Miscellaneous Alert

No. 030 28 Apr 2023

Type Of Incidents

Root Causes Identified

 Human Factors such as Lack of Situational Awareness, taking shortcuts and various other fac-
tors form the majority of the Root cause and contributing to about 41 % of incidents.

 Inadequate planning and supervision of the job contributed to about 40 % of the incidents.

 A proper tool box meeting and a continuous risk assessment/ Identification process will have a
positive impact on reducing such incidents.
 Miscellaneous Alert
No. 030 28 Apr 2023
Bunker Barge crane fell on deck causing damage
Incident
The Vessel was made fast on starboard side to Berth
No 1, Vopak Deer park Terminal, Houston for dis-
charging cargo.

Bunker barge was made fast on the port side aft near
break of accommodation to supply bunkers. While the
VLSFO bunkering was in progress, the bunker barge
crane boom luffing wire parted which resulted in the
Bunker barge crane boom falling on the port side life-
boat embarkation deck of the vessel, near the break
of accommodation. There was minor deformation of
the ship side railing and one emergency light.

What went wrong?

Substandard act by Bunker Barge—The Bunker barge was alongside on the port side to supply bun-
kers to the vessel. During VLSFO bunkering, the bunker barge crane boom luffing wire parted which re-
sulted in the Bunker barge crane boom falling on the port side lifeboat embarkation deck of the vessel,
near the break of accommodation.

Rupture in ship’s hull due to anchor slipping

Incident
The Vessel was on a loaded voyage. The
Ship’s staff carried out maintenance on both
Bow stopper pins. Port side bow stopper pin
was not put back in place after the mainte-
nance.

Prior arrival Singapore, during pre-arrival

checks chief officer observed that port anchor
had slipped. Anchor lashing was found bro-
ken. Port anchor had slipped about 8-9 m
from its position while ship was underway
which resulted in hull breach on portside of Holes in the Fore Peak Tank
forepeak tank at about 8.0 – 8.5 m draft level
causing water seepage into forepeak tank.
 Miscellaneous Alert
No. 030 28 Apr 2023
Rupture in ship’s hull due to anchor slipping

What went wrong?

 Failure to Secure . After the mainte-

nance of bow stopper, the bow stopper
pin was not put back in bar securing loca-
tion by ship’s staff resulting ineffective-
ness of bow stopper. During arrival while
the vessel was underway it was pitching
moderately, while trying out the main en-
gine the anchor wire lashing parted, and
the anchor slipped. The weight of anchor
came on the bow stopper. But since the
bow stopper pin was not in place it was Repairs Completed
not effective, and anchor slipped damag-
ing the ship’s side when anchor struck
the hull.

 Lack of risk perception/risk awareness. Ship’s staff did not realize the consequences of not se-
curing the anchor properly after the maintenance job was over. The ship’s staff should have been
more careful and checked anchor securing arrangements after the completion of maintenance.

 Inadequate Supervision. The action of ship’s staff of not putting back the bow stopper pin in
place shows complacency and lack of basic seamanship. Chief officer or Bosun did not check the bow
stopper pin after the maintenance was completed.

Learning From Incident (LFI):

 Securing : The vessel’s anchor shall always be secured using the bow Stopper. The Bow stopper
shall always be secured using the pin as it ensures that the Bow stopper will not lift up during the
rough weather.

 Risk awareness and tool box meeting: A tool box meeting shall always be carried out prior pro-
ceeding to any job. Critical jobs such as maintenance of stopper shall be done with a proper risk as-
sessment.

 Supervision : The senior officer shall verify the effectiveness of the controls put in place while car-
rying out such critical jobs. Upon completion of the maintenance, the status of the equipment/ task
shall be verified by the senior officer.

 Planning of Anchor/ Anchor equipment maintenance Jobs : Jobs related to anchoring equip-
ment shall be planned while the vessel is at anchor or in port (As far as practicable). In case the ves-
sel had to carry out maintenance at sea, effective controls shall be identified to reduce the risk in-
volved during the maintenance of anchoring equipment.
 Miscellaneous Alert
No. 030 28 Apr 2023
Damage to Starboard Gangway during Heavy weather
Incident
The Vessel was on her loaded cross Pacific
Ocean passage from Singapore to San Fran-
cisco.

