Tag: collision

Insanity? Warships that go bump in the night…

Porter-Fitzgerald Collision Photos 2

“Insanity : doing the same thing over and over again and expecting different results.” – Albert Einstein

Almost five years ago, USS Porter was involved in a collision in the Straits of Hormuz with the MT Otowasan.  The damage pictured above was severe and cost in the neighborhood of $50 million to repair.  Thankfully, there was no payment in blood for USS Porter, as there were no fatalities nor injuries to the crew.  The same could not be said five years later and just two weeks ago when USS Fitzgerald was involved with a collision with the MV ACX Chrystal.  In this latest tragic collision, seven U.S. Navy sailors lost their lives.  In addition, there were numerous injuries on USS Fitzgerald, including the commanding officer (CO).

The similarities in the collision location are striking, as can be seen in the side-by-side photos above.  The circumstances of the collisions may differ, but the result was very similar.  In the Fitzgerald’s case, the damage – particularly below the waterline – was much more extensive due to the pronounced bulbous bow of a containership.  Had USS Porter been struck by a different vessel (or same vessel as USS Fitzgerald), the situation may have been more dire.

It’s ironic that the January 2017 issue of the U.S. Naval Institute’s Proceedings contained an article referencing the USS Porter’s collision in 2012.  That article (linked below) recounts the fact that many can learn from the mishaps of others.  The article’s author, Capt. John Cordle also lamented that there is a paucity of reports regarding such collisions or incidents.  It appears that reporting of more minor incidents, also known as near  misses throughout the safety industry, is discouraged or frowned upon within the U.S. Navy surface warfare community.  This, as well as the lack of access to official reports of collisions, groundings, etc of U.S. naval vessels, is unfortunate as, once again, much can be learned from the mishaps of others.

Albert Einstein is oft-quoted as saying that the definition of insanity is doing the same thing over and over again and expecting different results.  The use of incident reports or near misses – whether they be from commercial or naval vessels – can help educate the junior officers – again, whether they be commercial or naval.  The price paid, be it in blood, tax dollars or corporate income, is not worth the silence that often follows major incidents.

The U.S. Navy is certainly not alone in not wanting to shed light on some of its actions.  Flag states such as Panama, Liberia, Cyprus and other flags-of-convenience (FOC) frequently publish minimal or no investigation reports for major incidents.  Try to find out what caused the explosion on Hyundai Fortune (Panama-flagged) in 2006 or the loss of Leros Strength (Cyprus-flagged) in 1997 and you will find the same stone wall as if you wanted to know how USS Porter was involved in a collision.

Let’s be safe out there.

Additional Reading and Links

USNI Proceedings January 2017 : We Can Prevent Surface Mishaps – Capt. John Cordle, USN(R)

USS Porter Bridge Audio – August 2012

Fishing Vessels : Avoiding them means avoiding the consequences

12 miles off the coast of Cochin, India a small fishing boat bobbed in the sea.  Perhaps the fishing was done for the day and the 14 Indian fishermen onboard were resting, awaiting the rising of the sun and a new day.  Or, perhaps they were taking advantage of the light of the full moon to extend their work day.  Regardless, tragedy approached for 3 of the 14.

Tragedy arrived at approximately 2 in the morning in the form of the bulk carrier Amber L.  Enroute from Eilat, Israel to Cochin, Amber L. reportedly collided with the fishing vessel in the early morning, sinking the fishing vessel.  While 3 of the fishing vessel’s crew perished, the remaining 11 were rescued by another fishing boat.

What happened?  Was the crew of the bulker maintaining an effective lookout?  Was the fishing vessel displaying the proper lights – specifically, the lights for a fishing vessel?  Or, were they dimly lit (if at all)?  Or brightly lit, obscuring their navigation lights?  Who was on the bridge of Amber L?  Was anyone awake on the fishing boat?

Unfortunately, these are all questions that will likely be answered after a full investigation.  Indian officials are investigating and the bulker’s flag-state, Panama, should investigate as well. Unfortunately, there are questions that extend beyond this tragic collision.  The bulker, Amber L., was detained by the U.S. Coast Guard in February of this year.

