total commitment of captain “na choi go” safe sailing

Vol. Ⅴ

Publication Registration Number

11-1192251-000011-10

Case studies of marine incidents in 2016 with illustrations

Total Commitment of Captain “Na Choi Go” to Safe Sailing

Contents

Case studies of marine incidents in 2016 with illustrations

Total Commitment of Captain “Na Choi Go” to Safe Sailing(Vol. Ⅴ)

Chapter 1. Risk of Fire Accident

1. Risk of Fire Accident due to Soot from Funnel ·································································06

2. Smoke from Dangerous Goods Container in Cargo Hold during Unloading ················08

3. Risk of Explosion during Incineration ················································································10

Chapter 2. Risk of Collision Accident

1. Risk of Collision while Overtaking ····················································································· 14

2. Risk of Collision due to Excessive Speed on Approach Controlled by Pilot ·················16

3. Risk of Collision due to Lack of Experience in Radar Operation ····································18

4. Risk of Collision with a Fishing Fleet by a Newly Appointed Officer ······························20

5. Risk of Collision due to Dragging Anchor in Anchorage Area ········································22

Chapter 3. Risk of Pollution

1. Risk of Pollution due to Oil Leakage during Bunkering ······························································· 26

2. Insufficient Inspection of Drain Valve after Cleaning the Fuel Filter ···························· 28

01Chapter

02Chapter

03Chapter

Total Commitment of Captain “Na Choi Go” to Safe Sailing(Vol. Ⅴ)

KOREA MARITIME

SAFETY TRIBUNAL

Chapter 4. Risk of Casualty

1. Risk of Suffocation in an Enclosed Space ···································································· 32

2. Risk of Injury due to Internal Pressure of Fire Hydrant ··················································34

3. Risk of Injury from a Mistake with Winch Operation ·······················································36

Chapter 5. Danger of Engine and Vessel Equipment Accident

1. Risk of Detachment of Crankshaft Counter Weight ····················································· 40

2. Failure of Main Engine in the Exchange of Fuel Oil ····················································· 42

3. Engine Failure of Lifeboat ······························································································ 44

4. Hole in the F.O Tank Ventilator inside Cargo Hold ······················································ 46

5. Navigation Risk from Detachment of Container Equipment during Cargo Work ········· 48

Chapter 6. Risk of Stranding

1. Heeling before Departure due to Inadequate Ballast Operation ································· 52

2. Risk of Stranding due to Inaccurate Nautical Chart ···················································· 54

What is a Marine Incident Management System? ····························· 56

*Please refer to the name of vessel mentioned in this book is false name.

04Chapter

05Chapter

06Chapter

1. Risk of Fire Accident due to Soot from Funnel

2. Smoke from Dangerous Goods Container in Cargo Hold

during Unloading

3. Risk of Explosion during Incineration

Risk of Fire Accident

Chapter 1.

76“나최고” 선장의 안전운항 필살기 제5편

Chapter 1.


6 ㅣ Total Commitment of Captain “Na Choi Go” to Safe Sailing : Vol. V

1. Risk of Fire Accident due to Soot from Funnel

Oh! There’s a fire!

Oh no!

Situation of Danger

A bulk carrier, “Atlantic”, was sailing to Brazil to load ore when the officer on watch noticed that

the pilot ladder, which was stored at the ship’s stern, was on fire. Immediately the fire alarm

was set, the crew took their emergency positions, and the fire team put out the fire. The fire was

extinguished within five minutes and all crew were confirmed to be safe. After inspecting the

accident site, the pilot ladder was found to be completely destroyed and the wall of the engine

casing burned.


Chapter 1. Risk of Fire Accident ㅣ 7

● Eradicate Main Sources- Proper maintenance of the main engine fuel injection system - Review installation of the spark arrester

● Manage Combustible Objects- Store the pilot ladder out of reach of soot - Use non-flammable pilot ladder and ladder cover

● Comply with Safety Management Procedure- Confirm with duty officer before doing soot blower - Engineer on duty checks the site before doing soot blower

Preventive Measures

● Generation of Soot from Funnel- Irregular soot blower inspection - No site check by the duty engineer prior to doing soot blower- No confirmation with duty officer prior to doing soot blower

● Inappropriate Management of Combustible Objects (pilot ladder)- Inappropriate storage location of combustible objects - Non-flammable pilot ladder and ladder cover not used

Potential Factors of Accident

I am going to do the soot blower. Is there anything combustible at the back of the stern?

No. There is no problem.

