Enclosed/confined space entry – The One Way Assassin

We’ve been concentrating on enclosed/confined space entry this month, here’s the fifth in the series:

The Case Of The One Way Assassin
Kurt was a young ambitious officer with the world of command ahead of him
but he forgot the golden rule: when you go into a trap,
make sure you’ve got two pairs of eyes.

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New Podcast: The Case Of The Rusty Assassin – The Viking Islay Tragedy

New Podcast: The Case Of The Rusty Assassin

The Viking Islay Tragedy

Three men lay dead in the anchor locker.
What they’d need to stay alive was everywhere around them
except in the one place it could have saved them:
The air they breathed

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The Case of The Cygnet’s Kiss Podcast

New Podcast:

Beware, overconfidence and single watchkeeping could be the swan song for your career

The Case Of The Cygnet’s Kiss

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Maritime Safety News Today – 29th May 2008

Maritime Safety News Today – 29th May 2008 is now online at the News @ Mail section, click here.

Stowaways – A Deadly Business

Two communications arrived in MAC’s inbox over the past couple of days with bad news for the families of four now-dead stowaways.

Two bodies were found in a hold aboard the bulk carrier Pascal in Ayr, Scotland. The two men apparently boarded the vessel in Tunisia and hunkered down in a phosphate filled hold with a single bottle of water between them on or around 15th May before the hatches were sealed. Their bodies were discovered on 26th May, eleven days later.

On the day that story broke, Denmark’s Maritime Authority, DMA issued its report on the August 2007 deaths of two stowaways aboard the Danish coaster Danica Brown.

Read the rest at Maritime Accident Casebook here

Praiseworthy MSC Napoli Crew Knew The Drill

We’ll be covering the MAIB’s 56 page and two annexe MSC Napoli report in more depth anon but a footnote got our immediate attention:

“It was evident during the investigation that the master had placed a great deal of emphasis on the importance of safety drills and the maintenance of lifesaving equipment, and that the preparation and lowering of lifeboats had been well-practiced in accordance with company policy.”

No-one was hurt during the evacuation from the ship, and that may be owed to the seriousness with which the master took safety procedures and drills.

The abandon ship did not go without a hitch, “the crewman sitting nearest the forward painter release could not pull the release pin sufficiently far to allow the painter to disengage. He was squeezed between two other crew and his movement was restricted by his immersion suit. The painter was eventually cut by the chief engineer, who had a knife, and was able to reach the painter via the lifeboat’s forward hatch.”

Conditions in the lifeboat were far from easy: “The motion of the lifeboat was violent and the atmosphere in the lifeboat was very uncomfortable; all of the crew suffered from sea sickness. Although the lifeboat was certified to accommodate up to 32 persons, the 26 crew wearing immersion suits and lifejackets were very cramped. They were very warm and several felt faint and de-hydrated. The situation became more tolerable after the crew cut off the gloves from their immersion suits with the chief engineer’s knife. This allowed them to use their hands more effectively, and they were able to drink from plastic drinking water bottles they had brought with them.”

Says the MAIB report: “The abandonment of a vessel in any conditions is problematic. Therefore, the abandonment and successful recovery of the 26 crew from MSC Napoli, in the severe conditions experienced, is praiseworthy. By the time the master arrived at the lifeboat embarkation position, the crew were on board and wearing immersion suits and lifejackets, the engine was running, extra water had been stowed on board, and VHF radios, SARTs and the EPIRB were ready for use. Despite the vessel rolling heavily  the enclosed lifeboat was lowered without incident and then manoeuvred clear of the stricken vessel. Although there were a number of practical issues that should be noted, this successful abandonment clearly demonstrates the importance and value of regular maintenance and drills.”

Sadly, drills are often carried out for the sake of filling in bits of paper, and sometimes not at all, but drills are a pretty good insurance policy.

Lessons from a Beaver

I’ve never known seafarers to adverse to beavers so the picture below may be helpful in making a point about experience versus safety.

