Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2154
Initial Report
During a daylight approach to a buoyed channel, the main engine of a loaded tanker was stopped to allow more time for congestion at the berth to clear. On passing the harbour’s outer entrance, the main engine was requested to Dead Slow Ahead but failed to start. Several minutes elapsed without explicit information from the engine room as to the nature of the problem, which eventually appeared to be a control issue with fuses.
The engineers, on request by the master and pilot, could not establish local control of the main engine immediately, so it was decided to dredge the starboard anchor to a temporary anchorage close to the safe water area. A tug was requested at the location to assist in relocating the vessel to a designated anchorage area. The engineers eventually provided local control of the main engine. Approx. 2 hours later, the tug arrived on location and was made fast forward before commencing weighing anchor. The vessel was towed to the designated anchorage using the local control of the main engine as required. The vessel remained anchored for three days while repairs involved the Class surveyor’s attendance.
The reporter’s concern was the excessive time to assess the mechanical problem necessitating the immediate need to anchor and the need for more familiarity with the emergency side controls.
CHIRP Comment
The report highlights that accurate assessment skills and familiarity with maritime emergency equipment are crucial in ensuring the safety and effectiveness of maritime operations. The importance of experience in identifying the causes of engineering problems is highlighted, emphasising the need for the engine team to engage in collective thinking to enable effective collaboration with the bridge team for anticipating and planning necessary actions.
However, infrastructure support and assistance availability can vary depending on the vessel’s location, adding extra complexity to emergencies.
In terms of training engineers to collectively address engineering problems, the Short Term Strategy (STS) approach is recommended, especially when no predefined rules or procedures are available. Conducting meetings in the Engine control room to discuss the problem, assess risks, and evaluate available time can significantly enhance teamwork, establish a shared mental model, and improve communication between the engine and bridge teams. This collaborative approach helps ensure a coordinated response to challenges.
The report also suggests that engineers should be well-versed in operating side controls specific to their ship and practice using them regularly to maintain familiarity with the systems. Requiring every engineer to operate the side control at least once during their tour of duty (typically every three months) can help keep their skills sharp and ensure they can effectively manage critical equipment.
The report also acknowledges the professionalism displayed by the master and pilot in the specific incident mentioned. Their actions were in line with the severity of the engine problem, reflecting their expertise and ability to handle challenging situations appropriately.
Key Issues relating to this report
Alerting- Keeping the bridge informed of the problem in the engine room is vital. Information exchange should be concise and clearly transmitted. If you are still trying to figure out the problem, say so. The bridge team can act on this information and make contingency plans. The bridge team should understand that problem-solving can be challenging and consider it during contingency planning.
Teamwork- Create a shared mental model of the problem and encourage challenge. This is a skill set that all operational leaders should be trained to apply during emergency response operations.
Capability- Ask the question on your next ship- do we all know how to operate the engine emergency side controls? When was the last time you practised using them? DPA/Ship managers should request to see the ESC in operation when circumstances allow.