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A crew member found some small oil leaks from the glands of the suction and delivery valves of the fuel circulation pump on both generators. He took it upon himself to stop the leaks by adding gland packing, but he was working alone and had not informed anyone else of his plans. 

Once the work had been completed on one generator, he started the pump to ensure the leak had been corrected. After confirming there was no oil leak from the valve gland, he started to work on the valves of the other generator, but neglected to stop the pump. When he slackened the gland of the delivery valve to install the gland packing, hot oil splashed on to his face and body. 

As a result of the incident, he received first and second degree burns to many parts of his body including his face, ear, left arm and left hand. 

Lessons learned:

• Although this accident may still have happened even had the crew member been working with someone else, it is often advisable to work on such projects as a team. Mistakes are more likely to be caught before negative consequences occur. 
• Always inform your superior about work that is not planned but that you see as necessary - never improvise. 
• Work methodically and continue to do a running risk assessment as you accomplish the task at hand. 
• PPE, PPE, PPE!! 


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A 1,100 teu container ship was leaving berth assisted by a small port tug. The tug, with a 320hp engine and a single fixed-pitch propeller in a nozzle, was normally used to move barges rather than large ships. It was serving as a temporary replacement for the port's usual ship-assisting 1,200hp Voith configured tug, which was undergoing maintenance. 

On the bridge for the departure were the Master and pilot, the chief officer and a helmsman. All communication between the pilot and the tug was conducted in the local dialect, which the crew were not able to understand. 

According to the agreed plan, the tug had been secured on the container vessel's port quarter with two of the ship's mooring lines payed out about 40 metres. The lines were placed over the tug's single towing hook. 

The Master was initially concerned about the tug's ability to assist the ship effectively in the planned manoeuvre, and requested the pilot to direct the tug to pull on the port beam with full power.The tug's performance satisfied the Master, so the stern mooring lines were let go. With the stern lines away and the tug continuing to pull at full power, ahead propulsion was ordered and starboard helm applied on the container ship. The resulting actions caused the vessel to pivot on the remaining forward backsprings, thereby enhancing the stern's movement away from the quay (diagram 1). 

Within a few minutes, the container vessel's stern was about 25 metres from the quay; the forward backsprings were then let go. The engine was then initially put dead slow astern with the bow thruster full to port, and then hard to starboard helm and dead slow ahead, with the bow thruster remaining full to port. Shortly afterwards the helm was ordered amidships and then hard to port, but the vessel was by now moving astern with its stern coming dangerously close to the mooring dolphin (diagram 2). Half ahead was ordered and the bow thruster half to port, and then full ahead, hard to starboard helm and bow thruster full to port in order to avoid hitting the dolphin. Soon, the ship was moving ahead at more than 5 knots. The tug, which was now astern of the vessel, was unable to gain a safe position because of the unexpected (to the tug crew) and rapid forward motion of the container ship. It quickly girded and capsized. 

The Master immediately ordered stop engines and the local pilot boat proceeded to assist the tug crew in the water. After rescue operations, two of the tug's crew were pronounced dead.  

Although the rapid forward movement of the container vessel that had led to the tug's girding was ultimately the primary unsafe event, several aggravating factors on the tug also contributed to the negative outcome: 

• The towing hook was not fitted with an emergency release mechanism 

• A gog rope was not rigged 

• Doors and hatches were left open during the towing operation 

• None of the tug's five crew was wearing a lifejacket or other buoyancy aid. The official investigation found, among other things, that: 

• The container ship's ahead movement was not communicated to the tug crew, so the tug was caught in an unsafe position and was subjected to girding. 

• The pilot and Master concentrated solely on trying to prevent the ship's stern from making contact with the mooring dolphin, so communication with the tug was less than optimal. 

Lessons learned 

• When in doubt, reconsider your plan. In this case, the tug in service was approximately one-quarter as powerful as the tug normally used and the Master had some doubts about its efficacy before undertaking the manoeuvre. 

• Always keep assisting tugs appraised of your vessel's movements, preferably before the movement begins. 

• For tug crews, ensure your vessel is seaworthy and the crew properly trained and equipped. 


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While at sea, an engine room crew member began work using the ship's drill press and a securing vice. He was drilling 18mm holes into stainless steel plates of about 2-3mm thickness, wearing his usual personal protective equipment (PPE), including cotton gloves. The hole was drilled without incident, but when the drill bit was retracted, it jammed in the plate hole. Under the rotational force of the spinning drill bit, the plate came out of the vice and spun with the drill bit. The spinning plate caught the operator's left hand, which was on the vice-handle. 

The operator quickly stepped on the 'stop control'foot pedal, but the momentum of the plate was high enough that the drill did not stop immediately. The victim was treated as far as possible on board and then evacuated to a shore hospital. Unfortunately, the severity of his injuries - complete removal of skin and muscle tissue down to the bone of the left index finger - required the amputation of the finger. 