The vessel was facing very heavy weather

conditions due to Temperate latitude de-
pression (TLD). The vessel was rolling and
experiencing shipping seas on main deck.
Deflection in the Gangway
The starboard gangway was damaged due
to heavy weather condition. All parties were
informed. Flag state dispensation was grant-
ed for unavailability of Starboard side ac-
commodation ladder. Considering the dam-
ages, a new Gangway was ordered.

What went wrong?

Damages to the Gangway

 Exposure to adverse weather condi-

tions : On her loaded passage, the ves-
sel faced very heavy weather conditions
due to Temperate latitude depression
(TLD). The vessel was rolling and experi-
encing shipping seas on main deck. The
starboard gangway was damaged due to heavy weather condition

 Unclear Information - According to weather routing services and weather report vessel was sup-
posed to encounter max wind force of Beaufort scale 07-08. Vessel kept checking the position and
movement of the low pressure on hourly basis and constantly monitored weather forecast. Vessel
followed route recommendation as per advice of weather routing agency. The vessel was observing
wind force of Beaufort scale 8 and was proceeding at SE’ly course at max possible speed to move
away from the TLD. Suddenly the Vessel started experiencing sudden gust of wind up to Beaufort
scale 10-11, which was not in line with the weather forecast provided to the vessel by weather rout-
ing agency and EGC weather forecast.

Learning From Incident (LFI):

 Heavy Weather Precautions - Heavy weather precautions shall be followed and extra wire lash-
ings shall be taken to avoid damage.

 Situational Awareness - Vessels shall be vigilant to any changes in situation or threats. Heavy
weather precautions shall be reviewed and enhanced with changing conditions.

 Team Work - While preparing the vessel for sea/heavy weather, ship staff shall work as a team and
any short comings shall be brought to the notice of master or C/O.

 Effective communication - It is important to have an effective communication among ship staff.

Any task assigned by the master/ HOD shall be completed and reported back.
 Miscellaneous Alert
No. 030 28 Apr 2023
Heavy Weather Damage
Incident
The vessel was on laden passage in
the south China sea.

During the passage, the vessel faced

heavy weather and wind speeds up to
BF scale 8/9. This resulted in two of
the chemical drums stowed on top of
the midship store broke loose.

The loose drums came in contact with

other drums and caused damaged to
them. As the drums fell down from the
midship, they damaged the midship
store railing as well.

The ballast pump header tank and pi-

lot line were also damaged by the
loose drums. Once the vessel cleared
the TSS and the traffic, the vessel al-
tered course and took the sea on the
port bow. After that, the drums and Heavy Weather Damage
other equipment were secured .

What went wrong?

 Exposure to adverse weather conditions : The vessel experienced adverse weather due to
which she was rolling pitching (moderate ~ heavy) and shipping sprays from port BOW. As the ves-
sel had altered course for avoiding traffic and joining the TSS, the sea and swell came abeam and
vessel encountered heavy rolling. During this time, it was observed that the Tank Cleaning Chemical
Drums (which were stored on top of the mid-ship store) lashing had broken loose and a two of them
had fallen from the top of midship store on the main deck

 Inadequate practice (MSCAT BC 5.8), Inadequate Work Planning (MSCAT BC 8.7): The
vessel took heavy weather precautions by complying with company checklist S-5.10 C -Navigation in
heavy weather, however, the chemical drums kept on top of the midship store were lashed with
ropes. Due to the heavy weather, the lashing ropes came under prolonged & excessive strain and
gave way.

