Feb 172016
 

At 2215 local time on 12 August, 2014, the outbound bulk carrier Flag Gangos collided with the berthed oil tanker Pamisos on the Mississippi River at Gretna, Louisiana. Flag Gangos then made contact with a pier at the facility where the Pamisos was berthed, and the pier struck and damaged a fuel barge, WEB235, berthed behind the Pamisos. No one was injured, but about 1,200 gallons of oil that was being transferred at the time spilled from the transfer lines, and some of the oil entered the river. Damage amounts were reported as $16 million for the terminal, more than $500,000 each for the Flag Gangos and the Pamisos, and about $418,000 for the fuel barge.

Yet moments before the steering vanished it appeared to be working fine.

US National Transportation Safety Board, NTSB, investigators discovered the dirty secret of the Flag Gangos,

flaggangos

Four hours before, prior to departure from the Cargill dock in Reserve, Louisiana with a cargo of grain and corn, the pilot requested that the steering system be tested and was satisfied with the rudder’s responsiveness. All seemed to be well.

About 2212, when the Flag Gangos was near mile marker 98 with the city of New Orleans the pilot ordered a 2-degree heading change to starboard. The helmsman applied 15 degrees of starboard rudder, and the rudder responded correctly.

But, when the helmsman turned the wheel to port to ease the rudder input, the rudder did not respond, which the pilot saw on the rudder angle indicator. The pilot immediately noticed that the ship’s heading continued to swing to starboard. and he asked the helmsman,

“Where are you going, man?” he asked the helmsman, then ordered 20 degrees to port to correct the heading. The helmsman turned the wheel accordingly, but again the rudder did not respond.

The vessel went on to play dodgems.

Investigators discovered that a hydraulic solenoid valve and coil had failed in the port side of the hydraulic control block of the Flag Gangos’ steering system. The hydraulic valve was jammed with debris and unable to move properly. The coil failed electrically and was unable to actuate the hydraulic solenoid valve as designed.

And there was more: Nearly a year earlier, the steering system manufacturer, Rolls-Royce, emailed a service letter to the vessel’s operating company, Golden Union Shipping Co., warning about possible failures of this model of coil, which was also installed in the starboard side of the steering system. At that time, in October 2013, the Flag Gangos was being delivered by the Cosco Guangdong Shipyard in Guangdong, China, where the ship was built. The service letter stated in red print, “MANDATED ACTION REQUIRED”.

The email was unambiguous: It has become apparent that solenoids installed on some of our steering gears may fail
prematurely which can impact the steering gear’s performance. In order to resolve the reliability issue, Rolls-Royce will modify the hydraulic isolation drive circuit for Rolls-Royce frequency controlled steering gears with 230V AC solenoid coils, type: Eaton-Vickers 230V.

The modification would take one day. Rolls-Royce letter stated that, during the vessel’s next scheduled class survey, the vessel’s classification society would verify that the mandated solenoid upgrade had been completed and also said that Rolls-Royce would contact Golden Union to schedule the upgrade.
Seven months later, in May 2014, Rolls-Royce contacted Golden Union about upgrading three of the four Golden Union vessels with affected steering systems, but did not mention the Flag Gangos.
In June 2014, Golden Union provided Rolls-Royce with three possible dates during which the Flag Gangos would be in port in Central America and could have the upgrade completed. Rolls-Royce replied that it would send the parts for the upgrade to the local agent, and requested a 3-day window to complete the solenoid upgrade and two other upgrades.

However, because of the bulk carrier’s operating schedule, the upgrades were postponed to after the Flag Gangos’ port call in New Orleans, they were to be completed in Japan in July 2014. The accident occurred before the upgrades could be completed.

Note that the vessel was virtually a newbuild. Indeed, soon after the newly-built Flag Gangos left the Guangdong shipyard, onboard alarms indicating clogged steering system filters began to activate repeatedly. From October 2013 through April 2014, the alarms activated as frequently as 48 times per month. In response to the filter alarms, the engineering crew would open, inspect, and clean the filter inserts―although the filters reportedly looked clean―and put them back in service. After the chief engineer sent a guarantee claim to the Guangdong shipyard, new and larger filters and housings were sent out but took nearly 8 months to reach the Flag Gangos due to the bulk carrier’s operating schedule.

After the new filters were installed in June 2014, filter alarms no longer activated. However, the crew did not send samples of the hydraulic oil ashore for analysis to determine the cause of the filter alarms at any time after the alarms activated.

The steering system’s operating instructions stated that the oil should be analysed every 6 months (this would have placed the first of such analyses in March 2014, about 5 months before the accident). Despite multiple requests from investigators, Golden Union produced no evidence indicating that the steering system oil had been analysed. After the accident, in March 2015, investigators obtained oil samples from the steering system and filters and sent them for laboratory analysis, and the results were “critical”, in a possible range of “good,” “caution,” and “critical”, for the port side. This oil, which should be clear and light yellow in colour, was dark yellow and turbid with visible debris.

Microscopic examination showed ferrous particles, oxides, sand, and silt. The results from the portside filter were also “critical,” with very high levels of ferrous particles, sand, plastic particles, and dust.

NTSB determined that the probable cause of the accident was the delay by Flag Gangos’ operating company in completing a mandatory upgrade to the vessel’s steering system, and failure to routinely test the steering system’s hydraulic fluid for debris as required by the manufacturer. Contributing was the failure of the steering system manufacturer to schedule and complete the mandatory upgrade.

Read the report here.

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