Don't underestimate UV light.

                             Ultra violet light caused eye injury

Whilst changing the ultra violet (UV) lamp in the ship’s fresh water steriliser unit, a crewmember inadvertently switched on the UV light and stared directly into it. Later on in the day, he experienced irritation, redness, pain and temporary blindness in the eye. He was given first aid on board and subsequently was sent ashore for treatment.

Result of Investigation1 The crewmember was not wearing appropriate personal protective equipment (PPE), such as the shaded UVEX glasses which were available on board and would have filtered the UV light;
2 The crewmember did not read the warning notice posted at the site, which outlined the hazards of UV light.

Root cause /contributory factorsNon-compliance with procedures:
1 No risk assessment was carried out to understand the hazards related to the task;
2 Lack of compliance with the company PPE matrix.

No excuses for hydraullic system. Pay attention to reopen the valves which was closed.

                         Injury from burst hydraulic valve  

On a cargo vessel in drydock, the crew was testing the operation of an electro-hydraulic mooring winch after completion of repairs. The team, led by the C/E, and comprising of the 3/E, J/E and an OS, entered the hydraulic machinery room and started the main pump motor. Without warning, the return line gate valve before the filter disintegrated and the detached bonnet flew through the air, hitting the J/E on his face and fracturing his skull and nose. He was immediately hospitalised ashore. Very fortunately, he narrowly escaped more serious injury that could have resulted in permanent damage to the eyes and brain and was able to recover fully from this accident.

Result of investigationDuring an earlier trial, it was noticed that one of the valve flanges next to the filter was leaking. After isolating the line, the crew renewed the gasket, and then opened the valve before the filter, but forgot to open the one after the filter. When the pump was subsequently started, the sudden build up of high pressure on the upstream side of the valve resulted in its violent disintegration.




Lessons learnt1 It is extremely important that, before commissioning hydraulic systems, all line valves are verified to be fully open and the system is thoroughly purged of air and primed with the correct quantity/type/grade of hydraulic fluid;
2 Return lines are not designed to take high pressure in most hydraulic systems.

Corrective/preventative actions1 The second valve (after the filter) was considered redundant. It was removed and replaced with a spool piece, reducing the risk of the inadvertent closure of the return line;
2 A sign was permanently installed next to the hydraulic pump motor starting switch warning personnel to ‘Ensure all return line valves are fully open’.

Take care electrical epuipments when U are to work with water.

                                      Fire on electrical transformer

The C/E, fitter and oiler were engaged in the routine maintenance of the common cooling water system of the ship’s refrigeration plant and air conditioning plants. While they were opening up the condenser cooling water line, due to a leaking line valve, a large quantity of water spurted out and fell on the main power transformer located directly below. A fire started around the transformer and there was an immediate blackout. The crew put out the fire by using a portable CO₂ extinguisher.
Root cause/contributory factors1 System failure: company procedures did not contain specific instructions on carrying out work on refrigeration and heating, ventilation and air-conditioning (HVAC) systems;
2 Defective equipment: section valve in the cooling water line was leaking in shut position;
3 Inadequate risk assessment: cooling water line should have been blanked and drained before disconnecting;
4 Inadequate work planning; electrical equipment directly below work site was not protected against likely discharge of water.
Corrective/preventative actions (post-incident)1 Defective valve in cooling water line was replaced;
2 QHSE safety bulletin on the incident issued to the fleet;
3 New SMS procedure and risk assessment checklist created with guidelines on cleaning and maintenance of cooling water systems.

 

How to take pressure test to Fresh Water Generator safely When It was suspected in leakage.

