MARINE

ACCIDENT, INCIDENT

NEAR MISS REPORTS

(OFFICIAL REPORTS ADAPTED FROM

Marine Accident Investigation Branch - MAIB)

Одесса - 2017

Part 1.

NEAR MISS REPORTS

A near miss (потенциально опасное происшествие) is a hazardous event which does NOT result in accident / injury but a situation has arisen where an accident or an incident could have happened.

Some examples of near misses which occur during day-to-day activities:

A seaman is found aloft (на высоте) not wearing a safety harness (страховочный пояс),

Acid is spilled while filling up emergency batteries,

A cargo net breaks while taking on stores but there is no damage,

Emergency action is required to avoid collision.

Near misses should be reported to a Senior Officer or the Master who will complete a near miss report to send to the office.

Near miss reports should be completed in full so that a complete picture of the incident can be built up.

Near miss reports do not need to be signed.

Once received by the office a near miss will be analysed and compared to other near misses. In this way, trends can be identified and changes put in place to improve safety onboard.

Near miss reports should be filed onboard so that action can be followed up and they can be accessed by external examiners / auditors.

CASE STUDY

Case study - 1. Pilot Ladder Insecure

Weather: SW winds, 26 knots cloudy with showers.

The pilot vessel came alongside the departing ship from Fremantle Port inner harbour. The procedure is to check that the Pilot ladder is correctly rigged as per the guidelines set by the International Maritime Pilots Association, before the Pilot disembarks. The testing of the ladder involves placing weight on the ladder and pulling on the manropes. When the manropes were tested it became apparent that one of them had not been correctly secured.

The pilot then proceeded to instruct and assist the crew to correctly rig both manropes. The pilot proceeded to disembark with no problems. This near miss is a reminder of the dangers that the pilot is exposed to when transferring between pilot launch and ships at sea. Had the Pilot crew not correctly followed procedure and had the pilot not noticed, it is certainly possible that the pilot may have fallen.

1. Answer the questions.

Weather: SW winds, 26 knts cloudy with showers. What is the force of the wind in this case according to the Beaufort scale?

According to what organisations should the Pilot ladder be rigged correctly?

How should the Pilot ladder be tested properly?

5. Can you explain the expression “placing weight on the ladder”, and “pulling on the manropes”. Describe the process.

6.What is “near miss” ? Why is it so important to report near misses to the company?

7. Who is responsible for securing the Pilot ladder on board the ship?

2. Decide if the following statements are True or False. Correct the wrong ones.

The reminder of the dangers that the pilot is exposed to is called dangerous avoidance of the accident.__________

The pilot vessel was underway alongside the departing ship from inland harbour Fremantle Port.__________

Prior the Pilot disembarks, the officer must be sure that the pilot ladder is secured correctly.

____________

When the manropes were tested it became clear that the pilot ladder had been rigged properly.

______________

5. The Pilot crew had not correctly followed the procedure and the pilot had not noticed that the ladder was unsecured. _____________

3. Give synonyms to the given words. You may use more than one.

departure _____________________________________________________________________

harbour ______________________________________________________________________

guidelines ____________________________________________________________________

apparent _____________________________________________________________________

pilot launch ___________________________________________________________________

danger ________________________________________________________________________

to rig_________________________________________________________________________

Read a near miss report (see a sample in annex).

Complete a near miss report covering the following items.

1. Description of the situation;

2. Possible cause of situation (root cause) and possible consequences;

3. Which preventive measures have been taken;

4. Master's decision (plan for further handling of above incident)

Case study-2. Very Near Miss

Own ship, a British registered container feeder vessel, running from Jeddah to Aqaba with a Russian crew, plus British Master and Chief Engineer. The other ship was a ferry, probably running from Jeddah to Egypt. Weather calm, clear, good visibility. Daylight, early afternoon, local time. Little traffic, plenty of sea room.

