2. Direct causes, root causes of the accident;

3. Remedial actions and recommendations.

Case study - 5. Crew Injured by Pilot Ladder

A general cargo-cum-log carrier in ballast was approaching the pilot station to embark the inward pilot. Being fitted with twin port and starboard hatch covers, and also the standard structures and fittings for the carriage of timber deck cargoes, the width of the upper deck between bulwark and hatch side coaming was extremely narrow.

There was a deckhouse near the pilot transfer point, but as the doorway was too narrow for the coiled ladder to be taken in, when not in use, it was the practice on board to hand-carry the coiled pilot ladder aft a distance of about 20 metres, past many obstacles, to be last in way of the accommodation. To rig the ladder, it had to be carried this distance back along the deck and, after securing the inboard rope ends to the deck pad-eyes, two seamen would lift the coiled ladder outboard over the bulwark and drop it in to uncoil against the ship's side, a practice that was as punishing on the crew as it was on the ladder.

On this occasion, due to a sudden change of plan, the pilot had to be embarked from the side opposite that which had already been prepared. In a great hurry, two crew members scrambled to prepare the spare ladder, with the pilot launch already alongside and hooting impatiently.

In order to save time, while one seaman was stooping over and securing the end ropes, the other hurried seaman began uncoiling the ladder and heaving sections of it overside. After about half its length was outboard, the remaining section of the ladder suddenly ran out of control, causing a flailing spreader to strike the first seaman's chin from below and inflicting a cut that needed three stitches.

Fortunately, the end ropes that had been just secured to the deck, held, and the dropping ladder narrowly missed the pilot and his boat crewman stationed at the boat's inboard rail.

Lessons Learned

1. Pilot ladders can be awkward and cumbersome to rig/unrig in restricted deck areas.

2. Sufficient manpower must be present for rigging and recovery.

3. A tool-box discussion must be held by the crew before each operation so that every person is aware of the exact procedure and actions of others.

4. As far as possible, pilot transfer arrangements must be decided in advance and last-minute changes avoided.

5. Pilots and bridge teams must avoid putting undue pressure on crew members carrying out a critical operation and hassled crew must resist the temptation to hurry through a task.

6. Naval architects must ensure that their designs incorporate safe and workable pilot ladder stowage, handling and rigging arrangements.

7. Where practicable owners/managers must consider retro-fitting pilot ladder stowing reels or at the very least, provide a suitable deck trolley for the safe and efficient handling and stowage of conventional pilot ladders. This will not only avoid the hazards outlined above, but also preserve the pilot ladder from abuse, damage and soiling.

1. Answer the questions

1. What are specific features of a general cargo-cum-log carrier's structure?

2. Why did the crew hand-carry a coiled pilot ladder?

3. What should be done to rig the ladder?

4. What did a change of plan result in?

5. What remedial and preventive measures must be taken by crew to avoid accidents?

2. Match the following terms from the text with their definitions

bulwark a) a place onboard the vessel where people live

hatch b) a round opening that a line runs through, or that/which provides an

attachment point

deckhouse c) a small vehicle for carrying equipment and other things

on board

ladder d) a part of ship’s side that is above the upper deck

timber e) a short, house-like structure on the upper deck of a ship

accommodation f) a hole in a ship, used for loading goods

coaming g) an informal talk that focuses on a particular safety issue

pad-eye h) a piece of equipment used for climbing up to or down. It

consists of two long sides crossed by parallel rugs

• tool-box discussion i) a vertical border around the hatch or other hole in the

• deck, preventing water from running below

deck trolley j) wood material used for building or making things

• 3. Complete an accident report (see annex) covering the following items.

1. Description of the situation;

2. Direct, root causes of the situation;

• 3. Remedial actions and recommendations.

