INTERNATIONAL MARITIME ORGANIZATION

E
IMO FSI 15/6 2 March 2007 Original: ENGLISH

SUB-COMMITTEE ON FLAG STATE IMPLEMENTATION 15th session Agenda item 6

CASUALTY STATISTICS AND INVESTIGATIONS Report of the Correspondence Group on Casualty Analysis Submitted by the United Kingdom SUMMARY Executive summary: This document contains the report of the Correspondence Group on Casualty Analysis in accordance with the terms of reference given in paragraph 1 Paragraph 15 FSI 15/6/1

Action to be taken: Related document:

Terms of reference 1 The Correspondence Group on Casualty Analysis, under the co-ordination of the United Kingdom, continued its work intersessionally under the following terms of reference: .1 based on the information received from Members States on investigations into casualties, to conduct a review of the relevant casualty reports referred to the group by the Secretariat; identify safety issues that need further consideration; place on GISIS the review of each individual casualty investigation report. Prepare a synopsis of all reports reviewed, for preparation of the co-ordinators composite report that would be forwarded to the Secretariat for preparation of the correspondence groups report; consider in detail the study carried out by the Inter-Industry Working Group (IIWG) (MSC 81/8/1 and MSC 81/INF.8) and, in particular, the issues relating to availability of casualty data for reporting to MSC 83, taking into account the information provided by Sweden in plenary and the recommendation by the Correspondence Group to refer the report on the Chassiron to the BLG Sub-Committee for consideration of the lessons learned from the accident (FSI 14/5, paragraph 15); and submit a report to FSI 15.
For reasons of economy, this document is printed in a limited number. Delegates are kindly asked to bring their copies to meetings and not to request additional copies.

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Members of the Correspondence Group 2 Representatives of the following Member Governments and associate Member participated as Members of the Correspondence Group for the analysis of reports of investigation into casualties and incidents: Australia, Canada, China, Denmark, Germany, Italy, Japan, Malta, Netherlands, Norway, Republic of Korea, Sweden, United Kingdom, United States and Hong Kong, China, together with observers from the International Chamber of Shipping (ICS), the Oil Companies International Marine Forum (OCIMF), the International Transport Federation (ITF), INTERTANKO and the Institute of Marine Engineers, Science and Technology (IMAResT). Quality of the investigation reports Annex 1 3 The analysis of the reports submitted for this session has confirmed that the standard of report writing continues to rise steadily. The content of many report analysed, in general, met the requirements of IMO resolution A.849(20), paragraph 14. Most of these reports were reasonably well presented and contained enough factual information to analyse the accident indicating that the casualties and incidents had been carefully investigated. Some reports would have benefited from a more structured and detailed analysis of human factors. Overview of the analysis of reports and draft text of lessons learned for presentation to seafarers Annexes 2 and 3 4 Annexes 2 and 3 contain the overview of the analysis of reports and the lessons learned for presentation to seafarers, respectively. The lessons learned and safety issues relate to: .1 .2 .3 .4 safe speed and collision avoidance; correct stowage, inspection, maintenance and rigging of pilot ladders; properly designed and fit for purpose safety critical equipment; conflict between the national or local regulations and current industry guidelines concerning ship/shore electrical continuity bonding cable; maintenance guidance in fire fighting installation manuals; control of passenger movement on ro-ro ferries; safety management system and fire fighting installations and drills; and information and instruction on the carriage of hazardous dry and chemical bulk cargoes.

