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Navigation Act 1912
Navigation (Marine Casualty) Regulations
investigation into the grounding of the
navigational aids service vessel
CAPE GRAFrON
on Dent Island,
Whitsunday Group, Queensland
on 2 June 1994
No 70 "
I
!
Published: August 1995
ISBN 0 642 19956 6
To increase the value of the safety material presented in this report, readers are encouraged to copy or reprint the material in part or in whole for further distribution, but should acknowledge the source. Additional copies of the report can be obtained from:
Inspector of Marine Accidents Marine Incident Investigation Unit Department of Transport PO Box 594 CANBERRA ACT 2601
Phone: 062747324 Fax: 062746699 Contents
Summary ..: ...... ~ ...... 1
Sources of Information ...... 2
Narrative ...... 3 Introduction ...... 3 The vessel ...... 3 AM SA ...... 4 The selection of and fitting out of hull no. 408 ...... 5 The delivery voyage ...... 7 The incident ...... 9 Post accident tests and trials ...... 14 Comment and AnaJysis ...... 17 International Safety Conventions ...... 17 Circumstances of the grounding ...... 1 9 General ...... 19 Engine control room alarm printout ...... 22 Equipment issues ...... 25 Stop blocking the generators ...... 25 Overload protection ...... 26 Emergency 24 volt supply ...... 31 Emergency switchboard ...... 31 Emergency batteries ...... 34 Human factors ...... 34 Experience and training ...... 34 Operating instructions and procedures ...... 35 Clutch and pitch controls ...... 38 Fitting out and survey ...... 41 Conclusions ...... 45
Details of Ship ...... 47
Submissions ...... 49 Contents continued
Photographs and Illustrations Photograph and General Arrangement - Cape Grafton ...... following pages Dent Island - Position of grounding ...... 10 Bridge contrbls ...... 16 Schematic of propulsion plant ...... 18 Engine control room ...... 23 Part of main switchboard synchro panel ...... 28 Circuit breaker control (n o. 1 generator circuit breaker) ...... 29 Emergency switchboard plan ...... 32,33
Attachments - Submissions 1. Acting Chief Executive, AMSA 2. Technical Adviser - Ship and Personnel Safety Services 3. Chief Engineer, Cape Grafton 4. Barnes and Fleck Pty. Ltd. 5. James Woolley Pty. Ltd. ( 6. L1oyd's Register of Shipping l
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;;)II!IOQII'O ... . ,~ ..:JGlIIlIToClII'" . ___ ... , ~"i --XI"'I" ...... (I:DI.. ~------"~~"~---~~--~~"~-"~~-i ~,~ On the morning of 2 June 1994, the Tne grounding was relatively minor in Australian Maritime Safety Authority nature and Cape Grafton refloated navigational aids service vessel, Cape without assistance on the afternoon Grafton was anchored off Dent Island tide. Nobody was injured and no in the Wbirsunday Group, Queensland. pollution resulted from the grounding. Cape Grafton, a dieseVelectric powered vessel, had arrived in Such vessels are required to routinely Australia in March, having been built operate close to the shore or and fitted out in S pain. The vessel was navigational hazards, where on its first operational deployment and co=ercial vessels would not was scheduled to carry out routine normally navigate. maintenance on Dent Island lighthouse. While the investigation established operational factors which contributed At about 0740, Cape Grafton started to to this particular incident, significant weigh anchor to move closer to the defects in the ship's systems meant that lighthouse and to make a lee for the the vessel was vulnerable to loss of work boat, which was used to convey control. Put simply, if the accident had men and materials to the land. not occurred on 2 June, there is a strong probability that it would have Anchor was weighed at 0752 and the occurred at some time in the furore due Master manoeuvred towards the to incorrect control settings, the lighthouse turning to starboard, away configuration of interfaces between the from the island, before making the main units in the vessel's propulsion necessary lee. At about 0755 the system and deficiencies in the supply vessel suffered a total loss of power for of emergency power to essential a few seconds, this 'blacked out' all navigational instrUments, as they means of propulsion and existed at the time. instrumentation for a critical period. Although electrical generating power The report outlines the background to was restored within a few seconds and the incident and considers the machinery was restarted, control was contributory factors. 1 Sources of Information ,. The Inspector acknowledges the help and cooperation of the following in compiling this report: The Masters and officers of Cape Grafton The Australian Maritime Safety Authority Factorias Vulcano Shipyards S.A, Vigo, Spain Lloyd's Register of Shipping Novamarine, Newcastle Barnes and Fleck Pry Ltd James Woolley Pry Ltd North Queensland Engineering & Agencies 2 provided by chree medium speed Narrative Caterpillar 3516 DITA diesel generators_ The diesel engines have a V 16 configuration, running at Introduction 1000 rpm and the electrical output of Cape:Grafton grounded on Dent Island each set is 920 kW at 415 volts. The at approximately 0802 on 2 June 1994_ engines are fitted with an air start As with almost any accident, the system_ In addition to the tb...ree main explanation for the grounding is not generators, the ship has a harbour simple. The grounding occurred when generator and an emergency generator, a number of causal factors came these two being siruated in a co=on together at a critical time in the space in the funnel casing on the upper operation of the ship. To understand deck. Each has its own side of a the factors contributing to the co=on, but split, switchboard in the grounding, some appreciation of the same space_ vessel and the events preceding its Propulsion power is provided by two arrival at Dent Island are necessary. 800 kW (continuous rating) Indar air cooled induction motors driving, The vessel through clutches and a gearbox, a single shaft and a KaMe Wa Cape Grafion is a purpose-designed controllable pitch propeller in a Kort navigational aids service vessel, owned' nozzle_ and operated by the Australian Maritime Safety Authority (Alv!SA)_ The gearbox is a 'Valmet' single Chosen by AlY1SA as a hull, at the reduction, twin input/single output type Factorias Vulcano SA Shipyard, Vigo, with integral thrust block_ Each S pain, the vessel was completed in: propulsion motor is connected to the January 1994. gearbox by means of an MCD 'Twindisc', Omega style, slipping The ship has a length of 74.4 m., a clutch. This variable speed hydraulicl moulded breadth of 125 m, a gross friction drive allows the speed of the tonnage of 2065 and a load propeller shaft to be varied while displacement of 2901 tonnes at a maintaining constant speed of the draught of 4.49 m_ It was built, not propulsion motors. only as a navigational aids vessel, but also as an oceanographic research Operation of the three main generators vessel, being fitted with a scientific is controlled by a Norcontrol, hold, research laboratory and programmable logic controller (PLC) acco=odation for 47 persons_ It has based, power management system_ a helicopter deck and carries a 'LARC' Under normal seagoing conditions, one amphibious vehicle. of the main generators is selected as the duty machine and the two other The vessel is propelled by a diesel main generators are selected as electric drive, electric power for the 'stand-by l ' and 'stand-by 2'. Any main propulsion motors, auxiliary generator may be selected, by means of systems and hotel services being switches. to fill any of the above roles. 3 When the power management system 1991. Of the six business units that senses that the electrical load on the form the structure of Nv!SA, four are swi tchboard is reaching the limit of essentially 'operational' in narure, power available with the number of Navigational Services, Ship and generators connected, it will Personnel Safety Services, Marine automatically start up the next stand-by Safety Services and Marine machine, synchronise it and connect it Environment Protection Services. to the bus '. Similarly, if the load on the running machines drops below a The Navigational Services Business preset level for a preset period of time, Unit provides a national integrated the power management system will navigational service to meet the needs automatically disconnect and shut of co=ercial shipping for safe down the stand-by machine(s). This navigation. This includes the provision automatic 'shut down' can be inhibited of 394 aids on or off the coast of by the application of 'stop blocks' to Australia. Navigational Services and the running generators. Under this its predecessors operated navigational condition, the running machines will aid vessels providing logistic support remain connected to the switchboard for construction, maintenance and no matter how low the demand for resupply of marine navigation aids. electrical power may fall. S top blocks can be applied either from the bridge Navigational Services also manage and or in the machinery control room. operate the vessel Rig Seismic, engaged in geophysical survey The design of the control systems was activities for the Australian Geological such that the three generators, the twO Survey Organisation. propulsion motors, the electrically driven stand-by oil pumps for the two In 1963 and 1964, three navigational Twindisc clutches, the two steering aids vessels were delivered to the motors and the fire pumps, could all be Co=onwealth to replace its existing started and stopped from the bridge. fleet. Over time, with the conversion This design was intended to pernrit of lights to solar power, greater totalllnmanned machinery space automation and in=asing use of (UMS) operation, including start up of helicopters, the requirement for ship machinery from the bridge. In spite of support was reduced to a stage where this design, however, it was still only one vessel was required to ful.fi.l necessary for the engineers to start the the function of servicing navigational controllable pitch propeller (CPP) aids. hydraulic pump and the fresh and salt water cooling pumps in the engine The selection of and fitting room before the engines were ready for out of hull no. 408 sea. To maintain a reliable servicing regime for the offshore navigational aids, the AMSA AMSA Board recognised that it was The Australian Maritime Safety necessary to consider a number of Authority was established on I January options for servicing such aids . . A bus is (he JITaIlgement of copper conductors (bus bars ) within a switchboard. from which the circuits are suppJied.. 4 One of the options was the builder's capability in terms of quality replacement of the thirty-year-old Cape assurance and management and made Moreton, the remaining navigational an overall assessment of the yard's aids vessel. In October 1992, ;:wo ability co deliver the desired ship. He partly completed vessels were noted that a 'Yard Standards' booklet identifred as meeting A..:.v!SA was no t available, but the relevant requirements, one in Spain and one in information could be provided. Poland. It was decided to pursue the However, this was not considered option of a replacement vessel and the necessary as the yard was at an purchase of one of the rwo hulls was advanced stage of implementing a confirmed in December 1992. quality assurance system to the International Standards Organisation's AMSA appointed a joint consultancy, ISO 9001 and the yard management consisting of a consulting marine was confident of achieving full engineer and a firm. of naval architects certification by June 1993. (Tills to advise on technical aspects of the certification, from Det Norske Veriras, selected hulls. Draft specifications was attained August 1993). A..:.v!SA were drawn up by the consultants, decided to accept the tender of which were submitted to AMSA in Vulcano Shipyards of Vigo, Spain; a January 1993. yard with experience in building over 500 vessels. With the Spanish hull preferred, its specification was subsequently In May 1993, the contract was signed amended by a process of consultation berween AMSA and Factorias Vulcano with senior marine staff, shore to fit out the selected hull in technical staff, and legal advisers. The accordance with the specification, with detailed specification was reduced to a completion and hand-over date of one third of the original size, removing 9 December 1993. The joint repetition, items that were consultancy partners were appointed as subsequently not required and general Project Managers and as the AMSA editing of the text. There was a 'Representative' under the terms of the general requirement for the vessel to building contract, with the ;:wo conform CO International Safety consultants alternating in Vigo. Conventions, Australian Standards and the relevant Marine Orders. Modifications to the deck arrangements were started in May, Conscious that the Navigation Services followed by the construction and Business Unit had little shipbuilding fitting out of the accommodation experience, Al\1SA consulted a number spaces and engine room. The of Australian shipping companies as to Representatives' reports from the yard the best way to proceed, particularly indicated a good standard of with a vessel to be fitted out overseas. workmanship and co-operation. Based on this advice, an independent However, within approximately ;:wo consultant, engaged by the AMSA weeks of the signing of the contract, Board. inspected the Factorias Vulcano concern was raised in the weekly yard in Vigo, Spain. He assessed the Representatives' report co AMSA. 5 regarding the building schedule, which complex and the correct configuration was falling behind that planned. of controls and wiring was essential for Concern was also expressed. on a safe operation. number of occasions, about the supply and processing of drawings and plans, The Master, who was to command the and their approval. ship on its departure from Vigo, arrived at the siJ.ip on 15 December Al"{SA seagoing staff were appointed 1993, in time for sea trials. Sea trials, to stand by the ship in Vigo, including a UNIS trial, were conducted progressively from June, the first to on a number of days including arrive being a chief engineer. A1\1SA 22 December, 5 January and management gave an oral briefing to 11 January. Toe items contained in the their stand-by staff in Vigo, that they 'Trials and Test Protocol' document were to: were signed for on these dates, the bulk being signed for on 5 January. 'assist but not to do the project management or supervision of the On 18 January 1994, a facsimile from shipyard work'. the A1\1SA staff in Vigo confirmed that For various reasons, the fitting of the 'all relevant documentation covering the acceptance of the main propulsion equipment, generators and propeller systems, together with vessel was passedjrom Vulcano to the electrical control wiring and alarm AMSA in accordance with the systems, was delayed until mid specifications' November, about three weeks before and Cape Grafton was accepted by the scheduled completion date. The AMSA. weekly report to AMSA from their Representative raised the issue in Sea trials and familiarisation for the reportS of 8 and 15 November. The newly joined Master and crew were yard. which was experiencing conducted on 20 January, lasting for a problems in completing the ext=al little under 3 hours. On 21 January, painting program, sought an extension while alongside and preparing to put to of time, to the middle of January, to sea for further trials, a watertight door complete the ship's painting closed on an electrical shore supply programme. cable, resulting in a large voltage 'spike' on the ship's systems, which Another significant concern raised was destroyed two control cards in the that, while the Caterpillar generators, electrical circuits. No spare cards were the Indar propulsion motors and the held and the necessary replacements KaMeWa controllable pitch propeller had to be flown in from the system were reliable items of manufacturers in Norway. A further equipment, the control systems and the 2 hours 20 minutes of trials were held electrical interfaces between the on 25 January, the day before the various components were relatively vessel sailed from Vigo. ' " 6 The delivery voyage le:licage were addressed. The engineers found a number of electrical circuits Cape Grafton sailed from Yigo, bound and systems incorrectly marked. These for Australia via the Panama Canal, on faults were rectified and warning 26 January 1994. notices were placed on easily accessible 415 volt feeder terminals. A builders representative Era velled with The engineers also discovered that the vessel as 'Guarantee Engineer', to many of the electrical wiring diagrams assist with any 'teething' problems that supplied at hand-over were not might arise, also to train and advise the accurate and did not relate to the ship's staff on all aspects of the control wiring acrually fitted on board. and machinery systems. In addition, an electronics engineer and an Much of the delivery voyage, other electrician from the yard sailed with than port manoeuvring, was conducted the ship from Vigo to Las Palmas to with only two generators in operation, continue work on rectifying defects in a required capability of the system. but the 24 volt electrical and al= it was found that the pitch needed to be systems. adjusted according to wind, sea and on-board operational conditions, to The vessel sailed via Las Palmas and prevent electrical overload of the the Panama Canal for Honolulu and generators. then to Sydney, the call at Honolulu being timed to coincide with an During the investigation it was stated International Association of that the ship experienced automatic Lighthouse Authorities conference. pitch reduction, or 'auto slow down', Attendance at this conference had been on three occasions in the Pacific under consideration by Al.