Own vessel sailed from Jeddah in the late morning bound for Aqaba, making about 12.8 knots eventually on a course of 328. Other vessel sailed somewhat later, making about 2 knots more than us. Shortly before noon I noted the ferry on the quarter slowly overtaking us. I went down for lunch at about 1230, noted the ferry through the messroom porthole a couple of points abaft the port beam, she looked to be paralleling us at about a mile off. I looked up again a short while later and the ferry was a couple of cables off, heading towards us and closing rapidly. I went directly to the bridge where the 2/O was talking to the ferry on the VHF. The ferry was telling us to slow down so that he could pass ahead of us. I put the wheel to hand and went hard a starboard, telling the 2/O that I had taken control of the watch. At this stage the ferry was about a cable away. We swung away rapidly and the ferry said thanks.

Answer the questions.

1. What vessels participated in the near miss?

2. What was the course of the container feeder vessel?

3. What was the position of the ferry in regard of the container vessel?

6. Who was keeping watch on the container feeder vessel?

7. What vessel was making an attempt to overtake the own vessel?

8. Who took control of the watch?

9. What were the ferry’s recommendations to avoid collision?

10. Can you assess it as a close-quarter situation? Give your reasons.

11. What actions were taken by both vessels to avoid collision?

Choose the factors which could become a reason of possible disaster and discuss them.

1. Negligence

2. Language barrier

3. Bad visibility

3. Self-confidence

5. Adverse weather

6. Lack of information

7. Fatigue

3. Decide whether these statements are true or false. Correct the wrong ones.

1. The own vessel was a British registered reefer.__________

2. Own vessel was making about 10 knots eventually on a course of 258._____________________

3. The Chief Officer was keeping watch when the other vessel requested to speed up.________

4. 2/O put the wheel to hand and went hard a starboard._________________

5.2/O was talking to the pilot on the VHF.____________

6. When the 2/O took control of the watch the ferry was about a cable away from the own ship. ____________

4. Read a near miss report (see a sample in annex). Complete a near miss report covering the following items.

1. Description of the situation;

2. Possible cause of situation (root cause) and possible consequences;

3. Which preventive measures have been taken;

4. Master's decision (plan for further handling of above incident)

1. Case study - 3. Irresponsible Actions (near collision)

I was on board a 290 meter Panamax box ship as harbour pilot and outbound from a major US East Coast container port with 11.6 meters draft. An inbound vessel was a 190 meter box ship with 9.4 meters draft. She was drifting offshore, awaiting the berth occupied by the outbound vessel. As is customary, the pilot station dispatcher advised the inbound vessel to stay a minimum 1.5 miles east of the fairway buoy while the outbound vessel cleared the channel. The ship was also informed that the pilot on the outbound ship would be her pilot inbound.

As my vessel shaped up in the final cut of the channel steering 070 degrees True, the inbound vessel was seen exactly head on, tracking on the leading lights marking the channel centreline of 250 degrees True. Due to my ship's draft, the fairway buoy must be passed on our port side. Due to wind and current conditions, my intention was to pass the fairway buoy on my port and then turn to port for a proper lee. Because this was a special situation and I was very concerned about the inbound vessel's proximity to the marked channel, I raised her on the VHF. I asked her to clear the boarding area, turn to her port so that we could meet starboard to starboard. The inbound vessel agreed. She also stated that she was five cables east of the fairway buoy. Based on her aspect, a port-to-port passage with the inbound vessel was unacceptable. Her draft prevented her from passing the fairway buoy to her port. Her proximity to the fairway buoy also prevented me from passing in between her and the fairway buoy.

This special situation demanded observance of the printed cautionary warnings about the Precautionary Area around the fairway buoy (see below). The inbound ship ignored them all. Two minutes elapsed and I observed her still dead ahead on a reciprocal course. She hadn't budged. The distance apart was now about 1.3 miles. A 9.45 meter shoal lies west of the fairway buoy on the north edge of the dredged channel, preventing most ships from transiting that side of the fairway buoy except in emergencies. The master and I agreed that immediate action was necessary to avoid a collision. As we cleared the last pair of buoys, we turned to port and managed to squeeze in between the shoal and the fairway buoy. Hard-a-port rudder and increase RPM's were ordered to turn to port westward of the fairway buoy. Amazingly, the inbound vessel maintained course and speed and entered the marked channel without a compulsory pilot. Once in open water, I disembarked and eventually boarded the inbound ship. Fortunately, there appeared to be no Gulf Stream current, as the inbound ship was always seen head on, all navigation lights visible. Now she was two miles into the marked channel.