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Consideration of the study carried out by the Inter-Industry Working Group and reported to MSC 82 5 The Inter-Industry Working Group (IIWG) reported that in its study of casualty reports of incidents of explosions on chemical and product tankers under 20,000 dwt, it found that
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investigators had not asked the relevant questions to find the evidence to give support for the human element as a contributing factor in the casualty. 6 Because of this lack of evidence the IIWG was unable to make a conclusive analysis of the casualty reports. 7 Given this observation, the group noted that an analysis of a chain of events of technical failures is an inadequate basis on which to formulate safety recommendations. This is because the analysis does not go into sufficient depth to explain the reasons why the casualty occurred. 8 It is also impossible to envisage combining this analysis with other similar analysis for statistical purposes. 9 Only by collecting and properly analysing human element evidence can meaningful statistics and safety recommendations be developed. 10 The observation of the IIWG reflect those analysts who observe that, although the standard of report writing continues to rise steadily, the human element in casualties is not always investigated to sufficient depth to give firm ground on which to base safety recommendations. 11 IMO recognizes the need to investigate the human element in casualties. The Maritime casualties and incidents database in GISIS accommodate human element fields. Resolution A.884(21), Amendments to the Code for the Investigation of Marine Casualties and Incidents (resolution A.849(20)) in appendix 1, advises a step-by-step and systematic approach for the investigation of the human element. IMOs Model Course 1.11 for the investigation of marine accidents and incidents includes a module on the investigation of the human element. 12 Given the observations of the IIWG and the analysts, and IMOs recognition of the need to investigate the human element in casualties, the Sub-Committee is invited to consider the means to encourage Member States to develop further the human element investigator skills of its marine casualty investigators. 13 Further to the findings of the IIWG, and IMOs concern about fires and explosions in chemical and oil tankers, it would be useful if the casualty report on the Chassiron is referred to the BLG Sub-Committee. Analysts reviews of the reports of investigation into casualties 14 The list of reports of investigation into casualties which have been reviewed by the analysts members of the Correspondence Group is annexed to document FSI 15/6/1. Action requested of the Sub-Committee 15 The Sub-Committee is invited to approve the report of the group in general, and, in particular, to: .1 refer the analysts reviews of the reports of investigation into casualties, the overview of lessons learned and the draft text of lessons learned for presentation to seafarers (annexes 2 and 3 and FSI 15/6/1) to the Working Group on Casualty Analysis, for review;

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refer to the relevant Committees and sub-committees those reports reviewed by the analysts and considered by the Working Group on Casualty Analysis and which are of interest to them. In doing so, the Working Group will submit supporting information derived from the casualty analysis procedure used for the development of recommendations for consideration by the Committees and sub-committees; consider the means to encourage Member States to develop further the human element investigator skills of its marine casualty investigators; and refer the report of investigation into the Chassiron casualty to the BLG Sub-Committee.

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ANNEX 1 OBSERVATIONS ON THE QUALITY OF INVESTIGATION REPORTS

1 The content of many reports analysed, in general, met the requirements of resolution A.849(20), paragraph 14. Most of these reports were reasonably well presented and contained enough factual information to analyse the accident indicating that the casualties and incidents had been carefully investigated. The reported recommendations appeared to be sound. 2 Some reports would have benefited from a more structured and detailed analysis. In two reports at least, human error was a factor in the casualty, yet no further analysis was provided to indicate the genesis for the unsafe act or condition. This analysis is important, since it may reveal the underlying causes for the unsafe act or condition and identify the safety issues that need to be addressed. 3 Useful to the reader is a report of the analysis of possible causal factors that have been considered but subsequently dismissed, such as alternative possible sources of ignition, or possible sources of water ingress. While the absence of such information does not of course indicate that investigators have not considered such possibilities, it is re-assuring to have it recorded. 4 The analysis of the reports submitted for this session has confirmed that the standard of report writing continues to rise steadily.

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ANNEX 2 OVERVIEW OF LESSONS LEARNED

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COLLISIONS

Safe navigation 1 A safe speed is required for collision avoidance. Higher speeds require earlier detection, longer monitoring and more sea room for effective avoidance. Voyage planning needs to account for traffic areas. Any communications used for collision avoidance need to be early and unambiguous, including ship/shore communications or the lack thereof. Any uncertainty needs to be resolved before actioning agreed manoeuvres. A safe speed is required for collision avoidance. DAMAGE TO SHIP AND EQUIPMENT

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Pilot ladders 1 Pilot ladders should be manufactured and certified in accordance with appropriate standards. They need to be properly stowed, carefully inspected and maintained and correctly rigged in accordance with relevant SOLAS provisions. Pilot ladders should be rigged so that entrapment between the ships hull and the pilot boat is avoided if possible. The rigging of man ropes should be considered, especially in adverse sea conditions.

Safety management system 3 Maintenance procedures should take into consideration the trading pattern and condition of the ship. The importance of ship managers to realise that safety management system procedures and plans do not necessarily address all the possible outcomes. The crew members on board have to make their own assessment of the situation and then act accordingly. One of the pre-requisites of a safety culture on board is an informed culture. Restricting dissemination of information within a shipping organisation may result in that organisation becoming blind to risk. Shipboard operations, tasks and/or work methods which require personnel to put themselves at reasonably foreseeable and unnecessary risk should be redesigned, rescheduled and/or rethought to minimize or eliminate such risks. Safety critical equipment, such as a davit winch brake handle safety pin, operating winch handles in way of access ladders, and lifeboats lashing lines, should be properly designed and adequately maintained to ensure that they are fit for purpose and operating correctly at all times.
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FIRES AND EXPLOSIONS

Ship to shore interface 1 There is general confusion surrounding the actual connection of the ship/shore electrical continuity bonding cable, particularly when the national or local regulations are not in line with the current industry guidelines. There is a clear need for agreement on International Standards to be adopted with respect to the precautions required to minimize the risks associated with static, electrical charge generation and discharge.