\1SA since Ocean. The auto slow down, in which late September 1993. propeller pitch is quickly reduced to 50 per cent, is a system designed to For the ship's engineers, much of the protect the generators from the voyage was involved in tracing and consequences of over heating, low rectifying earth faults, particularly in lubricating oil pressure or overload. the monitoring systems. Although, These three instances were recorded in before sailing from Vigo, they had the engine room log book. been assured that faults on the 24 volt systems had been rectified, earth faults On one such occasion, on the morning continued to appear. Some significant of 12 March, the ship experienced an time was spent on cleaning the engine automatic reduction in pitch to below room bilges of debris left by the 60 per cent. No al= came up to builders. indicate the cause of the problem and all pressures and temperatures were With the assistance of the Guarantee found to be normal. By changing from Engineer, problems of ventilation, air normal control to the backup mode, conditioning and electrical earth they were able to increase the pitch to 7 80 per cem. On 13 "'larch. an 'auto stop blocks should be applied to the slow down' again occurred. Toe main generators. to prevent them from problem was craced to a faulty jacket disconnecting from the main water cooling temperature sensor on switchboard under conditions of no. I generator and the Guarantee intermittent power demand, such as Engineer disCGnnected the wires of the when the ship was manoeuvring. auto slow down circuit at the KaJ.v!e Wa Cape Grafton berthed in Sydney on central control panel while working on 21 March, where it was open to the the problem. The Guarantee Engineer public for inspection. After one week reconnected them when the fault had in Sydney. the vessel sailed for been bypassed. However, the engine Brisbane. room log book indicates that, fo llowing further problems with the 'PTIOO' In Brisbane. modifications were temperature sensor fitted to the carried out to the emergency Caterpillar engines and some switchboard and an extra (emergency) unsuccessful attempts to bypass these generator was installed. This involved problems, the auto slow down function splitting the emergency bus into two was disconnected on 18 March sections. one for 'essential' circuits, pending receipt of spare sensors when which were connected to the new the ship arrived in Sydney. emergency generator and one for 'non essential' circuits. which were The Master recollected that while the connected to the existing harbour wires were disconnected, thus generator. These modifications were bypassing the auto slow down system carried out without fo=al drawings. in order to allow the vessel to maintain . speed to Sydney, extra care was taken In addition, the automatic start system to ensure that cooling water for the Twindisc clutch hydraulic temperatures and lubricating oil pumps. which were previously pressures were maintained and that the activated by a slight movement of the load on the generators and motors was bridge clutch control, was kept to a reasonable level. Tills was to disconnected and individual electrical be maintained until the new sensors circuits were fitted for starting these. were received by Cape Grafton. and other pumps required for the operation of the propulsion system, During the delivery voyage. the ship's from the bridge. The classification officers, with the help of the Guarantee society. in submission on the draft Engineer, started to gain experience in report, stated that these modifications the operation of the vessel's systems were not drawn to the attention of the and drew up a series of guidelines for surveyor who was present on the vessel operation of the ship. based on their in Brisbane. experiences of the vessel and on the assumption that Cape Grafton would Also. while in Brisbane, some spare be controlled from the bridge. These PTIOO sensors were received and procedures included a stipulation that defecti ve sensors on the generators during manoeuvring operations the were replaced. 8 The incident the water, two cables' off the shore line. The three mates remained on Cape Grafton sailed from Brisbane at bridge anchor watches for the night 1825 on 18 May 1994, to service and the propulsion machinery was navigational aids nonh of Brisbane and maintained on 'five minures notice'. in the .Dreat Barrier Reef area. The Master had taken over corumand of the On Taursday 2nd June, the yIaster vessel on 9 May, having carried out a awoke at abour 0600 and went to the familiarisation period from 21 March bridge where he spent some time with to 25 April. During this time, only two the Mate, before going to breakfast at days of which were spent at sea on 0700. Between 0700 and 0720, the passage between Sydney and Brisbane, Mate tested main engine controls and he had perfo=ed the duties of Mate. steering in preparation for o-ettin 0- - -= 0 The Chief Engineer had joined the under way. The Electrician, the duty vessel for the first time on 20 April, engineer officer for that day, started a receiving a hand-over during the main generator and, assisted by the following two weeks. Chief Engineer, changed over to the main power supply from the harbour On the passage north, the vessel generator, located in the emergency anchored on four occasions--off generator flat. Before rerurning to the Mooloolaba, Breaksea Spit, Lady engine- room, the Chief Engineer Musgrave Island and Nonh Reef. The initiated the harbour generator- auto vessel also called at Gladstone from shut down sequence. 27 May to 30 May, before continuing to Dent Island. The Master and Chief The ship took its tidal data from Shute Engineer adopted a practice of using Harbour with a high water of 3.0 m two generators when manoeuvring to above darum at 0558 and a low water and from an anchorage and three of 0.7 m at 1229. Tidal streams in this generators when operating within a area run south with the flood and nonh port. with the ebb. The wind was from the south-east at 15 knots and the tide was The vessel arrived at the Whitsunday ebbing. Islands on the afternoon of Wednesday 1 June, for the purpose of servicing the The bridge and engine room controls Dent Island lighthouse, siruated having been tested, the Mate carried towards the southern end of the west out the procedures for starting the main coast of the island. As the area off the propulsion units. He pressed the lighthouse is unsuitable for overnight 'START REQUEST button, but as only anchorage, being steep-to and subject the 'master' generator was run:n.ing at to strong tides, the Master chose to that time, there was insufficient power anchor off a small bay, one mile to the available and there was a short delay north. while the 1st stand-by generator started and connected. As soon as the second At 1618. the vessel was brought to a generator was on line, the 'START single. port anchor, five shackles' in ACCEPTED' light was illuminated and I Shackle :: ::!7. ..J. metres I Cable = IS 5.2 merres 9 DenrIs .' Hamilton ~ I Island Tide 20' 22'S ' . J , '"\ . A " \ l DENT IS, QLO. o 2 3 4 5 6 7 8 9 \ cables Soundings in metres 10 the Mate pressed the 'START burron. to starboard. he reduced the propeller starting the first propulsion unit. He pitch co 30 per cent. His intention was then went through the procedure to to take the vessel wide until west of the start the second propulsion unit:., there lighthouse, then to make a 300 degrees being no delay in the start acceptance rum to port and to head west in order on this- occasion. to provide a lee on the starboard side for launching the work boat, before re The Master rerumed to the bridge at anchoring. 0730 and instructed the Mate to advise the engineers that 'clutch-in' would be Tue Mate instructed the IR to leave the at 0740. Acrual tiIDe of clutch-in was port anchor ready for letting go, then 0742, after which the Master instructed rerumed to the bridge, where the the Mate to telephone the engine Master detailed him to go down and control room and ask the engineers to plan the day's operation with the Chief start the aft thruster. Wbile trying to IR. make contact with the engine control room, the Mate noticed a light blinking As the vessel neared the required on the generator control panel, heading of 210°, the Master moved the indicating that a generator was shutting pitch control to 70 per cent. Tne down. Tne Chief Engineer and vessel over-shot the course slightly and Electrician had left the engine control he applied about two degrees of port room, once they were satisfied that the rudder. Then, as he moved the rudder clutch-in was fully effected, to check back to amidships, Cape Grafton around the engine room, and therefore suffered an electrical 'blackout'. The the Mate received no response. The time was recorded in the bridge Master, not wanting to delay, said that movement book as 0755 and was the aft thruster could be started later indicated by the engine room alarm and instructed the Mate to go forward printout as 07:52:45. with the watch Integrated Rating(IR) Just before the blackout occurred, the to weigh anchor. Chief Engineer and Electrician were As the Mate and IR went to the standing by no. 3 generator, about forecastle, the Third Mate arrived on three metres from the control room the bridge, to assist the Master and to door, when they heard the noise of a write up the movement book. At the main generator loading up. As soon as time the Mate co=enced weighing the blackout occurred, the two officers anchor, 0745, the vessel was lying on a dashed to the control room door and, heading of 190°. as the Electrician opened the door, they heard a main generator circuit-breaker At 0752, as soon as the anchor was automatically close back onto the main aweigh. the Master put the pitch switchboard. The Electrician then set control to ahead 40 per cent and about accepting the alarms on the applied 10 degrees starboard rudder to control panels while the Chief bring the ship around to a heading of Engineer set up the second and third 210°. As soon as the ship was turning generators. 11 Tne Master remained at the main shut down the emergency generator. control position, but the blackout had VVllen they arrived. they found that it caused the loss of the navigational was not running. On their way, they instruments, including the rudder angle had met the Second Engineer who, and pitch indicators, which were not appraised of the situation, went to the restored wheu· the main generator steering gear flat. He stated that when restarted. The Master sem the Tnird he reached the steering gear flat, he Mate forward, co stand- by the anchors. found that one steering motor was running and that the tiller was The Mate, unaware that the blackout bunting'. had occurred, returned to the bridge, where he noticed that the steering gear While the Electrician was absent, the panel alann was sounding and that the Chief Engineer instrUcted the bridge to vessel was starting to swing co port, start the 'essential' pumps. The printout cowards the shore of Dent Island. The from the engine room data-logger Master info=ed him that he had lost shows that at least one (the port) steering control and that the control propulsion motor was started at panels were 'dead'. 07 :j4:j6, although a dispute exists berween those present on the bridge The Mate tried to cancel the steering and those in the engine room, as to panel alann, but was unable to do so. who started the propulsion motor(s). Although the yellow 'POWER The motors had, when geTting under FAll-URE' light was illuminated, so way, been started from the bridge and also was one steering motor green could again have been started from light, indicating that a motor was there unless the selector switch on the running. The Mate switched the ECR console had been switched to stand-by steering motorto 'RUN', but 'ECR START in which case they as nothing happened he returned the could, just as easily, have been started switch to the 'STAND-BY' position. from the engine room. The Master continued trying to regain At about this time the Electrician control, by depressing the 'CON:f1vfAND returned to the engine control room REQUEST button and trying to apply and closed the bus tie breaker starboard rudder with the main steering reconnecting the emergency control, but the rudder angle indicators switchboard to the main switchboard, showed no movement. Both he and before he set about accepting alarms on the Mate then tried the stand-by the control panel. Shortly afterwards, steering control, but again no rudder the Chief Engineer was told by the movement was indicated. Master that the bridge had no pitch or steering controls. As the Chief Engineer was connecting the main generators to the main The reconnecting of the emergency switchboard, the Electrician, switchboard to the main switchboard accompanied by the First Engineer, had activated the 'CONTROL POWER who had responded to the blackout, FAll-URE' alann on the bridge control went to the emergency generator flat to console. The Master accepted the 12 'CONLROL POW"ER FAILURE' alarm Very shortly after the Mate pressed the and arrempted to regain pitch ~ontrol propulsion motor 'STOP' buttons, Cape by pressing buttons on the Ka.L\1e Wa Grafton grounded on the rocky shore concrol panel but still did not get of Dent Island, eight cables north of control of the pitch or, as far as he was the lighthouse and two cables from the aware,- the steering_ overnight anchorage position. The 0 vessel ....grounded on a heading.....' of 120 However, with the ship closing with at an angle of about 30 degrees to the ~ ~ Dent Island, no particular notice was shore. taken of which, if any, of the navigation equipment was restored, The time of the grounding was The Master gave orders for the port recorded in the bridge movement book anchor to be let go, but it failed to run as 0802. The tide was falling and at properly, so the Tnird Mate and IR put this time was about 3 m above daturn. the windlass into gear and started to From the time of weighing anchor to walk the anchor back. The Master the grounding the vessel had made tried to change the propeller pitch from good a distance of about 3.j cables in ahead to astern, but there was no not more than 10 minutes. response, the control lever being returned to its fanner position by its Following the grounding and as soon servo motor, giving him the impression as the alann situation on the engine that control had defaulted to another room console had been stabilised, the control position. Chief Engineer went to the bridge. The Master told him that there was no The Master told the Chief Engineer control of either the steering gear or that he needed to go astern as the the propeller pitch. The Chief vessel was about to run aground, and Engineer tested the pitch control, then gave orders for the starboard which he confirmed was not working, anchor to be let go. The starboard and transferred control to the engine anchor was let go from the pipe and room, where controls were tested and went with a rush. The Master ordered found to be working properly. Control the Third Mate to hold on at three was then satisfactorily transferred to shackles but when the brake was the port bridge wing and finally to the applied, due to the excessive weight on bridge control position. it, the cable started to jump over the gipsy and then parted. Soundings were taken of double bottom tanks and the forepeak tank, The Master considered it essential to which indicated that the hull had not try to regain controls and to apply been breached. The Master sent a astern pitch, rather than merely stop message to AMSA, advising them of the propulsion motors and he again the grounding, then attempted to stressed this need to the Chief refloat the vessel, using astern pitch on Engineer. Realising the grounding to the propeller and using the aft thruster, be imminent, the Chief Engineer flrst but was unsuccessful. The Chief advised the Master to declutch and Engineer expressed concern about sand then to stop the propulsion motors. being churned up into the cooling 13 Water intakes, so me Master decided to discussion of me incident, me wait fo r me afternoon bigh tide, before Electrician recalled mat the Guarantee making funher attempts to refloat me Engineer had shown me engineers on vessel. In the meantime, ballast water the delivery voyage how to bypass the was pumped from the port side tanks, auto slow down system by to induce a list proportional to that disconnecting the circuit between the caused by tire grounding, so as to avoid switchboard and the Ka.MeWa central undue strain on the hull. Ballast was control unit. On checking the system also pumped from the forepeak tank. he fo und that the circuit was The starboard anchor cable was fo und disconnected. to have parted about three metres On Sarurday 4 June, under observation beyond the second joining shackle. by one of the investigating officers, a Attempts to refloat Cape Grafton on senior AlyfSA representative and a the afternoon flood tide were Lloyd's surveyor, the power supply successful, the vessel floating free status and manoeuvring operations of under its own power at 1628. The the morning of 2 June were replicated, Master then took the vessel to anchor with two generators running but not to the west of Henning Island, to await stop blocked, and the auto slow dGWIl instructions. On the morning of circuit disconnected. On this occasion 3 June, Cape Grafton was repositioned also, Cape Grafton suffered a blackout, to a more suitable anchorage in the main and second generators Port Mole, off the north-west shore of tripping from the mam switchboard Long Island. due to overload after the propeller pitch control had been moved to the Inspection of the underwater hull by ahead 70 per cent position. the vessel's team of divers revealed a 300 = wide band of indentations to As on 2 June, the main generator 50 = depth on 'A' strake on the port circuit breaker automatically closed side, between frames 82 and 95, and back onto the main switchboard within heavy indentations, to 100 mm, and a seconds and power was restored to one deep gouge in the box keel. There had steering motor. Also as experienced on been no injuries to personnel and no 2 June, bridge instrumentation, steering pollution. and pitCh control panels remained without power. Testing of the steering systems proved that the main steering system was without power, but the Post accident tests and trials stand-by steering system was in fact An investigating officer from the operational, although there was no Marine Incident Investigation Unit, indication of this on the bridge-the together with senior technical staff rudder angle indicator remaining from A..tVlSA arrived on board Cape inactive. Grafton early on the afternoon of 3 June. When the emergency switchboard was again linked to the main switchboard After the investigating officer had by closure of the tie breaker, full arrived at the ship and during electrical power was restored to the I 14 \ bridge and the power failure alarm on worked as an integrated unit. The the console sounded, as had occurred second report, from a well qualified on 2 June. Bridge conrrol and and experienced Al.YfSA electrical indication were restored.upon engineer, examined the state of the cancellation of the power failure alann ship's electrical systems in general and and ~ pressing of the 'COMNiA.l'ID the relationship between the systems as REQUEST button. they existed at the time and as shown in the electrical drawings. This repon Following these trials, the itemised a significant number of classification society imposed a defects, including poor terminations in Condition of Class under which the distribution boards, disconnected ship was required to proceed to Cairns wires, live wires left coiled and for repairs. unconnected and incorrect settings on As a major factor in the grounding was circuit breakers and overloads. Toe the loss of electrical power, and the report concluded that the ship was incident had been replicated in the electrically unsafe and A;.\1SA trials of 4 June, A.J.VfSA commissioned withdrew the ship from service, laying two reports on the ship's systems over it up in Cairns during August and the following weeks. The absence of September while the electrical defects any documentation which detailed the were addressed. relationship between the various In July, September and October, the components of the propulsion system, ship completed a number of trials safety systems and interlocks, led to . related to its propulsion controls in an the requirement for the first report, attempt to identify and rectify faults in from Novamarine (the Australian the systems. agents for the manufacturers of the machinery control system), who were All the reports generated by the A.J.YfSA . commissioned to establish exactly how investigations and trials were made the propulsion system and its controls available to the Inspector. 15 . . : ~ .-'" :." .. . ~ ~ , "'.~Jt/ ::: rrc:.., -- ... - . =.. . ~ i . ; :.:,~~ '= :..: : ..,- ,'!' I' ~ . ; .' .~ . / I / . ~ <. ., . ~ ~ ; : :,: ·,' '''.... Cl . . !"~ : 1 :: .", " <: :'; ';'': :,'-.;~ ...; ::... . ",~ . ' i. : t..c: .... ,;: . • H ." .; .:; J . :: ~I -:: C·_ ;'= "-" ·:. c::'\ .-.---- = ---- .-.