It’s unlikely that the cause for that detention – the lack of audible and visual alarms indicating a loss of power to the steering gear – played any role in this collision 4 months later. It IS an indication that the ISM (International Safety Management) Code is not being properly applied onboard, however.  A systemic failure of the vessel’s safety management system could certainly lead to an effective safety culture and further unsafe acts.  Granted, these are simply hypotheses that should be proven or disproved by the flag state’s incident report.

Or will they?  While Panama appears to be reporting serious marine casualties to the International Maritime Organization (IMO) in accordance with the Casualty Investigation Code (CIC), detailed reports are wanting.  As serious marine casualties happen daily around the world and across the maritime industry, the ability to learn from another’s error, mishap or misfortune is key.  The open sharing of lessons learned by flag states is a crucial part of reducing incidents.  It’s unfortunate that some flag states, such as Panama, restrict this open exchange of information and best practices.

Without dwelling on the collision of Amber L. with the fishing boat off Cochin or the hindrance to safety presented by Panama, the incidences of merchant vessel collisions or near misses with fishing boats should be addressed.  Depending on where you are in the world, fishing boats can range from dugout canoes to commercial production vessels the size of small ships.  Understanding how these vessels operate in often far from obvious.  The UK P&I Club has put together a guide for vessel master’s and bridge teams to assist with just that – understanding how the fishing vessel is operating, what risk that causes in terms of potential collisions and some lessons learned:

  • It is not always easy to determine what sort of fishing gear a boat is using, or sometimes even whether it is fishing or not;
  • Fishermen are sometimes concentrating more on catching fish than on safe navigation; it may be best to assume that they are not aware of your presence;
  • Fishing gear can sometimes extend very long distances from the vessel using it, sometimes many miles; if in doubt, assume the worst case;
  • Fishing vessels can have many sets of fixed gear at sea at any one time and appear to move quickly and erratically between them
  • Small fishing vessels may not show correct lights or signals, nor are they likely to have a VHF radio;
  • Fishing vessels might use a number of bright lights to assist their crew when working on deck at night. These lights might interfere with the lookout on the bridge of the fishing boat.
  • Do not assume that because you are in a channel, harbour approach or separation lane that the fishermen will know what regulations apply or that they will be in a hurry to get out of your way; sounding the ship’s siren or horn will attract their attention;
  • Any manoeuvres to avoid collision should start well in advance and should be large enough to ensure that the vessel passes clear from the fishing boat with adequate CPA;
  • Always proceed with safe speed, making appropriate adjustments according to the visibility and intensity of traffic in the area;
  • Inform Master if visibility reduces – lax practices in this regard should not be tolerated; § When transiting areas where fishing traffic is to be expected, radars should be set in a way to facilitate the detection of small stationary or slow moving targets – long relative trails are a great tool in this regard. Clutter on the radar screen (especially in periods of rain) can prevent small targets to be discovered on time. Long relative trails will show that a target exists even thought it might be hidden in the clutter. They also provide for an extremely useful visual indication of the danger of collision that a target on the radar screen might present.
  • If possible, communicate, where necessary, with a loud hailer or VHF and find where the gear is deployed; § Sound signals should be given as appropriate.
  • In crowded areas it may be wise to station a lookout on the bow of your vessel, with means of communicating with the bridge;
  • In a collision with a fishing boat, the fishing vessel will most likely suffer serious damages, will be in danger of sinking (with the associated loss of life) and will need immediate assistance. The main concern of the other ship, involved in the collision, should be to do their best to provide the required assistance. So if you think you might have hit a fishing vessel, stop immediately and check!

That last point was especially pertinent in the collision of Sinokur Incheon with the fishing vessel Toshimaru off Japan.  After passing close enough to a fishing boat to lose sight of it and then not being able to regain sight of it, the 2nd officer delayed notifying the master for over a half hour due to his disbelief that he could have been involved in a collision.  As is noted in the accident report, the second officer was “in doubt” as to what had happened.  Based on that “doubt,” he should have notified the master earlier, which might have allowed the fishing vessel’s crew to be rescued.