Once to the wheelhouse, I asked the Master and Officer of the Watch if they enter other ports around the world without a pilot and why they failed to act on the passage agreed to. Plenty of excuses were given but none a good reason for entering the port with such reckless abandon.

Supplementary Notes

Chart notes "A Precautionary Area exists around the light buoy. Large commercial ships inbound and outbound will board and disembark pilots within this area and will be severely limited in their ability to manoeuvre. All vessels are advised to exercise extreme caution when navigating within this area."

ALRS Volume 6(5) NP 286, states, "The Pilot Boarding and Cruising Area is close seaward of the Light Buoy. Large deep-draught vessels are requested to stay at least 1 nautical mile eastward of the Light Buoy for pilot boarding because of the strength and proximity of the Gulf Stream current."

1. Answer the questions.

What was the rank of the narrator of the Panamax box ship?

What were technical particulars of both vessels?

Why was the inbound vessel drifting offshore?

What was the pilot station dispatcher's advice for the inbound vessel?

In what position was the inbound vessel seen exactly?

How was the fairway buoy passed by the Panamax box ship?

Why was the pilot very concerned?

What did he ask the inbound vessel to do?

Why was a port-to-port passage unacceptable?

What cautionary warnings did this special situation demand?

How did the Master of Panamax box ship act to avoid a collision between two vessels?

How did the inbound vessel enter the marked channel?

What did the pilot ask the Master and Officer of the watch about?

2. Choose the factors which could become the reasons of possible collision between Panamax box ship and the inbound vessel.

Bad weather conditions in the container port.

Experience and self-conditions of the Master of the inbound vessel.

Negligence of observance of the printed cautionary warnings about the Precautionary Area around the fairway buoy.

3. Decide whether the statements are true (t) or false (f). Correct the wrong ones.

A 290 meter Panamax box ship outbound from a major US East Coast container port with 11.7 metres draft. __________

An inbound vessel was drifting offshore. _________

Due to wind and current conditions, the pilot's intention was to stay at the fairway buoy.

_________

The inbound vessel stated that she was six cables east of the fairway buoy. _____________

The inbound vessel's draft prevented her from passing the fairway buoy on her port.__________

The inbound vessel's proximity to the fairway buoy prevented Panamax box ship from passing in between her and the fairway buoy._______

4. Divide the following actions between inbound and outbound vessels. Analyze the situation as if you were a harbor pilot. Make a short report

To clear the channel to turn to port for a proper lee to drift offshore

to track on the leading light to pass the fairway buoy on her port

to stay east of the fairway buoy to pass port to port

to be in proximity to the marked channel to meet starboard to starboard

to be dead ahead on a reciprocal course to increase RPM

to be in proximity to the fairway buoy

Inbound vesselOutbound vessel

4. Read a near miss report (see a sample in annex).Complete a near miss report covering the following items.

1. Description of the situation;

2. Possible cause of situation (root cause) and possible consequences;

3. Which preventive measures have been taken;

4. Master's decision (plan for further handling of above incident)

Case study - 4. Confession

Own vessel was on a course of 090 x 12 knots, off the coast of Oman. We were due to make an alteration of course to 075 in 10 minutes time. It was a clear dark night. A container vessel on parallel course at a speed of 21 knots was overtaking us on the port quarter, giving a CPA of 0.2 miles in 20 minutes. I was observing this vessel for the previous 20 minutes and she did not seem to have any intention to keep clear. I was concerned with the small CPA and gave her five flashes on the ALDIS lamp. There was no response. I was also concerned of the alteration that I was due to make to port according to the passage plan.

