Good equipment design can eliminate operating and maintenance hazards. In this case, it could have been possible to design the crane to be lowered to the deck to allow maintenance to take place without ever sending someone aloft. If that were not possible, the designer could have added hand-holds and connection points for safety harnesses to be attached so that the crew had safe access.

When accepted into service by the Flag State and Classification Society, did either organisation audit the maintenance routines to ensure they were safe? It is unlikely that either body would agree that sending people aloft by balancing on greasy wires is a safe system of work.

Is this then a poor local practice? If so, it is sadly a common practice that occurs on many ships. CHIRP questions why the wire cannot be run out onto the deck and grease added as the wire is rewound in?

The maintainers are wearing loose plastic overshoes – this is a common (but unsafe) way of keeping your footwear clean and avoiding transferring the grease from the wires onto the deck. However, grease and loose overshoes significantly increase the likelihood of slipping and falling, and you should carefully consider the risks if you use them.

The crew member in white overalls appears to be wearing only a harness around the waist, not a full-body harness. An incorrect or badly fitted harness increases the risk of internal injuries when coming to a sudden stop at the end of the lanyard.

Fall arrestors reduce this shock but need you to fall another 2-4m to work correctly. If there is insufficient clearance to fall this distance without hitting an object or the deck, the wearer could hit these objects at full speed and be seriously injured. In the photograph, the crew members would likely fall onto the crane arms before their safety harnesses could work.

Hanging motionless in a harness restricts blood circulation and can cause breathing difficulties (this is often called ‘suspension trauma’) if you are not rescued within 15 minutes. If you are sent aloft wearing a harness, make sure there is a rescue plan in place. A rescue plan is a pre-planned procedure to safely retrieve someone suspended at height in a harness. It should also be regularly practised to ensure it can be done safely and quickly.

If your ship uses safety harnesses for working aloft, make sure there is a rescue plan in place.

CHIRP questions why this task could not have been delayed until the weather had improved and wonders if this is an indicator that the ship’s programme was too full to allow maintenance to be properly and safely completed.

The pilot made the right decision to abort the planned manoeuvre in restricted waters because he did not have confidence in the main engine. Luckily the incident occurred in an area where tugs and shore assistance were readily available.

The exhaust valve failure so soon after the previous maintenance interval could indicate poor engineering standards. These can result from insufficient training, supervision or time to adequately maintain the spares. It could also result from inappropriate procurement choices: cheap and poor-quality parts may not last as long as expected.

Items identified as critical spares should be in a good enough condition to be used when needed. None of the three spares carried was in this condition, which could be bad luck or an indication that they were listed as a critical spare for documentary, inspection and audit purposes only. The company had concerns because they ordered a fleet-wide review of spare parts.

Either of the vessels could have slowed down to avoid a close-quarters situation at the entrance to the TSS deep water lane. It is considered unlikely that a few minutes’ delay at this point would materially change the arrival time at their next port. The container vessel could safely have navigated the alternative lane to the east but ignored the pilot’s advice to do so and entered the lane to the south, against the general direction of traffic flow for that lane.

Did the container vessel’s Standard Operating Procedures empower the OOW to amend their speed (i.e. slow down) or amend their nav-track to allow them to proceed in the alternative lane. If not, the master should be called.  Slowing down could have generated the space to avoid a close-quarters situation and provided more time to assess the situation. CHIRP encourages watch officers to think in terms of ‘time’ as well as ‘space’.

When approaching a congested area such as the entrance to a traffic separation scheme, it is good practice to prepare a contingency plan if the situation allows, and identify the time or place by which you need to make a decision. In this case, the container vessel had a choice of two traffic separation lanes and, when it became apparent that the tanker was using the deep water route, could have elected to use the alternative route to the east.

The action by the container vessel was very hazardous and contravened international regulations regarding traffic separation schemes; good seamanship demands that vessels use the correct lane and proceed in the general direction of traffic flow for that lane.

Establishing a tow between a tug and ship should be conducted at as low a speed as practicable in the circumstances and conditions to give the tug greater manoeuvrability and avoid it departing from the “safe zone” where dynamic interaction is less likely to occur.

Ship masters (especially pilot-exempt masters) and tug masters must thoroughly understand the theoretical and practical aspects of safe tug/ship operations.

Tugs should be fit for the purpose for which they are being used, with sufficient power and manoeuvrability for the intended operation, and should always comply with stability requirements. Down-flooding will quickly erode any stability reserves and will be a significant factor contributing to a capsizing. During critical or high-risk operations, all doors and other openings that need not be opened should be securely closed.

It is considered necessary for tug masters to have a good understanding of the elements of tug stability. They need to know where the limits are and the consequences of tug handling practices not conforming to the rules of stability in normal circumstances.

A tug’s stability is not a static condition but can change rapidly due to the evolving forces acting on the tow line and the dynamic interaction between the tug and its tow. These changing forces can negatively affect the tug’s stability if they are not adequately monitored and controlled. In this case, as tragically shown in this report, it culminated in the capsizing of the tug with loss of life.

The uncontrolled release of stored pressure is a recurring factor in many reports received by CHIRP. Working on stored energy systems (heat, pressure, potential, tension etc.) always requires additional care, and CHIRP encourages the use of written checklists to confirm that the pressure is reduced, e.g. in this case, by ensuring the pressure relief valve was open before work was started.

Distraction or forgetfulness could have been a factor, especially given that the time gap between the toolbox talk in the morning and the work taking place in the afternoon was almost 6 hours. During that time, the material state of the system could have altered, and furthermore the team could have forgotten critical pieces of information eg whether the pipe was pressurised or not.

The PtW system is an independent audit that a safe system of work is in place. By signing the PtW and then conducting the work, the senior engineer undermined the critical supervisory value of the PtW. CHIRP suggests that where the senior engineer is the only one qualified to do the work, another engineer assess the PtW prior to it being signed off. This does, though, rely on the senior engineer being willing to be held to account! The work had been completed a month earlier with two qualified officers. Cadets are not qualified and are still under training. The Permit to Work and the RA should have identified the experience required to carry out the job.

Although 1.5 bar pressure may not seem high, in anything other than a very short pipe it would be sufficient to eject a significant quantity of liquid as the pressure was released. The temperature of the liquid suggests that not enough time had been allowed for the liquid to cool after the pipe was isolated. Does this indicate that the team were under time pressure?

Toolbox talks are a good safety management tool, but they must be carried out in an environment where everyone can hear what is being said and respond accordingly. The toolbox meeting was conducted in the morning but the work did not start until after lunch. Because of this time delay, the toolbox meeting should have been repeated.

There have been a number of incidents of tugs foundering, and in several cases the common cause was the leaving open of weatherdeck doors . Although this may make it easier to access internal compartments it compromises the tug’s watertight integrity and is an incorrect and unsafe local practice. Watertight doors must be closed during towing operations, especially during heavy weather.

This report again reinforces the need to understand the stability characteristics of the tug doing the towing.

The forecastle is particularly prone to wind updrafts, and eye protection should never be removed until the job is completed.

It is well-known that many types of eye protection can mist up with moisture, blurring the worker’s vision. Some poor-quality goggles can be poorly fitting which makes them uncomfortable to wear, so the temptation to remove the goggles can be compelling. If this happens, stop the work, clean the goggles or adjust them, but never remove them while the work is still taking place.

We only have one pair of eyes, and every effort must be made to protect them.

Common thoughts – I do not need them; it will only take a second; no problem, I’ll be ok; the goggles are uncomfortable; I’ll use my sunglasses. Sounds familiar?