CHIRP Maritime FEEDBACK 71 (Summer 2023)

An independent and confidential Issue 71

MARITIME FEEDBACK reporting system for the Maritime industry Summer 2023

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Addressing common factors in Maritime Adam Parnell Director (Maritime) Lastly, insufficient supervision and oversight can contribute to unsafe practices. The incident involving inadequate supervision and risk assessment of In this edition, we focus on three critical factors that painting the ship’s side (M2107) clearly illustrates the affect maritime safety: communication failures, dangerous consequences of prioritising schedules over the pressure to meet commercial demands and safety. Furthermore, the collision with a yacht (M2114) inadequate supervision. These recurring issues underscores the importance of maintaining a proper underscore the urgent need for improved practices lookout and remaining vigilant in congested waters. and a stronger safety culture within the industry. To address these issues, the maritime Firstly, effective communication plays a vital industry must foster a culture of safety and open role in ensuring safe operations. In the case of the communication. Companies should invest in power shutdown incident (M2109), the lack of continuous training and development to ensure communication between the chief engineer and proficiency in critical areas such as communication the bridge crew resulted in an unintended loss of and risk assessment. Supervisors and officers must power. Similarly, incidents involving engine failure take proactive measures to guarantee the safety (M2117) and incorrect information during the of their crew and operations, including adequate master-pilot exchange (M2118) highlight the risks of supervision and adherence to established procedures. inadequate communication. The incident involving Moreover, regulatory bodies should play a communication difficulties (M2113) highlights the substantial role in enforcing safety standards and significance of proficiency in maritime English for promoting best practices. Regular inspections and effective teamwork and emergency response. assessments can help identify areas for improvement Secondly, the pressure to meet commercial and hold companies accountable for maintaining high demands often creates conflicts with safety safety standards. considerations. While many companies claim that By addressing these key themes and safety is their top priority, this commitment is not implementing necessary changes, the maritime consistently reflected in the commercial demands industry can enhance safety, prevent accidents, and placed on vessels or in the time and resources safeguard the well-being of crews and vessels. allocated to them. Until the next edition – stay safe!

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M2117 Some masters fear that by declaring defects, they may be subject to a Port State Control inspection. Ironically,

Engine status not known many pilots tell CHIRP that a vessel that proactively declares defects are likely to be viewed as having a good safety culture on board and, thus, is less likely to be inspected! Initial Report In some cases, commercial pressures are often in While transiting the harbour’s main channel outbound, conflict with safety. The best place to undertake repairs is a large vessel suffered a main engine failure. The pilot alongside where technical support and spare parts can more informed the shore authorities, and tugs were immediately easily be sourced. If a vessel misses its scheduled departure provided. The vessel’s speed at the time of the engine failure because of the time to fix the defect, then this must be was ten knots, and it could maintain its heading until clear of accepted as the safest option. This is preferable to losing any danger under its momentum. control of the vessel and suffering catastrophic damage due The cause- a fuel blockage - was quickly reported to a breakdown because the defect was not fixed. as cleared, and the main engine was restarted. At this CHIRP encourages companies to drive proactive risk point, the vessel was still making five knots, so the vessel management throughout their fleets and to empower navigated back into the main channel. The pilot stood their masters and chief engineers to take positive safety down the tugs after the master verified that the main actions to mitigate the risks. Prudent overreaction is always engine was working correctly. better. Ultimately, empowering staff to make bold decisions The pilot then disembarked, but shortly afterwards, they to remain in the harbour to undertake defect repairs is heard the master contact the shore authority to request an essential for ensuring the crew’s safety and the vessel itself. anchorage to fix the main engine, contradicting what he had By fostering a culture of safety and open communication told the pilot on board. and providing the necessary training and resources, organisations can help ensure that all crew members are equipped to identify and address potential issues with the M2118 vessel promptly and effectively.

Factors identified in these reports Incorrect Information Pressure – Companies should be aware that inappropriate pressure on crews to meet commercial deadlines Provided during Master- compromises safety by impairing decision-making and hindering the timely and effective completion of Pilot Exchange maintenance or repairs.

