International MARINE ACCIDENT REPORTING SCHEME

MARS REPORT No 160 February 2006

MARS 200604 Fall from Gangway

0220 Vessel all fast. Main shore gangway, which could 0900 Stations called fore and . Moorings tended and only be moved up-down vertically and not in a made tight as required. Duty officer on poop horizontal direction, nor could it be slewed in any for aft stations and Chief Officer on forward other direction, lowered to correct height. stations. No one was paying any particular Connecting gangway (sometimes referred to as attention near the gangway as it was located on an MOT gangway or formerly known as a brow) main deck and out of view from aft stations and was placed on the main gangway. The other end nobody was expected to visit the ship. of the brow was placed on the ship’s rails and 0918 Main engines tried out ahead/astern. made fast there. The ship’s safety net was used 0920 One person from the Seaman’s Club tried to board and a step ladder was made fast to ship’s railings the vessel, in spite of having been warned by the to facilitate the safe access onto the deck. Also a terminal operator (in his native language) against life buoy with a line was placed near the gangway. doing so, and caused the brow to over balance The gangway was manned at all times by a duty and he fell into the water along with the brow. A.B. The Cadet saw this happen from the deck and raised the alarm. I immediately rushed to the spot and deployed the lifebuoy. Fortunately, the ladder did not injure the man and just dropped vertically into the water, nor did he get entangled with the net. He managed to haul himself onto the jetty foundation clear of the water. 0925 Ship’s crew managed to haul the brow out of the water by means of ropes. Port authorities and Agent informed. Warm winter jacket and gloves were passed on to the unfortunate victim but he was a lucky man and he climbed onto higher supports underneath the jetty. Shore rescue squad on scene. Passed on hot flask of coffee to the man whilst rescue team were busy deciding on the next course of action. 0955 The 60 year old casualty was finally removed from under the jetty by the rescue squad and taken to hospital for shock treatment.

0300 Commenced cargo operation. The vessel was informed there would be a stoppage in cargo operation at 0830 on account of ‘Bore Tide’ passage at 0930. All safety checks were carried out prior to commencement and were satisfactory. 0815 One hour notice tendered to engineer for preparing the engines. 0820 Cargo loading was suspended by terminal. Ship’s manifold valve was closed. 0830 Chicksan disconnected. Crew given 30mins notice to stand-by on deck at 0900. Manifold blanked-off. Ship’s steering gear tried out. 0845 Brow unlashed from ship’s rails and shoved out onto the shore main gangway, assisted by the terminal operator, who was pulling it from his side on shore, it was left halfway on the main gangway and the other half left overhanging, so that it had a ‘see-saw’ effect and would trip if someone overbalanced it. Also the access to the main

gangway was not sealed, nor were there any Lessons learnt: warning signs posted or any barrier erected to deny access to the gangway. 1) Nothing should be taken for granted. In this case, final moorings were to be three headlines and the ship and shore took for granted that no-one lines and two springs fore and aft. will be expected to visit the ship and so there was an air of complacency in that the brow was not At 0814, one stern line was ashore and the Master properly removed, nor were there any notices put ordered this to be taken up tight and then pass out the up warning visitors that the gangway was not in remaining lines. Meantime the headlines were still place. being paid out. Apparently there was a problem with the forward drum and so the lines were not being 2) Notices should always be displayed or the access paid out as fast as normal. The stern line was already sealed off to all visitors once the ship-shore made fast aft. This line was on the drum and caused access is compromised. the to swing out away from the jetty in spite of the tug pushing it alongside. The other stern lines were 3) The terminal operator was slack in his duty and being passed out. During this period, all the headlines was not able to impose his authority to halt the were sent out and were tightened one at a time. But person from trying to board the vessel even after the bow was not coming alongside since the stern line there was no proper access. was already tight and was preventing it from coming in. The Master asked the stern line to be slackened by 4) The person, having been verbally warned, was about two meters. This order was promptly executed apparently not paying attention or had other things and reported back to the Master. on his mind which may have caused him not to take notice of the warning. Also the age-factor In order to send out the additional stern lines, it was may have been the cause that hindered his necessary to pass the heaving line over the other stern hearing ability. line, which had been slackened. For this reason, the A/B was standing next to the stern line and Having said this, it was still the duty of the terminal manipulating the heaving line over it. One moment the operator to physically drag the man away from the stern line was slack and the next it had gone tight and gangway or remove him from the scene. had too much weight on it. Before anyone could realise, the stern line jumped off from under the ‘lip’ of 5) As a Duty Officer at the time of the incident, I feel the fairlead roller and hit the A/B on the right knee cap. guilty and responsible for the accident in spite of Fortunately, the blow was not so hard, and he escaped the fact that the circumstances were entirely with a bruise and swelling which was treated and he beyond my control. could walk unhindered in a few hours. However, the point is that there was an accident involving moorings in 6) The quick and prompt action taken by the ship- spite of repeated warnings and discussions held prior to staff and also the fact that the person was not commencing the operations. injured helped to resolve the situation and bring it under control and get the man out of water. The reason that the stern line became so tight was probably due to the fact that the headlines were being 7) The response of the rescue personnel was tightened. This caused the bow to come alongside satisfactory but could still have been improved as rapidly and the two meter slack that had been rendered it took 30 minutes from the time they arrived on- aft was not enough and caused the stern line to strain scene to the time they finally managed to remove and ‘jump’ from under the ‘lip’ of the fairlead roller. the person from underneath the jetty.

