16 Feb 2012

IMB ADVISORY

"Recently, it was reported that 2 casualties involving 2 innocent fishermen
trying to protect their nets when security team fired at them assuming that
they were pirates"

K.C.

Received: from MPD at Globe Wireless;
Thu, 16 Feb 2012 11:46 UTC
Message-id: 928498734

AIW

AIW

Nothing else to report.

K.C.

Received: from MPD at Globe Wireless;
Sun, 05 Feb 2012 17:31 UTC
Message-id: 924078338

Comments on the Crash of Air France 447

The Airbus's vertical stabilizer recovered

I just read a couple of articles about the crash of Air France 447. My take, (as a mariner, I am not an aviator)  is that the root cause of the crash was the  failure  to avoid bad weather.

The first article is from Popular Mechanics: Air France 447 Flight-Data Recorder Transcript - What Really Happened Aboard Air France 447 - Popular Mechanics


The factors which led to the crash were:

- The plane encountered bad weather
- An iced up  pitot tubes caused a loss of aircraft speed data
-With the loss of airspeed  data the computer  disconnected the autopilot
- The controls  switched modes from  "normal law" to "alternate law
- The junior most pilot panicked and stalled the plane.
- The yoke system averaged the input from the pilots and co-pilots yoke but without providing information that one pilot was pulling full back, this made it impossible  for the captain and other co-pilot to determine the cause of the plane's behavior.

Because of the unusual combination of factors above the crew flew a  perfectly good, highly sophisticated  plane with 228 passengers into the ocean.

The second article is from BoingBoing - the post is Disaster book club: What you need to read to understand the crash of Air France 447

This article points out that the crash is an example the type of incident described in the book Normal Accidents by Charles Perrow


I agree the accident could be viewed as a normal accident but my take is that the error made was the simple one of failing to avoid bad weather. The root cause can be found in the very first line from the synopsis in the  Popular Mechanics article.

At 1h 36m, the flight enters the outer extremities of a tropical storm system. Unlike other planes' crews flying through the region, AF447's flight crew has not changed the route to avoid the worst of the storms.

So it begins. It ends at 2h 11m when the plane hits the sea surface. 

Had the plane flown around the bad weather, the latent conditions and the weird, unexpected failure path never would have been revealed.

One other point,  you can't avoid heavy weather if you don't have or don't pay attention to the forecast. Typically, shipboard the mates will simply rip what ever comes off the INMARSAT printer and, regardless of it's relevancy,  post it without reading it. I don't allow that. On my ship I have a specific, written procedure that insures the correct weather forecast is read, understood and posted.

Knowing the weather forecast is not just a way to avoid disaster. It also should be part of routine on a well run ship as weather impacts almost all maritime operations.

K.C.


Avoid heavy weather - that's a principle I've posted about twice before:  Parametric Rolling of a Car Carrier in a Head Sea 

In that post I wrote: "

- avoid heavy weather. Hidden flaws, the so-called latent condition, ..... are more likely to reveal themselves when the ship is being tossed about in bad weather, just when you can least afford to cope with it.

In the second post  Heavy weather encounter - The Satori. ,  I wrote:

It is not only the vessel that encounters heavy weather, it is the vessel, crew and cargo. Operating vessels, and their crews, near limits increases risks and chances of failure, - but the path of failure may not be the one expected.

 I've posted about normal accidents a couple of times: Normal Accidents and here "Thinking Like a Mariner - Managing the unexpected." 

BTW - not much posting in the near future. I should be home again in March gw&wp

Risk Assessment Video from Walport

High and Heavy (Photo by K.C.)

Like most mariners I like to keep things as simple as possible. But  today's ships are big, relatively complex and  have lots of systems.

A big PCTC for example has 12 cargo decks. The cargo equipment includes hydraulic powered movable decks and ramps as well as a 150 ton capacity, computer controlled, hydraulic powered (with a separate cooling system) cargo elevator. Not to mention the engine room, the house, mooring systems and so on.

