TSB’s report on the contact and grounding incident involving the general cargo vessel Claude A. Desgagnes as it entered Iroquois Lock in the St. Lawrence Seaway, is a tale of sticky decisions, poor communications and whose-in-charge confusion. One lesson is that once you’ve made a decision, keep in constantly under review.
Here’s the short version:
As the vessel proceeded downriver, the master and pilot spoke, but did not develop a shared understanding of the manoeuvre to be used in the approach to the Iroquois Lock. While the pilot had explained his plan to dredge the anchor to the officer of the watch (OOW) earlier in the voyage, the details of the plan were not relayed to the master when he arrived on the bridge. Continue reading »
Tugs are unforgiving vessels. The enormous forces involved mean that when something goes wrong it goes wrong very fast and often with fatal consequences. North Tug’s crew were lucky, after inexperience, poor communications and a lack of mandatory requirements led to the vessel capsizing while assisting
The workboat North Tug capsized and sank when it was assisting the cruise ship Ocean Princess during its departure from the quay in Kirkenes on 10 June 2013. The plan was to move the cruise ship sideways out from the quay, and North Tug was to assist in pulling the bow of the cruise ship away from the quay. There was a change of plan without this being communicated to the skipper of North Tug. This led to North Tug being pulled along by the cruise ship and moving backwards with the towline over its stern. This is a very unstable situation for a conventional tugboat with the towing point forward of the propellers. Because of the speed at which North Tug was moving astern, the aft deck started to fill up with water, which caused the boat to heel. North Tug ended up partly sideways on the direction of movement. The tug capsized as a consequence of water on deck and the transverse forces from the towline. Both crew members on board North Tug saved themselves by jumping into the water.
When the anchor-handling tug supply vessel Bourbon Dolphin capsized it came at enormous cost. Not just the loss of an almost new and expensive vessel, and a fine of more than $700,000 against Bourbon Offshore Norway, but, most importantly the loss of eight lives including that of a 14 year old schoolboy whose own life had yet to begin. It was a wake up call to the offshore industry that resonates even today.
It happened not because one man made an error but because an entire system failed to protect those onboard, because policies, procedures and practices that should have created a virtual safety net proved wanting, because not everybody was singing from the same songsheet.Continue reading »
If it ain’t broke fixing it may break it is the message from the US Coast Guard in a safety alert regarding embarkation hull ladder magnets after a State Pilot fell suffered concussion as he was boarding a vessel using its pilot ladder. In this case the modified magnet arrangement disconnected, fell, and hit the pilot on the head.
It wasn’t the first such accident to be caused by a modified magnet arrangement. Other incidents with injuries have occurred on other vessels at several different ports, says the USCG. In each instance the hull magnets were modified prior to the accident. Moreover, in all cases, after restoring the hull magnets to their original design no further problems were experienced. Continue reading »
It is still dark early on the morning of 30th March 2007 in Scalloway, Shetland as Norwegian Captain Oddne Remoy boards the Bourbon Dolphin for the first time. Bourbon Dolphin is less than a year old, painted in the distinctive green and white house colours of Bourbon Offshore Norway. She flies the Norwegian flag.
Remoy is to relieve from the vessel’s existing master, Frank Reiersen, as part of the vessel’s shift – five weeks on and five weeks off and is replacing the ship’s other regular master, Hugo Hansen. Hansen and Remoy have already discussed Bourbon Dolphin by telephone.Continue reading »
Curiosity is a much underused tool for improving safety. From the commissioning of the 93m chemical tanker Key Bora in 2005 no-one wondered why the astern response of its controllable pitch propeller, CPP, was four times slower than its forward response, it was accepted with a shrug as just one of the quirks of this particular vessel. It had not gone unnoticed, it had just gone unquestioned until she rammed a jetty in Hull putting a 90cm hole in her bulbous bow just above the waterline.
It is a good example of how something Not Quite Right, NQR, can lead to a close call and when both go unremarked sooner or later there will be a hit. In the old days of naval warfare the first shot rarely hit the target, it would either overshoot or under shoot the target. A range adjustment would be made and a second shot fired. If that didn’t hit the target it still enabled the gun crew to get a more accurate range, to bracket it, and the next shot would hit the target. A wise commander on the target vessel would take avoiding action to prevent the aggressor bracketing his vessel.Continue reading »
Owned by Odfjell Asia, operated by Ceres Hellic Shipping Enterprises and flagged in Singapore, Bow Mariner left New York at 0500 on February 28, 2004, 22 of her cargo tanks empty except for the vapour of Methyl Tert-Butyl Ether. The tanks were not inerted. Six of the ten remaining tanks contained 13.5 million litres of ethanol.
