Mar 202017
 

We are republishing some of our posts on Toxic Masters. Have you a horror story about dysfunctional leaders aboard or ashore? Tell us in confidence at mac@maritimeaccident.org, we’d like to hear what you have to say – and do share the post with your friends in the industry.

Recently an account from a former master of a close encounter that under other circumstances could have led to a collision sent MAC scrambling to Google to find out what information was available on toxic leadership at sea resulting in an accident. There were precisely five results, out of a potential of 132,000 hits on maritime accidents and of those on the top of the list was MAC’s post on the Maria M incident and the IMO model course on leadership and teamwork. That drilling into the remaining three results produced nothing on maritime accidents and toxic leadership suggests that it is an under-researched area of maritime safety.

A member of MAC’s LinkedIn maritime accident investigation group provided this account of a close call:
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Are Your CO2 Systems Designed For Living? Take Napoleon’s Approach

 Accident, close call  Comments Off on Are Your CO2 Systems Designed For Living? Take Napoleon’s Approach
Jan 282015
 

Bad, confusing design is a hazard we don’t hear about very much but in an emergency the difference between good design and bad design may be the narrow gap between success and tragedy. Take a look at the picture at the top of this page: Can you immediately tell which tags to pull to cut off fuel and which to pull to activate the CO2 fire suppression system? In the dark? In rough weather? In a hurry? Continue reading »

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Near Miss Highlights Gas Bottle Moves

 MSF, Safety Alerts, safety flash  Comments Off on Near Miss Highlights Gas Bottle Moves
Jan 192011
 

Gas bottles should be transported on gas racks when being transferred. If a gas rack is not available then consider moving the gas bottles one by one, says a safety flash from Marine Safety Forum.

Says an MSF safety alert: “The ship’s crew were loading stores using the ships crane, a pallet holding 6 gas bottles snagged on a deck fitting as it was being lowered onto the deck. The pallet tilted causing the bottles to slip from the securing bands and fall onto the deck from a height of approximately 1 metre.
•    The crew had not carried out a risk assessment for the operation.
•    The securing arrangements of the bottles on the pallet were not checked prior to lifting, as
the banding straps had worked loose during transportation.
•    There were 6 bottles on the wooden pallet, 4 Acetylene and 2 Oxygen.

This incident has highlighted a need for ship’s crew to be vigilant when performing common tasks, such as loading stores using the ships crane.

All lifting operations should be risk assessed.

All pallets should be checked to ensure goods on them are secure and cannot fall off.

If crews are in doubt then the lift should not be undertaken and the pallet rejected for loading.

Oxygen and Acetylene Gas bottles should where possible be transported in gas racks.

Best practice and the safest method for transportation and lifting onboard is by gas racks but if the bottles are delivered on pallets then consideration should be given to the lifting of the bottles
individually from the pallet onto the vessel.

When lifting gas bottles individually and no rack is available, the lifting strop should be attached so that the bottle cannot slip. Never lift a bottle using the transportation cap.

It is recommended that Gas Racks would be the preferred transportation method for gas bottles.

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Unfamiliar, Unfocussed + Autopilot = Close Call

 Accident report, offshore, Safety Alerts  Comments Off on Unfamiliar, Unfocussed + Autopilot = Close Call
Nov 202010
 

imageAn OOW was not familiar with the 360° azimuth propulsion on his vessel had not been informed of, or familiarised with, the full operational status of the system. He did not fully understand the Azimuth / Auto Pilot interface system and alarm and was unable to quickly understand what was happening when he tried to stop the vessel as it approached a barge.

The result was a close call, says Marine Safety Forum in a safety alert.

Although the OOW was an experienced officer he had not used Azimuth propulsion systems before joining this vessel. He first joined the vessel at sea 6 months before the incident; Vessel operations were on-going and no induction or formal introduction to the systems, equipment or procedures was given although he had put great individual effort into familiarising himself with these in so far as he was able.

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The DO That Didn’t

 maritime safety, Safety Alerts  Comments Off on The DO That Didn’t
May 312010
 

imageBy its nature, many of MAC’s posts have unhappy endings. The question is: if you were this storeman would you have identified and acted on a hazard to your shipmates?

Sometimes we get so wrapped in getting the job done that we forget to add ‘safely’. Be alert because the life you save may be your buddy’s.

Marine Safety Forum reports the happy tale thusly:

“Whilst working at the starboard lay down area emptying a container the store man noticed, directly underneath the grating, there was a tank hatch open with a ladder leading down inside. This was the entry into the cargo tank which had been opened for repairs at the bottom of the tank.

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Is Silence The Greatest Pilot Error?

 maritime safety, pilot, pilotage  Comments Off on Is Silence The Greatest Pilot Error?
Apr 142010
 
image

Hugues Cauvier

Reporting near-misses and unsafe conditions has proven to help reduce serious accidents. In the case of pilots, legal issues get in the way of reporting close calls says St-Lawrence River Pilot Hugues Cauvier, of pivot point fame, calls for greater transparency.

Says Hugues: “I would like to share some thoughts with you gentlemen whom I feel may be concerned by the title subject. It might be naive to hope that the regulations can be changed but stirring the idea may be better than doing nothing at all.