Learning From Incident (LFI):

 Heavy Weather Precautions - Heavy weather precautions shall be followed and extra wire lash-
ings shall be taken to avoid damage. Use of Fiber ropes shall be avoided to take lashings of the mov-
able and heavy objects.
 Securing Points - The securing points of the heavy objects shall be of sufficient strength to sup-
port the load caused due to movement of the vessel.
 Situational Awareness - Vessels shall be vigilant to any changes in situation or threats. Heavy
weather precautions shall be reviewed and enhanced with changing conditions.
 Fleet QHSE Alert
No. 30 28 Apr 2023
MISCELLANEOUS

Blackout and contact at Douala channel

Incident: A vessel was
maneuvering in Douala channel
to pick up pilots for berthing
where she experienced a Own Vessel-
blackout. anchored at Douala
Channel due to
Responding to the emergency, blackout
the vessel dropped anchor near Outbound Vessel-
Buoy No.18, in the dredged aground vessel due
to less space in the
channel. The width of the Channel
channel is about 180 meters.
The vessel informed Port
control and Pilots. While the
vessel was at anchor, one
outbound vessel got aground
close to the vessel’s position.
There were two subsequent
contacts between both vessels Picture showing Own vessel and outbound aground vessel
which resulted in damages to both vessels.
Soon the power was restored, the vessel heaved up anchor and berthed for cargo operation without any
further issues.
A damage assessment was carried out on the vessel which revealed some damages.

What went wrong ?

 Improper operation of Equipment/Machinery- using low sea chest while transiting areas with low
UKC -The vessel was transiting the channel with low UKC, however, the sea chest was not changed to
the upper one. Due to this, the system sucked muddy water from the low sea chest, and thereby the LT
filters got choked which resulted in low flow on the LT cooler outlet side. Subsequently, there was a rise
in A/E temperature and blackout.
 Inadequate communication/Implementation of policy/procedure practice, Lack of Supervisory - The
vessel staff completed the Engine room Pre-arrival checklist, and the 4th Engineer marked in the
checklist that the sea chest has been changed to the upper one, however, the same was not done. This
was not cross-verified by the Chief Engineer.

Learning from Incident (LFI):

 Change over of the sea chest to upper one prior to arrival- Company procedures require vessels to
complete the Engine room Pre-arrival checklist (S-4.10 C) which includes the changeover of the sea chest
to the upper one prior to arrival. The checks to be done diligently by the Duty Engineer and to be cross
verified by Senior engineers where required.
 Emergency response during black out- In the event of a black out whilst in a river, canal or other similar
confined or shallow waters use of both anchors to be considered, where applicable.
 Fleet QHSE Alert
No. 30 28 Apr 2023
MISCELLANEOUS

STBD Gangway wire parted

Incident 1: A vessel was anchored at Singapore anchorage, the STBD gangway was being heaved up to clear
STBD side for the FO Bunker barge to come alongside. While the gangway came up to the deck level, the heaving
wire suddenly parted, and the gangway fell into the water.
What went wrong ?
 Inadequate Maintenance/inspection
- Inadequate preventive lubrication-
The last renewal of the STBD
accommodation ladder wire was
carried out within the company
renewal regime. The last monthly
inspection (including greasing) was
carried out in line with PMS and the
ladder was reported to be in good
condition.
 Wear and Tear- During the
investigation, it was found that the
wire section which broke always
remains stationary during the gangway lowering and heaving. The lower section of the wire on sheaves
remains inaccessible, thus remained ungreased, and subsequently got corroded over a period of time.

Incident 2: A vessel was transiting Panama Canal from the Pacific side to the Atlantic side. During canal
transit, the vessel was underway and picking up the STBD accommodation ladder for securing. During this time,
the accommodation ladder wire parted , and subsequently, the ladder fell and touched the waterline. Luckily
there were NO injuries due to the incident.
What went wrong ?
 Inadequate work/process planning-The accommodation ladder wire could not be renewed during the last
yearly routine, due to the non-availability of new wires on board. The requisition for new wire was raised just
a few days prior to the due date for renewal. The same could not be supplied due to the lead time, trading
pattern of the vessel, and logistic issues.
 Inadequate Maintenance/inspection- The last monthly inspection (including greasing) was carried out as per
PMS and the ladder was reported to be in good condition.
 Wear and Tear-Due to the age-related wear and tear the accommodation ladder wire gave way while
heaving. The close-up inspection of parted wire revealed inadequate greasing, which further contributed to
the weakening of the wire.