Crews on ships like this can not take a simple approach to complex tasks and  expect to get the job done effectively and safely.

Risk assessment training and tools can help crews evaluate the risks involved in shipboard tasks.

The Walport video below is from Marine Cafe Blog -  Risk assessment: the how and why




K.C.

Reducing Information overload in heavy Ship traffic

ARPA display

Information overload is often  a big problem for new third mates when they encounter heavy traffic.  A typical difficult situation might involve  two or three large ships, a few fishing boats and maybe a tug and tow all moving a different speeds
 

Finding a solution to traffic problems can be done  by the bridge watch either entirely by visual means,entirely with electronic aids such as ARPA (radar) or along the  spectrum between the two. When the ship is in zero visibility there is no visual information available the bridge watch must work entirely at the radar end of the radar/visual spectrum. In clear weather  an experienced deck watch officer or pilots might  maneuver in  traffic without the use of radar at all.

Most commonly however in clear weather, in heavy traffic most bridge watch officers will find themselves relying mostly on visual information but using the radar/ARPA as an aid to verify or confirm what they see out the window. 

Not so however for the new third mate.

 From a  gcaptain post Technology on Ships Can be Dangerous, Warns P&I Club 

In another case cited by the club, the OOW decided to use the Automatic Radar Plotting Aid to track 99 different ships whilst transiting a congested anchorage and to overlay the radar image with Automatic Identification System data. With so much information being displayed, he failed to notice that one of the targets had both a minimal closest point of approach (CPA) and time to CPA and, ultimately, there was a collision.

This doesn't surprise me. When a new third mate attempts to solve a difficult traffic situation, most new watch officers  do not trust solutions "by eye" but prefer instead the precision provided by radar/ARPA almost as if they were in zero visibility.

I've gone up to the bridge in traffic to find the mate switching from radar to radar each one with different mix of features trying to solve a problem that can be solved by a more experienced mate in just seconds by eye.

In aviation new pilots must first learn to fly a plane using visual flight rules and then later gaining an instrument rating.

The key to improving the ability of  a new mate to deal with traffic is to increase his/her confidence in solutions found by eye with radar/ARPA confirmation. That sometimes means prying them away from the radar and demonstrating to them how traffic problems can be solved by looking out the window.


K.C.

Moneyball and Safety Management Systems

Nick Swisher (from Wikipedia)

In this post I  connect the book Moneyball with shipboard SMS (Safety Management Systems).

Moneyball, (stealing from Wikipedia) "is a book about the Oakland Athletics baseball team and its general manager Billy Beane The premise of the books is that the collected wisdom of baseball insiders  is subjective and often flawed."

The conventional wisdom was, that to win ball games you need good players, and to get good players you used traditional scouts and you paid top dollar. But, in the case of the Oakland A's, with a low budget, they couldn't  pay top dollar. The key, as my old port engineer used to say is, "ya gotta be smart".  Being smart in this case meant measuring the right thing, player performance and scoring metrics, the right way. To measure is to know.

The link to SMS  comes from a line in the book: "it's looking at the process rather then the outcomes". The key to winning games was, stick with the program,  follow the process.  

During the game, general manager Billy Beane,  based on what he knew from objective measures, (sabermetrics), focused on the process. For instance he wanted the player at bat to get on base. The surest,  safest  way to get on base is to get a  walk. Players on the other hand, focused on the outcome,  tended  to swing at pitches they shouldn't, trying for the home run.(more here  Moneyball at Slate .)

Shipboard, the process is the Safety Management System which  are: "instructions and procedures to ensure safe operation of ships" -  there's more to it of course but that's the heart of it.

Many mariners tend to be  impatient with forms and paperwork. Often these "git er done"  mariners consider SMS to  have little relationship to the actual  work but view it instead as a separate set of  tasks  that have to be done  in addition to the job.

That's the wrong approach. A good SMS  provides the process to arrive safely at the intended outcome.

