1.

Fire in the freezer

A high temperature alarm sounded for the freezer. The chief engineer went to investigate. On
opening the main door he could smell burning and he saw flames coming from the back of the
freezer. He activated the alarm nearby, called ‘fire’ on the radio, and fought the blaze with a dry
powder fire extinguisher. The fire attack team soon arrived and took over extinguishing
operations. There was no significant damage apart from some food and boxes.

O alarmă de temperatură ridicată a sunat pentru congelator. Inginerul șef a fost sa investigheze.
La deschiderea ușii principale, a putut mirosi arderea și a văzut flăcări provenite din spate a
congelatorului. A activat alarma de foc din apropiere și a luptat impotriva focului cu un extinctor
cu pudra uscata. Echipa de atac de foc a sosit curând și a preluat operațiunile de stingere. Nu a
existat nici un prejudiciu semnificativ de la unele alimente și cutii.

The investigation revealed that the heating element, which is coiled around the drain pipe, had
become damaged over time and was touching nearby boxed stores. When the freezer went into
defrost mode, which it does automatically twice a day, the heat ignited a box or the packaging
that was in contact with the coiled element. The vessel was about 10 years old and the freezer
defrost had been operating in this way since new.

Ancheta a arătat că elementul de încălzire, care este înfășurat în jurul conductei de scurgere, a
devenit deteriorat în timp și atingând magazinele în Box în apropiere. Când congelatorul a intrat
în modul de dezghețare, care se autosornește automat de două ori pe zi, căldura a aprins o cutie
sau ambalaj care a fost în contact cu elementul de înfășurare. Vasul avea o dată de 10 ani și
dezghețarea congelatorului funcționează în acest mod de la noi.

Lessons learned
- It appears that there had been no regular checks of the wiring. Such checks could have helped
discover the damage the coil had experienced.
- Wires carrying electrical current should be protected against physical damage. In this case,
boxes and stores were placed directly against the defrost heating element. Not only could this
practice damage the wire, but once the wire is damaged, as in this case, it could initiate
combustion with contacted boxes.

Lecții învățate - se pare că nu au existat niciun control periodic al cablajului. Aceste controale ar
fi putut ajuta să descopere deteriorarea pe care boulia le-a experimentat. - Firele care poartă
curentul electrice ar trebui protejat împotriva daunelor fizice. În acest caz, cutiile și magazinele
au fost plasate direct împotriva elementului de încălzire de dezghețare. Nu numai că această
practică nu deteriorează firul, dar odată ce firul este deteriorat, ca în acest caz, ar putea iniția
combustibil cu cutii contacte.
 2. Crane boom falls into hold
A general cargo vessel was in port loading packaged timber. The ship was moored to a large
barge equipped with a knuckle boom crane. This was being used to load the ship, together with
one of the ship’s own cranes. Two stevedores worked together in the ship’s cargo hold, directing
the loading and uncoupling the sling. No other member of the stevedoring team was on board to
act as signalman or hatch boss to supervise and control the loading operation from the ship’s
deck.

O navă de marfă generală a fost în port. The Work ambalated cherestea. Nava a fost mocrată la o
barjă mare echipată cu o macara cu braț de tăiere. Acesta a fost folosit pentru a încărca nava,
împreună cu una dintre macarale proprii aspirației. Două stedorete au lucrat împreună în carnea
de pornire a navei, direcționarea încărcării și decuplând mângâierea. Nu a fost la bord și altul
membru al Sendentului, pentru a acționa ca Senumb sau Hatch BOSC pentru a supraveghea și a
controla operațiunea de încărcare de pe puntea navei.

