Specialised Cargo Requires Specialised Guidance

If a specialised cargo is to be transported and crew are inexperienced in the special considerations required, always ensure expert guidance is employed for all phases of the work.

SWZ|Maritime's April issue features a selection of Mars Reports. Read the full March Mars Report below, including an incident with packages of timber tumbling overboard with fatal consequences. 

PPE for Cooks Too: Mars 201814

On a vessel underway, the cook was in the galley preparing meals. One of his tasks was to skin and cut poultry. While attending to this job he accidentally cut a finger on his left hand. The investigation revealed that although the chicken was tested for appropriate tenderness before cutting and the knife used was properly sharpened and the correct size for the task, the cook was not wearing a protective ‘cut glove’ on his left hand.

Lessons Learned

Using a protective ‘cut glove’ on the hand that holds the item to be cut is not always the first choice for cooks, but it should be. Just as hard hats and steel-toed boots are now the norm on deck and in the engine room, in the kitchen appropriate PPE should become part of the culture.

Improvised Pressure Test Causes Injury: Mars 201815

Two engine room crew were about to undertake a pressure test of an auxiliary engine air cooler. To this end, the sea water outlet pipe of the cooler was sealed using a large wooden plug and a piece of cloth acting as an improvised gasket. The air cooler was partially filled with water and then air pressure of about 4 bar was applied to the cooler from the sea water inlet side. Suddenly, the wooden plug shot out like a bullet with tremendous force and speed.

Red arrows show the trajectory of the plug.

After bouncing off a casing the plug hit one crew member on his helmet, then ricocheted and hit the other crew on his forehead. While the first crew was unhurt, the second was injured, suffering swelling of the forehead with severe pain. Fortunately, the injury was not serious.

Lessons Learned

• Wooden plugs or other improvised methods that do not ensure positive and secure closing should never be used for pressure testing.
• Other than on pressure vessels like boiler shells or compressed air bottles, pressure tests should be carried out by hydrostatic means, by filling the appliance with water and creating a head of pressure appropriate for the required test.

Don’t Drink That!: Mars 201816

Edited from IMCA Safety Flash 29/17

The crew noticed that there was no extra diesel fuel on the fast rescue craft (FRC), so they searched for containers to store the fuel. Some plastic bottles were found and used to store the diesel in the FRC. Later, during a vessel inspection, these containers were observed and it was pointed out that storing diesel in inappropriate containers is a safety deficiency. These containers were old water bottles, which could cause confusion and possibly induce someone to mistakenly drink from one of the bottles. The bottles were subsequently emptied and discarded; a safety stand-down was held with the crew.

Lessons Learned

• Never use improvised containers for fuel or chemical storage, especially old drinking water bottles. This has the double disadvantage of being a risk to the environment and dangerous for anyone who might drink the contents
• Always insist that ready-use fuel or chemicals are stored in appropriate containers
• If ready-use containers for fuel or chemicals are bought in bulk, ensure they are labelled correctly, including safety data sheet references and full product name.

Editor’s note: Any time you improvise you may well be making a serious mistake. Think safe – do your running risk assessment. Ask yourself, ‘What could go wrong here?’ There have been cases where fuel, thinners and other harmful substances have been consumed accidentally because water bottles were reused for other substances.

Pinch Point Discovered the Hard Way: Mars 201817

As edited from IMCA Safety Flash 04/16

A crewman needed to lift an escape hatch cover from the machinery spaces. He grabbed one of the yellow handles and raised the hatch, but he was unaware of a pinch point that existed between the handle and a nearby pipe. As he brought the hatch to the upright position his finger was caught in the pinch point causing a serious injury to his finger.

Lessons learned

• Risk assessments should be done on your vessel and pinch points should be targeted. If possible, these hazards should be eliminated.
• If it is physically impossible to eliminate certain pinch points, they must be clearly indicated and should form part of the vessel’s familiarisation checklist.

Deadly Girding Accident: Mars 201818

Edited from official MAIB report 16/2017

A 1,100teu container ship was leaving berth assisted by a small port tug. The tug, with a 320hp engine and a single fixed-pitch propeller in a nozzle, was normally used to move barges rather than large ships. It was serving as a temporary replacement for the port’s usual ship-assisting 1,200hp Voith configured tug, which was undergoing maintenance. On the bridge for the departure were the Master and pilot, the chief officer and a helmsman. All communication between the pilot and the tug was conducted in the local dialect, which the crew were not able to understand.

According to the agreed plan, the tug had been secured on the container vessel’s port quarter with two of the ship’s mooring lines payed out about 40 metres. The lines were placed over the tug’s single towing hook.

The Master was initially concerned about the tug’s ability to assist the ship effectively in the planned manoeuvre, and requested the pilot to direct the tug to pull on the port beam with full power. The tug’s performance satisfied the Master, so the stern mooring lines were let go. With the stern lines away and the tug continuing to pull at full power, ahead propulsion was ordered and starboard helm applied on the container ship. The resulting actions caused the vessel to pivot on the remaining forward backsprings, thereby enhancing the stern’s movement away from the quay (diagram 1).

Within a few minutes, the container vessel’s stern was about 25 metres from the quay; the forward backsprings were then let go. The engine was then initially put dead slow astern with the bow thruster full to port, and then hard to starboard helm and dead slow ahead, with the bow thruster remaining full to port. Shortly afterwards the helm was ordered amidships and then hard to port, but the vessel was by now moving astern with its stern coming dangerously close to mooring dolphin (diagram 2).

