British Sapphire FRC: Interlock “Could not work as designed”

 Accident, Accident report, ATSB, Australia, Fast Rescue Boat/Craft, maritime safety news  Comments Off on British Sapphire FRC: Interlock “Could not work as designed”
Jul 262011

A fail safe interlock device should have prevented the drop

Incorrect electrical installation of a ‘fail-safe’ interlock and early activation of a wave compensator led to a fast rescue craft being dropped 18 metres while being deployed in an emergency, says Australia’s Transport Safety Bureau. The chief engineer, who was being medically evacuated, second mate and fourth engineer were injured in the incident on board the Isle of Man registered liquefied natural gas tanker British Sapphire.

ATSB says that that, in the process of lowering the rescue boat, the wave compensator mechanism on the fast rescue boat’s davit was activated early, before the rescue boat had reached the water. A fail safe interlock device should have prevented this by placing the wave compensator into standby mode, only becoming operational when the fast rescue boat was waterborne. However, the electrical installation of the interlock was incorrect and meant it could not work as designed, allowing the wave compensation unit to always operate and the fast rescue boat to make the uncontrolled descent to the sea.

The investigation identified safety issues relating to the commissioning, maintenance, testing, operating instructions and procedures for the fast rescue boat’s wave compensator and its safety interlock system. Further safety issues were identified relating to the job hazard analysis for the use of the fast rescue boat, crew resource management principles and approved training courses for fast rescue boats.

Tests were carried out on board the three sister ships, British Sapphire, British Emerald and British Ruby. with the wave compensator not working correctly on any of them. However, a crucial discovery was made when the engineers on board one of the ships noticed that the electrical drawings had been altered in red pen. As a result of this finding, BP Shipping asked Davit International to supply a set of ‘original’ electrical drawings. These drawings were then forwarded to the ships for further checking.

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Bulk Carrier Polska Walczaca Fatality: Work At Height + Confined Space

 Accident, Accident report, ATSB, Australia, confined space, enclosed space, falls, fatality, SafeSpace  Comments Off on Bulk Carrier Polska Walczaca Fatality: Work At Height + Confined Space
Jul 212011

Work at height remains work at height when it is carried out in a confined space, as a report into a fatality aboard the Vanuatu-registered bulk carrier Polska Walczaca from the Australian Transport Safety Board.  The fatality occured while the victim was intalling a repaired safety handrail on a platform 5 metres above the tank bottom of a cargo hold.

The victim did have a safety harness but was not wearing it, it was found on the platform from which he fell. He also appears not to have worn his hard hat properly, it was found without signs of impact damage some distance from the victim.

The two most obvious lessons are: wear a safety harness, wear a hardhat properly. However, there are other issues worth looking at.

The OS could only see as far as the second platform.

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Jul 192011

Damage to Far Swan

Shared mental models can be hazardous when they are based on inadequate data and don’t match reality, as the chief mate and lookout of the  offshore supply vessel Far Swan discovered on the night of 6 October 2010 when it collided with the barge Miclyn 131 being towed by an aluminium catamaran Global Supplier. Confirmation bias does not help, either.

That evening Global Supplier was towing the flat barge Miclyn 131, a total tow of around 180 metres from the bow of Global Supplier to the stern of Miclyn 131. Global Supplier was not showing the requisite two white masthead lights in a vertical line and a yellow towing light in a vertical line above its sternlight. The lights had been ordered but not yet fitted.

Global Supplier was not fitted with AIS or radar and was not required to be.

The barge was equipped with portable BargeSafe lights which should have been visible at three nautical miles. They were placed in such a way that the lights were easily missed against background lights and were all-round rather than sectored, making them more difficult to determine accurately at night. Continue reading »

Apr 132011

Watchkeepers on the bulk carrier Sheng Neng 1 were so fatigued after supervising the loading of coal at Australia’s Gladstone port that they were not fit to carry out a navigational watch, concludes the Australian Transport Safety Board’s investigation into the subsequent grounding.

No fatigue management was in place and the grounding occurred because the chief mate did not alter the ship’s course at the designated course alteration position. “His monitoring of the ship’s position was ineffective and his actions were affected by fatigue”, says ATSB.

The ship’s hull was seriously damaged by the grounding, with the engine room and six water ballast and fuel oil tanks being breached, resulting in a small amount of pollution.

At 1705 on 3 April 2010, the Chinese registered bulk carrier Shen Neng 1 grounded on Douglas Shoal, about 50 miles north of the entrance to the port of Gladstone, Queensland. The ship’s hull was seriously damaged by the grounding, with the engine room and six water ballast and fuel oil tanks being breached, resulting in a small amount of pollution.

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Pacific Adventurer Gets Lashed For Rocking Roll

 Accident, Accident report, ATSB, Australia, container accident, containership, Pollution  Comments Off on Pacific Adventurer Gets Lashed For Rocking Roll
Jan 292011

Hull damage caused by oberboard containers

Australia’s Transport Safety Board has released its report into the lost of containers from the containership Pacific Adventurer, the subsequent holing of the hull and subsequent pollution.