---. . i .:::====- --_. ., c' ! l d :- " ----::::------:=-- ~ --. ' " 'a 12 ~~ . ~ . ? .;;;;; ---=-----\- - ,' ----=~-----~'-'~- ------'- 16 parallel operation. provision shall Comment and be made, for instance by load shedding, to ensure that. in case of Analysis loss of one of ihese generating sets, the remaining ones are kept in operation without overload to International Safety permit propulsion and steering, Conventions and to ensure the safety of the Cape Grafton was specified co be built ship. ' and fitted out in accordance with the 2. While this is designed to prevent a International Safety Conventions blackout on board a ship. ships are relevant to its size and purpose. The also required to be provided with an Convention requirements have been emergency source of electrical adopted as Australian law and are power. On Cape Grafton the published as :Vlarine Orders. No long emergency power is supplied by an te= exemptions from the provisions of emergency generator. SOLAS74 the Marine Orders were sought or Regulation 43 .3.1.3 and Marine granted co Cape Grafton, other than an Orders. Part 20.6S2 requires that it exemption covering the requirements must be capable of being: for the separation of the navigation lights and a temporary exemption , ... automatically staned and recognising the harbour generator as an supplying the required load as emergency generator for the voyage to quickly as is safe and practicable Australia. subject to a maximum of 45 seconds. ' The building contract also required the vessel, including its machinery, 3. Amongst the equipment required to equipment and firtings, to be be supplied by the emergency constructed co the rules, regulations source of electrical power, by and requirements of Lloyd's Register Regulation 43.2.4.2 and Marine of Shipping. Orders. Part 20.6.5.1 (d)(ii), are: The following Regulations from 'the navigation aids as required by Chapter n, Safety of Life at Sea 1974 regulation V/12; .. . ' (SOLAS74). as amended by subsequent prococols. cogether with 4. The navigation aids listed in Australian Marine Orders adopting the SOLAS74, Chapter V, Regulation SOLAS74 provisions. are relevant: 12 (m) and Marine Orders, Part 21.4.6 include indicators showing: 1. Regulation 53.2.1 and Marine Orders. Part 20. Ship Machinery 'the rudder angle, the rate of Appen dL"(· -,_. -1._? . I • reqwre:. revolution of each propeller, and in addition, iffitted with a variable 'ff the electrical power is normally pitch propeller . .. , the pitch and supplied by more than one operational mode of such generator simultaneously in propellers. ' 17 Englno fout! ~Ignnl ------1 · Slow down" 'dgnnl ~ , 'O.~ , OVOIloIJd I OCU-- I I lslgnol - ~'I I11 Gen 1 'I .. ~ /- "slays ' I ~ - ] 1 c:"~~~~:n~:~unll Cate ;~III"r J-- 920 DB:;'01 : TermInals 55 & 50 --./' oog_ CkW'J : ' I .. __ . I , I 800 kW Fnull Molor --- --0 -- ~ " 10 003 ~ e '------' )( Cpp . . t!J_::o- 1° QI ., 0 GCU I ' t: QI m I ______-Jo, y I .- - 2 Ge" 2 :r~11 ~ ~ a: ~ -- -- I Ceierpiller 920 t:: - ~ r ;;:c)--err hvd,.ullc f:t--=- 1--( ~, I b 0 (!J engine - kW ~ ~ . pump lJ Ruddel Angle I------~ ------I 118nsmillp.T .~ -~ r-(~~!~} - [J= Pllch conlrol FnlJlI , Plopaltof ptlch 81gn. ~1 Rudder nflQle ~IOOOJ I ~ ~, sIgnal 111' Gcul , I" 0, ------I13.J Gen 3 ~~ f, ___ J_ _ 0, CoterpiII.r 920~, j, --0 engine I [-kW ;--;--" - .l:; co rn' ~I '" c T"" I C' 1 ~ 0 , QI 1= "; I MI -- - Et\i u :;:, ;> , ~ owe, -~ii m : - - I I 2'vollOCp .~~GIg' o!I ' Slop block" slgl191 '"" - d __1 ~ - - - - 1 horn Orldge 0 1 Ecn . ' - - , I we' .g_" -- -·0 > _ ,: Recllflers ...J 1_ ------, - "'~ , 24 volt , 2<1 YolIsub·bootds BrIdge " v, ° '------1- ' emergency E - , ------I G~U I batteries ----- ~-.- I ~~.rr"It} C~ - [- -lI- _ _ _ ,:' "_ : 1110,~our - - I - 1 >'0 [-"./00- __ v t- 1 -_ .. , I Generalor kW r I . .. - . _" . _.- -_- Non-e •• enlial bus 415 volt CAPE GRAFTON Simplified schematic showing relationshIp belween COI1IrO unll Items of equipment mentioned in the lext and which relale 10 lhe grounding on 2 June 1994 Enll'!lI grm r. /, 50 f-- On 2 June, the Mate tested the bridge Although a new ship, no course equipment and started the essential recorder was fitted, nor was there any pumps and the propulsion motors some form of record of the amount of time between 0720 and 0730. To start propeller pitch applied. Neither, the propulsion motors the Mate had to however, are required under Australian wait until two generators, the master legislation or by international and stand-by, were connected to the convention. Those on the bridge and main switchboard to provide sufficient in the engine room kept no record of power to handle the load surge the engine movements and as the involved in starting propulsion motors. situation became critical, recording At about 0742, just before the Mate times was .the last thing on their minds. went forward to weigh anchor, he noticed that one of the generator When the blackout occurred the vessel indicator lights on the power was on a heading of about 2100 with management board was flashing, over 4 miles of clear water ahead. It indicating that it was automatically was diverging from the coast of Dent shutting down. At the initial interview, Island which was about 400 m on the he was unable to say whether it was port beam. The engineers, although the harbour generator or the stand-by they were aware of the approximate 19 position of the ship, were unaware that Tne power supply to the navigation the ship was in any immediate danger. instruments. including the rudder angle It was only when the tone of the and pitch indicators, was lost at the telephone messages became more time of the blackout. Power was also urgent and the Master told the Chief lost to both steering motors, one of Engineer of the imminent danger of which was connected to the 'non - ~ ~ grounding that the urgency of the essential' bus of the emergency situation was realised. switchboard and the other to the main switchboard. Power was not restored Over a period of seven minutes the to the instrumentation until the main ship changed its beading from 210° and emergency switchboards had been through 90 degrees to port, to about reconnected. 120° the approximate beading wben the vessel grounded. Tnere is a conflict of evidence as to when power was restored to those To explain this alteration of course it circuits on the bridge which were was suggested that an incorrect entry supplied by the emergency was made into the autopilot, causing switchboard. The engineers estimated port rudder to be applied. The Second that the time lapse was about Engineer's observation that the steering two minutes. Those on the bridge gear appeared to be bunting' when he maintain that they had no control over went to the steering flat, was after the the propellers and no propeller blackout had occurred and after the indication until after the grounding. Mate had tried to cancel the steering Evidence from the engine room alarm gear panel al= and change to the printout, to support either claim, is not stand-by stee.-1g. The Master stated totally conclusive but is considered on that be steered the vessel manually and pages 22 to 25. did not use the auto pilot, and this was supported by the Third Mate. If the When a main generator reconnected to vessel had been on automatic steering the main switchboard, within a few the Master would not have needed to seconds of the initial blackout, one apply a manual correction to bring the steering motor again became ship's head to a course of 210°. The operational. However, because the Inspector is satisfied that the vessel main steering was supplied from a was being steered manually. distribution board (LV3) which lost power when the tie breaker opened, the From subsequent investigations it has main steering system was inoperative. been established that Cape Grafton bad Subsequent tests proved that the stand a normal tendency to pay-off to port by steering should have been working, when its rudders were in the midships however as the power to the rudder position. This fact bad been angle indicator had also failed, there established during the sea trials, was no indication to show those on .the although apparently no offset had been bridge that this was the case. applied to the rudder at that time to compensate for this. The rum to port Following a blackout. a number of was therefore probably due to this ancillary pumps for the propulsion tendency. machinery need to be restarted upon 20 restoration of electrical power. In those in circuits supplying the bridge, many UMS vessels this is were loose, although the individual accomplished automatically by a terminals involved were not identified 'sequential start' system in the main in their report. Wbatever the level of switchboard, but Cape Grafton is not probability, it is not beyond the bounds fitted,with such a system. of reasonable possibility that these loose terminations included the supply On Cape Grafton, hydraulic pressure to the pitch control panel and the for changing propeller pitch is supplied system suffered an intermittent fault, or by two pumps, an electrical stand-by the status of the essential and non pump and a mechanical gearbox-driven essential bus was not precisely pump. Tne electrical pump was replicated for the trials of 4 June. connected to the main switchboard and would have been lost with the According to the engine room alarm blackout. However, this pump cut in printout, at least one main propulsion again after power to the main motor was restarted at 07 :54:56, (about switchboard had been restored and as 0757 bridge time). The clutch lever on pressure from the gearbox-driven pump the bridge console had been left in the began to fall as the vessel lost way. 'S'l'GAGED' position. In the absence cpp hydraulic pressure was at no time of any interlock to prevent the motors lost and control could have been re starting with the clutch engaged, clutch established, despite the loss of pitch engagement would have been indication, by switching to the backup automatic once the motors were up to KruVfeWa pitch control which was speed. connected to the emergency accumulator batteries and should have At 0759 and at a distance of two cables been unaffected by the continuing loss (370 m, or just under five vessel of power from the non-essential bus of lengths) from the shore, Cape Grafton the emergency switchboard. Following would have required an average speed the closing of the bus tie breaker of four knots to run aground at 0802, between the main and emergency which supports the estimated speed of switchboards, instrumentation was grounding given by the Master and restored to the bridge. Those on the Mate, although the trials data would bridge, however, maintain that the suggest a higher speed. KaMe Wa propeller pitch control panel remained unlit and apparently The blackout was pivotal to the inoperative. When tested on 4 June, grounding and occurred because the power for the main control of propeller running generator was overloaded. pitch was restored when the bus tie Defences designed into the system breaker was closed reconnecting the failed to operate to protect the main and emergency switchboards. generator from overload. An examination of the system on 3 June A detailed examination of the wiring revealed that the auto slow down circuits on 20 September, by marine function had been disconnected from electrical contractors. established that a the KaMe Wa central control unit, number of wire terminations, including rendering the system inoperative and 21 removing this procective function from Engine control room alarm all three generacors. Lacer printout investigation revealed that, due co the configuration of the acrual wiring in Tnere is some confusion and dispute the Kalvle Wa central control unit, this among the ship's staff as to what action had als.p disconnected the rerum acrually happened after the blackout, signal for the auto shut down function how quickly and at what time pumps (i.e. reduce pitch to 0 per cent) which and other auxiliary machinery were was intended to protect the reduction started and controls became available. gearbox in the event of loss of oil In particular there is dispute as to the pressure. time that propulsion control was restored to the bridge and whether or Had the ship's electrical systems not the Master or Mate misread the operated as required by the SOLAS74, indicator lights and failed to accept and Marine Orders Part 20 (Ship control of the propulsion at the Machinery), the blackout would Kalvle Wa panel on the bridge console. probably have been prevented. The only independent record of any The blackout was compounded by the type is the printout from the engine following: room alarm logger, which shows alarm conditions on such things as running • the emergency generator did not machinery, electrical and control automatically connect to the systems and essential tank levels. The essential bus and supply those alarm logger was not synchronised circuits identified in SOLAS74 and with the bridge and was about Marine Orders Pan 21 (Equipment - 21,4 minutes behind the bridge time. Navigational) • there were no effective and The alarm logger does not record the comprehensive procedures for the routine starting and stopping of the operation of both bridge and engine generators or other machinery, unless room; there is an alarm condition. However, when the generators are stopped and • nobody seemed aware that the started the associated alarms related to backup pitch control system and lubricating oil pressure and the stand-by steering were functional. temperature of the jacket water cooling are prevented (inhibited) from alarming Even if the emergency generator had until the machines are again running. operated as required, other deficiencies The times of stopping and starting the in the design of the essential and non main generators may be detennined essential bus configuration would have with some confidence from the 'inhibit meant that the system would not have alarm' or 'inhibit ok' which are printed supplied power to essential bridge out. (The harbour generator, utilising instrumentation. an air-cooled radiator, has no 'inhibit' 22 ~. \ \ . ~ ~ . .~ :I.a ,I (1-; a::):a:a:aa.:a~ •.• • i' ;1 i' i' ,t . ~ :a:a:a:aaaa~~ Engine room - ~er- . -= (:rtcr :~r.. T~~--- -- ~ function so the times of its starting or It also seems that the blackout occurred swpping cannot be determined from ten minutes later when the engine room the printout.) alann printout recorded a block of 16 alarms, amongst them: The stopping and starting of the 02.06. 07.52:47 Ai-70.I propulsion motors are similarly GEN.2 Ai..ARJ.'vfS IN PMS AL. indicated on the alarm printout. The port propulsion motor showed Power to the engine room alarm 'inhibition' conditions on the printout, system reverted to bartery back up. but the starboard motor did not. It was The prinwut also indicates, however, later reported to the Inspector that, at that the central processor unit of the the time of the incident, the computer N orris alarm system lost this battery was not programmed to print this data power at some time after 07:54:58. from the starboard motor on the alarm printout. An extract from the alarm printout shows: Despite the length of the investigation, 02.06. 07:54:58 AI-AO.l none of the ship's staff or AlY1SA CPP CTRLPOWER FAlL AL management ashore could explain just what many of the alarm conditions 02.06. 07:57:18 AI-AG.I meant, neither could they interpret the CPP CTRLPOWER FAlL AL sequence of alarms on the printout into The first printing at 07:54:58 was actual events. immediately followed by a repeat From information provided by the ship printing of the same alarm at 07 :57: 18. builder and direct investigation, the One would expect an 'OK' condition to probable sequence of events as be printed between these two, rather recorded by the alarm system has been than the 'AL' condition, but this did not established. oc=. As the latter was the first of a block of 16 previously extant alarms, The evidence from the printout is that all of which were again printed out in the stand-by main generator had alpha-numeric sequence at 07:57:18, disconnected itself from the board and the indication is that the central actually stopped at about the time the processor failed for a period of time Mate left the bridge to go forward to then re-scanned all the existing alarms recover the anchor. The engine room and printed them out when its power alann printout records: was restored. 02.06. 07:42:43 Ai-50.8 This loss of backup battery power has INHIBmON GENER.i AL. not been explained, but possibly the 1bis would correspond to the Mate's battery voltage fell too low to sustain observation of the flashing indicator the computer, as the batteries were light on the bridge generator control reported to have been in poor condition panel, indicating a generator was when the vessel was at Sydney, having shutting down. been charging at an excessive current. 24 The central processor unit is normally power had been restored to the non supplied by 24 volt power originating essenual bus. and hence to the 24 volt from the non-essential bus. As the systems, at 07:56:33 , approximately computer cakes 45 seconds to 're-boot', three minutes and fifty seconds before the indication is that itS power was the vessel grounded. restore 25 where a correctly installed auto stop started fro m the engine concrol room block system would create any undue and the second. automatically, upon the problems. start request from the bridge for a propulsion motor. While the ultimate Although the propulsion system could responsibility to ensure the stop blocks be started from the bridge, the were activated rested with the Master, engineers on 50ard prior (0 the vessel the written procedures did not cover reaching Honolulu and after sailing this siruation. from Brisbane on 18 May (wbere some modifications bad been made (0 the On the morning of 2 June, the stand-by concrols of the bridge start up system), generator bad automatically closed preferred to start the main generators down leaving only the master generator from the engine room, while the connected to the main switchboard. propulsion motors were started from Although, while manoeuvring, the the bridge. stand-by generator bad not been stop blocked, the power management Bridge procedural instructions noted system should have prevented overload the possibility that, under conditions of of the running generator by reducing light load, the second generator may pitch until the second generator had 'idle' and, after about ten minutes, will connected automatically to the automatically shut down. switchboard. Although the second generator would automatically start again if demand A stop block system is not designed to provide a defence against overloading was sufficient, this could take a minute or two to occur, depending on the the generators. There is no logical reason to assume that the application lubricating oil pressure in the stand-by generator and on bow long it bad been of the stop blocks would have prevented overload of the generators stopped. Therefore, while and the subsequent blackout on 2 June manoeuvring, the procedures called for as, during rrials on 4 June, two the generators to be stop blocked, generators were known to be running preventing the second or third and connected to the main switchboard generator automatically disconnecting when a blackout still occurred. from the main switchboard during periods of low power demand. If the blackout had not occurred on However, on 2 June these procedures 2 June, underlying deficiencies in the were not followed. ship's electrical, concrol and propulsion systems would almost The procedures were silent on whose certainly have caused a blackout and responsibility it was to stop block the generators when a subsequent loss of concrol on some subsequent occasIOn. generator started automatically. As the procedures were designed for those starting the machinery on the bridge, it Overload protection may be inferred that the responsibility A number of defences were included in rested with the person starting the Cape Grafton's design to prevent propulsion system there. However, in overload of the propulsion motors, this instance. the fIrst generator was clutches and generators. 