Inert gas systems 3 The installation of inert gas systems on board chemical tankers, irrespective of ships size, can enhance fire or explosion safety.

Passenger safety 4 For safety reasons, passengers should not be allowed to remain in their vehicles while the roll-on/roll-off passenger vessel is underway. Crewmembers on board passenger vessels must be readily identifiable to passengers and follow all procedures laid down in the Vessels Emergency Response Manual in emergencies. It is important that crewmembers on board non-Convention passenger vessels should be provided with training courses in crowd management, crisis management and human behaviour. The installation of low-location lighting on board non-Convention passenger vessels can assist passengers and crew to identify escape routes and exits.

Safety management system 8 A ship should not be operated with an engine room or cargo holds without the full protection of its fire fighting system. When vessels enter port with defective safety equipment it is essential that defects are rectified, if necessary, with external assistance, and before the vessel departs if complete rectification is not possible then appropriate alternative means must be provided to the satisfaction of the Administration and the RO responsible for the issue of the relevant certification. When fighting fires in electrical equipment the failure to isolate electrical power during firefighting exposes the crew to undue risk. Safety Management Systems should incorporate set procedures for fighting electrical fires, especially in vessels fitted with a high degree of electrical equipment.

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When planning fire drills, simulated electrical fires should be included. Fire fighting installation instruction manuals ought to contain precise details of procedures to be followed to prepare and test such installations for periodic inspection. The text of it should be approved by the Flag Administration and Classification Society as part of the approval process. Ships operators and ships surveyors should be required to refer to this section of the manual when preparing for or conducting an inspection. The manuals should also indicate, or at least recommend, what maintenance may be carried out by ships personnel, and what should be restricted to fully trained personnel employed by the manufacturer or its recognized/licensed representative.

Cargo Hazards and Characteristics: Dry bulk cargoes 14 Vessels Master and Crew should be properly informed and instructed on the handling of cargoes of doubtful hazard characteristics. They should be made aware of all associated probable hazards. The recognized competent person and the vessels owners and managers should be involved in the loading and transport process. Shippers certification should be double-checked and records verified to ascertain that the pre-loading condition of the cargo has been met in that the cargo should be stabilised as far as possible prior to loading. Special consideration should be given to the potential evolution of hydrogen gas during transport of a cargo. Operators of vessels fixed to carry bulk cargoes susceptible to exothermic reactions should ensure that suitable and appropriate monitoring equipment, correctly calibrated to a recognized standard, is carried and utilised throughout the loading period and subsequent voyage. Full instructions on the use of the equipment, supplemented if necessary by appropriate training, must be provided. Records of the condition of the cargo should be maintained. Cargoes of DRI Fines with a diameter greater than 4 mm should be carried in specialized ships in which proper inert gas installations have been provided. For DRI Fines with a diameter of less than 4 mm. proper forced ventilation using intrinsically safe fan drives is appropriate.

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Cargo Hazards and Characteristics: Chemicals in Bulk 18 Ships operators should emphasize to crews the extreme hazard of entering cargo tanks for cleaning, especially with SCBAs which may themselves give rise to a spark through metal to metal contact. Entry into the tanks should not be allowed until the oxygen level has been confirmed to be sufficient and there are not any explosives/flammables or toxic gases present.

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Ships operators and senior officers should properly implement the company and vessel instructions and guidance, especially with regard to:

Specific cargo inerting requirements Tank cleaning procedures Entry into cargo tanks Conduct of regular and effective fire and boat drills Proper relief and indoctrination/familiarization training for crew members Reporting the failure of critical and/or safety related equipment Carrying out and accurately recording all prescribed training.

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Venting of toxic and flammable gas during gas freeing should be through the vessels approved gas freeing outlets. Cargo vapours should not be allowed to escape at deck level. If portable ventilation equipment is to be used to blow air into a tank, tank openings should be kept closed until work on that tank is about to commence. CAPSIZING Changes of a vessels characteristics and equipment must be inspected and approved by a qualified authority. Putting additional weight on a vessel will almost always affect the stability of the vessel. If the weight is high in the vessel it will reduce the stability. It is important that a ships management team has a basic knowledge of the theory of stability. A passenger vessel should not be allowed to sail without a certificate specifying the maximum number of passengers allowed on board and approved procedures for the check of the number of passengers. A maintenance system and procedures should be in place. The system should contain appropriate intervals of inspections, reporting procedures for non-conformities, follow-up actions and documentation for the finalization of corrective actions.