Aboard her were three Greek senior officers: Captain Efstratios Kavouras, Chief Officer Spiridon Melles and Chief Engineer Legantis-Eley Anasthasiou, and 24 Filipino crew, including Third Officer Lugen Ortilano on his first voyage as a licenced officer and second assistant engineer Edimar Aguilar, who joined the ship twenty three days before.
Only four other crewmembers survived the next 14 hours: Electrician James Bactat, Chief Cook Dominador Marentes, Messman Reynaldo Tagle and Able Seaman Ramon Ronquillo.
The three senior officers had created a climate of fear and intimation on the ship. Junior officers were prohibited from eating the the officer’s mess. They were prohibited from reading the Safety Quality and Environmental Protection Management documents, or from carrying the jobs specified in it. Senior officers did not train their subordinates in the technical and administrative skills they needed to operate the vessel safely.
The vessel carried no immersion suits. Fire and lifeboat drills were rare. Safety training records and the minutes of safety committee meetings were little more than fiction.
It was the second to last day of February, it was cold, with the air temperature at 4.4 Celsius, the sea a little more than a degree higher at 5.5 Celsius. There was a two metre sea running east and a 15 knot wind Northwest.
Third Officer Ortilano was officer of the watch from 0800 to 1200. A little before 10.00 hours, Captain Kavouras gave the order that would doom the ship. He told Ortilano to have the crew open the 22 empty tanks that had held MTBE and Ortilano followed that order.
MTBE vapour is heavier than air, it would not simply rise into the air and disperse when the tanks were opened. It can flow along a surface until it finds a point of ignition. It has a flashpoint of -25.6 degrees Celsius, well below the air temperature. The tanks were full of its vapour. As tank cleaning proceeded, those vapours were displaced, emerging onto the deck and collecting in pockets in corners and spaces.
Vapours like MTBE need a certain amount of oxygen in order to ignite. If the amount of vapour is below a certain level, called the Lower Explosive Level or LEL, it won’t explode. If the amount of vapour is above a certain level, called the Upper Explosive Level, UEL, it also won’t explode. Between these two levels it will explode if there’s a source of ignition.
When the tanks were opened, air entered the tanks, diluting the MTBE vapours to somewhere between the LEL and the UEL..
Put simply, when Third Officer Johnny Acuna replaced Ortilano at 11.50 with instruction from Chief Officer Melles for Ortilano to help with tank cleaning at 13.00, the ship was already a floating bomb. There was a strong smell of MTBE vapour on deck All it needed was a spark.
The tanks were not gas-freed, so Boatswain Aquilino Tabilin put on SCBA gear equipped with steel bottles and took an air-operated Wilden Pump into the tanks to remove residual MTBE from the cargo tanks with the help of an Ordinary Seaman and a Deck Cadet. By the time Ortilano arrived, the number nine centre starboard and wing tanks had already been emptied of remaining MTBE and Tabilin was working in the number eight starboard cargo tank.
Boatswain Tabilin’s entry into a cargo tank filled with explosive vapours wearing SCBA followed no known safe procedures to put it mildly.
At 13.30 the Wilden pump failed. Tabilin had it hauled out of the tank. While he was trying to repair it, Captain told him to get the Norclean Eductor, a kind of industrial vacuum cleaner used for draining combustible fluids, from the midship deckhouse.
When it arrived its drum was damaged so Kavouras told Ortilano to get two standard drums and have them adapted to replace the damaged one on the Eductor. The drums were strengthen, but there was no bonding between the drum itself and the lid, a precaution designed to prevent build-up of statical electricity.
The first drum was finished at 15.00 and taken on deck. At 17.05, Ortilano and an Engine cadet carried the replacement drums to the deck. The crew had already gone to eat but the Eductor had been mounted on the first drum, and the suction hose lead through the Butterworth opening near the the number eight starboard cargo tank expansion trunk, but the unit was not in operation.
Ortilano had lunch and at 17.30 went to his cabin to rest in readiness for his next watch.
Meanwhile, Ramon Ronquillo and Pumpman Tomas Ventenilla were blowing down cargo lines with compressed air. They probably weren’t aware that this was a bad idea. Blowing down cargo lines can create a static electrical charge which can spark and ignite any explosive fumes still in the pipe. They should have used an inert gas.
At 1800 the crew reported for overtime and went to work. It was twilight and the deck lights were switched on.