8) Fortunately for the man, he was not injured, not even a scratch, as this accident could easily have cost him his life.

MARS 200605 Mooring Injury

We picked up the pilot and proceeded to our berth with a strong NW’ly off-shore wind blowing across our bow. The vessel made fast two tugs fore and aft, with tugs lines through the centre Panama leads. The whole operation was being carried out in day-light so there was no excuse of poor lighting.

The headlines were the first line to be sent ashore, followed by the aft back- springs. The shore mooring gang consisted of just one person attending the moorings at each end. This did not put any strain on the ship-staff to “hurry-up” the mooring operation. The vessel was nicely alongside and in position with the loading arm. The

Lessons learnt: been stripped off are known to be dangerously slippery. The Third Officer was not wearing spiked or studded 1) Whenever any lines are being tightened or boots which are recommended to be worn while slackened, personnel should keep well clear of the walking over such log cargo. area. The Company reminds all Officers that the guidance 2) When headlines or stern lines are tightened, given in “Code of Safe Practice for Ships Carrying proper communication should be made between Timber Deck Cargoes” Chapter 5 is to be strictly the Bridge and the Duty Officers, so that they are followed with respect to personal protective gear, walk aware that the lines will be under strain, even ways etc., in order to avoid such accidental falls. The though they have been slackened. Company also reminds all Officers of our earlier memo on dangers of oxygen depletion in spaces where logs 3) Mooring lines, even though they have been made are carried. fast and apparently under no strain, have to be given a wide berth. The Duty Officer must ensure this at all times. MARS 200608 Fall from

This report was sent by the Office of Investigations MARS 200606 Fall in Ballast Tank and Analysis, USCG Headquarters. Questions or comments may be addressed to: As part of a routine inspection of ballast tanks, an [email protected]. enclosed space permit was completed prior to the inspection. The Bosun was the first to enter the fore In 2003, an un-inspected towing vessel (UTV) peak tank, he stood by for the Chief Officer at the first suffered a personnel casualty while engaged in a level. The Bosun stood clear of the ladder to allow the dredging operation. The incident resulted in serious Officer to come down to the first level. injury to a crew member and an undisclosed monetary settlement of a Jones Act Claim against the marine After descending to the first level, the Officer employer by the injured crewman. continued to go down to the next level ahead of the Bosun. Whilst doing so the Officer slipped and fell into The crew member was conducting an unscheduled the hole in way of the ladder but managed to avoid repair to a navigation light fixture attached to the mast falling right through by holding out his arms. In the located above the upper wheelhouse. For personal fall process, the Officer was struck on the lower back on protection, the crewmember collected a body belt and a the right hand side and felt a sharp pain in the contact positioning lanyard from a storage location on the area. The officer was able to climb out of the tank vessel. assisted by the Bosun The crew member climbed the mast, fastened the The Officer was incapacitated for a period of 9 days, lanyard around the mast, leaned back supported by the and was later disembarked so as to undergo further belt and began working. Just minutes into the repair medical checks and treatment. Needless to say, if the the lanyard parted. The crewmember fell to the deck Officer had fallen right through, then the consequences approximately 40 feet below and sustained a broken may have been more serious. leg, arm, ribs and contusions to the and back.

On investigation, it was noted that the ladders and The Coast Guard's investigation focused on the human platform were in a good condition. The surfaces were a element and equipment performance. Although the little wet, but not slippery. Lack of sufficient illumination investigation is not yet complete, important regulatory could have been a contributory factor leading to the issues regarding the use, training, and storage of incident. It cannot be over stressed that proper Personal Protective Equipment (PPE) have been illumination is important so as to allow oneself to discovered. Specifically: become familiar with the surroundings in an enclosed space. ¾ Effective January 1, 1998, body belts were deemed unacceptable for use as part of a The lessons to be learnt as a result of the above are personal fall arrest system by the that more attention should be paid when working in Occupational Safety and Health Administration enclosed spaces. If the various procedures and checks (OSHA). as outlined in the enclosed space permit had been carried out correctly, then incidents like the one above ¾ The manufacturer's instructions for the proper could be prevented i.e. there would have been proper use, care and inspection schedule for the body illumination. belt and positioning lanyard were not followed.

