Feb 192015
 

When the esteemed Denis Bryant says: “This incident was the result of too many errors and failures and misadventures, including an unfortunately timed potty break, to easily summarize. I highly recommend reading the report in full” you can be sure that the report, in this case the US National Transportation Safety board’s report on the contact between the fishing boat American Dynasty and the Canadian warship HMCS Winnipeg, is worth reading.

Says the NTSB report: “American Dynasty was approaching the graving dock at Esquimalt in British Columbia, Canada, when it lost electrical power and propulsion control. The vessel veered off course and collided with a Canadian Navy frigate, HMCS (Her Majesty’s Canadian Ship) Winnipeg FFH 338 (“Winnipeg”), moored nearby. Both vessels sustained extensive structural damage, and the naval pier required repairs. Six shipyard workers suffered minor injuries.”

While in port in Seattle, the chief engineer had been using the emergency generator on its harbor mode setting to generate electrical power. When in harbour mode, the emergency generator was not able to automatically start in the event of a power loss. It was not switched over when the vessel departed Seattle.

After two assist vessels were secured for the approach to the graving dock, the docking pilot assumed control of the American Dynasty and requested that the master shut off both main engines and the radars to prepare for entering the Esquimalt graving dock. The master called the engine room, and the oiler answered beause the chief engineer had stepped out to use the restroom). The master did not determine who answered the call, but simply stated that he was transferring propulsion control and then hung up.

The master transferred the CP control to the engine room. The oiler had never previously accepted propulsion control, and he consulted with the electrician who was in the engine room. The electrician advised the oiler to accept the propulsion control by pushing a button on the CP panel.

However, the main engines also needed to be shut off, which the master did not communicate and which the oiler did not know. After accepting propulsion control, the oiler left the room and entered the machinery space to stop an ongoing fuel oil transfer in preparation for the repair facility. The CP system was set at zero pitch, but both main engines were clutched in and turning the propeller shaft. The vessel’s speed was 1.6 knots.

On the bridge, the master continued to shut off navigation equipment. After he had hung up the phone with the oiler, he shut off both steering pumps and the bow thruster motor. About 15 seconds after the propulsion control transfer, the American Dynasty experienced a complete loss
of electrical power. The auxiliary generator was still running, but the breaker that tied the power to the main electrical power bus had been tripped open.

At that point, the trawler was about 2,500 feet from the graving dock entrance. The chief engineer and the oiler quickly returned to the engine room when the power loss occurred. The chief engineer tried to reconnect the auxiliary generator

to the main switchboard but was unable to. In addition, because the emergency generator had not

been changed from harbor to emergency mode after leaving Seattle and was not set to provide

emergency backup power in the event of a power loss, the trawler was dark. The CP control system

had also lost power. The trawler’s main engines were still running and turning the propeller shaft.

On the bridge, the British Columbia coast pilot noticed that the trawler’s speed was increasing and that the heading was drifting to starboard toward the Canadian Forces Base in Esquimalt. Also, the master noticed propeller wash behind the vessel and tried to call the engine room using the service phone, but it had lost power and was inoperative. The master could have
used the available sound-powered phone or portable radio to contact the engine room, but instead asked the chief officer on the bridge to go to the engine room for an update.

The crews on the harbor assist vessels also realized that the speed was increasing and that the trawler was turning away from the graving dock entrance. The master on the Seaspan Foam paid out additional line and tried to pull on the American Dynasty’s stern, but the force of the trawler’s acceleration overpowered and damaged the brake on the tow winch.

Meanwhile, the master on the Charles H. Cates XX tried to pull the American Dynasty’s bow to port and in line with the graving dock entrance, but the towline parted and the trawler veered to starboard and gained further speed. The American Dynasty was now rapidly approaching the Winnipeg, a Halifax-class frigate moored starboard-side-to the west side of Pier 3C at the Canadian Forces Base, undergoing maintenance. Numerous shipyard workers and uniformed personnel were on board the Winnipeg.

The chief engineer was unaware of the impending collision and continued his efforts to manually close the breaker connecting the auxiliary generator to the main switchboard to regain electrical power. He also tried to close the breakers for both shaft generators to energize the switchboard, but failed. Shortly thereafter, the auxiliary generator shut down. The chief engineer left the engine room and entered the machinery space to investigate why the auxiliary generator had stopped. About this time, the master ordered the anchor dropped and tried to sound the trawler’s
whistle, which had not been tested before leaving Seattle and which was nonfunctioning.

Neither the master nor the pilots tried pressing the main engines’ emergency stop buttons, which were located prominently on the bridge control console. Pressing these buttons would have stopped the
propeller shaft from rotating and would have reduced the trawler’s speed.

The speed had now increased to 5 knots, and when it became obvious that a collision was imminent, the crew abandoned the attempt to use the anchor.
At 0817, the bow of the American Dynasty struck the port side of the Winnipeg. The collision causing the frigate’s stern to pull away from the dock, damaging the vessel’s starboard side and Pier 3C. Six shipyard workers on board the Winnipeg sustained minor injuries in the collision.

Investigators found a damaged magnetic pickup sensor on the auxiliary generator’s diesel engine. This sensor was supposed to emit a signal to the engine’s speed control unit, allowing controllers to regulate the engine’s speed; if the sensor failed, the engine was designed to shut down. However, investigators discovered that a failsafe feature on the auxiliary generator’s
control panel had been disabled with a bypass jumper wire, and this prevented the engine from shutting down when the sensor failed. It could not be determined when or why the failsafe had been disabled, nor why the auxiliary generator’s engine eventually shut down despite the bypass.
Because the emergency generator was not set to start automatically and accept the electrical load once the auxiliary generator shut down, the trawler’s emergency batteries should then have provided power to the CP control system. However, investigators found that the batteries, which were supposed to automatically supply power to several of the trawler’s
essential systems during a power loss, were incapable of holding a sufficient charge. Although the crew kept a log that tracked the testing of the batteries, no established schedule was in place for their maintenance or replacement. All of the batteries had last been replaced in 2009.

Further, investigators found that the CP system had a leak in the hydraulic oil distribution box, and the actuator allowed hydraulic oil to leak by, which enabled the propeller pitch to be in the ahead-direction during a power loss. The CP oil distribution system and seals were scheduled for overhaul during the Esquimalt shipyard period.

The American Dynasty’s heading change to starboard was attributed to the trawler’s forward progress with a slight deflection of the rudder of about 2.5 degrees to starboard and a starboard 10-degree bow thruster pitch before the motor was shut off. When the trawler’s speed accelerated, the harbour assist vessels could no longer control the heading.

Further, as relief master, he was not fully familiar with the American Dynasty’s bridge equipment, such as the AIS, which he needed assistance to activate. Also, he and the chief engineer had not agreed on an arrival plan with identified risks or contingencies, such as procedures during loss of power to the CP control system. Finally, although the vessel company
had a computerized tracking system for shipboard maintenance, this system did not include procedures or schedules for critical components, such as the batteries and the whistle. The system was based on class requirements for maintenance but did not include original manufacturer recommendations, such as the need to examine the CP hydraulic components at 80,000 hours.

There’s all the fun of the fair in this report and it’s a good example of the Jenga model of safety.

Read the NTSB report

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