Communication – To maintain navigational safety, masters Initial Report must openly and transparently report any defects during The pilot boarded a logger vessel just before it entered the the master-pilot exchange. Failing to do so jeopardises the harbour. No defects were reported during the master-pilot integrity of pilotage operations. exchange. As the vessel passed the breakwater, the pilot (now on the starboard bridge wing) ordered dead slow Teamwork – Share the problems with your team and astern. The master relayed the order to the mate inside the always encourage challenges to ensure the issues have been wheelhouse, but the engine rpm indicator on the bridge thoroughly considered. In report M2117, the issue was not wing continued to show ahead propulsion. Believing that fixed, and in the second report, M2118, the known problem either the master or mate had misheard the order to go was not communicated. Adopt a shared mental model when astern, the pilot repeated the order. The master assured the confronted with operational or technical problems. pilot that the engine had gone astern but that the indicator on the bridge wing was wrong. As a precautionary measure, Culture – Open reporting creates trust, whereas withholding the pilot ordered the tugs to come to the vessel earlier than vital information from the pilot can quickly erode trust. required, and the vessel safely berthed. After berthing, the chief engineer came to the bridge and informed the master and pilot that the problem had been M2113 resolved. The pilot asked what the problem was, and the chief replied that there was a wiring problem inside the indicator. The pilot spoke with the master, reminding him he had not declared any defects during the master-pilot exchange. Communications CHIRP Comment difficulties hinder Before entering or leaving a port, all equipment must be tested to ensure that it is working as expected. Similarly, any understanding defects discovered must be passed on during the master- pilot exchange. Initial Report CHIRP increasingly receives reports of masters unwilling A pilot encountered major communication problems to declare material deficiencies to pilots, which only come when speaking to the master, who had a poor knowledge to light when the vessel does not manoeuvre as expected, of maritime English. Other than simple orders such as thereby increasing the risk of a navigational incident. ‘starboard 10’ or ‘dead slow ahead’, the pilot struggled to

MFB 71 | Summer 2023 www.chirp.co.uk/maritime

communicate with the master. The pilot found it difficult as it was passing the breakwater. All navigational control was to integrate with the bridge team, who all spoke in their lost as a result, but luckily the emergency generator started, language and not maritime English. and power was quickly restored.

CHIRP Comment Proficiency in maritime English is an essential safety enabler. It is the official language within the shipping industry and is the foundation of effective communication. Recruitment Placement and Service Licences (RPSL) play a critical role in ensuring that officers and crew members have adequate language skills in maritime English, which is essential to meet the requirements of the International Safety Management (ISM) code. This includes emergency preparedness and response, which requires quick and efficient communication to prevent dangerous situations. Once certificated, all seafarers should be provided with ongoing training and development in maritime English to ensure their communication skills remain current and effective. This can be achieved through various means, including language courses, on-board training programs, and continuous language proficiency assessments.

Factors identified in these reports Communication – Like any skill, competency in maritime English will quickly fade if it is not constantly practised, significantly increasing the likelihood of miscommunication or misunderstanding. Companies should invest in ongoing language training throughout a seafarer’s career. Port State Control could remove the master if they consider that their inadequate proficiency in maritime English does not meet the requirements for safely operating the vessel with 3rd parties/contractors and emergency responders.

M2109 CHIRP Comment The chief engineer in the Engine Control Room should have Incorrect response to requested permission from the bridge before changing the machinery state of the vessel so that the bridge fuel leaks results in an team are always aware of the limitations of power and propulsion – especially when manoeuvring in or out of the unintentional power harbour. Because the conversation would have also been broadcast over the loudspeakers in the engine room, those shutdown in the engine room would have been aware that only one generator was providing electrical power to the ship. After a lengthy period in dry-dock, and particularly Initial Report when the material state of the vessel has been altered, The vessel left the dock and proceeded to sea to conduct the hazards and risk assessments should be reviewed and sea trials after a lengthy period in dry-dock, where enhanced controls put in place, e.g., additional watchkeepers work had taken place on both main engines. A vibration in place while leaving the harbour. specialist and a Classification Society surveyor were also on board. Both generators were running and connected to Factors identified in this report the electrical switchboard. Communications – Restoring standard communication While the vessel was still inside the breakwater, the procedures, particularly after a lengthy period in dry-dock, chief engineer disconnected one of the generators from the needs to be reinforced. Taking the generator offline and not switchboard but left it running in cool-down mode. They did communicating this to the engine room team and the bridge not inform the bridge that they had done so. was unsafe. The 2nd engineer was in the engine room, next to the generators, helping the vibration specialist to gather Teamwork – A heightened level of teamwork is required readings from the gearbox. They noticed that a high- to ensure that the engine room, which has been subjected pressure fuel line to one of the generators had split and was to overhauls and repairs from external contractors and the spraying oil onto the hot exhaust manifold. ship’s staff, is seaworthy. Consider operating an enhanced The 2nd engineer hit the generator’s emergency stop watchkeeping routine for the first day and night back at sea. button, and the ship experienced a total electrical failure just This reduces the risk of something going wrong.