The ATSB investigation found that the most plausible explanation for Pacific
’s severe, and at times violent, rolling motions was synchronous rolling, as a result of the ship’s natural roll period matching that of the encounter period of the waves experienced.

While the master took action to avoid the rolling, in accordance with the guidance in the ship’s safety management system, this action was not sufficient. The option of altering the ship’s stability by adjusting the seawater ballast in its tanks, and therefore its natural roll period, as the ship made its way up the Queensland coast, was not considered.
Much of the ship’s fixed and loose lashing equipment was in a poor condition. Continue reading »


River Embley Bulker Fire: Maintenance and Automation But Crew Get Fire-Fighting Thumbs-Up

 Accident, Accident report, ATSB, Australia, engine room, explosion, fire  Comments Off on River Embley Bulker Fire: Maintenance and Automation But Crew Get Fire-Fighting Thumbs-Up
Jan 252011

Nobody could remember testing the fire alarm/shut-off

Australia’s Transport Safety Board, ATSB, gives the master and crew of the buk carrier River Embley a pat on the back on it’s investigation report of an engine room fire but also brings up issues of maintenance manuals, fatigue and automation.

Says the ATSB: “… the crew’s response was well organised, controlled and coordinated. They understood their roles and responsibilities, worked as a team and appropriately considered the evidence at hand when planning their response. .. Together, the master and crew demonstrated how effective a trained response to an unexpected emergency can be”

The fire followed an explosion in the vessel’s number three compressor due to overheating. The machine’s automatic high temperature alarn and shutoff was not working and probably had not been for some considerable time. Says ATSB: “Had the device operated correctly, the fire and explosion would not have occurred. ”

None of the engineers aboard could recall maintenance being carried out. The system was not part of regular shipboard maintenanc procedures nor was regular testing covered in the manufacture’s manual.

Action has been taken to correct these shortcomings.

The report notes that the duty engineer had started the compressor, which had previsiously be running wihout trouble, using remote start button in the engine room and went to bed. Within an hour the fire started. The second engineer, who was probably fatigued, did not check the compressor when he came on duty.

Says ATSB: “Traditionally, watch keeping engineers were trained to check machines, like air compressors, before starting them; and then confirm that the machine’s operating parameters had settled to their normal state after the machine had been running for a short period of time. However, today, this good engineering practice is often being disregarded. Many items of machinery are started and stopped automatically and engineers often start machines remotely without checking them once they are running.

Engineers have, over time, become more and more reliant on automation. However, while automated shutdowns and alarms can react to changes in system parameters, they are not as effective as a human in predicting future problems based on early diagnosis. Well trained engineers can use all their senses to determine if something is wrong or if a system parameter is different to normal before it reaches a critical ‘shutdown’ stage.”

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Atlantic Blue Grounding

 Accident, Accident report, ATSB, Australia, grounding, pilot, pilotage  Comments Off on Atlantic Blue Grounding
Dec 202010

Masters, of course, are at the pointy end of any sharp stick poking around after an accident and, in some jurisdictions, can be detained for more than a year even when not accused of a criminal act. MAC was, therefore, interested to note a part of the Australian Transport Safety Board’s report into the grounding of the tanker Atlantic Blue at Kirkcaldie Reef, Torres Strait in February, 2009, while under pilotage that does not seem to have it even into the maritime media:

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Petra Frontier: Dodgy Ship+Dodgy Relationships = Fire

 Accident report, AHTS, ATSB, Australia, fire, maritime safety news  Comments Off on Petra Frontier: Dodgy Ship+Dodgy Relationships = Fire
Dec 162010

Petra Frontier - an unhappy ship

Poor relationships between officers and crew, together with bloody mindedness, meant that when a fire broke out on the AHTS Petra Frontier it was an hour before a senior officer took command of firefighting efforts, in the meantime leaving an undrilled crew working with good intentions but little effectiveness. The case highlights the link between relationships and safety.

Fortunately the incident did not become a tragedy but the potential for bad relationships to influence effectiveness a crisis is well demonstrated by The Case of the Unfamiliar Mariner.

Says the Australian Transport Safety Board report: “On 28 September, during the initial and extremely important stages of the emergency response, the master and the chief mate remained on the bridge and discussed how they should best respond to the fire, without involving or effectively directing the crew. At the same time, the crew assembled on the main deck and decided to enter the space and extinguish the fire without waiting for direction from the master or chief mate. The actions of the two groups were independent of each other. This suggests that the pre-existing inter-departmental issues were having a disruptive effect on the crew’s ability to work together as a cohesive team”.

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ATSB Employment Opportunity: Research Analyst

 ATSB, Australia  Comments Off on ATSB Employment Opportunity: Research Analyst
Sep 152010

image The ATSB is seeking to recruit an analytical person with an interest in safety to join the Research Investigations & Data Analysis branch based in Canberra.
Applicants must have developed research, analysis and database skills, and be able to independently write concise, accurate and meaningful technical reports. A background and interest in safety and/or transport, in particularly aviation, is highly desirable. Applicants also need a tertiary qualification involving research methodologies.