Minor repairs had just been completed on the shell plate of the fresh water generator (evaporator) by a shore workshop while in port. As an original spare was not available, the damaged sight glass was substituted with a disc cut from a 5 mm thick acrylic sheet.
Upon restarting the plant after sailing, it was observed that the drum chamber was not developing sufficient vacuum. The ship’s engineers decided to carry out a pressure test of the casing to locate any leaks. Without considering the hazards, the crew introduced compressed air into the vessel and raised the internal pressure to about 3 bar. Suddenly, the acrylic sight glass shattered, injuring the electrical officer, who was applying soap solution to the shell’s exterior.
Lessons learnt1 It is very unsafe to subject vessels, tanks or containers to uncontrolled pneumatic pressure for testing purposes as there is great risk of permanent deformation or violent rupture;
2 A controlled hydrostatic test i.e. filling up the container with water to a permissible head (preferably under Class supervision) is the most appropriate and safe method for leak testing on board;
3 When a pneumatic test is considered the only practicable method, compressed air must be admitted through a suitable reducing arrangement and pressure must be closely monitored by a manometer/water column gauge, ensuring safe limits are never exceeded;
4 Fresh water generators should ideally be tested by creating an internal vacuum and applying a liquid dye externally on suspected areas.

Thermal Oil boiler explosion because of bent needle valve and using D.O

                          Crew injuries from oil heater explosion

Over a period of two days at anchor, one of the two vertical thermal oil heaters of a product tanker was observed to be not firing reliably. The crew opened and cleaned the burner unit and also adjusted the igniter electrodes twice, but after the second attempt, the heater refused to fire. On the third day, the C/E discussed the remedial action plan with the crew. They opened up the burner unit and cleaned the burner lance and igniter electrodes again. This time, the heater operated for about 90 minutes (eight firing cycles), after which it again failed to ignite. Resuming work after lunch, the electrician re-inspected electrical systems while the 3/E and cadet dismantled and cleaned the burner lance and nozzle unit, reassembled it under the C/E’s supervision and refitted it to the heater one more time.

When the test firing commenced, the 3/E, cadet and electrician positioned themselves on the top of the heater to monitor the automatic starting and firing sequence. The forced-draught fan went through a four-minute purge programme, but when the igniter sparked, there was a violent explosion.
The explosion lifted the thermal oil heater casing top, snapping most of the securing bolts. The burner arrangement was pushed out of alignment and the inspection cover was torn from its securing bolts. The ducting from the externally mounted forced-draught fan was torn apart at the flexible insert. Fuel lines running across the top of the thermal heater were deformed, and at least one began to leak from a weakened joint. The explosion triggered the engine room fire detection system, initiating a fire alarm on the panel at the fire control station, and also activated the local automatic water mist system. The three persons on top of the heater suffered burns over large portions of their bodies as the flame front engulfed them momentarily, but they were able to walk from the area to the accommodation. They were assisted by the mustered crew, who removed the remnants of the burnt coveralls and ill-advisedly pierced and drained (lanced) the blisters before placing dressings on the burns. The injured persons were also given painkillers and water to drink but remained seated in a cabin despite being in severe pain and trauma.

About half an hour after the explosion, the Master reported the incident to the port control and his local agents and requested medical assistance. Unfortunately, his request for helicopter evacuation (medevac) was initially denied due to the mistaken assumption ashore that helicopter operations over a tanker that had just suffered an explosion would be hazardous. Subsequent miscommunication between the response teams on shore added to this delay.

Paramedics boarded by launch about an hour after the accident and after rendering further medical treatment, they insisted on immediate evacuation of the casualties by helicopter. Eventually, after another hour, the men were winched off and conveyed to a shore hospital.

Result of investigation
1 The burner nozzle had been incorrectly assembled, probably during the several investigation and repair attempts. As a result, the needle valve stem became bent and due to an improper seal, the circulating fuel continued to spray into the furnace during the pre-ignition start sequence;
2 The crew, except the C/E, had very limited experience in servicing this equipment;
3 The manufacturer’s manual was poorly written, and lacked a clear drawing of the burner, details of spare parts, instructions for troubleshooting, servicing, inspection or testing;
4 In order to reduce maintenance costs, at some time prior to the incident, the company had approved a change of fuel from heavy fuel oil (HFO) to marine gas oil (MGO) for the heater, but the crew failed to make the necessary changes to the fuel pre-heating circuit and the auto-start programme;
5 Excessive diesel fuel entered the furnace which was probably at about the operating temperature (about 160 °C), and instantly vaporised (flash point ≈ 68 °C) and formed an explosive mixture with the charge air;
6 The crew failed to refer to the proper sources for advice on the treatment of burn injuries, resulting in the casualties being given inappropriate first aid (especially the deliberate puncturing of blisters);
7 The port’s contingency plan for responding to a vessel casualty and medical emergency in the anchorage lacked detailed documentation that would have ensured reliable information exchange among the concerned parties.

