Steering Gear : Curing the Root Cause, Not Just the Symptoms….

 

Flag Gangos Collision

On August 12, 2014, the bulk carrier Flag Gangos was downbound on the Mississippi River, outbound for sea with a full load of grain and corn.  During the outbound transit she suffered a steering gear casualty that resulted in her collision/allision with a moored oil tanker, pier and tank barge at IMTT Gretna, Louisiana.  Total damages to all vessels and the oil terminal totaled close to $17.5 million.

Why did this happen?

The short answer was that a hydraulic valve became clogged with debris, preventing it from actuating normally.  The long answer starts almost a year prior, shortly after the vessel was launched in Guangdong, China.  For the first seven months of operation, the “clogged steering system filters” alarm sounded up to 48 times per month.  While the filters were repeatedly checked, cleaned and ultimately upgraded to a larger size in June 2014, little else was done to identify a root cause.

During post-accident investigation, samples of the hydraulic fluid were taken from both the port and starboard steering hydraulic systems.  The analysis of these samples indicated that the oil was at a “critical” level with very high levels of ferrous particles, sand, plastic particles, and dust.

Ultimately, the U.S. National Transportation Safety Board identified two root causes.  The first was a delay in upgrading a steering gear component previously identified by the manufacturer as requiring replacement.  The second was the failure to routinely test the steering gear hydraulic fluid.

As mariners, whether on the deck or engine side of the house, we need to be cognizant of best practices in the industry. If there is a standard procedure, such as sampling lubrication or the determination of a root cause when an alarm or incident occurs, we must ensure the proper procedures are followed. Not delving down to the root cause of why the filters were clogging or indicating clogged on Flag Gangos allowed an unsafe condition to persist. Curing the symptom (much like a medical doctor) does not necessarily cure the real issue.

How could the root cause of these alarms have been determined?

While there are numerous systems out there for determining the root cause(s) of incidents, one of the simplest is the 5-Why method.  To boil it down to the very basics, identify the incident (i.e. alarm sounds for clogged filters) and ask “Why?”  Repeat this process with the answer (or answers) you have generated and by the 5th “Why,” you should have your root cause.

In the case of Flag Gangos, the answer might be because the filter became clogged.  The next step would be to ask, “Why did the filters become clogged?”  The answer in this case could be that either the filters installed were too small for the job or that the hydraulic fluid was contaminated.

Following this causality chain further, we ask, “Why was the hydraulic fluid contaminated?”  Note, we are now at 3-whys and starting to zero in on the real problem.  The answer might be (and entirely hypothesizing now) that the hydraulic fluid had to be removed at some point for maintenance and was stored in dirty drums before being pumped back into the system.

It can be seen that there are multiple answers possible for each level of why.  At the second level, we had two branches.  The first, that the filters were too small and the second that the hydraulic fluid was contaminated.  For whatever the reason, the first branch – that of filters being too small – was followed, with the result that only a symptom of the root cause was cured.

It is crucial that all possible root causes developed by the 5-Why analysis be investigated.  Simply resolving the simplest and most expedient (and sometimes least expensive) possible root cause is usually the most attractive.  Unfortunately, that leaves the actual root cause hanging out there, ready to strike at the most inopportune time – like when you are passing an oil terminal outbound.

Additional Reading and Links

The Maritime Executive – MSC Ship Aground in St. Lawrence Seaway – January 24, 2016

NTSB – Flag Gangos Collision/Allision – August 2014

Swedish Club Monthly Safety Scenario – February 2014 – Steering Gear Failure

Safe Transit Program : A Guide for Preventing Engine and Steering Failures

Marine Insight : 8 Common Problems Found In Steering Gear Systems of Ships

Marine Insight : Procedure of Testing Steering Gears on Ships

Understanding How to Use The 5-Whys for Root Cause Analysis

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Avoiding the Single Point of Failure in BRM

BRIDGE CARTOON

BRM or Bridge Resource Management is much more than a buzzword.  Growing out of the research and successes of Crew Resource Management (CRM) in the aviation industry, leaders in the maritime industry such as Captain Richard Beadon have taken these tenets to new levels of effectiveness.

The American Practical Navigator, better known simply as Bowditch, speaks of BRM as “the study of the resources available to the navigator and the exploitation of them in order to conduct safe and efficient voyages.”  A mouthful for sure, but boiling BRM and CRM down to the basics of risk management and human error management, we can see that one of the main goals is the elimination of the single point of failure, or in this case, error.

