CHIRP (Confidential Hazardous Information Reporting) reports

October 6th, 2018 by JCB
Posted in Incidents & Investigations, Technical and Training | No Comments »

Members may wish to familiarise themselves with the following incidents which could or did happen in pilotage waters.
The organisation CHIRP, or Confidential Hazardous Information Reporting, is an independent non-profit organisation that receives reports on safety which are then assessed and published. The Association is privileged to have two advisers to the organisation from our membership. CHIRP also produce reports and guidance publications, the most recent being on fatigue management.

Bow Thruster Availability  | 8 th March 2018

Outline:    A misunderstanding when changing over the control position for a bow thruster.

What the Reporter told us:

I was recently piloting a vessel and experienced an issue whilst changing over the bow thruster control from the central station to the starboard bridge wing. The Master and Chief Officer (of different nationalities) had some misunderstanding as to the correct procedure to transfer control. This resulted in the Master becoming flustered, running from the bridge wing to the wheelhouse whilst the vessel was approaching the berth. I had to intervene and ask the Master to stay at the bridge wing control for engine movements. Two tugs were made fast, so the bow thruster was not crucial for the manoeuvre. Eventually the problem was resolved and thruster control was made available should it have been required.

CHIRP Comment:

The Maritime Advisory Board commented as follows; The report demonstrates a lack of understanding of the bridge equipment and changeover procedures. It is essential that changeover procedures are clearly understood and implemented. Testing of the changeover procedure should form a part of pre-arrival checks. In addition, the design of the changeover of controls should provide for a simple, unambiguous process, with appropriate operational instructions.

Human element issues can be noted in the lack of situational awareness and communication between the bridge team members. Since two tugs were made fast, the bow thruster might not have been needed. Nevertheless, as a generic learning bow thrusters should be tested prior to arrival so that they are available in case of any emergency. Report ends…

Categories: Alerting, Capability, Communication, Communication, Complacency, Culture, Design, Local Organisation, Pressure, Situation Awareness, Teamwork, Training.

Helmsman Error  | 8 th March 2018

Outline: A report outlining a loss of concentration by the helmsman whilst under pilotage.

What the Reporter told us:

On the northern bend in a port approach channel, the helmsman put the wheel to port instead of to starboard. The Pilot and Master immediately picked up the error and rapidly corrected the helmsman. A few minutes later the Pilot ordered starboard five degrees helm, but the helmsman seemed to be disorientated and left the wheel amidships. The request was reinforced by showing a hand direction to starboard prior to the helmsman refocusing his attention. Initially the helmsman seemed to be very alert, but his performance deteriorated quite suddenly during the pilotage. This occurrence was near midnight and reinforces the fact that crew fatigue can creep in at any moment, especially around the hours between midnight and 0300 hours when the body clock is most susceptible.

CHIRP Comment:

CHIRP contacted the DPA and were disappointed that there was no response. The Maritime Advisory Board commented that this is an example of effective bridge team supervision, and noted that best practice is to reinforce a helm order with a hand movement indicating direction to ensure that the request is understood. It was noted that fatigue is a possibility but there are other potential factors which affect the ability to concentrate, e.g. bad news from home. The Board mentioned that the helmsman is an extremely important member of the bridge team and suggested the following best practice:

• Know your personnel – the helmsmen should be encouraged to alert any bridge team member if there are any distracting issues, or if feeling fatigued.
• The helmsmen should be relieved on a regular basis.
• Always have someone to check the rudder angle indicator for correct response to helm orders.
• Good company procedures will take the above factors into account.
• It was finally noted that fatigue is an ongoing topic at the IMO, and the Human Element, Training and Watchkeeping (HTW) sub-committee is currently revising fatigue guidelines. Report ends…

Categories: Alerting, Communication, Distractions, Error Enforcing Conditions, Fatigue, Fit for Duty, Organisation, Situation Awareness,Teamwork

Main engine – failure to start

Outline:  An outline of a main engine failure when departing the berth.

What the Reporter told us:

During an unberthing/departure operation at a container terminal, the main engine failed to start. Control was transferred from bridge control to manual local control in the engine room, and after approximately ten minutes the main engine was able to be started and run ahead. The aft tug remained attached for the passage out of the harbour until clear of the channel. The vessel was deep draft and was restricted to the centre of the channel which at the time was experiencing a strong flood tide. The Master was advised that the problem was a stuck fuel valve on one of the main engine units. The vessel subsequently went to anchor and carried out repairs to rectify the problem. Once completed, the vessel continued on its voyage to the next port. Further dialogue with the reporter confirmed that it was not normal practice to have an outward-bound escorting tug. With respect to any speed issues caused by the stuck valve, it was confirmed that speed was kept to a minimum to accommodate the escorting tug and to reduce squat in the narrow channel. There was thus no attempt to increase outbound speed.

CHIRP wrote to the company and received the following response.

The main engine failed to start due to non-operational spill valves in the fuel pumps for six units.

As a precautionary measure, the vessel tried to start the engine from the local stand in the ER. At this point, failure of the push rods was noted. All were loosened, and from there the vessel immediately resumed normal operations. We suspect the fuel oil quality to be the possible cause because the fuel pumps were recently overhauled by the manufacturer. The fuel oil specification was checked and found to be within ISO specifications. The vessel eventually eased up the push rods and the engine resumed normal operation. We are currently in discussion with the manufacturers as to what exactly triggered this malfunction.

CHIRP Comment:

The CHIRP Maritime Advisory Board commented that the response in this case has been positive from the company and is evidence of a good report and the adoption of best practice. In this case not only has the problem been rectified, but moves are under way to ensure that there is no repeat. CHIRP is aware of other cases where an engine has either failed to start or that the response has been “sluggish”. Any further reports detailing these issues will be welcomed. Finally, although not mentioned in the report itself, CHIRP would comment that it is best practice to test a main engine prior to departure by turning it over on both air and fuel. This will necessitate suitable precautions, such as raising the gangway and having personnel standing by moorings.