How to Avoid Bligh Reef - Keep a Navigation Plot

Track of  tanker Exxon Valdez to Bligh Reef

How to Avoid Bligh Reef.

From the Old Salt Blog - Two Constants – Bligh Reef and Human Error

The Coast Guard report on the grounding on the tug Pathfinder on Bligh Reef prompts the Old Salt Blog to point out that this is  the same reef struck by the Exxon Valdez on March 24, 1989.

As pointed out, both incidents have in common Bligh Reef and human error. They also both share a lack of a proper navigation plot.

The chart (chart and times from  Visualizing the Decision Space )  above is marked with key points (click to enlarge chart).

1. At 2324  Exxon Valdez drops off the pilot
2. At 2330 Hazelwood changes course to 200T
3. At 2339 Third mate Cousins plots a fix /  Hazelwood changes course to 180 T (due south)
4.At 2353 Hazelwood leaves the bridge, orders third mate Cousins to change course when abeam Busby Light (2 minutes ahead)
5. At 2355 Third mate Cousins plots a fix abeam Busby but does not change course.
6.At 2400 (midnight)  Lookout reports Bligh Reef on the Stbd bow -  Cousins orders Right 10 rudder
7. At 0004 Cousins orders right 20 rudder
8. 0007 Cousins orders hard right
9. Exxon Valdez strikes Bligh Reef at 12 kts.(at 12 kts 1 mile = 5 minutes)

The key here is that giving verbal instructions to the mate does not suffice. It's critical that an intended track-line be  laid down with anticipated turning times labeled on the chart. When a navigator plots positions, courses and times on a chart it moves navigational information from the officer's mind, to the paper chart where it can be more easily examined by all involved.   Plotting navigation information  is both a way to determine turning times, distances to hazards and so forth but also, importantly, it is also a  communication tool.

When Capt Hazelwood ordered Cousins to "turn when abeam Busby Island" we don't know if Hazelwood  had full situational awareness, specifically the ship's position and distance from hazards and we don't know how Cousins interpret  his instructions. Placing the relevant plotting information on the chart would have closed understanding  gaps between mate and captain.

Next, the case of the tug Pathfinder.

From Report faults captain in tugboat grounding on Bligh Reef.

The captain of a tugboat that ripped open on Prince William Sound's Bligh Reef in 2009 was unaware of the boat's position when he put it on a crash course with the infamous and well-known navigational hazard, according to a Coast Guard report.

"Unaware of the boat's position". My experience is that captains and mates on tugs don't keep a paper plot. In many cases they should. If the crew is so familiar  with the area that they fully aware of the vessels position at all time, for example in a marked river channel, then a full plot is not necessary. In many other cases some form of a plot should be kept.  According to Bowditch

"a small craft navigator of limited experience may underestimate the importance of professional navigation. However his vessel's safety depends on his skill. He must plan his track and know his position at all times. Small craft navigation also requires a complete, accurate, and neat plot."

But the captain on the Pathfinder had over thirty years of experience including ten years on the Pathfinder. Not a navigator of "limited experience".  This is an example of what a ship mate of mine describes as "I'm so good I'm brain dead"

For captains this is simple, insist on a formal plot. For mates it's a little tougher. I've sailed on tugs where the captain forbid making marks of any kind on the chart. But if allowed don't accept "hand waving" when changing watch. If the off-going officer does not have a plot take the time  to lay one down before you relieve.

K.C.

Alaska Ranger - Sailed though loophole created by the Coast Guard

F/V Alaska Ranger - USCG Photo

Both the Coast Guard and the NTSB have now released their reports on the sinking of the Alaska Ranger. The Coast Guard's report can be found at the CG site Homeport - type "Alaska Ranger" into the search box to find the report. The NTSB's report can be found here.



The Alaska Ranger case is not complex. The hull of the vessel  was in such poor condition that, in typical Bering Sea conditions, water entered and flooded the entire vessel. The actual point of failure evidently was the Kort nozzles which were tacked onto the vessel in 1991.

The Coast Guard report claims that there was ambiguity in regulations regarding the Ranger status as a fishing vessel or a processor. Thirty-two of the forty-nine people aboard the Ranger were titled "Factory Processors", that makes it a processor.