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ANNEX 3 DRAFT TEXT OF LESSONS LEARNED FOR PRESENTATION TO SEAFARERS

MAIN ENGINE TURBO CHARGER FAILURE

What happened? The second engineer was in the engine-room carrying out some maintenance jobs when he noticed that the main engines turbo charger was over speeding at a dangerous rate. Before he could reach the control room to shut down the main engine, the turbo charger exploded. This was the second turbo charger explosion in four months, but no one was injured. Why did it happen? 1. The turbo charger compressor sustained a centrifugal overload condition, resulting in a radial fracture of the impeller; A scavenge fire may have provided sufficient energy to the turbo charger turbine to over speed to a dangerous rate; Poor cleanliness of the scavenge space; A leaking piston crown O-ring resulted in oil forming a gummy residue on the scavenge reed valves and liner ports; and Blocked liner ports contributed to fuel after burning.

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What can we learn? Thorough scavenge space inspection and cleaning is very important, especially when the vessel is operating on short voyages with prolonged low load running of the main engine. A COLLISION LEAVING PORT What happened? A ship left port in the late evening with a pilot onboard. Just before passing the harbour entrance, the pilot left and the ship proceeded full ahead. On the starboard bow was another ship, approaching the pilot pick-up area. The pilot to the approaching ship was still in the pilot boat and delayed. He saw that a close-quarter situation was coming up and called the outgoing ship via VHF, asking for intentions. He was answered that the outgoing ship was keeping course, due to obstructions. He therefore advised the incoming ship to go to port, which it did. However, it was too late and a collision occurred.
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The outgoing ship had damage in the hull and took in water. The anchors were dropped, but with assistance of tug-boats and after the anchor chains were cut, the ship was beached close by. The approaching ship could berth without assistance. Why did it happen? If the pilot on the outgoing vessel had stayed a little longer, the accident may have been prevented. Both ships claim that they did not hear the conversation of the other ship. The outgoing ship did not apply to the COLREGs, claiming obstructions. The investigation shows however, that there was space and water enough for her to change course. What can we learn? Keeping a VHF-traffic listening watch help you to keep up to date with what is happening around you. Follow the COLREGs and keep to standard procedure. It may reduce confusion. Pilots should stay on board until their task is completed. SHIP MISSING What happened? A tug, towing an unmanned ship, left port for a long and slow journey. Fifteen days later the last noon-report was received at the company. Another 4 days later, the company requested a radio station to call the tug. No answer was received. A month later, an EPIRB-signal was picked up and traced to the tug. The position was searched, but only the EPIRB, a small drifting plate and a small oil-slick was found. Investigation found that the EPRIB had been manually activated. The batteries last for only 92 hours. Later, the towed unmanned ship was found, but not the tug. The rescuer found the tow rope snapped and two emergency towing rigs had failed. The tug and a crew of 13 were never found. Why did it happen? The reason why the tug was lost is unknown. What can we learn? If the company asked for search earlier, there might have been better possibilities finding the crew.