The ship’s crane had difficulties reaching certain zones of the cargo hold; this resulted in the
crane arm being operated close to or even beyond its lower limit. When cargo handling had been
ongoing for around a day and a half the topping cable released from the winch drum and the
crane arm fell into the cargo hold, landing about half a metre from the stevedores. Fortunately,
there were no physical injuries.
Macara navei a avut dificultăți în a ajunge la anumite zone ale țării de așteptare; acest lucru a dus
la brațul macaralei care funcționează în fața lor sau chiar dincolo de limita inferioară. Când
manipularea încărcăturii a fost în curs de desfășurare pentru o zi și jumătate din cablul de topire
eliberat din tamburul de crină și brațul macaralei a căzut în poziția de încărcare, debind
aproximativ o jumătate de metru de la Stevedores. Din fericire, nu au fost răniri fizice.

The official SHK investigation found, among other things, that:

- The ship’s crane had been modified. An extra switch had been installed which, when activated,
bypassed the crane’s limit switches for maximum lowering. It appears the modification had been
made by a previous operator and crew. The reason for the modification could not be determined.
Bypassing the limit switches allowed the crane boom to be lowered to a level which was too low
for cargo handling, and to a point where there was not enough cable remaining on the winch
drum to hold the combined weight of the crane boom and cargo load.

- The present crew, relatively new to the ship, had not discovered the bypass switch during the
course of their own inspections.
- The crane operator did not perform a full operational check of the crane before the start of
lifting manoeuvres. Such a check may well have helped in the discovery of the nonconforming
bypass switch.

Lessons learned
- Never bypass safety equipment such as limit switches.
- Always do full operational tests before using cargo handling equipment.
- Always use a signalman during cargo operations.

3. Near miss – Not dropped but reported

A supply vessel was unloading a mud skiff and cargo to an offshore platform. During the hook
up preparations a post cover was removed from its normal position and placed on the top of the
mud skiff while lashings were fitted to the cargo. There was a change of shift on the supply
vessel and a new deck crew continued the securing operations and the lift. The new crew did not
notice the post cover, and it remained balanced on the mud skiff as the skiff was hoisted to the
platform.

The occurrence was later reported by the crew of the offshore platform as a dangerous incident
(potential dropped object). Weighing approximately 4kg the post cover, unsecured on the mud
skiff being raised to the platform, was potentially a lethal hazard.

Lessons learned
- No procedure was in place for managing the removal and replacement of post covers during
cargo operations. As a consequence the post cover was forgotten on the mud skiff and, being
unsecured, it became a hazard. - Reporting incidents such as a potential dropped object, even as
in this case where there was no adverse consequences, allows ship operators to improve their
procedures and increase safety.

4. The lifejacket that didn’t float

Recent inspections have found some vessels with inadequate lifejackets. The unicellular foam
buoyant material within the nylon outer shell had degraded significantly over time, and in some
instances was reduced to dust.

The lifejackets were properly stored, kept dry, and not under direct sunlight; however, the
storage location was very hot at times. These particular lifejackets, manufactured in China, were
the Type 1, 160RT model distributed by The Safeguard Corporation of Covington, Kentucky.
They were approximately nine years old.
Lessons learned
Lifejackets should be regularly inspected for indications of failure or degradation, specifically
for:
Compression: The lifejacket may be compressed from many years of stowage.
Loss of resiliency: The lifejacket is excessively hard, stiff or its foam is brittle. Normally after
compressing the lifejacket to about half its initial thickness, the foam should expand to its
original dimension in a short period of time.
Shrinkage: A physical reduction in size may be indicated by ‘wrinkling’ of the coating on vinyl
dipped types or by a loose fitting shell on a fabric-covered lifejacket.

5. Unsafe practices become the norm

A car carrier sailed from port under the con of a pilot, with 1,633 cars and various heavy
equipment loaded. The ship proceeded out, making good a speed of 10 kts when the pilot gave
the first helm order to starboard. The turn was completed without incident, the ship heeling to
port and returning upright as expected. A few minutes later, as the car carrier entered the main
channel, the pilot requested that the ship’s speed be increased.

Meanwhile, the chief officer was still undertaking final stability calculations in the cargo control
room. He became concerned that the indicated metacentric height (GM) on the stability computer
was less than his earlier departure stability calculation had predicted. He sent the deck cadet to
take soundings of the three aft peak tanks in preparation for loading additional ballast water. The
chief officer began setting up the ballast system as he anticipated that he would require
additional ballast in the aft peak tanks.