Simply follow these steps:

1. Print out picture
2. Put picture in wallet.
3. Wait for someone to say “I’ve been doing this job all my life, don’t tell me how to do it safely”
4. Give picture to speaker
5. Run away

Maritime Safety News Today – 12th April 2008

Ferry Boat Collision in New York Harbor
Military.com – USA
There were an estimated 150 passengers on each vessel. “We quickly dispatched investigators and they are on scene now,” said Chief Petty Officer James Moore

Canadian navy ship called to assist burning cargo vessel in mid …
The Canadian Press – HALIFAX
They are slowly and deliberately assessing the situation but the vessel is not in danger of sinking at this time.” Jeri Grychowski, a spokeswoman for the

Remains of missing Filipino in Japan ship collision found
Inquirer.net – Philippines
By Veronica Uy MANILA, Philippines — More than a month after a three-ship collision off Japan caused the disappearance of two Filipino seamen, ..

Investigators: Atago lookout inadequate
The Daily Yomiuri – Osaka,Japan
… crew members inside the ship were unaware of the fishing boat until immediately before the collision, making it impossible for them to avoid an accident

MAIB Reports on Dublin Viking Fatality

The UK’s Maritime Accident Investigation Branch has published its report into an incident aboard the Dublin Viking last year in which a stern line parted and snapped back,  leading to the death of the second officer.

A full report can be downloaded here.

“On 7 August 2007, the ro-ro passenger ferry Dublin Viking was preparing to leave her usual berth for a scheduled sailing from Dublin. Wind and tidal conditions were benign, but in the process of letting go the stern line, the operator of the stern line winch heaved in the line instead of paying out slack. The stern line parted with a loud crack and snapped back, striking the second officer’s legs. Both his legs were broken and the left leg was almost severed. The recoil of the line also dislocated a shore worker’s shoulder and elbow.
The vessel’s first-aid team and off duty master quickly arrived to treat the second officer. His injuries were severe and it was difficult to control the bleeding. The second officer was evacuated to hospital, where his left leg had to be amputated. He remained in a critical condition and died 6 days later.
The second officer, in charge of the after mooring deck, was obliged to stand in ‘snap-back’ zones near the fairleads, so that he could relay orders to line handlers ashore and deck crew. Analysis of the mooring line after the accident showed that it had deteriorated, its breaking load having reduced from 60 to 35 tonnes, largely due to exposure to Ultraviolet (UV) radiation from sunlight. Although the vessel’s mooring ropes were required to be inspected, the onboard procedures were informal and no records were kept.
The winch operator was attempting to control two winches at the same time, one heaving up the stern ramp and the other veering the stern line. The operator had controlled the winches before, and knew that the controls of the mooring winch operated in the opposite sense; however he was distracted and pushed the stern winch control away from him when intending to veer the rope. This caused the winch to heave in. Tests showed that the electric mooring winch was capable of pulling a far greater load than its stated output for a very short period when it first started to turn. This was sufficient to part the mooring line.
Following the accident, the vessel’s management company has implemented a number of measures designed to prevent a re-occurrence, and the winch manufacturer has undertaken to mark all new mooring winches with their maximum, as well as nominal, rated loads and also to provide more detailed technical information in its manuals.
Recommendations have been made regarding: the technical information supplied with winches; the need to consider the implications of any shore supplied moorings on the mooring structure as a whole; and the dissemination of a “flyer” that the MAIB has published, drawing attention to the lessons learned from this accident.”

The flyer can be downloaded here. It makes the following points:

• The risks in conducting mooring operations must be rigorously assessed and safe working practices developed. Every vessel should have a set of guidelines for achieving a safe mooring which can be modified to suit operational or environmental circumstances.

• Man-made fibre mooring ropes deteriorate in service and can have serious consequences if they part. Operators should develop a Rope Management System to provide a formal inspection routine of all mooring lines, and include as a minimum:

• Assigning competent people, with adequate training and experience to assess the condition of ropes.

• A process of permanently identifying each rope, describing its function, specification and linking it to its warranty certificate.

