An LNG tanker was proceeding in the open sea at a speed of approximately 21 knots in good visibility. At 05:14 the lookout spotted a light and reported it to the OOW as a ‘fishing boat’, approximately 5 degrees to port. About 22 minutes later, the lookout reported that the fishing boat was right ahead and that he believed that it was close to their vessel.

The OOW used his binoculars to try and estimate the distance of the fishing boat. He believed that it was still quite some distance away. However, the lookout’s assertion that the fishing boat was close raised some doubts in his mind. As a result, the OOW made a small alteration of course to starboard to avoid having the fishing boat right ahead and to clear it visually from the vessel’s vent masts.

Five minutes later the lookout reported the fishing boat ahead once more and suggested to the OOW that it was now crossing from port to starboard. The OOW determined visually that the fishing boat was indeed crossing from port to starboard and made a two-degree alteration of course to port to put it fine on the starboard bow. A few minutes later the OOW again altered course to port a few degrees to a new course of 239°.

The fishing boat now appeared on the radar right ahead and was acquired. It was 7.6 nm away, making a speed of 5.5 knots. Soon, clearer visual contact was made with the fishing boat and both the OOW and the lookout observed green and red navigation lights. The OOW started giving light signals to the fishing boat using the bridge Morse light as per the collision regulations.

At 06:03, the fishing boat now only 1.7nm away, was seen to alter course further to starboard showing only its red light. The OOW deemed this to be an attempt by the fishing boat to cross ahead of them. Finally, the OOW ordered hand steering engaged and ordered 10 degrees to port and then hard port. Shortly after the fishing boat disappeared from view from the conning position.

The OOW went out onto the starboard bridge wing and observed the fishing boat in contact with their vessel mid-ships. He ordered the helm hard to starboard to help move the stern away from the fishing boat. The fishing boat’s port bow came in contact again in way of the tanker’s starboard engine room water ballast tank and then cleared. The OOW called the Master, and it was confirmed that the fishing boat was intact, and the crew were not injured.

Lessons learned

• The OOW did not use all available means to determine if risk of collision existed. For example, he did not take compass bearings of the light when it was first reported to port and as the range decreased.

• At a critical decisional moment, with the fishing vessel 7.6nm away and clearly on a reciprocal course the OOW decided to alter course to port – but only by a few degrees. With a closing speed of about 26 knots this meant the vessels would meet in about 3.5 minutes. Now was the time for an alteration to starboard large enough to be readily apparent to the fishing vessel.
• Hand steering was not engaged until virtually the very last moments before contact. Given the situation and the levels of risk, it would have been more appropriate to do so much earlier.

Real Life Incident: Vessel Collision in Good Visibility appeared first on Marine Insight - The Maritime Industry Guide

A RoRo ferry had finished loading and was leaving the berth. A strong onshore wind was pushing the ferry against the quay, and two bow thrusters were working at 100% to push the bow off the berth. Meanwhile, forward, the seamen were preparing the lines for the next berthing.

In order to set the berthing lines with their appropriate heaving lines, the deck crew were passing the heaving line outboard from position A, where the deck crew was standing on a platform due to the high bulwark, to position C, via position B. A gaff was used to catch the line through a bulwark port at position B. The line was then passed outboard to position C. A deck crew at position C had his arm out of the bulwark port holding a gaff to catch the heaving line.

A few seconds before the line passing manoeuvre began, one of the bow thrusters came offline due to an overpower surge. There was no alarm to warn the bridge team of this situation. The ferry was quickly pushed back to the berth, and the bridge team, realising the situation too late and preoccupied with the manoeuvre, gave no warning to the deck crew, who were unaware that the ferry was closing on the berth. The ferry’s starboard side struck a berth fender at the level of the bulwark port at position C just as the deck crew had his arm outstretched and outboard. His arm was instantly severed.

The victim was treated immediately for profuse bleeding. Within minutes the vessel was re-berthed and the victim sent ashore for professional medical attention. The official investigation found that, among other things, the ferry, which was a new build still under guarantee, had suffered numerous bow thruster and electrical problems since beginning service a few months prior.

Lessons learned

• Following the accident, a task analysis made it possible to establish a work method which eliminated the risks due to the use of a gaff outboard.
• Everyday practices, when conditions are benign, can hide hazards in plain sight. Take the time to re-analyse current work methods using the ‘what if’ risk assessment methodology. Can risks be further reduced by eliminating hazards or questionable procedures?
• New vessels can be subject to a ‘breaking in’ period where numerous minor or even major anomalies are discovered. These should be corrected as soon as possible to avoid unwanted negative consequences.

