CHIRP Annual Digest 2021

MARITIME

Annual Digest Reports and Insight Articles

MARITIME

Are you interested in becoming a CHIRP Maritime Ambassador? CHIRP and the Nautical Institute have an established ambassadors scheme to raise awareness of our incident reporting scheme and encourage the submission of incident, accident, and near-miss reports.

As an ambassador, you will join an international network of seafarers who share your passion for safety, giving you a broader knowledge of current safety issues.

By working together to promote learning and just culture across the maritime sector, you will be part of a team that is helping to improve maritime safety.

If this sounds like you, please get in touch with us to discuss this opportunity at mail@chirp.co.uk

MARITIME

Annual Digest of Reports and Insight Articles 2021

The CHIRP Charitable Trust, One Kingdom Street, Paddington Central, London, W2 6BD, United Kingdom © The CHIRP Charitable Trust Designed by Phil McAllister Design Printed in the UK by The Print Consultancy

Impact Statements “It is noticeable, and even more so since the success of the CHIRP Maritime COVID papers, that the CHIRP Maritime programme is gaining recognition and attracting interest from the most senior governmental and non- governmental organisations.” Core sponsor

“We really appreciate your hard work and superb ‘delivery’.” InterManager

“Our charitable activities are international, so we were impressed by the now global outreach of the programme and its effect in significantly influencing for the good, safety at sea” Lloyd’s Register Foundation.

“Thank you for your email, the issue has been relayed to all our vessels and re-enforced during my visits for audits etc. It has created much discussion in the fleet… Keep up the good work!” Company DPA

“Last week we completed the modification on the last of … vessels under our ship management as per modification previously shared with CHIRP. Thank you for your relevant input to this case.” Deputy DPA

Reporters’ comments: “With regards to the report, it covers all the issues and I appreciate the confidential manner in which it has been written.”

“Thanks for taking my report on board and taking action on this serious issue… this WILL save lives of seafarers who work on this type of vessel.”

“By the way, I really appreciate CHIRP’s work, and study the reports carefully, I always learn something and share with crews.”

“Thanks so much for all the hard work that you and your team in CHIRP do to spread the safety message and help us all to learn from the experiences of others.”

“Good day. I want to thank you for responding in my report, it is a very big help to me... Thank you very much and God Bless.”

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Maritime Director’s Foreword Welcome to the seventh edition of our Annual Digest and my first as CHIRP’s Director Maritime, very ably assisted by Captain Dave Watkins who also joined CHIRP last year. I want to take this opportunity to thank my predecessor Captain Jeff Parfitt for his successful stewardship of CHIRP’s maritime programme and wish him the very best of luck in his new role at The Nautical Institute.

I also want to acknowledge the generosity of our sponsors, without whom this publication would not be possible. Their financial assistance once again ensures that we can spread our safety messaging to an international The number audience – our last edition was despatched to individual seafarers and of reports maritime institutions in over 50 different countries! Don’t forget that we also provide a quarterly newsletter in 6 languages – Chinese, English, Filipino, received Indonesian, Portuguese and Spanish – to reach as many seafarers in their continues first or chosen language as possible. to increase Our reports tell us that, sadly, the work of CHIRP has never been more year-on- important. The number of reports received continues to increase year-on- year. Many of year. Many of these are the result of an industry under pressure due to the lingering effects of Covid, tighter profit margins, lengthy assignments these are the with little shore leave and long working weeks. In this edition of the Annual result of an Digest we have addressed some of the consequences, including mental health, crew welfare and social integration, and fatigue. industry under pressure Because you have told us how important our incident reporting programme is to you we are currently upgrading our website and social media channels to make it easier to communicate with us and receive our safety messages, and we will also shortly be releasing a CHIRP app to make reporting your concerns to us even simpler.

I hope that you enjoy reading this edition and find it interesting, insightful and most of all useful. Let us know what you think of it, and whether it helped you stay safe. We rely on your incident and near-miss reports and encourage you to submit your concerns so that we can keep you and your fellow seafarers safe.

Yours in safety

Adam Parnell CHIRP Maritime Director

CHIRP Maritime the Voice of the MARINER

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Introduction Welcome to our seventh annual digest of CHIRP Maritime but we believe the standard of those reports is higher than reports, covering all the cases we published during 2021 as ever and we wish to publicly thank all our reporters for their well as several in-depth articles specially commissioned to excellent feedback. highlight important safety topics. Last year we did our best to support seafarers by We have again been fortunate in finding generous publishing guidance on dealing with the pandemic, and this sponsors who have made it possible to produce this year we have commissioned experts to highlight another Annual Digest. They are listed at the end of the Digest, aspect which has largely been ignored in the past – the and we are extremely grateful for their support and their stress which arises after a serious accident. Crews are ongoing commitment to safety. often interviewed or interrogated immediately after they 2021 has been another very difficult year for seafarers witness traumatic events, with no thought for their mental with the ongoing Covid-19 pandemic causing major wellbeing or the psychological effects of a major accident. disruptions, particularly regarding crew changes. Many We hope our Insight article will lead to a debate on the of our colleagues are still trapped at sea long after they topic, and more sensitive treatment of the people involved should have been repatriated, while others are stuck in major maritime accidents in future. Last year we wrote

