Початковий звіт
The vessel was undocking following a successful survey in dry-dock. The plan was to move to an inner anchorage to conduct sea trials before her scheduled departure. The vessel was in a very light condition with a draft of 5m and a freeboard of 17m.
The deck and engine room teams completed their pre- departure procedures, but the main engine was not tested. A passage plan had been prepared, and this was given to the pilot by the master. Three dock masters were also in attendance. Strong winds were forecast (27 knots with gusts of up to 35 knots) from the port side.
Five tugs were in attendance, with two attached to the bow, one attached to the stern and two others standing by. The main engine was set to ‘Stand By’, and the vessel was pulled out of the dock by the tugs. As the vessel exited the dock, the two tugs at the bow were released and the bridge ordered ‘Dead Slow Astern’ on the telegraph. The engine failed to respond, and the vessel started to drift to starboard because of the strong winds.
One of the tugs was directed to make fast on the port side and pull the vessel to port. The tug attached to the stern was not directed to do anything, so it did not assist.
The vessel drifted onto a newly-built moored vessel which was extensively damaged, as were some of the nearby shore facilities. Fortunately, there were no casualties or pollution. Shortly afterwards, a third tug was made fast on the port side, and the pilot was able to manoeuvre
the vessel to the allocated anchorage. An investigation undertaken by the authorities, owners and the engine manufacturers found the exhaust valves had not been properly calibrated whilst in dry-dock.
Коментар CHIRP
Manoeuvring into and out of a dry dock would be an unfamiliar operation for most ship crews. Our maritime advisors questioned why the vessel was allowed to undock, given the very strong winds, and asked if this was due to commercial pressure?
The presence of three dock masters and five tugs suggests that a plan had been developed. Still, the lack of a coordinated response to a reasonably foreseeable event (the engine failure) indicates that the emergency response plan was missing or inadequate. Most tugs can push more powerfully than they can pull, but the three available tugs were not ordered to ‘push on’ to arrest the drift caused by the strong wind.
The fact that the main engine was not tested before departure, despite undergoing significant repairs, is a major failing concerning risk mitigation and reflects poorly on the management, supervision, and the organisation.
Given the proximity of nearby vessels immediately outside the dry-dock and the prevailing onshore
wind conditions, the risk assessment, including the consequences for loss of control, was not considered. Nor was emergency anchoring considered.
The dry dock pilot should have insisted that the main engine be tested before departure. Was this raised during the master-pilot information exchange?
Фактори, що стосуються цього звіту
Situational Awareness (SA) – Collective situational awareness is based upon formal Risk Assessment and the adoption of agreed Standing Operating Procedures. It also relies on everyone understanding the plan and their part in it and knowing what to do if things go wrong (the emergency response plan).
Capability – The crew in this incident did not have recent experience of undocking a vessel and had to rely on the three dock masters. Did the difference in experience and capability make it difficult for the crew to raise questions or concerns? When writing the risk assessments for uncommon or infrequent tasks, do you consider’ capability’? How does your ship empower a ‘challenge’ culture?
Pressure – The undocking went ahead even though the weather conditions were unsuitable. Dry docks usually are fully booked, and overstaying can be financially costly. Did the master and crew feel under pressure to undock even though the conditions were unsafe?
Teamwork is situational: crews who perform strongly in familiar situations may not do well when facing unfamiliar challenges. This takes time, leadership and open communication. How does your company ensure that your team is ready to face its next task?
Training – The crew did not respond appropriately to the machinery breakdown. Do you regularly conduct machinery breakdown drills on your vessel?
Manoeuvring into and out of a dry dock would be an unfamiliar operation for most ship crews. Our maritime advisors questioned why the vessel was allowed to undock, given the very strong winds, and asked if this was due to commercial pressure?