Standing a proper lookout by “all means available”  is particularly important when dealing with fishing boats.  First, they (fishing vessels) can be very small and not necessarily visible on radar, which should place more emphasis on a visual lookout (and the use of target trails on the radar).  Second, they may be maneuvering erratically.  Remember an ARPA (Automated Radar Plotting Aid) requires both vessels to be steady courses and speeds for 3-6 minutes to generate an accurate solution.  And third, but not least, the use of AIS (Automatic Identification Systems) can provide false confidence.

As more and more vessels carry AIS transmitters, watch officers need to remember that not everyone has them, especially in less developed areas with smaller fishing vessels.  In addition, smaller vessels frequently use less-expensive type B AIS transmitters.  Unfortunately, these do not have the priority of type A transmitters and it’s been found that some ECS (Electronic Charting Systems) do not register type B transmitters at all!  The collision of the cargo vessel Frank W. and fishing boat Lilly is a prime example of this phenomena.  In their case, the absence of an AIS target and limited visual range due to the sun’s glare lead them to rely on “scanty radar information.”  Keep in mind the weaknesses of “all means available.”  Checking the different means (visual, radar and AIS) against one another will help counter their inherent limitations.

Ensure that you and your bridge teams use all means available to detect and monitor fishing traffic in your vicinity!

Let’s be safe out there!

Additional Reading and Links

Risk Focus : Reducing the Risk of Collisions With Fishing Vessels : UK P&I Club

JTSB : Sinokur Incheon / FV Toshimaru Collision – February 2016

DKMAIB – Frank W. – FV Lilly Collision – June 2011

U.S. Coast Guard PSC Detentions – February 2017

 

Nightmare for Mariners, Shipping Companies and P&I Clubs : Collision at Sea

safmarine meru collision
provided by Chinese news media zj.people.cn

“In meeting steamers do not dread when you see three lights ahead, right your wheel and show your red.

If upon your port is seen a steamer with a light of green, there’s not much for you to do, the green light must keep clear of you.

But if on starboard red appear, tis your duty to keep clear. Do as judgment says is proper, port or starboard, back or stop her.

In meeting steamers you should try to keep this maxim in your eye. Green to green and red to red, perfect safety go ahead.

If in safety or in doubt, always keep a good lookout. Should there be no room to turn, stop the ship and go astern.” – Rickard Anderson

Poetry or COLREGS mnemonic?  Things have changed a little since the time that an aged Swedish master mariner taught this to his son.  Red to red is the way to go for a head-on (meeting) situation, and green to green is frowned upon.  It is easy to imagine that generations of mariners have learned the basics of COLREGs in this manner.  It’s unfortunate that in this modern day, it doesn’t appear to always be remembered.

Off the coast of Ningbo, China the bridge watches on container ships Safmarine Meru and Northern Jasper managed to disregard, forget or otherwise fail to follow the above axiom.  Watching the AIS recreation below provided by VesselFinder, it appears that in the final close quarters situation, one vessel went left, while the other vessel went right – a situation that is almost sure to end in disaster.

We will likely not have all the facts in this case until years down the road, when the accident report is released by the flag state of one or the other of the ships involved.  Looking at the AIS picture a short 12 hours after this incident, other ship traffic in the area is heavy and it is also an area where large fishing fleets are encountered.  Whether it was factors such as these, navigation hazards or the ever-looming specter of the human element, yet another collision has occurred.

RULE 14

Head-on Situation

(a) When two power-driven vessels are meeting on reciprocal or nearly reciprocal courses so as to involve risk of collision each shall alter her course to starboard so that each shall pass on the port side of the other.

(b) Such a situation shall be deemed to exist when a vessel sees the other ahead or nearly ahead and by night she could see the masthead lights of the other in a line or nearly in a line and/or both sidelights and by day she observes the corresponding aspect of the other vessel.

(c) When a vessel is in any doubt as to whether such a situation exists she shall assume that it does exist and act accordingly.