26 The AiyfS A building specifications condition. Ae the ci.me of the incident, stipulated: these meeers had been fitted but no e wired up . These meters were not to 'If the propulsion motor electrical substirute for overload protection, bur systems sense overload, the intended as an aid when manoeuvring concrol system is to reduce the vessel. pf~peller pitch slightly fa maintain the motor at or just below full load Although the final specification current. ' included specific reference eo overload The KruYfe Wa propeller pitch control of the propulsion motors, it did not system does produce an automatic detail any particular requirement to pitch reduction signal if the propulsion guard against overload of the motors become overloaded., but generators. The specifications covered reducing the load to 50 per cent rather the requirement for the protection of than to a level where it maintains the the 'propulsion and steering' through motor at or just below full load current, reference to SOLAS74 and Marine as called for in the specification. In Orders. Tne shipbuilders fitted a system which utilised the 'engine addition, the system allows for a manual setting, by means of the 'load overload' input to the Kru\1e Wa system limit' on the engine room console, to and which, when the overload relay on limit the amount of load that could be the relevant generator had operated, applied to the propeller. The load limit caused the pitch to reduce until the In could be overridden from the bridge in load was 50 per cent. the words of the Ka!.v[eWa documentation cases of emergency. However, the load concerning the use of this input, limit control in the KaMeWa system is designed to prevent overload of the '... the system will then nor prevent propulsion motors, not the generators. engine overload bur will reduce On 2 June, the 10ad limit' was set at the pitch when engine overload 100 per cent. occurs. ' The solution adopted by the delivery The documentation was written with crew to prevent overload was to ensure reference to a conventional diesel that, when manoeuvring, the generators driven installation, but in this instance, were stop blocked and to avoid any the inpur signal used was from the 'heavy handed' use of the pitch control. main switchboard. It was stated that the need to avoid excessive and sudden pitch changes As no closed control loop existed was emphasised and passed to between the generating plant and the relieving masters and mates, although propulsion system (there being no this was not included in the written feedback from the switchboard to the procedures. pitch control indicating the load on the generators), this system did not prevent The ship's staff also requested kilowatt the generators reaching the overload meters at the bridge conning positions condition, but could only reduce load to monitor the load on the generators after an overload had occurred. The and an audible alarm to warn when the consequence of this is that the system, generators approached the overload after overload occurs. continuously 27 .=rom automation ~!pment. L.r:Ni luoricatlng 011 pntSSUt8 ,81 c82 ' 80 Hiq{! jadaJt coOling *"0. S.Jl16 5.3116 5.3('16 • 083 S.2/4 4S4 .t.53 Terminals 55 & sa (see teXl) 083 5 6 . Kamewa CPP . : 'auto slow down' : : to 50% pitch Extract from electrical drawing 40829 - 0404 8 'Part of main switchboard synchro panel' cycles between the overload condition A.J.\I!SA Representative, who were and the '50 per cent pitch' condition. present during the final stages of fitting until the signal from the pitch control out, it is clear that they did not fully lever is manually reduced. appreciate the requirements of SOLAS74, and the Marine Orders, as Although this system may be construed they relate to the possible loss of as meeting the SOLAS74 requirements generating power and the need to (Ch.ll-I 49.1.1) it is using a safety maintain propulsion and steering where system in place of a control system. electrical power is supplied by more Nevertheless, this auto slow down, than one generator. which automatically reduces the pitch on the propeller to 50 per cent in the Through the initial stages of the event of generator overload, high investigation, AMSA staff were unable jacket cooling water temperature, or to fully explain what factors would low lubricating oil pressure, should induce the operation of the auto slow have prevented the running generator down system, nor could the essential from tripping off the switchboard on elements of the system be identified. It 2 June, had it been connected . . was subsequently established that each of the three generators was protected From interviews with the ship 's staff, by an overload relay which would A.MSA ship management and the acruate another relay for each 28 ,s, / ,~ , a.3 080 \ \ 5.415 '. 5.3116 ,i ' 62 ~. iricoush \ Reverse _;-=- Ovanoacl 31 X17 . 034 \. ,Oower '. I From autcmation 9Q1..upmem : .. \ av...c""" I H~nlhign Ja.d J4 I o i L-~'~63L-~ __-, ______~ : 12 , Overload gt \ '15% S.2/.t \ \ ! t3 ; j 2J4 ! \ ! 231 ! 164 dao Circuit breaker ,---'--,i aGt Trip Relay I MX 5.1110 tM4 Extract from electrical drawing 40829 - 0402 'Circuit breaker control (no. 1 generator circuit breaker)' generator (dSO, dS1 and dS2 The load on the generators had been respectively), any of these three being decreased by automatic reduction of able to energise a single relay (DS3) the propeller pitch to about 50 per cent. which initiated a slow down in the . It was found that the auto slow downs KaMeWa system. Sensors to protect were the result of faulty PTIOO against generator high jacket cooling temperature sensors. The Guarantee water temperature and low lubricating Engineer isolated the slow down signal oil pressure were connected to the from the propeller pitch control system respective generator control units, by disconnecting two wires (on which also connected to relay DS3 . terminals 55 and 56) at the KruY!eWa DS3, which was located in the main central control unit, to overcome the switchboard, was connected to the recurring problem. These wires were KruY!e Wa central control unit. reconnected when the faulty sensor had been investigated and the problem During the fmalleg of the voyage, bypassed. between Honolulu and Sydney the vessel had been subject to a number of On 18 March, three days before auto slow downs, because of apparent arriving in Sydney, following further over heating of jacket cooling water. similar instances and unsuccessful 29 attempts to bypass the problems, these overload signal was removed by the wires were left disconnected co enable tripping of the circuit breaker, the auto the vessel co maintain speed to Sydney. slow down signal was lost and the propeller pitch was restored to its The result of this action was that all previous sertiog. auto slow down functions to all three generacors were isolated. Also, as was Ln summary, Cape Grafton blacked out discovered during later investigation, as a result of a failure co prOtect the this disconnection removed the retillTI running generacor from overload path for the signal for auto shut down because the signal for auto pitch (reduce pitch co zero) in the event of reduction from relay D83 in the main failure of gear box lubricating oil switchboard had been disconnected at pressure and hence this prOtective terminals 55 and 56 of the KaivfeWa function was also lost. cena-al control unit. However, even had these wires not been disconnected, The control system was designed such the blackout is unlikely to have been that the generators should be able to prevented, as the generacor overload sustain an overload of 115 per cent for relays had been set coo low and the six seconds. However, it was reported sertiog of the time delay between the that an inspection of the generacor pitch reduction signal and the circuit overload sertiogs, conducted after the breaker trip was too short, the two grounding, revealed that the overload occurring almost simultaneously. It trips were found to have been set too was not possible, however, co low (and were adjusted upwards) determine when the generator overload hence it is likely that the overload sertiogs on the switchboard were signal was premarurely initiated to the altered prior co the incident. circuit breaker trip before the generator had reached full load condition. In SUbmission, Al\1SA stated that the Guarantee Engineer had reconnected (Later still, when examined by the auto slow down wiring before the AMSA's Electrical Engineer, the vessel arrived in Sydney, however it sertiogs were found to be too high.) was again disconnected with the Notwithstanding the disconnection of knowledge of, at least, the Master, the relay D83, the shipyard stated that Chief Engineer and Electrician, to the system was designed with an maintain the ship's speed co Sydney. adjustable time delay between the An entry was made in the engine room activation of the pitch reduction log book, and was also noted in the function and the tripping of the circuit Electrician's hand-over notes when he breaker of the overloaded generator. left the vessel in Sydney. The ship's However, after the overloads had been staff knew that the wires were reset co the correct values, trials off disconnected when the ship left Cairns on 6 July revealed that, upon Sydney and when it arrived in operation of the overload relay, the Brisbane. The wires were not auto slow down function and the trip to reconnected to the terminals after the the circuit breaker occurred almost faulty generator sensors were replaced simultaneously. Ln addition. when the in Brisbane, indicating a significant 30 breakdown in communications or determined that the intended use of the procedures on the part of the ship 's barbour/emergency generator would staff require an additional emergency generator to comply with yfarine Emergency 24 volt supply Orders Part 20. It was decided that The essential lighting, instrumemation, sucb a generator would be fitted in navigation lights and navigational aids Brisbane when the vessel arrived after are run from a 24 volt supply, under its delivery voyage from Vigo and normal conditions this 24 volt supply is drawings of two alternative provided from the 415 volt main configurations were produced by the switchboard, throurn a tie breaker to shipyard. These drawings were the emergency switchboard, and then approved by the classification society, through transformers and rectifiers, as however, the installation carried out in 24 volts DC, to distribution boards in Brisbane did not conform to these the engine room and on the bridge. drawings. The new 'emergency' generator was Emergency switchboard fitted at Brisbane during April and On vessels in which the emergency May 1994. At this time, the emergency generator is fitted with an 'auto start' switchboard was divided into an system, a total power failure causes the essential bus (connected to the bus tie circuit breaker between the emergency generator) and a non main and emergency switchboards to essential bus (connected to the harbour open automatically. With the generator), thus the emergency emergency switchboard isolated from generator was supplying only the the main switchboard, the emergency essential bus. The system was so generator should automatically connect arranged that, provided the tie breaker to the emergency switchboard within between the main and non-essential 45 seconds, supplying power to all the buses was not opened manually, power circuits required of the emergency to the non-essential bus should have power supply by SOLAS74 and, on been restored when the main Australian ships, Marine Orders switchboard bus tie breaker was Part 20. closed, thus supplying the bridge instrumemation. Cape Grafton sailed from Vigo with the harbour generator arranged to start It was reported to the investigation that automatically in an emergency. This the modifications to the switchboard had been tested before sailing and were tested in the presence of found to operate and supply all the surveyors from the classification circuits from the emergency society and AJ,VlSA. However, at the switchboard. Provision of an time of the grounding on 2 June, emergency generator dedicated to drawings of the installation in its fmal emergency use only, was not required form, had not been presented for class under the A1VlSA building approval and no formal or detailed specifications covering the fitting out drawings of the new installation were of Cape Grafton. however it was later available to the Inspector. 31 . ~ ~ ~ 0 , ~ \ Gen 2 ; : Gen 3 . , Gen 1) ; Gen 3) Y ' .~ .. y $/ 'y I. /.. I. •1 760 Amol 1760 Aml= 1760~1 : 1750 Am\:l 1760 Am 500 Amo ~ I soa Amp Sus tie oreake' T1 8us tie breaker wrm no-volt cOli with no-volt coil I (tripped) MAIN SWITCHBOARD MAIN SWITCHBOARD r-- - Emergency Harbour Emergency Harbour generator generator generator generator 1\, ,~ \ !/"\ \ j " n i 100 Amp 530 Amp 100 Amp 530Amp ] T2 , N.C. Manual T2 i N.C. M ...... 500 Amp ':\ I r-- C3 : ii&-braaket C3 : n..o"""'l .300 Amp (auto) (autO) I 1 . Cl . C2 l Cl C2 I 400 Amp 400 Amo I 'f··1(autO) . Non essential bus T··· (au1O) Non essential bus I ! I Essential bus Essential bus I EMERGENCY SWITCHBOARD EMERGENCYSWrrCHBOARD (a) 'Normal' supply· situation immediately (b) Situation shortty after blackout. No.2 Gen prior to blackout. no.2 Gen. on line back on, emergency generator running but supplying all switchboards. no.1 Gen. not connected and emergency switchboard first stand·by. isolated from all supplies. As configured on the Cape Grafton, However, although there is evidence when the bus tie breaker (TI) opens, that the emergency generator did start the emergency generator should start (and then shut itself down), it did not and, when the operating voltage is connect to the emergency switchboard, established, the circuit breaker (Cl) see diagram (b) between the emergency generator and essential bus should close. If Cl closes, Because no.2 generator reconnected the interconnected circuit breaker C2 automatically to the main switchboard must open. The emergency generator within a few seconds of the blackout, would then supply the essential bus the emergency generator sensed only, rather than the whole emergency voltage on the main switchboard, even switchboard, see diagram (a). though the bus tie breaker (T!) was still open. The circuit breaker (Cl) On 2 June, When Cape Grafton blacked between the emergency generator and out, the bus tie circuit breaker between the essential bus did not close and the the main switchboard and the emergency generator was inhibited emergency switchboard (T!) opened. from supplying the essential bus and 32 / ~ , ~ ~. : Gen 2 ' I \~j y ~3 !1 760 Amo .... 1760Amo ~OOAmo aus tie oreaxer witn nOoYQIt COtI (mcpec) MAIN SWITCHBOARD Emergency Harbour generator generator ,/\ ~, ,: lOO Amp 530 Amp N.C. Manual TiIHJreal C1 Non essential bus i Essential bus EMERGENCY SWITCHBOARD Situation which would have existed if the emergency generator had sensed no voltage from emergency switchboard. Main generator supplying main switchboard, emergency generator supplying essential bus .. Note: non essential bus remains isolated. closed down automatically. This It is also not clear to the Inspector-why occurred because the 'no volt' sensing it was necessary to split the emergency coil, part of the emergency generator switchboard. AJ,YfSA's ship control system, was sensing from the management stated that the emergency main switchboard side of the bus tie generator could take all the emergency breaker connecting it to the main load, but did not have sufficient switchboard. In submission, the capacity to power the air conditioning classification society stated that the and galley equipment; routinely operation of this system had been supplied in port by the harbour successfully demonstrated to their generator. However, the supply for the surveyor, and the AMSA surveyor, in air conditioning and galley equipment Brisbane upon completion of the came from the main switchboard, installation. It is unclear to the connected to the harbour generator Inspector, however, how it could have through the non-essential bus and tie operated successfully given the breakers T1 and T2, and circuit configuration outlined above. breaker·C3 . The emergency generator 33 -:. is not required to supply the galley and whatever period. was a factor in the air conditioning. grounding of Cape Grafton. Drawings and subsequent eXamination Emergency batteries of the emergency generator system As the emergency generator was after the modifications to the main designed to start automatically with a switchboard inBrisbane, show that the minirnU.l11 of delay (well within the new installation was designed such that required 45 seconds) and connect itself it could supply only the essential bus to the emenzencv- . switchboard, and, when operating, was disconnected SOLAS74 did not require a transitional from both the main switchboard and source of power to maintain an the non-essential bus of the emergency unintemlpted supply to the emergency switchboard. circuits. Paradoxically, the power supply to the The low voltage distribution board on navigating instruments, the navigation the bridge, LV4, was backed up by the lights, the main (autopilot) steering battery supply and it was from this system, the KaJ.\lfe Wa propeller pitch supply that the backup propeller pitch control and indication and the supply control was fed, although no for one steering motor, remained corresponding backup pitch indication connected to the non-essential bus. was provided. LV3, however, which Therefore, even had the emergency supplied the rudder angle indicators generator supplied power to the together with other instrUmentation, essential bus, this equipment would was not connected to the backup have remained inoperative. battery supp Iy. The intention of the original ship Neither SOLAS74 nor classification design was that one steering motor society rules required accumulator should be fed by the emergency supply batteries to supply the navigational and it would have been prudent and aids, including pitch and rudder angle sensible to have connected one steering indicators. motor to the essential bus, although it is only mandatory to do so if a vessel's Human factors rudder stock is more than 230= in diameter (measured at the tiller). Cape Experience and training Grafton has three linked rudders The Master was an experienced officer . operating from the same steering in navigational aids vessels. Over a motor, all of whose rudder stocks are period of 13 years, all of which had 140= in diameter - a situation not been on older ships of conventional covered by the regulations. design, he had regularly relieved the substantive Master for periods ranging Since the grounding on 2 June 1994, from a few weeks to some months. He all equipment formerly supplied from had first been appointed to Cape the non-essential bus has been Grafton in Sydney on 21 March 1994, transferred onto the essential bus. serving for a familiarisation period The vessel did not comply fully with the until 25 April. During his requirements of \1arine Orders Parr 20 familiarisation period he was fulfilling and the loss of this instrumentation. for the functions of Mate, which would 34 have detracted from his familiarising propulsion svstem. particularly me biroself with the manoeuvring and interfaces b;rween the major units; the bandling characteristics of the vessel. generators. the propulsion motors and He was appointed to Cape Grafton as the propeller pitch cancral. Master on 9 May, nine days before the . The design and operation of the vessel 5ailed from Brisbane on its first pro~ulsion units fitted to Cape Grafton operational voyage. On the voyage to marked a fairly radical departure from Dent Island he had anchored or berilied the existing navigational aids service the ship on six occasions and had therefore accumulated as much vessel. Toe concrol concepts were experience in bandling this vessel as logical and scraighrforward, if fully any other master. understood. However, at no rime was any COurse instiruted by the AlvfSA The Chief Engineer bad first been management to explain the workings promoted to that rank in December of the system or to arrive at agreed ". : .' . . 