As the vessel made the next turn, this time to port, it heeled progressively to starboard until its
rudder and propeller were clear of the water. The vessel then suffered a blackout. Several cargo
units and items of ship’s equipment broke free from their lashings and shifted as the ship heeled.
This resulted in a hole being punctured through the shell plating in way of the ship’s gangway
recess, allowing sea water to enter deck 6 when it became submerged.

Two tugs were tasked by vessel traffic services (VTS) to proceed towards the vessel and assist as
required. Eventually the car carrier grounded. The inclinometer on the bridge was indicating a
list of 40° to starboard.

Following the accident, all 24 crew were successfully evacuated from the ship or recovered from
the surrounding waters. There was no pollution. A major salvage operation successfully refloated
the vessel and it was taken to a safe berth.

Official findings
A key finding of the official investigation is that a departure stability calculation had not been
carried out on completion of cargo operations and before the car carrier sailed. Witness and
anecdotal evidence suggests that this practice extends to the car carrier sector in general. The
critical task of establishing whether the ship has a suitable margin of stability for the intended
voyage before departure had been eroded on board. This unsafe practice had become the norm.

Many contributing factors were interconnected with the unsafe practices, such as:
-The actual cargo weight and stowage were significantly different from the final cargo tally
supplied to the ship.
- Cargo unit VCGs (vertical centres of gravity) were not considered when calculating the
stability condition.
- The vessel’s ballast tank gauges were broken. As a consequence, the quantities were estimated.
These differed significantly from actual tank levels.
 6. Battery explodes
The electro-technical officer (ETO) was repairing an instant reaction electronic welder’s mask.
The tablet-style lithium ion battery needed replacing, and because of the compact nature of the
equipment it was considered that this could only be done by soldering connections on to the new
battery.

The first connection was made successfully. While soldering the second connection, the battery
overheated and popped, spraying the battery contents into the ETO’s eyes.

First aid was immediately administered by applying copious amounts of water to both eyes for
10-15 minutes using the emergency eye station sachets.

The Master called for medical advice and was advised by an eye specialist to apply cortisone
steroid drops three times daily and analgesic drops as necessary. The doctor did not feel medevac
was necessary, but advised the Master to monitor and call back if necessary.

After the first dose the victim’s eye condition improved rapidly, with a significant reduction in
redness and irritation within 15 minutes. Fortunately for this crew member, the excellent
emergency medical crew response on board meant that no permanent damage was sustained.
Lessons learned
- Eye protection is essential when carrying out activities that have a risk of eye injury.
- Rapid and correct first aid response and treatment can make the difference between fast
recovery and permanent injury.
- A risk assessment should always be carried out for unusual or uncommon jobs.

7. Lively dead tow

A barge was being brought into port as a dead tow by a tug under the con of a pilot. As the tug
approached the fairway buoy at the port entrance, the towing gear of the tug began to part. The
crew deployed one of the barge’s anchors and managed to prevent it from drifting into other
vessels in the anchorage.

The tug crew recovered the damaged towing wire and changed to a second wire in order to hold
the barge steady until a plan could be devised. The pilot requested tug assistance from the port
but received no response. Pilot and Master then decided to attempt to enter the breakwater, with
the understanding that two harbour tugs would meet the barge at a point on passage, but this did
not occur. The two tugs remained inside the breakwater as the tug and barge continued on
passage in heavy wind and swells.

As this manoeuvre was unfolding the second towing wire parted. By this time two small harbour
tugs were close at hand, though not made fast. Both tugs attempted to hold the barge in position
but it ended up sideways in the main channel nonetheless, only just missing rocks as it swung
through 90° in the main channel.

Lessons learned
- Tug and towing gear should be appropriate for the job. In this case the tug and gear in question
was rated at 68-tonnes bollard pull while the recommended bollard pull for the barge in question
was 100t.
- Only one pilot was assigned for this complicated and delicate job. Best practice in many ports
would be to assign two.