Corrective/preventative actions1 The ship’s operator renewed the burner units for both oil-fired heaters and altered the control system to better suit the fuel being used and the load demands placed on the heaters;
2 The heater’s makers reviewed and amended relevant sections of the equipment’s service manual and relayed the incident details to ancillary equipment suppliers, including the burner equipment manufacturer;
3 The port reviewed the emergency contingency plan and implemented revised procedures, including training, drills and exercises for its staff.

Lessons learnt1 Ship’s crew must remain vigilant to safety even when conducting repeated or seemingly simple tasks;
2 Manufacturers must provide comprehensive and accurate documentation for onboard service and maintenance and the crew must follow these along with the more generic procedures given in a ship’s SMS;
3 Manufacturers should conduct research and implement engineering solutions to resolve potential design weaknesses that may lead to failure or hazardous conditions in service;
4 It is desirable that critical items of equipment are serviced by specialist shore-based technicians, but if this is impracticable, ships’ crews must be given appropriate training arranged by the makers or suppliers of such equipment;
5 In case of illness or injury on board, ships’ crews must first refer to the approved publications carried onboard, if required, supplemented by correct radio medical advice obtained from shore. They must be capable of providing immediate and appropriate first aid. Burn injuries should always be immediately cooled, under clean, cold running water, for at least 10 minutes.



 

Don't believe dockyard man. They can make U headache.

                               One Experience with shore repair

In our ship, M/E no. 3 unit coincide with PMS and Framo pump is also time to take maintenance. We requested for office we will overhauled M/E no.3 and because of insufficient time please send shore repair for Framo Pump. On the contrary, Office manage to overhauled M/E instead of Framo pump by shore repair company. In a nutshell, After overhauling M/E , the ship depart from Singapore to Korea. In pilotage way, there was no problem with M/E and everything was OK. After pilot away, M/E was to run in full away and we start increase speed gradually. In this M/E, MCR is 140 rpm . There was no problem until 120 rpm. But, when RPM is near 140, very loudly knocking sound is coming up in overhauled unit. Chief Engineer and First Engineer got head ache and thought probability and maintain M/E with 120 rpm and keep on sailing. In next port, we find fault and checked for hydraulic line for Exhaust valve, fuel pump and fuel system and mechanically looses. But we can not solve that problem till another port and finally, we notice that when we changed Exhaust valve, one" O" was lost in high pressure pipe for exhaust valve. We fitted with new spare " O" ring and problem is game over.

    Just one 'O" ring which they did not pay attention.



Fuel leakage from main engine fuel pump

A product tanker was proceeding on a long voyage after the completion of drydocking and associated surveys. During the ocean passage, the fire alarm suddenly activated in the engine room. Instead of a fire, the cause of the alarm turned out to be a large leakage of fuel oil from a flange on the inlet pipe of the main engine no. 4 fuel injection pump.

Result of investigation1 The fuel system had been overhauled, but no senior ship’s engineer supervised its refitting in drydock. As they did not have a new spare, the yard workers had reused the gasket of the flange connection on the suction side of the fuel injection pump even though it was damaged;
2 The insulation and leakage containment cover over the fuel line had not been renewed/refitted.
Lessons learnt1 Proper planning is necessary in drydock and during major repairs to ensure that responsible officers are delegated to supervise the refitting of critical components;
2 The condition, integrity and tightness of piping should be regularly checked, especially on critical equipment and fuel oil systems;
3 The vessel must ensure that adequate quantities of original spare parts are available at all times, and that all gaskets are renewed whenever pipelines are opened up and reconnected;
4 Wherever appropriate, lagging and containment covering must always be refitted, or renewed, if damaged;
5 All defective parts discovered after an incident must be carefully preserved to allow detailed investigations and to establish the underlying cause(s) so that effective corrective and preventative actions can be taken.