Was this viewed by both vessels as a head-on situation?  Were there other factors as mentioned above?  Regardless, paragraph (c) of COLREGs Rule 14 would direct a vessel in such doubt to alter her course to starboard.  The fact that Northern Jasper turned to port is concerning and may play a critical role in apportioning fault.  Captain Sabbir Mahmood of the Bangladesh Marine Academy shares his knowledge and history of tort law in maritime collision cases in his dissertation (linked below).

Our thoughts are with the mariners involved with this collision and their families.  It is our understanding that all mariners are accounted for and safe.  The preliminary and final reports from Hong Kong (Safmarine Meru) and Liberian (Northern Jasper) maritime authorities are anxiously awaited.

Let’s be safe out there.

Additional Reading and Links

USCG : Navigation Rules – Inland/International

Japan P&I Club : Bridge Watchkeeping and Collision Avoidance

Captain Sabbir Mahmood : Liability in Maritime Collision Case : How Is Fault Apportioned?”

Madden Maritime : Collisions Happen….

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

COLREGS Moment : Meeting situation gone bad….things that go “Bump” in the North Sea

Photo provided by the VBZR Vrijwillige Blankenbergse Zee Reddingsdienst

Something went dreadfully wrong off the coast of Belgium early Tuesday morning.  Whether it was a machinery malfunction, the misapplication of the International Collision Regulations (COLREGS) or other human element factor, a collision occurred between two merchant vessels – the 315-meter LNG carrier Al-Oraiq and the 130-meter cargo vessel Flinterstar.  As can be seen below in the YouTube video of their AIS data, the incident happened off the port city of Zeebrugge.

Of the 12 man crew on the cargo vessel which was severely damaged, 11 apparently were rescued unscathed, while the 12th crew member was treated for hypothermia.  With the water temperatures off Zeebrugge around a chilly 16° C, it is fortunate that the Flinterstar did not sink completely and came to rest on a bank.  The LNG carrier sustained damage, but was able to make it to port in Zeebrugge with the assistance of a tug.

COLREGS Rule 14

Head-on Situation

a) When two power-driven vessels are meeting on reciprocal or nearly reciprocal courses so as to involve risk of collision each shall alter her course to starboard so that each shall pass on the port side of the other.

b) Such a situation shall be deemed to exist when a vessel sees the other ahead or nearly ahead and by night she could see the masthead lights of the other in a line or nearly in a line and/or both sidelights and by day she observes the corresponding aspect of the other vessel.

c) When a vessel is in any doubt as to whether such a situation exists she shall assume that it does and act accordingly.

The investigation report for this incident will be read with great interest when it is published.  In the meantime, we can only speculate that there was a lack of communication and poor application of the rules of the road.  We might expect that vessels in such a situation would both alter course to starboard, eventually passing safely port-to-port.  In the event that either vessel couldn’t comply – due to factors such as water depth – early and effective communication of the actions taken would be paramount.

Also of interest might be the use of any sound signals in the final moments prior to collision, as well as the rest-work cycles of the crew members involved.  As safe manning of vessels comes under increased scrutiny, might this incident be a sign of the lack thereof?  Or is it simply a matter of training?  Whether there was a lookout (or an effective lookout) might also be a question to be answered.  Any way we view this incident or questions it raises, we can use it as a teaching moment and discuss with our bridge teams what NOT to do and what we might do instead.

Let’s be safe out there!

Collisions Happen…….Today.

A year ago, we talked about the continuing threat of collisions between vessels.  That article can be viewed at Collisions Happen….

Today, off the coast of Singapore, the container vessel Hammonia Thracium and the chemical tanker Zoey proved that collisions are still happening.  Reviewing the vessels’ AIS tracks on Marinetraffic.com, there doesn’t appear to be any definitive information on the cause, although others report, “Prior to the incident, MPA’s Port Operations Control Centre provided traffic information to the two vessels and alerted Zoey that the vessel Hammonia Thracium was crossing the traffic lane.”

Oil spill response contractors are said to be on scene or enroute to deal with the close to 80 metric tons of bunkers that have been released from Hammonia Thracium.  The Maritime and Port Authority of Singapore (MPA) will investigate the cause of this collision, while the vessels assess their damages and options.

We look forward to learning from this incident investigation and lessons learned.