CHIRP Maritime FEEDBACK 73 (Winter 2023)

An independent and confidential Issue 73

MARITIME FEEDBACK reporting system for the Maritime industry Winter 2023

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The key ingredients of safety together effectively, accidents can be averted or Adam Parnell mitigated. Encouraging a shared approach to safety Director (Maritime) not only contributes to stronger teams, it can enhance well-being and reduces risks too! Situational awareness (being alert to your surroundings) are also crucial to proactive incident

W elcome to our latest newsletter, which once again is full of real-life reports submitted by seafarers and companies like you. These help us prevention, as demonstrated in our reports related to dry-dock operations as well as gangway usage. The importance of good equipment design once to raise awareness of key human factors critical for again features in several of our reports, particularly safety in the maritime industry, and we humbly thank the ease of inspection and maintenance. Even newly- you for your reports. Please keep them coming! built vessels can suffer from this! Regular readers will recognise many of the This will be the final Maritime FEEDBACK edition factors that are highlighted in this edition because for 2023. We will shortly be publishing our Annual they frequently feature in the reports that we receive. Digest, containing all of the reports we’ve published this As ever, effective communication tops our list. year, in case you missed any of our back-copies. Don’t Whether it’s swiftly alerting the Bridge to a galley fire forget that you can access all of our reports on our or ensuring clear and unambiguous instructions for website and on our app, and you can also subscribe to ferry passenger evacuation drills, communication is get them delivered to your email in-box too! critical to safety. Until the next edition in 2024, stay safe! Teamwork is another common feature, and our Yours, reports demonstrate that when crewmembers work The CHIRP Maritime team.

Please note all reports received by CHIRP are accepted in good faith. Whilst every effort is made to ensure the accuracy of any editorials, analyses and comments that are published in FEEDBACK, please remember that CHIRP does not possess any executive authority.

M2167 Light switches should be properly labelled and containers overboard only a few years beforehand. Despite Alerting – Create a positive alerting culture so that risks for positioned in sensible locations close to the storerooms these ongoing concerns, the base lock issue remained all operations are raised and actioned.

