When the merchant ship of just over 2,000 gross tonnes had been pulled off the ground, the tug gave the order to loosen the hawser. When the hawser was loose, the tug warned the ship that it was floating in the water and that absolutely no engine manoeuvres should be carried out until the hawser and wire had been recovered. Suddenly, the captain ordered forward in the engine room and said, ”We don’t need tugs, we can go by our own engine!”. The pilot then gave the order ”Stop engine” on which the captain ordered reverse to the engine room and the pilot again ordered, ”Stop Engine”. Then the engine was stopped. The towing hawser was drawn down in the ship’s propeller. The hawser and wire were pulled up very quickly. The chief engineer on the tug had no time to duck and was struck in the face by the cable. Later on in the emergency department, only tissue damage and shock were reported. In this type of accident a few centimetres can mean the difference between life and death. Everyone must be aware of the risks and communication between all the parties involved is vital. There must be a clear procedure in the SMS and it must be complied with. As far as possible personnel should not stay on the deck area when a broken or quickly tightened rope can whip past or be stretched up. On 29 January the experience database contained 3,034 reports. The event below from the database gives an example of failure in a critical system.
No rudder action and no alternative steering methods
A large ship had just cast off when the alarm ”Power Failure” was sent from the steering gear after the rudder stopped functioning. When the bridge tried to follow the instructions for another steering option, that did not work either. The explanation was that a fuse had blown in a relay box in the steering gear. After a test of the system and alternative procedures, it appeared that the instructions were incorrect. In the report, immediate measures are specified to deal with direct faults and then to revise and improve the instructions in the manual and improve training. In the long term, research, analysis and FSA are suggested.
Systems architecture and automation on today’s ships are so complex that it cannot be assumed that everyone understands them and is immediately able to deduce the source and deal with problems that arise. Therefore the human brain creates models that reduce the complexity of the work and/or increase predictability in the system by providing all players with the same view of the current situation and status of the system. The combination of the picture the operator created and the incorrectly described procedures constitute an obvious risk. Since the options that remain are very good knowledge or correct procedures, it is reasonable to quality assure and test procedures with respect to the user’s perspective.
Foresea ID: 3335