Lessons learned from US maritime casualties in 2017

5 March 2019 – SAFETY4SEA

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Lessons learned from US maritime casualties in 2017

The NTSB issued its ‘Safer Seas‘ annual report providing an overview of key lessons to be learned from the most major maritime casualties, noting that many of the issues noted in last year’s reports were recurring topics, such as fatigue, poor bridge resource management, and distraction. The 41 marine accidents included in the report involved allisions, capsizings, collisions, fires, explosions, flooding, groundings, and equipment damage, resulting in loss of life, injuries, and significant property damage.

Casualties | 09/11/18

#1 Watertight Integrity

The failure to maintain watertight integrity was the number one cause of vessel losses during the 2017 reporting year. NTSB advises owners:

• To conduct regular oversight and maintenance of hulls and watertight bulkheads, even during layup periods.
• Oversight should include monitoring the hull thickness, maintaining sufficient marine coatings, and using cathodic protection systems.
• Known issues with watertight integrity and wastage need to be repaired using permanent means.
• Bilge piping and pumps should be in good working order and alarms should be tested regularly.
• Watertight doors should be checked and maintained to ensure they are properly sealed when closed. While under way, all watertight doors should be closed at all times.
• Example: Lady Gertrude

#2 Heavy-Weather Operations

• Mariners should always exercise caution when heavy weather is forecast
• Emergency in heavy weather risks endangering the crew and rescue response personnel.
• When dangerous conditions are predicted, mariners should consider delaying getting underway, returning to port early, or altering the vessel’s route.
• If heavy weather cannot be avoided, special care must be taken to ensure cargo remains secured and watertight integrity is maintained.
• Example: El Faro

#3 Fatigue

• Despite increasing awareness, fatigue continues to be a leading cause of accidents in all modes of transportation.
• In marine transportation, this is particularly true in high-tempo sectors such as the fishing industry, but it is not limited to this sector.
• Fatigue impacts responsiveness, decision-making ability, judgment, and productivity.
• Crewmembers should recognize the effects of fatigue and get adequate rest.
• Vessel owners and operators should adopt policies to mitigate the effects of fatigue and provide a sufficient complement of crew to allow for required rest.
• Example: Nathan E Stewart

Fatigue is not a badge of honor; it is a recipe for disaster

#4 Bridge Resource Management

• The collective vigilance of the watchteam mitigates the weaknesses or oversight of any one watchteam member.
• The presence of a pilot onboard does not relieve bridge team members of their responsibilities for the safe navigation of the ship.
• The master and the officer of the watch must collaborate closely with the pilot to maintain an accurate check of the ship’s position and movement.
• In addition, they must not hesitate to challenge or, if necessary, take appropriate action to prevent a collision, a grounding, or an allision.
• Communications should be open and, where circumstances permit, involve discussion of the intended maneuver or any deviations from the plan.
• Example: Ocean Freedom

#5 Cell Phones and Distraction

• Using cell phones and other portable electronic devices has been demonstrated to be visually, manually, and cognitively distracting.
• Talking on cell phones can have serious consequences in safety-critical situations, and texting can be even more distracting because it requires visual attention to the display screen of the device.
• Control of the vessel and attention to the safe handling of the ship must be maintained at all times until the ship is safely anchored or moored.
• Example: Aris T

#6 Anchoring in High Water and Strong Currents

• The risk of dragging or losing an anchor is substantially increased in rivers and channels during periods of high water and strong currents.
• Mariners should adhere to Coast Guard advisories and pilot association guidance for the prevailing conditions and be able to respond effectively to an anchor-dragging situation.
• Mariners should consider measures such as increasing the scope of anchor chains, stationing navigation and engineering watches, keeping propulsion and steering systems at the ready, and retaining a pilot onboard.
• Example: Star of Abu Dhabi

#7 Preventive Maintenance

• Without necessary preventive maintenance, equipment cannot be relied on to perform as designed and may fail during critical operations.
• Mariners should review the manufacturer’s manuals and guidance on a regular basis to ensure conformance with recommended maintenance plans.
• Maintenance should be carried out in accordance with manufacturer’s instructions and with the appropriate tools.
• Additionally, owners and operators should ensure that personnel performing maintenance are adequately trained and qualified for the work.
• Example: Carnival Liberty 

#8 Safety Management Systems

• An effective SMS has a company safety policy, a risk management program, a safety assurance system, and a safety promotion program.
• The safety policy is management’s commitment to continually improve safety.
• The risk management program determines the need for, and adequacy of, new or revised risk controls based on the assessment of acceptable risk.
• Safety assurance is management’s system of internal evaluation intended to assure the execution of safety-related measures and to make certain that employees understand their roles.
• The safety promotion program advances the principal of safety as an organizational core value using practices that support a sound safety culture.
• Example: Peter F Gellatly, El Faro

#9 Monitoring Rudder Order Response

• Bridge team members should always monitor the helmsman’s response to rudder orders for correct angle and direction of movement.
• If an error is detected or if there is confusion about the order given, a correction or clarification should follow.
• The presence of a pilot on the bridge does not relieve the other bridge team members of their duty to actively monitor the vessel’s position.
• Example: Sparna 

#10 Vessel Abandonment

• In the event that personnel must abandon a vessel in an emergency, both passengers and crew must have sufficient information, training, and equipment so that they can survive until rescue.
• Lifeboat and liferaft assignments must be updated after crew changes.
• Crewmembers must be trained on the proper use of all lifesaving and survival gear on board.
• Non-crewmembers should be given a complete safety briefing prior to departure that includes actions to be taken during emergencies.
• Where applicable, personnel should have access to properly sized immersion or exposure suits.
• During training or safety briefings, immersion suits should be donned to ensure proper fit and familiarity with instructions.
• Example: Exito

#11 VHF Reception

• Mariners that operate offshore or in remote waters should be aware of ship-to-shore VHF coverage limitations and have an alternate means to contact search and rescue centers, such as satellite communication.
• Crewmembers should be familiar with and able to use all of the vessels installed marine distress and alerting systems.
• Example: Maximus 

Explore more in the full report: