UK P&I - Shipowners Club - Loss Prevention - Case Studies

Loss Prevention

Case Studies

Contents

Case studies are summaries of claims that have been notified to the Club. We produce these to raise awareness of the causation of claims and their outcome so that other Members can benefit from the misfortune of others and pass this knowledge on to all relevant sectors of their organisations.

Introduction

The case studies within this publication are arranged by vessel type and then categorised by area of claim e.g. Navigation, Personal Injury/Illness and Operations.

We hope that Members will find the following compilation of case studies useful.

David Heaselden Loss Prevention Manager

David Heaselden

Section 1� Dry Cargo Vessels

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The Incident: In this case the barge concerned was secured alongside, working cargo. A coastal vessel then entered the port and without obtaining permission from the terminal moored alongside (double banked) to the barge. After berthing the crew of the coastal vessel reportedly went ashore by passing through the accommodation of the barge. It was at this time (1035 hrs) that the crew of the barge noticed that a breast line at the after end of the barge had parted and therefore proceeded aft to replace it. Upon arriving at the stern they found one of the crew members from the coastal vessel lying injured on the port side of the main deck adjacent to the accommodation. It appeared he had been

struck by the rope as it parted. The barge’s crew immediately reported the matter to their shore office who in turn informed the Hong Kong Marine Department and other officials. Shortly afterwards police officers attended the barge along with an ambulance and the fire department. Personnel from the ambulance were unable to board the barge on account of the prevailing heavy sea conditions. Therefore oxygen equipment was passed to the barge’s crew who were duly instructed on its use. The firemen then boarded the barge and hoisted the injured person ashore where he was taken to hospital. Unfortunately the injured person died later in hospital.

Dry Cargo:� Bulk

Personal Injury/Illness

Only Use Equipment for it’s Designated Purpose

Observations:The nylon rope (8 inches in circumference) had been used as a mooring line and was observed in poor condition. The eye splice had been extensively cut with only a few strands remaining which were rust stained. The vessel’s crew noted that the rope had been used for towing prior to being utilised as a mooring line. It is imperative that ropes are utilised for their intended use. Once they have been used to perform a function they should not be reused for other purposes. Ropes should be subject to regular examination including telltale signs of wear (powdering in the case of nylon ropes).

Root Cause:Incorrect use of vessel equipment.

Financial Cost:US$43,362.

Issue Date: 05/02/08 Case No. 50055

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The Incident: A 1,200 ton gearless bulk carrier was discharging her cargo of rape seed meal. Shortly after discharge commenced cargo operations were suspended during a heavy rain shower. The crew had some difficulties in reopening the hatch covers and as a result discharge was delayed.

Following this incident stevedores requested that discharge continue during periods of rain. The Master asked for written authorisation and this was reportedly promised by the stevedores. On the strength of the promise of a letter of authorisation to work in the rain the Master allowed discharge to continue in the rain and made no attempt to cover the hold during lunch breaks.

When a cargo claim for wet damage was presented by the consignee the stevedores refuted any knowledge of a letter of authorisation to permit working during periods of rain.

Cargo

Loading During Rain Causes Cargo Claim

Observations:The only people with the power to authorise the discharge of water-sensitive cargo during periods of rain are the shippers or consignees. Stevedores do not normally have the authority to do so.

In many parts of the world stevedores are paid by ton of cargo loaded or discharged with the result that interruptions to the cargo operations because of rain represent a loss of income. When requested to continue loading or discharging water-sensitive cargoes in the rain Masters should ensure that they have received written authority to do so from the shipper or consignee or someone acting with their authority. In cases where the authorisation is given by persons other than the shipper or consignee the Master should ensure that the person authorising the operation has the power to do so otherwise responsibility for damage to the cargo may remain with the ship.

Root Cause:Non compliance with good cargo operational practices.

Financial Cost:17.5 tons of cargo were damaged with a market value of over US$3,000.


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The Incident: This case concerns the grounding of a vessel in mid-afternoon during a coastal passage. At the time of the grounding visibility was good with a light easterly breeze, smooth sea and no swell. The Master was on the bridge chatting to the officer of the watch and there was also a deck cadet on the bridge.

The vessel was on a regular run between two ports in an area of relatively shallow water, liberally scattered with coral reefs. The Admiralty Pilot advises mariners that charts of the area were based on old surveys, (few systematic surveys have been carried out), and that much of the information is derived from lines of soundings taken by vessels on passage. The working chart carried the following caution:

Navigation

Grounding as a Result of Poor Navigational Practices

Unsurveyed Areas No hydrographic survey has been conducted and accordingly mariners attempting to enter these areas should proceed with extreme caution as unidentified shoals, reefs and other navigational hazards may exist.

The chart shows a recommended track for transiting the area which passed to the south of an offshore reef. The vessel’s course line did not follow the recommended track. Instead the Master inked in a course which cut a corner, passing to the north of the reef through an area clearly marked as unsurveyed. The Master had apparently regularly followed that route when a junior office on a smaller vessel. His departure from the recommended track was increased by the second mate who, after fixing the vessel’s position at 16.00 hrs, decided to alter course to cut the corner even more, taking the vessel further into unsurveyed waters.

Observations:The grounding was the result of sub-standard navigational practices. The Master and Owners had allowed a culture of corner-cutting to develop. Subsequent investigation revealed that recommended tracks were often ignored when a straight line between two points would save a little distance. In many cases this took the vessel into close proximity to shallow water whilst saving only minimal time and distance.

Numerous other areas of sub-standard navigational practices were revealed including failure to correct charts in accordance with the latest Notices to Mariners. This working chart had not been corrected for over two years and the Admiralty Pilot for the area was missing the latest supplement which contained information relevant to the area of grounding.

In addition it appears that almost total reliance was placed on GPS despite being in close proximity to a steep coastline with numerous features, giving a good clear radar echo and ample opportunity to take visual bearings. The working chart is endorsed with the caution:

SATELLITE-DERIVED POSITIONS Positions obtained from satellite navigation systems are normally referred to the WGS Datum; adjustments for plotting such positions cannot be determined for this chart. Mariners must determine the position of their vessel in relation to the charted positions of dangers and navigational features by visual or radar means.

Fortunately the vessel suffered no major damage in the grounding and was refloated within 12 hours. The Master was relieved of his command.

ROOT CAUSE:Inadequate navigational practices.

FINANCIAL COST:Issue Date: 01/02/02 Case No.28862

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The Incident: The Club has recently dealt with a number of claims that have been caused by known intermittent faults occurring at the wrong time.

This particular incident involved a 500 gt Dry Cargo vessel fitted with a main engine gearbox.

After loading a cargo of stone the vessel proceeded on her laden passage without problem. The discharge port was located inland from the coast requiring passage through locks and a canal. The vessel entered the lock without event, but upon departing, the Master experienced difficulties engaging the gearbox from ahead to astern. After several attempts the problem “disappeared” and the vessel left the lock.

Shortly afterwards the decision was taken to moor the vessel alongside a layby berth and whilst manoeuvring alongside the gearbox again failed to engage astern. As a result the vessel made heavy contact with the quay, she came off and after several further attempts the gearbox successfully engaged and the vessel was safely berthed.

The damage to the vessel was severe enough to warrant the attendance of a Class surveyor. As can be seen from the photograph above, the quay was also badly damaged as was a section of public road that ran along it.

Navigation

Intermittent Faults can be more Serious than a Permanent One

Observations:The Master and Chief Engineer had both recently joined the vessel and were not aware of any previous problems with the gearbox. However, the vessel’s Superintendent upon hearing of the incident advised the Master that it was a known problem and had been experienced on previous occasions.

It is very disappointing to note that the previous Master and Chief Engineer did not consider problems engaging astern movement of the vessel serious enough to warrant advising their reliefs, or that the ship’s managers via the superintendent did not take any positive action in trying to solve the problem. At least the relief Master should have been advised to take suitable precautions until such time as the fault had been rectified.

The Member was fortunate that the incident took place after entry into the lock; if the vessel had hit the lock gates the incident could have had very serious repercussions.

Intermittent faults should be considered serious on two counts. Firstly they are notoriously difficult to detect and rectify by their very nature and secondly, because they are intermittent, complacency arises and quite often contingency plans do not take into account any recurrence, when in fact they should.

Root Cause:Onboard maintenance programme failure.

Financial Cost:The cost to the Member is in excess of US$45,000.


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Lessons learnt

Expensive and relatively fragile components 1. should be given a higher level of planning and supervision.Although a task review was conducted during 2. the initial work planning, it was not documented and should have been followed up with a risk assessment and a tool box meeting. There was a failure to assess the risks adequately, 3. specifically vessel motion and the possibility of the crate contents shifting.


The Incident: Please note that this Case Study has been provided by The Nautical Institute’s International and Confidential Marine Accident Reporting Scheme (MARS) - Report No. 200824

On a ship at anchor, a crate containing machinery spares, reeved with two webbing slings, was being lowered into the engine room through the engine room hatch using the ship’s stores crane. During the lowering process, a corner of the base of the crate caught on a section of ducting immediately below the hatch coaming, became unbalanced and tipped through the slings, falling to the deck below. The impact destroyed the crate; however, there were no injuries or damage other than that the spares were rendered unusable.

Operations

Crate Dropped During Lowering

Root cause/contributory factors

Failure to sling the crate properly; webbing slings 1. not tight around the top of the crate; Ship rolling slightly at anchorage, causing the crate 2. to swing during passage through the hatch; Failure to conduct/review formal risk assessment 3. prior to the lifting operation;It is thought that the spare part was inadequately 4. secured inside the crate and as the crate tilted, the internal shift of weight assisted the ‘tipping’ motion;The crate’s height was greater than the other two 5. dimensions, which made it more prone to tipping; The crate had no fitting to prevent the slings from 6. slipping off in case the load became unbalanced;‘Routine task’ complacency and inadequate 7. understanding of risk assessment among the ratings.

Corrective actions

The company issued notices to Masters and 1. safety bulletins on risk assessment, work planning and safe lifting techniques. Crane operator familiarisation training was 2. conducted on board and will be supplemented by further computer based or practical training in crane operations and rigging/slinging. Permit to work system presently applying only 3. to lifts within hazardous areas to be extended to include all lifting tasks. Investigate and solicit vessel proposals for a steel 4. cage/box to be used for lifting operations into the engine room.

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The Incident: This case involves a vessel on which 1.5 million cigarettes (150 boxes) were discovered in the fore peak hidden under a tarpaulin during a search by the Customs and Federal Police. The search was thought to be the result of a ‘tip off ’ by the European Bureau for Fraud.

During subsequent interviews the Master and Chief Mate denied all knowledge of the smuggling but a crew member confessed, admitting full and sole responsibility. He stated that he purchased the cigarettes with money obtained from the sale of his apartment, transported the cigarettes by van to the vessel and brought the cigarettes on board the vessel without assistance. He alleged that on the vessel’s arrival in the discharge port he was to liaise with a Russian man only known to him by the name of ‘Sergei’.

A week later, while the authorities were still investigating the case and prior to obtaining an order to seize the vessel or formally make charges, the vessel was allowed to depart. During the following voyage the seaman concerned went missing. A full vessel search was immediately made which lead to the discovery of a suicide note in his cabin. It stated again that he was fully and solely responsible.

Miscellaneous

Smoking is Not Good for Your Health

The body was recovered two months later and despite the fact his left ankle was tightly bound with rope the inquest concluded death by drowning with no obvious signs of violence.

Observations:Criminal charges were initially brought against the seaman, the Master and our Members. Due to the seaman’s death the criminal charges against him have been dropped. No civil charges have been made as the cigarettes have been seized.

Article 265 Section 3 of the Belgian Customs Code provides that in cases like this Members could be held vicariously liable for fines and costs which are imposed on conviction of the Master. Accordingly, it may also be possible for Members to be found liable to pay not only a fine imposed directly on them but also any fine imposed on the Master.

Root Cause:Illegal smuggling.

Financial Cost:A nominal fine was incurred.

Issue Date: 17/03/08 Case No: 48633

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The Incident: This incident involves a gearless dry cargo vessel which had been equipped with a large mobile crane to enable it to operate at berths without cargo handling equipment. The crane had been designed for industrial operations ashore. Its tracks had been removed and it was temporarily bolted to the deck of the vessel. The crane was fitted with a jib 120 foot long and had a maximum capacity of 136 tons at an 18 foot radius of operation. As a heavy lift was being discharged the vessel listed slightly and the crane jib collapsed. The jib fell on a vehicle killing the occupant. The ship itself was undamaged but the cargo was a total loss.

Observations:The design of the crawler crane was typical of its type, having a long narrow latticework boom. These cranes are designed for use on a level steady surface where the boom acts merely as a strut in compression and is not subjected to sideways or twisting forces. In this case as the load was slowly swung over the vessel’s side, the vessel began to list causing the load to swing out of the plane of the jib. The list also increased the effective radius of operation, increasing the stress. The combination of increased load and side force caused the jib to fail at its base where it was attached to the body of the crane.

Dry Cargo:� General


Crane Collapse Results in Death of Bystander

Extreme care must be taken to avoid excessive side loads on cranes not designed for marine use. Detailed guidance from the crane’s manufacturers and national authorities should be sought. As a general rule however the vessel should not be allowed to list more than 5° during the discharge operation and the load should never exceed 50% of the crane’s safe working load for operation on land.

The vessel’s stability was adequate but in order to counteract the anticipated list as the load was swung towards the wharf, orders were given to deballast the double bottom tanks on that side. The deballasting had not been completed at the time the load was moved horizontally and the free surface effect of the liquid in the partially filled tanks served to increase the vessel’s list. The number of slack tanks must be kept to a minimum when heavy loads are handled.

Root Cause: Incorrect operation of equipment.

Financial Cost:The cargo claim was settled for US$500 in line with the package limitation contained in the bill of lading. The claim of the vehicle driver was covered by his motor insurers who rather surprisingly failed to subrogate their claim against our Member before it became time-barred. The owners faced a number of prosecutions brought for alleged breaches of the Canada Shipping Act and the Tackle Regulation, most of which were quashed at trial. Despite a very favourable resolution of the claims, the costs incurred in investigating and defending the Member reached US$33,000.


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The Incident: This incident involved a large explosion on board a general cargo vessel when flammable gases given off by the cargo were ignited by an electrical spark. The explosion killed two crew members, injured several more and caused severe damage to the ship. The vessel’s forward hatch covers were blown off, landing on and severely damaging two tugs moored nearby. Extensive damage was caused to surrounding buildings and a nearby papermill was shut down for a week following the explosion.

Cargo

Flammable Gases Cause Explosion

Observations:The vessel was loading a cargo of spent pot liner, the carbon-based lining of an aluminium smelter which absorbs impurities from the metal. It eventually becomes saturated and has to be replaced. The impurities in the spent pot liner react slowly with water producing inflammable gases.

Our investigations revealed that the cargo loaded into number 1 hatch had come from two different storage areas. Wet reacted cargo from an open stockpile had been mixed with dry unreacted cargo which had been stored in a closed shed. Moisture from the weathered cargo migrated to the dry, causing it to react with the result that an accumulation of inflammable gases built up in the hold and fan rooms overnight. These gases were ignited by an electrical contactor operating the hydraulic system for the hatch covers.

The shippers, although aware of the problem of inflammable gases, did not advise owners or charterers of the danger, nor did they provide the vessel with a copy of their material safety data sheet. Information on spent pot lining was not available from the IMDG Code, the IMO Code of Safe Practice for Solid Bulk Cargoes, the Dangerous Bulk Materials Regulations or any other official publication.

The explosion could have been avoided if all the pot lining had been weathered prior to shipment or proper steps had been taken by the shipper to ensure that wet cargo was kept separate from dry unreacted cargo. The shippers should have provided the vessel with safety data sheets. Appropriate measures could then have been taken to ensure that the cargo was kept adequately ventilated and the accumulation of explosive gas could have been avoided.

Root Cause:Unsafe loading practice.

Financial Cost:The claims arising out of the explosion totalled over US$30 million. In the end they were settled for just under US$11 million with the shippers of the cargo bearing by far the greatest proportion. Nevertheless the costs of investigation, defending the various legal actions and with a very modest contribution towards the settlements brought the cost to our Members the charterers to US$1.3 million.


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The Incident: Please note that this case study has been provided by the MAIB Safety Digest 2/2007, Case 6.

After completing the weekly planned maintenance routine on a rescue boat and its crane, it was usual for the crew to lower the boat to the water for training purposes while alongside. The boat was lowered and manoeuvred in the water for a short time and then brought back to be hoisted on board. As the boat was being hoisted, the wire rope parted and the boat fell into the sea.

Fortunately, the company had already identified this as a high risk operation and had stopped the practice of having the crew in the boat while hoisting or lowering during training exercises. There were no injuries, and the boat was not damaged.

On investigation, it was found that a new wire rope had been fitted 14 months previously, and it had passed a thorough examination about five months before the incident. It was also inspected/greased on a weekly basis as part of the ship’s planned maintenance programme. Despite the checks, the incipient corrosion had not been discovered and the wire eventually failed at the top of the steel ball counter weight.

Miscellaneous

Corrosion – The Hidden Enemy

The accelerated corrosion was partly due to the harsh environment in which the rescue boat and its crane were located, at the aft end of the vessel. The ball weight had a crevice at the top where the wire passed through, and this formed an ideal trap for sea water, salt and sulphur deposits from nearby exhaust outlets to accumulate and obstruct regular inspection.

The investigation discovered that unsuitable grease had been applied, and this had not been effective in lubricating the wire core and served to obscure the underlying corrosion (see photograph of wire and crane ball indicating the point of failure).

The failed segments of the wire rope were sent to a laboratory for testing, and the subsequent report confirmed that the wire rope had failed through ductile tensile fractures of wires wasted by corrosion. The laboratory was also able to confirm that a contributory cause of the failure was inadequate maintenance greasing over a significant period of time.

The body was recovered two months later and despite the fact his left ankle was tightly bound with rope the inquest concluded death by drowning with no obvious signs of violence.

Conclusion:The inspection of all wire ropes should be 1. thorough, and should include the removal of old grease to assess the condition of the wire rope before re-coating with fresh wire lubricant.Senior staff should regularly monitor planned 2. maintenance procedures which are carried out by crew.Consideration should be given to the use of a 3. thinner self penetrating lubricant on seldom used wire ropes, especially where they are used or stored in a harsh corrosive environment.

Issue Date: 09/12/07 Case No: 12377

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The Incident: As the last few containers were being loaded on the deck of a 3,000 gross ton inter-island cargo vessel she capsized and sank alongside the dock, damaging the dock as she went down. The Port Authority issued a wreck removal order. The Club invited tenders for the removal operation and a contract was finally agreed with a Singapore-based salvage company. The wreck removal was effected using a large sheerlegs which had to be towed over 2,000 miles to the site of the accident. The wreck was cut up into manageable sections and dumped at sea. The berth was finally cleared some five months after the ship went down. The majority of the cargo was a total loss.

Dry Cargo:� Containers

Cargo

Capsize During Loading

Observations:Our investigations revealed that the cause of the loss was an error in calculating the vessel’s stability. The Chief Officer had failed to make proper allowance for the height of a stow of bagged cement in the lower hold when calculating the vessel’s vertical centre of gravity. As a result his calculations produced an over-optimistic prediction of the vessel’s stability on completion of loading. There was no established procedure on this ship for an independent check of the Chief Officer’s calculation. Had there been one it is highly likely that the mistake would have been noticed and the loss of the vessel avoided.

Root Cause:Error in stability calculation.

Financial Cost:Cargo claims totalling over US$3 million were submitted to the owners. By using package limitation and defences available to the owners under the Hague Rules, those claims were finally settled for less than US$500,000.

The costs of removing the wreck of the vessel approached US$1.5 million.

Claims by the Port Authority and individual crew members brought the total cost of the claim to almost US$2.2 million.


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Financial Cost:The total cost of this claim was in excess of US$660,000; a great deal of this was accounted for in recovering containers that sank in the approach channel to the berth.


These factors combined to result in a drastic reduction of transverse stability which was insufficient to withstand the forces created by the pushing tug.

Ironically, the top tiers of containers had not been secured but this allowed the containers to fall off and the vessel returned to the upright.

One of the contributing factors to the overloading was the under declaration of the containers weights by the shipper. This case highlights the need to monitor the vessel’s condition at all times. By observing the drafts, the overloading would have been noted at an early stage and the vessel’s lack of adequate stability detected.

Root Cause:Failure to observe stability requirements.

Cargo

Stability Needs Careful Attention

The Incident: A Feeder Container vessel had completed cargo operations at one berth and was in the process of shifting to a second berth. A harbour tug commenced pushing the vessel towards the berth when the Member’s vessel began to heel over. When heeled over to approximately 10 to 15 degrees, containers began to fall off the vessel; the tug stopped pushing, and this action in conjunction with the loss of containers enabled the vessel to return to near upright.

Observations:The subsequent investigations showed that poor operational practices were allowed on board, with very little regard given to the safety of the vessel. The centre of gravity (KG) of the vessel was determined to be well above the maximum permitted and no account had been taken of the numerous free surfaces in the ballast tanks. To make matters worse, it was calculated that the vessel was in fact 400t overloaded, resulting in a reduction in the freeboard of 30cms less than the minimum permitted.

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Root Cause:Inadequate lashing.

Financial Cost:This turned out to be a very expensive claim as enormous efforts had to be made to locate the sunken containers that fell overboard. The final cost was in the region of US$580,000.