Real Life Incident: Severe Injury To Deck Crew While Leaving Berth appeared first on Marine Insight - The Maritime Industry Guide

A tanker in ballast was departing from a river port, from a position which required a turn of approximately 180°. There was one pilot on board and one tug (the only one available) made fast aft.

Winds were from the south at about 20-25 knots and there was a northerly current setting. Once all lines were clear the vessel was taken off the berth and a turn to port was initiated.

The tugboat aft was ordered to move to vessel’s starboard bow to better assist in the rotation. With the tug pushing at the starboard bow, the vessel was now moving aft with a Speed Over Ground (SOG) of 2.4 knots. Soon, the vessel had turned about 60° to port, but the current and wind were moving the vessel to the north. The main engine was set to half ahead while rudder was hard to port.

As the vessel achieved approximately 90° of the turn, it was reported to be 10 metres from a dolphin on the starboard bow. The tug was at full power, but could not control the vessel’s set toward the dolphin and had to abandon its position for fear of being crushed. The vessel’s main engine was set at full astern, but the starboard bow brushed against the south corner of the mooring dolphin. Within minutes the vessel completed the turning manoeuvre and commenced the outbound passage to the anchorage, where damage to the hull was observed.

Lessons learned

• In a very restricted waterway and with wind and current conditions that made for a complicated 180° turn, the use of one tug is, in retrospect, a hazardous decision.
• Only one tug was available in this port, so the hazards were ‘normalised’ by the Master and pilot as ‘acceptable’.
• Plan a manoeuvre beforehand and think about the forces acting on your vessel. In this case the vessel had to come 180° after leaving the berth and at one point was perpendicular with the current in a restricted channel. The tug could not overcome the forces acting on the hull pushing it to the North.

Real Life Incident: Departure Damage in Very Restricted Waterway appeared first on Marine Insight - The Maritime Industry Guide

Vessel A was making way at about 13 knots, gaining slowly on Vessel B which was making about 10 knots. The pilot of Vessel A observed Vessel B cross their bow from starboard to port about 0.5nm ahead.

Based on this action, the pilot assumed the vessel was headed for the North exit of the Traffic Separation Scheme (TSS). Up to this point, there had been no VHF communication between the two vessels. Vessel A continued to gain on Vessel B, and it appeared they would pass Vessel B on their port side at a distance of about 200 metres.

Meanwhile, on Vessel B, the lone watchkeeper was contacted by the local Vessel Traffic Services (VTS) on VHF. VTS inquired if they were headed to ‘K’ anchorage.

The OOW, although unsure of the exact anchorage, responded in the affirmative. The VTS then informed the OOW that in order to make ‘K’ anchorage they were required to navigate the Traffic Separation Scheme (TSS) on their starboard side.

The OOW was surprised but took the VTS advice as an order. He knew he had to act quickly to enter the TSS, so he informed VTS he was coming to starboard. He knew there was a vessel astern, but without verifying, he assumed it was still some way behind.

The local VTS immediately called Vessel A on VHF and informed the bridge team that Vessel B was destined for an anchorage and that the vessel would take the appropriate TSS to starboard. At about the same time, the pilot of Vessel A saw Vessel B begin to turn sharply to starboard, which meant that this vessel would cut in front his vessel. He attempted to call Vessel B on VHF but there was no response.

He ordered the main engine be put to stop, while the Master simultaneously ordered hard to starboard. At the same time the OOW of Vessel A blew a long blast on the whistle. Despite all this, a collision was now unavoidable and Vessel B collided with the port side of Vessel A. The starboard bow of Vessel A then struck the navigation buoy that had been close to starboard.

Lessons learned

• Assumptions made by both vessel operators on the actions or position of the other vessel contributed to this accident. Keep your situational awareness honed sharp and communicate with other vessel operators to augment understanding and shared mental models.
• When passing another vessel close by, as in this case about 200m, it may be advisable to have a mutual understanding of the manoeuvre.
  Return to listing

Real Life Incident: Low Situational Awareness Has High Impact Consequence appeared first on Marine Insight - The Maritime Industry Guide

A loaded tanker had dropped anchor in a designated anchorage in depths of 30 m, using six shackles in the water. Upon receiving clearance to berth the deck crew began recovering the anchor but the windlass was experiencing considerable strain.