Hydraulic oil leak starts fire in engine room.If oil was sprayed on Exhaust manifold in anyhow, take a watch or make corrective action.

Hydraulic oil leak starts fire in engine room

On a tanker on passage, the fire alarm suddenly sounded. At the same time, the engine room crew saw small flames and smoke rising from the after exhaust manifold and cylinder heads of the running main engine. After extinguishing the localised fire, it was discovered that hydraulic oil from the cargo pump system had leaked from a flange connection in the vent/overflow line situated directly above the main engine cylinder head platform.

Result of investigation1 At the previous discharge port, a submerged cargo pump hydraulic motor had malfunctioned. In preparation for carrying out repairs, an engineer had closed the vent-cum-overflow line valve located before the service/header tank without draining the line;
2 Due to the residual pressure in the line, the flange connection (later found to have loose fasteners) leaked and a fine spray of hydraulic oil began falling on the hot surfaces on the top of the exhaust manifold and ignited after attaining self-ignition temperature.

Root cause/contributory factors1 Inadequate work planning – line was not depressurised/drained before closing of valve before header tank;
2 Inadequate management of change – the hydraulic piping had been modified some years ago to tap off a new branch line before the header tank leading to an offline oil filtering system. A stop valve was fitted before the branch without properly assessing risks;
3 Inadequate communication – the engineer who closed the valve failed to inform other members of this fact.

Corrective/preventative actions1 Ship’s staff removed the stop valve from the vent line, and the piping was re-modified to ensure that the offline filtration circuit was independent of the vent/overflow line;
2 All joints in the hydraulic system lines were inspected for proper condition and tightness;
3 Sister vessels fitted with the same filtration plant were advised to check the lines to ensure that the overflow line could not be inadvertently shut. All vessels were instructed to thoroughly inspect all nuts and bolts on flange joints and tighten them.





Comment: I don't understand about hydraulic system in this system. Anyway, If U touch the hydraullich system, first priority to think is how to release line pressure and to understand the system and follow the drawing.

Battery is a bomb if it was charged in excess current.

Battery damage caused by charger failure

 A ship’s engineer was carrying out planned maintenance of the emergency generator. When he started the generator, he heard a loud bang from the battery container. On investigating, he discovered that one of the starter batteries had exploded, with the top of the battery detaching from the body. The battery was safely removed and the engine was temporarily left in the manual starting mode.

On investigation, it was discovered that for an unknown period of time, the vessel’s emergency generator battery charging system was wrongly set up in such a way that two chargers could be charging the battery simultaneously. This resulted in excess evaporation of the water content in the electrolyte, substantially lowering the liquid level and exposing the plates. It is thought that internal arcing occurred across an air gap, triggering an explosion.

Lessons learnt1 All charging systems should be checked to ensure that the charging current cannot exceed the specified safe range;
2 All battery containers / receptacles should be checked for tightness of fixtures and overall integrity as part of planned maintenance.

Wrong installation of Limit switch which operates ventillation system was shared for intending for officers.

Pressure switch location for fire suppression systems

Source USCG Marine Safety Alert 05-12This safety alert addresses the location of fire suppression system pressure switches aboard vessels.

These critical components sense the activation of the system and then electrically secure the ventilation systems operating in the protected space. Securing the ventilation is essential in extinguishing a fire onboard a vessel. It assists in isolating the fire within the space, minimises the introduction of additional oxygen to fuel the fire and prevents the loss of fire suppression agents from the space.

Recently, a vessel with an installed fixed CO₂ fire suppression system suffered extensive damage due to a fire that started in the engine room. During the firefighting efforts, the crew reported that the engine room ventilation could not be secured. A post-casualty damage survey of the vessel revealed that the pressure switch used to secure the ventilation was located within the engine room [see photographs of the damaged pressure switch and new switch.]

The Coast Guard strongly reminds owners and operators of vessels with installed fixed fire suppression systems to ensure that these switches are properly located aboard their vessels. If the pressure switch or switches are located within the space being protected, they should be relocated by a properly trained fire suppression service technician. Doing so will assist in ensuring system functionality and accessibility in the event of an emergency. Failing to do so could have serious
consequences to the vessel, its crew and the environment.

