Smoke inside Bosun’s Store on LPG tanker

Initial report

As a laden LPG tanker prepared to depart a berth with a pilot embarked, smoke was detected in the Bosun’s store in which the motors for the hydraulic winches were housed. The motors were immediately stopped using the remote shut-off controls and the Master immediately suspended the unberthing operation to allow the alarm to be investigated.

Once the smoke had cleared it was discovered that loose screws were allowing lubricating oil to leak onto the hot motor which started to combust. To enable the vessel to sail, the Master allowed the winches to be restarted for a very short time to allow mooring ropes to be slacked off before the motors were once again stopped. The ropes were recovered by hand. Keeping the winch switched off was the only sensible precaution to avoid a significant fire or explosion.

After the vessel had departed the port, full cleaning was carried out to thoroughly investigate where the source of the leakage had come from. The engineers carried out maintenance on the winch hydraulic pumps and replaced the gaskets to prevent further leakage.

The reporter stated that this incident was the result of a near-miss being ignored for a long time, with maintenance not being done properly because the ship’s staff believed that the new ship was poorly built.

The potential consequences of an explosion on a laden LPG tanker in a port are obvious

CHIRP Comments

This incident reinforces the power of acting on near-miss reports. CHIRP was informed that the crew had known about the loose screws prior to the incident but had not tightened them. If they had, the fire would not have occurred. Fortunately, the fire was immediately extinguished but the potential consequences of an explosion on a laden LPG tanker in a port are obvious.

The comments about the vessel’s build quality cannot be substantiated, but CHIRP acknowledges that a crew’s belief that their vessel is poorly built can significantly erode morale and could result in a culture of not caring about the material condition of the vessel. However, the speed with which the loose screws were fixed shows that this repair was easily within the crew’s capability. The fact that they had not been fixed suggests that the inspection and maintenance routines on board were not being properly carried out and furthermore indicates that supervision was also lacking.

Readers are invited to contrast this report with M1761 (published in Maritime FEEDBACK 64) in which a replacement Master and crew took over a vessel with many defects but immediately took ownership of the vessel’s condition and worked to fix all the engineering and documentary shortcomings.

Human Factors relating to this report

Culture – Whether or not the crew’s belief that the build quality of the vessel was sub-standard was correct, they believed it to be the case, and such concerns must be taken seriously and properly addressed. Crew morale can significantly impact the quality of work undertaken. In this instance the consequences could have been horrific: significant loss of life on board and in the port, considerable infrastructure damage and a major environmental pollution incident. Readers who are in management positions are encouraged to consider how they would address similar concerns from their crews to ensure that morale and pride can be maintained?

Alerting – Convincing busy crews of the value of near-miss incident reporting is difficult because a near-miss does not result in injury or damage. But such reports offer valuable insights into what could happen in the future if they are not acted upon. In this incident, the consequences could have been enormous. In general, people are reluctant to report near-misses because they do not like to admit mistakes. To improve near-miss reporting, managers need to encourage and celebrate those who make reports, make the reporting system as easy and user-friendly as possible, and (most importantly) take every report seriously and act on it as appropriate.

CHIRP published an in-depth report on the value of near-miss reporting in its Annual Digest 2020 which readers can find on our website.

Report Ends……………………………