Ortilano, Bactat and Ronquillo were in their rooms, sleeping or resting. Chief Cook Marentes, Messman Reynaldo Tagle and messman Rosello were cleaning the galley. Second Assistant Engineer Aguilar was doing his rounds.
As Aguilar placed his hand on the handle of the engine room door, he heard the first explosion. By the time he reached the interior stairwell on his way to his room, the ship was already listing to starboard. He couldn’t open the door to his room. He went up to the bridge and got a lifejacket from the Pilot room.
In his cabin on the port side, Electrician Bactat heard a noise, the ship moved violently and began to list to starboard. Opening the window blinds he saw orange flame. He grabbed his coveralls and lifejacket struggling against the list, he made his way up to the bridge, where some of the windows were broken. He met with four others and made his way down exteriors ladders to the deck, the list making it hard to climb down.
In the galley, Chief Cook Marentes heard a boom and the ship shook violently. Messman Rosello started to panic. Marentes told him to calm down and get a life jacket, then came another, ear-shattering explosion. He went to his own cabin to get his lifejacket. His lifeboat station was on the port side but because of the list he went down an exterior ladder to the winch deck.
In his cabin, Ortilano head a sudden series of explosions, then a loud boom. Through his forward windows he saw flames. Dashing out into the passageway he saw AB Elmer Manahan who told him to get his lifejacket. Ortilano went back into his cabin, got the lifejacket, and exited the accommodations aft.
In a group were Captain Kavoras and Chief Engineer Anasthasiou, talking in Greek, together with four other crew members, including Messman Tagle who couldn’t understand what they saying. They were waiting for instructions, but none were given.
There was no question of using the lifeboats. Because of the list, the port lifeboat almost certainly could not be launched. The starboard lifeboat seems to have been caught by the explosion and fire. Its bow was damaged by the flames and more damage occurred as it fell from its falls in the blast.
Ortilano asked Captain Kavouras whether a distress signal had been sent. Kavouras did not reply. Ortilano went to the bridge, activated the DSC alarm and sent out a mayday.
He didn’t wait for a response. He went up to the bridge top, activated the EPIRB and cast it overboard.
Meanwhile, Tagle followed Captain Kavaoras, Chief Engineer Anasthasiou and the rest of the group to the winch deck on the starboard side. For a moment he covered his eyes. When he look up, the rest had gone over the side. There was a third explosion and someone called to him in Tagalog to jump. Tagle jumped into the water.
As the ship listed an estimated 30 degrees, Electrician Bactat, with a second group, made his way to the starboard winch deck and simply walked into the water. He found a piece of wood and clung to it.
The ship came back on an even keel, her bow sinking rapidly. Aguilar, Marentes and Ronquillo got to the stern railings and held on, determined not to enter the water until the last possible moment. It wasn’t something they’d be trained to do: They’d remembered the movie Titanic.
Ortilano climbed from the bridge top down to the winch deck. Their were people in the water, the lights of their lifejacket lights shining in the darkness. A life raft floated off starboard, still attached by its painter. Ortilano told the men at the stern railings to wait until the ship sank further. He waited himself, then, from a height of three or four metres jumped into the liferaft.
Aguilar jumped for the lifeboat, missed, fell into the water and climbed into the liferaft. Then Ronquillo jumped and climbed in, followed by Marentes.
They found the life raft equipment, cut the painter, and searched for survivors. Ortilano lit flares, hearing cried for help each time. He called out to them to swim towards the flates. Two men, so covere in oil as to be unrecognisable, got close enough to be helped into the life raft, messman Tagle and Electrician Bactat.
At 1937, the Bow Mariner sunk under the waves, her deck lights still shining until almost the last moment.
Top, above side scan sonar images of Bow Mariner on the seafloor, courtesy NOAA. Compare to photo below from Marine Marchande.
Rescue efforts were already underway by the US Coast Guard and two ships that has seen the explosion. A Coast Guard helicopter, CG 6026, arrived at 19.28. There were more than a dozen lifejacket lights floating in the water and spotted the life raft with signs of people aboard.
Battling darkness, fumes, and the heavy fuel oil that covered the survivors, it took half an hour to rescue the six men from the liferaft. They were flown to Norfolk Sentara Hospital. The helicopter was grounded due to contamination.
The only survivors were those in the life raft, Ortillano, Aguilar, Marentes, Ronquillo, Tagle and Bactat.