1993 and was fmt appointed to Cape procedures which properly described Grafton on 20 April 1994, undergoing and integrated the bridge and engine a rwo- week: familiarisation period room operations, particularly the duties before taking over as Chief Engineer. required for the start up and shut down of the propulsion systems from the The Mate bad first joined Cape bridge. Contingency plans to be used Grafton at Panama, going on leave in the event of a major malfunction had from Sydney and rejoining in Brisbane. received little, if any, consideration. As a watch officer he was invol vec!, from rime to rime, in carrying our the Regardless of any action or inaction by start up procedures when preparing to the ship's staff, operating instructions . . . get under way. should have been developed and pur in None of the senior officers assigned to place covering agreed starring the fmt operational voyage had been procedures, defining responsibilities involved in the fitting out or trials of and addressing emergency scenarios. the vessel in Vigo. Before the vessel Also, the appropriate sbip's staff left Brisbane, however, the Master and should have undergone some effective all the deck and engine room officers training in the operation of the ship's systems. Tne absence of proper had sufficient rime and opporrunity to ensure that they understood the basics training and the lack of appreciation of the systems and to ensure that they and knowledge of the propulsion, could safely manoeuvre the vessel steerin!r_ and electrical systems,J were under both normal and emergency factors in the grounding on 2 June. slruauons. Operating instructions and During the course of the investigation procedures it bec:une apparent that no single The AMSA building specifications member of the AlvfSA staff involved in were silent on the details of the the latter stages of the firung OUt of the interfaces between the main machinery vessel. or in its subsequent operation, units- the generators. the propulsion had a complete conceprual motors and the pitch control system. underst:lllding or the vessel's Other [han the gener:li requirements 35 contained in SOLAS74, the shipyard change over of Staff. Instead, on was given only limited guidance on 9 January, the shipyard completed a how the owners believed the 'contractual modification report' propulsion system should work. relating to the supply of a Guarantee Engineer for the delivery voyage: On 7 August, the Ai\;fSA Representative present in the yard at 'Our Gu.arantee Engineer will the time, wrote in his weekly report to train and advise your staff on all Al\tlSA management: aspects of control and machinery systems on Cape Grafton during 'As previously highlighted to the the voyage 10 Australia '. yard, we have concerns about the interfacing of the systems and of The AlVISA staff involved from what we will end up with Novemberto early January, during the critical electrical and engine system Because we do not have all the fitting out srage, were relieved in Vigo equipment, alarm and electrical and none of them formed parr of the drawings we cannot at this stage delivery crew or returned to the ship prevent the Spanish idea of an for its first operational voyage. Hence electrical and alarm installation. any degree of continuity was lost and the staff that might have been expected . .. It is imperative that we get to have some overall concept, or copies of these drawings for study greater knowledge of the systems, had and approval otherwise the little involvement with the ship systems could turn out to be a between the time of sailing from Spain problem area during the life of the and the time of the grounding. vessel. ' While manuals for the individual items On 30 September, the same AMSA of machinery (generators, propulsion Represenrative asked the shipyard for: motors, propeller pitch system etc.) 'an explanation of how the Power were supplied, no instructions or Management System logic worked manuals were provided to the ship that in relation to the wheelhouse.' explained the overall system and the interfaces between the various units. The shipyard stated that they held three meetings with the Represenrative to Guidance notes on the operation of the explain the systems. Although the propulsion machinery had been Inspector could neither find., nor was developed by the Master and Mate given, any records of such meetings with the help of the Guarantee after 30 September, the Engineer, on the passage from Vigo. Representative's weekly report dated These were amended in Brisbane. 6 September noted that the shipyard These guidelines related to starting and confirmed that they would provide a stopping the propulsion machinery functional description of the system. from the bridge and contained general However, this was not supplied in any information on the various written form and any other explanation components. But they did not give seems to have been lost with the specific instructions on the sequential 36 procedure co be adopted and were When the vessel suffers a blackout, somewnat ambiguous, particularly as it control or the Katvle Wa system does referred to the clutch and the need for noe default to another position. it to be disengaged when starting a However. after power is restored, second propulsion morar. They did not there is no control at any position, include reference to the generator or either bridge or engi..ne room. until the propulsion motor overload protection, appropriate acceptance routine bas or the interfaces berween the been followed. This routine for generators, the propulsion motors and regaining- - control at the bridge- central the propeller pitch control system. control ,oosition is quite. different to that for no=al transfer of control from The guidance notes did state that wben the engine control room. starting and connecting the Caterpillar generators : If control prior to the blackout was at the bridge, then upon restoration of To prevent auto shut down under power the 'CONTROL POWER FAIL' light loads press stop block and light will start flashing and buzzing. execute together. After a few The acceptance routine, as established seconds stop block will light up', by the investigation, is: and also wben starting the electric • Press the 'ACKNOWLEDGE' propulsion motors; button. The light will become , "Clutch out, stan ready" steady and the buzzer will stop, but indicato r must be lit'. nothing else bappens. After approximately 10-12 seconds, it will This latter note, although not specific, start alartning again. would suggest that the clutch should be • Press 'ACI0fOWLEDGE' again. disengaged. The alarm will stop and 'BRIDGE' When pitch control is transferred from indication will be lit. (However the engine room to the bridge, a light there is no control anywhere at on the main bridge console will flash this stage, neither on the bridge and. by pressing a button tagged nor in the ECR). The pitch control 'BRIDGE ACCEPT', control is passed lever will return to the 0 per cent to the bridge and a light marked 'IN position under the influence of its COMMAJ.'ID' illuminates to show that servo-motor. the central bridge position has controL • Press 'COMMAJ.'ID REQUEST at The bridge bas three control stations, the bridge central command position the main console, and the port and and control is restored. (However, starboard bridge wing controls. pressing 'COMMAJ."ID REQUEST Control can only be transferred to at either of the bridge wing positions another control position by pressing . will not restore control under these the 'COMMAJ.'ID REQUEST at the circumstances.) new position. This system was explained in the Kat\1eWa manual but There are no instructions relating to the not in the bridge guidelines. above procedure and it is doubtful if 37 this operation bad been performed at When the blackout occurred on 2 June, any previous time, or was understood, the Master was in a somewhat by those in vol ved. invidious position, standing on the bridge without instrumentation or The bridge guidelines did not mention apparent control. The Inspector anything about the starting and accepts that, with hindsight, holding stopping of me stand-by KaJ.\tle Wa the stand-by steering lever to starboard hydraulic pump, or the maimenance of would have steered Cape Grafton away hydraulic pressure by the gear box from the land. Also, the backup pitch driven pump. Befo re Brisbane, the control was operating and the pitch stand-by hydraulic pump had to be could have been put astern. started from [he engine room. Tnis arrangement had been changed in What was overlooked, and omitted Brisbane, and in order to start it from from any instructions developed by the the bridge, required the pressing of a ship's staff, was the ability to 0 brain bridge start button. Nor did the bridge emergency control of the steering in guidelines have any reference to the the steering flat and of the propeller backup KaMeWa pitch control system. pitch by using the 'backup' system. The KaMeWa manual referred to the The evidence is that emergency backup system 'if there is a failure in procedures for changing over to the main system'. However, there was secondary systems, in particular the no indication that this was connected to critical pitch control system and the accumulator battery supply. telegraph, had never been exercised. Starting, stopping and emergency The propeller pitch can be set at the procedures had been left to the ship's gearbox in the engine room by means staff with no direction from the of a hand pump. It is essentially a 'get management. The procedures that me home' system, requiring the were developed were based on shutting down of the K3..1\tfe Wa system inadequate documentation and lack of and the connection of hydraulic hoses technical guidance. to the oil distribution box of the CPP. It is not a system that can be reverted Clutch and pitch .controls to quickly in an emergency situation, The bridge instructions for starting the such as that experienced on 2 June. main propulsion motors contain the The engine room had not developed line: any written standard operating '''Clutch. out, start readv. " indicator procedures for starting the propulsion must be lit'. system and no procedures had been Ho wever, owing to incorrect settings developed that were common to both of the system, the bridge indication . engine room and bridge. There were that shows 'CLUTCH ENGAGED' did no documented procedures to cover not indicate that either clutch was ";-. any situation where the bridge lost engaged, only that hydraulic oil was . control over the engines or for passing flowing within the clutch, before the control to the engine room and using oil had reached the required pressure to . the conventional telegraph system for engage the clutch. engine commands. ". 38 When the ship blacked out. the Al though the wires for this interlock propulsion mocors stopped and the ship were connected to the terminals at the lost propulsion power. Tne clutch KaJ.'vle Wa unit, there were no comrol on the bridge was left in the corresponding terminals on the port or 'CLUTCH ENGAGED' position starboard propulsion motor starters. causing the clutch co engage The wiring to the port propulsion automatically when the first propulsion mOtor starter was found CO be mocor was started. disconnected, and that to the starboard motor starter was connected to the There is a conflict of evidence, as to overload terminals-an incorrect whether the fIrst propulsion motor was connection. started from the engine control room or from the bridge. From wherever it was There was no requirement under restarted, there was no interlocking SOLAS74 or Marine Orders for protection to prevent either mocor interlocks to be fitted, neither were being started with the clutch lever in interlocks required by the building the engaged position and, in rum, the specifications. Lloyd's Rules and clutches to be engaged while the Regulations for the Classification of propeller was carrying significant Ships, however, require under Part 6, pitch. The clutches are fined with Ch.l, 3.1.2: mechanical pumps driven from the gearbox input shafts (the propulsion 'Where machinery is arranged to mocor shafts), and will supply the stan automatically or from a necessary pressure to engage the remote conrrol station, interlocks clutches whenever the propulsion are 10 be provided to prevent stan motors are running. Similarly, the up under conditions which could hydraulic pressure necessary to apply hazard the machinery.' pitch to the propeller is no=ally In submission the shipyard stated that supplied by a gearbox-driven pump interlocks were not a requirement and and hence this pressure can be were not specified and they had no provided so long as the propeller shaft intention of fitting an interlock system. is turning at normal RPM. They also stated that interlocks were In August 1994, the wiring unnecessary as the generating power interconnecting the propulsion units available allowed the motors to be was examined by a fmn of marine started with the clutches engaged and electronics engineers. It was with pitch applied to the propeller. In discovered that drawings of the the opinion of the Inspector, however, electrical systems were not 'as fItted' starting the propulsion motors with the and some of the drawings provided clutches engaged and propeller pitch were not accurate, resulting in no (possibly 100 per cent) applied, is a reliance being placed in any of the condition which could hazard the electrical drawings unless the wiring machinery, in particular the soft was physically checked. It was found starters for the propulsion motors, that the KaMeWa system had terminals which the manufacturers stated are not for a 'zero pitch' interlock signal. designed to handle the starting currents 39 involved. In addition, even if the bridge clutch control lever to the design approach adopted had proved 'DISENGAGE' position and initiated satisfactory fro m the mechanical and 'start up' procedures, albeit with some electrical point of view, it completely urgency. overlooked the operational aspects of the vessel, all<:,wing it to be inadvertently All this depended upon the time driven full ahead or astern, perhaps available, whether he realised that while alongside, or in such insaumentation had been restored and circumstances as were exemplified by the proximity of the shore. Both the the grounding on 2 June. Master and the Mate, when the latter had returned to the bridge, were faced Not directly related to the zero pitch with a number of problems and interlock issue, but symptomatic of the concentrated their attentions on the wiring on 2 June, were three other steering and pitch controls. As Cape significant wiring conditions within the Grafton was being driven closer propulsion system: towards the shore line by the restarted motors, their options for taking action • The wiring for the overload signal reduced. from the starboard motor starter to the CPP system was disconnected at The Master could have pressed the the motor starter and at the propulsion motor stop button as soon KaL\I!eWa unit was connected to the as he realised he had no control, wrong (port) terminals. instead of waiting until moments before the vessel grounded. • The wiring for the overload signal from the port motor starter to the Attempts were made to release both CPP system was connected correctly anchors, in the event only one anchor at the motor starter but disconnected would run and, at a speed of 3 to 4 at the Kal\l!e Wa unit, where the knots, the 34 mm cable parted. If the starboard motor starter had been propulsion motors had been stopped or wired to the 'port' terminals. the clutch had been disengaged the • The clutch overload signals were strain on the cable would have been correctly connected at the KaMeWa reduced and the vessel may have been unit but disconnected at both successfully stopped by the anchor. clutches. It has been suggested that the On the morning of 2 June, when the grounding could have been avoided if emergency and main switchboards the spring-loaded handle of the stand were reconnected, the Master had the by steering had been held over to ability to go through the starting up starboard regardless of the fact that the procedure. To do so, he had rudder indicator was not working. With approximately three minutes and fIfty hindsight, this would have allowed seconds (from the time that steerage, however there was no instrumentation was restored) to regain indication that the rudder was moving control of the situation on the bridge. and their concentration was on gaining The Master could have returned the control of the propeller pitch. 40 I Had the zero pitch interlock between requirements of International Safety the Katvle Wa central control unit and Conventions. Marine Orders and the propulsion mO[Qrs been connected Lloyd's Register of Shipping 'Rules then the ship would noe have been and Regulations for the Classification driven ashore and the chances of the of Ships'. These documents, although anchqr preventing the grounding would separate references. were an integral have been significantly increased. part of the building specification. During the investigation it became clear that the AtvlS A Ship Operations Fitting out and survey staff and the Representative present Cape Grafton's design concept would during the [mal stages of the firting seem [Q make it highly suitable for its out, were not aware of the intended purpose and the construction implications, application or detail of of the hull and acco=odation appears these documents as they related both to to be of high qUality. However, it the protection of generators from would be surprising [Q find any ship overload and to the need for interlocks straight from a building yard without berween units of the propulsion some faults, or one that is not subject system. It would appear that these to criticism of design or layout. details had also escaped the attention of classification society. W1rile the new ship was designed and required to meet the relevant rules and Similarly, when the new generator was regulations and extensive planning bad installed at Brisbane, the requirements been devoted to its capabilities in for the supply of emergency power [Q relation to servicing navigational aids, the emergency switchboard for those no safety analysis had been undertaken items detailed in SOLAS74 and to identify the risks related to the Marine Orders was also overlooked. navigation of the ship. Cape Grafton is In respect of prevention of overload of routinely taken into areas where other the generators, the specification was vessels would not venture, to gain silent, however the requirement to access to lighthouses and buoys. ensure that propulsion and steering are Senior management had recognised the maintained to ensure the safety of the risks involved in operating a 30-year ship is a SOLAS74 requirement and old vessel in an area of such the shipyard fitted a system which was environmental sensitivity as the Great intended to comply with this. It was Barrier Reef and the need to replace apparent to the Inspector. however, that such a vessel. However, no specific neither the AtvlSA representative, nor safety analysis of the risks such the AlYlSA staff. nor the Guarantee operation posed to navigation, or the Engineer fully understood the system possible need for defences in the which was fitted. propulsion system to guard against failures, were considered. Factors, relevant [Q the grounding, involving the failure of equipment or The [mal'specification for 'hull no. 408' systems required by Australian law and was relatively brief and relied largely SOLAS74, within six months of on conformity with the general acceptance of the vessel by A.MSA. 41 call into question the condition of the 4. on the voyage from Brisbane, vessel when accepted and the quality between 18 May and 2 June; or of subsequent modilications to the 5. during two or more of the above vessel, made before the grounding. stages. The more significant of these were: The management systems were no t • the seaing of the overloads and effective in meeting the requirements trips ; of the project, particularly in the final stages of firting out. Toe load 00 the • the auto pitch reduction system; single AYfSA Representative under • the emergency switchboard these circumstances must have been arrangement; extreme. Senior ship staff had been present at the yard since June 1993 , • the zero pitch signal from the although there had been a oumber of KaJ.