The Incident: This incident occurred on a 316 TEU feeder container vessel/bulk carrier immediately after loading had been completed.

On completion of loading the vessel had a 1° list to starboard. This slowly increased. Corrective action was taken, but despite this the list continued to increase. By the time it had reached approximately 15°, a number of containers fell off the top tier into the harbour waters. The vessel then violently rolled to port. The list increased until the water line had reached the hatch coamings and progressive flooding started to take place. Fortunately more containers fell off the top tier, reducing the list. The situation was eventually brought under control by discharging cargo and the vessel returned to an even keel.

Cargo

Be Prepared

Observations:This incident was caused by a poorly prepared stow plan resulting in the vessel having negative stability upon completion of loading. The onboard calculations were incorrectly executed, as they appear not to have taken the effects of free surface into account, so masking the true stability condition of the vessel.

Feeder container vessels are renowned for their short turn round times and frequent cargo changes. Operators of these vessels should ensure procedures are in place to minimise the potential for errors. Shore prepared stow plans must be checked for accuracy, preferably by a second person before they are issued. Means should be provided to assist ship’s staff in assessing the stability condition of the vessel so as to reduce the possibilities of errors being made in hastily completed calculations. This could take the form of computers or encouragement to use prepared pro forma. Owners should satisfy themselves that the senior officers on board are fully familiar with the stability requirements of their vessel.

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The lashing system did not follow normal acceptable practices and a number of deficiencies came to light during the Club’s investigations:

the lashing gear was not certified or provided •with identification marks; the amount of lashing gear used was insufficient. •Where used, twist locks were only applied to two corners of each container and not all four and only minimal wire lashings were used (see pictures) in-board containers were not secured at all ; •the leads for the lashing wires were totally •inappropriate and bulldog wire rope grips were insufficient in number, positioning and size; it is doubtful whether the lashing gear utilised was •in fact of sufficient strength for the task required of it; no account appeared to have been taken of the •differences in height between standard and high cube units, which prevented the satisfactory use of bridge fittings; no maintenance programme was in place for the •upkeep of the lashing gear.

The Incident: This claim arose on a river craft specifically designed for a container feeder service between two terminals.

Whilst manoeuvring off one of the terminals with a cargo of 92 twenty and forty foot containers, the vessel experienced a squall and started rolling as she turned beam on to the wind.

A number of containers moved as the vessel rolled, striking adjacent containers. The lashings on two of the containers struck consequently failed and two forty foot units were lost overboard.

Cargo

Complacency Rules

Observations:This claim arose because of poor operational practices on board. Investigations showed that the lashing system employed was far from satisfactory. Local regulations did not require operators to have approved securing manuals and the operators did not have any requirements or guidelines of their own. Consequently the securing of the containers was left to the crew who relied on their experience.

No procedures had been established requiring calculation of the vessel’s stability and therefore the Master had no indication of the stability condition of the vessel (e.g. too large or too small a GM) when she sailed.


Financial Cost:Salvage teams fortunately were able to recover these containers therefore the Members have only been liable for their salvage and loss of contents. This is estimated to cost US$7,000.


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Observations:Notwithstanding the source of the water leak into the hold, the prime cause of this claim was the poor condition of the hold bilge pumping system. Access to bilge wells can be restricted due to the compact nature of container stowage and it is not always possible to use portable pumps to remove cargo hold bilge water if the main system fails. Therefore it is of the utmost importance to ensure that the bilge pumping arrangement is regularly tested and maintained in full working order. Similarly the sounding pipes must be kept clear at all times.

The water entered the hold through cracks which had developed at the base of the cell guides where they connect with the tank top. During the course of loading and discharging, these guides suffer considerable physical stress and if the bases are weakened through corrosion at all, cracks will eventually occur. It is important therefore that these areas are inspected regularly and repairs carried out promptly.

It is apparent that the amount of water noted in the hold on completion of discharging and during the voyage was not considered significant, but obviously no allowance was made for the fact that the level will rise and fall when the vessel rolls and pitches in a seaway. Any water in a cargo hold is unacceptable and should be removed as soon as it is detected.

The Incident: This incident involved loading containers into a hold that contained water and was compounded by the fact that the bilge pumping system was not operational.

On completion of discharging, water was noted lying on the tank top and efforts to remove it failed because the bilge pumping system was found to be inoperative. Time constraints apparently prevented any other means to remove the water to be utilised. Loading was then commenced and the vessel subsequently sailed.

During the course of the voyage the hold bilge levels were reportedly monitored although some doubt exists as to whether or not the bilge sounding pipes were clear enabling soundings to be taken. It would appear that during the voyage, the bilge levels did in fact rise.

Once the hold in question was discharged, the majority of the lower tier of containers were found to have had their bases immersed in water.

Operations

It will be Alright – But it Wasn’t

Root Cause:Insufficient maintenance.

Financial Cost:This claim was settled for US$60,000.


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Observations:The incident was caused by free water in the cargo hold.

Choked hold bilge suctions prevented the water being pumped out by the ship’s staff.

Investigations showed that the vessel had sustained two fractures in the tank top. These were believed to have been caused by the heavy landing of containers during loading. The problem was further exacerbated by the fact that the heeling tank filling pipe had corroded through. Ironically therefore, ballast water used to correct the list increased the leakage into the hold, aggravating the problem.

The Master was criticised for not conducting a more thorough investigation at the time of the initial listing.

A regular systematic daily sounding programme is a well established procedure of good seamanship and would give an early indication of any problem. It would do away with the need to engage in the dangerous practice of entering enclosed spaces to visually check the hold.

The difficulties in pumping out the hold once the water had entered were reportedly due to the suctions being choked with debris. This highlights the need for the holds to be kept free of rubbish and the regular proving of the pumping arrangements. The provision of a hold bilge alarm would have given a very early indication of the water entering the hold.

The Incident: This incident took place on a 25 year old 370 TEU feeder container ship. Shortly before arriving at the pilot station, an unexplained port list suddenly developed. The list was corrected and “sounding round” showed there to be about 100 cm of water in her hold.

Until berthed, the vessel had flopped one way or another on a number of occasions, each time corrected by moving ballast. Alongside she lay with a 15° list against the quay.

The Chief Officer carried out an assessment of the stability and deemed the vessel to be unstable. The port authority subsequently refused to give permission for cargo operations to commence until the vessel was upright, the cause of the listing was determined and stability was confirmed by the Classification Society.

Efforts to pump out the hold bilge were thwarted by choked suctions. The services of a local salvage company were engaged to pump out the hold and remove the top tier of containers in order to regain positive stability. The ballast tanks were closely monitored during this operation and it became apparent that water from two ballast tanks was entering the hold. The stability calculations were reworked and showed the vessel to have positive stability. This was later confirmed by the Classification Society.

Permission for cargo operations to commence was given nearly three days after the vessel’s arrival at the port.

Operations

Free Water and Poor Maths Result in Delays

The original erroneous stability calculation was a major contributing factor to the delay suffered by the vessel. This should have been carried out prior to leaving the load port. Third party calculations can not be relied upon.

The base of cell guides which carry the brunt of heavy container movements, should be inspected on a regular basis so that corrosion and weakness can be detected at an early stage.

Root Cause:Inadequate maintenance procedures.

Financial Cost:The total claim is expected to be in the region of US$75,000 to US$100,000.


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The Incident: This case involves cargo theft within the port area. A brewery shipped a consignment of 282 cartons of beer on three shrink wrapped pallets between two depots in south east Asia. There was no direct shipping service between the depots. The beer was therefore shipped to an intermediate port where it was discharged for trans-shipment. The beer was loaded onto trucks for delivery to our Member’s vessel. As was their custom, our Member signed for receipt of the beer at their dock gate office. The truck and its consignment of beer disappeared somewhere between the dock gate office and the ship’s side. As a result of poor communications between the ship and the dock office, the disappearance of the beer was not noticed and it was only after the voyage was completed and a claim for non-delivery was received from the brewery that the circumstances came to light. The brewery was able to produce the road hauliers documents signed by the shipowner showing that the beer had been delivered and had been accepted into the care of the shipowner. As a result the owners had to pay for the loss.

Dry Cargo:� Ro-Ro

Cargo

Premature Signing for Cargo Consignment Causes Hangover

Observations:Shipowners accepting cargo into their custody must take reasonable precautions to prevent loss or damage of the cargo. The custom and practice at the load port was for shipowners to accept consignments at the dock gate rather than at the ship’s side. There was however no system for controlling or monitoring the progress of the cargo from there to the ship. In this case the loss could have been avoided either by only signing for the cargo when it had been actually delivered to the vessel itself or ensuring that proper procedures were in place for monitoring the progress of the cargo after acceptance at the dock gate.

Root Cause:Lack of shore procedures.

Financial Cost:The cost to the shipowner exceeded US$5,000.


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Financial Cost:The damage to the vehicles amounted to US$128,150.


The Incident: During a voyage across the English Channel in heavy weather some vehicles on the car decks broke their lashings with the result that 18 lorries, their cargoes and three cars were damaged, resulting in many claims.

Cargo

Poor Lashing Procedures Cause Destruction

Observations:Surveyors appointed by the Club reported that the principal cause of the damage was the ship’s crew’s failure to properly lash the articulated vehicles. Our surveyors reported that there was no company operating manual on board giving the crew guidance on car deck operations and safety. M-Notices and IMO publications were also unavailable. The Master had given no standing orders relating to car deck safety, nor had he set weather criteria above which cargo should be lashed.

The majority of the damage was caused by a number of articulated vehicles which were only secured by four lashings, one at each corner of the combined vehicles. This lashing system was totally inadequate for vehicles that did not form a rigid unit. In each case the damage was caused by the vehicles jack-knifing, i.e. hinging at the joint between the tractor and trailer units. The jack-knifing resulted in the general slackening of the lashings which were then subjected to shock loadings from the movement of ship and vehicles, with the consequence that they eventually parted.

The claims that resulted from this incident were completely avoidable. Lashing the vehicles in accordance with IMO guidelines would have prevented the jack-knifing and consequent damage. Companies operating ro-ro ferries are now required to provide their vessels with a comprehensive cargo securing manual and Masters should issue standing instructions on when lashing is required and who has responsibility for ensuring that it is done.

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Section 2� Tankers

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The Incident: A small tanker went into a repair yard to have damage to her starboard bow repaired. The vessel habitually carried premium motor spirit in all her cargo tanks and prior to arriving at the yard had cleaned and gas freed the tanks by filling them to overflowing with seawater. Before hot work commenced the owners brought in a surveyor to test for explosive atmosphere and issue a gas free certificate. The certificate declared the vessel fit for hot work and indicated that all cargo tanks had been tested and found gas free. As shipyard workers started to cut away the damaged section an explosion occurred in the fore peak tank, severely damaging the vessel and badly injuring two workers.

Tankers:� Petroleum


Explosion in Dockyard

Observations:The explosion almost certainly occurred as a result of an accumulation of explosive vapours in the fore peak tank. The reason for the accumulation was never discovered. The coffer dam separating the fore peak tank from the cargo tanks was found to be clean, dry and free of cargo vapours. The incident highlights the desirability of testing the atmosphere in all enclosed spaces on tankers prior to commencing hot work.

In this case there was no formal contract between the vessel’s owners and the repair yard. The question of responsibility for ensuring that the vessel was fit for hot work to be carried out was not clear. We would recommend that owners ensure this subject is addressed in every repair contract and that where possible the shipyard be given this responsibility.

Root Cause:Insufficient safety procedures.

Financial Cost:The entire fore part of the vessel had to be replaced at a cost of US$200,000. Claims by the injured workers were met by the shipyard’s insurers. In addition to this surveyor’s fees exceeding US$4,000 were incurred.


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The Incident: This accident involves a serious injury during unmooring operations as the vessel prepared to sail. The crew had been sent to stations and the vessel had been singled up while awaiting customs clearance. The last two lines on the foredeck were those permanently stored on the windlass drums. At 08.30 customs clearance was obtained and the order was given to let go forward. When the foredeck crew tried to slack down the line on the starboard drum for letting go it would not do so. During efforts to free the rope the chief officer’s foot was caught in the machinery, resulting in very serious injuries to his toes.


Injury During Unmooring Operation

Observations:The berth had been exposed to a heavy swell which had caused the vessel to surge continually whilst alongside. The surging action had resulted in the mooring rope on the starboard windlass drum becoming buried in itself. When it became necessary to slacken down the line it jammed. The chief officer attempted to pull the line clear and in the process put his foot on the winch-bearing A-frame support forward of the starboard drum. The A-frame support is close to the drum face which had four flat bar stiffeners welded to it. The stiffeners passed close to the support, creating a guillotine-like effect. The mate’s foot was caught in the gap when the drum rotated and despite wearing steel-capped safety boots he was severely injured.

The mate was fortunate as immediate hospitalisation and extensive microsurgery managed to save his toes.

Following this incident the winch drums were modified to prevent a recurrence.

This accident highlights the dangers of working too close to winches. The accident would have been avoided if the chief officer had employed a method of freeing the rope which did not involve close proximity to the machinery. One possible method might have been to put a stopper on the mooring rope while continuing to veer, thus using the power of the winch to free the rope without creating the necessity for personnel to be in close proximity to it.

Root Cause:Defect with equipment design.

Financial Cost:


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Observations:Although the owners had provided the vessel with a considerable quantity of safety documentation, that in itself was insufficient to instil a safety-conscious attitude amongst the crew. Unless senior management take a close interest in enforcing a proper safety regime on board, a safety culture will not develop within the company. If safety consciousness had been highly developed, the radio officer would probably not have considered working aloft without taking the proper precautions.

Root Cause:Insufficient safety environment.

Financial Cost:The owners had to pay substantial compensation to the radio officer even though he was primarily responsible for the accident occurring. The total cost to the company after costs were taken into account was almost US$40,000.


The Incident: This incident occurred on board a tanker lying at anchor in sheltered waters. The vessel had been having trouble with its SSB radio and the radio officer had been instructed to investigate this problem.

Shortly after lunch the Master was awakened from his afternoon nap by a loud thump. When he investigated he found the radio officer lying injured on the deck having fallen 18 metres from the mast. The radio officer who had broken both legs, an arm, a rib and sustained internal injuries, was evacuated immediately to hospital where he was placed in intensive care.

This company had compiled and provided the ship with a safety manual which included detailed instructions for working aloft. In addition several copies of the Code of Safe Working Practices for Merchant Seamen were available on board for the crew’s use. The radio officer had not complied with the requirements of either the Code or the safety manual. He was working alone and had not advised the duty deck officer that he would be working aloft. He was not wearing a safety harness.


Severe Injuries Result From Failure to Follow Proper Procedures.

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Cargo

Deviation from Agreed Discharge Plan Leads to Cocktail

The Incident: The vessel involved in this case is a coastal tanker carrying a full cargo of four grades of lubricating oil. The vessel arrived at the discharge berth where she was due to discharge into both shore tanks and barges moored alongside. After the ship was ullaged and samples taken, a written discharge plan was agreed between the ship and the terminal. The plan was signed by the ship’s officers but retained by the terminal with no copy being left on board. The details of the plan were recorded in the duty officer’s notebook. It had been agreed that initially two parcels, 500 SN and 100 SN, would be discharged to the shore followed by 200 SN and 150 SN.

The 500 SN and 100 SN manifolds were prepared for the cargo hoses. After the 500 SN hose had been connected the jetty operator asked whether the second open manifold was for 150 SN. The duty officer advised him that it was the 100 SN manifold. The jetty operator told the duty officer that he wanted the 150 SN not the 100 SN. The duty officer reminded the jetty operator that it had been agreed in writing that the 100 SN would be discharged before the 150 SN. Despite this the jetty operator continued to insist that he wanted 150 SN and as a result the manifolds were changed over and the hose connected to the 150 SN manifold. After approximately 1½ pumping the shore asked the vessel to stop despite the fact there was approximately 70 metric tons left on board. On investigation it turned out that despite what the jetty operator had said, the terminal had been adhering to the original discharge plan with the result that 180 tons of 150 SN had been pumped into the wrong tank, contaminating the 220 tons of 100 SN it contained.

Observations:The vessel had followed the correct procedure up until the time the second cargo hose was connected. At that point the duty officer agreed to deviate from the written plan without proper authorisation. If the officer on watch had insisted that a new cargo discharge plan had been drawn up or the original one amended in writing, the confusion within the terminal would have become apparent and the contamination would have been avoided.

Root Cause:Non compliance with procedures.

Financial Cost:The shipowners and terminal operators negotiated a commercial settlement with the owners of the oil. The cost of investigating this incident and obtaining the legal advice on which negotiations were based amounted to US$17,000.


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Observations:The design of the vessel is such that two valve separation can only be maintained when each of the three pumps is used on its own designated tanks or the two outside pumps (nos 1 & 3) are utilised; whenever consecutive pumps are lined up on tanks of one of the other systems then only one valve separation is possible. Unfortunately in this incident, the decision to utilise No.2 pump on No.1 system cargo tanks resulted in single valve separation between the two grades. (It is believed that during the stripping phase of discharging one of the grades, the pressure differential across the valve allowed the contamination to take place).

The Incident: This claim involved a 5000gt products tanker discharging two grades of cargo simultaneously. During the course of the discharge cross grade contamination occurred.

The vessel is designed so that she can carry a maximum of three grades of cargo whilst maintaining two valve separation and on this particular occasion two grades were carried.

Loading was completed without incident.

Discharge of the two grades was commenced simultaneously utilising No.1 pump for one grade and No.3 for the second grade. During the course of the discharge, No.1 pump developed a leak at the forward seal and the pump became unserviceable. The pump was stopped and the pipelines set up to discharge the unleaded gasoline via No.2 cargo pump. The discharge was continued. At some stage thereafter the terminal advised the vessel that contamination between grades had been noted ashore.

Cargo

The Cost of Ensuring the Vessel’s Turnaround Time can be Outweighed by the Final Overall Cost

Two valve separation between grades is considered the minimum acceptable by the petroleum industry as the likelihood of two valves failing at the same time is considered to be acceptably less than the failure of a single valve. [Failure can be caused by: i) a defective seal; ii) debris lying in the valve seat; and iii) the valve not being closed fully].

In this incident, the decision to continue discharging both grades simultaneously after the pump failure was wrong, however it is not known what commercial pressures, if any, were placed upon the vessel to expedite the discharge.

In such circumstances if shore terminals insist on ships continuing operations, the representative making the request should be made fully aware of the possible consequences and requested to accept the responsibility for any adverse effects. If responsibility is to lie with the Master and vessel, then the operation should be continued within the limitations of the vessel’s design.

Root Cause:Failure to comply with vessel design.

Financial Cost:The cost of this claim is US$110,000.


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Observations:The tanker’s ring main system only permitted single valve separation between the two grades of cargo with the result that the failure of a valve or operator error in the manipulation of the valves would inevitably result in cross contamination. Subsequent to this incident the vessel’s pipeline system was modified to give proper segregation between cargo grades.

Root Cause:Failure to comply with vessel design requirement.

Financial Cost:On this occasion the oil company was able to resolve the problem of the contaminated fuel by blending and no cargo claim was made. Nevertheless the costs of investigating the matter amounted to approximately US$1,000.


The Incident: This vessel was a small parcel tanker time chartered to an oil major, plying between two of their terminals. The vessel was fitted with five sets of cargo wing tanks, fed by a ring main pipeline system. On the voyage in question the vessel was ordered to load two grades of motor spirit. The first, unleaded petrol, was loaded into 2 and 4 wing tanks. This was followed by leaded petrol being loaded into 1 and 5 wing tanks. Number 3 wing tanks remained empty.

On arrival at the discharge berth both grades were to be discharged ashore simultaneously, the leaded petrol was to be discharged using the portside pump/line system and the unleaded via the starboard side pump/line system. Shortly after discharge commenced the starboard pump broke down. As a consequence 1 and 5 wing tanks were completely discharged whereafter the line was flushed with fresh water and disconnected. The unleaded hose was then connected to the portside pump/line system which was then used to discharge the second parcel. Shortly after discharge resumed terminal personnel informed the vessel that measurement of shore tanks indicated that an additional 90 cubic metres of product had been discharged with the first parcel of leaded petrol. Discharge operations were stopped and an investigation was mounted. The investigation revealed that a crossover gate valve in number 2 port cargo tank had not been properly closed, with the result that unleaded petrol had been drawn from the starboard line system and discharged with the leaded petrol.

Cargo

Two Valves are Better than One

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The Incident: This tanker had been chartered to a company which had a contract of affreightment with a major oil company. The vessel was ordered to load premium motor spirit and automotive diesel oil at two separate berths. The motor spirit was loaded in 2 wings and 4 wings at the first berth and the automotive diesel oil was loaded in 1 and 3 wings at the second berth. On arrival at the discharge port the cargo in 2 wings was rejected by the consignee as being off-spec. The remaining cargo was found to be within the specification and was discharged. After discharge the shore tank was sampled and it was discovered that not only were both parcels off-specification but the outturn of volume of the motor spirit had apparently increased by over 100 tons while the volume of diesel oil had decreased by a similar figure. The contaminated oils could not be reprocessed at the discharge port and the vessel was delayed for over seven weeks while owners, charterers and the oil company argued over the disposal of the contaminated oil. The terminal lodged a claim for US$420,000, this being the value of the entire cargo.

Cargo

Poor Tanker Practices Leads to Expensive Delay for Member.