A second helicopter, CG 6588 located a body in the water. Wearing only a shirt and a gold necklace, it showed evidence of traumatic injuries to the head, legs and arms, perhaps a sign that he had been caught by one of the explosions. It was Chief Officer Melles.
Five other bodies were eventually recovered. Each one dead by drowning associated with hypothermia.
Of the remaining 18 bodies, the sea took them for eternity.
The damaged starboard lifeboat. Fourth engineer Ajoc was found alive, holding onto the boat’s lifelines but died on the way to hospital. USCG photo.
Capsized port lifeboat.
There are so many lessons to be learned from the Bow Mariner incident that it’s hard to know even where to begin.
What sparked the explosion isn’t known and hardly matters. The situation was such that disaster was inevitable.
The senior officers confused arrogance and intolerance with leadership. Educating and training subordinates to work safely is part of leadership.
As we saw in the first series of Maritime Accident Casebook, it isn’t uncommon for senior officers to get complacent about the cargoes their ship carries, to assume they know better than the guys who wrote the safety procedures. It’s a life-threatening assumption.
Make sure your subordinates are aware of safe procedures, make sure they know what’s in the SMS, or in this case, SQEMS.
Encourage them to be safety aware and pro-active to take the initiative if they see what they believe to be an unsafe situation.
Ensure you have a good working relationship with your subordinates, it might save your life.
It might be a good idea, too, that they know how to make a distress call. Lugen Ortilano didn’t give his vessel’s position, which could have led to a delay in response to the emergency. He didn’t wait for a response to his call. Both are understandable since the ship was a bomb, all the same it’s worth ensuring that those who might have to make such a call practice how to speak calmly and clearly and give the ship’s position and its situation. Valuable time could be saved.
But let’s look at survival. Those aboard the life raft survived. Those who did not wore lifejackets that would have kept them afloat. Why didn’t they live?
The water was just 5.5 degrees Celcius. Two things happened when the men jumped into that sea. The first was cold shock. It was difficult to control breathing, their heart rate soared, and their blood pressure went up. It was hard to think clearly. For a few critical minutes, they were totally incapacitated. Cold shock can kill.
Those who survived cold shock were victims of hypothermia. Our bodies need warmth, indeed, they generate warmth. But in a cold sea, the body’s core temperature can fall so far that it can’t be maintained. It induced a fatigue, a fatal desire to sleep. In that situation, sleep is death. With unconsciousness, they drowned.
Aguilar, Marentes and Ronquillo were right to delay entering the water for as long as possible. The sooner you’re in the water, the sooner you die.
Of course, it’s best not to get in the water at all, get a lifeboat if you can.
When in the water, huddle together as much as possible and try and keep others awake.
Depending on the water conditions, some survival techniques commonly taught may not be useable. Dr. Frank Golden, a specialist in survival, gave the following suggestions to Maritime Accident Casebook:
Regardless of the water temperature, be sure wear a lifejacket, especially in cold water.
Before getting into the water, put on as much clothing as possible. and put something on your head, it will reduce heat loss.
If you can, keep your arms as close to the body and legs together to reduce heat loss.
Tighten crotch strop to ensure a near 40° angle of flotation and to help keep the back of head out of the water to reduce heat loss.
Keeping yourself warm, is the best way to keep yourself alive.
Today, Lugen Ortilano has a framed letter in his wall commending him for his heroism that night. Perhaps once in a while he wonders why such heroism should have been necessary in the first place.
All the key ingredients for a navigational accident were in place long before the Malta-flagged oil and chemical tanker Ovit grounded on the Varne Bank in the Dover Strait in the early morning darkness of 18 September 2013. The report on the incident from the Marine Accident Investigation Branch, MAIB, identifies several layers of factors, not all of them on the bridge of the Ovit, that led to the grounding without which it would not have occurred.
The vessel was equipped with a Maris 900 ECDIS supplied and installed by STT Marine Electronics in Istanbul. An installation certificate issued on 1 April 2011 indicates that all systems had been properly configured and tested. They had not.
…90 minutes after Third Officer Lugen Ortilano sent that distress call, the 174 metre long chemical tanker Bow Mariner was 77 metres down on the bottom of the Atlantic, 53.5 nautical miles off the Virginia coast. Twenty one of her 27 crew were dead or dying. More than thirteen and a half million litres of ethyl alcohol, 864 thousand litres of heavy fuel oil and 216 thousand litres of diesel had entered the ecosystem leaving a trail of pollution two and a half kilometres by 56 kilometres.
The Bow Mariner and three quarters of her crew met their end because of mismanagement, ignorance, incompetence, intolerance and fraud.