Fire Accident on Fishing Boat, “Galmaegi”

The fishing boat Galmaegi, was on its way to the fishing ground when suddenly someone shouted “Fire!” from the stern. A soot from funnel had sparked to the line box. The line box and buoys stacked along the passage were on fire, and the crew tried to extinguish the fire, but the fire became impossible to control. The crew called for rescue. The 20 crew members were rescued, however, the fishing boat sank.

08:30. May 02, 1991. S40° 45' E007° 20' at sea.

Actual Marine casualty Case

Always check with the duty officer on Bridge before using the soot blower!I will check.


Chapter 1.



2. Smoke from Dangerous Goods Container in Cargo Hold during Unloading

Hey! There is smoke coming from the hold!

Situation of Danger

During unloading at the Haiphong Port in Vietnam, the 20ft DG (dangerous goods) 4.2 Class

5van, which was to be unloaded at the Gwangyang Port in Korea, was loaded in hold no. 2.

After loading, the quarter master who was patrolling the ship saw smoke coming from inside the

hold and immediately notified the officer of the deck and the terminal. The cargo was promptly

unloaded. A cargo of DG 4.2 Class may be stocked inside the hold but as they can spontaneously

ignite in temperatures over 44°C, it is assumed that the cargo self-ignited as the atmospheric

temperature in Haiphong increased to over 40°C. If the smoke from the cargo had not been

spotted immediately before the ignition, the resulting cargo fire may have spread to other DG

cargo stored in the same hold, which would have led to a large fire.



A work plan should be written after fully considering the cargo characteristics with regards to the regional and seasonal effects.

Containers should be stored with appropriate space in consideration of the minimum ignition temperature based cargo information.

● Write stowage plan to account for cargo characteristics as well as regional and seasonal effects● When storing dangerous goods, conduct inspections regularly during and after loading with the duty officer

of the deck ● Operate the hold fan when the atmospheric temperature approaches the minimum spontaneous ignition

temperature

Preventive Measures

● No confirmation by duty officer of stored DG● No knowledge of cargo characteristics vulnerable to spontaneous ignition therefore the hold fan was

not used (Non-functioning of the hold fan)


Class 1 (Explosives) Class 5 (Oxidizing substances and organic peroxides)

Class 2 (Gases) Class 6 (Toxic and infectious substances)

Class 3 (flammable liquids) Class 7 (Radioactive materials)

Class 4 (Combustibles) Class 8 (Corrosives) Class 9 (Miscellaneous dangerous goods)

Dangerous Goods Label and Mark


Chapter 1.



3. Risk of Explosion during Incineration

Situation of Danger

The third engineer of the ship was disposing waste when suddenly, an explosion occurred along

with a loud noise inside the furnace of the incinerator. The third engineer immediately stopped

the incinerator and after the flame died, inspected inside the furnace. The result of the inspection

found that a spray can had been disposed of without having made holes through it.

Boom

Ahhhh!



Plastic

Paper

Oil Rag

It is important to check combustible waste in advance!

To prevent addit ional accidents, waste should be recycled appropriately.

● Conduct education on the process of shipboard waste disposal

● Check in advance combustible waste before using the incinerator

(Especially when a large amount of waste is inside a plastic bag)

Preventive Measures

● Spray can in inappropriate waste receptacle (incinerator vice recycle bin) Incinerator contents not confirmed prior to operation

● Lack of caution to prevent additional accidents in abnormal conditions* The flame may have died when inspecting inside the furnace but there is a risk of backfire when opening the furnace. A backfire results in explosions and burn injuries could take place.


<Ship incinerator>

Chapter 2.

1. Risk of Collision while Overtaking

2. Risk of Collision due to Excessive Speed on Approach

Controlled by Pilot

3. Risk of Collision due to Lack of Experience in Radar Operation

4. Risk of Collision with a Fishing Fleet by a Newly Appointed Officer

5. Risk of Collision due to Dragging Anchor in Anchorage Area

Risk of Collision Accident


Chapter 2.



Huh?EEK! Why is it overtaking so suddenly?Such excessive veering could lead to a collision.

1. Risk of Collision while Overtaking

Situation of Danger

The ship was entering Incheon Port (before passing Bukjangjaseo) when a large vessel entering

the New Port Container Pier overtook the ship at port side and veered excessively to enter Route

3 of Namjangjaseo. This overtaking almost resulted in a collision.


Chapter 2. Risk of Collision Accident ㅣ 15

Is your vessel trying to overtake us from starboard?

When overtaking a vessel , an overtaking sound signal must be sent.