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CONTROLLABLE PITCH PROPELLER FAILURE What happened? While entering the port, the Master noticed that the speed of the vessel was greater than usual and that it did not correspond to the pitch settings. The emergency system was selected, but the starboard propeller remained set on full ahead. The starboard anchor was let go, causing the vessel to deviate from its course. Subsequently, the vessel struck a dolphin. The shock from the impact resulted in a blackout and a loss of propulsion. Why did it happen? The starboard propeller pitch failed to reverse. The servo control piston had seized inside the cylinder. It was later determined that there was presence of water and rusted particles in the hydraulic pitch control system. The master opted to engage the emergency system and not to stop the starboard engine. What can we learn? Regular tests of various pitch commands are necessary to confirm the operational state of the equipment. Regular maintenance of the hydraulic control systems and the frequent testing of the oil, prevents the degradation of the equipment and allow for early detection of water and other particles in the system. COLLISION BETWEEN AN OIL TANKER AND RO-RO VESSEL What happened? An oil tanker was proceeding in a westerly direction. Visibility was good. The OOW of the oil tanker saw a ro-ro vessel ahead, proceeding in an easterly direction. The oil tanker made a number of small alterations to starboard with the intention to pass ahead of the ro-ro vessel. When the two vessels were about one-half mile apart, the oil tanker called the ro-ro vessel. The ro-ro vessel proposed a green-to-green passing. Realizing that it would have to make a large course alteration to port, the oil tanker proposed a red-to-red passing and, because it was not permitted to be closer than two miles from shore, it would maintain its course and speed. Two minutes before the collision, the ro-ro vessel indicated that it would manoeuvre toward the oil tanker. The ro-ro vessel struck the port side of the oil tanker. Both vessels sustained damage, but there was no release of pollution. Escorted by a tug, the vessels proceeded to port under their own power. Why did it happen? Neither vessel monitored the developing situation involving a risk of collision and did not take frequent relative bearings. The arrangement for passing was made only a few minutes prior to the vessels colliding with each other. Furthermore, the OOW on board the ro-ro vessel became perceptually confused by the discussion with the oil tanker to make passing arrangements. The OOW only called the master when the oil tanker was about one mile away.
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What can we learn? Closely monitor vessel traffic in the vicinity to enable the early identification of developing collision situations. Take early and substantial action to keep well clear of vessels. A succession of small alterations of course is to be avoided. Avoid taking action that does not conform to International Regulations for Preventing Collisions at Sea. If in any doubt as to the other vessels actions or intentions, the OOW should seek clarification from the vessel and, if doubt still exists, notify the master immediately and take whatever action is necessary before the master arrives. EXPLOSION ON BOARD A CHEMICAL TANKER What happened? A chemical tanker docked at a terminal to discharge a cargo of methanol. About 15-20 minutes into the unloading of the cargo, an explosion occurred in way of one of the cargo tanks. The fire was extinguished by the crew. There was minor damage to the vessel, but there were no injuries. Why did it happen? There was an accumulation of combustible vapours in the cargo tank the vessel was not equipped with an inert gas system. The intermediate shaft of the cargo pump was rubbing against the casing, providing a source of ignition. What can we learn? Suitable maintenance of shipboard machinery and equipment used in hydrocarbon-related cargo operations is necessary to ensure the safety of the vessel and crew. Use of an inert gas system helps to prevent explosions in cargo tanks. Shore-based inert gas systems may be available for use in some ports. KILLED BY THE RELEASE OF CARBON DIOXIDE What happened? While attempting to release a large quantity of high pressure CO2 to atmosphere, to rectify an earlier error, the resulting reaction from the force of the gas exiting the open unsecured pipe fractured the gas manifold in the CO2 room. The escaping gas killed all four people within the CO2 room at that time.

