CHIRP Annual Digest 2022

An independent and confidential reporting system for the Maritime industry

HUMAN FACTORS DECK SAFETY ENGINEERING, TECHNICAL AND ENVIORNMENT COLREGS AND NAVIGATION YACHTS, FISHING AND RECREATION TUGS AND TOWING SAFETY CULTURE AND REGULATIONS

Annual Digest of Reports and Insight Articles

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

The number of reports received continues to increase year-on-year. Many of these are the result of an industry under pressure

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Maritime Director’s Foreword

I am pleased to present our annual digest for 2022-23, the publication of which is only possible because of the generosity shown by our sponsors and we are very grateful to them for their continuing support. And I’m proud to report that CHIRP continues to deliver meaningful impact. In 2022-23 we raised safety concerns with a greater number of Flag States and Classification Societies than in previous years, and attended a record number of safety events, either in person or online, in the UK, India, Greece, Brazil, New Zealand and the US. We also published 47 reports, up by 50% on the previous year, and we introduced Arabic and Ukrainian language editions of our Maritime FEEDBACK newsletter which is now available in 8 languages. We also introduced a new publication, Superyacht FEEDBACK, focusing specifically on that community. Our Ambassadors promote CHIRP to their local maritime networks, and I’m pleased to say that we now have 48 Ambassadors in 28 countries. To further improve accessibility and engagement, we launched an updated website and an ‘app’ which places our reporting system and safety publications right into seafarers’ pockets. We also significantly expanded our digital presence by posting our Chinese- language editorials on popular social media sites in that country and this, along with other initiatives, has doubled the total number of followers that we have to almost 6,000. I hope that you find this digest both informative and interesting. We are always keen to receive your thoughts on this or any other maritime safety topic which you can email to us at mail@chirp.co.uk.

Adam Parnell Director (Maritime)

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Introduction W elcome to the eighth annual review of CHIRP Maritime reports, covering all the cases we published during 2022 and including some in-depth articles specially express our opinions on any topic, whilst recognising that Adam has the final decision. If more ships followed this excellent style of leadership I believe we would have a commissioned to highlight important safety topics. much safer and more efficient industry. This was our first full year under the guidance of 2022 was another difficult year for seafarers. As the Adam Parnell as Director, Maritime, and Dave Watkins Covid-19 situation showed signs of improving, mariners as his deputy, and you will see their influence in the way were faced with added dangers due to conflicts, especially we analyse reports and seek to extract key points for our in waters off Ukraine, and we have marvelled at the readers. As always, they benefit from the wise counsel of courage of many of our colleagues who have, for example, our Maritime Advisory Board (MAB) and feedback from our kept vital grain shipments moving despite the risks. In growing band of Ambassadors, who volunteer their time to shipping, we are well aware of the sacrifices being made spread the safety message as widely as possible. to keep the world’s trade moving, but more generally there In our editorials in 2022 we have often mentioned is widespread ignorance of the services our seafarers recurring themes in the reports we receive, and a common continue to provide. I can only repeat what I wrote last year theme has been a lack of communication, either between – perhaps one day the world will acknowledge the great those on board a ship or between the ship and the shore. debt it owes to the men and women at sea. It strikes me that our small team at CHIRP Maritime Given the difficult conditions, it is a wonder that our have managed to avoid many of the potential pitfalls of reporters still find time to submit so many excellent reports failing to communicate effectively. Adam and Dave give to CHIRP Maritime, but they have never failed us, and this regular briefings and hold discussions with our MAB, our Annual Digest is above all else a tribute to their dedication. I Ambassadors and other staff members to ensure we all am delighted to thank all our reporters on your behalf. know what is going on. They always welcome input from Our Maritime FEEDBACK magazine continues to the CHIRP Maritime community, and all of us feel free to be published in English, Chinese, Filipino, Indonesian,