For the full safety alert go to http://www.uscg.mil/hq/cg5/TVNCOE/Documents/SafetyAlerts/PressureSwitch.pdf

Don't open the door after releasing CO2 within 24 or 48 hour although noticeably reduction in heat and smoke.

                    Premature reopening of fire area causes re-ignition
While underway a towing vessel with six crewmembers on board experienced an engine room fire. The chief engineer was in the engine room when the fire broke out. The only exit was an accommodation ladder which was in the path of the oil spray fire. The chief engineer exited through the fire, which ignited his clothing. The other crewmembers, who had also been alerted to the fire, discovered the chief engineer and extinguished the flames on his clothing. Nonetheless, the chief engineer suffered burns on more than 90 percent of his body.

As a first response, the crew released CO₂ from the vessel’s fire suppression system into the engine room and extinguished the fire. After observing a noticeable reduction in heat and smoke, the Master reported that the fire was extinguished and crewmembers opened the doors to the vessel’s superstructure and began de-smoking it. However, this action compromised the fire boundary by allowing CO₂ to escape and fresh air to enter the interior of the vessel, which caused the fire to reflash and rage out of control, consuming most of the tug’s superstructure. The crew had to abandon ship and were later rescued by SAR resources.

The vessel’s chief engineer was fatally injured, and the five remaining crewmembers suffered minor injuries.

Findings of the report* The engine room fire was probably caused by the ignition of lubricating oil that sprayed from a fatigue-fractured fitting on one of the main engine’s pre-lubrication oil pumps onto the hot surface of the main engine’s exhaust manifold.
* Contributing to the extent of the fire damage was the crewmembers’ compromise of the fire boundaries when they prematurely began de-smoking the vessel’s superstructure.
* The inability to completely secure the engine room’s fire boundaries also exacerbated the consequences of the fire.
* The abundance of flammable material throughout the vessel was also a contributing factor to the severity of the fire.

Editor’s Note: This is but one example of how the premature opening up of a fire scene can be disastrous. In my past activities as an accident investigator I have come across this same phenomenon on several occasions, especially for fires in the cargo hold. Essentially, once the fire area has been closed down and CO₂ released, there is usually no overriding reason to open up until absolutely certain that all sources of heat have been eliminated. This can take time; up to 24 or even 48 hours. Another tip – if at all possible, do not open up until additional help can be mustered such as SAR resources or port facilities.

Never try to rescue someone without fully protecting yourself.

    Extra two men were dead by lack of knowledge.
A cargo ship was to discharge a cargo of copper sulphide concentrate and hatch covers of cargo holds No. 1 and No. 3 were opened to that end. Before discharge operations began, the stevedores had a safety meeting and discussed the unloading procedure. It was to be as follows:
1 Foreman has crew of the ship open hatch covers.
2 Foreman measures oxygen concentration in the holds.
3 Foreman opens entrance hatches of holds to be discharged and closes other hatches.
4 Foreman sets notice boards on entrance hatch.
5 The ship’s crane hoists the backhoe and carries it into hold.
6 Backhoe gathers cargo (copper concentrates) in the centre of hold.
7 Grab bucket of the on-shore crane grabs cargo and drops it into hopper.
8 Discharge the remaining cargo that the grab bucket cannot grab and collect using scoops and brooms.

Oxygen content was apparently measured at various points in both holds and found to be normal (20.9%). The driver of the backhoe for hold No. 3 entered the hold via an access hatch and went down a straight ladder (about 2.5m length), across a landing, and another slanting ladder (about 4m vertical). When he moved to the second landing, he fell feet-first, landed on his behind, and remained motionless. The crane operator who witnessed the fall put the backhoe down on the cargo pile and raised the alarm. He then got off the crane and ran to the entrance hatch of cargo hold No. 3.

Two stevedores entered the cargo hold through the entrance hatch leaving the self-contained breathing apparatus (SCBA) on the upper deck.