The Coast Guard created a loophole in the law  called the Alternate Compliance Program which according to the Coast Guard

"allows exemptions to the class and Load Line requirements while at the same time creating improved safety requirements for these vessels, thereby avoiding the incentive to operate strictly as uninspected fishing vessels. ACSA vessel owners work with the Coast Guard"

In effect the Coast Guard put it's stamp of approval on a vessel which was not seaworthy but which carried thirty non-mariners onto the 32 degree waters of the Bering Sea.

This is a case of risk assessment, scrapping the Alaska Ranger would have risked adversely impacting the owner's bottom line.

K.C.

Heavy weather encounter - The Satori

A U.S. Coast Guard HH-3F Pelican 

In my post Parametric Rolling of a Car Carrier in Head Sea. I wrote that hidden  flaws are more  likely to be revealed in heavy weather. An example is the car ship Figaro - Inadvertent Release of CO 2 - in that case heavy weather was the trigger that caused the unintended release of CO2.

Another, less obvious example is the case of the Sailing vessel Satori  which was the sailing vessel in both the book and movie The Perfect Storm.

The Satori is: 

a short masted, heavy displacement rig. She weighs 11 tons and is designed for heavy seas. Eleven stays keep the forty foot mast secure. When the boat was built Ray requested heavy rigging to be certain that Satori could handle more severe storms.

When the owner and captain of the Satori, Ray Leonard, hove to in 40 kt winds and 30 ft seas he felt confident that his vessel was well within its limits but was unexpectedly  forced to abandon his vessel. Leonard's confidence in his vessel was not misplaced, the Satori was later recovered with little damage.   The path of failure  was not the vessel but the crew: From the story: He (the captain)  was unable to convince the crew that this motion was uncomfortable but not dangerous.

This second knockdown put the crew into a heightened state of panic. They began to insist that they call the Coast Guard for a rescue. Karen believed that the boat was going to break up any minute. The captain explained that there was no need for a rescue and that Satori had been through this before and would ride out this storm. At this point, Susan and Karen were not listening and kept insisting that they wanted to call. Ray agreed to let them call,

The Coast Guard required Capt Leonard to abandon his vessel and sent a HH-3F helicopter from Elizabeth City, N.C.  Rescue swimmer   Dave Moore went into the 30 ft seas and pulled the captain and two crew out of the water.

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.

K.C.
__________________________________________
The  son of Ray Leonard, posted a rebuttal to the book The Perfect Storm.

The Alaska Ranger - shitty job, shitty boat

The Alaska Ranger, which sank Mar 23, 2008 killing five crew, in Dutch Harbor(Photo by U.S Coast Guard) .
Based on the TV show The Deadliest Catch the general public may get the impression that the Alaska fishing fleet is made up of small but seaworthy boats like The Time Bandit and the
Northwestern with experienced captains like third generation fisherman Sig Hansen with an experienced crew with maybe one greenhorn, often the younger brother of another crew member.

That's not the whole story. At the other end of the spectrum , its about Gulf of Mexico mud boats, beat to hell in the Gulf and then sold cheap to low cost / high profit companies like The Fishing Company of Alaska (FCA) , converted to factory trawlers and run by down on their luck fisherman, crewed by inexperienced fish factory workers.


From GQ, The Longest Night

Kenny had a shitty job on a shitty boat.....He was one of forty-seven captain and crew on the Ranger, a 200-foot tub that sailed out of Dutch Harbor,..... She was built in 1972, with a flat bottom designed for the warm, calm waters of the Gulf of Mexico, then retrofitted into a head-and-gut trawler and bought cheap at auction in the ’90s by the Fishing Company of Alaska. She had a new factory, where the fish were processed, but the rest of her was old and decrepit, with seals painted over so many times that the doors wouldn’t latch tight and a rusty shell that had been patched and rewelded over the years. That flat bottom gave her an unnatural, unnerving roll in the big swells of the Bering Sea, but she could stuff well over a million pounds of fish in her holds before she’d have to off-load at Dutch.

The real scandal though is not that captains, mates and engineers have to work on an unseaworthy vessel, at least they know they're risking their lives to make a buck. What about the men and women recruited to work in the fish processing factory? Many of them have never been to sea, are out of work, out of cash and out of luck, and are lured by the promise of a relatively high paying job but have little concept what they are in for on the Bering Sea on an old, beat to hell, converted Gulf mud boat.