Galley fire they serve. They should also be clearly labelled. If in doubt, unresolved. The nautical and safety superintendent was ask the electrical officer to check the function of the switch unaware of the twist lock conditions on the ship, and there Culture – The company should look at how issues are in question. had been no requisition raised in the planned maintenance raised with the company and evaluate the current state of its Initial Report Storage of any material should always be considered system (PMS) program for some time. safety culture. As a chef was leaving the galley area, having closed it from the point of view of fire risk and how to control that risk. Our reporter approached CHIRP for assistance because down after the meal, they noticed smoke seeping from a Eliminating the hazard is the best way to reduce risk. If, after they were worried that containers could be lost overboard door in a smaller, less frequently used section of the galley. the debrief for this incident, the heating lamps are found to if they were not correctly secured. CHIRP approached the M2172 Concerned, the chef investigated and found that several serve no operational function, consideration should be given company, which cited a breakdown in communications with pizza boxes had caught fire. These had been stored under to isolating the circuit. Hence, they become non-operational the ship and immediately arranged for the replacement parts heating lamps, which, unknown to anyone, had been inadvertently switched on during the cleaning process. and labelled as such. The incident underscores the importance of crew to be sent to the ship. RoRo crewmember Acting promptly, the chef immediately reported the fire to the bridge using the radio communication system, then members’ vigilance and highlights effective teamwork and everyone’s critical role in ensuring the ship’s and its CHIRP Comment According to the World Shipping Council, in 2022 there were hit by vehicle turned off the heating lamps and retreated to a safe distance near the doorway. occupants’ safety and security. Different crew members’ collaborative and swift actions - from the chef’s initial 661 containers lost at sea. Although this is a tiny percentage of the 250 million containers transported annually, each while unloading Responding swiftly, the duty deckhand arrived at the discovery to the coordinated response efforts - ultimately represents a hazard to the ship, and a general navigation scene without delay. Their initial attempt to suppress the contained and extinguished the fire. and environmental pollution risk, quite apart from the Initial Report fire using the high fog system was met with challenges The ISM Code Section 8, Emergency Preparedness, financial loss of the contents. This report was submitted by the company, who are to be due to the fire’s growing intensity. Meanwhile, another chef mandates regular exercises and drills for emergencies. This The security of the cargo is a significant safety factor for commended for being so willing to share this incident report joined the effort, moving the burning pizza boxes away from concise response highlights its value, and whilst there were the ship, crew, and the environment. It requires the highest to enable others to learn from their experience. other items to contain the fire’s spread. With the escalating areas for improvement, the crew contained and extinguished level of attention to ensure it is carried out correctly. Internal The incident involved a distressing personal near- situation, the duty deckhand used a foam extinguisher to the fire. It is a valuable lesson for maritime safety and and external safety management audits should identify miss incident on a RoRo cargo ferry. The crewmembers effectively put out the flames on the pizza boxes and the emphasises the importance of continuous training and equipment falling below acceptable standards. Additionally, responsible for the daily task of overseeing freight area surrounding the heating lamps. preparedness. ship manager visits should focus on these areas of cargo movements were experienced and qualified individuals. Additional crewmembers quickly arrived and took security. They must also adhere to and check the proper During the incident, the reporting crewmember positioned decisive emergency measures, shutting down all electrical Factors related to this report maintenance history in a PMS, and establish a realistic himself in a blind spot in front of a freight vehicle. systems and ventilation in the galley to prevent the heat Situational awareness – The crew’s response to the reordering stock level for cargo securing equipment. Unfortunately, he was knocked over when the freight driver from the fire from spreading. Simultaneously, nearby doors emergency was swift and appropriate. There needed to The reluctance by the ship to report the state of the misinterpreted a “thumbs-up” signal from the linkspan were promptly closed to curtail the spread of smoke to other be more awareness of the switch’s function (controlling cargo-securing equipment to their management indicates operator. This signal indicated that the freshwater hose had parts of the ship. the heat lamp) by the crew. It was very likely that the heat the company’s poor reporting and safety culture. Given been successfully connected. However, the freight driver The ship’s engineers discussed the manual operation lamps had been switched on before with no consequence. that container security issues in the past had been a incorrectly interpreted this gesture as a cue to proceed of the ventilation system from the engine control room However, this time, pizza boxes were stored near the lamps problem, CHIRP notes that this should have been a high- with discharge. This misinterpretation occurred despite the (ECR), aiming to extract the lingering smoke from the galley and combusted due to radiated heat from the lamps. priority matter. The reporting culture should be addressed presence of red flashing lights that were meant to signal that area efficiently. promptly. Encouraging employees to speak out about it was not yet safe for vehicles to move. From the moment the fire was reported to the bridge, Communication – This switching arrangement was likely safety concerns is vital and should be encouraged. A The incident unfolded in a generally favourable the containment and control of the fire took approximately similar in other ships of the same class. Communicating the crew and other stakeholders that prioritise safety should environment with mild and dry conditions, good visibility, and six minutes. possible hazards to other ships of the same type by labelling be considered an asset to any company in the maritime moderate background noise from fans and vehicle engines. the switch and providing safeguards for preventing contact industry. Safety should always be a top priority, and Noise from fans was also audible within the driver’s cabin. CHIRP Comment with flammable materials is required. How does your organisations must promote a culture where safety The Linkspan area was adequately staffed within the CHIRP praises the crew and the management for having a company communicate design hazards? concerns can be raised freely. organisation with three crewmembers. A senior rating led well-trained crew which handled a potentially dangerous The management company, Flag and the P&I Club were this team, overseeing the deck and the discharge process. situation swiftly. However, there are a couple of points Design – Better design at the new building stages, providing all informed of this report with a request that they check The equipment used in the incident was functioning worth highlighting. The bridge was notified by radio and built-in safeguards for heat contact and switches in the on the status of the cargo-securing equipment on this and correctly. However, concerns were raised about the responded to the incident. Anyone discovering a fire should same room, as the lamps would help prevent accidental use. other ships in the fleet. effectiveness of the red flashing lights as a control measure. always raise a loud vocal alarm (eg shouting ‘Fire, Fire, Fire’), Guidance on securing containers, published by the Past instances have shown that these lights can sometimes and the fire alarm, if fitted, should always be sounded. Both Standard Club, can be found here: 3368203-sc-mg- be disregarded, indicating a weakness in their ability to of these alert everyone in the vicinity that there is a fire so M2175 container-securing-2020-final.pdf (standard-club.com) influence behaviour and prevent accidents. that they can assist in tackling it. The ventilation should be CHIRP is happy to report that the company took positive stopped if not done automatically. The use of high-fog as action to address all the issues concerning cargo-securing CHIRP’s comment an extinguishing medium was ineffective and, in this case, raises the question of whether it is the right application for a Damaged cargo securing equipment and has thanked CHIRP for bringing this matter to their attention. Conflicting work activities were taking place when the incident occurred, and there was no common situational awareness. fire that has taken hold. Heat energy transference from an energy light source equipment Factors related to this report The incident’s beginning lies in certain assumptions made by both the crewmembers and the freight driver. The can be extremely high, and direct contact is not necessary to Initial Report Communications – How easily can you raise a concern to crewmembers operated under the assumption that freight start a fire. Materials such as cardboard and plastic coverings When inspecting the cargo securing equipment, our reporter management concerning a safety matter? How well do they movement would only commence upon explicit instructions will quickly smoulder or melt, even in close contact with discovered that a large number of base locks and twist-locks respond to your concerns? from the designated authority figure. Their belief in the red normal shipboard lighting sources. A minimum distance were worn and no longer fit for purpose. They reported this flashing lights being an effective safety measure to regulate warning sign should be positioned near any heat lamp so to the master, but no requisition was raised to the company. Teamwork – Encourage a shared mental model for cargo freight movement created overconfidence, contributing to that flammable material cannot be heated to combustion, Our reporter remained concerned because stevedores safety and alert each other when issues arise. This is the incident. Additionally, they trusted that the presence or a suitable guard should be placed around the lamp to from other countries frequently reported issues with needed on a large ship where checking on cargo securing of the bosun in the freight vehicle’s path would deter any provide a physical barrier that meets the minimum safe automatic twist lock malfunctions during cargo operations, items cannot be left to one person due to the sheer size of untimely movement of the freight vehicle. However, the distance if applicable. resulting in delays. Moreover, the company had lost many the vessel. bosun, who was in the blind sector of the freight vehicle,