The hydraulic motor was damaged due to the heavy load, so the operation was stopped and VTS informed accordingly. A spare hydraulic motor was installed and about 12 hours later clearance was again received to heave the anchor.

On this attempt, the anchor was successfully lifted out of the water. The crew observed the vessel’s anchor was fouled with another anchor and chain. After careful consideration and with the exercise of good seamanship, this abandoned anchor and chain were freed from the vessel’s gear and the vessel continued normal operations. The local VTS was informed.

Lessons learned

• If you lose an anchor and/or chain in a designated anchorage always report such an incident to the local VTS, as it will then be identified as a possible foul ground area.
• If your windlass is struggling to lift the anchor in otherwise normal conditions consider the possibility of it being fouled. Divers may be needed to inspect.

Real Life Incident: Fouled Anchor in a Designated Anchorage appeared first on Marine Insight - The Maritime Industry Guide

A tug was towing a scrap metal barge in coastal waters in easy wind and wave conditions. The scrap metal was ‘shredder feed’, which is a lower grade than heavy melting steel.

Shredder feed consists of a variety of different metal scraps, including end-of-life vehicles that have been crushed (but with free-flowing liquids – gasoline, oil, paint, anti-freeze, lubricants – removed), household appliances, and various other ferrous metal pieces greater than one-quarter inch in thickness.

Early one morning a crew member on watch saw smoke and a red glow emanating from the pile of scrap metal on the barge being towed 200m astern. Soon, flames were seen coming from the same area of the barge. The alarm was raised. The fire on the barge was quickly getting larger, and the tow wire was shorted to about 100m to better control the barge

Soon, Coast Guard and local authorities arrived on scene and began fighting the fire. At this point, the fire on the barge had grown exponentially. The barge was towed into shallower water and beached. Firefighting efforts continued for the next 24 hours before the fire was finally extinguished. No pollution or injuries were reported. Damage to the barge was extensive and estimated at $7 million.

The NTSB determined that the probable cause of the fire was the ignition of a combustible material by an undetermined source, such as sparking from shifting metallic cargo, self-heating of metallic or nonmetallic cargo, improperly prepared vehicles and appliances, or damaged lithium-ion batteries. The International Maritime Solid Bulk Cargoes Code (IMSBC Code), lists scrap metal as a ‘Group C’ cargo, which is unlikely to liquefy, does not possess chemical hazards, is noncombustible, and has a low fire risk.

Lessons learned

• Scrap metal seems innocuous and is listed as noncombustible in the IMSBC Code, but is nonetheless a fire risk. Another MARS report of this type can be found at 202243 and below, at 202346.
• Scrap metal fires tend to be hard to extinguish and burn hot and long, often causing major damage. See MARS report below.

Risk reduction measures for this type of cargo could include:

• Checking the temperature of the cargo regularly to ensure the load is not self-heating. If the temperature is higher than 55°C, the cargo should not be loaded. If, during the voyage, the temperature rises to 80°C, this is a potential fire risk and the vessel should immediately proceed to the nearest port.
• Appointing a qualified cargo surveying company to assist the vessel’s Master before and during loading.

Source: The Nautical Institute

Real Life Incident: Fire On Barge Carrying Scrap Metal Causes $7 Million Worth Of Damage appeared first on Marine Insight - The Maritime Industry Guide

A passenger ship was on a berthing approach to a dock. The Master took the con about 0.5nm from the pier, with the ship making about 7 knots.

When the vessel was about 0.37nm from the pier and making about 6 knots, the Master began the near 180° rotation to port in order to back into the berth and make a starboard docking. Two of three bow thrusters and both azipods were online.

The Master, staff captain, and a pilot were stationed on the port bridge wing. The ship rotated to port, with its stern swinging to starboard toward the pier. It needed to clear the pier’s northernmost mooring dolphin. The staff captain managed communications with the forward and aft mooring decks; he also operated a starboard bridge wing camera (using a joystick), which allowed him to see the pier and mooring dolphins.