● Excessive speed in order to enter route 3 by overtaking vessel (large vessel) ● No overtaking signal was sent to indicate overtaking (port, 2 long blasts, 2 short blasts) nor was VHF

communication used● No signal sent by the stand-on vessel expressing its lack of understanding of the course of the give-way

vessel (did not send a signal to question the give-way vessel by using VHF communication and/or sound signal (question signal 5 short blasts)

● No action was taken by the stand-on vessel to cooperate with the overtaking manoeuver


● When it is difficult for the overtaking vessel (large vessel) to overtake the stand-on vessel in entering route 3, it should sail at a safe speed

● The overtaking vessel, should use VHF communication or send an overtaking sound signal (port, 2 long blasts, 2 short blasts) to convey overtaking intentions to stand-on vessel

● The stand-on should send 5 short blasts or use the VHF communication to indicate its confusion or lack of understanding of the overtaking vessel’s intentions

● When aware of the overtaking vessel or the overtaking intention, the stand-on vessel should implement the overtaking cooperation action the stand-on vessel should sail at a slower speed in consideration of the tidal current and the surrounding environment

Preventive Measures

| Sound Signal |

●: short blast (1 second) / ■■■: long blast (4~6 seconds)

Sound Signal Meaning based on Navigation Law

● I am altering course to starboard

●● I am altering course to port

●●● I am operating astern propulsion

●●●● ● I am taking a large turn to starboard

●●●● ●● I am taking a large turn to port

●●●●● Your intention is not clear

I am sailing with a time restraint

●● I am not under command.

● I am overtaking you on your starboard side

●● I am overtaking you on your port side

● ● You may overtake me


Chapter 2.



Huh?

Pilot, sir! It looks like we are going to crash into the barge, please reduce speed.

2. Risk of Collision due to Excessive Speed on Approach Controlled by Pilot

Situation of Danger

The ship was entering the port with the pilot on board. The port traffic near the entrance of Port

OOO was busy so the ship had to enter the breakwater (width of navigable waters about 2

cables) after veering at a large angle. At the time, the closest point of approach (CPA) was “Zero”

with the barge that was approaching at a transverse angle from about 5 cables apart, but the pilot

maintained Half ahead ENG (vessel speed 14 knots) and did not take additional measures.

The captain of the boat requested the pilot to take caution and reduce the speed (dead slow

ahead) so that the ship could enter port safely after letting the barge move past first. The pilot at

the time was presumed to have been under the influence of alcohol and did not have a sense

of speed and foresight about the dangers of the situation. The captain avoided a collision by

commanding a half astern ENG. order directly to the third officer.



Pilots, please manage your condition well, and act responsibly.

I don’t think the pilot is in a good physical condition.

● In cases of unfit/unsafe pilot operations, there exists a need an immediate reporting measure by the captain to the shipping company and the administrative office

● Strengthen training on the responsibilities of the pilot

Preventive Measures

● Unfit physical and mental condition of the pilot resulted in lack of judgement and concentration while piloting the ship

● The captain did not respond appropriately earlier to the impaired condition of the pilot


Contact with Floodgate Facilities of a Bulk Carrier “Bada”

Bada, a bulk carrier, was approaching a floodgate of 50 thousand tons with a pilot on board to enter Incheon Port. The pilot did not reduce the speed of the ship until it came very close to the reading pier which was in front of the bow. The ship lost control over the forward movement with its astern engine and crashed its bulbous bow into the reading pier on the side of the outer port of the floodgate of about 10 thousand tons at Incheon Port. It damaged the curve of the bulbous bow and fractured a part of the reading pier structure.

14:29. August 29, 2012. Reading Pier on the Side of the Floodgate of 10 thousand tons at Incheon Port, Incheon Metropolitan City



Chapter 2.



Nearby fishing boats are not being detected due to a lack of experience with radars.

3. Risk of Collision due to Lack of Experience in Radar Operation

Situation of Danger

While sailing across the waters in tropical rain, the officer on watch adjusted the rain clutter to

obtain a clear radar screen. After passing through the area with tropical rain, the officer on watch

identified with the naked eye a fishing boat that was not on the radar screen. At that time, the

officer on watch realized that he had not returned the rain clutter back to its original state after

passing through the rain. If the officer on watch had sailed relying on the radar only, it could have

resulted in a collision with the fishing boat.



The watch-keeping duty should be carried out using all means possible rather than solely relying on navigation equipment.

When operating two radars, one should be kept at standard state.

