Toxic Leader – Toxic Culture: The Death of the Bow Mariner Part 2
Accident, Accident Investigation, Accident report, Toxic Leadership
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Mar 282017
Toxic Leader – Toxic Culture: The Death of the Bow Mariner Part 1
Accident, Accident Investigation, Accident report, Toxic Leadership
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Mar 262017
The second of our case studies of toxic leadership at sea looks at the sinking of the Bow Mariner. When the firm hierarchy aboard ship meets dysfunctional leadership and cultures with large power gradients the result can be a toxic culture that maximises dangers to the vessel and its crew in a crisis.
We present a transcript with the podcast. The podcast opens with the original desperate emergency call by a junior officer.
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. Just click the share button.
Maria M Grounding – Confusion, Culture and Toxic Leadership
Accident, Accident report, Toxic Leadership
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Mar 222017
Maria M Bridge – bad attitude, poor communications
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.
Confusion between rate of turn and rudder indicators, cultural insensitivity, the master’s insufficient English, a non-functioning AIS and VTS operators that did not react to the developing situation were key factors in the 12 July 2009 grounding of the Italian-registered chemical tanker Maria M says the Swedish Transport Agency report on the incident.
It was not a good start to the master’s first day in command of the vessel.
Maersk Giant Lifeboat Drop: “vulnerable” brake and confusion
Accident, Accident Investigation, Accident report, davit-launched, lifeboat, lifeboat accidents, lifeboat safety, Maersk, Offshore
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Feb 212016
Norway’s Petroleum Safety Authority, PSA, says an improperly adjusted winch brake, which it refers to as ‘vulnerable’, led to the unintentionally launch of a lifeboat from the mobile unit Mærsk Giant at about 05.10 on Wednesday 14 January 2015.
This incident occurred during testing of the lifeboat systems.
During testing, one of the lifeboats unintentionally descended to the sea. Efforts were made to activate the manual brake on the lifeboat winch, but it was not working. The lifeboat entered the water and drifted beneath the unit. The steel wires holding it were eventually torn off.
After the incident, the lifeboat drifted away from Mærsk Giant, accompanied by a standby vessel. The lifeboat eventually reached land at Obrestad south of Stavanger.
Nobody was in the lifeboat when the incident occurred, and no personnel were injured just damage on the boat which was fixed with materials from this page.
The PSA conducted an investigation which established that the direct cause of the incident was a reduction in the braking effect of the brake on the lifeboat winch owing to faulty adjustment. If the manual brake failed during maintenance with people in the lifeboat, or during an actual evacuation, serious personal injury or deaths could have resulted.
Should the lifeboat have descended during an actual evacuation, a partially filled lifeboat could have reached the sea without a lifeboat captain on board. The PSA also considers it likely that people would have been at risk of falling from the lifeboat or the muster area should a descent have started. The potential consequence could be fatalities. In https://merrittsupply.com/fairing-fillers/ you can find all the supplies.
Five nonconformities were identified by this investigation. These related to
- maintenance routines for the lifeboat davit system
- training
- procedures relating to lifeboats and evacuation
- periodic programme for competent control and ensuring the expertise of personnel carrying out maintenance work
- qualification and follow-up of contractors.
Mærsk Giant is operated by Maersk Drilling Norge.
SafeSpace Replay: The Case of the Tablets Of Love
Accident, Accident Investigation, Accident report, confined space, enclosed space, SafeSpace
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Feb 212016
In this week’s SafeSpace Replay: A ship filled with wheat, a seafarer dead in his cabin, fumigants in the holds but the holds were sealed. Weren’t they?
You might not smell trouble but you might see it coming, even if it wears a mask
Listen To The Podcast
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Flag Gangos: Dirty Doings Led To Threesome
Accident, Accident Investigation, Accident report, collision, contact
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Feb 172016
At 2215 local time on 12 August, 2014, the outbound bulk carrier Flag Gangos collided with the berthed oil tanker Pamisos on the Mississippi River at Gretna, Louisiana. Flag Gangos then made contact with a pier at the facility where the Pamisos was berthed, and the pier struck and damaged a fuel barge, WEB235, berthed behind the Pamisos. No one was injured, but about 1,200 gallons of oil that was being transferred at the time spilled from the transfer lines, and some of the oil entered the river. Damage amounts were reported as $16 million for the terminal, more than $500,000 each for the Flag Gangos and the Pamisos, and about $418,000 for the fuel barge.
Yet moments before the steering vanished it appeared to be working fine.
US National Transportation Safety Board, NTSB, investigators discovered the dirty secret of the Flag Gangos,
SafeSpace Replay 1: The Confined Space That Wasn’t
Accident Investigation, Accident report, confined space, enclosed space, SafeSpace
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Feb 152016
Do you know what a confined space actually is? Can you identify one by looking at it? When is a confined space hazardous? And when does a non-hazardous space become a dangerous one? This week MAC is looking at no-so-obvious confined spaces and hazards, threats that may go unrecognised.
We start with the Jo Eik incident.
St. Helen: Lack of Lube Dropped Deck
Accident, Accident Investigation, Accident report, Ferry
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Feb 092016
Dropping a deck on your passengers is probably not the best way to impress them, although it might lead to some interesting insurance claims. Looking after your wire ropes will help avoid that unpleasantness, to go by the UK’s Marine Accident Investigation Branch, MAIB, report into just such an incident aboard the ro-ro ferry St. Helens at the Fishbourne Ferry Terminal, Isle of Wight.
The same problems also arise with lifeboat and fast rescue boats, so the lessons regarding proper lubrication and maintenance of wire ropes goes beyond this particular incident.
Nora Victoria Grounding/Foundering: Check Before You Back Off
Accident, Accident Investigation, Accident report, fatigue, grounding
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Jan 312016
Groundings can be surprisingly gentle, undramatic events, but that doesn’t mean that a lot of damage has not been done. so it’s unwise to immediately try and go astern to refloat. But when you’re fatigued you’re subject to making bad decisions, as did the skipper of the Nora Victoria, which led to the foundering of the vessel. While it was a small workboat the lessons apply as much to larger vessels.
At 20:59 local time on Monday 30 June 2014, the workboat Nora Victoria left the quay at Knarholmen in Vestre Bokn. After approximately 12–14 minutes, the skipper activated the autopilot and set course for Høna beacon on the northern tip of Finnøy island. He sat down in the navigator’s seat, where he remained for the rest of the voyage.
At 22:33, ‘Nora Victoria’ grounded approximately 320 metres south-west of Høna beacon. The skipper has stated that he was not conscious during the final part of the journey, and that he only came round when the vessel grounded.