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Why did it happen? The Chief Engineer did not fully understand the Fixed Fire Installation and during maintenance work inadvertently discharged CO2 from storage cylinders into the discharge manifold where it was trapped. The Management of the vessel failed to take the opportunity of calling in expert assistance to rectify the original mistake while the vessel was in port and, instead, embarked on a misguided and dangerous attempt to release the trapped gas to atmosphere. Ships staff failed to understand the reactive forces occurring when high pressure gases are released from an open pipe/nozzle. Whenever a high pressure fluid especially a gas is allowed to discharge through a nozzle the pipe must be adequately restrained from movement. In the attempts to rectify the situation, the ship was placed in an unsafe condition since the Fixed Fire Installation had been rendered inoperable. What can we learn? Utmost care should be taken when carrying out any maintenance, inspection or testing of CO2 Fixed Fire Installations. Full instructions must be available and studied before commencing work. Effective training in the maintenance and operation of such systems is essential. Maintenance work should only be carried out by fully competent personnel. When in doubt ask. If a Fixed Fire Installation is rendered inoperable, the Flag Administration, Classification Society and, in some instances, the Port Authority must be informed immediately. The energy content of compressed gases should never be under-estimated. A FATAL DRY BULK CARGO OPERATION What happened? Three days after a bulk carrier loaded a cargo of DRI Fines, and while the crew were routinely opening cargo hatches to ventilate the cargo, a series of explosions occurred, resulting in the death by injury of the master. Five members of the engineering staff remain missing, presumed dead. The vessel was lost. Why did it happen? There was some confusion over the nature of the cargo and the manner it should be cared for during transit. However it was known that there was a possibility that the cargo would give off hydrogen gas if in contact with water and there were instructions from the shippers to open hatch covers if the temperature of the cargo was seen to rise. The accident investigation concluded that
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an accumulation of hydrogen ignited. The source of ignition was not determined but was most probably from hot spots within the cargo. What can we learn? Vessels Master and Crew should be properly informed and instructed on the handling of cargoes of doubtful hazard characteristics, such as DRI, and be made aware of all associated hazards. The recognized competent person and the vessels owners and managers should be involved in the loading and transport process. Shippers certification should be double-checked and records verified ascertaining the pre-loading condition of the cargo; the cargo should be stabilised as far as possible prior to loading. Any discrepancy between the instructions on cargo care and monitoring provided by the prospective shipper, the vessels owner/manager and external guidance such as the BC Code should be settled to the mutual agreement of all parties and the satisfaction of the Master before commencing loading. Special consideration should be given to the potential evolution during transport of hydrogen. Operators of vessels required to carry bulk cargoes susceptible to exothermic reactions should ensure that suitable and appropriate monitoring equipment, correctly calibrated to a recognized standard, is carried and utilised throughout the loading period and subsequent voyage. Full instructions on the use of the equipment, supplemented if necessary by appropriate training, must be provided. Records of the condition of the cargo should be maintained. A FATAL TANK CLEANING OPERATION What happened? A chemical tanker caught fire and exploded while the crew was engaged in cleaning residual MTBE from one of several opened cargo tanks, resulting in the loss of the vessel. Only six of 27 crew members survived. Why did it happen? The crew opened up the tanks and entered one of them for cleaning before the tanks were fully gas-freed. Opening the tanks exposed the crew to toxic fumes, permitted flammable vapours, that were heavier than air, to accumulate on deck. They diluted the rich atmosphere in the cargo tanks, bringing them into the flammable range. The ignition source could not be precisely determined, but it was noted that one person was in the tank wearing an SCBA. On that occasion it was considered unlikely that metal-to-metal contact from the SCBA and tank surfaces was unlikely to have been the cause, but the practice is not recommended. Other possible sources of ignition included: electrostatic discharge; mechanical sparks caused by metal-to-metal contact; faulty electrical equipment; hot soot or particles from the funnel; and

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sparks from changing the batteries of portable electrical equipment in a hazardous location.