\t1e Wa central unit to the changes of personnel, the final change propulsion motor starters; occurring on 5 January. These changes, coupled with the change in • the ability to start the propulsion the Representative in mid November, motors with the clutch control in the when the electrical fit-out was engaged position. gathering momenrum, would have It is not possible to establish, with made continuity difficult. certainty, where or when some of the It seems that, while individual system defects in these systems occurred. components were tested at the From the evidence of the two reports to manufacturers' works or on board, AMSA management on the engine sufficiently comprehensive testing of control systems and the ship's the generators, propulsion motors, electrical circuits, together with clutches and KaMeWa units as a consequent examinations of the single, integrated, system had not been system, it is clear that wiring, including undertaken after the installation or . the wiring of important interlocks, had during acceptance trials. either not been connected; or had vibrated loose; or had. at some stage In the fmal days before sailing, the been disconnected. It is possible that Chief Engineer and Electrician had the control circuits and alarm wiring serious misgivings about the state of were deficient: readiness of the vessel's electrical systems, particularly the flre detection 1. when the vessel left Vigo; or and alarm systems, essential for UMS 2. through the ship 's crew or operation. They were very concerned Guarantee Engineer disconnecting, that their professional views were not or modifying, the circuits on being needed. AMSA management passage from Spain to Australia; or undertook that the ship would not sail unless the staff were satisfied it was 3. through modifications or tampering safe, however, it was agreed that carried out at Brisbane from 30 minor, non-safety systems could be left March to 18 May: or to the ship's crew on passage. 42 Throughout me project the These documents included tests on me classification society provided a auto shut down of the generarors surveyor, not only ro ensure that the through over-speed.. lowflow lube oil vessel complied with the society's pressure, or bighihigh jacket water rules, but also to act on behalf of temperarure. No evidence of tests A..lvISA in terms of international could be loc:lted for the related but starurory certificates covering hull, separate system or auto slow down in load line and machinery. the event of overload, low lube oil pressure or bigh jacket water On 14 January 1994, Lloyd's Register temperarure. of Shipping issued an 'Interim Certificate of Class' stating that the Factorias Vulcano submitted that no vessel had been constructed to the time consrraints were imposed upon society's rules , and an 'Interim Cargo them which they would not consider Ship Safety Construction Certificate', 'normal in ship building practice'. The stating that the condition of the delivery of the vessel was delayed by structure, machinery and equipment bad weather in Vigo, which prevented met the SOLAS74 requirements, as painting of the hull and upper-works modified by the 1978 Protocol.. The exteriors. They also stated that when ship, according to the classification the ship was delivered, none of the society, complied with Chapters IT-I work required under the specifications and IT-2 of the Convention. was outstanding, although they noted The building specification called for one variation to the specification, wharf and sea trials to be conducted in which had not been completed, that accordance with the Institute of Marine being the new emergency generator Engineers' publication 'Commissioning which was to be fitted in Australia.. and Sea Trials of Machinery in Ships'. To assist in the investigation, the However, while diesel, steam rurbine Inspector tried to acquire 'as fitted' and gas rurbine vessels are included in drawings, drawings stamped and the publication, there is no specific verified by signature and date as reference to diesel/electric propulsion. showing the fmal condition of the ship. Although the source of power for the The shipyard stated that all propulsion system is diesel engines, modifications made by the yard during the introduction of electric motors into the fitting Out were detailed in 'as the system introduces variations fitted' drawings and that they were relating to overload and interfacing of given to the owner following the equipment not covered by the trials procedures under the yard's protocol.. International Standards Organisation Documents relating to the protocols of 9001 QUality Certificate. However, tests and trials, for various engine such electrical wiring and system room and propulsion systems, were drawings were not found on board or at signed for by the Al"!S A the AlYlSA offices. Relevant drawings Representative. the classification that were located, bore no evidence of society. and the building yard in late being 'as fitted' and. in many cases, December 1993 and in January 1994. were shown to be inaccurate and did 43 not show me wiring systems as mey and me associated wiring were existed in June 1994. introduced in Brisbane in April and May 1994, and critical machinery In addition, no guidelines or settings may have been altered after the instructions were provided to the ship vessel left Vigo , certain elements to explain the .interfaces beTWeen the originated at the yard. Tne two reports different components of the propulsion to A..V!SA on me general condition of system, all of which were made by the wiring indicated that, although a different manufacturers. Although a decision had been made not to connect Guarantee Engineer was provided by the interlocks beTWeen the elements of the yard and it was agreed that he the propulsion system, some would: connections had been made but were 'train and aavise ... on all aspects of incorrectly wired. control and machinery systems ... ' These defects, together with other the Inspector is not satisfied that this significant electrical and hydraulic was achieved. faults appear to have escaped detection by either the classification society, The shipyard submitted that there were AiVfSA surveyors, the Representative no defects in the drawings or in the or the ship's staff when the vessel was wiring that could be seriously related in the shipyard. The number of such to the grounding. The Inspector defects may be seen as symptomatic of accepts that the quality of the drawings the level of supervision, survey and was not related to the grounding, quality of work at the time of fitting however, in his opinion, the supply of out the vessel, particularly in the latter drawings put on board the sbip at stages when the machinery control completion were not of a standard or equipment was fitted. accuracy that would normally be expected and these drawings could not The defects that were factors in the be regarded as 'as fitted' drawings, in grounding, the absence of accurate 'as the normal use of the te=- fitted' drawings and problems experienced in wiring circuits and The Inspector was presented with a other systems not directly related to variety of contradictory information as this report, call into question the to the origin of defects and when they quality control regimen followed by had, or might have, occurred. the various parties involved and the Although substantial defects in the validity of quality assurance in the face emergency switchboard configuration of such defects. 44 to me absence of any instructions or Conclusions manuals explaining how me different componenrs worked as a system or detailing the These conclusions identify the interconnections between each unit, diffen:nt factors contributing co the the bridge and engine room control circumstances and causes of the centres. Tois general lack of incident and should not be read as understanding, and the lack of any apportioning blame or liabiliry ro any drawings of the overall propulsion particular organisation or individual. machinery system, led to the The Inspector concludes: commissioning of the Novamarine report on the functioning of these 1. The grounding of Cape Grafton was systems. the chance coming together of a number of factors at a time when the 4. Both the absence of accurate 'as vessel was close ro shore in a fined' drawings and those defecrs vulnerable position and reaction that were factors in the grounding, time was limited. rogether with problems experienced in wiring circuirs and other systems 2. There is little doubt that, had those not directly related to this report, on the bridge and in the engine call inro question the quality control room worked together properly, had regimen followed by the various the Master thoroughly understood parties involved and the validity of the operation of the propulsion quality assurance in the face of such system and the steering, had the defects. secondary systems and local controls available in an emergency It is further concluded that the been appreciated and had these been following factors contributed directly utilised, the grounding could have to the grounding of the Cape Grafton: been prevented. This lack of 1. The Master's lack of understanding operational knowledge, however, of the propulsion system and the was compounded by significant fact that he: systems defecrs and management deficiencies. (a) did not take early action to stop the propulsion motors, or 3. The investigation found a general lack of understanding, throughout (b) declutch the propeller shaft, or the A2vlSA Ship Operations staff, of (c) utilise the backup pitch and the operation of the ship's systems, emergency steering controls. control equipment and protective devices, in particular the interfaces 2. The auto slow down system, between the various unirs intended to protect the generators on comprising the propulsion system overload was defective: and irs controls, the overload (a) it was' disconnected at the protection system, the engine room propeller pitch control central unit; data-logger and printout. and the emergency generator and (b) there had been a failure to ensure switchboard. This waS due. in part, that the system was reconnected 45 after defective sensors had been b) the installation of systems noe replaced in Brisbane; thoroughly understood by management or ship staff; (c) it is possible that. even had these wires remained connected, the c) ineffective qualiry control during system would have failed as the the installation of electrical and overload trips were set too low and concrol systems; the time serting between the overload signal from the generators d) the failure to undertake a suitable and the tripping of the generator risk assessment for the new vessel, circuit breaker was incorrectly sec. relating to its frequent operation close inshore in hazardous 3. There was a loss of emergency waters. electrical power to the navigational instruments, particularly the rudder 7. The failure of the ship's emergency angle and pitch indicators, through: generator and associated electrical circuits, to comply with Marine (a) the design of the emergency Orders Part 20.6.5.1 (d) (ii), in generator auto-start system, in that it respect of the maintenance of a was able to sense that a main power supply to the ship borne generator was running, although the navigational equipment, which tie breaker between the main and includes indicators for rudder angle, emergency switchboards was open; pitch and the operational mode of (b) the division of the emergency the propeller. switchboard into essential and non 8. The lack of clear, unifo= essential supplies and the supply of operational instructions and power to the bridge instrumentation, procedures, co=on to bridge and pitch control and one steering engine room, for starting and system, from the non-essential bus. operating the ship's propulsion and 4. The wiring of the zero pitch associated machinery. interlock between the KaiYfeWa system and the propulsion motor 9.The absence of any contingency starters was not properly connected planning for the passing of and allowed the propulsion motors machinery control from the bridge to be started with pitch on the to the engine room under emergency propeller. conditions or plans to utilise the backup pitch control and the 5. The lack of interlocks requiring the emergency steering in the steering clutches to be disengaged before a flat. propulsion motor could be started. 1O.The absence of any structured 6. Defects in the management system training for the operation of Cape leading to: Grafton that would have provided an a) the installation of equipment that overall concept of the elements of was not thoroughly tested in all the propulsion system and how they respects: interfaced with each other. 46 Details of Ship Name- Cape Grafton IMO no. 8518964 Flag Australian Classification Society Lloyd's Register of Shipping Ship type Navigational aids service, ocean science and survey vessel Owner Australian Maritime Safety Authority Year of build 1994 Builder Factorias Vulcano Shipyards SA Vigo, Spain Gross tonnage 2065 Summer deadweight 1152 tonnes Length overall 74.4 m Breadth extreme 12.5 m Draught (summer) 5.3 m Engines - Diesel Electric Generators· three medium speed Caterpillar 3516 DITA diesel generators 900 kW each. Propulsion motors· two Indar induction motors 800kW each Crew 22 (Australian) 47 Consultants Submissions Barnes and Fleck Pry. Ltd. J ames Woolley Pty. Ltd. Under sub-regulation 16(3) of the Lloyd's Register of Shipping Navig.ation (Marine Casualty) Reguiations, if a repon:, or pan: of a Group Regional Manager for . - rep on:, relates to a person's affairs to a Australasia - material extent, the Inspector must, if it is reasonable to do so, give that person Submissions on the fmal draft of the a copy of the repon: or the relevant pan: repon: were received from the Acting of the report. Sub-regulation 16(4) Chief Executive, ALY1SA, and from the provides that such a person may Technical Adviser--Ship and provide wrinen comments or Personnel Safety Services (on behalf of information relating to the repon:. the General Manager). The flnal draft of the report was sent to Submissions were also received from the fo llowing: the Chief Engineer of the vessel at the time of the incident, from both AL'vfSA consultants and from Lloyd's Register. The Chief Executive A submission on the flrst draft, which was of assistance to the investigation in The General Manager, producing the flnal rep on:, was Navigational Services received from Factorias Vulcano The General Manager, Ship & although no submission on the flnal Personnel Safety Services draft was received. The Manager, Ship Operations These submissions are reproduced in full, with permission, as arrachments. It The Survey Manager, Brisbane will be found that, in those instances Technical Adviser, Survey that the Inspector considers are Planning & Development appropriate, the text of the repon: will have been amended (or expanded Masters of Cape Grafton upon) to reflect or correct points to Chief Engineers, Cape Grafton which reference has been made in submissions. Page numbers referred to Chief Officer, Cape Grafton in the submissions have been amended Electrician, Cape Grafton to correlate with the changes in page numbers caused by formatting for flnal publication. Factorias Vulcano S.A. yard, Vigo, Spain During the course of the building, The General Manager differences in opinion and approach The Guarantee Engineer developed in the joint consultancy 49 between me two frnns engaged by project, Bames & Fleck Pty.Ltd., and Al'vIS A to oversee the project, with one the second from James Woolley consultant effectively ceasing Pty.Ltd. The two submissions reflect involvement with the project in mid those differences which arose. November 1993. There are ilius two separate submissions, the frrst from ilie The Inspectors notations are in bold consultants who acted throughout ilie italics. 50 Attachment 1 Submission - Acting Chief Executive, AM SA Dated: 13 June 1995 I refer to year letter of 3 May 1995. enclosed with which was a further draft of the report into the Cape Grafton grounding in June 1994. In response to your invitation to comment, the following observations are submitted. AlVfSA has no objection to this letter being reproduced in its entirety but does not agree to selective quotation from it. The opportunity has been taken to comment in derail both on the earlier draft, both in writing and in discussion with your staff. In this response, ANfSA wishes to focus mainly on generalised observations in the conclusions which, because of their lack of specifics, are seriously misleading. In conclusion 3 you should be specific about which particular facets of the ship's system in which there was a lack of understanding among AlVfSA staff. As presently phrased, the first sentence is an unsustainable extrapolation by your investigator. It is also based on conversations with a small number of AMSA staff, in circumstances in which reticence on the part of individuals, in the face of an investigation which might lead to critical comment being directed to them or their colleagues, would be understandable. (The text has been erpanded in view o/this submission.) AlVfSA considers the first line of conclusion 6 to also be misleading. It fails to recognise that the management system put in place on industry advice to ensure best management practise was followed. This system ensured that the vast majority of the ship's construction and fitout was totally satisfactory. It also ensured that the vessel was completed to budget and with a minimum of delay. AMSA submits it would be accurate were your judgements in this conclusion to be introduced with the wording: 'Management of the project was deficient in the following respects: .. .'. (The text has been amended to reflect this submission.) Conclusion 6d has been introduced since the first draft was seen by AlVfSA and discussed in derail with your staff. AMSA does not accept this conclusion. Neither is it aware of any aspect of the investigation on which it may be based. In fact the consideration of risk was a major factor in the decision by the AMSA Board to replace the former Cape Moreton and in the determination of the characteristics of the new vessel. We would be happy to discuss this issue further with your staff to facilitate their understanding of these aspects of the Board's considerations. . (The report has been amended to reflect certain aspects of this submission.) Attachment 1 - 1 of 1 Intentionally Blank Attachment 2 Submission - The Technical Advisor, on behalf of the General Manager, Ship and Personnel Safety Services. Dated: 9 June 1995 Cape Grafton - Grounding 2 June 1994 at Dent Island I acknowledge receipt of your letter of 3 May 1995 also that addressed to the Acting General Manager, All1SA and after careful review the Acting General Manager, A.MSA has requested that I reply on his behalf. Accordingly, the following co=ents are offered for your consideration. 