Machinery Failure: Defect Not Reported
The ATSB has released its investigation report into the machinery failure on the heavy cargo ship HC Rubina and subsequent contact with the wharf at Brisbane, Australia, on 29 October 2013
On 3 October 2013, immediately before HC Rubina sailed from Beira, Mozambique, the control system for its controllable pitch propeller failed. The ship subsequently made its voyage to Brisbane, Australia, with the propeller’s pitch manually operated from the local control station.
On the afternoon of 29 October 2013, a pilot boarded HC Rubina for its passage in to Brisbane. While the ship was being manoeuvred off its berth, a flexible coupling for the shaft alternator that was providing power to the bow thruster, suddenly failed. The aft end of the engine room rapidly filled with smoke, forcing the engineer controlling the propeller pitch to leave the local station. Consequently, the ship’s propulsion was no longer being controlled and the ship made contact with the wharf, sustaining minor damage.
What the ATSB found
The ATSB found that HC Rubina’s shipboard planned maintenance system provided no guidance for the maintenance of the shaft alternator’s flexible coupling.
The ATSB investigation also identified a number of other safety factors. The ship’s managers did not ensure that the defective propeller pitch control system was reported as required to relevant organisations to allow them to consider the risks arising from the defect. Further, the method used by the ship’s agent, in Brisbane, to collect information for the port’s online booking system did not ensure that such defects were captured.
The increased risk arising from the ship’s defect and the weather conditions leading up to the incident were factors that should have been considered to determine whether the pre-prepared passage plan remained appropriate.
Although it did not directly contribute to the incident the ATSB investigation did note that at a critical time during the incident, the crew communicated in Russian instead of English, the mandated working language for all ship’s bridges. As a result, the pilot was left out of the communication loop and his ability to make informed decisions was limited.
What’s been done as a result
Maritime Safety Queensland (MSQ), Queensland’s maritime regulator, has updated the training that it provides to the state’s ship agents to raise awareness regarding the gathering of information and reporting of ship defects. Further, MSQ, in conjunction with Brisbane Marine Pilots, has revised the procedure used to exchange information between vessel traffic services (VTS) and the pilot. Specific emphasis was placed on the reporting of defects that could affect the safe navigation of the ship.
HC Rubina’s agent in Brisbane has revised the method used for collecting information, from ship masters, by including a question that specifically asks if the ship has any defects.
Safety message
The incident highlights the importance that needs to be given to the maintenance of critical items of ship equipment and the reporting of their operational condition. Doing so can ensure that pilotage and other high risk operations can be appropriately pre-planned and managed to reduce the likelihood of an incident.
The full report is available here.