Learnings from both Incidents (LFI):

 Maintenance /Inspection- Proper inspection/maintenance of accommodation ladders to be carried out in
line with PMS. Greasing of accommodation ladder wire and other parts to be carried out as part of PMS.
 Special focus- Special attention is to be given to the stationary section of the gangway wire. During the
greasing of the gangway wire, the stationary section is to be slackened and the wire on the sheaves is to be
properly greased.
 Renewal of accommodation ladder and requestion- Renew the accommodation ladder wire yearly or
earlier if necessary. The requisition for Gangway wires and/or other wires to be raised well in advance, at
least 4 months prior to the due date of renewal as per company procedures.
 Fleet QHSE Alert
No. 30 28 Apr 2023
MISCELLANEOUS

Heavy Weather Damages

Incident 1: A vessel was in the Mediterranean Sea and experienced Heavy weather i.e., wind force BF
8~10, and swell height of more than 5.5 meters.
Due to the high swell (greater than 5 meters) from the STBD beam and quarter, the vessel was shipping
heavy seas. Due to this, the vessel sustained several damages.

What went wrong ?

Lack of Risk perception and Lack of Supervisory- The rough weather was extended over a large area in the
Mediterranean
Sea, so it could not
be reasonably
avoided. Though
the speed and
heading
adjustments were
carried out, but the
heading was not
sufficiently
adjusted to reduce
the impact of
rough weather, by
reducing the
shipping seas,
which caused
damage to deck
equipment. Weather forecast indicating surface winds
 Fleet QHSE Alert
No. 30 28 Apr 2023
MISCELLANEOUS

STBD accommodation Ladder damage

Incident 2: A vessel was on a voyage from Klaipeda (Lithuania) to San Juan (Puerto Rico).
During the voyage, while in the North Atlantic Ocean, the vessel experienced heavy weather (Westerly wind
BF 10 and swell 6~7 meters) with shipping seas on deck and subsequently sustained damage to the STBD
accommodation ladder.

Weather forecast indicating surface winds

What went wrong ?

 Lack of Risk perception- The vessel’s proposed route was shared with Storm Geo (weather intelligence
and ship routing services) and no deviation was recommended by them in their advice .
 Exposure to adverse weather- As per the weather reports received, the vessel was expected to
encounter winds of BF 7~8 and a swell height of 4~5 meters. The weather conditions (wind & swell)
experienced were more severe than what was forecasted (expected).
 Lack of Supervisory- Though the speed and heading adjustments were carried out to reduce the effect
of rough weather, the rough weather was extended over a large area. An early deviation from the
planned (recommended) route would have helped the vessel in avoiding the most vulnerable area of
rough weather, if the risk would have been perceived earlier.

Learnings from both Incidents (LFI):

 Weather assessment- Weather assessment to be done prior to commencing the voyage.
 Deviation from planned route and/or adjustment of speed/ETA- Check for any heavy weather forecast
on the route and if it will require deviating from the planned route, or adjustment of speed/ETA, to
maintain sufficient distance from the storm center/low-pressure area.
 Adjustment of heading and speed- When heavy weather is encountered, the heading and speed of the
vessel should be sufficiently adjusted to reduce the impact of rough weather to avoid damage to the
ship’s equipment due to shipping seas.
 Fleet QHSE Alert
No. 30 28 Apr 2023
MISCELLANEOUS

Adverse Terminal Feedback

Incident: A vessel berthed STBD side alongside Lyttelton Oil Berth. While the vessel was rigging the
accommodation ladder, there was inadvertent discharge of Ballast Water over oil berth jetty. Later, vessel
received adverse terminal feedback for this ballast discharge.
What went wrong ?
 Inadequate Equipment familiarization– This vessel’s BWTS is provided with auto-backflush overboard
on both sides, Port and Starboard. Although auto flushing unit (AFU) operation is automatic at the time
of system start and during BWTS operation, the manual menu on the BWTS control panel allows user to
select off-shore side AFU overboard discharge. The Chief Officer did not open off-shore side AFU
overboard, resulting in flush water being directly discharged on to the jetty for a brief period. The deck
ratings noticed water discharge towards the terminal and Chief Officer promptly shut down BWTS, total
time of flush water discharge was about 20~30 seconds.
 Inadequate reporting- This incident was not proactively notified by the Master, he remained under
assumption that this is not T/C reportable deficiency.
Learning from Incident (LFI):
 Familiarization with equipment- The officer responsible for operation of equipment shall make himself
familiarized with the equipment by studying the Operation manual. He shall conduct training sessions
with other staff involved in operation of the equipment.
 Quick reference Poster- Where there are specific constraints related to an equipment (BWTS in this
case), a poster to be displayed near the equipment, so as to serve ready-reckoner to the duty officer/
duty engineer prior commencement of operation.
 Incident reporting-The incident reporting should be carried out in line with company procedures and
voyage instructions.

D&A positive result

Incident: A vessel received annual unannounced randomD&A test results wherein the 4th Engineer was
found positive for Marijuana. The test was carried out by an external agency appointed by the company as
part of yearly unannounced random D&A test.
What went wrong ?
 Use of During the investigation, the concerned staff reported that he was using “Tab Cannapain plus”
while he was at home for a sprain in his leg. The company Doctor confirmed that it is very likely that the
use of “Tab Cannapain plus” can result in a positive test for Marijuana in which Cannabinoids are the
active ingredient.
 Lack of Risk perception/ Risk awareness- Reportedly, the 4th Engineer bought this medicine over the
counter on the advice of the medical store person. The 4th Engineer did not perceive the risk of taking
un-prescribed medicine over the counter.
 Inadequate detection of Drug during pre-joining medicals– The pre-joining drug and alcohol test did not
indicate any Drug abuse.
Learning from Incident (LFI):
 Prescribed medicines should be obtained only after consulting a certified medical practitioner.
 Company will carry out evaluation of Clinic where pre-joining D&A test of concerned staff was carried
out.
 Fleet QHSE Alert
No. 30 28 Apr 2023
MISCELLANEOUS

Alcohol Policy Violation

Incident:The vessel was loading cargo in the USA and the crew went on shore leave. One of crew
member had consumed alcoholic beverages along with his lunch.

While returning to the vessel, the Terminal security watch person identified that the crew member was
inebriated and was not in his sense.
The crew member was not allowed through the terminal gate and a senior officer stayed with him for
support. The agents arranged for a boat for him to board the vessel from the seaside in consultation
with the master.
Upon boarding the vessel, an alcohol test was carried out and his BAC content was found above the
permissible limit. As the test was positive, the crew member was relieved from his duties. The incident
was promptly reported to the company and other stake holders. The crew member was relieved and
repatriated to his hometown. Occurrence of above non-compliance was not only in violation of the
Valero Meraux Terminal Guideline but also the Company’s Drug & Alcohol policy.

What went wrong ?

 Failure to follow Procedures - Upon arrival at the terminal gate, the crew member was in an
inebriated state and not in his senses. This was a noncompliance of the terminal’s safety
procedures. Upon boarding the vessel from the seaside, the master checked the alcohol content of
the crew member and it was found to be above the allowable limit of 0.04 BAC. This was a
noncompliance of the company procedures.

 Inadequate Discipline - All seafarers had signed an undertaking that they will comply with the
D&A policies of Manager. The crew member was in violation of the company’s D and A policy. A
breach of alcohol policy is considered as a breach of discipline.

 Condone deviation from policy and Procedures - The crew member had gone shore leave
along with senior officers. The senior officers were aware of him having hard drinks on shore leave.
However, neither of the senior officers had given a word of caution to the crew member about the
possible violation of the company’s D and A policy.