1. Page 5; fourth paragraph: was full certification to ISO 9001 achieved by June and by whom (DNV?) (The text has been amended to incorporate this information) 2. Page 6; third paragraph: The co=encement of fitting of main propulsion equipment, generators, propeller systems, electrical control wiring and alarm systems only three weeks before scheduled completion date raises doubts as to the effectiveness of the shipyard's ability to achieve compliance with the standards implied by ISO 9001. 3. Page 6; fifth, sixth and seventh paragraphs: It appears that trials, to the satisfaction of Lloyd's Register and Owners, were completed on 11 January, with all relevant documentation, includin~ Llovd's interim Certificates of Class being passed from Vulcano to A.J.\1SA on 18 January. It is assumed that A.J.\1SA accepted the ship on that date, subject to any agreed outstanding matters being rectified within a specified period or under the contract guarantee clause. This raises the question of whether or not there were any agreed outstanding matters. Further, it is noted that, on 21 January (some three days after hand-over of' documentation) a serious electrical fault occurred which, after remedial work, was followed by a trial of 2 hours 20 minutes duration. This raises the question of whether or not Lloyd's Register was advised of these events, in accordance with their rules, so that they could carry out further examination, require re-trialing if considered necessary, and be fully satisfied that the validity of the Class Certificate, also the Safety Construction Certificate issued under AMSA's authority, were not affected by that electrical fault. 4. Page 8; second paragraph: It is suggested that the third line should read, "extra care was taken to ensure that cooling water and lubricating oil temperatures and pressures were maintained" ...... etc. (The text has been amended) Attachment 2 - 1 of 3 5. Page 8; sixth paragraph: Was it intended that the "Operation of the propulsion system from the bridge" should be entirely without the presence of engineer officers, ei ther on the bridge or in the engine roomry Was this to include start-up and shut do:vu of major propulsion machinery items ry (This information has been incorporated into the report) 6. Page 30; frfth paragraph: It appears that some editorial changes have been made with possible omission of text. (Refer also to text on page 29). (The text has been corrected) 7. Page 36; "Essential Batteries", second and fourth paragraphs: You may wish to re- examine the Classification Society rules with respect to the requirements for a transitional source of emergency power in the case of a cargo ship, also a special purpose ship of the "Cape Grafton" confrguration. We consider that battery back-up was not a SOLAS requirement in this case and the class rules reflect SOLAS. (The appropriate paragraph has been deleted in view ofthis submission) 8. Page 41; fifth paragraph: Suggest that the twelth sentence should read " ..... AL'v!SA Ship Operations staff...... " (The text has been amended) 9. Page 42; fifth paragraph: Were the misgivings of the Chief Engineer and Electrician fully considered and made know to Vulcano and Lloyd's? 10. Page 42; fifth paragraph: 1bis general statement is misleading; the fire detection and fire alarm systems were tested to the satisfaction of the attending AL'v!SA surveyor. 11 . Page 43; third paragraph: It appears that Lloyd's issued their Interim. Certificate of Class on 14 January, which is some four days before the date of hand-over of documents but seven days before the electrical fault on 21 January. 1bis again raises the question of whether or not Vulcano or AMSA advised Lloyd's of the fault (see also 3 above). 12. Page 44; penultimate paragraph: Was a description of the propulsion and control system, with a test schedule, submitted and approved by Lloyds in accordance with their Rules and Control Engineering System, Part 6 Chapter I)? (No complete description of the propulsion system and its control systems, particularly the interfaces between components, was available to the investigation and this is reflected in the report.) 13. Page 45; conclusion 3: Suggest should read ...... AL'v!SA Ship Operations staff..... " (The text has been amended) Attachment 2 - 2 of 3 14. A possible weakness. of the report is that positions are argued and conclusions reached which may be difficult to maintain should there be a rigorous external examination of the report. There is always an inherent risk in coming to a final position which is primarily based on assumptions and generalisations. I am sure that you are fully a ware of the inherent dangers in this approach. 15. There\ s no objection should yo u wish to reproduce a section of this letter in the report. However in the interests of natural justice any section should not be taken out of the context. It may be difficult to achieve this aim without at least reproducing (at a minium) the entire paragraph. Attachment 2 - 3 of 3 Intentionally Blank .... ,. " .1 . , ' ... Attachment 3 Submission - The Chief Engineer, Cape Grafton Dated: 2 June 1995 Comments on the NffiU Draft 2. page 12 par 6. Tne starboard propulsion motor start was not recorded by the data log because the Noris CU2000 was not programmed co relay this data to the data logger. (This information has been incorporated into the report) page 24 par 2. At the time of the incident the starboard propulsion motor was connected to the Noris panel. The CU2000 was not programmed to print the data on the data logger. page 24 par 4. The CU2000 in a under voltage condition, ie below 19V, will deactivate the power pack and a relay on the monitoring card will initiate a fault alarm. (The GCU's also shut down at 18V). page 24 par 5. The computer, ie CU2000 can re-boot itself in approximately forty four seconds, although it is not unco=on for the CU2000 to hang up whilst re-booting and taking a . considerably longer time period. page 25 par 2. The stiby cards will also raise a STIBY CARDS POWER FAIL alarm when the cards are powered and the power to the units that the stlby cards are controlling suffer a power failure. When the MSB was blacked out, the stiby cards were being supplied 24VDC by the battery back up and 415VAC to the units that the stiby cards control was interrupted whilst the MSB was dead. page 25 par 5 r assume this is extrapolated on the understanding that the CU2000 re-booted in forty five seconds. page :26 par 4. One main generator was started from the ECR which became the Master generator after the Master Status was transferred from the Harbour Generator. The Master generator does not require a manual stop block function to be applied. The second generator started, was initiated by a propulsion motor start request from the bridge motor start panel. (The text has been amended to reflect this submission) Attachment 3 - 1 of 2 page 27 par 2. The KaJ.vIe Wa propeller pitch control system produces an automatic pitch reduction signal if the propulsion motors become overloaded and reduces the pitch so as to reduce the motor propulsion load to 50%. Depending on sea conditions, a 50% motor load may relate to a different propeller pitch percentage. (The text has been corrected) page 27 As for the above. page 31 par 1. 415 volts. (The text has been corrected) page 34 par 7. LV-2 supplies the KaNIeWa Main, illumination and Indicator circuits. LV-3 supplies the rudder angle indicators. (The text has been amended) page 39 par 3. The clutches are fitted with mechanical pwnps driven from the input shafts (the propulsion motor shafts). page 40 par 2 It appears from the data logger print out that the stlby CPP hydraulic pwnp was energised as the alarm 07.53:57 AI-FO.I G.BIHYD.ST.BY PP.ST. was raised when the gearbox pressure fell and the pwnp started. (The report has been amended to incorporate this information) page 43 par 5. No evidence of tests could be located for the related but separate system of "auto slow down" in the event of overload, low lub oil pressure or high jacket water temperature. (This has been corrected) Attachment 3 - 2 of 2 Attachment 4 Submission - Consultants, Barnes and Fleck pty, Ltd. Submission dated: 9 June 1995 Draft report NO 70 was produced by the Marine Incident Investigation Unit. Tnis is the second draft of report NO 70 SUMMARY I disagree with many of the opinions and conclusions brought forward by the Inspector in this second draft report. Much material that is not relevant to the grounding is also discussed. The Inspector's blind persistence in achieving desired outcomes has led him deny mathematical results and read into reports info=ation that is clearly not there. In many cases opinions are not substantiated. The Inspector has still failed to research in depth the extensive reports and documentation available from AMSA and the statements obtained under his authority. The following comments serve to illustrate All comments relate to the draft report NO 70, 2 May 1995. REFER REPORT: PAGE 2 Sources of Info=ation. "The Inspector acknowledges the help and cooperation of the following ... " The report should not claim "1NVESTIGATION IN CONFIDENCE." An open enquiry would be preferable. REFER REPORT: PAGE 5 The Selection of and the Fitting out of Hull no. 408 Third Para:- ..... subsequently amended by a process of consultation with senior marine staff, shore technical staff, legal advisers and the tendering yard." . The tendering yard did not have any part in amendments to this specification. This was made clear in my comments on report NO 70 Jan 1995. (The text has been amended to incorporate this submission) Attachment 4 - 1 of 7 " ... specification was reduced co one tlrird of the original size, ..removing repetition,items thac were subsequently nO( required and general editing of cext." The specification was reduced (0 one tlrird the number of pages (but not words) by deleting repetitions, inconsistencies, contradictions, irrelevancies and engineering impossibilities. The imagined breviry of the specification has nothing (0 do with the grounding. -' "There was a general requirement... " There was a specific requiremenL REFER REPORT: PAGE 5 Sixth para:- "However concern was raised in the representatives report to Ai\lfSA, regarding the building schedule which was falling behind that planned." The major portion of overrun time was due to inclement weather which occ=ed after the marine engineer project manager had departed. REFER REPORT: PAGE 6 First para:- "Concern was also expressed on a number of occasions, about the supply and processing of drawings and plans for their approval." Minutes of meeting NO. 16 dated 09-07-93 say in part ''2. Mechanical drawings a problem. Rebolo says held up by our comments. Advised it is not our problem as the yard are responsible to get things right first time." Records show that it took the yard up to six attempts to "get things right" The Inspector's comment is not relevant to the grounding. Second para:- " ...assist but not do the project management of the shipyard work." .The statement by AJ.\I{SA management merely reinforces accepted shipbuilding standby practice. REFER REPORT: PAGE 8 The delivery voyage. Sixth para:- " ... the automatic start system for the Twin Disc clutch hydraulic pumps which were previously activated by a slight movement of the bridge clutch control, was disconnected ... " The clutch control was not disconnected by R.M. Lee when the vessel left Brisbane. Nova Marine have also failed to detect this disconnection. The Inspector should disclose his information. Attachment 4 - 2 of 7 REFER REPORT: PAGE 12 Si.."(th para:- " ... , although a dispure exists ... as to who started the propulsion motor(s)" Tills implies that after a black our star! control of the motors reverts to either station. Will the Inspector verify this? ... (The text has been amended to incorporate this information) REFER REPORT: PAGE 20 Circumstances of the Grounding. Fourth para: - "From subsequent investigations it has been established that Cape Grafton had a normal tendency to payoff to port ... " The vessel's bias was established during trials in Vigo in 1993 and still has that bias. (The report has been amended to reflect this submission) REFER REPORT: PAGE 21 Third Para: - " ...it is not beyond the bounds of possibility that these loose terminations included the supply to ... " NQEA'S quality control inspector reports 06302 through 06342 dated 09-09-94 to 20-09- 94 identify loose connections, however he has not identified any no loose connections on bridge supply circuits. Does the Inspector have other information? (The report has been amended to clari.fy this point) Fourth para:- "A main propulsion motor was restarted at 0757 ... " The claimed distance from Dent Island and the known propeller pitch of 70% does not support this starting time. At 70% pitch, with no clutch slip the Cape Grafton has a potential free running speed in excess of 10.5 knots. (ref. Builders trials, power curves.) Within this five minute period (0757 to 0802) to grounding the vessel would have been moving at 9.5 knots. Fifth para:- "At 0759 and at a distance of two cables ...... supports the estimated speed of grounding given by the Master and Mate." (4 knots) This statement cannot be supported. Calculations using basic velocity equations and the Inspectors given data shows. that this cannot be true.This was detailed in my comments on Draft NO 70 dated March 1995. Further. calculations using momentum theory show that the reduction of speed due to dragging the anchors and breaking the cable is insignificant. Attachment 4 - 3 of 7 REFER REPORT: PAGE 22 Engine concrol room alarm print out. Third para:· Tne harbour "generator" is radiator cooled. It is not air cooled. (The text has_. been amended) REFER REPORT: PAGE 26 "S top blocking" the generators Second para- "Bridge procedural insrructions noted the possibility...... will automatically shut down." My copy says "# To prevent shutdown...... press stop block... " It allows for the fact that it WILL shut down not POSSIBLY shut down. Fourth para:- "The procedures were silent on whose responsibility it was to stop block... " Bridge Departure Check list (current at the time of grounding) states under Engine requirements. "Generators start and block as required (min of 2)" This is not silent with regard to responsibility!. (The text has been expanded to clarify this point) REFER REPORT : PAGE 27 Overload protection. Fifth para:- "Although the final specification ...... it did not detail any particular requirement to guard against... " It did. The Inspector should read the Specification and the Regulations. See also page 41 Seventh para. REFER REPORT: PAGE 34 Third para: "The intention of...... a situation not covered by the regulations." a) When a total blackout occurs at full sea speed the vessel stops in little more than two minutes (see free stop trials), becoming unsteerable after about 1 minute, less if the propeller pitch returns to zero. With an allowable 45 seconds for the emergency alternator to come on line the helmsman has 15 seconds of quickly fading response time, if he is ready for it! Attachment 4 - 4 of 7 b) Multiple rudders are not new technology. Most competent designers and certainly the Classification society approval staff will sum the section moduli for the multiple rudder stocks to ensure that the sum does not exceed the rule size. The Inspector should satisfy himself that the Classification Society has detennined this correctly. Neither are relevant co the grounding. REFER REPORT: PAGE 35 Operating Instructions and Procedures. First Para:- " ... the shipyard was given no guidance on how the Owners believed the system should work," Tnis is incorrect. The Marine engineer project managers report for week 7 states that he is going CO have a meeting to discuss the operation of the system with the builder. His other reports also comment(refer to ADV note 60, ADV note 156, ADV note 189, ADV note 200, Fax N021 and minutes of meetings. Further, from the representatives first weekly report, Week 7 page 6. "The technical manager admitted that they have not built a vessel with this level of design ... and are treating the matter as critical ... " "We (ie AlV!SA representative) commend them for adopting such an attitude .. " "In order to clarify all aspects of the overall design and how the plant is to operate, a meeting will be held on Tuesday .• " "Problems have shown up in the power management system however after some input from us on how the system should operate and what is required., the suppliers are now doing a rehash of their ideas to overcome the problem. It may mean some re-design work on their part. ADV note 200 "Attached please find the wiring diagrams for the Twin Disk... from Twin Disk Electronics in the USA" "Please supply copies of these to Cederia and Noris and arrange for them to visit the yard on Wednesday and we will advise them how the system operates and how it is to be wired." Meeting No.2. dated 01-06-93. "1. Discussed power management system & came to agreement on what is required in .. then wheelhouse & how the system is to operate." The above is just a small sample. Further documentation shows that the project manager at the time had direct contact with some of the suppliers. Shipyard records claim that Project manager made changes to the control system on at least three occasions. Read also my comments on Draft Report NO 70 March 1995. Attachment" -;:- 5 of 7 REFER REPORT: PAGE 36 Investigators quote from the marine engineers reports. "As previously highlighted to the yard.. we have concerns about the interfacing of the systems and of what we will end up with. "Because we-c!o not have all the equipment, alarm and electrical drawings we cannot at this stage prevent the Spanish idea of an electrical and alarm installation. ,.. .It is imperative that we get copies of these drawings for study and approval otherwise the systems could turn out to be a problem area during the life of the vessel," Current day description of this is C. YA. The project manager has stated as early as June 6 1993 that he has all this in hand (see previous page) and is advising the yard. He also has had direct contact with suppliers in Belgium and America. REFER REPORT: PAGE 37 Fourth para:- This system was explained in the KaiYfeWa manual but not the bridge guidelines. " The Bridge Departure Checklist (current at the time of groundlllg) says " ... as a memory aid only and does not provide an operational guide to the individual equipment, this info=ation should be obtained from operators manuals (KaJ.YfeWa) and Marine Orders" It is not really appropriate to include complete manuals in a check list. REFER REPORT: PAGE 39 Clutch and pitch controls Sixth para:- "In the opinion of the Inspector, however...... is a condition which could hazard the machinery" For technical reasons I agree with the Builder and the Classification Society that start up' under these conditions will not hazard the machinery. The Inspector must justify his opmlOn. (The text has been expanded to reflect this submission) REFER REPORT: PAGE 41 Fitting out and Survey. Second para:- "No safety analysis of the risks ..... against possible systems failures, were considered. " Does the Inspector mean Risk Analysis? Attachment 4 - 6 of 7 t The first stages of risk analysis (Hazard and Ivlission analysis) were carried out with the Assistant Manager, Ships Operations, AlI1SA, about Nov 1990 during a visit to the vessel Cape More ton. Some of the results being reflected in the invitation to register interest in the