Observations:A thorough investigation by surveyors appointed by the Club revealed that the vessel had only been designed to carry a single grade of cargo, with the result that it was impossible to follow normal tanker practice in separating different grades of product by two or more valves. The surveyors also discovered that after completing loading at the first berth, certain valves were left open, allowing the cargo in 2 wings to become contaminated with diesel oil. The surveyor’s investigation also showed that during the discharge operation some more valves were opened in error, contaminating the remainder of the cargo. The surveyors were critical of the method and effectiveness of line-clearing at the discharge port.

Root Cause:Failure to comply with ship design requirements.

Financial Cost:In this case the owners were extremely fortunate as the provisions of the charter party enabled them to pass responsibility for cargo contamination on to the charterers. Nevertheless the costs of the investigation alone amounted to US$17,000. In addition to this the owners were unable to trade the vessel for approximately two months.

This vessel is no longer entered in the Club.


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The Incident: The claim arose on board a coastal tanker carrying premium motor spirit. The bill of lading was issued using the shore terminal’s figures. As this figure was greater than the quantity calculated a letter of protest was issued by the Master to the loading terminal.

At the discharge port the vessel’s cargo pumps lost suction before the tanks were completely dry. It proved impossible to regain suction and the cargo remaining on board was considered to be unpumpable. On completion of discharge the vessel was heavily trimmed by the stern with the result that the cargo residues lay in wedges at the ends of the cargo tanks aft of the sounding pipes. The actual quantity remaining on board could not therefore be accurately assessed.

Cargo

Master’s Commercial Awareness could have Reduced Claim

The receiving terminal claimed short delivery of over 50 metric tons based solely on the difference between the bill of lading figure and the shore out-turn figure.

At the next berth surveyors appointed by the Club attended on board and by reducing the vessel’s trim were able to accurately establish the amount of cargo remaining on board. It was found to be just under 22 metric tons and not over 50 as alleged by the consignee. The value of the difference was approximately US$7,000. The evidential value of our surveyor’s report was however seriously weakened because the survey took place some time after discharge had been completed, when consignee’s representatives were not in attendance.

Observations:If the vessel’s Master had reduced the vessel’s trim and properly quantified the unpumpable ROB before leaving the discharge berth while the consignee’s surveyor was still in attendance, the owners would have been in a much stronger position to resist the short delivery claim.

Root Cause:Insufficient operation procedures.

Financial Cost:It was possible to negotiate a settlement of the short landing claim however the total cost including surveyor’s fees exceeded US$9,000.


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Upon completion of the third discharge the vessel sailed and anchored off the port.

Further investigation by the crew at this time determined that “several years” prior to this spate of contaminations, the vessel had experienced cargo leaking out through a sea valve. As a result a 6mm blank was inserted on the outboard side of the sea valve, and unfortunately this had been forgotten. As time passed the blank had corroded through and when ballasting, unbeknown to the ship’s crew, a section of the pipeline filled with water. When cargo was subsequently being discharged, this water was then drawn into the cargo.

The Incident: This claim involved a products tanker delivering contaminated cargo on three consecutive voyages. On the first two occasions the terminal accepted the cargo, but although finally accepting it the third time it was with some reluctance.

During the course of each of the three discharges the products to varying degrees were found to be contaminated with water. Blending or further refining was required to return the products to the original specifications.

The cause of the contamination proved difficult to find because the water was noted to have very low chlorides which indicated (incorrectly) that the contamination was not caused by seawater. In addition, during the final discharge the contamination was noted to be intermittent.

It was finally assumed that the water was entering the cargo tanks through defective valve glands – although the cargo sample from the tanks was within specification!

Cargo

Out of Sight Really Can Mean Out of Mind

Observations:Whenever a blank is inserted into a pipeline it should be made as conspicuous as possible and all staff associated with cargo operations made aware of its existence, including subsequent crews.

In addition, a blank inserted in a pipeline as a result of a leaking valve is only a temporary measure and should not be left in place for years on end. The efficiency of the overhaul of ship side valves during dry docking must also be questioned.

Root Cause:Insufficient maintenance procedures.

Financial Cost:Because the receivers accepted most of the contaminated cargoes without complaint, the overall cost of this claim is US$5,000.


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Observations:This incident highlights the importance of tank cleaning and line washing in preparation for the carriage of high grade products and chemicals. In this case the cause of the contamination was never properly determined. The vessel’s tank coatings were in good condition and the tanks had been passed by an independent surveyor. The most likely source of contamination seems to be inadequate or incomplete line washing, with the result that a plug of the previous cargo became trapped in the pipeline system. It is vital that line washing be arranged in such a way as to ensure that every section of the pipeline system is thoroughly flushed through during the process.

Root Cause:Inadequate line washing.

Financial Cost:The total cost of this claim after the proceeds of the salvage sale had been taken into account exceeded US$73,000.


The Incident: This is a case of cargo contamination on board a parcel tanker. On its previous voyage the tanker carried a full cargo of gas oil. After discharge the tanks were washed in preparation for carrying a number of high quality products. Prior to loading the tanks were inspected by an independent inspector and passed as being clean, dry and suitable for the products to be loaded. A number of products were then loaded including a parcel of solvent C9 in 4 wings. On arrival at discharge port the samples of the solvent taken by the consignees’ surveyor showed a slight change in colour. Gas chromatography analysis revealed that the product had been contaminated by very small quantities of gas oil. Consignees claimed that the slight change in colour was sufficient to render the product unmarketable and rejected the entire consignment. The contaminated cargo was eventually sold to a salvage buyer for less than half its original value.

Cargo

Poor Line Washing Probably Caused Contamination

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The Incident: This incident occurred when a 1,500 GRT tanker was berthing at an oil jetty. During the berthing manoeuvre the vessel’s bow came into contact with the hose gantry on the jetty, damaging both the gantry and two cargo hoses. In his statement the Master alleged that the cause of the contact was the vessel failing to respond to an astern engine order.

Navigation

With the Tide is Against Convention

Observations:According to both the Chief Engineer and Engineering Officer of the watch, there was no mechanical problem during the berthing operation. Subsequent investigation by a surveyor revealed that the Master had been attempting to berth with the tide under his stern. It is highly likely that the Master simply misjudged the effect of the tide when applying astern power. This accident would probably have been avoided if the Master had adopted a conventional uptide approach to the berth.

Root Cause:Human error.

Financial Cost:The costs of repairs to the jetty exceeded US$46,000.


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The Incident: This incident involved a small bunker barge which had been engaged to supply lube oil to an ocean going vessel at anchor. During the bunkering operation the deep sea vessel’s gangway had been lowered and used to provide access to and from the bunker barge. After bunker operations had been completed the crew did not hoist the gangway before casting off the barge’s mooring lines. As the barge manoeuvred away from the side of the ocean going vessel it came into contact with, and damaged, the ship’s gangway. Although the negligence of the deep sea vessel’s crew was a major contributing factor in this loss, the Club was advised that the barge would be held liable for not exercising sufficient care while manoeuvring away from the vessel’s side.

Navigation

Member’s Involvement with Delay to Deep Sea Vessel Proves Expensive.

Observations:This claim illustrates how a relatively minor incident can be greatly inflated if the damage causes delay to a large vessel. In this case the problem could have been avoided if the bunker barge had insisted on the gangway being raised clear before departing.

Root Cause:Failure to comply with procedures.

Financial Cost:Repairs to the accommodation ladder took four days and cost US$13,000. In addition to the cost of repairs the owners of the deep sea vessel claimed four days’ loss of hire which when combined with additional port dues, survey fees and other miscellaneous expenses brought the total claim against our Member to almost US$36,000. Although we were successful in negotiating a settlement at a reduced figure, the total cost to the barge owners after surveyors’ and correspondents’ fees had been paid exceeded US$27,000.


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The Incident: In the early hours a bunker tanker finished loading a cargo of fuel oil and left the berth bound for the anchorage to await the arrival of the deep sea vessel she was to service. The anchorage was crowded and the vessel worked through the moored vessels at slow speed looking for a suitable spot to drop the anchor. The vessel came upon a clear area and the Master made a snap decision to anchor in that spot. The tanker had the wind on her starboard quarter and a 2 knot following tide. To bring the vessel head to wind and tide the helm was put hard aport and the engine full astern. Unfortunately the Master totally misjudged the strength of the tide and the vessel was swept broadside onto the bows of an anchored vessel. Number 3 cargo oil tank was breached and over 20 cubic metres of heavy fuel oil spilled into the water.

Navigation

Rushed Approach Results in Collision

Observations:This incident would probably have been avoided if the Master had not been in such a hurry to anchor and had adopted a more conventional approach. Instead of trying to swing the vessel immediately he should have continued on until he could turn his vessel safely and approach the anchorage position heading into wind and tide. The method of approach adopted prevented him properly assessing the effects of wind and tide on his vessel and as a result he completely misjudged his approach.


Financial Cost:In addition to the cost of repairs to the anchored tanker the owners received a substantial claim from the Port Authority for oil pollution monitoring and clean up operations. This brought the total cost excluding the cost of damage to his own vessel to over US$82,000.


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Before the vessel had moved far towards her track, the Master decided to steer directly for the white light which indicated the centre of the bridge’s span.

The vessel had recently been fitted with an electronic chart system following a similar accident on another of the company’s ships. The Master could see the electronic chart display, but was not using it other than to give him a rough indication of her position. He had never received any formal training in the use of this equipment.

As the vessel passed under the centre of the bridge, the Master used 10 degrees of port helm to bring her around 40 degrees to the required heading for passage. No allowance, mental or otherwise, had been made for the vessel’s advance and, unsurprisingly, she grounded on the southern edge of the channel.

The vessel sustained significant hull damage. She was holed in one segregated ballast tank but, fortunately, there was no pollution as a result of the incident.

Source of information - Marine Accident Investigation Branch (MAIB) safety digest No1/2007 - http://www.maib.gov.uk/publications/safety_digests/2007/safety_digest_1_2007.cfm

Root Cause:Insufficient navigation procedures.


The Incident: We have been advised of the following case, featured in the Marine Accident Investigation Branch (MAIB) safety digest No1/2007 (see below link for the document) that we feel will be of great interest to our Members.

“Poor bridge team management practices while approaching and entering a narrow channel led directly to the grounding of a 1,845gt tanker. It had been the early hours of the morning and the vessel was returning to her usual load port, in ballast. The bridge watch consisted of an officer of the watch, a lookout and the Master.

The vessel had passed through the same channel a few days earlier on her loaded passage, and reciprocal courses had been chosen for the return passage. The planned track involved a 40 degree alteration of course just one ship’s length before the entrance to the channel. The bridge that spanned the narrow passage at its entrance had a white transit light which marked the centre of the bridge and the channel.

As the vessel approached the channel at full speed, the Master took the con, switched the helm to hand steering and, against company instructions, started to steer the vessel himself towards and through the narrow entrance. The officer of the watch was looking on without a defined monitoring role. However, he had plotted a position on the chart, which showed the vessel to be north of the charted course line, and the Master had altered the vessel’s heading slightly in an attempt to partly compensate.

Navigation

But We’ve Always Done it That Way

Observations:The MAIB has frequently heard it argued that it 1. is unrealistic to expect coastal shipping to adopt the navigational practices that would normally be found on deep sea vessels, because of the nature of the trade and the size of crews. Owners and Masters must ensure that they do not use this argument to justify bad practice and complacency.

The wheelhouse was well manned with qualified 2. personnel, but the team was not used effectively to ensure the vessel’s safe passage. In this case, a better arrangement would have been for the seaman to have steered the vessel while the OOW plotted positions and the Master oversaw the whole safe operation.

Passage planning was ineffective. A planned track 3. that allowed the vessel to alter course and steady up on the new heading well before the entrance to the channel would have ensured this accident was avoided. Reciprocal courses were chosen for expediency, without consideration of this and possibly other factors. The use of parallel indexing techniques would have helped to ensure the vessel was on, and maintaining, the correct track.

Some of these lessons had been discovered by 4. the company as a result of a very similar accident a few months previously. However, the lessons had not been effectively communicated to this vessel or her Master. It is an unfortunate truth that accidents are a key source of useful safety advice, and every effort should be taken to learn and promulgate the lessons so that recurrence can be avoided”.

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The Incident: This incident involved damage to a loading arm at a small oil jetty. The oil jetty in question was specifically designed for small vessels and is typical of many in the region. The berth consisted of a central section containing the loading arms on either side of which was a mooring dolphin connected to the berth by walkways.

The incident occurred as the tanker was manoeuvring alongside the berth. The tanker was berthing in a light condition without tug assistance. The forward draft was only 0.6 metres. The wind was blowing onto the berth as the Master made his approach into the current. As he stopped his vessel parallel to the berth, the high windage forward caused the bows to fall off. The bow of the vessel entered the space between the dolphin and the berth, coming to rest with the vessel’s bow in contact with the central section. To extricate himself the Master put his engines astern and in the process the fo’c’sle railing caught the end loading arm, severely damaging it.

Navigation

Insufficient Ballast Causes Loss of Control While Berthing

Observations:Cargo loading arms on small jetties are particularly susceptible to damage by ships as they are usually mounted close to the edge of the berth. This incident could have been avoided by ballasting the forward end of the tanker to reduce the windage and increase the grip of the forefoot in the water. If operational considerations made this undesirable then the assistance of a tug should have been sought.

Root Cause:Inadequate operational considerations.

Financial Cost:The cost of repairs to the loading arm exceeded US$100,000.


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The Incident: This accident occurred as a 3,000 GRT tanker attempted to berth alongside an oil jetty in marginal conditions without tug assistance. The vessel was trying to berth for the fourth time, the three prior approaches had to be aborted because of the effects of wind and current. On this occasion the approach to the berth was going well with the vessel due to dock portside to. As she approached the berth the helm was put hard astarboard, the forward spring sent way and the engines put astern. The vessel did not respond to the helm and the ship’s port bow landed heavily on the jetty, damaging the concrete structure and the fendering system.

Navigation

Know Your Ship

Observations:The Club appointed a surveyor to investigate the occurrence. The surveyor discovered that the vessel was fitted with a lefthanded propeller. The transverse thrust generated when a lefthanded propeller is run astern tends to cant the bow to port rather than to starboard as is the case with the more usual righthanded propeller. It is likely that in the marginal circumstances the transverse thrust generated when the engines were put astern was sufficient to counteract the effect of putting the helm hard astarboard.

Root Cause:Crew unfamiliar with their vessel.

Financial Cost:The cost of repairs to the jetty including survey costs totalled US$15,500.


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The Incident: This case involves damage to a deep sea vessel while unberthing a bunkering barge. The deep sea vessel was lying head to tide which was running at approximately 1 knot. The wind was blowing on her starboard bow at about force 3 to 4. The bunker barge was secured alongside her starboard side. After delivering the fuel the Captain of the bunker barge gave instructions to single up to one headline and the forward spring. By steaming gently ahead into the spring and heaving on the headline the stern was sprung off to an angle of about 30°. The lines were let go and the engines put slow astern. With the bunker barge in a light condition the bows were high in the water and as she moved away the wind caught the bows, swinging them towards the deep sea vessel. The Captain of the bunker barge stopped his engines in the hope of softening the contact, the wind however continued to push the vessel’s bows to leeward with increasing speed until she collided with the deep sea vessel, scraping down her side.

Navigation

Good Seamanship is Still as Important as Ever

Observations:In conditions such as these it is essential that full account is taken of the effects of wind and tide. Bold and decisive action must be taken and full use made of engine and rudder. If the Captain of the bunker barge had put his engines to full astern after springing his stern out it is quite possible that he would have gained sufficient stern way to carry his ship clear of the ocean going vessel before much damage was done. In stopping his engines he left his vessel at the mercy of the wind and rendered the collision inevitable.

With the prevailing wind and current the Master of the bunker barge should have let go forward and held onto his stern spring, steaming astern as necessary to spring the bow off. The current on the bow would have been sufficient to counteract the effects of the wind and the transverse thrust from the propeller as she moved off ahead would help lift the bunker barge’s stern clear of the deep sea vessel.


Financial Cost:This owner was fortunate for although the damage to the deep sea vessel extended for some distance down its side the indentation was not deep enough to worry the class society and as a result a claim was not pursued.


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The Incident: A bunker tanker was engaged in delivering bunkers to an ocean going vessel. The transfer plan was to discharge numbers 2 and 5 tanks simultaneously using a separate pump on each tank but discharging into a common line. As the oil transfer commenced it was noted that the discharge pressure gauge on the pump connected to number 5 cargo tank showed no appreciable reading. As there was no improvement after a few minutes all pumping was stopped and the matter was investigated.

The pump was found to be full of air which was bled out through the air cock valve. As the pumps were restarted number 5 cargo oil tank overflowed on to the deck. Both pumps were stopped, all valves closed. Fortunately the oil spill was contained on the deck of the bunker barge.

Operations

Luck has Staring Role in Preventing Pollution

Observations:The problem with the cargo pump had allowed oil pumped from number 2 cargo tank into the common discharge line to flow back into number 5 cargo oil tank. This flow would have continued even after the pumps were stopped as gravity would have caused the oil in the discharge line to siphon back into the bunker tanker below. Had the vessel been fitted with high-level alarms it is likely that this spill could have been avoided. Adhering to good tanker practice by starting the discharge from one tank at a time and positively confirming that oil was flowing out of the tank before starting the next one would have done much to avoid the problem.

Root Cause:Ship design failure.

Financial Cost:In this instance although no oil reached the water, the company received a bill from the Port Authority for more than US$600. In addition to this the owner faced additional costs in disposing of the oil on deck and cleaning the vessel.


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Notwithstanding any regulations, if hoses (or any equipment) exhibit defects they should be tested immediately and measures taken to replace them. Satisfactory test results only show the hose is in an acceptable condition at the time of testing. It does not provide a guarantee the hose’s condition will remain satisfactory when subjected to further wear and tear. It should also be borne in mind that bunker vessels, by the very nature of their work, place a greater burden on their equipment than other tanker types and therefore their equipment should be examined on a more frequent basis.

Root Cause:Inadequate maintenance programme.

Financial Cost:The Club put up security for US$40,000 to cover the port authority costs.


The Incident: In recent months, the Club has been involved in a large number of pollution incidents which have been caused by transfer hoses bursting during bunkering operations. The following is a typical example.

The Member’s vessel was employed in the process of transferring 600mt of heavy fuel oil into a receiving ship. She was tied up starboard side alongside and the transfer was being effected by using one cargo pump and a 30 metre long 6 inch diameter cargo hose.

The Bunker Requisition Form was agreed between both parties indicating a pumping rate of 200 mt/hr with a maximum manifold pressure of 2kg/cm2 . The transfer began at 0950.

Operations

Hose Bursts Under Pressure

At 1125 a bang was heard and oil was seen leaking out of a section of the transfer hose lying on the deck of the Member’s vessel. Pumping operations were stopped and both crews implemented measures to reduce the spilling of oil into the harbour. After a short while the harbour authorities’ launch arrived and undertook clean up operations to minimise the effects of the oil spill.

Observations:At the time of the incident, the receiving vessel had 40 metric tonnes of the stem left to receive and the cause of the hose bursting was considered to have been over pressurisation when the tank valves were possibly closed in as the receiving vessel’s tanks were being topped off.

However investigations carried out by the Club surveyor showed the condition of the cargo hoses to be poor. Several splits were noted in the outer covering. The point at which the hose burst was located within a section of hose that had been parcelled to give protection against chaffing so any deformations or damage to this section would not be readily apparent. What the condition of the hose played in the incident is unknown.

The Member had complied with the local authority requirements for the testing of the hose which required a pressure test to be carried out twice every five years with a maximum interval between tests of three years. The regulations do not make any reference to the general condition of the hose. Because of the poor condition, the Club only agreed to provide security when it was proven that the local regulations had been complied with.

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The Incident: This incident occurred during bunkering operations in sheltered waters. The bunker tanker was delivering gas oil to an ocean going vessel when the gaskets on the strainer box on board the deep sea vessel burst, with the result that gas oil spilt over the deck and into the sea. The deep sea vessel was fined by the Port Authority and sought indemnity for this and the cost of cleaning their vessel. The deep sea vessel alleged that the bunker barge had greatly exceeded the agreed loading rate.

Fortunately the personnel on board the bunker barge had kept proper records of the transfer operation and we were able to show quite conclusively that the agreed loading rate had never been exceeded. It is likely that the increase in pressure which caused the packing to burst was the result of valves being closed on the deep sea vessel.

Pollution

Good Record Keeping Wins the Day

Observations:This case highlights the need to keep proper records during oil transfer operations. Had the barge’s crew not been diligent in recording events, taking regular tank soundings and noting pump speeds, we would have found it much more difficult to avoid liability.

Root Cause:Inadequate maintenance programme.

Financial Cost:Nil.


The Incident: This minor oil spill occurred during a bunkering operation in sheltered waters. The bunker barge was supplying fuel to the deep sea vessel from tanks 2 and 4. As the bunkering operation neared completion tank 5, containing a different grade of oil, overflowed on to the deck. The officer in charge of the cargo operation promptly stopped the bunkering operation. The spill was largely contained within the vessel’s oil spill coaming where plugged scuppers prevented the accumulated oil from flowing over the ship’s side. Nevertheless the vessel was fined by the harbour authorities.

The cargo of 380 CST oil in number 5 tank was contaminated by approximately 50 tons of 180 CST oil bringing the average viscosity down to 300 CST. No claim was made by the charterers who were able to dispose of this oil with no loss of value. Surprisingly no claim for short delivery of bunkers was made by the deep sea vessel involved.