Half ahead was ordered and the bow thruster half to port, and then full ahead, hard to starboard helm and bow thruster full to port in order to avoid hitting the dolphin. Soon, the ship was moving ahead at more than 5 knots. The tug, which was now astern of the vessel, was unable to gain a safe position because of the unexpected (to the tug crew) and rapid forward motion of the container ship. It quickly girded and capsized.

The Master immediately ordered stop engines and the local pilot boat proceeded to assist the tug crew in the water.
After rescue operations, two of the tug’s crew were pronounced dead.

Although the rapid forward movement of the container vessel that had led to the tug’s girding was ultimately the primary unsafe event, several aggravating factors on the tug also contributed to the negative outcome:

• The towing hook was not fitted with an emergency release mechanism
• A gog rope was not rigged
• Doors and hatches were left open during the towing operation
• None of the tug’s five crew was wearing a lifejacket or other buoyancy aid.

The official investigation found, among other things, that:

• The container ship’s ahead movement was not communicated to the tug crew, so the tug was caught in an unsafe position and was subjected to girding
• The pilot and Master concentrated solely on trying to prevent the ship’s stern from making contact with the mooring dolphin, so communication with the tug was less than optimal.

Lessons Learned

• When in doubt, reconsider your plan. In this case, the tug in service was approximately one-quarter as powerful as the tug normally used and the Master had some doubts about its efficacy before undertaking the manoeuvre.
• Always keep assisting tugs appraised of your vessel’s movements, preferably before the movement begins.
• For tug crews, ensure your vessel is seaworthy and the crew properly trained and equipped.

Editor’s note: Readers may recall the recent MARS 201780 report in which girding was also the focus of attention.

Severe Burns from Hot Oil: Mars 201819

A crew member found some small oil leaks from the glands of the suction and delivery valves of the fuel circulation pump on both generators. He took it upon himself to stop the leaks by adding gland packing, but he was working alone and had not informed anyone else of his plans. Once the work had been completed on one generator, he started the pump to ensure the leak had been corrected. After confirming there was no oil leak from the valve gland, he started to work on the valves of the other generator, but neglected to stop the pump. When he slackened the gland of the delivery valve to install the gland packing, hot oil splashed on to his face and body.

As a result of the incident, he received first and second degree burns to many parts of his body including his face, ear, left arm and left hand.

Lessons Learned

• Although this accident may still have happened even had the crew member been working with someone else, it is often advisable to work on such projects as a team. Mistakes are more likely to be caught before negative consequences occur.
• Always inform your superior about work that is not planned but that you see as necessary – never improvise.
• Work methodically and continue to do a running risk assessment as you accomplish the task at hand.
• PPE, PPE, PPE!!

Timber Deck Cargo Collapse Causes One Fatality: Mars 201820

Edited from official MAIB report 25-2017

A bulk carrier had loaded a cargo of packaged sawn timber. This was the first time timber had been carried on board the ship and the crew were inexperienced in this type of cargo. A supercargo had been appointed for the loading to help supervise and provide guidance to the chief officer on cargo loading and securing and ship stability requirements.

Following the supercargo’s instruction, the ship’s crew secured the deck cargo by means of top-over lashings using chains and turnbuckles. Wooden ladders were constructed at the fore and aft ends of the deck cargo stack to allow access between the accommodation and the forecastle.

Vessel loaded underway.

Upon arrival at the discharge port the ship’s crew removed the deck cargo lashings and cargo was discharged into barges secured alongside the anchored ship. All aspects of the cargo discharge, including operation of the ship’s cranes, were carried out by shore stevedores as required by the charterparty. During the discharge, the bosun was to carry out security rounds and to monitor operations for any damage caused to the ship. There was no supercargo to advise the Master and crew during discharge.

Two barges were alongside on the starboard side and one barge was positioned on the port side. At one point during the discharge about 20 packages of timber, each about 2 tonnes, tumbled overboard from the port side. Cargo operations were stopped. It was then realised that the bosun had been standing on top of the stacks that had gone overboard. A search of the water and the barge was begun. The bosun was found under a pile of timber on the barge. He was evacuated ashore, but was pronounced dead some time later.

Some of the official report’s findings include:

• With the deck cargo lashings removed, the cargo packages stowed on deck had insufficient stability
• The use of uprights would have helped prevent a deck cargo stack from collapsing once the securing lashings had been removed
• Prior to loading, the Master was not advised of either the deck cargo package racking strength or the frictional resistance of its plastic covering. Such information would have enabled him to make a more informed assessment of the deck cargo stack’s stability and security.
• Poor stevedoring practices that had been witnessed by the ship’s crew were not discussed with the stevedores’ foreman and so were allowed to continue.
• Without the provision of a lifeline, there were no readily available means for attaching a safety harness. Without edge protection or any means of fall arrest, the risk of falling from the top of a deck cargo stack, or as a result of a deck cargo stack collapse, was significant.
• The ship’s crew did not assess the level of risk correctly. For example, it was not considered necessary for a catwalk to be installed nor for safety harnesses to be worn while on passage. This miscalculation of risk continued during cargo discharge operations.

Lessons Learned
The provisions contained in the IMO Code of Safe Practice for Ships Carrying Timber Deck Cargoes (TDC Code 2011) is unequivocal in its recommendation that ‘uprights’, as shown below, at least as high as the stow, should be used to stabilise stowed round wood, loose sawn wood and sawn wood packages with limited racking strength.

• The presence of non-critical persons in the vicinity of cargo operations is a factor that unnecessarily increases risks to those persons.
• If poor stevedoring practices are observed, stop operations and discuss your concerns.
• If a specialised cargo is to be transported and crew are inexperienced in the special considerations required, always ensure expert guidance is employed for all phases of the work.

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.