Learning from Incident (LFI):

 Compliance with Policy: The ship’s crew shall always comply with the owner’s and managers
Drug and alcohol policy.
 Owner’s Policy: If the owner’s drug and alcohol policy are more stringent than managers, than the
owner’s policies will take precedence.
 Role of Gangway Watchkeeper: The gangway watchkeepers shall report any attempt of bringing
unauthorized alcohol on board.
 Reporting: Any suspicion of alcohol abuse shall be escalated to senior staff as this is a safety
concern for all on board.
 Safety Culture: Senior staff are encouraged to spread awareness on alcohol abuse and relevant
section of the QHSE manual. Any instance of alcohol abuse noted by the senior officers shall be
addressed and brought to the notice of the company.
 Fleet QHSE Alert
No. 30 28 Apr 2023
MISCELLANEOUS

Overdraft at Panama Canal

Incident:
The vessel was on laden passage and was under
pilotage while transiting the Panama Canal on
west bound transit (Atlantic to Pacific).
The local agency had indicated draft restriction
of 12.04m tropical fresh water for the transit.
However, at 3rd Gatun lock, vessel’s draft was
visually checked by the pilot, and he noticed that
vessel was over-draft by 15cms, due to which,
vessel’s further transit was not allowed.
The issue was promptly informed to the
charterers, owners and the company. On
considering the available options, it was decided
to transit back to the Atlantic side. The vessel
transited the atlantic side and investigation
revealed excess ballast. The Vessel de-ballasted
and achieved the transit draft. The vessel
completed the transit of the Panama canal after
delays of about 5 days 13 Hours.

What went wrong ?

 Improper Attempt to save time and effort - During the transit of the Panama Canal, the vessel
was found to be overdraft. The overdraft was caused due to the presence of the excess ballast on
board the vessel. The ship staff was not aware of the excess ballast on the vessel as –
• The manual soundings at the load port and during the passage were not taken.
• The water density at the load port was not verified.
• The visual drafts were not checked and not compared with the loadicator figures.
• Stripping of the ballast tanks was not carried out.

 Inadequate Communication/ Implementation of the policy/ Procedures/ Practice - The

company provides adequate guidelines on the importance of joint planning of the cargo operations.
However, the cargo planning and the stowage was not adequate. The chief officer had planned the
cargo loading condition with excessive ballast. The stowage plan and the cargo plan were presented
to the master for approval however, they were not cross checked and verified.

 Lack of Supervisory - The master had received an early indication from the Panama Canal
Authority about a possible breach of draft. However, it was not taken seriously. There was an
evident lack of communication between the master and the chief officer as the Panama Canal
authority concern was not relayed to the chief officer, which could have prompted him to reverify
the drafts and/ or check the deadweight calculation

Learning from Incident (LFI):

 Draft Comparison: The ships staff shall compare the drafts during the loading operations as safely
practicable while complying with the terminal guidelines. This shall be compared against the
loadicator in order to find out any discrepancies.
 Reliability of remote Draft Gauges - The remote Draft Gauges shall be compared with the
manual readings and shall be recorded in the company form.
 Dock water Density - While comparing the drafts, it is equally important to use the correct dock
water density as it will have impact on the draft readings.
 Ballast water - When making the ballast tanks empty, the tanks shall be stripped well at an
appropriate trim which is advised in the Ballast water management plan. This ensures maximum
loadable cargo quantity.
 Fleet QHSE Alert
No. 30 28 Apr 2023
MISCELLANEOUS

Bottom Touch
Incident:
The vessel was planned to be berthed and Pilot boarded the vessel. As per the pilot’s information and
agent’s confirmation, the berth had a minimum depth of about 9.8 Meters. The vessel had drafts of
8.60 Meters.
During the berthing operation, the vessel remained about 1~1.5 Meters away from the berth. The
vessel suspected bottom touch at forward and a lead line measurement confirmed depths to be about
7.5~8.0 Meters.

The issue was reported to the pilot, port, company, agent, P&I and other stake holders. Terminal
authorities boarded the vessel to discuss further action.
On consultation with the company. It was decided to shift the vessel to Berth 28. No ingress was
reported by vessel. The vessel was later shifted to another berth and completed her cargo operation.