Likely these workers are on the boat because they got backed into a corner and thought a job on a factory trawler was a way out, never dreamed they would find themselves, at 3 am, floating in the waters of the Bering Sea in 8-10 foot seas praying for a Coast Guard helo to pluck them out of the sea before they succumbed to hypothermia.

The reason fishing vessels have traditionally been unregulated is, in part, because presumably a professional fisherman can judge the level of risk involved in a fishing operation. This isn't the case on these "head and gut vessels" such as the Alaska Ranger. The crew hired to process the fish need not have any experience at sea and often don't. There is likely a presumption on the part of newly hired crew recruited by place like this that the company that has hired them to process catch will provide them with a safe work place. This is not the case.

K.C.

==========================

The Alaska Ranger which sank March 23, 2008 killing five crew members was a converted Gulf of Mexico OSV (Offshore Service Vessel) sold, modified and put into service in Alaska. The Alaska Ranger was not inspected, evidently not watertight internally and not seaworthy.

The Ranger was built in 1973 and operated as an offshore supply vessel in the petroleum industry. In 1987, the vessel was purchased by Fishing Company of Alaska, renamed the Alaska Ranger, and converted to serve in the fishing trade.

Evidently the rudder broke loose, dropped off and the steering gear room flooded. In an seaworthy vessel this alone should not be enough to cause the vessel to sink. An inspected vessel is required by regulations to be watertight internally to ensure that an incident such as this will not cause the loss of the vessel.

The Wikipedia article is here with links to audio and video.

From the NTSB:

The National Transportation Safety Board determined today that the probable cause of the sinking of the Alaska Ranger was uncontrolled, progressive flooding due to a lack of internal watertight integrity and to a breach of the hull's watertight envelope, likely caused by the physical loss of a rudder.

Regulations do not require that vessel like the Ranger be inspected.

Most commercial fishing vessels are exempt from U. S. Coast Guard inspection by law and must comply with only minimal safety requirements for lifesaving and fire protection equipment. The Alaska Ranger was part of a group of vessels enrolled in a Coast Guard safety program called the Alternate Compliance and Safety Agreement, which subjected vessels to more than the minimal safety requirements. The Alaska Ranger was enrolled in the program but had not yet met all requirements at the time of the sinking.

"Because commercial fishermen are involved in one of the most dangerous professions in the world, it is essential that the vessels they work on be subject to mandatory safety inspections," said NTSB Chairman Deborah A.P. Hersman.

Somehow these vessel still manage to dodge regulations.

the NTSB’s recommendation that the Coast Guard seek legislative authority to inspect commercial fishing vessels (Safety Recommendation M-87-64) has not met with a similar success. Although in 1992, the Coast Guard submitted a plan to Congress that would require inspection of all commercial fishing industry vessels, Congress did not grant that additional authority. As a result, the commercial fishing vessel industry is still largely unregulated.

=================================
Also:

-There are some interesting comments at Bitter End post Struggle for power on doomed trawler regarding this type of vessel when they have a heavy load and the rudder stock gland is submerged. According to the NTSB report the modifications done to the Ranger when it was converted to a trawler resulted in an increase of draft of 2 and 1/4 feet.

- Another angle, fishing regulations: Jones Act Blog has posted an article regarding NTSB recommendation that the National Marine Fishery Service to review regulations intend to limit catches but which strongly discourages replacement of aged fishing vessels:

The NTSB strongly worded letter criticized NMFS policy, stating: "NMFS' decision to permit vessels to be replaced only if they are lost or deemed ineligible to fish runs contrary to the interest of safety. Replacing a vessel after it sunk is too late."

- Article from Fishing Journal The struggle for power on doomed Bering Sea trawler (PDF) good article with details about the vessel owner, The Fishing Company of Alaska and the buyer Anyo Fisheries. The owners of each were married to each other at one point.

Bryant's Maritime Blog last month posted NTSB – report on sinking of fish processing vessel Alaska Ranger- the report MAR0905 PDF here.

UPDATE: From comments - my husband was on that boat when it sank. i nearly lost him. thank you for telling it how it was. it was a disaster in the making. he said it was the roughest boat to ride on. flat bottomed boats have no business being in such rough waters. thank you kami
kami | 12.25.09 - 11:55 pm | #

Alaska Ranger thread on Deadliest Catch fan forum here.

