One of the fundamental principles of safety management is that all incidents and accidents are preventable. Therefore, it is important to ensure that if there is an accident or incident the causes are thoroughly investigated and measures are taken to prevent recurrence. 

With its new course “Accident Investigation in Shipping – Analysis and Root Cause” GL Academy provides a fully comprehensive understanding of the procedures involved in, and requirements for the reporting, investigation and analysis of maritime accident and hazardous occurrences. 

Effective accident and near-miss investigation and analysis are one option to reduce accidents and incidents in the shipping industry.However, the necessary procedures, techniques and tools for effective accident and incident analysis are not necessarily part of the usual training profile in shipping companies. In recent years, thorough accident/incident investigation and analysis has become more and more the focus in the shipping business with the objective of avoiding damage to human life, the environment and property. 

In order to reduce accident rates, a deep and thorough understanding is needed: Why do accidents happen, what really causes them and how can a “Just Culture” help to prevent them. 

The International Civil Aviation Organisation (ICAO) has defined a “Just Culture” as "A culture in which frontline operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated." 

Business success depends on managing risks effectively; to manage risks you need an effective safety culture; to have an effective safety culture you need an effective learning culture; to have an effective learning culture you need an effective reporting culture. This cannot exist without an effective Just Culture.   

In this new GL Academy course the trainer will introduce selected techniques and tools that will enable the designated investigator to improve the effectiveness and quality of the analysis of maritime accidents and hazardous occurrences with the objective of identifying and eliminating the root causes. 

During the course conduction special emphasis is put on: 
•    Legal requirements and best practice guidance for the conduction of investigations
•    Techniques and tools for the systematic gathering of evidence, including interviewing techniques
•    Reconstructing the accident event sequence and causal factors
•    The concept of safety barriers in shipping operations
•    Root cause analysis and follow-up activities after accident and incident investigations

Based on the IMO Resolution MSC 273(85) which amended the International Safety Management Code, the course fulfils the requirements of the ISM Code element 9.

Source: GL Academy

The Hong Kong Marine Department has issued Merchant Shipping Information Note regarding a fatal fall on slippery deck. A bosun of a Hong Kong registered bulk carrier fell down on deck and died shortly while he was checking and closing the hatch covers after finishing the loading of coal cargo. This note draws the attention of Shipowners, Ship Managers, Ship Operators, Masters, Officers and Crew to the lessons learnt from this accident.

The accident

1. A Hong Kong registered bulk carrier was loading coal cargo at the outer anchorage of Samarinda, Indonesia. The bosun fell down on deck and died shortly afterwards while he was checking and closing the access hatch cover of a cargo hold.

2. At the time of the accident, it was raining, the wind was slight and the sea was calm. No rolling or vibration of ship was experienced, but the deck was slippery with wet coal dust.

3. The investigation revealed that the bosun probably slipped and fell while he stepped on the slippery wet coal dust on deck, and sustained fatal injury

Lesson learnt

4. A vigilant seafarer helps to minimize casualty at work

Source: Hong Kong Marine Department

On Thursday or Friday a group of shipowners, suppliers, classification company representatives, and consultants will enter the bowels of Emma Maersk, which has been drained. This marks the beginning of the process to place the responsibility for the damage sustained to the ship. ShippingWatch has learned that a new theory is in play.

Emma Maersk has been pretty much drained of water in Palermo, where the ship was towed after one of its its rear side port propellers was torn loose, punched a hole in the hull, and filled the container ship with several thousand gallons of water.

In the next few days, representatives of Maersk Line, the accident commission AAIB, Rolls-Royce, who supplied the side port propellers, and the classification company American Bureau of Shipping, among others, are headed to Sicily to begin the next chapter about the unfortunate ship, that is, to inspect the damages, which are now visible from the inside of the ship after the water has been drained. There is no real doubt that the propeller was torn loose, causing a hole in the hull. Consequently, the propeller will be removed and sent to Rolls-Royce, which produced propellers for all eight ships in the E series.

Theory about the mystery
One of the mysteries concerns why the engine room was flooded in the process. For logical reasons, the room in the ship where the side port propeller was mounted was flooded, as the hull was breached, but Maersk Line has been wondering why the water continued into the engine room. One theory is now that the plates holding the cables that run between the engine room and the room where the side port propellers are mounted weren't strong enough to keep the water out of the engine room, according to ShippingWatch's sources. As a result, these plates are already being examined on the seven other ships in the series.

"Everyone should have access to the same information, and our primary interest is to find out what went wrong," says Group Press Officer Michael Christian Storgaard to ShippingWatch.

Expectations are that it will be another two to four months before Emma Maersk is sailing again.

Source: Shipping Watch

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 investigation
1 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 factors
1 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 actions
1 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.

Source: Mars,The Nautical Institute

Over the years, UK P&I (as well as numerous other organizations) have issued multiple Bulletins and articles related to Entry into Enclosed Spaces. Despite the wealth of information available, many deaths have been caused by seafarers being unaware of, or ignoring the correct procedures prior to entering an enclosed space.

Two weeks ago, a junior officer died after entering a cargo hold to collect a cargo sample. Despite being warned by multiple crew members of the dangers prior to entry, the officer entered the hold and then exited due to "bad air" inside. The officer then re-entered the hold after a mere five minutes of unforced ventilation. Once inside, he was quickly overcome by gases caused by the cargo and fell unconscious, losing his grip on the ladder and falling. The alarm was raised and he was extracted from the hold by ship's crew using Breathing Apparatus and taken to hospital where he unfortunately passed away. No senior officers were aware of his entry to the hold, and the proper SMS procedures had not been followed.

These incidents are not particular to any ship type, crew nationality, rank or age and are caused only by seafarers being unaware of, or disregarding the proper procedures, guidelines and advice.

The following articles contain a wealth of material designed to teach and inform seafarers of the proper, safe entry procedures which, if followed, will greatly reduce the number of deaths caused as well as highlighting the risk present should the proper procedures not be followed.

Click here to view these articles

Source: The UK P&I Club

In the last week of November 2012 the 91st session of the Maritime Safety Committee (MSC) was held at the IMO in London. The topics for this session were amendments to the SOLAS convention covering new requirements for passenger vessels, the Code for noise levels on board ships, procedures for recovery of persons from the water, requirements for on board drills related to fire fighting and furthermore piracy, goal-based standards and the approval of circulars from other subcommittees.

SOLAS II-1/3-12 NOISE
One of the major developments which took place during the MSC 91 committee meeting was the introduction of the new SOLAS II-1/3-12 regulation covering reduction of noise on board.

New ships will have to be constructed in a noise reducing manner and personnel must be protected from noise. The maximum noise level limits for control rooms, machinery spaces workshops, accommodation and other areas are laid down in the new “Code on noise levels on board ships”. It will enter into force on July, 1st 2014.

It will be applicable to new ships of 1600 GT or above for which the building contract is placed on 1st of July 2014, or, if there is no contract, construction (keel laid) is 1st of January 2015 or the delivery is on or after the 1st of July 2018. The code includes both mandatory and non-mandatory parts.

SOLAS II-2 Fire Fighting
With regard to the topic of fire fighting some new requirements were discussed during the meeting. Most of them will be reflected in SOLAS II-2. They are expected to enter into force on 1st of July 2014.

To ensure good communication between different fire fighter teams a minimum number of explosion proof portable radio telephones is required to be available on board of tankers (II-2/10).

As regards training, the fire fighting regulation II-2/15 will require on-board means of recharging breathing apparatus cylinders, or at least a suitable number of spare cylinders.

In accordance with the FSS code Ch 3, 2.1.2.2 an audible and visual alarm of low level of air must be available. Regular drills and training on board are essential elements of the operational safety of a vessel.