www.chirpmaritime.org at home and do not know when they will be able to that “we hope the people who investigate such cases work again. The professional way our colleagues have will bear in mind the almost intolerable pressures on our continued to move the world’s trade goods, often in terrible seafarers”. This year, we offer scientific evidence which conditions, has been an inspiration. Perhaps one day the demonstrates why they should. world will acknowledge the great debt it owes to the men Early in 2021 we witnessed several staff changes. Adam and women at sea. Parnell replaced Jeff Parfitt as Director, Maritime, and Despite all the hardships, seafarers have still managed Dave Watkins replaced Howard Nightingale as his deputy. to submit reports to CHIRP Maritime and the results are Ranjith Cheerath also retired as our Maritime Advisor in here for all to see. Not only are we still receiving reports, Singapore. Fortunately, the transitions were seamless and

CHIRP Annual Digest 2021 5

both Adam and Dave have fitted in very well. Readers will interest both to seafarers and people in shore positions. One

notice that their influence is already apparent in the way message which does come through, unfortunately, is that we analyse reports from the human element perspective, not all companies are able to demonstrate a robust safety and the questions we pose at the end of every report, culture, so there is still a great deal of work to do to reach but we welcome your feedback on the way we present our goal of ensuring that every seafarer returns home safely our information. Ian Shields has moved onto the Maritime at the end of every tour of duty. Advisory Board (MAB) so we continue to benefit from his Within most sections you will again find Insight articles wise counsel, and Stephanie Dykes is back from maternity that illuminate topics covered in that section or provide leave to keep us all in order. additional information. They are written by experts and are As ever, we are guided by the MAB volunteers, who well worth reading. are an outstanding source of maritime expertise with over All our videos, publications and databases are easy to 700 years of combined shipping experience. They provide access through our website, so we hope you will look at expert analysis and contribute many of the Insight articles them when time permits. For more detailed and focused which appear in this digest. All our work is overseen by research, we recommend the searchable database on our trustees, while our ambassadors continue to promote the website. There is a useful guide in the banner on our our work around the globe. Indeed, the work of our home page which explains how to use our site if you are ambassadors is vital in spreading the news about CHIRP in any doubt. Maritime to as many countries as possible. There is more We hope that you find this edition both interesting about their role in an interesting article later in this Digest, and informative. Please let us know. our comments are so please contact us if you would like to join the scheme. important, and we read them all to ensure CHIRP Maritime Our Maritime FEEDBACK magazine is now published continues to provide the information you need to make our in English, Chinese, Filipino, Indonesian, Spanish, and industry safer. Portuguese, and we are most grateful to all the sponsors and Until next time, take care and may all your voyages lead translators who help make this happen. Please let us know you safely home. if there are other languages you would like to receive or, even better, if you would like to sponsor a version in another language. There are still a few of the major seafaring nations which we do not reach in their native language, so we would Editor: Captain Alan Loynd be delighted to hear from you if you can help. FNI FITA MCIArb BA(Hons) The generosity of all our sponsors is acknowledged in our publications, and we could not function without them, but our reporters (both individuals and companies) remain anonymous for obvious reasons. It is a pleasure for me to acknowledge them once again all and thank them for their support, without which we would not exist. The usefulness of their reports is demonstrated by the increasing number of examples where CHIRP Maritime is quoted in other publications, and by our growing number of readers around the world. We have divided the Digest into themed sections to assist readers to find the topics which most interest them, but inevitably many reports could be allocated to several Please note all reports received by CHIRP are accepted different sections. I am not sure whether this means incidents in good faith. Whilst every effort is made to ensure the are becoming more complex, or whether our analysis is accuracy of any editorials, analyses and comments that becoming more sophisticated, but we urge you to study all are published in this digest, please remember that CHIRP the sections because they all contain reports which will be of does not possess any executive authority.

