Jul 102014

pachucoConflicting goals and poor communications with unseen crewmembers are not conducive to safe handling of mooring lines, as a recent investigation by Denmark’s Maritime Accident Investigation Board, DMAIB, shows. The deck arrangements probably didn’t help much either, producing uncertainty at a critical time when crews are under pressure and mooring lines under extreme tension.

Pachuca, an Antigua & Barbuda flagged containership was engaged in regular trade between ports in Northern Europe and called at some six ports a week. The master and crew had been in Esbjerg several times before and were therefore familiar with the harbour area and mooring conditions The port stay was planned to last a few hours.
After discharging was complete at 0445, loading commenced and was completed at 0615. Shortly after the ship was ready for departure. The chief officer and the master were on the bridge and on the enclosed forecastle were the bosun, one ordinary seaman and one able seaman.
At 0620, the crew on deck started to single up to one forward spring line. There was a strong breeze from an easterly direction that made it difficult for the master to manoeuvre the ship from the berth. He turned the rudder hard to port and set the thrusters to push to starboard. He then gave the main engine a short forward order by setting the pitch propeller to 40%. His intention was to open the ship with the forward spring and get distance to the berth  then he could use the propulsion to move the ship into the middle of the harbour basin.
As the distance to the berth increased the crew on the forecastle slackened the spring line to ease the tension on the rope. Within 10 to 15 seconds, the spring line was slacked until there was no mooring rope left on the winch drum. The clamp, to which the mooring line was fastened, broke and the line struck the bosun.

The master saw the mooring line part from the ship. He tried to contact the bosun, but there was no reply. He realized that something was wrong and prepared to bring the ship along-side again. The AB reported from the forecas-tle that the bosun was seriously injured, but was still breathing. At 0635 the ship was alongside and moored again and the bosun was evacuated by ladder from a firetruck and brought to the hospital.No-one saw the bosun being hit but his approximate location is known:pachuco
There are at least three possible reasons why the spring line was put on the bollard on the quay in a loop: Firstly, if the mooring line is a loop, then the crew on the ship do not depend on the shore side personnel to let the line go. Secondly, there is the perception that a loop constitutes a stronger mooring than when the line is fastened on the bollard by the eye of the rope. Thirdly, the shipboard main manual stated that the “Mooring ropes should never be left on the winch drums (in port) for the purpose of securing the vessel as they are not designed for same. Only mooring bitts should be used”.No snap-back zones were marked on the foredeck. The DMAIB believes that, given the  vessel’s schedule and different mooring patterns at the ports at which it called, painting snap-back zones for each situation would have resulted in a confused and potentially misleading set of markings.

DMAIB says:”…crewmembers are constantly responding to a changing situation. The crewmembers are exposed to different risks as they are moving about on the deck area. It is, however, not predictable where the hazards will arise and the defined snap-back zones are only applicable in certain scenarios… although the snap-back zones are useful in some circumstances, the areas outside the snap-back zones are not necessarily to be considered safe areas.”Several factors coincided that morning: there was a strong breeze pushing the ship alongside; The master attempted to increase the distance between the ship and the berth by moving the ship forward; On the forecastle the crewmembers were basically facing the choice between holding the spring line while the ship had forward momentum, thereby risking the line breaking or slacking the spring line which could result in the ship colliding with the quay.
Also, the crew had to slack the line sufficiently to get the rope off the bitt on deck. As the line was slacked, they ran out of rope on the drum, it parted from the clamp on the drum and hit the bosun.  No-one knows exactly how the snap back from th rope managed to hit the bosun.

Says DMAIB: “Even though the crewmembers knew that the mooring line was considerably shorter than the nominal 220 metres they might not have recognized this fact in a stressful situation.
“It is not an uncommon scenario that crewmembers are in a situation where they need to negotiate conflicting goals. In this situation the crewmembers slacked the mooring line to ease the tension on the rope.”
None of the crewmembers had a clear view of the mooring drum so were not aware that there was no rope left on the drum.
The shipboard manual was unhelpful. It did not address the specific situation the crew found themselves in on the day of the accident.
Design may have been a factor – the winch control was positioned so that the operator of the winch had little or no overview of the mooring situation. Therefore, any response to the changing circumstances would be delayed because the information was passed on between several crewmembers.
Basically the design of the mooring arrangement meant there was lack of overview, small working area and exposure to ropes under tension, exacerbating goal-conflicts under changing operational circumstances. Similar situations affected incidents aboard two other vessels investigated by DMAIB, Altair J and Torm Republican.

The position of the control box gave little or no view of the deck area in front of the winch and to the port side of the winch or of the mooring line on the winch drums . Furthermore, the fairlead that was typically used for the spring lines was not visible therefore, the operator of the winches relied on communication and signalling from the other crewmembers when determining when to heave or slack the mooring line. Plus, the operator of the winch had difficulty judging the tension applied on the mooring line, as the distance from the winch to the pedestal bitt in front of the winch was short, approximately 2-3 metres, and thus offered little slack on the rope.

The crewmembers had a limited overview of the operation from their positions on the forward deck (figure 6). Therefore none of them had the realization that the mooring line was slackened until there was no rope left on the drum.

Download Pachuco report

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