When operating the rain clutter, rain and clouds could be removed from the screen as seen on the image above. In this case, however, small ships could also be excluded so the officer and crew on duty must keep a close watch with their naked eye when using this function.

Rain Clutter

Operate the rain clutter by turning the switchRemember to check function of radar after passing through rain

● Keep a close watch using all means possible rather than relying on navigation equipment only● When operating two radars, one should be kept at a standard state● Communication between officer on watch and duty members● Establish a system to ensure radars operating appropriately for sailing conditions

Preventive Measures

● Over-reliance on navigation equipment (eliminate possibility of error and reflected wave)● Inappropriate operation of navigation equipment based on weather conditions



Chapter 2.



What? There are so many fishing boats nearby that did not show up on the radar!

4. Risk of Collision with a Fishing Fleet by a Newly Appointed Officer

Situation of Danger

A third officer who was on watch-keeping duty at night with low visibility came across a Chinese

fishing fleet equipped with the Automatic Identification System (AIS) while sailing near Ieodo

Island. The third officer had been avoiding the fishing fleet by relying on the radar and the AIS

due to restricted visibility. However, the AIS information of the Chinese fishing fleet had not shown

up. The results showed that the large number of fishing vessels had exceeded the limit of the AIS.

Although the information did not show up on the screen, the third officer was not aware of this

and eventually sailed into the fleet. The third officer immediately reduced the speed, contacted

the captain, and under the command of the captain, navigated safely out of the fishing fleet.



Captain! I am requesting help. There are many fishing boats.

I, Captain Na Choi Go, will navigate the ship.

Watch-keeping duty should be carried out in pairs.

● Lack of knowledge of a newly appointed officer in navigation equipment functions (AIS) ● Solo navigation of a newly appointed officer in waters where fishing fleets can be expected


● Strengthen educational training (navigation equipment instructions, navigation method etc.) for newly appointed officers

● Have the captain sail in dangerous waters● Instruct crew to call the captain in dangerous situations or whenever difficulties arise in navigation● Comply with the duty system of working in pairs (officer on watch, duty member)

Preventive Measures

In heavy fog, the boat is navigated by depending on the radar because it is difficult to see other ships with the naked eye. The radar detects ships with reflected waves but it also receives their AIS information. So even when the reflected wave is weak, it can detect the location of another ship. However, when a small fishing boat or a large number of vessels, the AIS information can be misleading due to error or information overload, thereby reducing the trustworthiness of the information. Therefore, when coming across a fishing fleet in heavy fog, it is necessary to reduce speed, position additional watch-keeping crew members, send a fog signal, and adjust the radar.


Chapter 2.



The vessel to the side is turning around! I should contact it immediately!

Huh?!

5. Risk of Collision due to Dragging Anchor in Anchorage Area

Situation of Danger

Unlike other vessels that changed due to the tidal current while being moored at Yeosu A

Anchorage at 01:00 on June 23rd, Alpha turned its bow and continued to drift closer to the vessel

nearby. The concerned vessel immediately contacted Alpha and alerted it to the situation. The

concerned vessel requested the engine room to prepare the engine in case of an emergency and

then asked Alpha what the length of its anchor chain was in order to calculate the closest point of

approach between their stern and Alpha. The calculation of the anchor chain was about 1 cable.

Alpha had not known that it was drifting towards another vessel until it was contacted by the

concerned vessel. * 1 cable = 185.2m** Closest Point of Approach (CPA): the closest distance between two vessels



When anchoring, or dragging anchor, a safe distance should be kept. Crews should carefully consider the appropriate length of the anchor chain based on the location of their vessel.

The officer on watch should continuously check the distance from other vessels, the climate, and marine conditions.

● When anchoring- Place the anchor after considering the safe distance from nearby vessels

● After anchoring - Heave up the anchor and re-cast the anchor when weather worsens and anchor starts to drag, causing the vessel

to drift closer to other vessels- The officer on watch should regularly check the distance to other vessels, the weather, and marine conditions

● Other - Conduct training on anchoring and responding to dragging anchor (appropriate length of anchor chain, vessel location)- Maintain the main engine on stand-by so that the vessel could be moved immediately in an emergency

Preventive Measures

● When anchoring- No consideration of safe distance from nearby vessels

● After anchoring- No regular calculation of vessel traffic and safe distance from other vessels until the point of the accident- No confirmation by the officer on watch of the situation including distance from nearby vessels- No confirmation by the officer on watch of tidal current, climate and marine conditions


Contact with Breakwater of General Cargo Vessel, “Haeyang”(Safety Investigation Report)

After having anchored the vessel at an anchorage to escape a storm, the vessel started to drag anchor and crashed into the breakwater. The vessel sank and of the 19 crew members, 8 were rescued and 11 were found dead. Of the 10 caissons of the breakwater, the upper and lower parts of 7 caissons were destroyed.