What can we learn? Venting of toxic and flammable gas during gas freeing should be through the vessels approved gas freeing outlets. No escape of cargo vapours should occur at deck level (Tanker Safety Guide, Chemicals, ICS). If portable ventilation equipment is to be used to blow air into a tank, tank openings should be kept closed until work on that tank is about to commence (Tanker Safety Guide, Chemicals, ICS). The extreme hazard of entering cargo tanks for cleaning is emphasized especially with SCBAs which may themselves give rise to a spark through metal to metal contact No entry should be allowed until the oxygen level has been confirmed to be sufficient and that there are not any explosives/flammables or toxic gases present. Ships operators and senior officers should properly implement the company and vessel SQES, including referenced documents such as the Cargo and Ballast Operations Manual. Where any such documents leave uncertainty in the minds of the senior officers, clarification and, if necessary, subsequent amendments should be sought; under no circumstances should unapproved tank cleaning operations be undertaken. EMERGENCY DISEMBARKATION AFTER EXPLOSIONS ON BOARD What happened? Six out of 27 crew members survived an explosion on board a chemical tanker. All six had evacuated the vessel in a liferaft. All the other crew members evacuated to the water. Only three of these were recovered by rescue services one was found dead, the other two died en route to hospital. In another incident involving explosions on board a dry bulk carrier and the subsequent sinking of the vessel within 40 minutes of the first explosion, the surviving members of the crew evacuated the vessel via a lifeboat. Four crew members remained on board to launch the lifeboat, and then jumped into the sea, one of which was able to swim to the lifeboat. The other three remained in the water for 12 h, arms interlocked, until picked up by a passing vessel. That they had the presence of mind to remain together is to be commended but it should only have been necessary for one member to remain on board to control the rate of descent of the lifeboat. In this instant the four men in the water survived, but under inclement weather conditions they may well have been lost. Why did it happen? In the case of the chemical tanker lack of an organised response to the explosions contributed to the high loss of life. The master abandoned ship without sending a distress signal, without attempting to contact a nearby ship, without conducting a proper muster or search for injured crewmen, and without attempting to launch primary lifesaving appliances. Both the Master and
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Chief Engineer abandoned ship within 10 minutes of the first explosion, leaving behind crewmembers they knew to be alive. Their premature action exposed the crewmen who entered the water with them to the cold water far earlier than necessary, and contributed to the high loss of life. In the case of the bulk carrier, it is not known why four men, instead of one, were required on board the vessel, to launch the lifeboat. Neither is it known why none of them managed to enter the boat via the embarkation ladder. What can we learn? The importance of regular and meaningful emergency and evacuation drills cannot be overstressed. A CAPSIZE OF A CARGO SHIP IN FAIR WEATHER What happened? On approaching port in fair weather with a load of 107 containers the vessel started to list to starboard. The transfer of 5 tons of gas oil reduced the list. One hour later the vessel began to list to port. It was then noticed that water flowed into the cargo hold through a hole in the breather pipe of a ballast tank. Due to the increasing list the ships derrick broke loose and swung to port and several containers rushed to port and created port list still further. The crew abandoned the vessel. 10 crew members were rescued, one lost his life. The vessel capsized and sank. Why did it happen? The ship was old and the maintenance standard poor. There was lack of reliable inspections. There was an underlying pressure by the owner on the master to keep the boat running although several certificates were outdated. Serious hull failures caused water ingress and a free surface effect due to water in the cargo hold created the list. Further water ingress due to failure to close the emergency escape hatch between the engine room and the hold increased the list to the point of capsizing. What can we learn? A careful, qualified and documented maintenance is of great importance for the safety of the ship, especially for old ships, and its crew. VEHICLE DECK FIRE ON BOARD A RO-RO FERRY What happened? A fire was discovered on the lower vehicle deck of a non-Convention roll-on/roll-off ferry. The deluge system was activated and the fire was fought by ship staff as the ferry continued on its destination. Passengers were safety evacuated to shore and the fire was declared extinguished by the shore fire brigade. The vehicle deck 1 was suffered extensive smoke damage and considerable heat damage.
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Why did it happen? The fire originated in or around a tractor-trailer parked on vehicle deck 1; the cause of the fire is undetermined. However, one of the possible contributing factors was that passengers, particularly commercial truck drivers, continue to remain in their vehicles during transit despite inherent risks in doing so. What can we learn? For safety reasons, passengers should not be allowed to remain in their vehicles while the roll-on/roll-off ferry is underway. Crew members on board passenger vessels must be readily identifiable to passengers and follow all procedures in the Vessels Emergency Response Manual in emergencies. It is important that crewmembers on board non-Convention passenger vessels should also be provided with training courses in crowd management, crisis management and human behaviour. The installation of low-location lighting on board non-Convention passenger vessels can assist passengers and crew to identify escape routes and exits. A SERIES OF EXPLOSIONS ON BOARD A CHEMICAL TANKER What happened? A series of explosions and subsequent fire occurred inside the cargo tanks on a chemical tanker when unloading chemical to a shore terminal. Two seamen on the main cargo deck were killed and the chief officer was injured. The fire was eventually brought under control by local fire brigade. The damage caused a constructive total loss of the vessel. Why did it happen? The most probable cause of the initial explosion was due to a static or electrical discharge of sufficient strength to create an ignition source within a volatile environment that had developed on board the vessel. What can we learn? General confusion surrounding the actual connection of the ship/shore electrical continuity bonding cable, particular when the national or local regulations are not in line with the current industry guidelines. There is a clear need for agreement on International Standards to be adopted with respect to the precautions required to minimize the risks associated with static, electrical charge generation and discharge. The installation of inert gas systems on board chemical tankers, irrespective of ships size, can enhance fire or explosion safety.

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FAILURES OF PILOT LADDERS FAILURE 1 What happened? A pilot was disembarking from a ship when both rope sides of the pilot ladder failed. The pilot then fell approximately 27 metres to the deck of the pilot cutter below and was seriously injured. Why did it happen? The rope pilot ladder was old and had not been adequately maintained. The pilot ladder may have been damaged or strained when it was trapped between the ships hull and the pilot cutter immediately before the accident. The pilot ladder was not rigged high enough above the waterline which led to it being trapped between the pilot boat and the side of the ship. There were no man ropes fitted which may have allowed the pilot a grab when the pilot ladder started to fail.

What can we learn? Pilot ladders should be manufactured and certified in accordance with appropriate standards. They need to be properly stowed, carefully inspected and maintained and correctly rigged. Man ropes should be ready to be rigged, at the pilots request, especially in adverse sea conditions.