The professional way our colleagues have continued to move the world’s trade goods, often in terrible conditions, has been an inspiration. Perhaps one day the world will acknowledge the great debt it owes to the men and women at sea

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Table of Contents SECTION ONE 8 Human Factors 8 Handover follow-up 9 Fatigue in the international towage sector 10 Chief Officer’s mental health issues 11 Insight: MCA on human factors 12

SECTION TWO 14 Deck safety 14 Unsafe practice while working over side 15 Accommodation fire – two fatalities 16 Ship to Ship mooring incident 16 Cargo damage due to water ingress into cargo hold No. 5 17 Lifeboat on-load cable release unit defect 18

SECTION THREE 20 Engineering, technical and environment 20 Engine failed to start on sailing 21 Engine issues in bad weather 21 Flooding cofferdam during speed log maintenance 22 Steering gear malfunction 23 Personal injury – burn to body and face 24 Insight: Social integration (ISWAN) 25

SECTION FOUR 28 Pilot boarding and pilotage 28 Why do we get so many pilot ladder reports? 29 Was it an engine issue or a communication issue? 30 Better to keep going than stop 31 Once restarted, do not slow down 31 Insight: Effective use of tugs for pilots & exempt masters 33

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SECTION FIVE 35 COLREGS and Navigation 35 Colregs Rule 10 incident 36 Vessel touches bottom during canal transit 37 Machinery breakdown leads to a collision 38 Collison with bridge and barge after moorings parted in high winds 39 Insight: Trauma-Informed Interviewing in a Marine Setting TIMS 40

SECTION SIX 43 Yachts, fishing and recreation 43 Fire and sinking of a motor yacht 44 Sailing boat propeller fouled 45

SECTION SEVEN 46 Safety culture and regulations 46 Substitution of simulator time for sea time 47 Alleged MARPOL contravention and MLC non-compliance 48 Failure to declare reportable cases on entering port 49 Chemical burn to body 50 Insight: Aviation procurement, control, and maintenance standards 51

SECTION EIGHT 53 Correspondence received 53

APPENDICES 54 Appendix I: Acronyms 54 Appendix II: Insight on the role of Ambassadors 55 Are you interested in becoming a CHIRP Maritime Ambassador? 55 Appendix III: How the CHIRP reporting process protects your identity 56 Appendix IV: The Maritime Programme – How it works 57 Appendix V: Our Publications 58 Appendix VI: Our Sponsors 59

All Charts used in this publication are subject to © Crown Copyright and/or database rights. Reproduced by permission of the Controller of Her Majesty’s Stationery Office and the UK Hydrographic Office (www.GOV.uk/UKHO).

8 CHIRP Annual Digest 2021

Section one

Human Factors

CHIRP Annual Digest 2021 9

There is no doubt that human factors play a part in • there were no entries for maintenance or usage in

everything we do, and these days it is not enough to the Compressed Air Breathing Apparatus (CABA) simply point out that the majority of accidents are a result compressor logbook. of human error. This tells us nothing. • oil droplets and fatty deposits were observed on the Instead, we must ask probing questions to determine galley exhaust fan vent grille (which exhausted onto the the underlying causes which resulted in the appearance accommodation deck) and on the deck below the vent. of unexpected and dangerous human factors. Was there • there were no formal training records for the testing of a breakdown in communications, or a gap in training, or brake-holding capacity and brake-rendering capacity was fatigue an issue? The model we use to analyse these of mooring winches and windlass. and other factors has been included in previous editions • there was no formal numbering system for the of the Annual Digest, and it can be used at all levels from firefighting equipment. on board safety meetings to management analysis, and • 75% of personal oxygen analyser sensors were even by national and international organisations when unserviceable. they study marine accidents and incidents. • all the chemical Draeger tubes had expired. Without determining the underlying factors, it is • almost all the Chief Officer’s files located in the cargo impossible to suggest remedies, which is why we now control room were incomplete. include a human factors analysis in every report we • there were no gas reading records for the cargo tanks publish. We also pose questions for our readers to which has been recently inerted. consider, to encourage people to think about whether • several of the indicating sensors for the cargo valves they are at risk of a similar incident. did not show the correct value. In this section we have collected a series of reports where human factors are particularly prominent, but you CHIRP Comment will find other examples throughout this Annual Digest The management company should ensure that handovers and in all our other publications. occur in a suitable port with adequate time for an effective We begin with a report about a new-joining crew who exchange of information so that the incoming Master is were not given an adequate handover, and subsequently fully apprised of the vessel’s material condition. Handovers discovered many serious defects aboard their vessel. normally follow a procedure set out within the SMS The way they responded and tackled the problems was including, but not limited to: exemplary, but they should not have been placed in such • a report on the officers and crew, including their a difficult situation. This is followed by two reports about experience, highlighting their time on board, relief fatigue – one where the problem may have been company- schedules and any health matters. wide, and another which involved an overworked Chief • inspection of trading certificates including those where Officer and the stress he suffered as a result. Both are a survey is due. alarming and should never have been allowed to develop. • any conditions of class or memos. We conclude this section with an Insight article from • bridge equipment and navigational documentation, the Maritime and Coastguard Agency in the United passage plans, chart correction status, and Kingdom, where they discuss human factors and their navigational warnings. impact on crew safety and wellbeing. This is an important • the current cargo status including stability information. document which deserves careful study. • critical items of equipment that are due for maintenance or inspection / survey must be highlighted. • status of bunkers, fresh