CASE STUDY: COMPLACENCY CAUSES GROUNDING?
Published: August 1, 2016
The UK Marine Accident Investigation Branch (UK MAIB) has recently published its report on the HOEGH OSAKA, a pure car and truck carrier (PCTC) which grounded on Bramble Bank in the Solent shortly after departing Southampton in January 2015.
This article highlights the main issues raised in the UK MAIB report. Although the report will certainly have been studied by the operators of PCTCs (especially the parts of the report relating to the stability of the ship on departure and the procedural defects surrounding the departure) there are many other more general issues contained in the report that will be of interest to all owners, operators and crew.
The HOEGH OSAKA was on a regular route from Europe to the Middle East. On the voyage in question, the normal port rotation was changed and the usual last port call of Southampton was amended to be the first call. On arrival at Southampton, the chief officer met the port captain and told him that the pre-stowage plan had not been received by the ship. In fact, the master had been sent the pre-stowage plan the day before but had failed to pass it to the chief officer. The port captain then met the stevedore supervisor to discuss cargo operations but the chief officer was not present. Later that day, the chief officer calculated the ship’s departure condition based on the pre-stowage plan and reported a metacentric height (GM) on departure of 1.46m. As the loading progressed, the port captain made arrangements to load additional ‘high and heavy’ cargo (cranes, bulldozers and other construction machinery/vehicles) that was on the reserve cargo list. This was not discussed with any of the ship’s officers.
The chief officer spent most of his time in port in the control room keeping the ship upright and in the correct trim for the stern ramp. Heeling tanks no. 3 were used to keep the ship upright and the trim was controlled by transferring ballast between fore and after peak tanks. The ballasting operation could be undertaken remotely from the cargo control room where there were also remote tank gauges. However, only the fore peak remote tank gauge was operational at the time. The remaining gauges had not been working properly since July 2014 and were deemed ‘low priority’ as soundings could be obtained manually. The last full recording of all ballast was approximately two weeks before the Southampton port call. Ballast movement between tanks was estimated based on the time spent transferring ballast. The pumping capacity was 7 tonnes per minute and therefore this amount was simply multiplied by the number of minutes and this led to some uncertainty as to the quantity of ballast on board and its exact location. No ballast was taken on at Southampton.
The HOEGH OSAKA was fitted with a Loadstar loading program for the purposes of calculating stability, trim and draughts and this program was approved by Lloyd’s Register. This required the quantities of fuel, lubricating oil, ballast, fresh water and stores to be entered into the program. Vehicles on cargo decks should have been input in terms of their mass and actual Vertical Centre of Gravity (VCG). The last entry in the Loadstar program was found to be for the Southampton arrival condition. It was also found that a default VCG had been entered; it was that of the deck, rather than the actual VCG of the vehicles. The stevedores provided labour to drive cargo on and off the ship, to secure the cargo on board and to provide a final tally and stowage plan prior to departure. The stevedores used an electronic system to record the loading of the vehicles on board from a bar code on each car. Despite this available technology, the final tally provided to the ship was an estimated weight. This estimated weight recorded in the stowage plan/final cargo tally was 5549 tonnes. However, the actual weight loaded was 5814 tonnes.
When the cargo operations were complete, the deck cadet recorded the draughts which were adjusted by the chief officer with a standard adjustment for the stern ramp (which was still on the quay) to produce departure draughts of 9.0m forward and 8.4m aft. (These draughts were recorded incorrectly on the bridge and on the pilot card as being 8.4m forward and 9.0m aft). After the pilot boarded, the ramp was raised and this immediately caused a list of around 7° to starboard. This was well in excess of the 1 to 2° normally experienced. The list was corrected before departing the berth.
After unberthing, the chief officer and cadet went to the cargo control room to calculate the ship’s departure stability. Because of the many changes between the pre-plan and final load, the chief officer decided to re-enter all the cargo figures rather than amend the pre-plan condition. Once the calculations were done, the chief officer became concerned that the GM was less than his earlier calculation had predicted. The deck cadet was sent to sound the peak tanks. The chief officer, noting the increased displacement, anticipated an additional 300 tonnes of ballast in these tanks. Rather than question the declared cargo quantity, the regular practice was to adjust the assumed ballast quantity to compensate for the difference between the calculated and actual draughts taken before sailing.
In the meantime, the ship was making 12 knots and had completed the Calshot turn into the Thorn Channel. The next turn from the Thorn Channel around the West Bramble buoy required a sharp (120°) alteration of course to port utilising 10° of helm. This normally resulted in a heel to starboard but on this occasion the heeling continued to increase beyond what was normally expected. The engine was ordered to stop but the starboard list increased to 40°, exposing the rudder and propeller.
On the bridge, the master slid uncontrollably along the deck to the starboard bridge wing door. The pilot, helmsman and third officer managed to maintain their positions by wedging themselves between consoles and tables but for a time they were not able to reach or operate those consoles, including the VHF. Below decks, a crewman broke an arm and a leg falling 18m along a cross alley way. Several other crew suffered minor cuts and bruises.
Some of the large cargo units broke free from their lashings and shifted which resulted in the ship’s hull being breached. Sea water flooded into deck 6 and then into lower decks. The guard boat ‘SP’ (which was leading HOEGH OSAKA to prevent any small craft impeding its navigation) reported to VTS that the HOEGH OSAKA had developed a serious list and required assistance.
The severe list and the exposure of the rudder had resulted in the rate of turn to port increasing. The very fortunate result of this was that HOEGH OSAKA grounded on Bramble Bank. It is possible that HOEGH OSAKA would have capsized if she had not grounded. The pilot, realising further heeling of the ship had been prevented by the grounding, ordered the first tug on the scene to push the ship further aground.