FSS Code
As well as adding new fire fighting requirements to SOLAS, the FSS Code (Code for Fire Safety Systems) was also amended. The main changes are new requirements for a fixed pressure water-spraying fire extinguishing system to be installed in ro-ro spaces (chapter 7), the designation of a cargo control room to be equipped with a fixed fire detection system (chapter 9) and revised requirements for a fixed deck foam system to be installed on vessels carrying liquid substances according to the IBC Code (chapter 14). These and other amendments to the FSS Code are expected to enter into force on 1st July 2014.
SOLAS II/17 Recovery of persons from the water

“One hand on deck, one hand for the vessel” - This is an old seaman’s saying. Nonetheless, there is always the possibility that passengers or crew fall or are swept overboard, either from one’s own, or another vessel. Consequently every ship must be ready and able to assist in this situation. This requirement is reflected in the new SOLAS III/17, which mandates that ships have a plan and procedure on board to recover persons from the water. In addition there are guidelines for the development of such plans and procedures. The requirement will apply to all ships from 1st July 2014. The guidelines incorporate the plans and procedures into paragraph 8 of the ISM Code (Part A: Emergency Preparedness).

Ships which are exempted from SOLAS III will also be covered by a resolution.

Covering the issue from another point of view, the revised MSC circular for cold water survival was also approved.

SOLAS III/19 Enclosed space entry
Entering into enclosed spaces is always a risk. Good training is one of the preparations to minimise the risk of accidents. So MSC 91 approved, for final adoption at MSC 92, amendments to SOLAS Reg III/19 on emergency training and drills. Crew members with enclosed space entry or even rescue responsibilities will be required to participate in an enclosed space entry and rescue drill at least once every two months.

Goal Based Standards
The MSC continued its work on goal-based standards. They developed draft guidelines for the approval of equivalents and alternatives. The work on the guidelines will continue in a correspondence group. Member States and interested organisations were invited to submit comments on the safety level approach elements at the next session.

Coating
With regard to other issues arising from reports of IMO subcommittees, the MSC adopted amendments to update the performance standard for protective coatings for dedicated seawater ballast tanks in all types of ships and double skin spaces of bulk carriers. Furthermore the performance standard for protective coatings for cargo oil tankers was adopted. Reference is made to MSC.215(82) and MSC.288(87). Both are mandatory under SOLAS.

IBC Code
The Code for Construction and Equipment of Ships carrying Dangerous Chemicals in Bulk (IBC Code) was also amended. Changes were made to chapters 17 (liquid substances), 18 (hazardous liquids) and chapter 19 (products), with new substances being added.

ISM
Covering the operational safety of vessels the International Safety Management Code (ISM) is well known. The MSC has now approved amendments to improve their user friendliness and efficiency. There will be changes to the foreword clarifying some of the Code’s intentions and some further amendments. The changes will be circulated to all contracting governments with a view to adoption by MSC 92.

FSA
The issue of Formal Safety Assessment (FSA) was discussed during the committee meeting. They approved a circular on the Revised Guidelines for Formal Safety Assessment (FSA) and a circular on Guidelines for the application of Human Element Analysing Process (HEAP) for use in the IMO rule making process.
Forms of certificates

The amendments to the appendix of the annex to SOLAS are expected enter into force on 1 July 2014. Several forms of certificates and records of equipment were revised and will be amended, including the forms for the Cargo Ship Safety Construction Certificate and the Cargo Ship Safety Equipment Certificate.

Passenger Ship Safety
Responding to the Costa Concordia incident in January 2012 the issue of passenger ship safety is an ongoing topic. The committee agreed on a revised circular on recommended operational measures. Voluntary measures are already in place, such as:

(1) carrying additional lifejackets at places other than cabins
(2) the adequacy of the dissemination and communication of the emergency instructions for passengers
(3) carrying out the muster for passengers prior to departure if passengers are scheduled to be on board for more than 24 hours
(4) limiting access to the bridge
(5) ensuring that the voyage is in accordance with the voyage plan
(6) enhancement of emergency instructions to passengers (adding the instructions on the timing to put on a life jacket and confirmation of escape routes)
(7) recording the nationalities of passengers and crews
(8) carrying out the drills for crews to be prepared for the rescue boat embarkation of passengers.

The MSC approved a draft amendment to SOLAS regulation III/19 to require musters of newly embarked passengers prior to or immediately upon departure, instead of “within 24 hours”, as stated in the current regulations. The draft amendment will now be circulated with a view to adoption, at the next session, MSC 92, in June 2013.

STCW
With regard to training for seafarers, the MSC 91 approved revised Guidelines on the Medical Examination of Seafarers (STCW.7/Circ.19) and approved a STCW.7 circular providing Guidance on Electronic Chart Display and Information System (ECDIS) Training. Both were discussed in detail at the last STW committee meeting in May 2012. If you want to learn more about specific training requirements, please feel free to contact your GL Academy.

Piracy
Piracy is still an ongoing subject of concern in the maritime world, although the MSC 91 reviewed the latest statistics and observed a downward trend in the incidences of piracy and armed robbery. However, many seafarers are still being held hostage in Somalia, some of them for more than two years. The committee also noted the increasing number of incidents in the Gulf of Guinea.

Many shipping companies are now hiring armed security guards for the protection of their vessels. Consequently the International Organisation for Standardization has developed a new ISO PAS 28007 for Private Maritime Security Companies. One quality criteria that should be checked before working with one of these companies is whether the guards have adequate maritime knowledge in addition to their military knowledge.

GL Academy has the experience of undertaking a number of tailor-made programs supplying the necessary shipping knowledge to armed guards; making them aware of on board routines, procedures and requirements. Please contact us for details.

EEDI guidelines
The Marine Environmental Protection Committee (MEPC) in its 64th session approved interim guidelines for determining the minimum propulsion power required to maintain the manoeuvrability of ships in adverse conditions. The interim guidelines, which were disseminated as MSC-MEPC.2/Circ.11, can be used from the entry into force of the EEDI regulations on 1 January 2013 until the finalised guidelines are available.

Questions
Are you interested in regular technical updates? Do you have further detailed questions? Please get in touch with our technical experts at rulespilot@gl-group.com.

You can also register to receive ‘GL Rules Pilot – Online Tool to Keep You Informed’. To get an overview of the latest technical and regulatory updates, please go to http://www.gl-group.com/en/gl-focus-regulatory-technical-update.php.

A summary of all amendments from the latest IMO meeting will be available soon in our seminar “Latest Amendments”. Look out for new dates from January 2013 onward.

Source: GL Academy

Twelve months on from the Costa Concordia incident, a new Allianz report identifies that 106 ship losses were reported worldwide in the 12 months to November 25 2012 - up from 91 ships the previous year but a 27 percent decrease on the ten year average of 146 ships per annum.

Despite this long term downward trend, driven by technology, training and regulation and a proactive response from the shipping industry to safety improvement, human error remains the core challenge. In its annual 'Safety and Shipping Review' of maritime losses, marine insurer Allianz Global Corporate & Specialty (AGCS) highlights developments in shipping safety during 2012. The year was marked by two high profile accidents with the loss of the Costa Concordia off Italy on January 13th (the largest loss of the year at 114,137 gross tons) followed by that of the ferry, Rabaul Queen, off Papua New Guinea on February 2nd, both causing multiple fatalities.

According to the report, foundering (sinking or submerging) was the most common cause of losses in the past year (49 percent) followed by wrecking or running aground (22 percent). Collisions such as that involving the Baltic Ace and Corvus J in early December 2012 accounted for a relatively small number of losses (6 percent).

With 30 losses reported, twice as many shipping accidents centered on the seas around South China, Indo China, Indonesia and the Philippines. Shipping losses also occurred more often in the East Mediterranean and the Black Sea (15 losses in 2012) or around Japan, Korea and North China (10 losses).

Human error - still the key

The report highlights that human error remains a root cause of most incidents. Fatigue, economic pressures, and inadequate training are causes for concern. Dr Sven Gerhard of AGCS explains: "For some commercial ship-owners, especially in the hard-pressed bulk cargo and tanker sectors, there is little money for maintenance and little money for training."

New regulation focuses on the problem of human error.

The Maritime Labor Convention (2006), which comes into force later in 2013, will help improve safety by addressing the welfare and working conditions of seafarers. In general, passenger vessels have been the focus of attention throughout the year with both the International Maritime Organisation and the cruise ship industry taking action to tighten regulation and continuously improve operational practices.

Check and balance on the bridge

Major shipping companies have initiated self-regulation initiatives post-Costa Concordia, with the Cruise Lines International Association and the European Cruise Council partnering up to lead the industry-wide voluntary adoption of policies that go beyond international regulatory requirements.  In addition, moves previously pioneered in other industries (such as airlines) or by leading ship-owners are gathering force: for example, greater adoption across the industry of the 'function-based bridge' concept whereby the bridge command structure changes from the traditional captain's sole command towards a 'check and balance' approach. "We see such self-regulation of the industry as the core driver of safety", says Gerhard, who believes that such concepts will soon trickle down to other sectors where passenger safety is paramount.

In addition, technological improvements such as the introduction of mandatory Electronic Chart Display and Information Systems (ECDIS) in July 2012 are expected to reduce accidents, but only where properly applied with effective training and management oversight. "Technology is only as useful as the training behind it - and we don't always see this human element keeping up with other advances. What we do see with the best ship-owners is a proactive safety management culture, going beyond the minimum standards and running from top to bottom of the organization. This can really make an impact in improving safety", Gerhard says.

Source: Allianz

In the past four years, 153 marine accidents have occurred off the Indian coast and 66 people have died in these mishaps. In a written reply in Lok Sabha on Monday, shipping minister G K Vasan said seven people died in such accidents in 2009 while the toll was 24 this year. The reply said 78 ships involved in accidents had Indian flags. The nature of casualty included accidental death, collision, man overboard, fire, loss of ship and sinking

The minister also submitted that the government had stipulated that cargo ships above 25 years, oil tankers above 20 years and gas carriers above 30 years entering Indian ports, anchorages and offshore facilities should be classed with India Register of Shipping or any one of the 12 societies of International Association Classification Society.

Source: Times of India

A general cargo ship arrived with an import cargo that was stacked high on the hatch covers, exposing a large lateral wind area. A strong offshore wind was blowing during the final approach to the berth (starboard side to) with a pilot on board, but it had been already decided that the docking could be safely completed without tug assistance.

The forward mooring team on the forecastle consisted of the C/O, Bosun and an able seaman (AB). The vessel was fitted with a large wavebreaker right forward, which meant that the forecastle deck had very little clear area.

Standing on a small bulwark platform on the starboard side, the C/O was leading the team and also operating the mooring winches remote control levers located close by. The bridge team had no view of the forward mooring station due to the tallwavebreaker and high deck cargo.

The ship approached the berth at an angle of about 30 degrees and, with her bow close to the jetty, the forward spring line was sent ashore and belayed on a bollard. In order to bring the stern closer to the quay the pilot requested slow ahead on the engine and full port rudder. In addition, the bow thruster was activated to port so as to align the ship parallel with the wharf.

Before undertaking this manoeuvre, the Master warned the foredeck team on the portable VHF radio that the engine would be working ahead and that all personnel should stand clear of the taut backspring. This was acknowledged by the C/O, but for unknown reasons, he remained at his position.

The engine and rudder movement was performed but had to be repeated within minutes as the stern did not move sufficiently towards the quay. Again, before the engine movement, the Master called out a warning to the foredeck team and got confirmation from the C/O but he remained at his location near the winch remote control unit.

This time, the engine order lasted longer, and probably due to the bow moving ahead and away from the shore, the backspring came under very high tension and suddenly parted. The broken rope end snapped back violently and hit the C/O on the head and neck, who was felled and lay motionless. Unfortunately, despite all efforts by crew and paramedics, the ambulance doctor declared the C/O dead soon after.

Investigation of the accident

1 The spring line had only been in use for a month and appeared to be in good condition;

2 The method used to berth a high-sided vessel without tug assistance in the prevailing conditions by working engine, rudder and bow thruster against a single backspring constituted a high risk manoeuvre;

3 The C/O failed to move away from snap back zone even after being warned by Master;

4 Poor design - Confined/restricted area on the forecastle deck and improper location of winch remote control unit;

5 The company had no specific guidelines for mooring and the company management had not identified mooring to be a hazardous operation.

For more information click at Mars Report No. 65-2012

Source: Mars,The Nautical Institute

IMO's Maritime Safety Committee (MSC), meeting at the Organization's London Headquarters for its 91st session from 26 to 30 November 2012, agreed that rules to require passenger safety drills to take place prior to, or immediately upon, departure should be made mandatory, in the wake of the Costa Concordia incident.

The Committee approved draft amendments to chapter III (Life-saving appliances and arrangements) of the International Convention for the Safety of Life at Sea (SOLAS)  to require musters of newly embarked passengers prior to or immediately upon departure, instead of "within 24 hours", as stated in the current regulations, for a ship engaged on a voyage where passengers are scheduled to be on board for more than 24 hours.  The draft amendments will now be circulated for consideration, with a view to adoption, at the next session, MSC 92, in June 2013. They could enter into force at the end of 2014.

The Committee also agreed a revised circular on recommended operational measures, prior to the adoption of any mandatory measures following the analysis of the official marine accident investigation report into the loss of the Costa Concordia.

The revised recommended measures (which will update MSC.1/Circ.1446, agreed at the last session) include: additional guidance on common elements to be included in passenger muster and emergency instructions; recommending that the nationality of each person on board is recorded; guidance on lifeboat loading for training purposes; and that companies owning and/or operating passenger ships and the ship's Master should take steps to ensure that changes to the voyage plan are consistent with Company policies.

The recommended voluntary measures agreed at the last session remain in place, including:

• carrying additional lifejackets, to be readily accessible in public spaces, at the muster/assembly stations, on deck or in lifeboats, so that in the event of an emergency passengers need not return to their cabins to retrieve the lifejacket stored there;

• reviewing the adequacy of the dissemination and communication of the emergency instructions on board ships;

• carrying out the muster for embarking passengers prior to departure from every port of embarkation, if the duration is 24 hours or more;

• limiting access to the bridge to those with operational or operationally related functions, during any period of restricted manoeuvring, or while manoeuvring in conditions that the master or company bridge procedures/policy deems to require increased vigilance (e.g. arrival/departure from port, heavy traffic, poor visibility);  and

• ensuring that the ship's voyage plan has taken into account IMO's Guidelines for voyage planning, and, if appropriate, Guidelines on voyage planning for passenger ships operating in remote areas.

The action plan for long-term work on passenger ship safety, agreed at the last session  was also updated, to include additional items on the review of SOLAS regulation III/27, to add the nationality of all persons on board (current regulations already require a count of all passengers and information on their names and gender, distinguishing between adults, children and infants; and information on any passengers requiring special assistance, for search and rescue purposes).  Also included in the action plan is a review of resolution A.893(21) Guidelines for voyage planning.

The MSC also adopted amendments to SOLAS regulation III/17-1 to require ships to have plans and procedures to recover persons from the water, as well as related Guidelines for development of plans and procedures for recovery of persons from the water. Also, a related MSC resolution on Implementation of SOLAS regulation III/17-1 to ships other than those engaged in international voyages was adopted.  The amendments had been drafted previously and approved at the last session.

The Committee also agreed to include "Passage Ship Training" on the provisional agenda of the Sub-Committee on Standards of Training and Watchkeeping (STW 45).

The Government of Italy provided the MSC with the preliminary findings of its on-going investigations into the Costa Concordia. The final casualty investigation report is expected to follow later.  IMO is represented, as an observer, on the body overseeing the casualty investigation.

Source: IMO