¾ The marine employer did not adhere to the requirements of 29 CFR 1915.159 for personal fall arrest systems. MARS 200607 Slip on Logs ¾ The marine employer did not adhere to the While loading operations were in progress on one requirements of 29 CFR 1915.160 for of our vessels, the Third Officer slipped while walking positioning device systems. over log cargo stowed on deck. He fell overboard into the sea as a result. Luckily he was rescued unhurt by the barge men along side. Logs where the bark has ¾ The marine employer did not adhere to the in the deteriorating quality of today’s crew and officers. requirements of 29 CFR 1915.152, general If we continue on the road we're on right now, in a requirements for training and documentation. couple of years the practical knowledge of ship’s officers will get even worse and could be carried out by Investigators determined that the lanyard was automatons or monkeys. We would have to teach them manufactured in November of 1993. The the tricks and the ships can be exploited at minimum manufacturer's instructions called for semi-annual cost. A very dangerous situation indeed, because if the inspection and removal from service no later than situation deviates from the routine task, a solution to the November of 1998. Further investigation revealed that problem will not be available to these untrained people. company policy prohibited the use of a body belt for personal fall protection and required the use of a full In my opinion, seafarers who use "rules of thumb" body harness; however, the vessel was never provided without understanding the backgrounds – without with a body harness and instead retained two body proper training – are becoming more common every belts and lanyards. The Coast Guard could not day. In this example, instead of using the motto (read: establish that the involved individuals had been trained rule of thumb) to keep waypoints to port, seafarers on their use, storage and limitations. should realize that routeing computers are a good tool, but can never function as a primary means of voyage planning. It's the input of the well trained and experienced navigator that makes a voyage plan safe! Readers’ Feedback on MARS 200544 Waypoints to Port 3

1 I circulated the suggestion about leaving way points The suggestion to pass waypoints to port is not only to port and it received a mixed response. Most thought a good idea but would be easy to implement as it is just it a good idea but there were drawbacks. a continuation of normal navigational practice. We already 'drive on the right' at sea and normally leave However, it was suggested that where this is a real fairway and isolated danger marks to port so this idea problem (voyages from Dondra Head / Malacca Straits / can be seen as a continuation of that practice. But Singapore / S.China Sea) the problem could be would it really be that easy. My own observations of alleviated if there were more routeing schemes. I feel navigational practices over the last few years would that this is valid, especially off Pu Rondo and given that indicate that it wouldn't. the TSS’s have been extended in the Malacca Straits, extending them further to include notable choke points I am often standing by or working with drill would be an improvement in safety within the area. ships/semi-subs in isolated areas clear of established oilfields. Often these locations are in or near busy Full routeing is not needed, only partial schemes shipping routes. Over the last few years I have had to that are designed to split the traffic and encourage two request numerous vessels with a zero CPA to alter way flow with less crossing. This will also mean that the course. In at least two notable circumstances, one in ships going towards the common way points would at the Arabian Gulf and one in the South China Sea, the least be going in the same direction. Officer of the Watch has replied in the negative as the rig is on his course line. When the circumstances have then been adequately explained that the rig has 8 ranged with buoys over a mile from the rig More reports are always needed. If you have location, the OOW then has to call the Master to seek experienced any incident which you think may be permission to alter course. On one occasion this took of interest to others please send details, including so long that the vessel ended up inside the buoy pattern despite being warned when he was over 6 miles your name and a contact address, to: away. Perhaps a better idea would be to instruct officers doing the passage plan to offset the waypoint in Captain R Beedel FNI 17 Estuary Drive the first place. This would achieve the same result Felixstowe Suffolk IP11 9TL U K without taxing the OOW's thought processes too much. Email address – [email protected] Would following either of the two options possibly have helped avoid the collision mentioned in the New Fax Number +44 (0)1394 276534 Cepheus J/Ileksa report? I doubt it very much. What one vessel considered a decent offset from the The Council of the Nautical Institute gratefully waypoint would not be vastly different from the next acknowledge the sponsorship provided by:- vessel. Unless they were very near the waypoint, and had offset ideas at least a couple of cables apart, any THE NORTH OF ENGLAND P & I CLUB, difference in offsets would hardly be noticeable in the THE SWEDISH CLUB, THE U.K. P & I track each vessel was following. Applying either of the two options above would only aid in reducing reciprocal CLUB, heading situations. DET NORSKE VERITAS, THE MARINE SOCIETY, THE BRITANNIA P & I CLUB 2 THE JOURNAL SAFETY AT SEA In the mentioned MARS report, a navigator INTERNATIONAL suggests the introduction of a new motto: keep waypoints to port. This seems like a sensible idea. However, it's fighting symptoms. The real problem lies