8. Hydrodynamic interactions while passing

A container ship (A) had closed to approximately 8 cables astern of a loaded tanker (B) in a
restricted waterway. The pilots of the two vessels had made overtaking arrangements; the tanker
would move to the north side of the channel and reduce speed, and the container ship would also
reduce speed, move to the south side of the channel, and overtake the tanker on its port side.

Ten minutes later, the helmsman on vessel A found it necessary to use a considerable amount of
port helm (up to 23°) to maintain the desired heading of 235° Gyro (G). However, this
information was not relayed to the pilot, nor did the pilot detect it from monitoring the rudder
angle indicator. About one minute later, after passing a green channel buoy, the vessels were
beginning to draw parallel to each other. They were now about 75 metres apart. Vessel B had
reduced speed and was making 7.3kt, and vessel A was proceeding at 10.7kt.

A few minutes later, vessel B sheered suddenly to starboard. To regain control, the pilot ordered
hard-a-port helm and half ahead followed by full ahead. Once the vessel steadied on a course of
236° G, the engine telegraph was reduced to dead slow ahead. Shortly afterward, there was no
longer any apparent speed difference between the two vessels; both were proceeding at
approximately 8kt.

The pilot on vessel A then requested that vessel B further reduce speed so the vessel A could
complete the overtaking manoeuvre. The pilot on vessel B agreed to the request, adding that he
had just used ‘full ahead’ power to correct a sheer to starboard. For the next five minutes, vessel
A’s propeller pitch was modified incrementally on several occasions, resulting in an overall
increase in speed from 8.2kt to 9kt. The changes were carried out by the OOW, who used his
discretion to interpret the pilot’s orders, which were delivered in unquantified terms such as
‘faster’. As its speed increased, vessel A began to experience bank suction aft. The helmsman
maintained the desired heading and prevented the bow from moving to starboard by applying
more port helm. Again, this information was not communicated to any other members of the
bridge team.

A few minutes later the pilot of vessel A asked the pilot on vessel B to further reduce speed. Pilot
B replied that he was unable to comply without losing manoeuvrability. Moreover, vessel B’s
speed had now increased from 7.3kt to 8.2kt despite the fact that there had been no change from
the previous command of dead slow ahead. Despite full starboard helm at this point, vessel B
continued to move towards vessel A. For the next two minutes, the distance between the vessels
continued to decrease. Even with vessel B’s engine telegraph set to stop, the tanker continued to
accelerate to more than 8.5kt. Aboard vessel A, the pilot requested greater speed and eventually
full ahead.

With the vessels closing, pilot B asked for full ahead, in an attempt to pull away.
Notwithstanding this action, the two vessels collided, making parallel body contact about 9
minutes 40 seconds after the overtaking manoeuvre had begun.

Some of the findings of the official report were:

- Neither pilot appreciated early enough the strength of the hydrodynamic forces at work, nor the
need for early and decisive action to prevent the vessels from drawing together.
- Ineffective bridge resource management and poor communication between the vessels
prevented both bridge teams from recognising the developing situation and taking timely action.

Lessons learned
- When in the confines of a narrow channel, hydrodynamic forces between vessels are greater
than when in open water due to the reduced flow capacity around the vessels and through the
channel.
- When two ships pass or meet in the confines of a narrow channel, the squat experienced by
each vessel increases by a considerable percentage.
- Hydrodynamic forces experienced by the vessels are proportional to the speed of the vessels
through the water and inversely proportional to the distance between the vessels and the under-
keel clearance of each vessel.
- The overtaking ship’s resistance increases once past the overtaken ship, and the latter’s
resistance decreases. This can lead to a ‘trapping situation’ for the overtaking vessel.
- It is difficult to predict the onset and magnitude of hydrodynamic forces in the confines of a
channel when manoeuvring large vessels.
- The hydrodynamic pressure zones around vessels can extend farther than the 100 metres
commonly assumed.