The chief officer and another pilot were located on the starboard bridge wing. The first officer was stationed at the forward console to monitor the ECDIS – which used integrated radar – and inform the Master of the vessel’s distance to the pier every tenth of a mile as it approached the terminal. The second officer was stationed at the console at the back of the bridge. A helmsman and a lookout were also on the bridge. A crew member, who was in charge of the aft mooring deck team, was stationed on the stern to provide the vessel’s distance to objects and the pier by radio when requested by the staff captain on the bridge.

After the vessel began rotating, the first officer stopped calling out the vessel’s position relative to the mooring dolphin at the end of the pier. Instead, the Master relied on the bosun’s distance callouts via radio and the ECDIS display on the bridge wing to identify the vessel’s position relative to the pier, using the ECDIS.

The Master also used the starboard bridge wing camera operated by the staff captain to note when the ship, moving athwartships to starboard, was clear of the dolphin, allowing him to go astern to the berth. However, the crew stated that the camera froze during the manoeuvre due to a hardware issue. When the vessel was almost completely turned, the crew member aft reported the vessel was in line with the dolphin.

Soon after, he reported the vessel was 56 metres away from the dolphin. About 30 seconds later, he reported the distance as 35 metres and closing. Very shortly after, the ship’s starboard quarter struck the mooring dolphin at the end of the pier. Vessel damage was minor, but damage to the pier was estimated at $2.1 million.

The investigation found, among other things, that the cruise terminal pier had been extended northward by 120 metres with the addition of two dolphins and a connecting walkway about a year before the accident. However, this change was apparently not communicated to the responsible hydrographic authorities. As a result, the pier was not accurately depicted on any navigational charts.

Therefore, the vessel’s ECDIS showed the original, non-extended pier. Even so, as the vessel approached the pier, the weather was clear, and visibility was good. The Master and bridge team should have been able to see the extended pier and added dolphins. However, none of the members of the bridge team reported the extension as the vessel approached the pier. Instead, the Master relied on the ECDIS – which showed the old, inaccurate Electronic Nautical Chart (ENC) – to determine the vessel’s position relative to the pier.

The investigation determined that the crew member calling out distance aft was giving accurate distances to the pier’s northernmost dolphin from the ship’s stern. However, the Master incorrectly assumed the bosun was calling out how much clearance the ship would have as the stern passed the dolphin.

The crew member had either not been properly briefed before the manoeuvre or had received no instruction as to what exactly he was expected to communicate to the bridge team. Had the Master and crew member clearly understood what distances were being communicated, the Master and bridge team may have been aware of how close the vessel was to the dolphin and could have taken action to avoid the casualty.

• There is no substitute for clear, concise communication. In this instance, notwithstanding good visibility and daylight, the nine person berthing team either miscommunicated or under-communicated, thus paving the way for a negative outcome.
• Although an excellent navigational tool, ENCs can be inaccurate for a wide range of reasons. In this case, we observe that the berth extension of 120m completed about a year earlier was not reported to the hydrographic authority. As such, the ECDIS image the Master was referencing was not a reflection of reality.
• It is good practice in navigation and manoeuvring to use more than one source of position data input.

Source: The Nautical Institute

Real Life Incident: Passenger Ship Strikes Pier Causing Damage Worth $2.1 Million appeared first on Marine Insight - The Maritime Industry Guide

A general cargo vessel had berthed and was discharging cargo from the upper port cargo hold. The tween-deck had been emptied and next the pontoons would be removed in order to access more cargo below.

The vessel’s crew began the tweendeck pontoon removal, a job they knew well. One crew member was assigned to operate the crane. One seaman was assigned as signal man and was equipped with a portable two-way radio to communicate with the crane operator. He was assisted by another crew member. Together, they would be rigging (hooking-on) the tween-deck pontoons in the cargo hold.

The two crew were positioned in the forward part of the cargo hold, where they would hook the pontoons on to the crane. A third crew member was assigned to un-hook the pontoons once they were laid down on top of other tween-deck pontoons against the bulkhead in the aft part of the cargo hold. This crew member had to shelter in a safe position aft until the first pontoon was laid down on deck. The dedicated safe position during the manoeuvring was inside a passage between the port and starboard holds.

The first pontoon was hooked on and, once at a safe distance, the signalman gave hoisting orders to the crane operator through his portable two-way radio, as well as the usual hand-signal. As tension came on the slings, the signalman checked that the pontoon was well slung and that the other crew member was in the dedicated safe position. The signal man signalled the crane operator to hoist and move the pontoon by means of hand signals and verbal commands.