Pollution

New Ship, New Crew – Same Old Problems

Observations:The spill was caused by a crew member operating the wrong valves. This vessel had only joined the fleet a week prior to the incident and the crew were unfamiliar with the vessel. The valves were not colour coded nor were they clearly marked. The instructions given to the crewman were generic and did not specify precisely which valves should be operated. It is likely that this incident could have been avoided had the crew had more time to become familiar with the vessel, the valves been clearly marked and the crewman given precise instructions.


Financial Cost:This Member was fortunate as the fine and costs incurred did not exceed US$6,000. It could have been much greater.

Issue Date: Case No.

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The Incident: This incident involves an oil spill while loading a small bunker tanker. The bunker tanker had returned from supplying fuel to an ocean going vessel. It had oil remaining in numbers 2, 3 and 4 wing tanks. The plan was to load number 1 port and starboard first and thereafter top up 2, 3 and 4 wings, finishing in number 4. An 8 inch hose was connected and although the vessel was only due to lift 810 metric tons, the loading rate was agreed at 600 tons per hour. As number 2 wings were being topped off, the crew failed to shut the tank valves in time and oil overflowed onto the deck and into the sea.

Pollution

High Loading Rate + Too Few Crew = Pollution

Observations:Oil spills are most likely to occur when vessels are topping off their tanks. Extreme caution should be exercised at this stage and adequate personnel need to be stationed on deck to ensure that there are sufficient hands available to manipulate the valves as necessary. The loading rate should be reduced while tanks are being topped off. This procedure should be agreed with terminal personnel in advance. This incident occurred while cargo was being loaded at the full 600 tons per hour and only one man was available to monitor the tank level and manipulate the valves. The spill could have been avoided if the loading rate had been reduced and additional personnel utilised.

Root Cause:Insufficient operational procedures.

Financial Cost:The cost of clean up operations and the fine imposed by the Port Authority brought the total value of this claim to almost US$9,000.


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came to rest floating vertically in the water with her fo’c’sle structure above the water level. Hull and machinery underwriters immediately declared the vessel to be a total loss, leaving the owners with the problem of disposing of the wreck. After a lengthy salvage operation the vessel was refloated with her cargo intact. Considerable difficulty was found in disposing of the vessel and her cargo because none of the major oil companies were prepared to let a damaged LPG tanker berth in their terminal. The vessel and her cargo were ultimately sold to a salvage buyer for a fraction of their true value.

The Incident: This case concerns the capsize and total loss of a 690 ton gas tanker. The vessel was steaming between islands in the Philippines fully laden with LPG when she received a message from her charterers announcing a change of destination. On receipt of these new orders to return to a port that they had already passed, the helm was put hard to starboard while the vessel was proceeding at full speed. The vessel listed heavily into the turn and the list progressively increased until the result that the vessel capsized. Because of the buoyant nature of her cargo the tanker did not sink completely but

Tankers:� Gas

Miscellaneous

Capsize at Sea

Observations:The most likely cause of the casualty is a reduction in stability caused by free surface effect of liquids on board the vessel. Subsequent investigation revealed that the vessel was having problems with leakage. In this case there was no formal contract between the vessel’s owners and the repair yard. The question of responsibility for ensuring that the vessel was fit for hot work to be carried out was not clear. We would recommend that owners ensure this subject is addressed in every repair contract and that where possible the shipyard be given this responsibility.

Root Cause:Poor maintenance programme.

Financial Cost:The cost of refloating and disposing of the ship and cargo exceeded US$820,000.


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Section 3� Fishing Vessels

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The Incident: This incident took place on a beam trawler and a resulted in a non-fatal injury to a crew member.

During a late evening in fine weather conditions the fishing gear was being hauled. Four crew members were positioned on the top deck waiting to attend to the beams as they came on board.

As they cleared the water, with the derrick standing vertically, the starboard topping wire parted. It came down with some force and struck a deckhand. It was later found he had sustained a fracture to an ankle and there is some doubt as to his ability to return to a life in the fishing industry.

Fishing Vessels


Although Out of Sight it should be Kept in Mind

Observations:Unfortunately the head block was lost overboard during the incident and it is a matter of conjecture whether the block failed causing the wire to part or whether the wire parted causing the block to fail. The wire was reportedly only seven months old.

The rigging arrangement for the derrick was such that the topping wire only moved between 150mm to 200mm when raising or lowering the booms, thus the length which rounded the block had been hidden from view since it was reeved.

Although the skipper had in place a thorough greasing routine for the wire and blocks, the only way to examine this small section of wire was to land the derrick on to a quay, which had never been carried out.

Both ends of the wire were noted to be frayed which indicates that it was likely the wire had parted, destroying the block.

It is not uncommon for static sections of wire to corrode significantly in a short period of time and Members and Skippers should ensure that such sections of wire are frequently examined and greased.

Root Cause:Inadequate maintenance programmes.

Financial Cost:The cost of this claim is US$80,000.


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The Importance of Good Risk Assessment Highlighted

The Incident: The accident occurred when a crew member was attending the gilsen derrick guys as a catch was being brought on board. Three turns had been taken round the port warping drum of the trawl winch. The drum was rotating at a steady speed as the controls had been locked in position by the use of a piece of wood wedged between the control lever and frame. The crew member was tailing the rope behind the drum, surging or heaving as required

when the fingers of his left hand became caught between the rope turns and the drum. There were no witnesses to the accident but it seems likely that a riding turn developed on the drum and instead of letting the rope go and stopping the winch by pulling on a small rope attached to the piece of wood, the crewman tried to clear the guy while the machinery was still rotating. Despite medical intervention he lost the tips to three fingers.

Observations:There were two contributing factors to this incident. Firstly, the crew member was very inexperienced in working on a fishing vessel although the task he was involved in was not an unusual one in terms of seamanship. However it appears he tried to clear the riding turn whilst the winch was rotating. Secondly, despite two other crew members being present on deck, no one was designated to operate the winch which was left in the hauling mode by means of a makeshift modification. The crew member had allegedly been told to stop the winch in the event of any problems, but failed to do so. Had a winch operator been present, stopping the winch would have been easily achieved and the accident avoided. Indeed he should have been better supervised in view of his relevant inexperience.

Root Cause:Inadequate operational practices.

Financial Cost:The claim was settled for US$117,000.

Issue Date: Case No.

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No Excuse for Reduced Maintenance Regimes

The Incident: A Skipper was killed and two women injured when the starboard derrick, which had been topped up to its fully raised position, suddenly fell down on them as they stood on the quayside next to the vessel. It transpired that the eye of the starboard topping lift block had failed and subsequent investigation attributed its failure to the sudden propagation of a brittle fracture from a pre-existing manufacturing defect.

The claims eventually came to trial and the claimants’ primary case was that the Members had failed to put in place an adequate system of inspection and maintenance of the fishing gear. The Members asserted that their system of inspection and maintenance was in accordance with all applicable regulations and matched prevailing standards within the industry. They contended that, in any event, any shortcomings in maintenance were not causative of the loss since the block failed as a result of a latent manufacturing defect which could not have been, and was not, detected by the exercise of reasonable diligence.

Observations:The judge found that the Members’ practice of leaving all aspects of maintenance and safety to the crew was indeed in accordance with industry practice but that it was “simply naive to assert that good practice cannot call for more than compliance with the relative statutory regime”. He said that there should have been a system of planned preventative inspection and maintenance of all lifting gear blocks every six months by a person with sufficient practical experience and theoretical knowledge. He saw no reason to distinguish between the regime of inspection required of cargo ships’ derricks and lifting gear on a fishing vessel. As to causation, the metallurgist experts for both parties were agreed that the developing defect in the block would not have been detected during a routine inspection and overhaul of the vessel’s equipment. However, the judge

found that the crew were wholly untrained to recognise degrees of wear or corrosion in the vessel’s equipment, that there were other defects in the block which were patent and that a proper system of maintenance would have required the block to have been tested with the specific intention of identifying cracks.

Members’ attention is drawn to our Lookout article 06 of 2004 where a maintenance regime for lifting tackle on fishing vessels based on MCA requirements is detailed.

Root Cause:Inadequate shore maintenance procedure.

Financial Cost:The Members paid substantial compensation to the Skipper’s widow and the two injured women. With the associated costs, the total value of this claim was in excess of US$2,155,000.


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Death from Hydrogen Sulphide Poisoning

The Incident: The vessel involved in this case was a 97 foot fishing vessel which had left her home waters in Alaska to fish for albacore tuna in the South Pacific. The vessel experienced problems with her refrigeration system which culminated in a full catch of approximately 15 tons of tuna being rejected as being unfit for human consumption.

The skipper decided to cut his losses and return to Alaska, hoping to sell the catch as bait. It appears however that problems with the refrigeration system worsened and six days into the voyage the refrigeration system was shut down altogether. The three man crew started to dump the fish over the side. Nine tons were disposed of before the smell of decomposing fish became overwhelming. The Captain decided to partially flood the fish hold in the hope that the fish would rapidly break down into a soup which could be pumped overboard. After leaving the fish to decompose for a few days they commenced pumping the

mixture but after a short period the strum box clogged with fish remains. The skipper descended the ladder into the fish hold to try to clear the pump. Within seconds he was overcome by hydrogen sulphide gas given off by the rotting fish. The engineer attempted to rescue him and also succumbed. The one remaining crew member was unable to operate the radio to summon assistance and steamed in the general direction of Honolulu until the boat’s generator ran out of fuel and the electrical supplies to the steering gear failed. At that point he abandoned ship and set off the EPIRB. He was rescued by the US Coastguard.

The survivor claimed damages for post traumatic stress disorder. Claims were made by the families of the two dead crew.

Observations:This unusual incident highlights the dangers of entering enclosed spaces. The atmosphere of any enclosed or confined space which is not continuously and adequately ventilated may be deficient in oxygen or contain flammable/toxic fumes, gases or vapours. Crews should be made aware of the dangers and instructed not to enter enclosed spaces if there is any reason to suspect that the atmosphere may be hazardous. On no account should rescue attempts be made without wearing breathing apparatus, a rescue harness and lifeline. In this case the crew were aware that the fish were rotting but were ignorant of the effects of the gas being given off. The vessel carried no breathing apparatus, gas testing equipment or oxygen analysing equipment. This accident could have been avoided if the crew had been aware of the risks of enclosed spaces and not attempted to deal with the problem without proper equipment.

Root Cause:Inadequate enclosed space entry procedures.

Financial Cost:The cost of this claim exceeded US$650,000.

Issue Date:01/01/02 Case No. 14132

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The Incident: The stern trawler involved in this incident was lying in a port in Alaska undergoing repair work. The vessel’s trawl deck area was equipped with two cranes, one located at the forward starboard corner and the other portside aft. Repair work was being carried out on the starboard forward crane by independent contractors. The work involved cutting out and replacing a portion of a starboard forward crane. The after port crane was used to assist in the repair work.


Makeshift Platform Results in a Severe Injury

Observations:This incident highlights the dangers of makeshift working platforms. This incident could have been avoided if the had erected a proper scaffolding around the crane to provide a safe platform for his men to work from. In this case despite the contractor and his employees being fully aware that the movement of the plywood sheet was causing the winch to operate unexpectedly, they took no steps to replace the plywood with a proper structure or take any steps to guard the controls. Furthermore the contractor’s men were still using the winch as a stepping stone to reach parts of the crane knowing that it was liable to operate without warning.

Root Cause:Failure of 3rd party working practices.


The contractors could not reach the damaged portion of the crane from deck level. The contractors brought a large piece of plywood on board, placed it on top of the starboard trawl winch, which was conveniently situated just aft of and adjacent to the crane. At some point during the repair work it became evident to the contractors that as they moved about on the plywood sheet it pressed through the control ears activating the winch. The contractors approached the ship’s crew to ask whether it would be possible to turn the hydraulic power supply to the winch off and the ship’s crew advised that it was possible but as the deck cranes and trawl winches were operated from the same hydraulic supply, the contractors would lose the use of the aft port crane. The contractors however needed power to the crane and asked that the hydraulic power be left on. Not long afterwards the trawl winch was accidentally activated, trapping the foot of one of the contractors’ workmen. The injuries were so severe that the workman lost the big and first toe on his left foot, which disabled him to the extent that he was unable to continue with his previous occupation.

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Importance of a Safe Means of Access

The Incident: This incident occurred in harbour at the end of the fishing season. The vessel was being laid up for some months and the crew had been removing their belongings from the vessel dock. No proper gangway had been rigged and the only access to the vessel was by way of a jacob’s ladder tied to the top railing on the starboard side of the pilot house deck. As a crew member was clambering over the top of the railing he lost his balance and fell approximately 12 feet to the dock injuring himself.

The crew member suffered a severely broken wrist which required the insertion of metal pins. He was also found to have herniated a disc in his upper spine which gave rise to neck pain and dizziness. His doctors advised him that he should not return to work at sea.

Observations:This is one of the many injuries that occur every year as a result of the use of unsafe means of access to and from vessels. Small vessels often have greater problems ensuring safe means of access than their larger sisters. In this particular case it would have been difficult if not impossible to rig a conventional gangway. The accident could however have been avoided if the jacob’s ladder had been rigged adjacent to an opening in the ship’s rail which would have avoided the crew member having to clamber precariously over the ship’s rail. Alternatively a rigid vertical ladder extending above the level of the vessel’s rails could have been used.

Root Cause:Inadequate means of access.

Financial Cost:The total cost of this claim to the Shipowner was $214,114.


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Observations:The main cause of this fatality was a failure of the Master to ensure that all crew members were aware of the attendance of a diver whilst the vessel was alongside. By ensuring the facts were known beforehand, the possibility of the engines being used would not have arisen. Precautionary measures could have been taken including notices being placed on the starting handles and telegraphs. This case also highlights the need to ensure facts are clearly understood when language difficulties may arise due to different nationalities being employed on board. It is important that all senior crew members have at least a good working knowledge of one common language and can communicate effectively with their department staff.

Root Cause:It Pays to Plan Ahead.

Financial Cost:The cost of this claim was in excess of US$117,000.


The Incident: The Member’s vessel was tied up alongside and a diving company was employed to undertake underwater cleaning of the hull. The diver reported to the Master and then proceeded ashore where he changed into his diving gear and entered the water. The Master remained on deck to check work being carried out on a hydraulic winch. Soon after, the Chief Engineer approached the Master and requested permission to start the main engine so that electrical power could be provided to test the winch. The Master refused permission on account of the diver being in the water. Because of language difficulties the Chief Engineer had not understood what the Master had said and proceeded to the engine room to start the engine. The diver was working in the vicinity of the propeller and when the engine started he was instantly killed.


It Pays to Plan Ahead

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The Incident: The skipper of a fishing vessel was leaning into an ice box when the lid, weighing half a ton, fell on to him. He suffered serious chest injuries and has a 10% body impairment as a result. The normal procedure for opening the lid was to raise it by means of a rope and tackle and then insert a safety prop to hold it up.

Observations:Unfortunately, on this occasion the skipper relied on the rope to hold the lid open and did not use the prop. The lead of the synthetic rope was such that it came into contact with the funnel and the heat had a degrading effect on it which caused the rope to eventually part. Had the safety prop been used this accident would have been prevented. In all likelihood the rope would have parted when the lid was being either opened or closed and the crew standing clear.


Heat of the Moment

This incident highlights several facts:

Never rely on a wire or rope •to hold a hatch lid open. A safety prop or securing pin should always be used to secure it in the open position. Such a restraint must enable clear access to the opening.Wherever there is a possibility •of a synthetic rope coming into contact with an indirect heat source, it should be replaced, preferably by a wire rope or at least by a natural fibre one.Lifting arrangements should •be subjected to a thorough visual examination at regular intervals. In this particular incident, it was reported that the damaged section of rope was not obvious to a casual observer.



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As a matter of last resort and if it is considered absolutely necessary to use a tourniquet, then it must be released every ten or fifteen minutes for a short time in order to supply the tissue with blood. However the wound must be covered by a heavy pad and bandage to stem any blood flow.

In this case the injuries sustained, although serious, were treatable and a good if not full recovery would have been made if a tourniquet had not been used.

The Administration overseeing a vessel will have requirements for the medical qualifications required to be held by a vessel’s crew, and this case highlights the importance of ensuring regular training is undertaken.

Root Cause:Inadequate crew training.

Financial Cost:The cost of this claim was over US$77,000.


The Incident: This claim involved a Vietnamese fisherman who, due to the medical treatment he received on board, had his lower leg amputated.

Whilst fishing, a trawl wire became entangled around the propeller. During efforts to free the wire, the crewman became trapped between the wire and bulwark. As a result he suffered a fracture to his right tibia, injuries to his pelvis and serious bruising and abrasions.

Shortly after the accident, the victim was transferred to another larger fishing vessel which was proceeding to the nearest port. Once this vessel was within range, the ship’s helicopter was used to transfer him to the nearest island with medical facilities. The medical staff at the hospital did what they could for the fisherman but decided he needed more specialist care and arrangements were made to airlift him to the main land. Upon examination the attending surgeon was left with no alternative but to amputate the right leg from the knee.

Observations:As a result of the accident the fisherman was bleeding heavily. The fracture to the tibia was open and a tourniquet was applied to stem the bleeding. This remained in place until he reached the first hospital 14 hours later.

A tourniquet can be used to restrict blood flow to limbs, but the use of such a device has to be closely monitored because by restricting the blood flow the affected part of the body undergoes metabolic changes and unless blood flow is restored it slowly dies. In the case of the fisherman, the lower leg muscles had died by the time he received professional medical help and the surgeon was left with no alternative but to remove the lower leg.

A tourniquet is no longer recommended as a means of restricting blood flow from a wound. The preferred option is to apply pressure to the wound by using a heavy pad held in place by bandages or even ones hand (preferably whilst wearing disposable gloves). The blood will eventually clot and the blood flow stemmed.


When Applying First Aid – Ensure you Know What you are Doing

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Observations:The medical examination revealed the foreign body (a piece of rusted metal) was “lodged superficially” on the eye and was easily removed by the attending doctor.

Two points arise from this incident. Firstly, if the Chief Engineer had been wearing safety goggles, the chances of the metal entering the eye would have been prevented and the incident would not have occurred. Secondly it is a little surprising that no apparent attempt was made to treat the injured party on board. The foreign body was superficially lodged and the vessel carried a medical outfit compliance with flag state requirements.

Root Cause:Poor Safety Practices.

Financial Cost:The cost to the Member in terms of the deviation was US$15,500 comprising fuel, port and hospital costs. The cost to the Member in lost fishing time during the 7 day deviation far exceeds this amount.


The Incident: This claim involved a purse seine fishing vessel engaged in fishing for tuna.

The Chief Engineer was working in the vessel’s workshop when a foreign body entered his eye. The eye proved painful and the Master decided to land the injured engineer ashore for medical treatment. The nearest port was three days steaming away.

Doctors removed the foreign body and the vessel returned to the fishing grounds.


A Real Eye Opener

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Carbon Monoxide Poisoning on Fishing Vessels

The Incident: An experienced crewman of a 16 metre potter, who was both working and living on board the vessel, died as he slept due to carbon monoxide poisoning. This was caused by the exhaust fumes of a petrol-driven generator running inside the fish hold. The generator had been brought on board by the crewman himself to power an electric heater, TV and radio.

Observations:The bulkhead between the fish hold and the crewman’s sleeping cabin was neither watertight nor gastight.

Putting a petrol generator inside the fish hold introduced a number of hazards to the vessel:

Carbon Monoxide:

Has no smell or taste•Symptoms of poisoning are similar to the flu •People may not be aware they are being poisoned •

Fire/Explosion:

Petrol gives off highly flammable fumes •A petrol engine below decks can potentially cause •explosive fumes Other neighbouring boats could also be •destroyed

Electrical Hazard:

Household appliances are not designed for use in •conditions often found on board fishing vesselsCorrect wiring essential•

When living on board a vessel it is crucial to conduct a risk assessment so that:

Sufficient power is provided for 1. accommodation and lightingThere is adequate ventilation (more needed 2. for burners and stoves)There are adequate alarms to warn 3. sleeping crewmen of problemsCrew can escape from accommodation 4. in an emergencyIt is safe for a lone crewman to board or 5. leave the vessel at night

Source - Maritime and Coastguard Agency Email: [email protected]


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Careless Action Severely Injures Colleagues

The Incident: Whilst trawling the net became entangled on its reel. A crew member climbed onto the net reel to clear the tangled section. Whilst clearing the net, the deck boss, who was operating the winch, moved the net reel without warning and without checking that the crewman was clear. As a result the crewman fell from the winch and fractured his leg and severely damaged his kneecap.

Observations:The incident was caused by the failure of the winch operator to ensure all crew were clear before he operated the winch. It is not uncommon for winch controls to be positioned such that the winch operator is unsighted and in such circumstances clear procedures must be put in place to prevent the winch being turned without the prior knowledge of those working in the vicinity. Conversely, if a crew member has to approach a winch he should ensure the winch operator is made aware of his impending actions.

As is the case with most of these incidents, saving time is considered to be more important than safety and shortcuts are taken. It is only when injuries are suffered that crew have more than enough time to reflect on the consequences of compromising safety.

Root Cause:Dangerous operational practices.

Financial Cost:US$200,575.


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Observations:Although it was clear the injury was caused by the engineer’s own actions, the long term effects of the injury were due to the lack of prompt medical treatment. If the injury had been treated within 12 hours of the incident, it would have been unlikely that any serious or permanent injuries would have resulted.