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Spanish and Portuguese, so we are most grateful to all régimes are not always capable of finding and correcting the sponsors and translators who help make this happen. the problems. I can promise you that CHIRP Maritime will Please let us know if there are other languages you would speak up on your behalf if we are made aware of such like to receive or, even better, if you would like to sponsor cases. a version in another language. There are still a few of the Within some sections you will again find Insight major seafaring nations which we do not reach in their articles that illuminate topics covered in that section native language, so we would be delighted to hear from or provide additional information. They are written by you if you can help. experts, and are well worth reading. We have again been fortunate in finding generous All our videos, publications and databases are easy to sponsors who have made it possible to produce this access through our website, so we hope you will look at Annual Digest. They are listed at the end of the Digest them when time permits. For more detailed and focused and we are extremely grateful for their support and their research, we recommend the searchable database on the ongoing commitment to safety. website. The generosity of all our sponsors is acknowledged in We hope you will find this Annual Digest both our publications, and we could not function without them, interesting and informative, but please let us know. Your but our reporters (both individuals and companies) remain comments are important, and we read them all to ensure anonymous for obvious reasons. It is a pleasure for me to CHIRP Maritime continues to provide the information you once again acknowledge them all and thank them for their need to make our industry safer. support, without which we would not exist. The usefulness Until next time, take care and may all your voyages of their reports is demonstrated by the increasing number lead you safely home. of examples where CHIRP Maritime is quoted in other publications, and by our growing number of readers around the world. Editor: Captain Alan Loynd This year we saw a few more reports from the towage and leisure sectors, but very little from the fishing and FNI FITA MCIArb BA(Hons) offshore fleets. I am sure there are useful lessons to be learned from these vitally important parts of the industry, so we would welcome more reports from those of you who work in them. Once again, we have divided the Digest into themed sections to assist readers to find the topics which most interest them, but as always there are reports which could be allocated to several different sections so we urge you to study all the sections because they all contain reports which will be of interest both to seafarers and people in shore positions. One message which does come through, unfortunately, is that not all companies are able to demonstrate a robust safety culture, and there are still Please note all reports received by CHIRP are accepted ships where living conditions are abominable, safety is in good faith. Whilst every effort is made to ensure the ignored, and crew welfare counts for nothing. We may accuracy of any editorials, analyses and comments that are even be seeing an increase in the number of reports about published in this digest, please remember that CHIRP does such vessels, which indicates that the various inspection not possess any executive authority.

In shipping, we are well aware of the sacrifices being made to keep the world’s trade moving, but more generally there is widespread ignorance of the services our seafarers continue to provide. I can only repeat what I wrote last year – 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

1. HUMAN FACTORS 08 Machinery breakdown results in allision 09 Near Miss – distraction and work overload 09

2. DECK SAFETY 11 Unsafe lifting points for RIB Work Boat 12 Fatality: crew member caught by rope during mooring operations 12 Deck layout: hazardous by design! 13 Unsafe access! 14 Danger! Working at height! 14

3. ENGINEERING, TECHNICAL AND ENVIORNMENT 16 Smoke inside Bosun’s Store on LPG tanker 17 Fire in LNG carrier compressor room? 17 Fatality – Crew member scalded by steam from a boiler 18 Main Engine failure exposes maintenance deficiencies 19 Personal Injury: Multiple crew burns in engine room 19

4. PILOT BOARDING AND PILOTAGE 21 Accommodation ladder fails after pilot embarkation 22 Poor choice of knot puts pilot in jeopardy 23 Failure to challenge authority leads to a dangerous occurrence 23 Bridge Resource Management - Issues concerning helm execution 24 Failure to communicate a change in the pilot boarding arrangement 25

5. COLREGS AND NAVIGATION 26 Touching bottom while berthing causes rudder damage 27 Breach of the Collision Regulations Rule 15 27 Collision between a tanker and fishing vessel 28 Breach of TSS regulations 30 Contingency action to avoid a close-quarter incident with a passenger ferry 30

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6. YACHTS, FISHING AND RECREATION 32 Fall from vertical quayside ladder has near-fatal consequences 33 Boat tender strikes charted rocks at speed 34 Collision between power-driven vessel and yacht narrowly avoided 34 A sailing yacht grounded at the entrance to a marina 35 Insight: Demonstrating the link between working conditions and safety 35

7. TUGS AND TOWING 37 Collision between a passenger ferry and tug results in fatalities 38 Foundering of a tug 39 Mooring launch crushed against the side of a container vessel 39 Insight: Effective use of tugs for pilots & exempt masters 40

8. SAFETY CULTURE AND REGULATIONS 42 Poor safety standards on floating armoury vessel 43 Foundering 44 Fatality by drowning 45 Fatality – Falling from height 45 Personal Injury: Multiple crew burns in engine room 46 Enforcement of safety regulations – is it adequate? 47

9. CORRESPONDENCE RECEIVED 49

10. APPENDICES 50 Appendix I: Acronyms 50 Appendix II: Insight on the role of Ambassadors 51 Appendix III: How the CHIRP reporting process protects your identity 52 Appendix IV: The Maritime Programme – How it works 53 Appendix V: Our Publications 54 Appendix VI: Our Sponsors 55

