Jan 072013
 
Nobody checked the engines were going astern

Nobody checked the engines were going astern

Keen darts players will envy the precision with which the Liberian-registered Grand Rodosi neatly speared the, fortunately unmanned, Australian-registered  tuna fishing boat Apollo S, crushed her against the berth and sank her in Port Lincoln on 8 October 2010. It happened because no-one on the bridge or in the engine control room was ensuring that the main engine was doing what they thought it was doing.

In this case, according to the recently released Australian Transport Safety Board, ATSB, report on the incident the chief engineer, who was operating the main engine start/fuel lever in the engine room control room, did not allow sufficient time for starting air to stop the ahead running engine. Consequently, when fuel was introduced into the engine, it continued to run ahead, despite the astern telegraph orders.

Orders had been given to set the main engine astern and the orders confirmed but just because an order is given and confirmed it doesn’t necessarily mean that the ship is doing what it’s expected to do. It’s wise to monitor that the ship is doing what you told it to do: An engineroom alarm complained that the main engine was still going ahead. A tachometer on the bridge also indicated that the engine was still running ahead.  Nobody saw them.

 

Says the ATSB: “…the chief engineer’s mistake was not identified by anyone on the ship’s bridge or in the engine room control room until after the collision; that the master/pilot information exchange was less than optimal; and that bridge resource management principles could have been better applied during the passage to the berth”.

“It is of paramount importance that pilots and ships’ crews maintain awareness of main engine movements and check engine tachometers following every movement to ensure that the engine is operating in the desired direction. This is particularly important when main engines are being operated in manual control.”

It adds: “In addition, pilots and the bridge teams should ensure that all the necessary information is exchanged at the beginning of a pilotage, including courses to be followed and speeds at critical positions during the passage to or from the berth/anchorage, so that all members involved in the pilotage have a shared mental model and therefore, a good understand of the pilotage before it begins”.

Newlead Bulkers, the ship’s managers, has amended its on board procedures to ensure crew monitor the direction of main engine turning after each engine order. It has also increased awareness through the fleet about this type of incident occurring.

Flinders Ports, the provider of pilotage services in Port Lincoln, has revised its risk assessment for the manoeuvre being undertaken during Grand Rodosi‘s berthing to include new preventative, as well as restorative, measures to be followed. Flinders Ports has also revised the port’s pilotage passage plan to include indicative courses to be followed, both while transiting the channel and outside of it, and speed zones. This will enable the crews of visiting ship to be better informed about the pilotage passage their ship is about to undertake.

ATSB Animation of the incident:

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Download report

 

 

 

 

 

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