The investigation found that the cotton gloves worn by the victim probably aggravated his injuries. The company had issued a safety circular several years earlier prohibiting the use of gloves when working on the lathe and drill machines. However, this information was not displayed near these tools, nor had the victim received this information in any other way. 

The investigation also determined that there was a high probability the drill bit would jam in the hole, because of the size of the drill bit compared with the thickness of the plates. Clamping the plate in the vice without other support is not good practice. 

Lessons learned:

• A 'dead man's switch' is safer than an independent emergency stop switch. A dead man's switch needs to be continually depressed to keep the machine operating. 

• Under certain circumstances some kinds of PPE (such as cotton gloves in this instance) are actually counter-productive. Proper training and information placards can help inform crew what to wear and when. 

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An engine room crew member was assigned the task of dismantling the steering motor coupling chain. One of the steps in this job was to pull out a locking split pin using pliers. The crew member gripped the split pin with the pliers and began pulling with some force to extract it. Suddenly, the plier jaw slipped off from the split pin and, due to the force applied and the trajectory, hit his right eye. The injury was serious enough to require the crew member to be disembarked ashore for professional treatment and repatriation. 

Although the crew member had most of his personal protective equipment (PPE), he was not wearing eye protection. It was also discovered that instead of pulling on the pliers in line with the tool, he had pulled sideways, so that the serrated teeth of the pliers were less effective in keeping a grip on the pin. 

Lessons learned 
• No matter the task, simple or complicated, injuries can occur if you do not use tools correctly or wear appropriate PPE for the task. 
• Eye protection appears to come a poor second to the rest of the PPE wardrobe, with the result that eye injuries still occur quite frequently. Why not insist that crew always wear eye protection when working in the engine room or on deck regardless of the task? 

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On 13 January, at 1447, Nortrader, anchored off Plymouth with a cargo of unprocessed incinerator bottom ash (U-IBA), suffered 2 explosions in quick succession. The first explosion was in the forecastle store and the second in the cargo hold. The chief engineer, in the forecastle store at the time, suffered second degree burns requiring 4 months to recover. The vessel suffered extensive damage putting it out of service for over 3 months.

Safety lessons
1. Sea transportation of a cargo that was not included in the schedule of authorised cargoes of the International Maritime Solid Bulk Cargoes (IMSBC) Code
2. Not conducting appropriate tests that could have identified the propensity of the cargo, U-IBA, to release hydrogen when wet
3. The inadequacy and the inappropriateness of United Nations Test N.5 for the detection of flammable gases from non-homogeneous material

MAIB has made safety recommendations to:
- The Maritime and Coastguard Agency and the Environment Agency (2017/153) to work collaboratively to identify reliable methods and protocols for testing non-homogenous solid bulk cargoes for the property of evolving flammable gases when wet
- The Maritime and Coastguard Agency (2017/154) to update The Merchant Shipping (Carriage of Cargoes) Regulations 1999 with appropriate references to the IMSBC Code
- Hudig & Veder BV (2017/155) to review its operating procedures to ensure that the requirement to apply the provisions of IMSBC Code to all cargoes is clear
- NTO Shipping GmbH & Co.KG (2017/156) to review its safety management system to ensure that the requirement to apply the provisions of the IMSBC Code to all cargoes is clear

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On 18 December 2016, the bulk carrier Graig Rotterdam was discharging a deck cargo of packaged timber at anchor in Alexandria Port, Egypt. At 1109, the bosun, a Chinese national, fell overboard and into a barge that was secured alongside after the timber deck cargo stack on which he was standing partially collapsed. Although the ship’s crew provided first-aid following the accident, the bosun later died of his injuries.

Safety Issues

 - Poor stevedoring practices probably contributed to the unsecured cargo stack collapsing, and no measures were in place to prevent the bosun from falling overboard as a result

- With the deck cargo lashings removed, the cargo packages had insufficient racking strength to counter the effects of ship movement, cargo repositioning, dunnage displacement, barges securing to deck cargo stacks, and cargo discharge operations over a prolonged period

- Poor stevedoring practices that had previously been witnessed by the ship’s crew were not discussed and so were allowed to continue



Graig Ship Management Limited has been recommended (2017/149) to reinforce and, as appropriate, modify its Safety Management System with respect to the carriage of timber cargoes to ensure:

- A lifeline or other means for attaching a safety harness is available to counter the risk of ship’s crew or shore stevedores falling from the top of a deck cargo stack or as a result of a deck cargo stack collapse

- Where possible, appoint a master or chief officer with experience of the cargo type being carried

- Ship’s crew proactively engage with shore stevedores for the purpose of maintaining a safe system of work during cargo operations>>

Norlat Shipping Limited AS has been recommended (2017/150) to ensure that all cargo information, as required by the International Maritime Organization’s Code of Safe Practice for Ships Carrying Timber Deck Cargoes, is provided to the master or his representative prior to loading cargo for all ships that it charters to carry timber deck cargo.>>