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1. Human Factors All our reports contain references the pressure on the crew to do so to human factors, but the two we many things at one time. have selected for this section are These reports underline the need specifically concerned with situations for meticulous planning, and remind where the crew had to interact with us that we sometimes need to be numerous outside agencies. They quite firm with people from the shore. highlight the need for rigorous In addition, it is not enough to rely on contingency planning, and excellent experienced pilots or dock masters communication between all parties. to conduct operations safely – they In the first case, a ship was should be questioned in detail about undocking and intending to proceed their intentions, and a thorough on sea trials. This is a tricky operation risk assessment should bew made. at the best of times and is not Similarly, we have all experienced the something which most crews deal horror of arriving in a port and being with on a daily basis. In this case, inundated by people from the shore, there was a strong wind and the five all wanting our undivided attention, tugs available do not appear to have and all convinced that their business been used to best advantage, so takes priority over everybody else. We when the ship’s engine failed to start should develop robust contingency she drifted onto another vessel and plans to deal with such situations, and various shore facilities. I suggest that shore management In our analysis, we point out that should be taking the lead in ensuring the lack of a coordinated response to the ship’s staff are not swamped as a foreseeable emergency suggests soon as they berth, and that they inadequate emergency planning and have freedom to do their jobs safely. risk assessment. We also question A common factor when we analysed the situational awareness of the these reports, and the comments we participants and the capability of made are as follows: a crew faced with an unfamiliar operation, and ask whether they pressure were under pressure to undock the y recognising different workloads vessel despite the weather? and pre-planning can reduce the The second report concerns a pressure on the crew. This is a ship discharging oil at a terminal. team responsibility. An emergency stop order from the y were the master and crew under shore was given using the wrong pressure to carry out the operation wording, and the ship’s crew did not in unsafe conditions? hear it. At the time, the cargo control room was full of people including We also identified: a bunker surveyor and the ship chandler, while the vessel was also training having a class inspection, a port y the crew did not respond state control inspection and a vetting appropriately to a machinery inspection. breakdown. Do you regularly We highlight the danger of conduct breakdown drills on distractions during cargo work, and your ship?

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M1852 The dry dock pilot should have insisted that the main engine be tested before departure. Was this raised during

Machinery breakdown the master-pilot information exchange?

results in allision Factors relating to this report Situational Awareness (SA) – Collective situational awareness is based upon formal Risk Assessment and the Initial Report adoption of agreed Standing Operating Procedures. It also The vessel was undocking following a successful survey relies on everyone understanding the plan and their part in it in dry-dock. The plan was to move to an inner anchorage and knowing what to do if things go wrong (the emergency to conduct sea trials before her scheduled departure. The response plan). vessel was in a very light condition with a draft of 5m and a freeboard of 17m. Capability – The crew in this incident did not have recent The deck and engine room teams completed their pre- experience of undocking a vessel and had to rely on the departure procedures, but the main engine was not tested. three dock masters. Did the difference in experience and A passage plan had been prepared, and this was given to capability make it difficult for the crew to raise questions the pilot by the master. Three dock masters were also in or concerns? When writing the risk assessments for attendance. Strong winds were forecast (27 knots with gusts uncommon or infrequent tasks, do you consider’ capability’? of up to 35 knots) from the port side. How does your ship empower a ‘challenge’ culture? Five tugs were in attendance, with two attached to the bow, one attached to the stern and two others standing by. Pressure – The undocking went ahead even though the The main engine was set to ‘Stand By’, and the vessel was weather conditions were unsuitable. Dry docks usually are pulled out of the dock by the tugs. As the vessel exited the fully booked, and overstaying can be financially costly. Did dock, the two tugs at the bow were released and the bridge the master and crew feel under pressure to undock even ordered ‘Dead Slow Astern’ on the telegraph. The engine though the conditions were unsafe? failed to respond, and the vessel started to drift to starboard Teamwork is situational: crews who perform strongly because of the strong winds. in familiar situations may not do well when facing One of the tugs was directed to make fast on the unfamiliar challenges. This takes time, leadership and open port side and pull the vessel to port. The tug attached communication. How does your company ensure that your to the stern was not directed to do anything, so it did team is ready to face its next task? not assist. The vessel drifted onto a newly-built moored vessel Training – The crew did not respond appropriately to the which was extensively damaged, as were some of machinery breakdown. Do you regularly conduct machinery the nearby shore facilities. Fortunately, there were no breakdown drills on your vessel? casualties or pollution. Shortly afterwards, a third tug was made fast on the port side, and the pilot was able Manoeuvring into and out of a dry to manoeuvre the vessel to the allocated anchorage. An investigation undertaken by the authorities, owners and dock would be an unfamiliar operation the engine manufacturers found the exhaust valves had for most ship crews. Our maritime not been properly calibrated whilst in dry-dock. advisors questioned why the vessel was CHIRP Comment allowed to undock, given the very strong Manoeuvring into and out of a dry dock would be an winds, and asked if this was due unfamiliar operation for most ship crews. Our maritime advisors questioned why the vessel was allowed to undock, to commercial pressure? given the very strong winds, and asked if this was due to commercial pressure? The presence of