Looking at a variety of maritime casualty reports and in particular, the collision report of the tug Fred Bouchard, tug Seafarer and vessel Balsa 37 in 1993, we can see that errors by one person alone on each vessel contributed significantly to the resulting collisions and damages.  While it could be debated whether these errors constituted simple mistakes or were violations of procedures and rules, they were errors that were allowed to propagate.

With the advent of BRM, all crew on the bridge are encouraged, if not outright required, to speak up if they see or perceive an error.  Unfortunately, it was not so in 1993 where on the Balsa 37 in particular, the ship’s officers stood by while the pilotage and navigation were entirely in the hands of the embarked pilot.  It is all too easy for a single person to become distracted from the primary task of navigating the vessel safely from point A to point B.

It is for this reason that the concept of the bridge team developed.  Unfortunately, the practice of BRM is not as easy as the concept.  It takes time and commitment to implement a robust program and create a culture where BRM can be effective.  It takes only one captain speaking harshly to a junior officer when a problem – real or perceived – is identified to effectively shut down that officer from, possibly ever, identifying another problem.

How can we actively encourage all on the bridge that they can speak up when risk is identified?

BRM training in the classroom and simulator is certainly the first step, but cannot be the last.  Actively reiterating, training and practicing the art and science of BRM are the only ways to create that culture that will help eliminate the single point human error.  It is difficult to always be open and accepting of what might be construed as criticism while on the bridge, but in the interests of safety, patience must be exercised.

Whether it is the arrival or departure in port, the transit of a strait such as the Singapore Strait or Straits of Gibraltar, heavy traffic or reduced visibility, the bridge team composition and interaction can make a huge difference.  Any of these situations could be extremely stressful if all the duties (and potential errors) are centered on one person.  With a well trained bridge team, however, navigating these situations can actually become enjoyable.

The video below is from a 2013 meeting of Sail Training International where Andy Chase of Maine Maritime discusses the loss of the SV Bounty with regards to bridge resource management.  While from a far different part of the maritime industry, it raises and discusses many of the issues and ideas pertaining to BRM.  It’s worth the time.

Let’s be safe out there.

Additional Reading and Links

USCG – M/V Balsa 37, TUG Seafarer and T/B Ocean 255, and Tug Capt. Fred Bouchard and T/B No. 155 – August 1993

NTSB – SV Bounty Sinking – October 2012

TraFi Maritime : Co-operation On the Bridge

NI Navigator – October 2014 – Bridge Resource Management

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What If We Drove Cars Like We Drove Ships?

Tbone3

The mini van approaching the intersection to the right of me obviously had the right-of-way.  If nothing else, the red light in front of me ensured that observation, but I was in a bind.  My appointment was in ten minutes and I had to be there.

I picked up the microphone for my driver-to-driver VHF radio and called the other vehicle, “Red mini van approaching Mulholland and Main, this is the SUV to your left.

When they answered, I asked if they would slow down and allow me to cross ahead – my appointment awaited.  They declined, saying that rules were rules and they intended to follow them.  But what of my appointment?

Carefully observing the bearing drift of the approaching mini van (excellent, slightly to the right!), I determined that I could pass ahead without colliding.  A little extra gas to the engine ensured that we passed clear as I roared through the red light.  A miss is as good as a mile, right?

Sounds far-fetched?  Well, just recently I saw this exact scenario play out in a ship simulator in a crossing situation with an experienced senior deck officer in command.  Why is it that we are willing to play fast and loose with the rules of the road on ships weighing tens (if not hundreds!) of thousands of tons, but will comply with them in our personal cars?  Is the risk of being late for a pilot, dock or longshore gang somehow more important than the condition of the vessel, the lives of its crew or the prospect of losing your license and livelihood?

Or is it the ease of communication with the other “driver?”

The bridge-to-bridge VHF radio is an enticing piece of gear as we approach another vessel.  It allows us to ask what the other vessel is going to do – or as is so frequently stated, “What are your intentions?”  It should be assumed that the intent of the other vessel is to follow the collision regulations (COLREGS).  Yet, we so frequently ask those four words.

Those four words on the VHF that are doing three things.  