Although the skipper acted with the best intentions and was guided in his evaluation of the injury by the engineer himself, the fact that he did not obtain proper medical advice resulted in the shipowner being found liable. If they are in any doubt a Master should always seek medical advice. Such advice is readily available by radio and is free of charge.



The Incident: This accident occurred to an engineer on board a fishing vessel.

During fishing operations a hydraulic hose developed a leak. The vessel’s engineer was called and after examining the hose, the engineer placed his thumb over the hole and then instructed another crew member to operate the controls. As a result of this, hydraulic oil at 1600 psi was injected into his thumb.

The skipper was called to the scene. He examined the injury which initially resembled an insect bite. The skipper suggested that the vessel returned to port. The engineer himself opposed this idea and dismissed the injury as a trivial matter of no consequence. The skipper did not seek further medical advice.

The vessel returned to port three days later. By the time the engineer reached hospital his thumb had swollen considerably and he was in severe pain. Over the following two years he underwent a series of operations, but despite this he has been left with a permanent disability which prevents him from ever returning to work as an engineer.


Good Intentions Result in a Very Large Claim

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Observations:The Member’s vessel failed to maintain a proper lookout and this was compounded by the fact that an inexperienced crew member was left in charge of the watch whilst transiting an area of heavy traffic. Having noted a radar target on the starboard bow and making an initial assessment , no further observations were made until it was too late.

The importance of maintaining a proper lookout cannot be over emphasised nor can the need to monitor all vessels closely when navigating in busy waterways. Consideration should always be given to “doubling up” watches in these circumstances.

Root Cause:Inadequate lookout.

Financial Cost:The claim is expected to be no less than US$400,000.


The Incident: This claim involves a collision between a fishing vessel and a 17000 gt products tanker.

The Member’s vessel, a stern trawler was proceeding to her intended fishing grounds, which required her to cross a traffic separation scheme. The Member’s vessel contravened Rule 10c of the Collision Regulations by not crossing the traffic lane at right angles.

The Master had left the wheelhouse and an inexperienced 17 year old deckhand was left alone on watch.

A radar target was noted approximately 3 miles on the starboard bow, and after making a visual check, the watch-keeper made the assumption that the vessel would pass clear to starboard; having made this assessment the watch-keeper paid no further attention to his lookout duties. More than one vessel was in fact within the immediate vicinity and the fishing vessel collided with another ship shortly thereafter.

The watch-keeper realised a collision was to take place seconds before it actually occurred. He put the wheel over, but as he had not disconnected the auto pilot there was no response.

Fortunately there was no loss of life, but each vessel sustained heavy damage.

Navigation

When a Lookout should Lookout

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Observations:This incident emphasises the need to maintain a good lookout at all times as required by the International Regulations for the Prevention of Collision at Sea. Had the deckhand not arrived on the bridge at the time he did, the vessel would have undoubtedly ploughed into the beacon at full speed with possibly disastrous consequences for those on board.

Root Cause:Inadequate lookout.

Financial Cost:The repairs to the beacon cost A$96,500 (US$76,405).


The Incident: This incident involved an Australian cray fishing vessel. In common with the majority of this fleet this small vessel is highly powered and navigates at high speed.

The vessel in question had just undergone engine repairs to try to cure an overheating problem with the main engines. The skipper and one deckhand took the vessel out on sea trials. During the trials the skipper was keeping a careful eye on the engine temperature gauges. As no problems were encountered the vessel’s speed was steadily increased until she was travelling at approximately 18 knots. The skipper’s attention was so firmly fixed on the engine gauges that he failed to notice a navigational marker dead ahead. Fortunately the deckhand who had just come onto the bridge spotted the beacon before the collision, enabling the Master to kill the power. Nevertheless the resulting collision severely damaged the boat and the beacon.

Navigation

Distracted Skipper Dims Beacon Light

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Navigation

Total Loss

The Incident: A 360 ton deep sea fishing vessel had called at Pago Pago in American Samoa for bunkers en route to her fishing grounds east of Tahiti. She left Pago Pago in the afternoon, steering an easterly course set to pass nine miles north of Rose Atoll, the only US National Wildlife Reserve in the southern hemisphere. At approximately 4 a.m. in clear weather the vessel ran hard aground on the south western side of the atoll. The forward double bottom tank below the fish holds ruptured immediately and oil started to spill from the vessel. The vessel was abandoned later in the morning

after the engine room began to flood. The crew were picked up by a passing vessel without serious injury or loss of life. The nearest suitable salvage vessel was 2,000 miles from the site and by the time it arrived the fishing vessel had broken up, spilling nearly 100,000 gallons of gas oil bunkers. Damage to the reef caused by the grounding and the toxic effects of the oil extended to a radius of approximately 1 km from the wreck. The US authorities required that a clean-up operation be mounted and the remains of the vessel removed.

Observations:There were only two qualified officers on the fishing vessel, the Master and the Chief Officer. The Chief Officer’s responsibility was apparently confined to the operation and maintenance of the fishing gear. He was not involved in navigational duties. After sailing the Master remained on the bridge until midnight when the vessel passed south of Manua Island. Before retiring the Master set bridge watches which consisted of one senior and one junior seaman. The only instruction given to the seamen by the Master were to call him if they saw any lights. Rose Atoll is not lit.

None of the seamen given the task of keeping watch had any navigational training. They had no knowledge of the collision regulations and were not even sure in which direction the vessel was steaming. They had no knowledge of navigational hazards in the vicinity and there was no char t on the bridge. They were untrained in the use of radar and the set was switched off. The vessel was equipped with a GPS navigation system however the watchkeepers did not know how to ascer tain their position and were unable to check whether the vessel was following the course set by the Master.

Root Cause:Insufficient manning.

Financial Cost:In addition to losing a multi million dollar vessel the owner faced a bill of over US$1 million for clean-up and was also liable for fines and penalties under American pollution laws.


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Navigation

Fatigue Causes Grounding and Total Loss

The Incident: This incident involves the grounding and subsequent total loss of a seine fishing vessel. The vessel was returning to its home port at the end of the salmon fishing season. She was proceeding in company with another fishing vessel owned and operated by the captain’s brother. The maximum speed of this vessel was approximately 4 knots less than our ship. The two brothers believed that travelling rafted together in sheltered water would reduce their overall passage time. Thus when the vessels entered the Greenville Channel which forms part of the Inner Passage between the off lying islands and the coast of British Columbia the vessels were lashed alongside one another and proceeded as a rafted unit. In the early hours of the morning both vessels ran hard aground on a small promontory on the port side of the channel at a point where there was a slight bend to starboard. An order to remove the vessels was issued by the Department of Fisheries.

Observations:No agreement had been reached for controlling the navigation of the combined unit. Neither vessel could control the course or engines of the other. Both vessels were on autopilot. The wheelhouse of each vessel was manned by a single watchkeeper whose only method of communication with his counterpart was by VHF radio. At the time of the grounding the watchkeeper on the other fishing vessel had reportedly left the wheelhouse to relieve himself and the watchkeeper on our vessel had fallen asleep.

At some point shortly before the grounding the vessels had run into a bank of fog however this was probably not causative of the loss. The most likely explanation is that with one bridge unmanned and the other watchkeeper asleep the vessels failed to make the slight alteration of course necessary to follow the channel. The problem was probably compounded by the fact that the more powerful vessel lay on the starboard side of the other, making the combined unit more likely to veer to port.

It is unlikely that both vessels would have grounded had they been navigating independently. With the vessels rafted side by side both on autopilot and with no system for controlling the course or the engines of the other, the slightest error by either watchkeeper would almost inevitably end in disaster.

Root Cause:Poor navigational practices.

Financial Cost:The smaller vessel was a constructive total loss and the larger vessel was severely damaged. Both vessels were refloated by their respective owners’ efforts. Nevertheless the costs incurred exceeded US$20,000.


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Observations:The prime cause of the incident was the fact that the wheelhouse was undermanned. The vessel grounded only 100 metres from the shoreline which shows that during the time the Skipper’s attention had been diverted, the wind and current had set the vessel in towards the shore. Being alone on watch the Skipper had many tasks to attend to not least the navigation of the vessel, keeping a lookout and steering, all whilst operating close inshore. The failure of the hydraulic pump increased the demands placed on the Skipper which led to the wheelhouse being left unmanned for a period of time and navigation continuing unmonitored whilst the telephone call to the managers took place.

The incident was caused by a failure on the Skipper’s part to call for suitable assistance in the wheelhouse. There were no moves to supplement the wheelhouse watch whilst the Skipper’s attention was diverted to the problems with the hydraulic pump which is difficult to understand considering the proximity of the vessel to the shore. Manning levels on fishing boats, whilst in accordance with Flag State requirements do not always provide for the luxury of spare qualified crew members, but when circumstances dictate, as in this case, adjustments to work routines should be made to ensure the safety of the crew and vessel.

In all likelihood, had the cook been able to swim, he would not have panicked to the extent he did and would probably still be alive today. He was found wearing his lifejacket. The Flag States Code of Safe Working Practices for Fishing Vessels recommends that all fishermen should be able to swim. So do we.

Root Cause:Inadequate navigational practices.

Financial Cost:The cost to the Club was only US$2,776. Fortunately the vessel’s diesel oil was blown out to sea with no beach pollution taking place. The crew were covered under the Flag States Workman’s Compensation Act and the Club was not required by the authorities to remove the wreck even though it had grounded in a scientifically sensitive area.

The cost to the cook and his family was beyond calculation.


The Incident: This incident involved a boom trawler stranding whilst fishing for prawns and is one of a number of similar incidents the Club has been involved with recently.

The vessel was fishing approximately 0.5 miles from the shore with the Skipper on watch, alone. At approximately 23:00 on the evening in question, the engineer advised the Skipper that a problem had developed with the hydraulic pump for the trawl winch, rendering it inoperative. The Skipper left the wheelhouse to assess the situation for himself and returned shortly afterwards to telephone his managers. Whilst on the phone, the vessel grounded. After a list of some 35º developed, the crew donned their lifejackets, two liferafts were launched and the vessel was abandoned.

Unfortunately the cook could not swim and, on entering the water, he panicked and subsequently drowned.

Navigation

If Only he could Swim

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The Incident: The vessel involved in this collision was a 19 metre steel trawler which worked the scallop and prawn fishery off the coast of Queensland, Australia. The vessel fished by night and anchored during the day. She was manned by a crew of two. On the morning of the collision they finished fishing at 7 a.m. The skipper set course for her home port, handing over the watch to the deck hand in late morning. In the early afternoon the vessel collided with another fishing vessel which was lying at anchor.

Observations:At the time of the collision neither vessel was keeping a proper lookout as required by the International Regulations for the Prevention of the Collisions at sea. No anchor watch had been set on the anchored vessel and all her crew were turned in. The crew member that was supposed to be keeping a navigational watch on our Member’s vessel was in fact on the afterdeck cleaning when the collision occurred. The vessel was not fitted with a watch alarm, nor did it have a guardring facility on the radar.

Navigation

Unmanned Wheelhouses Cause Collision

Root Cause:Inadequate navigational lookout.

Financial Cost:Repairs to the anchored vessel cost over A$100,000. It was out of action at the height of the scallop season for over two months, giving rise to a substantial claim for loss of profits, which was eventually settled for A$45,000. In addition to this there was substantial damage to our Member’s vessel and it too was out of action for a substantial period at the height of the season.


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Navigation

A fatal nap

The Incident:The crew of a longline fishing vessel had to abandon ship in violent seas at night after she grounded on rocks. The skipper drowned and one crew member’s body was never recovered. Two other crew members were tossed against rocks in stormy seas for hours. Before the grounding, no one had been keeping an anchor watch.

The 18 metre steel-hulled commercial longliner set off on a three day voyage at a time when heavy storm warnings were issued for all of the country, and most vessels in the area were heading for safe anchorage. In the late afternoon of the second day, the skipper anchored in a large bay. To get there, the vessel steamed about 20 nautical miles past a safe and open port and instead anchored approximately 300 metres from a rocky coastline in about two metre seas.

The nearby port’s Harbour Master saw the vessel ‘punching’ through the seas and thought it peculiar for the vessel to stay at sea in such conditions. About an hour before the vessel weighed anchor, a nearby wave buoy recorded wave heights of 3.2 metres, reaching 6.2 metres and increasing. Soon after midnight, the crew all turned in for the night. No anchor watch was kept. The vessel was fitted with radar and a GPS, depth sounder and course plotter, but none of these were set to supplement an anchor watch or provide an alert.

At about 3 am, the crew were woken by heavy waves battering the vessel. They soon discovered the vessel had dragged her anchor and was almost aground against the rocky coastline. Wave buoy recordings show that by this time the swells had increased to 5.2 metres, reaching a maximum of 9.1 metres. At the vessel’s position, the waves would have been significantly higher in the shallow water.

Waves had damaged the vessel, and she was set in to the shore with big seas breaking over her. The crew attempted to recover the anchor, but the winch would not operate. Attempts to cut the anchor wire with bolt cutters failed. When the vessel hit the rocks, the skipper gave the order to abandon ship and set off a distress beacon. All four on board dived into the sea. The skipper and one crew member drowned.

The two remaining crew members spent hours in the water, being smashed by waves. One suffered a collapsed lung and extensive cuts and bruising. The other managed to crawl onto a small beach and suffered hypothermia. They were eventually rescued by helicopter and flown to hospital.

Observations:1. Given the weather conditions from the outset

of the voyage and the forecast, the vessel should not have set sail. Once en route, there were two ports within timely reach of the vessel where she could have berthed safely.

2. The position the skipper chose to anchor in was unsuitable for the conditions, but the skipper did not seek local knowledge about a better location from Marine Radio or the Harbour Master.

3. No anchor watch was kept by the crew. Maritime rules require that a proper lookout is maintained at all times and, given the conditions, was essential for the safety of the vessel.

4. In addition to its four crew members, the vessel was fitted with radar and a GPS, depth sounder and chart plotter, which could have been set to assist the designated watchkeepers. Failing to maintain an anchor watch appeared to be standard practice on this vessel.

5. The company that had contracted the vessel had adopted a ‘hands-off ’ approach to monitoring the safety performance of vessels it contracted. The operations manager knew this vessel was departing into the storm and, despite discussing the potential catch with the crew, made no mention of the weather. It was company policy to neither require nor dissuade a crew from undertaking a particular voyage.

6. The need for keeping an anchor watch, par ticularly in adverse weather or when anchored on an open coastline, should have been reinforced by the contracting company. Both factors applied in this case and the failure directly contributed to the loss of the vessel and two lives. This dangerous failing could have been identified and corrected.

7. As a result of this tragedy, the contracting company was fined and required to pay reparations to the victims’ families. The court found that the company failed to implement adequate policies or processes to ensure the vessel’s crew properly followed maritime rules by ensuring a proper anchor watch was kept..

Trading Area: Australasia & Pacific


This case study has been taken from: Maritime New Zealand’s ‘lookout’ issue 17.

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Observations:The vessel was detained by the harbour authorities on a number of deficiencies which came to light during investigations into the incident. These included:-

Oil Record Book not being 1. correctly maintainedSOPEP not updated2. Crew not familiar with 3. the procedures required by the SOPEPUnauthorised cross 4. connection between the bilge and bunker systems.

Notwithstanding the illegal cross connection, the primary cause of this oil spill was the fact that valves utilised during the previous day’s operation had not been closed upon completion nor had the manifold connection been blanked.

It is imperative that pipeline systems are fully closed down after use and when utilised again, the pipelines and valves are checked during the early stages to ensure the oil is only flowing to the required destination and nowhere else.

The ironic aspect of this incident was that the time saved in pumping the waste oil ashore via the bunker system was lost in the detention of the vessel which lasted four days.

Root Cause:Inadequate SOPEP procedures.

Financial Cost:The cost of this incident including fines and clean up charges is estimated to be US$90,000.

Issue Date: 27/10/05 Case No.42370

The Incident: This incident involved the inadvertent spill overboard of oil during an internal transfer of bunkers.

The day prior to the oil spill, the engineers had been pumping waste oil to a shore reception facility. Because it was felt the operation would take too long utilising the standard connection as required by the MARPOL regulations, a cross connection had been fabricated to fit between the bilge and bunker systems. The waste oil was then pumped ashore via the bunker manifold without incident. When an internal transfer of oil was commenced the following day, heavy fuel oil spilled onto deck through an open manifold connection and then spilt overboard.

Pollution

Short Cuts can take Longer

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Observations:To some extent, these incidents are all attributable to lax bunkering procedures. In one case, none of the vessel’s staff were on board overseeing the operation. All could have been prevented with a little more conscientious monitoring of operations. Loose flanges and open ended pipes appear to be a common feature.

All the vessels in question have a gross tonnage in excess of 400 tonnes, so are governed by the MARPOL regulations, in particular the Shipboard Oil Pollution Emergency Plan (SOPEP) which is in place to prevent instances described above.

The non-mandatory section of a vessel’s SOPEP Manual should contain the operating company’s bunkering procedures. Equally, vessels to which the regulations do not apply would be well advised to have in place similar procedures.

Such procedures we believe should include the following requirements:

All valves in a pipeline system not required to be 1. opened should be confirmed as being closed.All flanges not in use should be blanked off.2. A crew member should be detailed to remain on 3. deck at or near the manifold connection during the entire operation.

Bunkering operations should be started and 4. completed at a slow rate until a) it is confirmed that the oil is going into the correct tank and there are no leaks and b) the tanks are “topped off” in a controlled manner.Scupper plugs should be fitted and if this is 5. not feasible, savealls fitted around the bunker connections and air vents should be of a practical size.Oil spill clean up equipment and absorbents 6. should be placed on deck.

Root Cause:Inadequate bunkering procedures.

Issue Date:01/01/02 Case No. 35341

The Incident: The Club is concerned at the number of oil pollution claims arising from oil transfer operations carried out by large fishing vessels, particularly in European ports.

Typical examples are:

A 7300 GT fishing vessel was to pump the contents of her sludge 1. tank ashore to a road tanker hired for the purpose. The hose was connected and, immediately upon commencement of pumping, oil escaped on to the deck and into the dock from the outboard connection. Investigation showed that this unused connection had been left with its valve open and blank flange missing.A vessel of 2417 GT commenced bunkering heavy fuel oil. 2. Approximately 30 minutes later, personnel observed oil spilling on to the deck and into the harbour waters. The leak was traced to a loose flange on an elbow piece at the manifold connection.In another case oil was observed spilling out of an air vent and 3. subsequently over the vessel’s side. Investigations showed that the labels on the filling connections had been incorrectly placed and the wrong tank was being filled. (It should be pointed out that this bunkering operation was usually carried out on the other side of the vessel without incident, but due to operational reasons this was not possible on this occasion).During the final stages of a bunkering operation, heavy fuel 4. oil spilled out of the receiving tanks air pipe. Operations were immediately stopped but not before a quantity of oil had run out through the scupper pipes. It is thought the cause was an air bubble in the bunker tank which probably arose because of the vessel’s three degree list and large stern trim at the time. The other possibility was an incorrect assessment of the capacity available.

Pollution

Environmentally Unfriendly Bunkering

Section 4� Passenger Vessels

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Root Cause:Insufficient safety signs.

Financial Cost:The lawyers were of the opinion that the Member would be held liable for the incident as it would be very difficult and expensive to prove any contributory negligence on behalf of a minor, thus the case was settled out of court.

Total cost US$34,000.


The Incident: Shortly after boarding the vessel, a small passenger ferry, a young girl aged 10 fell down a storeroom access. She apparently climbed out of the 2 metre deep opening via a fixed ladder of her own accord.

Her parents notified the crew and aler ted the shore based emergency services. She was taken to hospital and spent twelve days in the Intensive Care Unit as she was diagnosed as having a ruptured spleen. Subsequently the young girl made a full recovery.

Apart from the girl’s parents, there were no witnesses to the incident.

Passenger Vessels


To be Forewarned should mean you are Forearmed

Observations:Doubt exists as to whether or not the hatch cover used to secure the opening was in fact closed and the view taken is that a 10 year old girl, whilst not incapable of opening such a device would be unlikely to. However, the facts are that no warning or “No Admittance” notices were posted on or in the vicinity of the hatch cover and apart from a hook, the cover was not locked to prevent unauthorised opening.

During investigations into the incident, the Chief Engineer admitted that he had observed on more than one occasion young passengers opening the hatch cover out of curiosity, but unfortunately he had neither taken any action to secure the opening or advise anyone else of what he had observed.

There are no safety reasons for the hatch cover not to have been padlocked closed when not in use as it only served a storeroom. Had it been secured in this manner, this incident would not have happened.

The posting of warning or prohibitive signs would have made passengers aware of the dangers and would have helped the Member’s defence.

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The incident occurred after the vessel had returned to the dock. The passenger and her husband had not disembarked with the main body of passengers as they had remained on board to search for a lost piece of camera equipment. Having found the missing item they ascended to the main deck and moved towards the gangway. To do so they had to negotiate a change in level on the upper deck where there was a 27 cm. step. In doing so the lady stumbled and fell, severely breaking her ankle.

This accident should never have been allowed to happen. Our investigations revealed that crew members assigned to the gangway had observed passengers stumbling on the step on numerous occasions. If the company had implemented a safety management system the crew members would have a means of reporting their observations and appropriate measures could then have been taken to minimise the risk to passengers. Those measures could have included painting the edge of the step in high visibility paint, of contrasting colour placing appropriate warning notices in the vicinity, fitting a handrail and stationing crew members to assist frail passengers in negotiating the change in level. Alternatively it might have been possible to replace the step with a ramp.

