What Maritime Tragedies Teach Us About Safety?

By April 7, 2016 Article, Events No Comments

^ The Costa Concordia Disaster of 2012 – Image Courtesy of Soerfm at https://en.wikipedia.org/wiki/File:Costa_Concordia_salvage_July_crop.jpg

Eternal Non Vigilance?

Recently, the Maritime Accident Investigation Branch (MAIB) of the U.K. released its Safety Digest 2016. The report compiles the accounts of a number of maritime accidents onboard U.K. vessels worldwide and non U.K. vessels in U.K. territorial waters.

An independent branch within the Department for Transport (DfT) of the U.K., the MAIB publishes such analysis with the lofty goal of raising awareness and preventing further mishaps. The objective is not to assign blame or fix liability.

For those with their eyes open, this is a wealth of information. Because while ordinary people learn from their own mistakes, the outstanding learn from other people’s errors.

Maritime accidents are a terrorizing prospect for all the involved parties. This is because they inflict heavy damages on life, limb, property, and the environment.

If this were not enough, salvaging vessels is a logistical nightmare. Imagine towing ships weighing thousands of tons from the middle of nowhere. The nearest port or repair yard can be hundreds or even thousands of miles from the accident location.

And if the involved vessel is a tanker, God help us all. For containing and, later, cleaning the oil spill is a mammoth operation spread out over months, even years. We all know of the catastrophe unleashed by the infamous Exxon Valdez oil spill.

Oil Covered Ocean after the Exxon Valdez Oil spill of 1989 Image Courtesy of the U.S. National Oceanic and Atmospheric Administration at https://en.wikipedia.org/wiki/File:OilSheenFromValdezSpill.jpg

Oil Covered Ocean after the Exxon Valdez Oil spill of 1989
Image Courtesy of the U.S. National Oceanic and Atmospheric Administration at https://en.wikipedia.org/wiki/File:OilSheenFromValdezSpill.jpg

Let us consider some statistics to put things in a better perspective. Despite sizable decline, the casualty rate in maritime accidents continues to be higher than in other sectors.

Take the rate in U.K. for example. It has fallen from 358 per 1000 in 1919 to 11 per 1000 in 1996-2005 – almost 97% decline. Yet, this rate is 12 times that of the rate in general workforce, 8.5 times the corresponding rate in manufacturing, and 2.5 times that in construction.

Financially speaking, post-accident operations such as towing, repair, possible regulatory fines, medical costs, shipment delays, and the probable dent in reputation may add up to unmanageable levels.

The U.S. Towing Industry Safety Statistics Report places the damages of a low intensity accident at $50,000. The corresponding figures for medium and high severity disasters stand respectively at $50,000-$250,000 and over $250,000.

Considering these harsh realities, one would expect the relevant parties to be eternally vigilant, to deal with this menace on a war footing. At least, when they are on duty. Sadly, that is not the case. To this day, maritime accidents occur with a disturbingly regularity.

And the cause for this sorry state of affairs is the result of a complex interplay between a whole set of factors – human, technological, organizational, and environmental.

Maritime System & Safety Culture

Safety Culture - Image Courtesy of arka38 at shutterstock.com

Safety Culture – Image Courtesy of arka38 at shutterstock.com

Right until the 1990s, the term safety culture – a set of operational practices and procedures that would prevent mishaps – remained surprisingly absent from the vocabulary of the industrial world. The maritime industry was no exception.

Talking of safety culture, it was an International Atomic Energy Agency (IAEA) report that first used the term when analyzing the causes for the Chernobyl Nuclear Accident of 1986 – the world’s worst nuclear power plant disaster ever.

Technical or equipment failure was the focus of enquiry in maritime accidents. Human errors were ignored. There is a fundamental flaw in such approach because finally it is the humans that operate all technology.

Now, human errors cause a staggering 75-96% of maritime casualties according to the U.S. Coast Guard. Not for nothing does the IMO regard seafarer behavior as the prime determinant of the safety of life and environment at sea.