When the vessel was about 2 miles behind us, I made the mistake of altering course to port to make the alteration as per the passage plan. The previous CPA of 0.2 miles now became 0.1 mile in 10 minutes. I now started giving more rapid flashes to the overtaking vessel, which were about as fast as my heartbeat! Suddenly, the container vessel altered her course to starboard and headed for a collision course! I put the wheel hard-over to starboard but realised that it was a point of no return - any action on MY part now could not prevent a collision unless the other vessel altered to port. I reached for the VHF and said "container ship on my port quarter - I am altering to starboard - please alter YOUR course to PORT". Miraculously this had the desired effect and she altered just in time to port passing us at a CPA of less than 0.1 mile.

After the incident, as our nerves calmed down, we analyzed the near miss and the following factors seemed contributory to me. I would welcome comments from others if they see other factors:

As per rule 13, the overtaking vessel had the duty to keep clear, even after we made our alteration to port. As per rule "Action to avoid collision" though, we should have altered to starboard on seeing the overtaking vessel not taking action.

The decision to make the normal course alteration to port (as per the passage plan) was a bad one and should have been delayed.

Having been on container ships for 5 years, I know for a fact that container ships "get tired" of altering for vessels they are overtaking and find a CPA of 0.1 to 0.3 miles in open seas quiet sufficient. I am simply stating facts as they are and not trying to justify anything.

It also seemed that the watch on the container ship had not seen us and they were only alerted at the second set of quick flashes. Then panic must have set in there and, seeing our port side light and masthead light, the OOW must have decided to alter to starboard. It is doubtful if her ARPA would have shown the vector correctly at such close range, especially if she was not tracking us earlier. It appears that the OOW must have put the wheel hard-over and then possibly checked other bridge equipment.

Of course, the entire near-miss could have been avoided if the overtaking vessel had just altered well in time and given us a berth of say 1 mile, but then, we don't live in a perfect world!

Under most circumstances, a close quarter situation with another vessel is far more risky than missing the way point by a few cables. If a slight adjustment to the way point on a coastal passage is more risky than having a collision, there must be something drastically wrong with the Passage Plan. Similarly, is it wise to put a position on the chart or make an entry in the log book when there are other vessels or hazards in close proximity? Make sure that there is no risk of collision or grounding before carrying out these secondary tasks.

Answer the questions.

1. What was the officer of own vessel due to make?

2. What course was a container vessel steering?

3. What was the author concerned with?

4. What vessel headed for a collision course?

5. How did the author reach the vessel steering a collision course?

6. Which rules were violated and could become a cause of calamity?

Explain the following expressions.

Near miss_____________________________________________________________________

________________________________________________________________________________

To take (the wrong) things for granted_______________________________________________

________________________________________________________________________________

To give a CPA__________________________________________________________________

________________________________________________________________________________

ALDIS lamp___________________________________________________________________

________________________________________________________________________________

ARPA________________________________________________________________________

________________________________________________________________________________

3. Correct the mistakes.

1. Own vessel was due to make an alteration of course to 0550 in 15 minutes time.

________________________________________________________________________________

2.Own vessel on parallel course at a speed of 21 knots was overtaking cellular container ship on the port quarter, giving a CPA of 0.2 miles in 20 minutes. ____________________________________

3. The container ship was asked to alter her couse to starboard. _____________________________

4. The OOW must have decided to alter to starboard when he saw starboard and masthead lights of the own vessel. __________________________________________________________________

5. A close quarter situation with another vessel is not so dangerous as missing the way point by a few cables. ________________________________________________________________

Put the words in the correct order.

1. It, that, OOW, appears, put, have, the hard-over, wheel, the.

________________________________________________________________________________

2. made, overtaking, port, vessel, to keep clear, even after, we, our, the, to, had, alteration.

________________________________________________________________________________3. the, per, made, the, of, altering course to port, to make alteration, as, I, the passage plan, mistake.

__________________________________________________________________________________________________________________________________________________________

4. gave, five, I, with, the, small, concerned, her, flashes, on, the, ALDIS lamp, was, and, CPA.

________________________________________________________________________________

5. now,The, 0.1 mile, 0.2 miles, became, in, CPA, 10, previous, of, minutes.

________________________________________________________________________________

1. Give the analysis of the situation mentioned in the text above and draw a sketch of ships’ movement. Explain what could cause a calamity (бедствие) and evaluate a huge role of human factor in the failure to perform the bridge duties.