Inside the Coast Guard's Most Extreme Rescue - From Popular Mechanics -

"For us this is pretty huge, about as big a case as you can imagine," McLaughlin reflected in the days afterward. "I've been on hoists when the boat sank in front of me. But there were five people, it was daytime," he said. The Alaska Ranger was something entirely different: "You get out there, you get on scene and you get into a hover and you look to your left, you look to your right, and you see strobe lights wherever you look. And you think, oh my God, where do I begin? Then you just pick a spot as quickly as you can and start getting people out of the water."

E Navigation - Shore Side Control on the Way?

VTS Conning the ship from shoreside? (photo from Wikipedia)

e Navigation is, according to the Marine Safety Committee of the IMO:

“the harmonised collection, integration, exchange, presentation and analysis of maritime information onboard and ashore by electronic means to enhance berth-to-berth navigation and related services, for safety and security at sea and protection of the marine environment”.

At 59-56N - 10 technologies to change shipping - #3 ECDIS Ryan Skinner links ECDIS and e Navigation to integrated operations, -the link is to Wikipedia, the key phrase there is "Splitting the team between land and sea"

At present the process of getting a ship safely into or out of port is a shared responsibility between the bridge navigation team and the pilot while the VTS (Vessel Traffic Service) role is limited (at least in the U.S.) to advising the vessel regarding other maritime traffic. If the VTS had an electronic chart display which included the vessel's planned track line they could take a more active role in reviewing and then monitoring the vessel's progress.

Before entering or leaving port a vessel could be required to electronically create and then transmit a planned track-line. If the shipboard and shoreside displays were synchronized so that during the passage, if the trackline was modified by the pilot or crew, the modifications could be instantly be transmitted and seen by personnel shoreside in real time.

The key to bridge team management is that each team member share the same understanding of the passage plan. The shoreside VTS cannot esily monitor a plan they can not see. These capabilities would likely have prevented incidents such as the Casco Busan or the Exxon Valdez.

K.C.

Human Error at 59-56 N

The site 59-56N has a post Human error = Management #FAIL

"It has always seemed petty and injust when managers, seeking someone to blame for a loss, point their fingers at the personnel at sea. "He should have done such and such,"

- The post makes a good point regarding sharp end / blunt end safety issues.

K.C.

Recovering Enclosed Lifeboats

Most of the complaint about modern ship's lifeboats focuses upon the dangerous on-load release gear. This is the problem that has killed the most mariners. The real problem is that the sole purpose of these boat is to meet SOLAS requirements. It is not safe to use them to train the crew.

I was once part of a crew that routinely launched and recovered boats in rough seas.

Recovering this style boat -

Open Lifeboat USCG Photo found at An Unofficial Coast Guard Blog

The Coast Guard Motor Whale boat crew consist of a coxswain, forward hook up and aft hook-up (usually the boat engineer)

With this ship.

USCGC Gallatin This set up makes use of frapping lines rigged from the main deck just below the boat to dampen the motion of the boat when the ship rolls.

Is not the same thing as recovering this lifeboat

Fully enclosed Lifeboat

The forward hook-up crew member has to stick his head out the opening in the bow while the mate is attempting to maneuver while looking out the window in the aft steering station.

With this ship.

PCC in New York Harbor photo from Towmasters

Here it is about 90 feet from the head of the davits to the sea.

With a little luck a trained and experienced crew can do it safely when it's flat calm - but the there is no requirement that mariners being issued lifeboatmen certificaton be trained on this type of boat.

One trick during recovery that might avoid the problem of improperly locked release gear is once the boat is hooked up don't bring it back aboard as was done here (gcaptain vid). Instead once the boat has been hoisted a meter or so above the sea, stop and have the crew check that the release is locked properly. The boat crew will have to be shown this beforehand. This check can not easily be done while the boat is pitching in a sea and the gear is crashing into the top of the boat with each passing wave.

This doesn't solve the problem of getting the boat hooked up in the first place with out smashing fingers, or heads. It is difficult for the boat crew inside to communicate with each other and the ship must use hand held radios, it's too far to communicate by voice.

From comments Babu links to this video from an outfit called Nadiro of an much improved system It uses what they call a drop in ball system. Notice the the opening for the forward hook-up crew is in the top of the boat not the front.

My guess is the price they want for that system means most mariners will never see one.

K.C.

Lifeboats and Car Ships - unsafe at any height.