Case study - 6. Fatality inside chemical cargo tank

The chief officer on board a chemical tanker died after entering a cargo tank which contained hydrocarbon vapours and was deficient in oxygen. When the ship sailed at night after the cargo had been discharged, the two tanks (5P and 7S) that had carried hexene-1 were still inerted with nitrogen gas. As the tanks were to be loaded at the next port within two days, the crew began day/night tank cleaning operations soon after sailing. The chief mate was a non watchkeeper, so was able to direct the tank cleaning crew continuously. Early the next morning, during post-cleaning ventilation, the chief mate, who was preparing to conduct pre-loading inspection of the empty tanks, was informed that a “petrol-like” odour was still coming from 5P tank. He had filled out the enclosed space entry checklists for the tanks he intended to enter that morning, but significantly, no enclosed space entry checklist was filled out for 5P tank.

Later that morning, when the master received an email from the ship's agent requesting pre-arrival information, he was unable to locate the chief mate. Eventually, his lifeless body was located slumped at the bottom of 5P tank. A rescue team donned BA sets and after carrying out tank entry checks, pulled out the officer and moved him to the upper deck. It was noted that the oxygen content of the atmosphere inside the tank varied between 12 per cent and 16 per cent.

Continuous resuscitation efforts were made until the arrival of a helicopter with shore medical personnel, who soon declared that the chief mate was dead. The next day, the vessel arrived at her destination and the chief mate's body was landed.

Root cause/contributory factors

1. Lack of compliance: the chief mate did not follow established industry standards and company specific safety procedures prior to tank entry and the checklist prepared for that day contained many improper entries;

2. The chief mate did not tell anyone that he was entering the tank;

3. An autopsy determined that the chief mate did not fall and that he died as a result of asphyxiation (oxygen deficiency) caused by inhaled hexene-1 vapours.

4. It is possible that, due to complacency or time related pressures, he may have mistakenly entered the wrong tank. In any case, despite his considerable tanker experience, competence and diligence, he inexplicably entered the tank without implementing common safety procedures.

Recommendations/corrective/preventative actions

The managers introduced/implemented the following measures:

1. Enclosed space drills to increase awareness of the danger associated with enclosed space entry and rescue;

2. A fleet advisory notice circulated regarding the accident;

3. Formal training for fleet superintendents, focusing on the permit to enter system at the checks they should carry out during their audits;

4. Enhanced warning signage at tank entrances, stating that the tank may be deficient in oxygen;

5. Development of a one-day training session on enclosed space entry for all officers and ratings joining the company's tankers.

1. Answer the questions

1. What was the cause of the chief officer's death?

2. What substance did the tanks contain?

3. What kind of operations was to be carried out before calling at the loading port?

4. Who was to be in charge of monitoring the tank cleaning?

5. Why is it necessary to provide accurate keeping of checklists and other documentation? What can inaccuracies lead to?

6. What procedures were to be done before entering an enclosed space?

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

1. The C/O died because of falling down the ladder during the tank cleaning procedure._________

2. The rest of vapours in tanks had the property of depriving oxygen from air._________________

3. As the C/O was a wathckeeper he didn't have to conduct pre-loading inspection of the empty tanks.______________

4. No Enclosed space drills should be provided before tank inspection._______________________

5. Appropriate signage at tank entrances should be provided to infrom the personnel that tanks may be deficient in oxygen._________

3. Choose the factors which could become a reason of an accident and discuss them.

Non-compliance with IMO Recommendations

Self-confidence

Fatigue

Lack of skills

Non-performance of drills

Law qualification of the C/O

Distractions caused by various factors in the course of working with documents

Lack of experience and training

4. Complete an accident report (see annex) covering the following items.

1. Description of the situation;

2. Direct, root causes of the situation;

3. Remedial actions and recommendations.

Case study - 7. Stowaways

A 6,600 GT purpose built heavy lift ship carried a full project cargo from Northern Europe to a West African port.The cargo was to be utilized as part of an inland oil and gas drilling and exploration project. A return cargo was to be loaded at the same terminal consisting of damaged or otherwise discarded items of oil drilling equipment, some containerized, which was being returned to the European headquarters for repair or disposal.