Officer instructed the deck crew to collect all the lifebuoys. regulations and had been tied to the railings on either side of An AB attempted to retrieve the port side man overboard the pilot embarkation station and ‘secured’ to the ladder by a (MOB) lifebuoy. Holding onto the line which connects the spliced eye wrapping around the side ropes. lifebuoy to the smoke float, he released the pin. Failing to It quickly became apparent that neither of these lashings anticipate the weight of the buoy, the line slipped from his had secured the ladder at all, and the ladder had been held grip, and the buoy fell, contacting the corner of the dock by the fortunate accident that the ladder step had jammed quayside before falling to the dock bottom. against the securing points on the rounded fishplate. The combined weight of 7.6 kg fell 22m to the dock Upon arriving on the bridge, the pilot discussed the bottom below. At the time, dock personnel were working on issue with the master, who seemed disinterested in the near the dock bottom but, fortunately, not close to the point of miss that had just occurred. The vessel was reported to the impact. An immediate halt was called to all work in the dock Designated Person Ashore (DPA) and Port State Control due bottom and onboard the vessel. All personnel left the dock to the non-compliant pilot ladder. bottom whilst the smoke float discharged its contents. CHIRP Comment CHIRP Comment This arrangement is a classic example of poor training and Seafarers are used to being at sea, but drydock operations leadership and a vessel that could be more compliant by require another level of risk management. design. Ideally, certified (≥48kN) lashing points should be Ultimately, the incident serves as a reminder that even skilled Had this incident, had the float hit a person as it fell, it positioned on the deck, more than 0.95m from the fishplate. would have caused a severe injury or fatality. The undesired This effectively prevents the pilot from accidentally grabbing crewmembers and freight drivers can face danger during routine tasks event occurred despite a risk assessment and a toolbox hold of a loose section of lashing or ladder as they gain meeting, which should have mitigated this risk. access to the deck. It allows the crew to secure effectively The risk assessment and the toolbox meeting only using a rolling hitch. captured some risk factors. An inexperienced crewmember This vessel was eventually allowed to sail after providing was used to do the job, increasing the risk of the lifebuoy a suitable securing arrangement and is likely to be removed could not be seen by the freight driver, so he did not provide that the company’s safety culture has improved, and the falling. Removing a man overboard lifebuoy is risky, from the list of approved vessels for the terminal operators. any physical deterrence. lives of those working on the ferries will be safer. especially in a dry dock where dry dock workers often have A costly mistake that thankfully didn’t cost the pilot his life. Conversely, the experienced freight driver held his to undertake tasks below the bridge wings. CHIRP notes that some ports refuse to put a pilot onto assumptions. Upon seeing a thumbs-up signal from the Factors related to this report A useful IMCA video on the hazards of dropped items a vessel until non-compliance has been rectified. However, linkspan operator (which actually confirmed the freshwater Alerting – Everyone involved in the operation must be can be found here: 0 Saipem DROPS – choice not chance – greater sharing of pilot incident data is required. Many pilot hose had been connected), the driver interpreted it as a clear reminded of the hazards of movement across the linkspan. IMCA (imca-int.com) jurisdictions have an app for collecting data, but this data is directive to proceed, ignoring the red flashing lights. The normalisation of risk must not be allowed to become only sometimes shared with other pilotage authorities and The presence of the bosun in a blind spot, invisible embedded. Regular training is required both for linkspan Factors related to this report only sometimes passed on to the next port. The best practice to the driver, cancelled out the intended human barrier to operators and freight drivers. Capability – Assigned work in dry docks must be allocated is to inform the next port so that they are forewarned. prevent movement. CHIRP advocates using physical barriers based on the knowledge and experience of the individual CHIRP contacted the DPA and received a very instead of relying on human presence – even