Fail to Plan, Plan to Fail

The U.K. Marine Accident Investigation Branch (MAIB) has released its first Safety Digest for 2016 highlighting the need for cautionary approach to risk.

Steve Clinch, Chief Inspector of Marine Accidents, stated: “A cautionary approach should be second nature to every mariner about to start a task or embark on a course of action on the bridge, in the engine room or on deck. It doesn’t matter whether you are sailing on a large commercial vessel, fishing boat or small leisure craft; taking the time to ask oneself “what can go wrong?” and then making sure bad things can’t happen before committing yourself to, for example a change of course or, an entry into a confined space is clearly a sensible thing to do. 

“Sadly, MAIB Safety Digests contain many examples where this simple lesson has been forgotten or ignored - this edition is no exception. Case 14 details how a failure to properly understand the risks of opening a main sea water line, or take appropriate measures to ensure the planned task was executed safely almost resulted in the loss of a ship.”

Case 14

On a fine day, a general cargo vessel was on passage with a cargo of limestone. The master was on watch on the bridge. In the engine room, the chief engineer, motorman and a seaman were undertaking maintenance on one of the two main ballast pumps; the chief engineer had recently joined the vessel and had prioritized this work owing to the presence of leaks and poor pumping rates.

The chief engineer intended to replace the mechanical seals on the ballast pump. He had electrically isolated the pump prior to starting the job. He had also closed both the sea water inlet valve, located between the sea chest and the pump, and the pump outlet valve, located between the pump and the ballast system valve manifold. On instruction from the chief engineer, the motorman disconnected the electric motor from the pump. He then removed the flange bolts connecting the inlet pipe to the pump.

Soon afterwards, water started to flow from the inlet pipe at a rapidly increasing rate. The chief engineer tried to reduce the rate by jamming rags into the pipe, but the flow was too strong. He then sent the motorman to fetch some pieces of wood, which he intended to force into the pipe. He also sent the seaman to collect a portable electric water pump, which was stowed in the forward store.

The chief engineer intended to start the main bilge pump, but as he was configuring the system he became distracted by the rapidly rising water level, which was now above the bottom plates. Worried about potential damage to machinery, he left the bilge system to stop the generator and main engine, and sent the motorman to the bridge to tell the master that the engine room was flooding. With the water level continuing to rise, the chief engineer evacuated the engine room, leaving open the watertight door between the engine room and the accommodation as he did so.

On being informed of the flooding, the master left the bridge to check the engine room for himself. Concerned with the rate of flooding, he returned to the bridge and sounded the general alarm, mustering the remaining crew. The seaman rigged the portable electric water pump on the main deck but, with the vessel now running on emergency power only, he was unable to start the pump.

The master contacted the coastguard by VHF radio and advised that the vessel was flooding. The coastguard transmitted a “Mayday Relay”, and RNLI lifeboats from two stations were tasked to assist along with a Royal Navy helicopter. Meanwhile the vessel’s crew prepared the rescue boat for evacuation.

Three salvage pumps were put on board the vessel. The pumps were rigged on the main deck with suction via the engine room emergency escape. Despite all three pumps operating at full capacity, the water level in the engine room could not be lowered. Following reports of water ingress to the cargo hold, all six crew abandoned to one of the lifeboats. 

The vessel continued to flood, with water entering the accommodation areas through the open engine room doorway. The vessel’s owner contracted salvors, who were able to stop the flooding and, once stable, the vessel was towed into port.

Lessons Learnt

1. The master was unaware of the work being carried out on the ballast system. A risk assessment had not been completed and no permit to work had been issued. This resulted in basic contingency planning not being undertaken and poor engineering practice being applied. A comprehensive risk assessment would have identified that, with only one valve separating the ballast pump from the sea, it was essential to ensure that the inlet pipe was completely isolated prior to removal of the flange bolts connecting the inlet pipe to the pump.

Control measures should have included:
•    Ensuring that all pressure was safely released from the suction side of the pump by using the bleed nut on the suction strainer.
•    Ensuring that the inlet flange was split in a controlled manner with a number of loosened bolts still in situ to enable them to be re-tightened in the event of the isolating valve not holding.

2. The crew’s response to the flooding was ineffective because they were not prepared for the emergency. They had never carried out an engine room flooding drill, and half of them had never carried out any form of emergency drill since joining the vessel. 

3. Examination of the isolating valve following the accident identified that the valve actuator had been defective, giving an impression that the valve was fully closed when it was not. Although there was a visual indicator located on the side of the actuator, this was not checked to confirm that the valve was closed prior to removal of the flange bolts. The actuator had previously been repaired. However, the chief engineer, who had only recently joined the vessel, was unaware of the actuator’s poor internal condition.

The Safety Digest is available here.