1. The ship had a Ship Security Plan in place. Gangway security was established but the gunwale of the ship was on the same level as the quayside such that people from ashore could step across the gap and didn’t use the gangway.The crew of nine, including master, used their best to control access but eventually conceded defeat.

On completionof loading the master solicited the help of the terminal managers and stevedore foremen to help him and the crew to conduct a thorough stowaway search. During a search which lasted two hours they found seven stowaways who were subsequently removed ashore. The ship sailed and after dropping the pilot the master dropped anchor and had the crew conduct a second stowaway search.

No more stowaways were found and the vessel commenced her voyage back to Northern Europe. However, one day later banging and shouting was heard from number two cargo hold and two young men / boys announced their presence. They did not have any identification documents on them and none was found subsequently. They did not speak a language which was understood by the master or any of the other officers and crew.The stowaways were uncooperative although they were not violent.

The master sought instructions from the ship operator and it was decided to continue towards the discharge port and try to repatriate the stowaways from Northern Europe.

On arrival at the discharge port the vessel was boarded by port State Control Inspectors who cited various alleged violations under the ISPS Code and delayed the entry of the ship for six days whilst they searched the ship and conducted a full scale security investigation.

Armed security guards were placed on board through discharge to stand guard over the stowaways until the ship sailed. The ship owners were presented with a bill for US$10,000 in respect of this 'security service'. The local immigration authorities refused to consider the possibility of repatriation through their country.

The true identity of the stowaways, and even confirmation of their nationality, could not be established and, consequently, no country visited by the ship would assist with attempts to repatriate them. The ship continued to face serious problems with alleged violations of security and ISPS Code wherever she went causing delays and consequential losses.

1. Answer the questions.

What was the type of vessel the incident took place on?

What cargo was to be delivered to a West African point?

What cargo was to be carried in return?

What measures were taken to prevent the stowaways’ access on board the vessel?

What was done on completion of loading?

When and where were the stowaways discovered?

What decision did the master take concerning the stowaways?

What happened at the port of discharge?

What problems did the ship face afterwards?

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

The cargo was to be repaired as part of an inland oil and gas drilling and exploration project._____________________

People from ashore could step across the gap only with the help of the gangway.__________

The crew succeeded with their Ship Security Plan._______

On completion of loading the master soughtfor the aid of the terminal managers._________

The stowaways were helpful but not aggressive_____________

1. It was decided to continue towards the discharge port and try to send the stowaways back home._______

2. The stowaways were successfully repatriated to their native country.________________

4. Give synonyms to the following expressions.

a return cargo_______________________________________________________

1. to be at disposal______________________________________________________

2. to concede defeat_____________________________________________________

3. to solicit the help of___________________________________________________

1. to conduct a thorough stowaway search___________________________________

   1. to drop the pilot______________________________________________________

   2. identification documents________________________________________________

to repatriate__________________________________________________________

3. to cite various alleged violations__________________________________________

4. Give the antonyms to these expressions and use them in the sentences of your own.

5. Discarded_______________________________________________________

Containerized____________________________________________________

1. Defeat__________________________________________________________

1. To drop the anchor________________________________________________

   1. Uncooperative____________________________________________________

   2. Violent__________________________________________________________

   3. To assist_________________________________________________________

4. 5. Complete an incident report (see annex) covering the following items.

1. Description of the situation;

5. 2. Direct, root causes of the situation;

6. 3. Remedial actions and recommendations.

Part 5

ENVIRONMENT RELATED INCIDENTS

7. Most countries will deal severely with vessels which discharge even small quantities of pollutant within their territorial waters. It should be noted that pollution inciedents may not be limited to discharges of oil as cargo or bunkers. Pollution may also emanate from non-tank vessels whether from cargo, bunkers, hazardous or noxious substances, garbage, sewage, ballast water or smoke emissions.