The crane operator first lifted the pontoon approximately 1.5 m by hoisting the crane hook. To move the pontoon aft, he then raised the boom of the crane while lowering the hook. By doing so, the pontoon was kept more or less stable at the same height whilst moving aft.

The lifted pontoon did not make any uncontrolled movement. The pontoon was not swinging or turning. Reportedly, nothing unusual was heard or seen until the signalman saw that the crew member who was supposed to be sheltering aft to unhook was lying on the deck. The signalman raised the alarm with the VHF radio and stopped the operation. The victim was given first aid and a doctor came to the scene but he was declared deceased.

The investigation found, among other things, that because the pontoon itself had blocked a proper and full view of the work area, neither the signalman nor the crane operator had been able to see that the victim had entered the danger zone between the bulkhead and the hoisted pontoon. Although the victim knew to stay in the designated shelter area until the pontoon was safely down, it is possible he attempted to quickly remove some cargo debris as the lift was under way.

• Human nature is such that we want to get the job done – the ‘can do’ attitude which probably explains the victim not remaining in the designated safe area. The ‘can do’ attitude can be perilous if we ignore established procedures in the process.
• The victim did not have a VHF radio so he would have been unable to stop the operation, had he seen this was necessary.

Source: The Nautical Institute

Real Life Incident: Crushing Fatality While Moving Pontoon Tweendeck appeared first on Marine Insight - The Maritime Industry Guide

A general cargo vessel was loading scrap metal into both the forward and aft cargo holds. A loader was lowered into the aft cargo hold to smooth the heap of scrap metal in certain areas. At one point, the operator of the loader saw a small amount of white smoke rising from within the scrap heap in the port aft section of the hold. He immediately raised the alarm.

As edited from JTSB (Japan) report MA2018-10

The shore fire department was called while crew prepared fire hoses. Soon, the loader operator – who was still in the hold – saw flames in the scrap heap. A few minutes later, crew were able to direct water jets from fire hoses onto the scrap metal heap. The loader operator evacuated the hold, leaving the arm of the loader extended above the hatch coaming. Local shore fire fighters arrived and took control of the fire fighting activities. Not long after, the crew were asked to evacuate the vessel for their safety.

The shore fire fighters decided, based on experience in past firefighting of ship fires, to use a protein foam spray delivered from a large aerial-platform chemical-spray fire truck. As they made preparations for the application of the protein foam spray, the vessel listed to port, and the firefighters on the vessel withdrew. The fire continued to increase in size.

About an hour after arriving, the shore fire fighters began spraying the protein foam into the aft cargo hold. This technique did not seem to have the desired effect and the shore firefighters asked the Master for permission to continue to use water. Permission was granted, but some 12 hours later, after the application of copious amounts of water, the vessel sank alongside the berth. The fire was then declared extinguished.

The investigation found, among other things, that the source of the fire was most likely to be a spark created by contact between metal objects, a battery, etc., in the scrap. The source then ignited combustible material mixed in the scrap (eg plastic, rubber, wood chips, paper).

It was not possible to determine the exact origin of the fire. The investigation also found that the Master did not think to use the hold’s fixed CO2 firefighting equipment after the fire was first discovered. In fact, this was a moot point because the loader was left with its arm extended above the hatch coaming. This would have prevented the closing of the hold’s hatch, a necessary first step before releasing CO2.

Lessons learned

• As seen in the previous MARS report (202345), scrap metal, while intuitively innocuous and listed as noncombustible in the IMSBC Code, is nonetheless a fire risk.
• Reactions during an emergency are honed with training. Masters and crew should be aware of the most efficient fire fighting methods on their ship and quickly be able to put these into practice.
• Copious and uncontrolled amounts of water poured into a ship will cause a loss of stability and possibly the foundering of the vessel. This will, however, probably succeed in extinguishing any fire on board.

Source: The Nautical Institute

Real Life Incident: Scrap Metal Fire Extinguished But Vessel Sunk appeared first on Marine Insight - The Maritime Industry Guide

In the early morning a small cargo ship left port bound for a short sea destination. The OOW was alone on the bridge as it was now daylight and visibility was good.

As edited from NSIA (Norway) report 2022/12

He set a SSE course, as per the voyage plan, and the vessel was making about 12 knots. The OOW scanned the horizon for potential dangers through the bridge windows and observed AIS signals from a few smaller vessels on the radar. He did not see any targets that concerned him, although there was a target near their heading line to port at about 6nm. The OOW then turned his attention to administrative tasks using a computer placed aft in the wheelhouse.