This is from Capt.Ben Dinsmore at The Maritime Site, the  post Increased Safety Measures and Performance Are Not Counter Productive. 

"I believe there is a misconception in the maritime industry (or any industrial environment for that matter) when it comes to operational safety and performance. While most people agree that safety takes priority EVERYTIME, there are a few people who suggest an increased safety focus is often at the expense of performance (productivity, downtime, etc.).  This is simply not the case."

 That's right. Stick with the program, follow the process.

There is  git er done and there is being safe but to do both you have to follow the process, ya gotta be smart.

K.C.

Piracy Update 13 Nov 2011

Piracy tactics in the Gulf of Aden (GOA) and Horn of Africa (HOA) areas continue to evolve in response to increased effectiveness of shipboard defenses.

First, from MarineLink.com - The Changing Face of Piracy.

Of interest is the 12 skiffs each with 5 to 8 pirates. This article has the security team firing warning shots as opposed to the more dramatic reports I noted in  my previous post: Will Somalia based pirates seize a ship with armed guards? - I still think that it is only a matter of time before pirates seize a ship with armed guards.

The first incident, on August 7, according to the report filed with the IMB’s Live Piracy Reporting Center3, saw 12 skiffs containing between five to eight pirates per skiff pursue and attack a bulk carrier approximately 20nm off the coast of Eritrea. As the skiffs approached to within 300m of the carrier, the Master ordered the armed security guards onboard to fire warning shots at the pirates’ skiffs. While this show of force saw the majority of pirate vessels break off their attack, two skiffs continued in their pursuit for some 30 minutes, returning fire at the armed guards until they, too, aborted their attack.  If one believes the report – and there is no reason to doubt the legitimacy of reports filed with the IMB – then even underestimating the number of pirates to just 60 still leaves us with evidence of a worrying trend in pirate tactics.

Secondly, from Jay Bahadur's blog The Pirates of Puntland a post The beginning of the end?

Though no vessel employing armed security has yet been hijacked, I am not quite as sanguine as Pelton about the impending end of piracy off Somalia. The pirates have demonstrated an uncanny penchant for adapting to the measures that shipping companies and the naval forces have thrown at them, and the hitherto quiet start to Pirate Season 2011-12 could simply be an ebb before the next torrent. The next evolution of pirate tactics could very well be to come out guns blazing, armed guards be damned.

Finally, found at gcaptain, at the post U.S. Goes Public with Support for Hired Guns Against Piracy I thought this, from Andrew J. Shapiro, current United States Assistant Secretary of State for Political-Military Affairs was very interesting - a shift of focus ashore:

We have also shifted our efforts to focus on the pirate leaders and organizers ashore. The focus ashore is essential, as piracy has evolved into an organized transnational criminal enterprise conducted for profit. It is increasingly clear that the arrest and prosecution of pirates captured at sea – often the low-level operatives involved in piracy – is insufficient, on its own, to meet our longer term counter-piracy goals. To maintain the momentum and space for action gained by naval operations, we have begun an effort to identify ways to disrupt these criminal networks and to determine the means to dismantle their financial networks.”

 This strikes me as a big deal, don't know what it means exactly. I wonder if there is link between this new focus ashore and this, also from gcaptain:


Fighting Pirates On Solid Ground: Puntland Foils Hijacking Plans

Local officials and police of Gara’ad district of Mudug region in Somalia’s semi-autonomous state of Puntland, with the help of residents and elders, successfully removed pirates from the district and surrounding areas........“We captured many vehicles from the pirates as well as nine speed boats they were going to use to hijack other ships,” he explained.

We shall see....

K.C.

Will Somalia based pirates seize a ship with armed guards?

Reported at Eagle Speak at the post Somali Pirates: End of October Brings out the Pirates.

