened. In this case, the strength of localised winds due to an apparent venturi or ‘channeling’ effect between the tanks was an undocumented hazard that needed attention.

Steering Mix up: Mars 201812

Edited from official TSB Canada report M16C0005

A container vessel was down-bound at about 16 knots in a confined river waterway. A helmsman was executing helm orders in Full Follow Up (FFU) mode and the OOW was on the bridge assisting the two pilots, one of whom had the con. Soon after a course change, once the vessel was steadied up, the vessel’s head began to veer to starboard. The pilot with the con mentioned this to the other pilot. The helmsman then said ‘Not working,’ which was understood by the pilots to indicate a steering failure.

One of the pilots repeated the order ‘Follow-up’ to the helmsman many times in quick succession. As the vessel was already in ‘follow-up’ mode, the helmsman did not take any action with the helm mode selector. Meanwhile, the other pilot asked the OOW to call both the Master and the engine room to report the failure of the steering gear. One of the pilots then selected non-follow up (NFU) on the steering mode control switch at the helm station. The OOW informed him, ‘This is non-follow-up, sir.’

The pilot then activated the handle of the override tiller, placing it hard-a-starboard, but under the impression it was hard-a-port. He did not know that the tiller was installed such that when moved to the right, the red part of the indicating disc would illuminate, even though the rudder went to starboard (see diagram below). The pilot then ordered ‘Hard to port’ and that the main engine should be stopped. The Master was soon on the bridge, while the chief engineer, who had just arrived in the engine control room, observed that the rudder angle indicator was at 35° to starboard (hard-a-starboard).

As the vessel was exiting the navigation channel, the OOW noticed that the rudder was positioned hard-a-starboard and brought the handle of the tiller to the left; the rudder then moved to 35° to port (hard-a-port), and the ROT diminished. Shortly, the vessel started to veer to port but it was too late to prevent the vessel from running aground.

The official investigation found several contributing factors to the grounding but also found, after extensive testing, that no steering gear failure had actually occurred. Some of the factors included:

• The vessel initially veered off course to starboard due to the helm likely being inadvertently placed 10° to starboard by the helmsman.
• The ambiguity of the verbal exchange between the helmsman and the pilots led the pilots and the OOW to incorrectly conclude that there was a steering gear failure. No immediate action was taken by the bridge team to verify the functionality of the steering gear once a system failure was assumed.
• The crew did not immediately switch to non-follow-up mode because the pilot mistakenly issued the order to use follow-up mode, the mode they were currently using.
• The helm tiller was not installed in accordance with the manufacturer’s specifications, nor was it consistent with internationally accepted standards. Because the pilot was unfamiliar with the particular ergonomics of the installation he unintentionally put the rudder hard-a-starboard instead of hard-a-port.

• The crew did not immediately switch to non-follow-up mode because the pilot mistakenly issued the order to use follow-up mode, the mode they were currently using.
• The helm tiller was not installed in accordance with the manufacturer’s specifications, nor was it consistent with internationally accepted standards. Because the pilot was unfamiliar with the particular ergonomics of the installation he unintentionally put the rudder hard-a-starboard instead of hard-a-port.

Lessons Learned

• Navigating in a restricted waterway and losing steering, or even assuming you have lost steering, can be stressful and cloud your judgement. As a first reaction, switch quickly to NFU and watch the rudder angle indicator, as well as the ship’s heading, for rudder functionality.
• While actual steering gear failures do happen and result in groundings, others have occurred due to an inopportune reaction to an assumed failure, as in this case. For some other examples, see: https://tinyurl.com/mars201813a https://tinyurl.com/mars201813b

Hot Oil Scalding: Mars 201813

Some engine room crew members were to clean out sludge from the waste oil tank. To do this, they first had to transfer the remaining oil from the tank to mobile drums. The steam valves to the waste oil tank had been shut on the previous night. The next day, the temperature had dropped from 110°C to 50°C. A risk assessment and toolbox meeting were held and a cold work permit was issued. The workers realised that the oil was quite hot as the discharge pipe had begun to get hot to the touch.

When one drum was nearly full, the hose was transferred to another drum. As the discharge hose was being changed, some residual oil in the hose splashed onto one crew member’s hands and he suffered severe scalding of his right wrist It was later found that the steam valves were leaking and the waste oil had not cooled as much as expected. In addition, the fixed tank thermometer showed about 20°C less than the true temperature.

The tank thermometer readings had probably been affected by sludge accumulation in the tank.

Lessons Learned

• Warning signs were not heeded! Even though the fixed thermometer was imprecise, it still showed 50°C. Yet a cold work permit was issued nonetheless. Crew realised the oil was quite hot because the discharge pipe was hot to the touch. They did not stop work and reassess.
• Even though the crew members knew the oil was hot, they continued to wear ‘cold work’ Personal Protective Equipment (PPE) such as short leather and cotton gloves.

Editor’s note: Factors that contribute to accidents are easy to identify, with hindsight. You should learn to do a ‘running risk assessment’ while working so you can identify the warning signs before the accident happens. Ask yourself: ‘What could go wrong?’, ‘How bad could it be?’, ‘Are there new risks?’ and ‘Do I have the right tools and PPE for the task?’

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.