I will be delighted to read your reactions if any of you feel like sharing them (Use the MAC contact from, or the ConReps form). Continue reading »

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Don't Lose Your Head When the Job Changes

 accident reporting  Comments Off on Don't Lose Your Head When the Job Changes
Apr 262009
 

When part of a job changes so do the hazards associated with it. Then it’s time to stop, step back and look at the job again. A good example, one fortunately without injury, has recently been issued by the Marine Safety Forum.

Says MSF: “The vessel was alongside the platform engaged in routine cargo operations. This operation was running smoothly with good communications, safe and efficient backloading / discharging. During this operation a compressor unit was required to be discharged. The AB’s proceeded to move into the correct position while observing the crane pennant as it slewed towards the lift. However one AB noticed that the lifting set had moved position (A to B) to the top of the frame and therefore was not easily accessible. He proceeded to step onto the base frame (C) to free the master link; by doing so he lost sight of the pennant wire which suddenly came in close proximity to his upper body narrowly missing his head and shoulders.crane1
Due to this new position of the master link the task had changed, the AB’s were no longer dealing with a routine hook on procedure. It is extremely important that when a job changes a new risk assessment STOP THE JOB. Re-assess the hazards/risks put in control measures and then continue.

REMEMBER YOU HAVE THE AUTHORITY AND THE RESPONSIBILITY TO STOP THE JOB”

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Lessons From Costa Atlantica – Be Like A Stripper

 accident reporting, collision, collision regulations  Comments Off on Lessons From Costa Atlantica – Be Like A Stripper
Nov 242008
 

Carnival UK, which includes Cunard, P&O and Ocean Village, is to commission a bridge simulator in Amsterdam following a close call incident between the Italian registered cruise ship Costa Atlantica and the panamanian-registered car carrier Grand Neptune in the Dover Straits in mid-May this year. All of the companies masters and deck officers will be required to have completed bridge team management, BTM, training by 2011. Masters and deck officers of vessels trading in Northern European waters will be required to have completed BTM training by 2009. The simulator is expected to become operational in 2009.

A recently released investigation report by the UK’s Maritime Accident Investigation Branch revealed that it was the first time the officer of the watch, recently promoted to Second Officer, had stood a navigational watch as OOW and had never stood a navigational watch while transiting or crossing the Dover Strait. He had been on the vessel for less than a month, having joined it on 25th April.

The master was unfamiliar with Northern European waters, including the Dover Straits. He did recognise his second officer’s inexerience and his own lack of familiarity. He increased the ship’s radar scale to assess risks posed by other vessels and increased speed to reduce the time it would take to cross the Traffic Separation Scheme.

To cross the TSS south west lane, the Second Officer intended to alter course to take the vessel across ahead of another ship, the MSC Serena. As a check, the master used the ‘trial manoeuvre’ function on the ARPA, which should have predicted the outcome, but he did not enter the time parameter. As a result, the radar display showed the vessel’s actual current CPA, not the predicted CPA after the trial manoeuvre, but is was this CPA on which the master based his decision to pass between Msc Serena and Grand Neptune.

Because the master and OOW were not familiar with the ‘trial manoeuvre’ function, the decisions now taken were based on inaccurate information. Had the second officer’s decision been followed, Costa Atlantica would, in fact, have safely passed ahead of MSC Serena by more than 1 nautical mile. Also, had the master and OOW continued looking at their options they might have noted that there was also a better, safer, crossing option between two other vessels.

Costa Atlantica entered the south west lane of the TSS at a fairly shallow angle rather than the 90 degrees required by Collision Regulation Rule 10(c). This made it appear that she was running against the traffic flow and her inentions were not immediately apparent to the pilot on the bridge of the Grand Neptune. Although Costa Altantica was manoeuvred to pass close astern of MSC Serena and ahead of Grand Neptune, the movements were so small that it was not bold enough to be apparent to the pilot onboard Grand Neptune.

For the safety of its passengers, it was practice on Costa Atlantica to use a turning radius of three nautical miles. In this instance this meant that the turn was not immediately apparent to other ships. Under such conditions it might have been more prudent to lessen speed, providing greater flexibility while maintaining the safety of passengers.

Soon after entering the traffic lane, Costa Atlantica was on a steady bearing with Grand Neptune. Steady bearings are bad news. The second officer did not respond to the sitution until Grand Neptune was at a range of 2.46 miles with a CPA of 0.06 nautical miles in 4.4 minutes. The second officer increased the turn to port but, again, this was not apparent to Grand Neptune.

A further issue was that those onboard Costa Atlantica were unaware of the limitations of ARPA and that, while accurate during a steady tracking state, it is less accurate when one’s own vessel is turning.

Given the uncertainties, and some difficulties in contacting Costa Atlantica, the pilot on Grand Neptune initiated a starboard 360 degree turn which resulted in a CPA of one nautical mile.

Fortunately the result was a close call rather than an accident with nearly 1,700 passengers on board the Costa Atlantica.

So, make sure you know how to run a trial manoeuvre and be aware unless you’re on a steady track you may not be getting the right answers from your ARPA.

Take those few extra seconds to go through options when in a crossing situation, the chances are you’ll find something better and safer.

Do remember to move like a stripper – be bold so there’s no mistake about your intentions.

Read the MAIB report here:

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