Because they entered the cargo hold without SCBA, another stevedore followed them to prevent them from going down. When the third man had climbed halfway down the slanting ladder he felt breathless and one of the men in the hold signalled him to go back. He exited the hold, as did the man that signalled, but the third man had collapsed.

While the two men that had just exited the hold were catching their breath, crew of the ship provided them with gas masks. The canister attached to the gas mask indicated ‘Inorganic gases and vapours’. One stevedore, equipped with a gas mask and carrying the SCBA, headed for the hatch of cargo hold No. 3. The chief officer advised the stevedores that they should use the SCBA gear and that going into the hold with only gas masks is dangerous. Nonetheless, a stevedore equipped with the gas mask and carrying the SCBA on his back entered cargo hold No. 3 through the hatch again. At the time, the other stevedore could not understand the chief officer’s advice (spoken in English). He thought the mask might be an oxygen supply mask and as such, he too went into the hold with only the mask. When he climbed halfway down the slanting ladder he felt breathless and when he arrived at the second landing he felt faint. He turned back to the upper deck and used all his strength to crawl up the ladder. When he arrived near the hatch, the ship’s crew rescued him by pulling him up to upper deck by his arms. The other stevedore began to climb up the final ladder but fell into the hold after climbing one or two rungs. Now there were three casualties in the hold and rescue efforts to remove them would take time – too much time to save them.

The subsequent report found that oxygen in cargo hold No. 3 was consumed by the copper concentrate through oxidation. Some of the other findings of the report related to oxygen testing practices by the stevedore company were as follows:
1 Measurement locations were not standardised and often O₂ concentration at the entrance hatch was not measured.
2 If the measured O₂ concentration was less than 20.9%, measuring continued until it returned to 20.9%, hence it is not strange that all values in the record book were 20.9%.
3 If an entrance permitted notice board was exhibited on entrance hatch, stevedores entered the cargo hold even without permission of the cargo work supervisor.
4 The person measuring the O₂ concentration did not inform the stevedores of the O₂ concentration; the stevedores entered the cargo hold relying on the smell of the cargo and the entrance permitted notice board being displayed.
5 Usually, a stevedore was not very aware of the O₂ concentration, but trusted the smell of the hold and his intuition.

Accident at Incinerator's door

201402 Incinerator door deals a crushing blow

An engineer attempted to open the incinerator door while underway. His thumb was trapped and crushed between the door holder lever and the stopper plate (see photo). He was quickly transferred to the ship’s hospital and first aid was administered. The victim was disembarked and at the hospital a fracture of the thumb was diagnosed and orthopaedic surgery was necessary.





There were no reported difficulties in opening the door, and it is not known why the engineer placed his left hand at the indicated location. The engineer had two prior contracts with the same ship so he was familiar with this incinerator unit. However, the day before the incident there had been an unexpected engine room Unmanned Machinery Space (UMS) suspension. Due to this UMS suspension he had to stand watches in the engine room and as a consequence had inadequate rest for the period leading up to the accident.

Direct causes1 Inappropriate handling of the equipment.
2 Improper decision-making and lack of judgement.
3 Fatigue due to violation of resting hours the previous day without adequate compensatory rest.
Also, it appears the risks involved were not taken into consideration. Since the duties of operating the incinerator were considered ‘routine’, no risk assessment had been done on the task. Therefore, the company also found the following:

Contributing factors4 Inappropriate management of engine staff.
5 Inadequate training and familiarisation.
6 Lack of a risk assessment on the use and handling of the incinerator.

Editor’s note: The company is to be congratulated for such a thorough report. It should be noted that the first two direct causes are in fact probably due to the third factor – fatigue. Fatigue has been said to be the equivalent of working while under the influence of alcohol, as both judgement and reaction time are impaired. In this case, the unexpected UMS suspension meant more work and less rest for the engineer. When unplanned extra work is incurred, mariners are encouraged to make every attempt to recuperate their needed rest hours to avoid unexpected negative consequences.



My comments.......

I don't want to translate above  report in Myanmar. Because Trying to understand in English will motivate you to reach many successful ways which we don't know.

 In Above this case,
One unconscious thing will make U in danger. Fourth Engineer put his hand on stopper in carelessness .