There are 3 main causes of pollution:

8. Collision, fire, explosion, grounding or similar type of incident;

9. Intentional discharge of oil, cargo residue, garbage or other waste from the vessel, e.g. the pumping of bilges, or deballasting of cargo tanks;

10. Accidental pollution while transferring fuel, cargo, garbage or other waste to or from the vessel.

This type of incidents include oil pollution – cargo and bunker related; noxious liquid substances; harmful substances carried by sea in packaged form; sewage; garbage; air pollution.

CASE STUDY

Case study - 1. Oil Spill during bunkering

1. Read the text. Analyze the situation yourself. Afterwards compare your opinion with the expert assessment.

A vessel started receiving HFO bunker from a barge while moored alongside a terminal. The first tank was filled to the ordered level by the chief engineer and the bunkering continued into a second tank.

The chief engineer and second engineer left for dinner, leaving the fourth engineer in charge alone, without any means of communicating with the barge. While monitoring the loading of fuel into the second tank the fourth engineer panicked because he thought there was a risk of the tank overflowing, which was not the case. He tried to contact the barge unsuccessfully. He then decided to slightly open the valve to the first tank and throttle the valve to the second tank to 50 %. The volume in the first tank was 87 % and the second tank was 71%. Then he tried to contact the barge again to suspend bunker operations but once again was unsuccessful. As there was no action taken on the barge or on the vessel itself, the first tank finally overflowed through the air vent and contaminated the deck and water in the po

rt. Fortunately the pollution was contained in the vessel’s vicinity by a mooring rope, which was laid on the surface. To stop the overflow, the wing tank valve was opened and the valve to the first tank was closed. Shortly after the bunker operation was suspended the barge left the vessel. Despite the presence of the scupper plugs, and also as a consequence of the heavy rain, some HFO had overflowed the edge of the portside deck plating, contaminating the shell plating and surrounding waters. A professional completed the cleaning operation of the vessel’s hull and the port. At the time of the overflow, the fourth engineer was attending the bunkering operation alone although the decision of the chief engineer to only bunker 891mt of HSFO in tank 1 and 2 to a total 93% to 94% of their capacity must have warranted extra precautions to be taken. The fourth engineer had no VHF available and could not communicate with the barge’s crew although the pre-bunkering check list confirmed that ‘’ship shore/barge communication channels established’’. The fourth engineer was in charge of both sounding of the FO tanks (on deck) and handling the tanks’ valves (in the engine room) when the latter is the second engineer’s responsibility as per the bunkering plan. It was discovered that the engineers had serious difficulties communicating with each other because the second engineer did not speak English. From interviewing the chief engineer, it appeared he was convinced that the overflow occurred from tank 2, although all evidence pointed to the fact that the overflow occurred from tank 1. Therefore there was a lack of communication between the engineers. There were serious ISM breaches by the vessel where the most serious were: Not sending the correct notification to the authorities about the incident according to IMO resolution 851(20). Disregarding bunkering and safety procedures as per SMS. The crew not being familiar with vessel and bunker procedures. Lack of communication between engine crew, i.e. the second engineer couldn’t speak English.

WHAT? Oil Spill during bunkering 1WHY? The fourth engineer was overseeing the bunker operation by himself and thought there was a risk of the tank overflowing. He panicked and decided to open the valve to the first tank, which was almost full. 2 WHY? The chief engineer and second engineer had left for dinner and the fourth engineer had no means of communicating with the barge, bridge or other engineers. As he could not contact the barrge, or anyone on the vessel itself, the first tank finally overflowed. 3 WHY? The company’s bunkering procedures were ignored by the chief engineer. No risk assessment was carried out; no record of any toolbox meeting exists, which is a requirement.The bunkering checklist was filled out but ignored. 4 WHY? Serious lack of communication, familiarisation and inefficient shipboard management by the chief engineer. 5 WHY? The company has not been able to establish an acceptable onboard safety culture and SMS Procedures are not thorough enough. Consequences: a) a vessel was detained because of serious failure of the ISM Code; b) substantial costs for cleaning the vessel’s hull and surrounding water; c) loss of time and employment of vessel due to the incident; d) an additional audit was carried out by the classification society to verify that non-conformities had been rectified.