Meanwhile, on a fishing vessel about six nm away, the two person crew were trawling for prawns. Both the navigation lights and day shapes for trawling were displayed. The AIS had been set to passive mode during the night to conceal the vessel’s position, as the location of specific prawn fishing grounds was considered a ‘trade secret’.

At about 08:28 the crew stopped trawling and started hauling the trawl net. Due to currents and because they were being pulled towards the trawl while hauling, the vessel was now moving astern at about one knot.

It was around that time that the skipper noticed the cargo ship coming more or less towards them, but he perceived it as part of the normal traffic in the area. He reactivated the vessel’s AIS about this time. As it was daylight and good visibility, he did not think it was necessary to communicate with the cargo ship.

After a few minutes, the skipper observed the cargo ship approaching ever closer, but initially assumed that the vessel would pass without any risk of collision. Soon, however, he realised there was imminent danger of collision; he set the engine to full speed astern but was unable to avoid impact.

On the cargo vessel the OOW felt something hit the bow of the ship. Looking out, he saw the mast of a fishing vessel close along the starboard side. The time was 08:35.

The collision caused the fishing vessel to heel over and turn around almost 180 degrees. Once clear of the cargo ship, the fishing vessel still had propulsion. The crew were unharmed and proceeded to check the status of the vessel, which had sustained considerable damage to the port bow bulwark but otherwise was out of danger.

After the collision, the OOW reduced the speed of the cargo ship, turned the ship around, called the fishing vessel on VHF and asked whether they needed assistance. Both vessels later returned to port for inspection and repairs.

Lessons learned

• Distractions, be they administrative or personal (mobile phones!) are antithetical to keeping a sharp lookout.
• Not all small vessels carry or use their AIS consistently, so keeping a sharp visual and radar lookout is essential.

Source: The Nautical Institute

Real Life Incident: Collision In Daylight And Good Visibility appeared first on Marine Insight - The Maritime Industry Guide

On a vessel underway, two engine room crew were detailed to clean the engine room ventilator water mist catcher using a pressure cleaner. The job progressed without incident and afterwards, the two crew proceeded to clean the carbon and other debris on the poop deck.

One of the crew was holding the lance of the pressure washer when he inadvertently pressed the trigger. The sudden pressure surge produced a hydraulic kick-back force in the lance, and the water jet hit him on his left leg just above the knee. The victim screamed and released the trigger and the lance. The other crewmember immediately stopped the pressure washer.

Lifting the coverall to reveal the injury showed that there was bleeding from a wound created by the high pressure water stream and that a small portion of the flesh in that area was missing. The victim was given first aid which was, in this case, sufficient.

Lessons learned

• A pressure washer is like a loaded gun. The water forces generated can cause severe injury in contact with a person’s body
• If a pressure washer is on, always hold the lance with both hands to have full control. Never point the lance at yourself or others

Source: The Nautical Institute

Real Life Incident: Pressure Washer Risks appeared first on Marine Insight - The Maritime Industry Guide

Current gantry crane practice and risk reduction measures are not adequate, finds a report from Dutch Safety Board (DSB).

The in-depth report on issues with gantry cranes was published in July 2022, following a string of accidents involving where crew or shore staff suffered injuries or death. The report was based on six occurrences that involved crushing by the gantry crane due to entrapment, with very similar sequences. Two took place on the same vessel within three years of each other. Readers can find past MARS reports involving gantry cranes at 202201, 202211, 201525, 201460 and 98058.

The report underlines some of the fundamental weaknesses of gantry crane installations and operations. Among other things, it highlights that:

• The crane operator’s field of view is severely restricted and does not allow a proper overview of both sides of the crane’s track.
• The vessel layout allows persons to cross the track of the gantry crane.
• Communication with others is essential for determining if the hatch crane can be operated in a safe manner. Yet, this introduces the risk of miscommunication which was a contributing factor in at least one fatality.

Various measures have been adopted to control bad outcomes, but these appear to still have unacceptable residual risks. For example, having alarms continuously sounding while the crane is operating is well-intended – but they can become routine. Their efficacy will probably decline with time as crew become desensitised to the alarm and qualify it as ‘normal’.