The lifeboats of two (sister) car ships can be seen in this photo (photo by K.C.)

gcaptain has posted a video of a lifeboat accident. It looks to me like the releasing gear may not have been fully locked. Here good article about this problem The Lifeboat Imbroglio by Captain Paul Drouin. (PDF) From that article:

The OCIMF survey also showed a general lack of confidence by seafarers in the hook/release gear.

Lack of confidence, that's one way to put it.

The article confirms what I have often suspected, since 1990 lifeboats have killed more mariners then they have saved.

This problem has been know for several years, from the article again:

Finally, what can be said about the lamentable time lag of the imbroglio? As early as 1994, the OCIMF survey into lifeboat accidents was right on the mark. Yet here we are, 14 years later and more than 20 years after serious accidents began to occur with lifeboats still grappling with the same issues.

On a car ship the problem is not launching it's recovery, try hooking up a boat with 90 feet of wire hanging from the davits. Imagine if the ship was rolling.

It seems to me the purpose of the lifeboats on a car ship is to meet SOLAS requirements, nothing more. The trick is to meet the requirements for drills without incident.

K.C.

Rules for Vessel in Fog. Out of Date?

What is a safe speed in restricted visibility?

According to this site - MCA orals the answer is:

(a) A speed that you can stop in half the visible distance you can see, so you can maneuver out of danger in the other half (if the visibility is zero, then minimum speed that you can keep your course.

That's what is known as the half-distance rule. Even my outdated edition of Farwell's acknowledges this rule is out of date. According to my sixth edition (1985) recent court rulings have allowed higher speeds but "not more then a knot or two"

However this article, Safe Speed in a Fog; Ancient Rules in a Modern Age (PDF) says what most mariners know to be true:

We all know that hardly any master will reduce speed in bad visibility nowadays. Instead radars and other electronic equipment are relied upon

and

We have experienced a tremendous technological development during the past 30 – 40 years while the rules have been static, in fact the present rules on speed in restricted visibility are based on the 1897 rules. And they do not recognise radars as a reliable instrument. This is in contradiction to how radars are viewed in other industries i.e. aviation and military and indeed to actual practise by the maritime community as well.

Why are mariners faced with this dilemma, that normal practices would be found in violation of the rules in the event of an incident?

The article argues that the rules need to be updated and quotes from Charles Perrow's Normal Accidents:

The navigation rules have developed to aid the courts in finding fault rather than aiding the ships in avoiding accidents

The author, Tor Lund, argues that:

Instead of taking any proactive efforts, administrations seems to be reactive; merely sending out occasional “notices” telling mariners to strictly follow the rules although they know that these notices will not be followed. This behaviour is contrary to what can be seen in other modes of transportation i.e. road, rail and air where authorities as well as other interested parties are proactive in order to constantly improve their systems and rules.

I agree, my derriere is hanging out too far already, time for an update taking into account such things as radar, AIS, VHF and VTS and other modern aids.

K.C.

AIS and the Nautical Rules of the Road

Photo by Ulf Larsen, on the bridge of the Norwegian coastal vessel MF Bastø II. (found on Wikipedia)

At the Navigation Electronic site PANBO, in the comment threat of this post Class B rollout, looking better, but mysterious the question came up: How is AIS (Automatic Identification System) being integrated into the Nautical rules of the road.

I think both rule 5 and 7 apply.


Rule 5 of the nautical rules of the road reads as follows:

Every vessel shall at all times maintain a proper lookout by sight and hearing as well as by all available means appropriate in the prevailing circumstances and conditions so as to make a full appraisal of the situation and of the risk of collision.

From Handbook of the Nautial Rules of the Road" Llana & Wisneskey"

Fortunately, mechanical means for maintaining a lookout are available. "Available" to Rule 5 means "shall be used" in appropriate circumstances. Some of these "other means" are listed below:

• Binoculars
• Radar
• VHF bridge-to-bridge radiotelephone
• Automated radar plotting aids (sometimes called collision avoidance radar)
• Differential GPS (DGPS) satellite navigation equipment
• Automatic Identification Systems (AIS) radio transponders
• Vessel traffic services
• Navigation and piloting instruments

Rule 7 is

Every vessel shall use all available means appropriate to the prevailing circumstances and conditions to determine if risk of collision exists. If there is any doubt, such risk shall be deemed to exist.

The same argument used in rule 5 hold true in rule 7, AIS is a tool that can be used to determine if risk of collision exists.

An important point here is both rules begin the same way: "Every vessel"

K.C.

F/V Dictator Incident a case for receive-only AIS?