Root Cause:Inadequate access.

Financial Cost:The cost of this incident exceeded US$46,000.


The Incident: This incident involves an injury to an elderly lady passenger disembarking from a tourist craft operating in north eastern Australia. The craft itself was of unusual construction, being a semi-submersible vessel which was designed to allow passengers to view coral reefs through windows in the lower deck below water level.


Difficult Step Causes Passenger Injury

Observations:The raised section of the upper deck was covered to within 6 cms. of the step by a black plastic mat. The lower level and the 6 cm. strip along the edge of the higher level was painted with white non-skid paint. The result was that the edge of the step was difficult to detect visually. There were no handrails and there were no warning notices or other visual warnings. Although crew members had been assigned to assist passengers at the gangway close by, none were assigned to assist passengers who negotiated the step.

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The Incident: The Members’ vessel was engaged on a wine and sightseeing tour. As the boat was leaving a jetty after a stop for refreshments and sightseeing, to return down river to her home berth, a passenger appeared to stand on the bow, step over the railings and jump or dive into the water. The skipper was alerted and he immediately put the engines into neutral. Efforts were then made to manoeuvre the vessel to pick up the passenger. However, because of the configuration of the twin hulls the passenger went under the bow and between the hulls where she caught her legs in the propeller housing causing the eventual amputation of both her feet.


One for the Water

Observations:Lawyers acting for the passenger commenced proceedings alleging that she had fallen into the water as a result of insufficient guard railings and that her retrieval from the water was delayed for some 20 minutes while the Master negligently manoeuvred the vessel causing her injury. (It is important to note that the official investigation by the authorities exonerated the Master from any professional blame).

The Members asserted in defence that the passenger deliberately jumped into the water and was entirely responsible for her own injury. Witness evidence appeared to support the Members’ position that the passenger jumped off the boat but also confirms that she was apparently intoxicated at the time. Despite this evidence the Members bore the brunt of the responsibility of this incident despite the fact that it would appear the passenger acted of

her own volition. This case proves that the courts hold the carrier liable in such circumstances. Members are responsible for ensuring that passengers are not permitted to board their vessel whilst under the apparent influence of alcohol or drugs, or to drink excessively whilst on board. If it is considered that the actions of passengers may put either themselves or others in danger, efforts must be made by the ship’s crew to prevent such conduct getting out of hand. Prevention is better than cure!

Root Cause:Lack of passenger supervision.

Financial Cost:This claim was finally settled at US$608,500.


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The Incident: This case involved an embarking passenger who slipped into a gap between the vessel’s starboard gangway and the ship.

The passenger, who has difficulty walking/climbing steps due to his weight, started to board the vessel assisted by two crew members. At the top of the steps the passenger paused for a few moments. As he continued he lost his balance whilst lifting his foot and he fell backwards into the gap between the steps and the vessel. The passenger’s leg was crushed. Due to the passenger’s weight the two crew members that were holding the passenger’s hands fell with him, one was injured. First aid was administered to the passenger and an ambulance was called. It was later learnt the passenger had a history of health, heart and leg problems.

During the incident two ABs and the Chief Officer were present, advising and monitoring passenger embarkation. The sea was calm.

The passenger had two operations to rectify the crushed skin on the damaged leg.

Personal Injury/Illness Reminder to Carry Out Frequent Risk Assessments, Especially on Routine Matters

Observations:Plaintiff ’s lawyers alleged the vessel’s employees were negligent in that they failed to provide and ensure suitable and safe embarkation devices or aids and/or failed to control and secure the vessel during embarkation.

As stated above three of the ship’s crew were present during the embarkation operation, ample safety notices were posted and company safety procedures were in place and being followed.

This event highlights the importance of carrying out risk assessments in operational matters even if ample procedures are in place.

Root Cause:Lack of passenger supervision.

Financial Cost:The claim was settled at S$12,500.


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The effect of the vessel falling into the trough was to bodily lift a number of the passengers located on the fore deck and as the bow rose quickly on the next wave, the deck came up to meet the still falling passengers. As a result four passengers were seriously injured.

As the vessel turned into a bay, the Master made an announcement over the public address system advising passengers that the seas may become “more choppy” and that they should take care when moving about the ship. Shortly afterwards, a higher than normal wave was experienced and the vessel rose and fell ; this wave was followed by an even larger wave which caused the vessel’s bow to rise even higher than with the previous wave and then fall into the steep trough that followed.

The Incident: This incident involved a 21 metre twin hulled passenger vessel engaged on a sightseeing voyage. The vessel was certified to carry 240 passengers and at the time of the incident she had on board 121 passengers.

As the voyage progressed, the weather conditions were fair to good with a moderate easterly wind with 0.5 metre waves on a 1 to 2 metre swell.

Approximately 15 passengers were standing on the foredeck.


Expect the Unexpected

Observations:The wave experienced could have been described as a rogue or freak wave, but the following investigation concluded that the possibility of experiencing such a wave could have been expected in the area that was being navigated. (The generation of such waves is very complex and is caused by two or more wave trains, being deflected by islands in the vicinity, meeting which can cause a resultant wave with irregular heights).

None of the passengers sitting within the accommodation were hurt and careful consideration must be given as to when to allow passengers out on to the foredeck. If such practice is restricted to periods of smooth waters or when the swells are low and even, the repetition of such an incident is unlikely.

The authorities found that the Master and crew handled the post incident situation in a competent manner.

The above case study is based on an investigation carried out by the Transport Accident Investigation Commission of New Zealand.


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The Incident: This accident happened to an elderly female passenger whilst disembarking from a tourist vessel operating off the west coast of Australia. As she was disembarking the passenger tripped, with the result that she lost her balance and fell injuring her right knee on the jetty. The passenger claimed that the principal cause of the accident was inadequate lighting.

The first notice of a claim came in the form of a letter from a lawyer many months after the event. On investigation we found that no contemporary records of the incident existed. The deck log could not be found, there was no accident report, nor was there an entry in the accident book. In addition during the intervening period there had been staff changes, with the result that only one of the deck crew could be traced. From the evidence of this one witness we learnt that it was possible that the gangway was not in use at the time of this particular incident. Apparently it had been the practice of crew not to use the gangway if the state of the tide brought the deck of the vessel level with the jetty. In those circumstances the passengers were simply assisted across the narrow gap.

Observations:The biggest problem the Club encountered in dealing with this case was simply lack of information. In the words of the lawyers advising the Club “in the light of .... your Member’s inability to refute the plaintiff ’s version of the events, we are of the opinion that you would probably be found liable”.


Financial Cost:The claim was finally settled for US$13,000. However Members should note that the costs incurred simply trying to piece together what had happened exceeded $5,000.



Good Record Keeping would have Reduced Claim

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Root Cause:Inadequate access arrangements.

Financial Cost:This claim was settled at nuisance value however the cost of lawyers, medical experts and investigation brought the total bill to over US$21,000.


Observations:This case is typical of many instances where claimants suffering from degenerative conditions try to link that condition to some ‘accident’ aboard a Member’s vessel in the hope of extorting large sums of money in ‘compensation’. These cases are often difficult to defend as first notice of the problem often comes many months after the alleged incident when it is difficult to identify the crew on board at the time and when recollections are no longer fresh in the mind. It emphasises the need to keep detailed records of crew and the need to document every accident, however minor, to provide a body of evidence to demonstrate to a court that utmost care was taken and even the most minor incidents were recorded. It is then easier to convince a court that an unrecorded incident is unlikely to have taken place.

The Incident: The owners of this vessel received a letter from lawyers representing an elderly lady who alleged that she had been injured when boarding the Member’s vessel 18 months previously. No incident had been recorded in the accident book on the day in question. The Master was interviewed and was quite emphatic that if an accident had occurred and the crew been aware of it, it would have been recorded. The other crew no longer worked for the company and two were known to have gone abroad. The remainder were traced but had no recollection of any accidents around the date in question.

To board the vessel passengers simply stepped on to the deck. The gap between the vessel and the dock varied between 2 and 10 cms. The claimant alleged that as she stepped across the boat moved away from the dock and her leg slipped between the vessel and the dock whereupon the boat moved back towards the dock, crushing her leg.


Good Record Keeping Prevents Claim

An investigation of her medical history revealed that the lady had suffered from osteoarthritis for some time and had been treated for the problem by her general practitioner prior to the alleged incident. There was no mention of an accident in her medical records. Some seven months after the incident was alleged to have occurred she had arthroscopic surgery on her knee joint and later underwent further surgery for a total knee replacement. Surgery however was not successful and she was left with a permanent disability. It was only then that a claim was made against the vessel owner.

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Initial medical opinion did not believe there to be any fractures to her leg, but specialists later discovered she had in fact suffered a fracture behind her knee.

People who are unused to a marine environment may not appreciate dangers that are readily apparent to a vessel’s crew. With this in mind, all areas to which passengers are permitted access must be regularly assessed for potential hazards and suitable precautions taken to prevent accidents, even if this means limiting access to non ship’s staff.

Root Cause:Insufficient safety signs.

Financial Cost:The case was settled at US$330,365.


The Incident: The vessel in question is a Mississippi type showboat steamer that carried out harbour cruises during which time passengers could enjoy meals and cabaret type entertainment. Passengers were actively encouraged to walk freely around the open decks, including the fore and after decks, to enjoy the views as the cruise proceeded.


Uncovered Hawse Pipe Leads to Expensive Passenger Trip

Observations:Situated in the bow area of the vessel was the windlass/winch arrangement and an associated hawse pipe which had not been provided with a cover (an oversight since building), leaving it exposed to all who passed by. It is not clear whether the fall was caused by the plaintiff stepping into the open pipe or catching her walking stick on it as she passed by. However the contributing factor to this incident is the fact the opening was not covered or fenced off. Another factor was considered to be the subdued lighting in the area with shadows masking the hazards.

At approximately 21.15 on the day in question, the attention of ship’s staff was drawn to the fact one 57 year old female passenger had sustained injuries to her leg after falling in the bow region of the vessel. Initially the injuries, although painful, were not considered severe enough to land the passenger immediately; in fact she expressed a wish to watch the evening’s entertainment. She was sent to hospital by taxi once the vessel returned to her berth later that evening.

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Financial Cost:This claim was settled within the Member’s deductible.


The Incident: This incident arose on board a harbour ferry operating in smooth water. The harbour ferry was fitted with hydraulic ramps designed for the embarkation or disembarkation of passengers. The ramps had been lowered to enable passengers to board the vessel and having been positioned hydraulics were ‘locked’. Shortly after passengers started to board another vessel backed into an adjacent wharf creating some wash. The combination of that wash and wave actions in the harbour caused the ferry to surge and roll. The movement resulted in the hydraulic ramp fitted to the ferry rising a few inches up off the connecting hydraulic ramp fitted to the jetty. When the vessel rolled back a passenger’s foot was trapped between the ramps.

Observations:Surprisingly the claimant’s lawyers did not argue that the ramp was unsafe because it did not hinge. Instead they concentrated on the fact that the wharfhand on duty had been preoccupied with tying up another vessel when the accident occurred and that the ramp was unattended. Plaintiff ’s lawyers alleged that had the crewman been at his place of duty he could have warned passengers of the danger and prevented them from boarding until it was safe to do so.

While there were considerable doubts about whether the presence of a company employee would have had any material effect on the incident, our lawyers advised that the simple fact that the Member did not have an employee on the spot overseeing the boarding process would almost certainly have led the courts to the conclusion that our Member had not discharged their duty of care to the passenger. This illustrates the high standards that are expected from the operators of passenger vessels carrying the general public and the levels of care which they are expected to maintain.


Passenger Injury on Access Ramp

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Initially the passenger responded well to treatment but shortly after 1 p.m. the passenger stopped breathing. The ship’s crew was swiftly to organise resuscitation. Their efforts were supplemented by a registered nurse and an anaesthetist from amongst the passengers. The crew’s efforts to revive the passenger continued until the helicopter containing a doctor and paramedic arrived and took over. Although the attempts to resuscitate the passenger continued for a further hour they were not successful.

The Incident: The incident occurred on board a tourist vessel ferrying passengers out to a resort pontoon on the Great Barrier Reef. Although weather conditions were moderate a passenger succumbed to seasickness during the voyage. On arrival at the pontoon most passengers then boarded a glass bottom boat to view the flora and fauna on the reef but the sick passenger and his wife remained on the pontoon. The crew provided a cabin for the gentleman so that he could lie down. Some minutes later his wife called for assistance as her husband was having chest pains. The passenger had a history of heart problems and it was clear that he was having a heart attack. The passenger carried medication for his condition which the crew supplemented with oxygen. The passenger was placed in a semi-sitting position with his legs elevated to reduce the strain on his heart. The Captain contacted his head office to arrange to evacuate the passenger. The head office were unable to locate a seaplane but were able to find a helicopter although that could not get to the ship for over two hours. The office called a doctor to the radio so that the Captain could obtain medical advice.


Passenger Dies of Heat Attack Despite Determined Effort by Crew to Save Him.

Observations:Although on this occasion the crew’s efforts did not save the passenger’s life, they did everything possible for him. In addition in the heat of the crisis they still found time to look after his wife and attend to her needs, comfort her during the ordeal and keep her fully informed of what was happening and the efforts being made to save her husband. The passenger’s wife later wrote to the company praising the efforts of all on board and commending them for their efforts and support.

This incident illustrates the benefits of maintaining good communication between the crew and the friends and relatives of a sick or injured passenger. It is essential to keep friends and relatives fully advised of all developments and the action being taken to help the passenger. Bad communication can increase anxiety and create distrust, leaving friends and relatives feeling that the ship’s staff could or should be doing more, which could in the future lead to acrimony and litigation.


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The Incident: The vessel involved in this incident was a purpose-designed sail training vessel built in 1991. The vessel carried a substantial bank of lead acid batteries to power emergency systems, radios and fire detection systems. The batteries were housed in a locker on the port side of the main deck below the wheelhouse.


Explosion in Battery Locker

Observations:The student who died had been removing rust accumulations from around the battery locker door with a rotary grinding machine. The battery locker door was secured by four lugs and wing nuts. In order to grind off rust around the lugs the student loosened the wing nuts and lifted them clear of the lugs. Sparks from the grinding machine entered the locker and ignited an accumulation of hydrogen gas causing the explosion.

The battery locker door was marked with the word ‘batteries’ in large red letters. Signs were fitted inside the locker to alert personnel to the presence of corrosive acid and the dangers of corrosive acid burns. There were no external warning signs prohibiting naked lights and smoking, nor was there any warning of the explosive risk.

Subsequent investigations revealed that the locker’s ventilation arrangements consisted of a single 20 mm diameter vent pipe which made no provisions for through ventilation. This was inadequate to dissipate the quantity of hydrogen gas given off at high charge rates.

Root Cause:Unsafe wing practices.


In addition to a permanent crew the vessel carried 31 students who, in addition to pursuing academic studies, assisted in the sailing and maintenance of the vessel. On the morning of the incident a party of students had been assigned the task of scaling and painting the port side of the deck house. During the work an explosion occurred in the battery locker. The blast threw one student overboard. Despite an extensive air and sea search he was never recovered.

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The Incident: In this case a passenger fell off his motorbike whilst disembarking from a ferry via the vessel’s ramp.

The accident occurred as the front tyre made contact with the ramp. This resulted in the bike sliding from under the claimant.

The passenger sustained an injury to his right hand and the motorbike sustained damage to the body work on the upper and lower right hand side. The rear bike pedal was also snapped off.


Hasty Exit Brings Slide of Despair

Observations:It is alleged that the accident occurred due to the combination of the highly polished surface of the aluminium ramp, which was wet due to the prevailing weather, and the motorbike’s speed.

It is recommended that an anti-slip paint or other means, e.g. raised treads, be applied to ramps and other passenger access areas as a preventative measure.

Speed restriction signs should be displayed in prominent positions.

Root Cause:Inadequate speed restrictions.

Financial Cost:US$2,333.39


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owner failed to take appropriate steps to ensure that passengers remain seated while the ferry was in motion. The court in Hong Kong gave judgement on case in November 2000. Judge Seagroaat found that the bulwarks near the mooring bits where there are no additional railings was high enough to protect the passengers disembarking properly at the appropriate time. More importantly however, the Judge carefully considered the duties and obligations on vessel owners on crowd control. In his judgement, Judge Seagroaat commented that passengers who leave their seats despite oral and written warnings to the contrary know, as any reasonable person knows, that the reason for such warnings or advice is that there is always a risk of sudden movement of the ferry or of it hitting the pontoon with some force thereby causing passengers to loose their balance and fall. Anyone who ignores such warnings does so at his or her own risk.

The Incident: This incident concerns a serious injury suffered by a middle aged male passenger while disembarking from a harbour ferry. The passenger was a construction worker who had used the ferry service for several weeks before the incident to travel to and from work.

During the crossing he occupied a seat near the bows of the ferry on the lower deck. As the vessel approached its berth an announcement was made to passengers asking them to remain seated until the ferry had berthed and the gangway had been lowered. Despite this the passenger, along with many others, left his seat to join a mass of people eager to disembark at the earliest moment. As the vessel came alongside the man somehow came to fall between the vessel and the dock suffering severe crush injuries to his pelvis. The exact cause of his fall has never been adequately explained however there has been speculation that the passenger had either tried to disembark by an unorthodox manner or had somehow been pushed over the bulwark by the pressure of the crowd.


Passenger Impatience Leads to Injury

Observations:The ferry berthed at a purpose-designed terminal. It was equipped with permanent gangways, which are hinged at deck level and lowered like a drawbridge onto the dock, which was level with the deck. There is solid bulwark extending to deckhead level for over two meters either side of the gangway. Beyond that there is a conventional solid bulwark to waist height which is supplemented by an additional rail approximately 30cm above the bulwark cap in all areas except adjacent to mooring bits.

Prior to docking the crew routinely make an announcement warning passengers to remain seated and the passenger decks are liberally supplied with multilingual notices to that effect.

The passenger sued claiming substantial damages alleging that the owners failed to erect railings in the region of the mooring bulwarks to prevent passengers falling off the ferry and that the

The Judge went on to say that he did not think the defendants could do anything to deter such action other than by announced and visible warnings. He did not consider it practicable or reasonable to require the size of the crew to be increased to such proportions as to be able to physically restrain adult persons hellbent on early disembarkation. Consequently he found the ferry operators were not liable for the passenger’s injuries.



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Certainly not a toast to good health

The Incident: A steward onboard the vessel, washing the dishes as usual, poured some concentrated industrial detergent into an empty green mineral water bottle, to assist in measuring the correct quantity to be put into the dishwashing machine. The partly filled drinking water bottle was then placed without any label indicating the contents with cleaning chemicals, near the galley sink.

The next day, the unlabelled mineral water bottle, partly filled with detergent was put in the refrigerator, obviously being mistaken for drinking water. Subsequently it was placed on the lunch table. Unfortunately the liquid was odourless and the unsuspecting seaman poured it into a glass and took a few quick sips. He immediately became aware of an acute burning sensation in his mouth and throat. Fortunately, the yacht was in port and he was sent ashore to the local clinic, however it was not equipped to handle such serious cases and the seaman had to be transported to a hospital in a nearby larger town. By then, he was suffering from breathing problems, had a swollen tongue and a purple face. The hospital managed to administer suitable treatment and confirmed that the seaman had suffered internal burns. His permanent disability was assessed at 7% and as a result of his injuries, he will suffer from a bitonal voice and slow digestion.

Observations:The use of a drinking water bottle for handling chemicals and also its careless stowage without any warning labels was the root cause of the incident. Furthermore, its storage within an area (the galley) where it was easily mistaken for drinking water was another major contributing factor. Chemicals should only be stored in containers specifically designated and adequately marked for the purpose. They should not be handled in any containers that can be easily mistaken for anything else. Only the required quantity should be used and the remaining quantity, if possible, must be returned to its storage container. The mixing containers should be cleaned appropriately and stowed back in their designated place..

Financial Cost:The total cost of this claim was USD 69,000

Trading Area: Europe


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Root Cause:Failure to comply with collision regulations.


The Incident: This case involved two high speed passenger ferries owned and operated by the same company, which collided in reduced visibility.

During the course of the early morning, both vessels had successfully carried out a number of runs between their designated ports. One vessel then commenced a scheduled new run that involved a reciprocal course to the other vessel in a relatively narrow channel. Both Masters were aware that the prevailing fog patches were reducing the visibility to 50 metres or less.

At the time of entering the same fog patch, the Masters each detected the other vessel on radar. Over the VHF, one Master requested a “green to green” passing but the other Master declined requesting “red to red” and at the same time put his helm to hard a starboard and reduced engine revolutions.

Shortly thereafter the vessels collided. Fortunately, of the combined total of 127 passengers and 7 crew there were no injuries.

Navigation

Familiarity Breeding Contempt?

Observations:The principal factors causing the collision were the excessive speeds of both vessels and the short radar ranges utilised by the Masters immediately prior to the collision. Investigations showed that the vessels had a combined closing speed of 36 knots yet both radars were set on the 0.75n.m. range. This resulted in the maximum duration of 75 seconds from the time the echo appeared at the edge of the screen to the time of impact. There were a number of additional contributory factors including a failure to comply with the Rules for the Prevention of Collisions at Sea, a failure to follow the company’s own procedures and the lack of a suitably qualified lookout on either vessel.