FAILURE 2 What happened? As a pilot was boarding a ship, the pilot ladders side ropes parted approximately five steps up from the bottom. The pilot was uninjured and subsequently boarded the ship using the pilot ladder on the port side. Why did it happen? The pilot ladders on the vessel were old and had not been adequately inspected or maintained. The pilot ladders were permanently rigged and subject to weather damage. What can we learn? Pilot ladders should be manufactured and certified in accordance with appropriate standards.

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They need to be properly stowed, carefully inspected and maintained and correctly rigged. INADVERTENT RELEASE OF A DAVIT WINCH BRAKE

What happened? While a ship was at sea, the bosun was sitting astride of a davit cradle, under a lifeboat, securing a trigger line for the davits harbour pin. In the course of his work, another seaman inadvertently stood on the davit winch brake operating handle which released the winch brake. The lifeboat started to move and its lashing lines, which were secured, failed under the load which allowed the boat to move further. The bosun was knocked backwards off the cradle and into the sea 15 metres below. Despite search and rescue efforts by local authorities and the crew, the bosun drowned. Why did it happen? The bosun had placed himself in a risky situation and was attempting to perform a two man job on his own. The location of the davit winch brake operating handle near the lifeboat davit cradle ladder resulted in the accidental operation of the brake. The safety pin arrangement on the davit winch brake operating handle was not correctly adjusted and it allowed the brake to be disengaged with the safety pin in the locked position. The wire rope in the lifeboats lashing line was severely corroded and resulted in its failure under the weight of the moving lifeboat. The bosun had had only four hours off duty in the previous 24 as a result of the ship being short staffed. At the time of the accident he was likely to have been suffering from some effects of fatigue. What can we learn? Shipboard operations, tasks and/or work methods which place the crew in danger should be avoided. Safety equipment, like the davit winch brake handle safety pin, operating handles in way of access ladders and the lifeboats lashing lines in this accident, should be properly designed and maintained to ensure that they are operating correctly at all times. ALCOHOL AND GROUNDING What happened? A ship, after undertaking some survey work, was returning to port when it ran aground. After some time, it floated free and then re-grounded nearby. The crew were evacuated but the master remained on board and grounded the ship again whilst attempted to get it to port. He took the ship off again and sailed back to port.
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Why did it happen? The master made a navigational error leading to the first grounding caused by excess alcohol consumption (it was a dry ship). Crew were aware of rules being broken but took no action. Independent actions by some crew members may have contributed to a more serious outcome.

What can we learn? Violations (rule breaking) should not be ignored as it may lead to an incident. Seafarers should ensure that they are familiar with the correct use of any equipment supplied. SLEEPING ON WATCH What happened? A ship ran aground, at night, when the master (OOW) fell asleep on watch. Why did it happen? The master was under the influence of alcohol. There was no lookout on watch. Previous incident involving the master was not properly investigated or followed up by the company. Poor navigation practices. Watch alarm was not used.

What can we learn? Violations (rule breaking) should not be ignored as it may lead to an incident. Lookouts need to be posted, especially at night. Watch alarms should be used if fitted. COLLISIONS IN THE PORT APPROACHES COLLISION 1 What happened? Two small tankers (no pilots required), one inbound, one outbound, collided in the port approaches, in a confined section of the main channel. The ships had to pass in an area that was restricted due to long term dredging activities. Both ships suffered significant damage.

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Why did it happen? The reduced width of the channel in the area of the dredging. Poor promulgation of information by the port. VTS allowed ships to make their own arrangements. There was a blind sector in the VTS coverage. Glare from shore lights affected inbound ship. Unsafe speed by both ships. Inadequate communications between the two masters.

What can we learn? Any communications involving collision avoidance need to be unambiguous and need to be made early. Uncertainty needs to be resolved before continuing into close quarters. The faster the ships travel to earlier decisions need to be made. Higher speeds reduce the chance of correcting mistakes and increase the consequences.

COLLISION 2 What happened? A collision occurred between two large container ships in the approaches to a high traffic port. Why did it happen? A high traffic volume of both larger high speed ships and small fishing vessels. Ships proceeding at high speeds, and changing speeds, as they approach and depart the port area making risk assessment and collision avoidance more difficult. Failure of the AIS signal on one ship may have distracted the watchkeepers on the other as they tried to communicate. Voyage plan did not identify the high risk imposed by the area of high traffic density. Fishing vessels complicated the manoeuvres of the larger ships.

What can we learn? Higher ship speeds require longer range risk assessment and continuous monitoring. A safe speed needs to take into account the traffic types and density. Voyage planning should identify areas of increased risk from traffic. Higher speeds reduce the chance of correcting mistakes. _____________
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