Oct 122009

imageLack of drills and training in procedures to be used in case of loss of steering have been identified as safety issues by Australia’s Transport Safety Bureau, ATSB, in its report on the 31 July 2008 grounding of the bulk carrier Iron King at Port Hedland, Western Australia.

The grounding followed two steering gear malfunctions on the outbound ship. After the incident a technician checked the steering gear rotary vane unit pressure and discovered that the actuator pressure was 75 bar when the rudder was turning to starboard, but only 20 bar when it was turning to port. He
determined that the aft actuator relief valve, one of two valves controlling oil pressure within the actuator, was draining oil from the actuator whenever the rudder was turning to port. As a result, the actuator pressure was being limited to 20 bar, a pressure that was insufficient to provide the torque required to turn the rudder to port when it was under load. The aft actuator relief valve was removed and the technician found that it was sticking.

image Says the investigation report: “(The Master’s) actions indicate that he probably did not have a thorough understanding of the ship’s steering control system and  that he was not aware of the correct procedure to be followed in the circumstances… Had Iron King’s master been aware of the ship’s emergency steering change-over procedures and adequately exercised their operation, it is likely that his automatic reaction would have been to follow them when the ship’s rudder failed to respond to helm orders.

“While the ship’s SMS procedures stated that emergency  steering drills should be  carried out, they did not detail how this task should be performed. As a result, it is possible that the master and the ship’s officers were not appropriately drilled in the emergency steering control changeover procedure… The ship’s SMS procedures also stated that steering gear tests should be conducted prior to the ship departing port, but did not detail how this task should be image carried out. As a result, the third mate, the deck officer responsible for testing the operation of the ship’s steering gear prior to the ship’s departure from port, had never tested non follow-up control during the pre-departure steering gear tests. Furthermore, he demonstrated at interview that he did not know what non follow-up steering control was, or how it worked.

“The reaction to an emergency situation like the one on the evening of 31 July should, as far as practicable, be a considered, tested and trained response. This is one of the main reasons why it is important that appropriate steering gear tests and emergency steering gear drills are regularly conducted. Hence, it is the responsibility of the ship’s operator, through its SMS, to ensure that steering gear tests and emergency steering gear drills are properly carried out. The SMS should ensure that the master and every officer who may be in charge of a bridge watch, has a complete understanding of the steering system and is aware of, and has practiced, emergency procedures like steering control change-over.”

Pilot training is also covered in the report:While it is possible, with the benefit of hindsight, to discuss what the pilot should, or should not have done, he had to evaluate the situation, consider the options
available to him, formulate a plan and implement it, all within a matter of seconds.

“If the modern risk mitigating strategies now considered necessary by most port authorities are to be as effective as possible, pilots should not be left in a position where they are expected to make this type of on-the-spot decision. The risks associated with pilotage within the port need to be identified and analysed and pilots need to be appropriately trained and equipped with the knowledge and experience to mitigate these risks… Prior to 31 July 2008, the Port Hedland Pilots had not appropriately analysed the operational risks in the port, formulated appropriate responses to mitigate the risks, and trained their pilots for these eventualities. Had Iron King’s pilot received such training, he may have experienced a steering gear failure, albeit in a simulated environment, and had practice in implementing a risk analysed response to this reasonably foreseeable emergency scenario.“

Download the ATSB report


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