WARNING: ATTACK A Vessel came under fire from an unknown number of skiffs in position 0810S 04606E at 2028Z on 31/10/11. Vessel was fired upon aft of bridge bulkhead, port and starboard side accommodation and portholes. On board security team returned fire and after 30 mins pirates left the vicinity of the vessel.

If this is correct pirates persisted for half an hour with an attack against a ship while an onboard armed security team returned fire. As far as I know this is a new development as in the past pirates have broken off attacks as soon as fired upon.

It is my view that it is only a matter of time before pirates seize a ship with armed guards. Ship masters should put BMP into place even with an embarked armed security team.

K.C.

Note: I have edited this post changing the source from  OCEANUSLive.org   Greek Tanker, Liquid Velvet, Hijacked in the Gulf of Aden to Eagle Speak

Vessel Encounters - The Play

In comments of my post Vessel encounters drunks. Which rule applies?   I said I was going to take another stab at making my point so here goes.

One of the books I have here at home is Mariner's Rules of the Road by William P. Crawford.  

The book uses the analogy of a play to explain the rules of conduct between vessels. From the book, regarding the rules:

"The structure, though, can be reduced to this: a code of conduct and a code of signals. Vessels are given a script to follow when they meet; that is the code of conduct."

and:

The analogy of a script is apt. Performers acting out parts in a theater are guided by the playwright's specifications of who says what and when.Vessels approaching each other so as to involve risk of collision also require direction.

When a recreation vessel deliberately uses it's superior maneuverability to harass a larger vessel one actor is not following the  script and  the play is over.

Searching through the rules of the roads for the appropriate rule in this case would be  like searching for Booth's line "Sic semper tyrannis"  in the script for Our American Cousin. It's not  there, the play was over when Booth shot Lincoln.

At sea, once Booth jumps onto the stage it's time for the pedantic types to turn to Rule 2 also called "The Rule of Good Seamanship and the General Prudential Rule.

Again from Crawford's book:

"If there is no script, or if what script exist won't work, then be ready to 'ad lib'."

K.C.

Would the stern swing to port?

What?? I have been researching the so called "Gross tonnage rule" and from a Coast Guard Auxiliary site I read:

"In other words, if a boat is moving a 5 mph east and you were in the vacuum of space, it would never stop traveling east at 5 mph. However, we all know when we stop our engine on our boat, we slow down".

I wonder if I was in the vacuum of space and I backed the engine would the ship and the propeller begin to rotate in opposite directions? I mean assuming my engine is going to run?

Anyway speaking of ships in outer space the blog Strait of Magellan has safely circumnavigated the sun.

K.C.

Use of the GPS to regain the track-line to recover a MOB

Typical Maine GPS

In the case of a crew (man) overboard many  GPS units have a MOB (man overboard) button which will give the bearing and range back to the position of the ship when the button was pushed. The problem is  the button may be overlooked  entirely or it may not pushed in a timely manner.  Even if it is pushed in a relatively timely manner it may be difficult to determine the distance between the MOB position on the GPS and the actual position of the crew in the water.

However,   the crew member in the water has to be somewhere along the previous track. This track  information is likely stored continuously and automatically on the GPS unit.

The GPS "PLOT", which shows the previous track, can be an invaluable aid in locating the ship's track while executing the man overboard turn.

It is important to know how to switch to the PLOT screen during the overboard emergency  and it is also important to check to insure that it is set up properly to continuously record the ship's track before the emergency.

The ship's track may also be stored in other electronic equipment. For example  "target trails" on the radar set at the appropriate time may also display the ship's previous track.


K.C.

Program to aid Seafarers subject to pirate attack.

[Photo: ITF Seafarers' Trust: Rob Murray]

A program  " to help seafarers who have been or may be subject to pirate attack." The Maritime Piracy Humanitarian Response Programme (MPHRP) has been established:

"to assist seafarers and their families with the humanitarian aspects of a traumatic incident caused by a piracy attack, armed robbery or being taken hostage"

The announcement from the International Transportation  Workers Federation (ITF) is here. 

K.C.