First, we are taking up precious time.  Time that might be spent taking action, “made in ample time and with due regard to the observance of good seamanship.”  Second, we are introducing the possibility of miscommunication into the situation.  While English is the official language for bridge-to-bridge communications, there are many deck officers standing watches that are not fully conversant in it.  A communication that is either misspoken or misunderstood can lead to vessels taking the incorrect action.  Thirdly and lastly, we are frequently asking another vessel to depart from the rules.  While there are situations that might rightly require a deviation from COLREGS, we must also anticipate these and make the necessary allowances so that we can comply with COLREGS to the best of our ability.  If we cannot follow the rules by course change alone (or at all), there is always the possibility of adjusting speed – if we have planned for it.

There are some good parallels between driving your personal car and “driving” your ship, such as checking your mirrors (looking over your shoulder on the bridge) prior to changing lanes.  Another we should get used to might be actually following the rules of the road, not just trying to do whatever might be expedient in our situation.  Thankfully, we are are unable to take some of our bad habits from the ships to our cars – like the overuse of VHF radios in collision avoidance.

Let’s be safe out there.

Additional Reading and Links

USCG : Navigation Rules – International-Inland

An Investigation Into COLREGS and Their Applications At Sea

MCA MGN 324 (M+F) : Radio: Operational Guidance on the Use Of VHF Radio and Automatic Identification Systems (AIS) at Sea

NI Navigator – February 2013 : Avoiding Collisions

MPA Port Marine Circular 18/2005 : CAUTION ON THE USE OF VHF RADIO IN COLLISION AVOIDANCE

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It’s Not Gambling……It’s Risk Assessment

“You’ve got to know when to hold’em,

Know when to fold’em,

Know when to walk away

And know when to run.”

-Kenny Rogers, The Gambler

Much like the gambler in a poker game, the master on a merchant vessel is sometimes put in that position of making a hard (and fast) call.  While the other players are holding their cards close to their chests, it’s up to the gambler to assess the game, read the “tells” from his opponents and make a calculation as to which one of the above choices he might take.  It’s not that much different at sea….

No, there’s no cards involved, but the players are much more powerful.  On one side of the table sits Mother Nature – all powerful, able to create devastating hurricanes, mountainous seas and screaming wind.  On another side sits Neptune, the Roman God of freshwater and the sea – the same God that merchant mariners might slip a small offering when crossing the equator.  And the fourth player?  The shipping company.

The master of the vessel has been given a trump card, however, in the form of the International Safety Management (ISM) Code.  This internationally recognized code specifically stating that the company should establish in its safety management system that, “….the master has the overriding authority and the responsibility to make decisions with respect to safety…”  Taken alone, this trump card could shift the onus of the game’s outcome solely on the shoulders of the master.  Luckily, one of the very next lines in the ISM Code states that, “The Company should ensure that the master is….given the necessary support so that the master’s duties can be safely performed.”  Not only does the master have a trump card then, but the shipping company must also stake him enough chips that he can safely play the game.

As the cards are dealt, the master has to assess the look on Mother Nature’s face – is she bluffing, does she really have a poor hand or is she holding a Royal Flush?  If he’s doubtful, perhaps he’ll walk away from the table.  Likewise, if King Neptune is looking too confident or a little treacherous, perhaps the master will fold.  And then there are the times that the look on King Neptune’s face grows darker and darker and Mother Nature is non-committal.  Perhaps, that is the time to run!

And where is that fourth player, the shipping company, through all this?  Well, they certainly play a roll, as they have chips on the table in front of them, as well as the ones they have provided to the vessel master.  With a larger stake in each hand, they will prefer that neither Mother Nature nor Neptune walk away holding the pot.  They are, however, limited by that trump card provided by the ISM Code that the master holds and the fact that sometimes the stakes are larger than they appear.

Playing that trump card – the overriding authority to say where the ship can go and what it can do safely – is not without its potential repercussions.  If the vessel master folds or walks away, allowing Mother Nature or King Neptune to take the hand with a pair of 2s, the shipping company might not want to stake him the chips again.  It is here where his experience and knowledge come into play – knowing if or when to play that trump card.  The knowledge that the shipping company will stake him in the next hand and support his decisions – understanding that Mother Nature and Neptune sometimes play erratically – is all important in allowing the vessel master to err on the side of caution.

In reality, this is not so much a competition, but a balancing act – ensuring that all players are satisfied and that the master walks away with all his chips – crew, ship and cargo.  At the end of the day, Mother Nature and King Neptune will continue doing whatever mythical deities do.  The shipping company and vessel master, however, will walk together to the next table to deal the cards yet again.  Or they may not.  The other possibilities include the shipping company staking a different vessel master in the next hand or, on a very bad day, King Neptune sweeping away all the chips – crew, ship and cargo – down to the watery depths.

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