Multiple Displays on a Ship’s Bridge Image Courtesy of NorthbySouthBaranof at https://en.wikipedia.org/wiki/File:Bridge_of_the_RV_Sikuliaq.jpg

Multiple Displays on a Ship’s Bridge
Image Courtesy of NorthbySouthBaranof at https://en.wikipedia.org/wiki/File:Bridge_of_the_RV_Sikuliaq.jpg

But, it is wrong to blame everything on humans. There is, as mentioned, a convoluted interplay between diverse factors. The maritime system comprises of:

  • People: pilots, crew, dock workers, vessel traffic service operators and so on
  • Organization: work culture, crew training and size, hierarchical structure, work safety standards, and work schedules
  • Technology: equipment and gadgets
  • Environment or Work Conditions: weather, temperature, noise, vibration, lighting, regulatory atmosphere, and existing economic conditions

Apart from inherent human limitations, the real reason for maritime mishaps is the mismatch between humans and the organization, technology, and environment.

If the management does not incentivize performance and reporting of observed inconsistencies, the crew will be ill motivated. Again, if the management minimizes crew sizes in order to cut costs and extends work schedules, they end up escalating error-causing fatigue.

By the way, the International Maritime Human Element Bulletin and the U.K. Marine Accidents Investigation Branch blame fatigue for most shipping accidents.

Fatigue is a Veritable Killer in the Maritime Industry Image Courtesy of Photographee.eu at shutterstock.com

Fatigue is a Veritable Killer in the Maritime Industry
Image Courtesy of Photographee.eu at shutterstock.com

Speaking of technology, it is widely whispered throughout the industrial world that technology suppliers create what is possible and what is marketable, not necessarily what is needed.

A common example of this is hi-tech gadgets that are difficult to operate – you are hard pressed to read screens that display important data or access control levers and buttons. Rough weather as well as extreme noise, temperature, and vibrations also promotes fatigue.

Economic slowdowns and bad financial status often force ship owners and operators to accept undue risks. The SS Torrey Canyon mishap of 1967 that spilled 100,000 tons of oil off the Cornwall Coast in England is an example in case.

A recent report The Impact of Crew Engagement and Organizational Culture on Maritime Safety in the Workboats and OSV Sectors published by Helm Operations, Canada provides further evidence of commercial pressures eroding safety norms.

Fathom Maritime Intelligence conducted research for the report while Southampton Solent University, U.K. collected and evaluated the data. Important findings include:

Crew Engagement Lowers Maritime Accidents Image Courtesy of bleakstar at shutterstock.com

Crew Engagement Lowers Maritime Accidents
Image Courtesy of bleakstar at shutterstock.com

  • 78% of the crew aboard workboats and offshore supply vessels (OSVs) believe commercial pressures affect safety-related work practices
  • About 50% said they would cut down on safety measures rather than say ‘no’ clients or senior management. Note: they are scared even of the senior management
  • Better organizational culture and crew engagement improves safety performance on OSVs and workboats – just like everywhere else

MAIB Safety Digest 2016: Have We Learned Anything?

What we learn from history is this: we do not learn anything from history. Which is precisely why we are condemned to repeat follies, follies that can turn fatal.

  1. Merchant Ships

Deputy Master of Trinity House in London, Ian McNaught describes in the introduction to the merchant vessel section how an Officer of the Watch (OOW) cannot look outside the window because he is surrounded by umpteen screens and equipment.

And if the ship has unmanned machinery spaces (UMS), he is supposed to monitor these while handling communications. Quite clearly, the trend towards minimizing crew and asking them to multitask without due regard to their training and their human limitations can prove lethal.

At the same time, overreliance on technology breeds a certain complacence and makes many navigators contract avoidable risks. Hi-tech gadgets are great aids to navigation, but so is the good old bridge window.

Cast 14 recounts how the failure to plan thoroughly and understand properly the nitty-gritty of a maintenance task almost resulted in the loss of a cargo ship carrying limestone.

When conducting repairs on a leaking ballast pump, the chief engineer failed to predict the possibility of leakage from the inlet valve that brings in water from the sea.

Case 14: Cargo Vessel as the Salvors Found it  Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

Case 14: Cargo Vessel as the Salvors Found it
Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

The engine room started to flood and when the chief engineer was unable to stem the flow using cloth and wood pieces as jammers, he tried using a portable electric pump. By now, the vessel was operating on emergency power and they could not switch on the pump.

While leaving the engine room, the chief engineer left open the watertight door between the engine room and the accommodation. The Master contacted the Coast Guard after visiting the engine room and sounding the general alarm.

Despite pressing three salvage pumps into service, they could not stop the flooding. The vessel’s owner contacted salvors who stopped the flooding and towed the vessel to port.