provision of a navigational aids vessel the following year. The Second stage (Consequence analysis) was limited to ship effect and excluded damage to the en viionment. Normal Naval architecrure procedure is that the above stages of risk analysis are carried out in any flrst off design. The Cape Grafton performs the same task as the proposed vessel of 1991. Considering A.J.v{S A's time and fmancial constraints the outcome must be considered very good. Third Para:- "'The final specification for "hull 408" was relatively brief ...... "Rules and Regulations for the Classification of Ships" ." Relati vely brief --Compared to ??? A survey of specifications (Two Norwegian, One Polish, Two English, one Spanish and one Canadian) from which larger and more complex vessels have been built shows the final specification for the Cape Grafton is quite long, whether one compares words or pages. Perhaps the Inspector is lacking knowledge and experience of accepted practice. J.R. Kane in the SNA.J.VIE publication 'Marine Engineering' has this co=ent about specifications. "Standards are also conveniently used when preparing specifications as they are well known and accepted by the industry and they avoid the necessity for many words." REFER REPORT: PAGE 43 Founh para:- " ... wharf and sea trials ... in accordance with the ..." Commissioning and Sea Trials of Machinery in Ships." The authors of the publication say that there is insufficient data to detail Gas Turbine vessel trials, nor does the publication cover slipping clutches. It advises that trials can be adapted for machinery similar to that described. The publication details diesel alternator/generator plants. I trust that the most junior Marine Engineer is aware of the similarity between electronic motors and generators, and indeed the simplicity of squirrel cage motors. The publication declines to detail interfacing of equipment and leaves much of this to Oassification rules and regulations. The Specification also draws on the knowledge of the manufacturer in tests and trials. What is the Inspectors problem? ' . Attachment 4 - 7 of 7 Intentionally Blank Attachment 5 Submission - Consultants, James Woolley Pty.Ltd. Dated: 14 June 1995 In general we have 110 major objection to the report and compliment your department on a Job well done. Our comments on various points are as follows:- 1. On page 5 paragraph 6 line 9 comment is made in the report concerning the representative's weekly report and the late delivery of the vessel. To be more explicit the following words should be added after the word 'however' to read as follows: However, "within approximately [Wo weeks of signing of the contract," concern was raised ...... (The text has been amended) 2. On page 6, paragraph 6 we nore mention of the drawings supplied to the vessel as per specification yet it would appear that these drawings were not checked for accuracy at the time which is supported by the report's comments on page 7 Paragraph 5 line 13. We wonder why they were not checked particularly when they were in the"main not submitted for approval by Owners. 3. In the trialing of a new vessel LR rules require a UMS trial which takes about 6 hours during which the vessel is allowed to run in a UMS mode to prove its reliability and that of the alann system. The report makes no mention of this trial having taken place. (The report has been amended to reflect this submission) It is noted also that the alann system was damaged by a voltage spike when shore power cables were cut whilst the vessel lay alongside. Did the UMS trial take place before or after this damage? (The relevant information has been incorporated in the report) If it had taken place prior to this damage then it would have been prudent to have repeated the UMS trial to ensure the system still worked in an approved fashion. If this alann system is said to have been correct in all respects for UMS operation, why did the vessel carry an instrumentation engineer on its maiden voyage from Vigo? Attachment 5 - 1 of 5 4. On page 43 the report states in paragraph 2 that LR had provided a Surveyor for compliance with LR Rules and on behalf of Alv!SA. This is to be clarified. a. the vessel was LR Oass and a surveyor was provided for this aspect of the contract. b. the vessel was also under A.J.YfSA survey for safety. radio and such things as oil pollution etc. A second and separate surveyor was provided here, appointed directly by AMSA Ship Safety Survey Section after a long procedure of checking qualifications etc. He acted as a non exclusive AlYfSA Surveyor totally independent of the no=al Oass Surveyor and answerable to AMSA Survey section. The idea being to cut down on AlVfSA's direct involvement in the surveys and of course costs. Late in the stages of construction a Senior AlVfSA surveyor from Brisbane went to Vigo to do an audit check on what the non exclusive AlVfSA surveyor had done and finalise the Statutory Surveys. 5. Page 12 paragraph 6 indicates the Chief Engineer asking the bridge to start essential pumps. Is there any reason why these were not started from the engine room? 6. Page 14 paragraph 5 seems to indicate that the power management system did not comply with original requirements. Our recollection of the original requirements we wrote for the bridge panel was that once an additional machine was started from the wheelhouse then it would automatically inhibit the power management system and remain on the board until it was shutdown by physically pressing the stop button on the bridge. Refer to the "Advice Notes" to the shipyard in June - July 1993. This was to prevent shutdowns during manoeuvring or in close waters in similar fashion to starting a second steering gear in close waters. 7. Page 15, paragraph 3 last line concerning the layup in Cairns. Some electrical defects may have been addressed but we think it would be more than appropriate to check whether control system defects were rectified. 8. The terminology used in the alarm system are not standard marine tenus and will tend to be confusing as the inspector has indicated on page 24 of his report. These should be changed so that anyone joining the vessel knows what the tenus mean. 8. Page 24 paragraph 11 comments on the battery system, if the backup batteries were in such poor condition then why was the vessel allowed to sail from Sydney let alone Brisbane on the voyage in question? 10. Page 26 discusses the power management system operation. Had the shipyard supplied the system logic information as requested then the design could have been changed to a satisfactory one incorporating all necessary operational scenarios. Attachment 5 - 2 of 5 Even now it would rake little effort to re-program the system and make it safer for all by reducing human input into what is supposed to be an automatic system, but that will require someone who knows the vessel and what the system requires. 11. Page 30 speaks about the generators and the overload sertings. If the vessel had been commissior;ed and trialed correctly then why were the sertings incorrect? 12. Page 3 1 Emergency 24 volt supply. Tue vessel's voltage is 415 not 440 volts. The specification clause 5.10 required all critical machinery controls to be connected directly to a 24 volt battery supply not to a rectified power supply. (The text error relating to voltage has been corrected) The reason for this being that control problems were experienced with some recent new buildings and to alleviate that problem the controls were connected directly to the batteries so that control power was always available. Had the shipyard submitted the drawings for approval then this may have been possible, it also may have been possible if the personnel on site at the time the vessel was completed and trialed were aware of what was specified and the reasons why. 13. Page 31, paragraph 5, we must question the testing of the emergency switchboard in Brisbane by Oass & AJ,\1SA. We note the main bus "no volt" sensing point was incorrectly connected thus holding the emergency alternator breaker open and the report's co=ent that the emergency set started and then shut down. See page 31 paragraph 3. The report also states on page 34 paragraph 2 that the navigational systems were connected to the "non essential bus" If the board was tested after modifications in Brisbane, then why didn't it work when the vessel grounded and why were the essential items required by the regulations left connected to the non essential bus when they are supposed to be connected to the emergency bus? The report states that the emergency switchboard modification drawings had not been approved by Oass when the vessel went aground. Had proposed work been approved before being carried out then the accident may not have occurred. In our experience with new buildings and modifications to safety related systems such as this, AJ,\1SA Survey Section also approved the emergency switchboard drawings to ensure they met the regulations & marine orders. Did they check them for this modification? 14. Page 33 paragraph 2, Class and international regulations only allow emergency systems to be connected to the emergency switchboard hence the board would have had to be split to comply. ": .. Attachment 5 - 3 of 5 If the system had been designed correctly the drawings shown on page 33 would have had breaker C I interlocked with breaker T2 which would have split the bus once the emergency set started. Tl would have tripped on under voltage at the main bus and T1 would be a manually reset breaker. 15 Page 34 paragraph 3, the centre rudder stock is larger than 140 mm diameter. It is closer to 230-mm we believe with smaller ones on the outboard rudders. On page 20 paragraph 4 last line of the report indicates that the vessel had a tendency to turn to port. It is no=al in such cases to compensate by offserting the rudder slightly with a slight amount of starboard helm. Why was this not done by the shipyard and standby crew'") (The text has been amended to reflect the second part of this submission) 16. Page 35, paragraph 6 states that the sbipyard were given no guidance on how the system should work. Various times we attempted to enlighten the shipyard on how the vessel should work but all efforts were rejected by the machinery design manager with the comment that "We have built diesel electric vessels before and know what we are doing", that is until the day we left the shipyard when he stated, quote "I cannot understand why you are leaving, you are the only person here who knows what is going on with that vessel." Unquote. 17. Page 36 paragraph 4 states the yard held 3 meetings to advise how the systems should work. We checked our notes and a meeting was held in early June where Indar, Twin Disk, Balino representing Ka!\1eWa (CPP) and Valmet (Gearbox) were present along with ourselves and the sbipyard. Caterpillar people came and left without taking part in the meeting. We were asked how we saw the system working and when we started to explain we were cut off and the meeting reverted back into Spanish. All that was achieved at that meeting was a preliminary definition of interfacing contacts required by each party. Later, after marking up a copy of the CPP preliminary drawings a meeting was held with Balino and the yard out of which all that was gained was the impression that Balino were not going to comply with the drawings we had amended. To our recollection there were no other meetings specifically for this purpose during our time at the yard. 18. Page 39 paragraph 6. Interlocks are required to be fitted to comply with Class rules where necessary for the safe operations of the vessel and its machinery irrespective of whether they are required by the specifications or not. Line 12 is incorrect, the propulsion motors cannot be started with the clutches engaged and pitch on the propeller as the soft starters will not carry the starting current required. This was confirmed by the Indar people in June 1993 at the meeting mentioned above. (The report has been amended to reflect the last line of this submission) Attachment 5 - 4 of 5 Had the shipyard allowed the system design to have been done correctly then the operational aspects would have been adequacely covered. Page 40 paragraph 5 relating co the clutch overload signals. These are not required in this propulsion train and are only used in rug boat propulsion systems as they are designed to trip the clutSh if a rope is caught around the propeller. Tile propulsion motor overload signals were required to be connected to the CPPsystem to reduce pitch slightly. The zero pitch aspect was originally left out because the vessel had slipping clutches however there is no doubt an interl"ock would have been required to prevent the clutches engaging once the propulsion motors had started. Bear in mind also that the clutch & other control drawings were not made available by the shipyard and to our knowledge they did not advise Twin Disk of any special requirements concerning the vessels operational requirements. 19. Page 42 paragraph 6 relating to testing & trials, we cannot agree more as none of the Owner's people at the shipyard had commissioning experience particularly a vessel as integrated as Cape Grafton. Shipyard commissioning experience in this situation was limited. 20. Page 43 paragraph 7 co=ents on the yard's ISO 9001 QA certification. The certificate was issued but in our view the production departtnent performance did not qualify for such certification. 21. It was originally intended by the undersigned that a controllogic book would be written for the vessel which would explain the vessel's layout and how all systems operated as we had previously done with other new vessels. This aspect was mentioned in the consultancy tender offer however at the date of our departure from Vigo the book had not been written because of the pressure of work and to date has not been written to our knowledge even though it is a shipyard contract responsibility to comply with Marine Orders. We do not consider the shipyard had the expertise to compile such a booklet and it is questionable whether the Owners have this expertise. 22. Page 44 paragraph 5 line 1 relates only to a lack of experience on the part of those concerned and it was in the interests of the shipyard that they be overlooked just to get the vessel handed over, even though ISO 9001 requires a thorough commissioning and testing procedure. In your letter you ask whether we have objection to our comments being reproduced. Provided that any sections reproduced are done on an exacting basis reflecting their true meaning and application to the related subject then we have no objections. Attachment 5 - 5 of 5 , .' Intentionally Blank J .! ; ,, Attachment 6 Submission - L1oyd's Register of Shipping Dated: 13 June 1995 Comments an Draft Report CAPE GR.A.FTON on Dent Island in the Whitsunday Group, Queensland on 2 June, 1994 1.0 Page 8, 6th paragraph and page 26, 1st paragraph None of the alterations was brought to the attention of the attending Surveyor whilst the vessel was at Brisbane prior to the incident. (The text has been amended to incorporate this submission) 2.0 Page 22, 3rd paragraph and Page 24, 4th paragraph Both AMSA and Lloyd's Register Surveyors attended trials at the engine supplier's workshop where it was observed that a number of "shutdowns" had been fitted to the engine management system. The engine suppliers were requested to remove these, which was duly done. A manual stop initiation was allowed to remain. The same AlYfSA and Lloyd's Register Surveyors attended trials onboard the vessel when a ship's engineer was requested to simulate a blackout by opening the main-to-emergency switchboard tie breaker at the main switchboard. The Surveyors who were in the emergency alternator room at the time this was done observed that the emergency alternator started and connected to the emergency switchboard iD. the required time. 3.0 Page 34, 8th paragraph The section headed "Emergency Batteries" states that the Oassification Society requITed a transitional source of power. This is not the case, since the Society's Rules are no more onerous than SOLAS, being a refelction of them In any event, for a cargo ship, the Rules (as does SOLAS) do not requITe a transitional source of electrical power unless the emergency generator is unable to meet Rule requirements, which include the ability to be started. connected and supplying specified loads within a maximum of 45 seconds. (The text has been amended) 4.0 Page 14 No mention is made of the Cairns Surveyor's attendance onboard 4th - 5th June, 1994 or to Conditions of Class imposed, requiring the ship to proceed to Cairns for repairs. (The text has been amended to reflect this submission) Attachment 6 - 1 of 3 5.0 Pages 8, [7, 21,41,44, 45 and 46 References are made to modifications to, and failure of the emergency power system., but only one reference on Page 31, acknowledges that drawings had not been submitted for approval. It is the Society's understanding that modifications had been done without drawings. (The text has been amended to reflect this submission) 6.0 Page 30, jth paragraph, 12th line: There appears to be a word missing after "too". (The text has been corrected) 7.0 Page 31 , 1st paragraph, jth line: Tnere is a reference to the 440v main switchboard. The system voltage is believed to be 415v. (cf. page 3, 4th paragraph, lOth line.) (The text error has been corrected) 8.0 Page 37, 4th paragraph. 3rd line: It is believed that the fourth word should be "console", not "consul" as shown. (The text error has been corrected) 9.0 A number of co=ents were made on the first draft of the report, some of which appear to have been acco=odated. Some co=enrs made then, however, still apply to the final draft. (As is to be expected, the page and paragraph numbers have altered.) 9.1 Page 31 , third paragraph, 7th line: "Provision of a dedicated emergency generator was not required under the AJ.\1SA building specifications ... " It is concluded that the AMSA specification would have required the vessel to comply with the Classification Society's Rules, which do require the provision of an emergency source of electrical power, be it generator, batteries or a combination thereof. The vessel is understood to have been allowed to undertake its delivery voyage with its effectively non-complying emergency electrical arrangements as a concession. (The text has been expanded to clarify this point) ~ttachment 6 - 2 of 3 9.2 Page 32: The arrangements as shown on the plans originally approved for the modifications to the emergencylbarbour supply differ from those shown in the sketches. For example, in the plans originally approved there are 4 circuit breakers interposed between the main switchboard_ and the essential bus and only 2 shown in the sketch, 3 between main switchboard and non-essential bus and only 2 shown in the sketch. (The sketches show the "as fitted" arrangement) 10 . Page 41 & 42 (supplied after the main body of the report) states that "During the investigation it became clear that Alv!SA staff, the Lloyd's Surveyor and the Representative present during the final stages of the firting out, were not aware of the implications, application or detail of these documents as they related to the protection of generators from overload and to the need for interlocks between units of the propulsion system." The documents referred to are "International Conventions, Marine Orders and Lloyd's Register of Shipping Rules and Regulations for the Classification of Ships". It is considered that this remark, with regard to an employee of the Society is unwarranted and cannot be substantiated. It is requested that it be removed prior to any further issue of this report. (The text of the report has been altered slightly to reflect this submission) \ \ Attachment 6 - 3 of 3 I