Rudder damage to Southwest Harbor scalloper Dictator. Laurie Schrieber photo
On some ships if you walk onto the bridge at near the end of the watch there is a good chance you will find the mate bent over the chart table writing up his log while the lookout is busy making a pot of coffee. Not my ship of course, but the point is this: don't bet your life upon the fact that a big ship doing 20+ knots is keeping a good lookout.

Consider the story of the fishing vessel Dictator which was fishing for scallops with about 50 other boats in heavy rain and fog, visibility of only about a half-mile The story is here from Fishermans Voice Container Ship Hits Fishing Boat by Laurie Schreiber

The wheelhouse watch never saw the ship coming until it was almost on top of them:

All I saw was this great, big, huge ship going down the side of us,” he said. “Water was coming over the stern from his wake, and he squirted us out from under his bow.”

I don't know what was happening on the bridge of the container ship, the watch might not have been paying attention or they may have lost the return from the Dictator in the sea clutter, or it might have been time to put on a fresh pot of coffee. Either way the crew of the Dictator was placing their lives in the hands of the watch aboard another vessel.

AIS (Automatic Identification System) may have prevented this incident. Had the Dictator been transmitting an AIS signal it may have been seen aboard the container ship. That solution however still relies upon the vigilance of another vessel. One possible solution might be a receive only AIS. The devices are inexpensive, there is a good article at Boating SF - Get AIS Ship Tracking on your boat.

Don't bet that yours is the only vessel not keeping a proper lookout.

K.C.

Risk Assessment Checklists

Risk Ready Reckoner from Bob Couttie's Marine Accident Casebook

The Document above can be downloaded as a DOC file here -Bob Couttie has it as a PDF at his site (next link)

Update below:

Getting mariners to use yet another check list can be a tough sell. The Risk Ready Reckoner recommended by Bob Couttie however could literally be a life saver.

From Bob Coutie's Marine Accident Casebook:

Just because there are safety procedures in your ship’s safety management system and various bits of bumf aboard doesn’t mean that you can’t develop your own safety system, one that belongs to you and which you use. Say hello to the Risk Ready Reckoner.

Bob also has an example of a hidden risk at Engineer Scalded - Risk not Mapped. The risk in this case was a pipe to an open tank that was plugged and unexpectedly filled with steam. It would have been difficult to uncover the risk in this case with a simple risk checklist, perhaps only previous experience would have uncovered this hidden threat.

There are some more sophisticated risk assessment tools available at this site: Step Change in Safety - A UK gas and oil site. This site includes the Task Risk Assessment Check list which is considerable longer then but more comprehensive then the Risk Ready Reckoner. The Task Risk Assessment Guide also at that site, is even more involved but I think it would be worthwhile going over with the senior officers. It might increase appreciation for risk assessment.

A captain I once sailed with had a term for mariners who felt they were too good to use checklist but often used unsafe practices. He would say that they were "so good they're brain dead".

K.C.


UPDATE:

In comments, Bob Couttie has pointed out that the Risk Ready Reckoner is aimed at all crew members, not just senior staff I had missed this and is an important point. From the Marine Accident Case Book. Read Make 2009 a Year of Safety Ownership

2009 should be SOS Year: Seafarer Ownership of Safety Year, a year in which active and positive efforts are made to give seafarers a sense of ownership regarding their own safety, that of their crewmates and their vessel.

Navigation, Visually and by Radar

Photo from Try Looking out the Window at Casco Bay Boater Blog
Look out the window. That's my message to new third mates. More then that, gain experience in the interpretation of what you are seeing.

I honestly don't understand why almost all new third mates have such a strong preference for using the radar when the situation can be more easily understood visually.


In aviation new pilots must first learn to fly a plane using visual flight rules and then later gaining an instrument rating. New mates on the other hand seem bound and determined to navigate entirely by instruments. My message to them is the same one I gave the mate that night in Alaska - Look out the [expletive deleted] window.

K.C.

Figaro - Inadvertent Release of CO 2

Car ship Figaro

This story is not new, but is very interesting : Read the excellent summary at the Monitor Not your average comedy. The vessel had to be taken into tow.

A LARGE car carrier was disabled by an inadvertent release of the ship’s fire-extinguishing equipment and was nearly wrecked on the Wolf Rock in the English Channel, a Marine Accident Investigation Branch report has concluded.