The vessel was attended by the class and during the class inspection, no damages to the hull or
interiors were noticed.
What went wrong ?
 Port and Berthing Facilities - During the berthing operation, the vessel remained about 1~1.5
Meters away from the berth and the vessel suspected bottom touch at forward. The vessel arrived
with a draft of about 8.60 Meters. The agent had informed in pre-Arrival Message, the location of
the of NERI Berth 27 and Max authorized draft allowed at berth is 9.00m. However, at the time of
the incident, the depth on the STBD side in way of No.2 WBT was found to be 7.5 m. Due to this,
the vessel touched bottom on a bank due to silting near one end of the berth which was not
reported or known to the ship’s staff.

Learning from Incident (LFI):

Terminal Information - The vessel had carried out due diligence in requesting the data from agents
and the pilots. However, the terminal’s information was not correct. As a good practice, it is prudent to
extract the local information from the agents/ terminal/ pilot. If in doubt, the masters shall take
guidance from the company superintendent.

Alleged contact with SBM while Unberthing

Incident:
The vessel had completed unloading at the terminal, and hose disconnection/unmooring from SBM was
in progress.
Prior commencement of lowering the chain, the vessel came close to within 5~10 meters of the SBM.
Master informed the pilot and used astern propulsion to increase the clearance from the SBM.
The vessel completed unmooring operation from the SBM and while the loading master was
disembarked from the vessel, he informed the pilot in the local language that the vessel might have
made an alleged contact with the SBM.
The issue was reported to the company and other stakeholders. However, there was no Letter of
protest issued by the terminal to the vessel in this regard. The issue was reported to the P and I club as
per their recommendation a counter LOP was not issued.
 Fleet QHSE Alert
No. 30 28 Apr 2023
MISCELLANEOUS

Alleged contact with SBM while Unberthing

What went wrong ?

 Substandard act by external party (Terminal and Tugs) - The vessel had completed the
cargo operation and was about to commence unmooring operation from the SBM. The vessel had a
pullback tug which was made fast in the aft. However, the aft tug had stopped pulling the vessel
without informing the bridge or the pilot and before the forward station could be adequately
manned for unmooring. As a result, the vessel drifted close to with in 5 meters of the SBM.
 No Mooring Master was deployed by the Terminal to coordinate unmooring operation between ships
staff, tugs and Pilot. present forward for unmooring Operation.
 Inadequate Communication/ Implementation of Procedures/ Practice. - The vessel was
moored at the SBM and a lookout was maintained at the forecastle deck to report the distance from
the SBM. The lookout reported the distances at regular intervals which as recorded in the vessel’s
port log. However, while the vessel was preparing from unmooring operation, the lookout person
momentarily left his station to renew his battery.
 While he informed the CCR while proceeding to change his battery, this was not reported to the
bridge. He left the forecastle deck at a critical stage of operation, without a suitable replacement.

Learning from Incident (LFI):

 SBM Procedures - The SBM procedures require a ship staff to be standby at forward stations to
monitor the SBM position regularly. The person manning the forward station shall not leave the
station until properly relieved.

 Situational awareness - The presence of pilot on the bridge does not mean that the bridge team
is relieved of their duties. The duty officer shall keep monitoring the vessel’s position and shall
report any of the concerns to the master and the pilot.

 Presence of Mooring master - The masters shall confirm with the terminal about the mooring
unmooring procedures from the terminal and the presence of a mooring master in the forward. If a
mooring master is not present, then the supervising officer shall be briefed accordingly.
 Fleet QHSE Alert
No. 30 28 Apr 2023
MISCELLANEOUS

Damage to Gangway due to surging at Jetty.

Incident:
A vessel was berthed at VITCO Terminal Jetty 1, Zarate- Argentina for discharging part cargo of ULSD.
The Vessel surged heavily due to passing of a larger vessel. Vessel’s port gangway was damaged due to
surging.

What went wrong ?

 Port & Berthing facilities - Terminal , lies in a narrow river, which is frequented by regular
inbound and outbound traffic. The moored vessel at the berth is exposed to the effect of
hydrodynamic interaction forces (Surging) due to vessels movement in the river.