www.chirp.co.uk/maritime MFB 71 | Summer 2023

Distractions – Checking that the status of the engine The ship that collided with us showed no sign of slowing room and all ancillary equipment is functioning must be the down and dragged us for about 2 miles even though the rest priority, and nothing should distract the engine room team of the crew fired distress rockets to attract attention. Nine from this task. were fired before someone from the ship noticed us, and the ship slowed down to stop dropping its port anchor. At the Competency – Drydocking requires the ship’s staff to same time, I also decided to activate the EPIRB because this have good operational adaptability and an elevated level would be the only way for someone to hear us. of risk knowledge. Management should ensure that certain Unfortunately, the DSC alert from the VHF was useless members of the ship’s crew have this when planning their because the antennas were damaged, and the portable dry dockings. radios had limited range. I sent out a MAYDAY call on the portable VHF handsets hoping anyone on the container vessel’s bridge would hear us. Within minutes of activating the EPIRB, we were contacted by the COSPAR SARSAT system, to which we passed all the information. They told us they had also alerted the local coast guard. However, nobody showed up or made contact. Over an hour after the event, five crew from the container ship descended onto the yacht from a ladder and, with some difficulty, managed to free the rigging and sails from their ship’s starboard anchor.” At around 07.00, we tied up everything we could and slowly motored the last 30 miles to enter our port of destination and safely moor.”

M2114

Collision with a Yacht in a busy traffic lane Initial Report A yacht left their island port for a 4-day passage in constrained but busy waters. Strong winds were forecast but the yacht’s wind instruments were broken. During the 4-hour night watches (2200-0200 and Not actual vessel 0200-0600) the crew divided into pairs. One would take the helm for 2 hours while the other slept in the cockpit, and they would swap over halfway through the watch. The sea CHIRP Comment and wind were moderate with occasional rain showers. This is a dramatic account of a serious incident, and The reporter said, “At 0415 on the third day our reporter although we lack the perspective of the container vessel, it was at the helm while their colleague slept in the cockpit. The underscores several crucial safety lessons. yacht was motoring in a traffic channel and AIS showed no Neither vessel saw the other, despite both showing vessels in the vicinity. Suddenly a huge shadow appeared on navigation lights. However, the range of yacht lights can the starboard side, and a loud noise enveloped the yacht. reduce significantly when heeled over, and the high bow of The mainmast plunged towards the stern and broke, container vessels can create a lengthy ‘dead zone’ ahead only held out of the water by the rigging. The mizzenmast of the ship for its lights and radar. Furthermore, radar clutter remained upright, but a large part of the starboard side was caused by moderate sea states and rain showers can impair badly damaged and torn away, along with the bowsprit, but the detection of yachts and smaller vessels. Many yachts there appeared to be no damage below the water line. carry only an AIS receiver, not a transmitter.

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Letting one person sleep while on the watch does ladders were on the dock. Once onboard, two other attempts not make sense: their sleep will be disturbed – leading were made to hoist the raft using the telescopic crane fitted to eventual fatigue – and the helmsman is deprived of a on their mooring station. However, it got stuck both times valuable lookout while navigating in congested waters. again under the mooring fenders causing the crew to fall Fortunately, distress rockets were fired, and the EPIRB again into the water! was activated, eventually attracting the container ship’s Once back onboard, they swapped sides and were attention. It’s essential to have emergency equipment and finally recovered from the starboard side platform, which procedures in place in case of such incidents. Unfortunately, was not initially used because of the fresh easterly breeze the DSC alert from the VHF was useless due to the damaged that created choppy seas in the harbour. antennas and limited range of portable radios. This highlights None of them was wearing any safety harness the importance of regularly checking and maintaining all attached to the sling and raft. Unfortunately, this practice communication equipment. Consideration should be given to (very common in the cruise industry) of lowering/hoisting a placing the VHF antenna in a safer location. manned paint raft is hazardous and should be discontinued. It’s concerning that the local coast guard did not show In addition to that, no supervisors and officers were up or make contact after being alerted by the COSPAR supervising the job, and even after the accidents, none SARSAT system. This may be something to bring to the showed up!” relevant authorities’ attention to ensure proper protocols are followed in emergencies. CHIRP Comment Overall, it’s essential to prioritise safety and The lack of supervisory leadership enabled a very preparedness when embarking on a lengthy voyage, unsafe situation to develop. A comprehensive plan especially in busy and congested waters. must be developed for any lifting operation, based on a comprehensive risk assessment. The positioning of the Factors identified in this report fender made this operation very difficult to carry out safely. Teamwork – Additional lookouts to assist