• Keeping records of planned inspections of each rope, including: date of manufacture and putting into service; condition; exposure to sunlight (or other contaminants) and any unusual loads to which it has been subjected, etc.

• Establishing objective criteria for rope replacement and a specification for new ropes.

• A storage routine in which all ropes are protected from damage and kept away from potential contaminants.

• Assess mooring arrangements as a system; consider the suitability of each element and the compatibility of individual components, particularly ship and shore supplied lines.

• Ensure that the full capabilities of mooring winches are known and understood by all those involved in conducting and managing mooring operations, including the Minimum Breaking Load of ropes to be used.

• Detailed information and guidance on mooring operations and rope inspection is available in publications produced by the Maritime and Coastguard Agency (MCA), Oil Companies International Marine Forum (OCIMF), the Nautical Institute and the Cordage Institute.

TSB Launches Discreet Queen Of The North Report

Canada’s Transportation Safety Board blames poor watchkeeping practices which lead to a course change not being made for the loss of the  8,889 gross tonnes ferry Queen Of The North on March 22, 2006 at Gil Island, Wright Sound, British Columbia, but has declined to provide details of a personal 14 minute conversation between the ship’s fourth officer and the quartermaster on the bridge immediately before the accident.

Speculation about what was said or happened has been of particular interest because  the female quartermaster and the male fourth officer had been in a relationship which ended two weeks before the incident. This was the first watch they had been on together since the break-up.

Despite aggressive questioning from some Canadian journalists, TSB chairman Wendy Tadros declined to give details of the conversation except to say “we have no evidence that it was a fight.”

Behind the discretion is concern about the willingness of crews to  provide information relevant to future investigations. While maritime accident investigations do not depend wholly on crew statements and recollections, often the weakest of evidence, they are still an important element and the co-operation of crew in giving information could be compromised by revealing personal details that do not directly relate to making travel safer.

Said Tadros “We learned what was happening with the vessel… we learned what we needed to learn.”

TSB has recommended the introduction of Voyage Data Recorders, VDRs, the maritime equivalent of aviation’s “little black box”, onto Canadian vessels. These record instrument data as well as what is spoken on the bridge.

About half the investigation’s $900,000 cost went on an ROV dive to recover data from the ship at a depth of some 1,500 metres.  The vessel’s Transas ECS was recovered, together with the AIS, GPS and DSC radio. The ECS data was able to be extracted.

The Queen of the North grounded and sank after failure to make a course change which the fourth officer believed he had ordered. Several distractions may have contributed to the failure. As second course change was due 27 minutes later but he did not monitor whether the first change had been made as he was involved in a personal conversation with the quartermaster for the next 14 minutes.

When he did realise that the vessel was off course, his actions were too little, too late, to prevent striking the island. ECS alarms that might have given a warning were switched off.

There a further delay in responding to the situation because the quartermaster was not familiar with the bridge equipment and did not know how to switch off the autopilot and revert to manual steering.

There should, in fact, have been at least two qualified officers on the bridge but the second officer was on a scheduled meal break at the time of the incident.

“Accidents speak to a failure of the system,” said Tadros, “Essentially, the system failed that night. Sound watchkeeping practices were not followed and the bridge watch lacked a third certified person.”

In its conclusions , the TSB report notes: “The working environment on the bridge of the Queen of the North was less than formal, and the accepted principles of navigation safety were not consistently or rigorously applied. Unsafe navigation practices persisted which, in this occurrence, contributed to the loss of situational awareness by the bridge team.”

At 08:00 p.m. on March 21, 2006, the passenger and vehicle ferry Queen of the North departed Prince Rupert, British Columbia, for Port Hardy, British Columbia. On board were 59 passengers and 42 crew members. After entering Wright Sound from Grenville Channel, the vessel struck the northeast side of Gil Island at 12:21 a.m. on March 22.

The vessel sustained extensive damage to its hull, lost its propulsion, and drifted for 1 hour and 17 minutes before it sank in 430 m of water. Passengers and crew abandoned the vessel before it sank. Two passengers were unaccounted for after the abandonment and have since been declared dead.

The full report can be downloaded here.