The speed of both vessels was excessive for the conditions and the basic principle of frequently scanning greater radar ranges in order to permit the early detection of other vessels in restricted visibility was not followed. The manning scales on board both vessels meant that the Masters were the only suitably qualified mariners on board, thus placing a great burden on both men at times of reduced visibility. The company had in place procedures and recommendations for courses to be followed, specifically designed to prevent end on situations and these were not adhered to.

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This case study is based on the investigation report prepared by the Australian Transport Safety Bureau.

Root Cause:Incorrect navigational procedures.


The Incident: A passenger vessel with 26 passengers and 12 crew on board ran aground in unsurveyed waters. At the time of the grounding the Master was alone on the bridge and the vessel was in automatic navigation mode. In this mode, course adjustments were initiated by a GPS linked to an electronic chart system which transmitted course alteration information to the auto pilot.

A number of passengers received minor injuries as a result of the initial impact.

Observations:The investigation deemed that the most likely cause of this incident was a discrepancy between the vessel’s true position and that determined by the GPS. Because total reliance was placed on the GPS with no other means used to verify the vessel’s position, the discrepancy went unnoticed. In addition, it was clear that with the Master being alone on the bridge, a proper lookout could not be kept and this is all the more pertinent as the vessel was navigating in uncharted waters. The investigation also raised concerns over the fatigue the Master may have been suffering, brought on by his intensive work routine.

Other navigational irregularities were highlighted including the fact the electronic chart system in use was not approved, in that the computer was not dedicated to the vessel’s navigation system but was also used for the ship’s administration.

This incident shows that no matter how technologically advanced a vessel’s navigation system is, there is no substitute for good old fashioned seamanship!

Navigation

If Only they had Tried Something Different

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The Incident: This incident occurred on the inland waterways of southern Australia. A passenger excursion vessel on a river passage collided with the river bank in good conditions and broad daylight. Fortunately little damage was done and passenger injuries were limited to a few cuts and bruises.

Subsequent investigation revealed that the Mate was not paying attention to his duties. He was trying to catch up with his paperwork and was not looking where he was going.

Observations:In recent years ever-increasing amounts of legislation have increased the administrative workload on board ship. Ships’ officers are spending increasing amounts of time on paperwork. Owners must however ensure that their officers’ attention is not distracted from their principal responsibilities in relation to the safe navigation of the ship and safety of life on board. Duties should be arranged so that adequate time is allowed for the completion of paperwork in a manner that will not interfere with an officer’s primary responsibilities.

Navigation

Paperwork Leads to Grounding

Root Cause:Failure to perform correct lookout.

Financial Cost:Although no claims arose from this occurrence the costs for a precautionary investigation to protect the owners from potential injury claims from passengers and any possible inquiry by the regulatory authorities exceeded US$5,000.


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The Incident: The claim involved three passenger vessels, two of which collided, whilst performing unberthing/berthing operations in a river.

Two of the vessels were berthed alongside a quay. To allow the inner vessel, with passengers on board, to sail the outer vessel manoeuvred “crabways” to starboard. When the route was clear the inner vessel sailed.

Navigation

Collision Alongside

Observations:The approaching vessel assumed both vessels ahead were •clearing the berth but never made contact to confirmNeither vessel made any effort to ascertain the •actions of the other vessels in the vicinityComplacency on the part of the vessel returning to the berth•No effective port control•

This claim reiterates the importance of keeping an efficient look out at all times, especially whilst performing manoeuvres in close proximity to fixed and floating objects. If in doubt contact should be made with the other vessels to confirm their intentions.

Root Cause:Insufficient communication.

Financial Cost:Approximately €35,000.


During this time the third vessel was approaching the same quay from astern of the other two vessels. The outer vessel began to return to the berth by moving “crabways” to port and did not observe the closing third vessel. A collision occurred between the second vessel on its port aft corner and the third vessel on its starboard fore corner.

Minor bruises were noted on some of the passengers on the third vessel and damage occurred to the second vessel.

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The Incident: This incident occurred when a harbour ferry failed to respond to the main engine controls with the result that she collided with the dock. The ferry had been approaching the berth at slow speed when the Master tried to engage astern power. At this point he lost bridge control of the main engines with the result that the vessel continued forward, colliding with the piles at the end of the jetty.

Observations:Investigation into the accident revealed that a similar problem had been encountered by the Master of the vessel during the previous shift. On that occasion power had been restored by jiggling the key in the engine control selector switch panel. Apart from completing a defects report no further investigation or repair work was undertaken. The vessel remained in passenger service and no special precautions were taken during the berthing operation to minimise the risk from sudden control failure. After the accident the control switches were replaced. Had the problem been properly investigated immediately and appropriate corrective action taken, this accident need not have occurred. In this case the two Captains would have benefited from clear guidelines on removing the vessel from service.

Root Cause:Insufficient maintenance system.

Financial Cost:The cost of repairs to the dock exceeded US$15,000.


Navigation

Intermittent Main Engine Fault Leads to Dock Damage

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Section 5� Offshore Vessels

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The Incident: The Member’s tug was standing by an anchored dumb barge which was being loaded with sawn timber. The tug Master noted that in the rough sea conditions, the barge was dragging her anchor and starting to drift towards shallow water. The decision was made to tow the barge back out to clear water.

The Chief Officer and Chief Engineer were instructed to pass the tow line to the barge, but in the weather conditions they experienced difficulty. The cook was observing the operation and, characteristically, offered his assistance. With the cook’s help the line was successfully made fast. The Master then took the strain on the tow line. The configuration of the tug, tow line and barge was such that the line was in contact with the tug’s towing pins. As the strain on the tow line was increased, the towing pin failed and the tow line struck the cook who was standing in close proximity. The force of the blow threw him overboard and his body was never recovered.

Offshore Vessels


A Scenic View but a Dangerous Place to Stand

Observations: This fatality arose because the cook was standing in entirely the wrong place when the strain was being taken up on the tow line. From the diagram it can be seen that the other two crew members were safely standing clear and were never in any danger.

The investigation into this incident did not determine the events or signals that were made between the Chief Officer and the Master once the tow had been successfully made fast, however it is abundantly clear that the cook was allowed to place himself in danger. The Chief Officer should not have given the all fast signal to the Master until all crew had cleared the danger area.

Whilst the cook’s voluntary efforts in his willingness to assist his fellow crew mates are commendable, this incident shows how naivety can have disastrous consequences. Catering and engineering staff are not necessarily natural seamen and do not always appreciate the dangers that tow lines pose, nor the destruction that can take place when a line under strain fails through whatever cause. It would appear that in this case no guidance at all was given to the cook – if it was and ignored then a formal order should have been given and towing not commenced until everyone was standing clear and thereafter kept clear until operations were over.

Root Cause:Poor operational practice.


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Observations:Investigations showed the rope to be old and in a poor condition brought about by its age, heat and exposure to sunlight. The conclusion drawn was that the rope was severed as it passed over the sharp edge of the container. The victim was positioned by the warping drum obscured from the winch operator’s view.

The method used to secure the container was inefficient and inherently dangerous. The vessel was fitted with more than an adequate number of dedicated securing rings and fixing points which would have enabled a correct method of securing to have been used.

This incident highlights the dangers of taking shortcuts, poor work practices and the use of old rope.

Root Cause:Poor working practices.

Financial Cost:The cost of the claim was US$33,000.


The Incident: This incident resulted in the death of a seaman whilst securing a container on deck.

A single 20 foot container weighing about 10 tonnes had been loaded onto the deck of an Anchor Handling Tug. The crew were engaged in securing the container by means of a 3 inch polypropylene mooring rope which was secured at one end and then led around the container. The loose end was placed on the drum end of an anchor handling winch and the slack was being taken up. The rope parted and struck the victim in the face. He was immediately evacuated to hospital. Never regaining consciousness he died fifteen days later.


Short Cuts do not Always Result in a Quick Job

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Observations:An expert in tropical medications examined this case and confirmed that the Members had not taken appropriate measures to ensure the health and safety of the crew. The anti-malarial medicine made available was of the wrong type for the area the vessel was operating in, and it was concluded that if the correct medication had been made available the fatalities would have been avoided.

In the malarial regions of the world, different strains of the infection build up resistance to the various medications available and it is important that medical advice is obtained for the area in question prior to the vessel arriving.

The Incident: A tug belonging to one of the Club’s Members was stationed off Point Noire Congo when one of the crew took seriously ill one evening. He was transferred to a nearby rig and, after assessment by a doctor, was transferred ashore to hospital where he later died. The diagnosis was a severe strain of cerebral malaria.

On passage to the next port, another crew member was taken ill with a mild strain of malaria and was repatriated.

A few days later, the Master took ill and the vessel was diverted to the nearest port but unfortunately he died before medical assistance could be arranged. His death was caused by malaria.

The families of the deceased took legal action against the Members for failing to provide adequate anti-malarial protection for the crew.


Prevention is Necessary as there is No Cure

The Ship Captain’s Medical Guide and Marine Guidance Note 257 (M) (published by the UK’s Maritime and Coastguard Agency) contain advice on the precautions to be taken and the medicines available. The Health Authorities of the Members’ country of domicile will be able to give advice on the type of preventative medicines to be administered whilst the vessel is in a malarial region.

Root Cause:Inadequate medical procedures.


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Observations:This accident would have been avoided if the second engineer had set a good example to the crew by wearing goggles while in the vicinity of the work.

Masters should be given clear guidelines about reporting on-going medical problems to head office. The fact that the second engineer’s condition did not improve quickly should have been cause for concern. If the second engineer had been repatriated earlier he may not have lost the sight of his eye.

Root Cause:Human Error.

Financial Cost:Although the engineer received benefits from his State’s welfare system the cost to the owners exceeded US$25,000.

Issue Date:01/01/02 Case No.21940

The Incident: This incident occurred on board an anchor handling supply vessel operating off the west coast of Africa. The second engineer was supervising the cleaning of the mechanism of the vessel’s towing pins as part of the vessel’s routine maintenance programme. The cleaning was being carried out using a high-pressure water jet. The operator of the high-pressure jet was wearing protective clothing in accordance with the manufacturer’s instructions.

During the cleaning operation the second engineer who was wearing no protective clothing was hit in the left eye at a distance of about one metre by the jet of water from the high-pressure washer.

His vision was affected and a few days later was examined by an ophthalmologist in Point Noire in the Congo. The ophthalmologist diagnosed a simple eye irritation. The ophthalmologist treated the engineer for approximately two months with antiseptic eye lotions without improvement. During this period there was no discernible improvement in his condition. The engineer completed his normal tour of duty. On his return home the second engineer consulted his own doctors who immediately diagnosed a detached retina. The officer underwent immediate eye surgery but because of the delay the doctors were unable to restore his vision.


Safety Goggles - Not Just for Hindsight

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Modern position fixing systems permit many operations to take place in closer proximity to navigational hazards than was possible in the past. Offshore personnel must however remain aware of the practical problems in accurately manoeuvring a large anchor handler without visual reference. In this case the anchor had been positioned only 30 metres from the wellhead, with the result that the Master was required to manoeuvre his vessel within less than half a ship’s length of the hazard without the benefit of a visual reference or a GPS monitor. This incident could have been avoided if divers had checked the depth over the wellhead and its position had been marked with a buoy.

The Incident: This anchor handling supply vessel had been chartered to deploy anchors for a pipelaying barge operating in shallow water. In addition to the new pipeline there was an old pipeline and an unmarked subsea wellhead in the vicinity. While retrieving one of the barge’s anchors the anchor handler hit the wellhead, breaching the engine room. The vessel’s pumps could not keep up with the ingress of water and it sank to the seabed impaled on the wellhead.

Observations:A few days before the incident occurred the barge Master had given the Master a new chart of the working area. Although the well’s position was accurately shown to within a metre the depth information was incorrect, leading the Master to believe that he would have an underkeel clearance of approximately two metres when in fact he had none. The barge was equipped with a sophisticated positioning system utilising differential GPS which was accurate to +/- 3 metres. Additional equipment on board the anchor handler allowed the surveyors on the barge to monitor the position of the anchor handler’s stern roller, enabling them to position the anchors with great accuracy. The anchor handler however was not given a monitor and had no way of accessing this information. The wellhead was not buoyed and the Master had no visual reference other than the barge. As a result he had been manoeuvring solely on the orders of the barge.

Navigation

Close Quarters Manoeuvring Results in Sinking

Root Cause:Inadequate third party procedures.

Financial Cost:The anchor handler valued at approximately US$3 million was a total loss. In addition to this the costs of removing the wreck from the wellhead and disposing of it exceeded US$2.25 million.


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Observations:The official investigation into the cause of this incident found that the junior Master had very little recollection of events. It was concluded that his performance was greatly reduced through a possible combination of tiredness, alcohol consumption prior to taking over the watch and the taking of prescribed medication. In addition, at the time of the incident he was the sole watchkeeper on the bridge after the AB had left following an altercation.

The vessel complied with the minimum manning requirements of the governing authority however the rest periods as required by the Hours of Work regulations were not being fully met for a number of reasons. The junior Master had been ashore immediately prior to the vessel’s departure consuming alcohol and he was also taking anti-depressants.

As is the case with these incidents, the causation was a collection of factors, not least of all bridge manning that did not comply with the regulations, the sole bridge watchkeeper having consumed sufficient alcohol to exceed the legal road driving limits and an element of tiredness due to poor use of off-duty periods.

Members are advised to ensure that their vessels are manned so that all regulatory requirements can be met and Masters instructed accordingly. This case has shown that familiarity with a navigating area is not an excuse for allowing standards to slip.

Root Cause:Inadequate Navigation Lookout.

Financial Cost:US$795,000


The Incident: This claim involved a small dredger operating a three times a week service between two local ports. She was manned by a senior and junior Master, two engineers and two ABs who were split into two teams of three, operating a six on, six off watchkeeping rota.

At the time in question the junior Master, at the request of the senior Master, had taken the bridge watch early upon the vessel’s departure from the berth at 1745.

As the vessel proceeded down a buoyed channel the VTS observed that the vessel was straying to port of her advised track and unsuccessful efforts were made to alert the vessel. Shortly thereafter the vessel should have made a substantial alteration of course to port, but did not make the turn, instead headed across the main shipping channel and towards a pier and shallow waters. The VTS again tried to make contact with the vessel to advise of the impending danger but no response was received. After narrowly missing a marina the vessel collided with a pier, causing severe structural damage. Fortunately no injuries were sustained.

Navigation

A Good Case for Adequate Bridge Manning

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Observations:The Master and crew man stated that they had fallen asleep in the period between the alteration of course and the collision, although this was at most six minutes. Notwithstanding the reason, the fact is that an effective lookout was not kept on the tug and it is very fortunate that the result of the collision was not a lot worse than it was.

The importance of keeping a good lookout at all times on all types of vessels when underway cannot be over emphasised. It also raises the ever present question of fatigue which must not be ignored.

Root Cause:Inadequate navigational lookout.

Financial Cost:The claim was settled for US$200,000


The Incident: This incident involved a harbour tug which collided with a moored tanker.

The tug had completed one assignment and was crossing the port to its next job. The skipper was assisted on the bridge by a deck hand, who prior to the incident had a prolonged toilet break. The skipper made a final alteration of course towards the vessel she was to assist. Shortly afterwards the tug collided head on with a vessel moored at the terminal. This caused damage to some sections of the tanker’s shell plating and the vessel had to be taken out of service for repairs. Fortunately no-one was hurt.

Navigation

Keeping a Proper Lookout at ALL Times

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The Incident: The supply vessel in question had been chartered by a drilling contractor to service a semi-submersible rig. The barge Master of the rig had instructed the supply vessel to act as safety boat on the starboard side of the rig while service personnel worked on a flare boom. The supply vessel was being manoeuvred in close proximity to the rig by an experienced Master.

Some of the supply vessel’s crew were using a hose to wash down the bridge and accommodation block. Water from their hose came into the bridge through an open bridge wing door, splashing the radar and other electrical equipment. The Master left the aft controls to close the door but in that short period the vessel moved astern and the port quarter came into contact with the centre starboard column of the semi-submersible.

Navigation

A Moment’s Lapse of Concentration Causes Collision

Observations:This incident highlights the risks of a momentary lapse of attention on the part of the officer in charge when manoeuvring in very close proximity to other vessels or structures. The incident would not have occurred if the Master had ignored the distraction and not left the controls. The Master should have used the deck loudhailer system to draw the attention of the crew to the problem.


Financial Cost:Repairs to the rig alone cost US$55,000 and by the time surveyors’ fees and other costs had been taken into account the total cost to the owner was over US$60,000.


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Observations:This incident shows how a number of factors can often combine to create a serious incident. It also emphasises the need to ensure that equipment is properly maintained in full working order, particularly when close quarters manoeuvring is envisaged. Although this was the first time the shark’s jaws had failed, overheating was a recurrent problem with the bow thruster which had never been properly repaired. In this case failure of either the bow thruster or the shark’s jaws alone would not have resulted in a collision, but when the effects of the two were combined when the vessel was in close proximity to the rig it became inevitable.

The Incident: This vessel was one of two anchor handlers shifting a semi-submersible rig. Conditions were not ideal. A strong wind was blowing on the port bow of the rig and a current of over 1 knot setting onto that side. The anchor handler was ordered to retrieve the no. 2 anchor on the port side which was run out at an angle of about 60° from the rig’s centre line. The anchor was lifted clear of the bottom and hauled up to the stern roller. The tug then manoeuvred slowly astern towards the rig while the anchor chain was being recovered by the windlass on the rig. As the tug approached the rig the barge Master asked that it swing aft to a position on the beam of the rig in order to give a better clearance to the no. 1 port side anchor wire. This brought the wind onto the beam of the anchor handler. To hold this position required full power from the bow thruster which started to overheat and eventually tripped out, with the result that the bow fell off the wind. The loss of the bow thruster made the supply vessel difficult to manoeuvre. Attempts were made to pass the anchor pennant wire to the barge crane, however the shark’s jaws malfunctioned and the pennant wire could not be released. The tug, pinned by the anchor wire at the stern, was swept down onto the rig by wind and tide. She landed heavily on the port side ranging up and down causing severe damage.

Navigation

Thruster Failure Causes Rig Damage

Root Cause:Insufficient maintenance programme.

Financial Cost:The rig was out of action for 10½ days. The claim for damage and loss of use exceeded the tug’s limitation fund under the 1976 Convention. The claim was settled for the limitation fund but nevertheless the total cost exceeded US$450,000. The tug itself suffered heavy damage as a result of the collision.


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Observations:The reasons why the barge did not negotiate the turn successfully have never been fully explained. There were however a number of factors which contributed to the accident.

Both tug skippers had carried out this operation many times before. Perhaps because of this there was no communication between the skippers when they met and no instructions were given by the lead tug.

This unsatisfactory situation was compounded by the fact that the barge completely blocked the coastal tug’s view astern, with the result that its skipper was unable to see where the assist tug was pushing. The primary function of the assist tug is to help hold the

barge close to the north side of the channel. If the assist tug pushes too far aft on the barge’s side it counteracts the lead tug’s efforts to pull the barge’s head round.

Tidal streams upriver are less predictable than at the river mouth. The flotilla may have arrived at the turn too early, before the flood had ceased. The last of the flood tends to flow from north to south across the basin between the bridges, which would have set the flotilla sideways down on to the railway bridge.

The incident could have been avoided by delaying the flotilla’s arrival until the ebb was flowing strongly and by proper planning and better communication between the tug skippers.

Root Cause:Inadequate operational planning.


The Incident: A coastal tug towing a barge carrying 6,000 tons of cargo encountered difficulties manoeuvring on the way up river at her destination. The tug lost control of the barge which collided with a swing railway bride causing damage valued at US$180,000.

The tug had brought the barge up the coast, arriving off the river mouth at midday. Before starting up the river the tug Master shortened up the tow, bringing the tow line right in until only the bridle remained out board - this brought the swim bow of the barge close up to the stern of the tug. The tug and barge then proceeded at slow speed up the north arm of the Fraser river, aiming to arrive below the Arthur

Laing Bridge after the ebb had started to flow. Arrangements had been made for a harbour tug to rendezvous with the flotilla at this point to assist them in rounding the bend and passing through the Marpole swing railway bridge. Despite the lead tug plying full helm and maximum power the flotilla failed to complete the turn and the barge struck the swing span protection pier, causing serious damage.

Navigation

Tidal Calculation Error Results in Bridge Damage

192 193

Observations:National laws and Port bye-laws normally hold vessels strictly liable for damage done to harbour works. The relevant law in this case provided “any damage done to wharves ..... by a vessel whether due to the incompetence or carelessness of the authority pilot .... shall be made good by the owner, Master or agent of the vessel”.

In any event pilots invariably contract on terms which severely limit their liability or absolve them entirely of responsibility for their actions. A pilot’s function is to advise and assist the vessel’s Master, who remains ultimately responsible for the handling of his vessel. The Master should have taken control and aborted the manoeuvre.


Financial Cost:The Port Authority’s claim exceeded US$50,000. On this occasion however they did accept that the pilot was largely to blame and the agreed to settle for two thirds of the actual repair costs. The pilot concerned was subsequently sacked.