This is an interesting story for several reasons. CO2 was released into the cargo holds and engine room during the working day. This turned out to be a difficult emergency that does not fit into common emergency drill scenarios. Another interesting thing was the root cause was that procedures used were unclear.

One lesson learned is this: If unclear procedures are discovered during routine maintainance they should be corrected.

K.C.

Time Management - Complying with Regulations

Fellow mariner at Deep Water Writing has put up an interesting post Rules, rules, and more rules. He discussed two beefs: mariners not allowed ashore and new pollution regulations. The first beef has also been discussed at Tim Times - On yer Bike and at Hawspiper

The other topic is the increase in rules and regulations imposed on shipping. Specifically new EPA rules, Deepwater writes:

The National Pollution Discharge Elimination System requires a record to be maintained onboard the vessel tracking all discharges incidental to normal
operations such as; Ballast water (There is allready is a record
keepingand reporting requiremet for ballast), deck washdown, cathodic
protection, reverse osmosis brine, elevator pit effluent and gray
water just to name a few of the 28.

Is there anyone, anywhere considering the cumulative effect of all these regulations on vessel safety? At what point does someone say enough?

In most cases there is sufficient time to comply with all the requirements, enough time can usually be found by cutting into leisure or rest time. But what will be the effect on the ship if the captain more and more frequently locks himself in the room to finish paperwork? What about the conversations with the Chief about fuel that get cut short, or the twenty minutes spend with the mate discussing operations now reduced to 10 minutes. What about those "get acquainted" chats with the third mate to put a new officer at ease.

Lower priority tasks such as reviewing the ship's security plan or improving the ships emergency response based on some problem uncovered at the last drill get pushed aside. If the captain was to reduce the interactions with the crew to the bare minimum that would not be a "show stopper", the ship would continue to operate. But a failure to properly comply with regulations can stop the show. Show stopper usually get first priority.

At some point, all the slack will be taken up and shifting ship's resources from operations to clerical work to insure regulation compliance will begin to impact safety. How will we know when that point is reached?

Cosco Busan coverage - One year later

It has been a year since the Cosco Busun struck the Oakland Bay Bridge. There has been some coverage on line regarding the Cosco Busan. The crew is still be held as material witnesses. - Forbes Article here.

A pilot commissioners' board in San Francisco found that pilot error was a factor in the incident - From Mercury News

The mistakes included allowing the ship to sail in heavy fog, failing to resolve concerns with the ship's radar system and an electronic chart system, and proceeding at an unsafe speed.

Another error, the report said, was failing to take into account communication difficulties with the Chinese crew, who had limited English-speaking abilities.

Robin Storm has a good summary of the incident from the SFGate here.

There have been congressional hearings, and several investigations. A report by the National Transportation Safety Board and the Coast Guard into the cause of the accident is due in January.

gcaptain has three interesting regarding the Cosco Busan, two by pilot Capt John Denham and one by Capt. John Konrad.


Deconstructing The Cosco Busan Incident - More On Accidents And Why - by John Denham

John Denham points out the importance of BRM:

"if the BRM is not functional the vessel is not seaworthy”

The Cosco Busan - A Failure in xx"x Resource Management - by Captain John Konrad

John points out both the pilot and the capt made errors but in addition points to the individual who authorized changing the entire crew of the vessel.

John Cota made two crucial errors; a willingness to proceed (even rush) under adverse conditions and refusal to fully utilize resources available to him, namely electronic charting systems. Captain Sun also made two critical mistakes; acceptance of the position and willingness to proceed on the day of the incident. The high level of proficiency and low incident rate of our nations pilots helps to explain Cota’s decision and Captain Sun’s trust of his decision to proceed that morning but does not explain either’s willingness to proceed knowing one important fact; the entire vessel crew was replaced just two weeks prior.

Feedback - A failure in XXX Resource Management - by John Denham

A vessel found undermanned, crewed with unqualified persons or lacking operational proficiency is unseaworthy and local authority, as a matter of public policy, should be responsible to detain it.

It will be interesting to see the NTSB and US Coast Guard report in particular the role of fatigue with regards to the ship's crew


K.C.

Shipboard Manning and Workload

In the Wheel house arriving in Singapore

Fellow mariner blogging at Deep Water Writing asks

"Why can't the very regulators who mandate safe manning levels for vessel operators increase the amount of crew to share the workload on board?"