Most of the crew gathered on the high side of the open deck but the crew in the engine room had to climb out using an emergency escape hatch. The chief officer and cadet, who had both been in the cargo control room, managed to reach the ship’s control centre, along with the second officer, and they passed out life jackets and immersion suits. The electrician and the bosun both had to jump into the sea to avoid being trapped and they were rescued by shore-based lifeboats. Other crew were successfully evacuated by the emergency services.
The roles of the relevant officers were defined in the ship’s SMS as follows:
Master: shall hold overall responsibility for the ship and her safety at all times.
Chief officer: is directly responsible to the master for the safety of the cargo operations, and the chief officer shall provide a positive report to the master prior to each and every departure. The ship meets all the requirements of the stability booklet.
The SMS also stated that tank soundings should be taken and recorded daily.
The role of the port captain, as provided for in the owner’s ‘Cargo Quality Manual’, was to form a link between the ship’s crew, the voyage planning manager, the local agents and the stevedores. The owner’s internal cargo operations manual stated:
‘Pre-plan loading and stowage of cargo; Plan loading and stowage of cargo; Supervise cargo operations according to plan; Ensure loading of ship in accordance with regulations and standards; Make, distribute after load report; Report on ship performance.’
The Cargo Quality Manual provided that the port captain’s role was to ensure that the cargo was loaded efficiently without harm or damage to crew, stevedores or ship.
The port captain received booked figures, consolidated them and produced a prestowage plan for each port. The plan would show the proposed stowage position of individual units on each of the decks. The plan was passed to the ship, stevedores and local agents. It also stated that any alterations to the agreed stowage plan were only to be made if authorised by the port captain or the ship’s master.
Reasons for insufficient stability The insufficient stability was due in varying degrees to the following:
1) The chief officer under-estimated the importance of accurately calculating the ship’s stability as it had not previously been a cause for concern. Various errors were identified: no allowance was made for the actual vertical centre of gravity (VCG) of the cargo; ballast quantities on board were only estimated; no priority was given to calculating the ship’s stability before departure; and no attention was paid to warning signals, such as the 7° list occurring after the ramp was lifted.
2) The port captain arranged the loading of additional cargo (approx. 600mt) from the reserve list without informing either the captain or chief officer.
3) The actual cargo weight and stowage were significantly different from the final tally provided to the ship. The cargo weights supplied were mostly estimated rather than actual, even though the actual weights were available to the stevedores.
4) Operational manuals did not properly address the relationship between the ship command and the port captain. This led the port captain to see little value in involving the chief officer and the chief officer in turn believed that he had no authority to question the pre-stowage plan.
5) The master was given the estimated departure stability condition by the chief officer but the master was unaware of how the stability had been calculated or what information had been used to make the calculations.
6) The fact that the company had been slow to repair the tank gauges led to a similar feeling of ‘low priority’ by the chief officer who resorted to estimating the ballast tank quantities.
7) Instruction about how to use the loading computer was not included in the familiarisation training given when joining the ship. It was also not featured in the owner’s two day training course for senior officers assigned to the PCC/PCTC fleet.
OTHER SAFETY ISSUES IDENTIFIED
The UK MAIB received witness and other anecdotal evidence which suggested that the practice of not calculating the actual departure stability prior to sailing was common in the pure car (PCC) and pure car and truck sector (PCTC) and not just on board HOEGH OSAKA.
HOEGH OSAKA had a cargo securing manual (CSM) on board which was accepted by Lloyd’s Register on the basis of previous approval. The CSM stated that for web lashings the maximum secured load (MSL) should be 70% of the breaking strain and that the MSL should be not less than 10,000kg and should have suitable elongation characteristics. The heavy duty web lashings on board HOEGH OSAKA had a MSL of 5,000kg which was half the required strength recommended by the IMO. Neither the port captain nor the stevedores had access to, or knowledge of, the ship’s CSM.
LACK OF COMMUNICATION
The port captain saw the planning and supervision of the loading as his responsibility. As he was implementing the pre-stowage plan for Southampton and was also performing the loading in the next two ports he considered that there was little value in involving the chief officer.
The chief officer had instructions to raise any problems that he found with the pre-stowage but the port captain had no instructions to involve the chief officer in any stowage preparations. The ramp meeting (which was required to inform all parties of the loading plan) went ahead without the chief officer.
The master had not provided the chief officer with the pre-stowage plan when it was emailed to the ship the day before but only when the ship had berthed at Southampton.
The company did not deem it necessary to repair the tank gauges. This may have contributed to demoralising the chief officer and also detracted from the importance of calculating an accurate departure stability which is critical. There was complacency throughout the operation as stability had not previously been considered as a problem.
UK MAIB: CONCLUSIONS
- The HOEGH OSAKA heeled heavily to starboard while rounding the West Bramble buoy as a result of insufficient stability.
- The ship had inadequate stability which had not been identified because accurate stability calculations had not been performed before the ship sailed.
- The HOEGH OSAKA’s departure stability was positive but she had insufficient residual stability under IMO requirements and had a 0.6m bow trim which would have been detrimental to her manoeuvring.
An incident is rarely the product of one single factor. In this case there were many causative factors which were largely ignored by the master, chief officer and port captain. This was mainly because they all presumed that as there had been no problems with stability in the past, there would not be any problems in this instance and so the individual issues were not dealt with and corrected.
This presumption was in spite of the fact that with this particular loading of cargo there were many differences to the normal routine: the change in rotation of the ship; the addition of cargo without informing master or chief officer; and the ship listing to 7° and not the expected 2° when the ramp was raised. None of this appeared to be a cause for concern or caution for the parties involved.
Following their investigation, the UK MAIB report has recommended some significant changes to procedures and operations for the charterers, ship managers and stevedores involved in this case.
The full UK MAIB report can be found the gov.uk website.