The Incident: A large cargo handling crane constructed in China was being transported to a new berth in South East Asia on the deck of a large ocean-going barge. Pilotage was compulsory at the port of destination and as the tug and barge combination approached its berth the vessel was effectively being controlled by the pilot. To assist the tug Master a company superintendent had been stationed on the barge itself and was in radio contact with the tug. In the final stages of the approach it became apparent to the superintendent that the angle of approach was too steep and the speed was too great. This information was passed to the Captain of the tug who requested the pilot abort the berthing manoeuvre. The pilot refused to do so. The Master did not take control of the situation and allowed the manoeuvre to continue. The barge made heavy contact with the dock, causing damage to the fendering system.

Navigation

Master’s Failure to take Control Causes Dock Damage

194 195

Observations:The vessel had been returning to her home port with the Master as sole watchkeeper. As he approached land the Master moved to the after end of the wheelhouse to make a radio telephone call. What the Master believed would be a short call proved more complex than expected. The Master lost track of time and the vessel continued under autopilot, eventually driving itself hard aground at full speed at the base of cliffs adjacent to the port. This incident occurred as a direct result of the Master’s failure to keep a proper lookout and maintain a safe navigational watch. The accident could have been avoided by augmenting the bridge watch to cope safely with the additional workload as the vessel closed the land.

Root Cause:Failure to maintain proper lookout.

Financial Cost:The cost of salving and repairing the vessel exceeded US$2.3 million. Anti-pollution measures added a further US$50,000 to the bill.


The Incident: This incident involves the accidental grounding of a rig standby vessel in an environmentally sensitive area. The vessel which was carrying 160 tons of oil at the time suffered extensive bottom damage and her engine room was flooded. Pollution prevention measures were immediately put in place and the vessel was finally salvaged.

Navigation

Grounding/Pollution because of Bad Lookout

196 197

Observations:This incident highlights the risks inherent in close quarters manoeuvring. In this particular situation there was little more that the Master could have done to avoid the collision. The vessel’s pitch control was arranged in the ‘conventional’ manner with the fail-safe position being full astern. For rig supply vessels however the greatest danger arises when the vessel is backed up to a rig and for this reason it is generally considered good practice for these vessels’ pitch controls to fail-safe to the full ahead position. Although there was a knock-for-knock clause in the charterparty its effect was restricted to claims between the owners of the supply vessel and the charterers in relation to their respective personnel and property. In this case the rig was not the charterer’s property and the rig’s owners were not bound by those contractual terms. If the knock-for-knock clause had been worded

The Incident: The incident occurred as a supply vessel was backloading drill casing from a semi-submersible rig. The vessel was backed up to the rig with her stern into the prevailing current and the wind on her port quarter. The vessel was being held in position by her engines and bow thruster. During cargo transfer operations the port engine pitch control failed and although its control was set to give forward thrust, the pitch moved to full astern. Despite the Master’s prompt actions in declutching the engine and applying full ahead power on the starboard engine, the vessel collided with and seriously damaged the rig leg.

Navigation

Knock for Knock Clause Fails to Protect Owner from Rig Damage Claim

in such a way as to include the contractors and sub-contractors of each party, then the owners of the supply boat would not have had to pay for the damage to the rig.

Financial Cost:Repairs to the rig were carried out concurrently with a routine refit. Nevertheless by the time surveyors’ fees and classification survey costs had been taken into account the total cost rose to almost US$160,000.


198 199

It was argued on behalf of the Master that the correct definition of ‘duty’ for the purposes of the Act is:-

“Whilst on duty means, in the course of his employment as a professional Master of a ship, performing or being liable to be called onto perform a safety critical function, in the operation of the ship, which it is his duty to perform.”

The Judge accepted this definition, accepted that the Master had not performed any ‘safety critical functions’ at the time he was ‘over the prescribed limit’ and acquitted the Master accordingly.

Whilst the definition of ‘duty’ put forward on behalf of the Master was accepted by the Court, the facts of the case assisted the Master’s defence, and in particular:-

The vessel was laid up with no orders to sail until the following morning.

The Chief Officer was certified 1. to act as Master on this particular vessel.The level of alcohol consumed, 2. whilst over the prescribed limit, was relatively low.The Master complied with 3. all company regulations and procedures as regards alcohol.The vessel complied with all 4. the local harbour regulations and bye-laws.Toxicology tests showed that 5. the Master would have been sober upon taking up his duties the following morning.

The outcome could have been different had any of these facts been different, for example, had the Master been breathalysed and found to be over the limit one hour before sailing.

Therefore whilst it is up to individual companies to decide whether they run dry ships, those that do not still need to ensure their staff are fully aware of their obligations under the Act in addition to any company procedures that may be in place, because the Master being removed from his vessel by the authorities can have serious commercial implications beyond those personal consequences suffered by the Master himself.

Although this case has arisen under the law in the UK, similar legislation exists in many countries around the world and it is appropriate to circulate it widely.


The Incident: Whilst alongside a lay-by berth on the UK east coast, the Master of an oil rig supply vessel was informed by charterers that the vessel was not required for working until the following morning. As usual on this vessel under such circumstances the Chief Officer went on duty for the night and deck and engine port watches were set.

The Master went ashore and returned some time later in the evening having consumed three or four pints of beer. Some hours after his return an incident occurred that necessitated police attendance. However, despite the incident not involving the Master he was breathalysed by the police and arrested and charged on suspicion of being a professional Master of a ship while on duty with a proportion of alcohol in his breath which exceeded the

prescribed limits of 35 micrograms of alcohol in 100 millilitres of blood, contrary to Section 78.1(a) of the United Kingdom’s “Railways and Transport Safety Act 2003”. A further test at the police station confirmed that he was over the prescribed limit.

A forensic toxicology report indicated that the Master would have been below the prescribed limit at 08:00 the following day when he was due to come back on duty. Furthermore, the amount of alcohol consumed did not put him in breach of his Company’s Drug and Alcohol Regulations.

The case was tried in the local Magistrates Court before a District Judge.

The case turned on whether the Master was ‘always on duty’ and particularly whether he was always

on duty for the purposes of the Act. The Act did not define ‘duty’ and furthermore ‘duty’ is not defined elsewhere. It is often thought that a Master is always on duty from the moment he/she signs on a vessel to the moment he/she signs off. It was argued that a Master’s duty was not unlimited in its breadth or scope; to find otherwise would confuse performance and discharge of duty with the existence of a status or responsibility. Furthermore, to do so would fail to distinguish between the different facets of a Master’s duties, which include duties by common law, statute, regulation, custom and by contract.

Miscellaneous

When is a Master Off Duty?

200 201

Observations:Members should be aware that in many parts of the world Canal Authorities, Harbour Authorities and other quasi-governmental bodies enjoy special status where the normal rules of business dealing may not apply. Members encountering problems with such bodies are advised to obtain assistance from the Club at an early stage while the matter is still open to discussion.

Financial Cost:The costs to our Member exceeded US$26,000.


The Incident: During a transit of the Suez Canal our Member’s vessels were alleged to have hit and severely damaged a navigation buoy. The first notice that the owners had was a letter from the Suez Canal Authority alleging that their vessel had damaged a navigational mark and inviting them to attend a joint survey. Our Member contacted the tug Master and the pilot, both of whom denied that there had been any contact. In view of this our Member wrote back to the Authority denying liability. A few weeks later they were shocked to find that the Suez Canal Authority had unilaterally deducted Egyptian £89,000 from their deposit.

Miscellaneous

Early Request for Club Assistance could have Buoyed up Members Defence

At that point the Member contacted the Club who instructed its correspondent lawyers in Egypt to defend the Member’s interests. Our lawyers advised that their past experience was that once the deduction had been made and it had been recorded in the accounts of the Canal Authority, it was almost impossible to persuade them to re-open the case. We were able to demonstrate that our Member’s vessel’s passed the buoy in the early hours of the morning and that the damage was not reported until mid-afternoon. In the intervening period the entire southbound convoy passed the location of the buoy and also some of the northbound ships, any of which could have done the damage. The Canal Authority prevented our correspondents from taking statements from the pilot or any other canal personnel. They refused to provide any documents, reports or other evidence to substantiate their claim that our Member was responsible for the loss.

The Canal Authorities remained intransigent and faced with an expensive legal battle which might not be resolved for ten years or more, the Members decided not to pursue the matter.

202 203

Observations:The Member’s foresight in equipping the tug with a satellite tracking system prevented a major claim. The cost of installation was recovered from this one unsuccessful attempt at hijacking the tug.

The speed in which recovery was possible clearly demonstrates the value of the tracking equipment. The Club would encourage all Members who operate such vulnerable craft, to consider seriously installing a satellite tracking system.

Financial Cost:No claim arose out of this incident and fortuitously all the crew were unharmed.


The Incident: A Member’s tug was towing a barge laden with coal between ports in South East Asia. Late one evening whilst on passage she was boarded by a gang of ten men, two of whom were armed. The crew were tied up and the towline to the barge cut. The crew were then taken near to the shore in the pirates’ speed boat and left to swim ashore, unharmed. The speed boat returned to the barge. The pirates then turned the tug through 180 degrees, presumably heading for a port at which they could disguise the tug.

Unknown to the pirates, the Member had installed a tracking device on the tug. Upon her failure to arrive at the discharge port as expected, an investigation was carried out and it soon became clear to the Member what had occurred. The authorities were advised and within 36 hours both the tug and barge (which had been drifting at the mercy of the elements) were located and arrangements made to recover them.

Miscellaneous

A Good Case for Tracking

204 205

Observations:An investigation into the cause of the sinking traced the source of sea water ingress to a small sea water pipe between the sea suction strainer and the refrigeration cooling water pump. During the period the vessel was laid up an elbow progressively corroded away at the welded seams on either side until it was so weakened that it fell off. The subsequent ingress of sea water slowly flooded the engine room space, initially causing the vessel to sink deeper into the water and then, as the starboard bilge grounded on the uneven bottom, to list and ultimately capsize.

The loss would have been avoided if good practice had been followed and all sea valves had been closed when the vessel was laid up. The leak would also have been detected if the owners had made arrangements with the shipyard for regular housekeeping inspections to be carried out by yard personnel.

Root Cause:Inadequate Procedure.

Financial Cost:The owners were fortunate that heavy lifting equipment was already available in the port, thereby avoiding heavy mobilisation costs. Nevertheless raising the vessel still cost over US$125,000 and the cost of anti-pollution measures reached US$20,000. Sea water had destroyed all the electrical equipment and installations and much of the machinery, with the result that the vessel required complete refurbishment.


The Incident: This 14 year old vessel had been inactive for three years. She was laid up unmanned at a shipyard belonging to an associated company. One morning the vessel’s agent noticed that she was listing 15° to port and reported this to the yard. Yard personnel were mobilised to investigate the listing of the vessel however prior to any remedial action being possible the vessel capsized, landing on her port side on a soft mud bottom. As there was no-one on board at the time she capsized there were no injuries. Shortly after the capsize an oil sheen started to appear on the surface. The Port Authority and the shipyard mobilised their pollution clean-up team. An oil boom was placed around the vicinity of the capsized vessel and dispersant was sprayed on the escaping oil. The Port Authority issued a wreck removal order. The vessel was salvaged ten days later.

Miscellaneous

Corrosion Causes Sinking of Laid-Up Vessel

Section 6� Harbour Craft

207

The Incident: The following accident report issued by the MAIB concerns an incident where a deckhand suffered multiple fractures to his arm whilst connecting a tug’s towing wire:

“The tug’s tow rope messenger was led through a Panama lead, around the bits at a 100˚ angle and on to the winch end whipping drum. The drum end seaman was standing with his back to the working part of the rope and the supervisor, as he hauled on the rope.

Unfortunately the tug was not paying out slack at a controlled speed and, feeling the strain of the jerking motion, the drum end seaman attempted to apply more turns to the whipping drum. During this process, the messenger rope snapped back, and the whiplash of the working part connected with, and broke, the drum end seaman’s arm.

The supervisor, who was standing in the precarious position of the bight of the rope, escaped injury. Had the rope come clear of the bits, the outcome for him could have been extremely serious.”

Harbour Craft


Face the Danger

Conclusion:Messenger rope arrangement

Stand facing the danger: always put the winch 1. between the operative and the potential danger zone. This, in itself, creates a safety barrier, allows full visual contact with the mooring team and surroundings, allows controlled surging on the drum end and keeps the operative clear of the working part.

Be aware of the dangers of sharp nips – these 2. cause excess strain on machinery, fittings and ropes – and use fairleads wherever possible. During our first day at sea, most of us were made 3. aware of the dangers of standing in bights of rope; a brief lapse of attention to this ordinary practice can so easily cause grief.Watch out for shipmates and their work 4. practices. Ships operate on efficient team-working, part of which involves looking out for our shipmates and recognising potential dangers to them. It is so much easier to stop bad habits than to patch up broken bodies.


208 209

Root Cause:Equipment design failure.

Financial Cost:The workboat, although eventually refloated, was a constructive total loss. The measures taken to prevent pollution together with the fees of lawyers and consultants exceeded US$14,000. The skipper’s family was compensated by the State Workers’ Compensation scheme.

Footnote: Following the incident another Member of the Club designed an automatic quick release towing hook specifically for small craft/workboats. Full details of the ‘Detach-Matic’ hook can be obtained from Navimar Corporation Ltee in Quebec, Canada, telephone number (418) 692 4830.


The Incident: This incident occurred as a small passenger vessel was being towed from a river into a harbour basin. This dead tow was being performed by a harbour tug acting as lead tug and a tug/workboat which was made fast aft. The Masters of the two tugs had agreed that the towlines would be shortened off the basin entrance and that the lead tug would then tow the vessel into the basin with the workboat holding the stern of the passenger vessel up into the ebb tide, which was running downriver at approximately 3 knots. As they commenced the final stage of the tow the tug/workboat was girted and capsized, drowning its skipper.


Girting Capsizes Small Tug

Observations:Once the towline had been shortened and the slack had been picked up the lead tug called the workboat to confirm that they were ready to proceed. On receiving the all-clear the lead tug progressively applied power, turning the tow into line with the approach. Power had been brought up to approximately half ahead when the tug received a VHF message asking it to stop. Almost simultaneously crew members on board the tow shouted to the lead tug that the workboat had capsized.

Based on information from the survivor and witnesses on the tow, it appears that the workboat skipper had intended to let the his boat drift into line with the stern of the passenger vessel as the slack on the towline was taken up. It seems that the workboat did not turn as fast as expected for when the weight came on the workboat was still lying at an angle of about 140° to the fore and aft line of the tow. It appears that the skipper realising the danger abruptly put his engines full ahead intending to swing his vessel into line with the tow. Before the workboat could turn the tow started to pull the workboat along with it. The workboat listed to starboard and a combination of the workboat’s engines, the river current and the forward motion of the tow dragged the starboard quarter under, with the result that the workboat capsized. The eye of the towline from the passenger vessel to the workboat had been placed over the bitts. There was no means of releasing the towline in an emergency.

210 211

The Incident: This claim involved a work boat which developed an engine fault. The fault was reported to the General Manager, who subsequently arranged for the company fitter to attend, although he could not do so immediately.

The following morning, before the fitter had attended and carried out the repairs, a new boatman took the boat out onto the water. Whilst manoeuvring alongside another vessel the engine went astern instead of ahead, contrary to the control lever, and the boat landed heavily against the vessel causing the boatman to fall. This incident resulted in the crewman suffering multiple rib fractures and a broken arm.

Observations:This incident would not have occurred if procedures had been in place to deal with the reported fault. In particular no positive steps had been taken to prevent the boat from being used prior to the fault being rectified. The General Manager reportedly gave verbal instructions not to use the boat, but this clearly was not sufficient.

When any item of machinery is known to be defective, positive action must be taken to prevent fur ther use until the problem has been rectified. This applies to all types of equipment no matter how important it is to a vessel’s operation.


Delayed Action has Painful Result

Root Cause:Inadequate maintenance procedures.


The Incident: This incident occurred on board a harbour craft servicing ships in the anchorage at Singapore. The vessel had carried a load of stores and spare gear out to the ocean-going vessel and was backloading a 14 ton piece of machinery. The small vessel was rolling slightly in the swell and while conditions were not ideal it was considered safe for the operation to proceed. The machine was lowered from the ocean-going ship to just above deck level where it was suspended while our Member’s crew adjusted its position. One of the crew members involved inadvertently placed his hand in a position where it could be trapped and realising the danger immediately tried to retract it, but his hand was caught by the load. Fortunately he was able to pull his hand clear before the full pressure of the load came to bear. Nevertheless he suffered serious crush injuries to the middle and index fingers of his right hand.

Observations:This incident illustrates the dangers that crew members can be exposed to if they have to work in close proximity to heavy loads being landed on deck. If this load had been fitted with rope tails it would have allowed the crew members to remain at a safe distance from the load while final positioning was carried out.


Handling of Heavy Cargo Load Without Rope Tails Leads to Crushed Fingers

Root Cause:Inadequate safety procedures.


212 213

The Incident: This incident occurred when two tugs were employed in shifting a floating dry dock of approximately 3,400 tonnes into deep water so that she could be ballasted down to sail out a vessel within.

The operation required the dock to be manoeuvred across the port approach channel, down which a supply vessel was navigating. In order to give this vessel more sea room, the tugs towing the dock eased off. The dock then started to drift towards vessels moored at a nearby berth and despite the best efforts of the tugs, the dock continued towards the moored vessels, eventually making contact with one.

Observations:Two factors played a part in the cause of this incident. The bollard pull of the tugs was considered insufficient for the size of the dock. A strong current was flowing at the time of the operation and the tugs were not of sufficient power to regain control. Secondly, neither the dry dock operations department nor the tug masters took it upon themselves to inform the port control of the operation.

Had this been done, the manoeuvre would have probably been delayed until the channel was clear or the inbound vessel prevented from entering the channel.

All in all the operation was very poorly planned.

Operations

Size does matter

Financial Cost:Whilst damage claimed was extensive we eventually concluded settlement in the modest sum of US$14,737.

Trading Area:Europe and Middle East


214 215

Section 7� Barges

217

The Incident: This incident involved a dumb barge loading containers using her own gear. Whilst positioning a 20 foot container on the barge the eye plate used to secure the topping lift block sheared away from the tripod mast. The container, derrick boom and gear all fell onto containers already loaded on the barge. Three 40 foot and two 20 foot containers in addition to the one being loaded were damaged. Fortunately there were no injuries to any of the crew or stevedores.

Barges

Operations

You Get What You Pay For

Observations:Investigations showed that the eye plate appears to have been repaired some time prior to the incident and the standard of the welding was very poor. There was minimal penetration in places and the remainder of the welding was uneven. The surveyor was of the opinion that the repair work had been carried out by poorly trained personnel. Needless to say this is entirely unacceptable, especially when the safe working load (SWL) of the derrick (approximately 30 tons) is taken into consideration.

Whenever major repairs are carried out on lifting gear or the associated fittings, a specialist company should be used that employs fully trained staff. Upon completion of these repairs the gear should be proof tested and a record entered in the Register of Lifting Appliances and Cargo Handling Gear.

Root Cause:

Inadequate maintenance procedures.

Financial Cost:US$14,541


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Contact Us

London Office

Charles Hume Chief Executive Email: [email protected] Skype: charles.hume Ralph Coton Business Services Director Email: [email protected] Skype: ralph.d.coton Ian Edwards Underwriting Services Development Manager Email: [email protected] Skype: ian.edwards11 Adam Howe Underwriting Manager Email: [email protected] Skype: adam.howe18 Britt Pickering Claims Manager Email: [email protected] Skype: britt.pickering Louise Hall Loss Prevention Manager - London Email: [email protected] Skype: louise.hall4

Simon Swallow Commercial Director Email: [email protected] Skype: simon.swallow1 Lawrence Aspinall Finance Director Email: [email protected] Skype: lawrence.aspinall Mark Harrington Underwriting Manager Email: [email protected] Skype: mark.harrington83 William Tobin Underwriting Manager Email: [email protected] Skype: william.tobin3 Kevin Lowe Finance Manager Email: [email protected] Skype: kevin.lowe2983

The Shipowners’ Protection Limited St Clare House, 30-33 Minories, London, EC3N 1BP Tel: +44 (0) 207 488 0911 Fax: +44 (0) 207 480 5806 Email: [email protected]

www.shipownersclub.com

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Singapore Office

David Heaselden Principal Officer / Director Loss Prevention Manager Email: [email protected] Skype: davidh2009

Steve Randall General Manager / Director Email: [email protected] Skype: sd.randall

Shipowners’ Asia Pte Ltd 6 Temasek Boulevard #36-05 Suntec Tower 4 Singapore 038986 Tel: +65 (65) 930420 Fax: +65 (65) 930449 Email: [email protected]


Vancouver Office

Rosemary Adams General Manager / Head of Underwriting Vancouver Branch Email: [email protected] Skype: rosemary.adams

Shipowners’ North America Protection Limited 1157-409 Granville Street Vancouver, British Columbia V6C 1T2 Tel: +1 604 681 5999 Fax: +1 604 681 3946


Luxembourg Office

Pascal Herrmann General Manager Email: [email protected]

The Shipowners’ Mutual Protection & Indemnity Association 16 Rue Notre-Dame L-2240 Luxembourg Tel: +352 229 7101 Fax: +352 229 7102 Email: [email protected]


Tine Lehrmann

Text Box

The Shipowners’ Protection Limited St Clare House, 30-33 Minories, London EC3N 1BP Tel: +44 (0)20 7488 0911 Fax: +44 (0)20 7480 5806 Email: [email protected]


October 2010

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UK P&I - Shipowners Club - Loss Prevention - Case Studies

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