Emergency crane stop buttons are now a common installation. Yet analysis found that in many past occurrences the emergency stop button was not used because it was out of the victim’s reach. Finally, an analysis of the accidents has shown that it is common practice to carry out hatch crane operations at the same time as other operations. In many cases, the victim was not expected to be in the danger zone because he was carrying out operations not related to the use of the hatch crane.

The DSB concluded that current gantry crane practice and risk reduction measures are not adequate. Clearly, a new paradigm is needed. In many industries, working in the ‘line of fire’ is not allowed. Yet, any crewmember stepping across a gantry rail while it is operating is in the ‘line of fire’. It is essential that work is coordinated. A clear framework and agreements for simultaneous yet disparate operations should be established. Without this, the risk of entrapment cannot be adequately controlled.

Lessons learned

• Never cross the gantry crane rails while the crane is in use. If it is necessary to cross the rails, the crane should be stopped.
• Unrelated work on deck or in the holds should not be scheduled while gantry crane operations are taking place. If schedules clash, one or other of the operations should be rescheduled.

Source: The Nautical Institute

Real Life Incident: Hatch Gantry Crane Safety Study appeared first on Marine Insight - The Maritime Industry Guide

A general cargo vessel was fully loaded with cut timber packed into plastic-wrapped packages, both in the cargo hold and on deck.

As the vessel was departing its loading berth, the linesman noticed that an electrical extension cord between the vessel and the quay had not been disconnected. The crew on the forecastle informed the bridge team, but the vessel was already moving away from the berth, and it was not possible to prevent the cable from breaking.

When the pilot left the vessel, he saw a few metres of the extension cable hanging down by the side of the vessel. The cable was not inspected after the vessel departed. During the voyage there were no observed anomalies.

The vessel anchored in a port to bunker via a bunkering barge. Just after the bunkering began, the crew of the bunkering barge smelt smoke. Then they saw flames emerging from the deck cargo of the general cargo vessel on the port side, forward.

They immediately informed the crew of the vessel and bunkering was stopped. The bunkering barge cast off and moved away. The crew on the barge then activated their water cannon and moved closer to the general cargo vessel in order to attempt to extinguish the fire. Meanwhile, the crew on the vessel were also attempting to extinguish the fire using the vessel’s own firefighting equipment. Other tugs and small boats arrived to help extinguish the fire, but all efforts were in vain.

Under her own power and with tugboats attached, the general cargo vessel was docked at a port of refuge seven days after the fire had first been detected. Finally, three days after the vessel had docked and fully 10 days after the fire was first detected, the fire was declared extinguished.

The official investigation found, among other things, that the extension cable that broke while undocking was probably live when the fire started. Although a circuit breaker normally trips rapidly if there is a direct metallic connection between two conductors, if the current is passing through an electric arc and electrical conductors with substantial impedance (electrical resistance), the current may be too low to trip the circuit breaker. So, in all probability, an electric arc had come into contact with the plastic packaging or the wood and eventually ignited the material.

Lessons learned

• Any situation where potentially ‘live’ circuits or wires are exposed should be corrected with the briefest of delays.
• The management of this vessel fire was one of the most extensive operations of its kind in modern times for Sweden. Among other things, the investigation revealed that multiple and overlapping responsible agencies needed to cooperate, but no protocols had been established prior to the emergency
• The management of ships in need of assistance must be robust. Prior planning for all contingencies should be undertaken by a wide swath of concerned agencies including at the local, municipal and federal levels

Source: The Nautical Institute

Real Life Incident: Cargo Fire Takes 10 Days To Extinguish appeared first on Marine Insight - The Maritime Industry Guide

In darkness and with visibility further reduced to about 150m in fog, a container vessel was being brought to a tidal river berth under pilotage.

To monitor the vessel’s progress, the pilot had set up his portable pilotage unit (PPU). He had connected the rate-of-turn generator to the vessel’s pilot plug and had set a variable range marker on the radar with a radius of 0.5 nm. The PPU had a predictor that continually self-updated to display the vessel’s next six predicted positions at intervals of 30 seconds.

The pilot and the Master had exchanged their respective information; the passage plan, local traffic and berthing procedure (pilot) and the vessel’s condition and manoeuvring data (Master). The pilot increased the vessel’s speed in order to overcome cross-currents at the mouth of the river and then commenced a starboard turn to enter the river as normal. Soon, the vessel’s speed was about 16 knots. At this point, the Master was using the ECDIS located at the starboard conning position to monitor the vessel’s progress, while the OOW was using a paper chart.