 Operating at improper speed, Sub-standard act by 3rd party - The close and high-speed
passage of large vessel near to the berth resulted in the sudden strong surging of the vessel at
berth due to hydrodynamic interaction. This led to vessel coming out of berth by about 3 m
resulting in stretching/damage of cargo hose. Excessive suction forces caused tension on the
mooring lines due to which mooring winches brakes were rendered. The fore and aft surging caused
the shore 16 feet portable aluminum MOT to bend.

 Terminal did not provide any information in advance regarding passing of another vessel at close
range with high speed. No safe access to shore was available other than ship’s gangway. Breast
lines although perpendicular, were too long.

 Lack of situational awareness/risk perception/risk awareness - Although vessel was

securely all fast, ship staff did not consider the fact that if another vessel will pass at a very close
range with high speed, this could result in surging & will cause the vessel to surge.

 Inadequate Risk Identification - Surging risks were not adequately identified by the ship staff.
The ship’s staff did not monitor the mooring lines adequately while other vessel was passing at a
near range.

Learning from Incident (LFI):

 Adequate mooring configuration: The mooring configuration should be enhanced Where there
is a possibility of surging at berth due to passing vessels in the busy/narrow channel.

 Adequate warning about passing vessels near the berth: The vessel should make an
agreement with the terminal/VTS to warn them if any vessel is proceeding at excessive speed in the
channel.

 Monitoring of mooring lines - The ship staff shall monitor the mooring lines regularly in ports
where the adjacent water way is busy and there is a risk of surging.
 Fleet QHSE Alert
No. 30 28 Apr 2023
MISCELLANEOUS

Drifting towards the buoy while swinging in the channel.

Incident:
After completion of loading at a terminal, Pilot boarded vessel for shifting the vessel to another berth
with in the Euro Port. After casting off, the vessel was supposed to take a port turn near buoy NW-3
and enter channel CALANDKANAAL from channel NIEUWE WATERWEG.
While turning to keep clear of another inbound vessel which was entering channel CALANDKANAAL the
turn of the vessel was over-reached, and she drifted close to MAAS 5 buoy.

Pilot with assistance of the tug cleared the vessel from buoy MAAS 5 and vessel was safely made fast
to the next berth.
What went wrong ?
 Improper Position for Task - Vessel was partially loaded and was in congested water,
considering factors such as turning circle, traffic in the vicinity, depth and width of the channel, pilot
should have commenced the turn from more STBD side of the channel NIEUWE WATERWEG as per
the passage plan where the width and depth of the channel is more or he could have passed the
Noorderdam Break water and executed the turn where there was sufficient sea room for the vessel
to turn around.

 Substandard Act by External Party - Pilot did not discuss with the bridge team about the
inbound vessel Navig8 Universe nor communicated with the inbound vessel and confirmed her
intentions.

 Lack of situational awareness/risk perception/risk awareness -

 There was a Lack of communication between pilot and the bridge team and Over reliance on pilot.
 Factors such as turning circle, traffic in the vicinity, depth and width of the channel was not
effectively considered.
 When it is necessary for the vessel to turn around in a restricted room due regard shall be had to
the available room for turning with respect to vessel’s length, prevailing currents and weather
conditions. The maneuver shall be carefully planned using the assistance of Bow thruster and tugs.
 An officer in charge with radio was not kept standby Forward and Aft to confirm vessel has sufficient
clearance from identified marks and or hazards.

Learning from Incident (LFI):

 Bridge team Interaction - The bridge team shall communicate adequately among themsleves. It
should not over rely on the pilot.

 Turning in a narrow channel - The bridge team shall consider factors such as turning circle,
traffic in the vicinity, depth and width of the channel.

 Restricted Sea Room - When it is necessary for the vessel to turn around in a restricted room due
regard shall be had to the available room for turning with respect to vessel’s length, prevailing
currents and weather conditions. The maneuver shall be carefully planned using the assistance of
Bow thruster and tugs.

 Monitoring of the turn - An officer in charge with radio shall be kept standby Forward and Aft to
confirm vessel has sufficient clearance from identified marks and or hazards.