Neither had the chief engineer informed the master of the repair plans, nor had he obtained work permit for the same. The work permit prescribes basic contingency planning that would have ensured complete isolation of the inlet pipe before commencing with repairs.

Later examinations revealed that the actuator of the isolating valve was faulty – it appeared it was fully closed when it was not. But the personnel failed to check the visual indicator that would have revealed this flaw.

Finally, the untrained crew responded to the emergency in a haphazard manner. The chief engineer left the door between the engine room and accommodation open. And the master visited the engine room before sounding the alarm wasting precious moments in the process.

Case 1: Perceived & Real Routes  Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

Case 1: Perceived & Real Routes
Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

Case 1 describes a tanker passing a coastline studded with sandbanks. Alone on the bridge, the OOW who was also the navigator was distracted as he was correcting the charts delivered just before the ship sailed.

First, he missed the warning alarms. Then he tried to correct course repeatedly. He also completely missed the effects of the tidal stream. Result: the tanker grounded on a sandbank on a fine day with good visibility.

As an OOW, his first responsibility was the safety of the ship. He could have corrected the charts latter. Neither did the master of the ship allot someone else as the OOW while he corrected the charts.

  1. Fishing Vessels

RNLI Fishing Safety Manager for the U.K. and the Republic of Ireland Frankie Horne composed the introduction for the fishing vessel section. He says that fishing is statistically the most dangerous peacetime occupation.

According to him, the real tragedy is the effect these accidents have on the survivors and the families of the victims. Most common fishing incidents involve:

  • man overboard
  • entanglement in ropes, gear, or machinery
  • capsize
  • carbon monoxide poisoning

Experienced fishers who have operated for years without accidents are vulnerable because of the false sense of (over) confidence. Simple precautions such a swearing a life jacket or carrying a personal locator beacon (PLB) can go a long way in saving lives during exigencies.

Case 19 demonstrates how even the most experienced of seafarers can get to within an inch of losing their lives. Despite years of experience and despite being respected for his abilities as a seafarer, the lone skipper of a steel beam fishing trawler almost died.

A little while after shooting his nets, the skipper realized that a fish hold bilge pump had tripped out. He decided to check this while the boat was in autopilot mode – with the propeller running.

When lifting the boards the covered the bilge well or the drive shafts, he either slipped or stepped down into the bilge hold. Here, a coupling bolt on a rotating propeller shaft got entangled with his oilskin trousers and pulled his leg around the propeller shaft.

Fortunately he was able to cut himself loose from the propeller shaft and make it to the wheelhouse. Here he used his mobile phone to call for help – the VHF radio was suspended from the roof where the injured skipper could not reach.

Although help arrived in time to save his life, they could not save him from the loss of limb. He had lost a lot of blood and doctors had to amputate him. The skipper recovered only after a long duration of remedial therapy.

Case 19: The Steel Beam Trawler  Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

Case 19: The Steel Beam Trawler
Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

Working close to the rotating propeller was wrong. The skipper should not have undertaken the investigation while the vessel was in autopilot. Then again, working alone is dangerous – you do not have access to immediate assistance that can be invaluable for saving life and limb.

It was perhaps the skipper’s iron will and years of seasoned experience that enabled him to disentangle himself from the strong propeller and call for help despite inaccessibility to the VHF radio. If he had carried and used a PLB, the rescuers would have reached the scene sooner.

Rescuers would also have reached him sooner, if he had not switched off the automatic identification system (AIS) in order to cut operating costs. For life is invaluable.

Case 20: Reconstruction of the Mishap   Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

Case 20: Reconstruction of the Mishap
Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

Case 20 further underlines the risks of working alone. A well experienced skipper was mortally wounded when straps on his trousers got engaged with the rotating warping drum. Operating close to rotating equipment in itself is a grave safety violation. The skipper paid with his life.

Enquiry revealed the incompatibility of the vessel with single-handed operation – the vessel was a 9.98 meter whelk plotter modified to a scallop dredger. The modifications had created an intricate mechanism for shooting and hauling the gear.

Plus, the skipper had not maintained the vessel properly. For example, the winch did not have any safety cut-off devices. And because he was alone, no one could provide him first aid or call for help. Lone Rangers are the stuff of movies only. These are none in the real world.