At 2150, the pilot ordered half ahead. About two minutes later the pilot ordered 15 degrees of starboard helm to initiate the turn through the next bend in the river. He then used the predictor to assess the vessel’s rate of turn. Soon he ordered the rudder angle to be reduced to 10 degrees to starboard, then to 5 degrees and finally to midships.

At 2153:20 the vessel’s speed was near 14 knots and the rate of turn was about 25 degrees/minute to starboard. About a minute later, with the speed now 13 knots, the pilot cross-checked information from the PPU predictor with the radar. The radar information showed the vessel was not proceeding as indicated on the PPU so he ordered counter rudder to port and full ahead on the engine to stop the turn to starboard and correct the vessel’s position in the channel.

This action was insufficient and the vessel grounded at 2156, within the navigable channel but in an area where silting had been reported and that the pilot knew was present. With the rising tide the team were able to re-float and dock the vessel about two hours later.

The official investigation found, among other things, that;

• The pilot’s PPU was obtaining information from the vessel’s AIS, which was subject to GPS ‘smoothing’. As a result, the predicted vessel positions displayed on the PPU were not accurately reflecting the vessel’s future positions, but the pilot was unaware of this. Also,
• The pilot did not inform the bridge team about the extent of silting within the navigable channel nor had the bridge team taken steps to obtain this information. As such, the bridge team was unable to identify or to assist the pilot in resolving the developing unsafe situation

Lessons Learned

• Had the pilot used an independent DGPS antenna for his PPU the predicted positions would probably have been more accurate than those represented by the vessel’s AIS pilot plug.
• Communication and planning is everything! The silting in the channel was not communicated to the bridge team by the pilot – but neither did the vessel’s team take the time to research this fact which was readily available via on-line sources.
• Speed changes everything! In this case the vessel was proceeding at near 13 knots (6.68m/sec) in a narrow channel in near zero visibility. Proceeding at nine knots (4.63m/sec) would have given them extra time, about one minute, to reevaluate the circumstances and manoeuvre. This would likely have prevented the grounding

Source: The Nautical Institute

Real Life Incident: Paltry PPU Position Predictor appeared first on Marine Insight - The Maritime Industry Guide

A ferry was inbound to a small port in daylight conditions with good visibility at a speed of 9.5 knots. A bridge team member called the port Vessel Traffic Services (VTS) to inquire if another ferry, already in the port and due to depart, would in fact leave on the specified time. Port VTS responded that the ferry would depart in the next ten or 15 minutes and that it would be best if the approaching vessel held position outside the port until the outbound ferry left, given the constrained nature of the port. This information was given as a ‘suggestion’ and not as an instruction.

About 18 minutes later, port VTS called the inbound ferry to advise that the outbound ferry was singling up and would be leaving in the next minute or two. This was acknowledged by the inbound ferry. However, instead of holding position, they continued inbound at a reduced speed of about six knots.

On the departing ferry, the bridge team were not monitoring traffic prior to departure; instead, they relied on information from VTS regarding the position of the inbound vessel. The OOW stated that the ECDIS and radar were checked only after all lines were clear and they had lifted off the berth. They were surprised to see the inbound ferry, now very close, and only quick manoeuvres and last-minute communication between the vessels helped avoid collision.

As it transpired, a relieving Master was bringing the inbound ferry into port as a training exercise under the supervision of the Master. Poor communication between the Master and the relieving Master contributed to the close quarters situation developing.

Lessons learned

As with most incidents and accidents, several contributing factors conspired to bring about the close quarters situation;

• The VTS only ‘suggested’ that the inbound ferry stay outside the port while the departing ferry was leaving. For unknown reasons the inbound ferry’s bridge team decided to ignore this suggestion and entered the port anyway.
• The inbound ferry’s bridge team had less than adequate communications with each other and with outside actors.
• The departing ferry’s bridge team had less than adequate situational awareness of the port traffic situation and in particular the position of the incoming ferry

With or without a pilot, always ensure you have an accurate picture of the traffic situation before departure. In constrained waterways, it is easier to hold the berth while traffic passes than be obliged to manoeuvre.

Reference: The Nautical Institute

Real Life Incident: Close Quarters Between Ferries appeared first on Marine Insight - The Maritime Industry Guide