The manning/workload equation has two sides. Along with manning the workload side should be looked at as well.

Take cargo operations aboard container ships for example. Why does a crew member, the chief mate have to be responsible to see that the containers are properly stowed, or the refers are plugged in? Why can't this responsibility be shifted shore side? In the aviation side you don't see the co-pilot supervising the stowage of baggage or any of the air-crew fueling the aircraft.

Or consider a ship approaching port, the captain is at the conn, the mate on watch has his hands full navigating, monitoring traffic and handling communications. Port control calls on VHF and requests the ETA, ship's name, position, length, beam, gross tonnage, net tonnage, IMO number, last port, next port, amount of cargo on board and so on.

Responding to this request requires the full attention of the mate for several moments while at the same time the bridge team is experiencing its highest workload. Is this the best use of time and attention of the bridge team as the ship approaches the coast?

The ship would be safer if the mate's time and attention was being used to monitor the vessels position and traffic. An additional mate could be called out but why? Why is it necessary to relay this information by voice radio? Couldn't this information be exchanged in some other way? Can you imagine this taking place in an aircraft cockpit as the plane was descending towards the runway? Of course not, passengers expect air-crews to focus exclusively on flying the aircraft.

The time and attention of the ship's crew is a limited resource. While a close look should be made of crew size we should also ask what work can be shifted ashore and how demands placed on ship's crew can be minimized.

Risk in Ship Assist work

Two tugs and a ship on the river Schelde made up "Europe Style"
From the post Death on the River Clyde: a tug is tripped and three men are lost in Scotland, from the site Master of Towing Vessels Association Forum:

"I would seriously question the wisdom of ever being out in front of a ship at all in conditions like that unless it was an actual dead-ship tow."

- read it if you do ship assist work.

I have limited experience with ship assist work but I have though that the way tugs make up in Europe, made upfore and aft on the center line, is in some cases more risky then the method used in the U.S and Japan, made up on the side.

Sometimes it can not be avoided as in the case of passing though a narrow bridge as in Rotterdam (my post below).

I would like know what other pilots and tug masters have to say on this subject.

K.C.

Pasha Bulker Grounding Report Released.

Bob Couttie has the story on the release of the report of the grounding of the Pasha Bulker and, big surprise, the master is to blame.There were 57 bulkers at anchor that day as the storm approached. Evidently the assumption on the part of shore side authorities is that each of these ships is commanded by a captain who is a well rested, experienced seaman, with superior judgment, unclouded by commercial pressure with absolutely no concerns, except the one that, in hindsight, is going to prove his and his ship's undoing.
The article points out that the anchorage was unsafe in bad weather condition.

Newcastle anchorage is suitable only in good weather and nautical publications contain warnings about the local weather conditions and recommend that masters put to sea before conditions become severe.

The master got just three hours of sleep the night before the incident, the question is what was he doing sleeping for three hours when he clearly should have been studying his nautical publications?

According to the report

"Newcastle Vessel Traffic Information Centres advisory role “was not properly understood by the masters of a number of the ships in the Newcastle anchorage on 7 June 2007″ says the ATSB."

Also this...

"Newcastle Vessel Traffic Information Centre asked the masters of three ships, including Pasha Bulker, to leave the restricted area off the ports entrance. Given that all three ships were struggling to clear the coast and that there was no need to keep the area clear because there was no traffic into or out of the port, these communications were of no benefit and unnecessary, and may also have adversely influenced the decisions of masters, including Pasha Bulker’s."

So, the captain of a 225 meter, 77,000 DWT bulker is clawing his way off the lee shore in 40 kt winds and 10 meter seas. At this point the Traffic Information Center calls and informs him that his ship has entered a restricted area. In hindsight, what the master should have done is to check his inbox to see is there a memo or circular informing him that regulations concerning the use of crude, obscene and vulgar language on the VHF will be waived in these circumstances. Because he should have told them to go fly a kite, but put in a more 'colorful" manner.

Electronic charts may prevent groundings

How could you not love a site called "The Art of Dredging"?

From that site, this is worth a read: Electronic charts may prevent one in three groundings.

"If Electronic Chart Display and Information Systems (ECDIS) are made mandatory on board ships, the number of groundings is likely to be reduced by a third according to a study carried out by Det Norske Veritas, a Scandinavian classification society."

I found site The Art of Dredging from the "recent remarks" at Bob Couttie's Marine Accident Casebook.