Case 17 and Case 22 both depict the effects of leaving the wheelhouse unmanned. Fortunately in both cases, there were no casualties. In Case 17, two wooden fishing vessels collided because vessel A’s wheelhouse was unmanned and vessel B had switched off navigation equipment.

Case 22: Sinking of the Vessel  Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

Case 22: Sinking of the Vessel
Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

In Case 22, the skipper of a 24 meter steel hulled fishing trawler went below deck to prepare supper while leaving the wheelhouse unmanned. No one could therefore take note of the bilge high level alarm that issued loud warning noises. The vessel sunk.

  1. Recreational Boats

What is this life full of care, we have no time to stand and stare. William Henry Davies’ words echo very strongly with our hectic schedules. Consequently when we are on a boating holiday, we go to the other extreme end – we drop down all our guard.

A relaxed holiday aboard a leisure vessel amidst cool winds and melodious music while gulping liberal doses of food and washing it down with intoxicating liquor can be the perfect recipe for disaster.

In the introduction to the recreational craft section, power-boating specialist Andy Proudfeet underscores the importance of preparation and precaution. This includes cancellation of the trip in the face of unfavorable weather forecast.

He also touches the issue of social media inspired peer pressure – we all want to be out there and post the photographs on our social media profiles. Boating holiday is great freedom. But with freedom, comes responsibility – towards your loved ones, towards yourself.

Andy Proudfeet also warns against the ‘this won’t happen to me’ impression. Opinions never saved a drowning man. Training and equipment will. Practicing what he preaches, Proudfeet takes two basic precautions – wearing lifejacket and using the kill cord.

Case 23 is about a family that went on a short excursion in their 5 meter rigid inflatable boat (RIB) with their dog. Everyone had put on life jackets and the owner secured the kill cord to himself before starting the engine.

A kill cord shuts off the engine in case the driver leaves his position by the steering. This prevents accidents due to the uncontrolled movements of the vessel.

One of the buoyancy tubes was flat and the owner inflated if after shifting the throttle to neutral and disconnecting the kill cord. Before resuming steering of the vessel, he did not reengage the kill cord, something that brought them to within a hairbreadth of catastrophy.

Now, when the owner moved the throttle ahead, the boat did not move ahead. Frustrated, he thrust the throttle too far ahead. Suddenly, the engine launched the boat violently and the family was thrown overboard as the boat kept encircling them.

The family somehow managed to swim away from the encircling boat as another boat rescued them. A third boat owner valiantly jumped on the encircling boat and shut off its engine. Luckily, the family and their dog escaped unhurt.

Case 23: The ‘Encircling’ RIB Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

Case 23: The ‘Encircling’ RIB
Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

But for the bold third boat owner, the encircling boat could have caused serious injuries to someone else in the vicinity. And it was a miracle the boat did not injure its owners. Always engage the kill cord before operating a boat.

You will also do well to follow the CLEAR before the boating ride:

  • C for (functional) communication equipment
  • L for lifejacket
  • E for (proper) equipment
  • A for able / ability to plan the trip
  • R for ready / readiness

Case 24 portrays the trouble that the crew of a powerful, 6.2 meter RIB got into by ignoring the forecast for heavy sea. The RIB capsized. What saved them was the fact that the crew wore lifejackets and that the accident occurred close to the shore where onlookers spotted them.

 

Finally

Case 24: The Recovered RIB Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

Case 24: The Recovered RIB
Image Courtesy of Maritime Accident Investigation Branch at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/512603/MAIBSafetyDigest1_16.pdf

In 2013 on his way to the Round Ireland RIB Challenge, Andy Proudfeet erred in judging a 24 knot wave and went overboard his RIB. His lifejacket-attached VHF device smashed on impact with water even as his boat drifted away. Andy Proudfeet drifted for three hours before rescue.

What saved him was that he was wearing a lifejacket, had attached the kill cord, was RYA trained, and used the PLB. Of course, there is the all important professional response of the rescuers. Precisely how training, experience, and equipment can save you under testing circumstances.

Technology will continue to expand its utility. But any further improvement of safety in the maritime sector will be the result of improved safety cultures that focus on humans, not machines. Management people have their task cut out.

And there has to be a halfway meeting ground between the human element and the other facets – technological and organizational. Humans have to adapt to technological and organizational changes. But technology and organizations cannot ignore human limitations. Bon Voyage!

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