MARS 2013

MARS 2013

201349 Off-centre steering position confuses helm orders

Official Report edited from Canadian Transport Safety Board M11C0001
The vessel was downbound through a restricted waterway at night. At a lock, there was a change of pilots. Information was exchanged between pilots and the Master, among others, that the gyro-compass was 3° high. As the Master exchanged information with the new pilot, he assumed conning and operational control of the vessel.
The vessel’s pilot card showed a schematic of the navigating bridge that portrayed it as symmetrical either side of the centreline of the vessel. None of the documentation on the bridge indicated the important information pertaining to the conning and steering position, which was offset from the centreline. As it was, the steering stand was almost three metres to starboard of the centreline of the vessel. This resulted in a parallax error of approximately 1.6° to starboard if the line of sight is taken from the steering stand. The pilot was apparently aware that the steering stand was offset from the centreline, but had estimated the potential error to be about 0.5°.

Furthermore, the pilot card did not clearly indicate that the vessel was equipped with an articulated flap-type rudder, nor were the Master or other crew members apparently aware of this.
As the vessel cleared the lock the speed over the ground (SOG) was about 4 knots. The pilot then asked the Master to increase the pitch to 20% and requested the helmsman to steer on a heading of 353° gyro (G) to bring the vessel to the south of the channel centreline. This manoeuvre was standard practice to compensate for the flow coming from the regulating channel, starboard of the vessel. A few minutes later the pilot ordered the helmsman to steer on the light in the middle of the bridge span ahead to bring the vessel back towards the centre of the channel. At this time, Traffic Control also informed the bridge team that the bridge pillars immediately either side of the channel were not illuminated.
By this time the Master and the OOW were close to the pilot and observing the manoeuvre as the vessel proceeded at about 5.5 knots SOG. About one minute later the pilot gave the helmsman orders to bring the vessel’s head towards the north pillar of the bridge, which was not illuminated but was visible. Once the vessel was steadied on the pillar, the pilot found the heading to be 349.5°G and ordered the helmsman to steer 349°G (346° True). Since the course of the channel was 348°T, this heading would bring the vessel towards the centre more quickly. The pilot then reduced the pitch to 15%.

Shortly thereafter the pilot observed that the vessel was more to the south than expected, but this was not judged to be abnormal. He then reduced the pitch to 10% for the entry into the narrower part of the channel ahead. As the vessel entered the restricted part of the channel with a SOG of 6.8 knots and a heading of 350°G the helmsman had to apply starboard rudder to keep the vessel on the desired heading (an indication of bank suction astern). Shortly thereafter the vessel’s course took a sudden sheer to port. Immediately, the pilot ordered the rudder hard to starboard and requested that the Master activate the bow thruster. The pilot used the CP propeller lever to produce an engine kick ahead, then set the CP propeller lever at full astern but the vessel continued crossing the channel at a 45° angle.
The vessel’s bow subsequently grounded on the north bank of the channel some 0.75 nautical miles downstream from the lock they had just exited, the stern to the south side of the channel thereby blocking the waterway; vessel traffic was interrupted for approximately 10 hours until the vessel was successfully refloated.

Some of the analysis and findings of the report indicate that:- Neither the offset steering stand from the centreline of the vessel nor specific and detailed information such as parallax error were provided to the pilot.

- On-board documentation did not clearly identify the vessel’s rudder type, nor were the bridge team members aware that the vessel was fitted with an articulated flap rudder.
Editor’s Note: Having a complete and detailed Pilot Card is crucial. Both the offset steering position and resulting parallax error as well as the articulated flap rudder are very important facts that should have been known to everyone involved. Yet, what was not mentioned in the official report was the apparent lack of complete communication between the bridge team, a critical element in good BRM. For example, the helmsman found he had to use more and more starboard helm to keep the required course, an early indication that the stern was experiencing bank suction. This fact should have been communicated to the pilot and Master/OOW instantly, thus giving advance warning of the onset of bank effect. This knowledge would have allowed countermeasures to be initiated before it was too late and the vessel took the sheer across the channel.