17:45. October 15, 2013. North Breakwater at Yeongilmanhang, Pohang,North Gyeongsang Province.


Chapter 3.

1. Risk of Pollution due to Oil Leakage during Bunkering

2. Insufficient Inspection of Drain Valve after Cleaning the Fuel Filter

Risk of Pollution


Chapter 3.

Risk of Pollution


It looks as if oil is leaking from the HFO hose.

HFO

LSMGO

1. Risk of Pollution due to Oil Leakage during Bunkering

Situation of Danger

The vessel was lifting the bunker hose on board by using the crane of the bunker barge to fuel

LSMGO and HFO at USA Port. While connecting the LSMGO to the bunker manifold, the HFO

hose, which had been lifted from the same crane, drooped down with the connecting flange

heading towards the sea. The second engineer who oversaw the fuelling observed that oil from

the HFO hose was dripping onto the upper deck of the vessel. Fortunately, HFO dropped to the

upper deck, which was below the bunker station, and a major accident of oil contamination of the

sea was prevented. * LSMGO : Low Sulphur Marine Gas Oil


Chapter 3. Risk of Pollution ㅣ 27

When fuelling the vessel, the chief engineer must be on site.

The mouth of the hose should point upwards to prevent any leakage.

● When connecting the fuel hose from the vessel to the bunker barge, transfer it by placing a sling on the flange to avoid oil from dripping (close the flange cover and make sure the mouth of the hose points upwards)

● When identifying danger during fuelling, stop the operation immediately and promptly notify the barge● Have the chief engineers on site during fuelling ● When transferring different fuel types, proceed with the operation one by one

Preventive Measures

● Mistake of the bunker barge- Incomplete removal of oil residue inside the hose- Faulty connection of flange cover- Transfer of hose with the mouth dropped to the floor- Simultaneous transfer of HFO and LSMGO hoses

● Mistake of the cargo vessel- Officer on duty does not point out the danger of transferring the oil hose to the barge - Lack of inspectors on site due to small number of operators



Marine Contamination Accident of Oil Tanker, “Haean”

During the transfer operation of sludge from the engine room to the vessel that was anchored at D1 anchorage after departing from the Gukdong Port in Yeosu, the inappropriate connection of the hose led to de-linking of the camlock coupling and sludge spilled over the upper deck of the oil tanker Haean. Of the spilled amount, 240 liters were discharged into the sea.

00:30. December 7, 2013. D1 anchorage, Yeosu Port, Yeosu, South Jeolla Province.


Chapter 3.

Risk of Pollution


Oh, no! The drain valve has not been closed!!

2. Insufficient Inspection of Drain Valve after Cleaning the Fuel Filter

Situation of Danger

The second engineer ordered the oiler to clean the fuel filter of generator no.3. Before cleaning,

the second engineer closed the fuel valve of generator no.3. After receiving the report that the

cleaning had finished, and thinking that the oiler had closed the drain valve, the second engineer

finished the operation after only checking whether there was another leakage. After a few hours,

the third engineer reported that there was a fuel leakage from the fuel filter of the generator

no.3. After checking the site, the drain valve of the fuel filter of generator no.3 was found open.

Fortunately, generator no.3 had been on stop, therefore, not much fuel had been spilled, and it

was immediately removed.


Chapter 3. Risk of Pollution ㅣ 29

The TBM (Tool Box Meeting) training should be conducted on site before the operation.

Instructions of the operational procedure should be discussed, and it is important for the officer in charge to double-check it.

Images of Fuel Oil filter Replacement Operation

● Conduct TBM (Tool Box Meeting) on site prior to operation● Have the officer in charge double-check the operation and highlight the need to double-check it● Develop simple guidelines on the operation and provide training

Preventive Measures

● Careless management by the officer in charge (insufficient inspection of the operation)● Lack of communication between operators● Lack of discussion on the operational procedure, instructions, and safety matters prior to operation


1. Risk of Suffocation in an Enclosed Space

2. Risk of Injury due to Internal Pressure of Fire Hydrant

3. Risk of Injury from a Mistake with Winch Operation

Risk of Casualty

Chapter 4.

32

Chapter 4.

Risk of Casualty


Third engineer! You don't look good! Come out of there right now.

1. Risk of Suffocation in an Enclosed Space

Situation of Danger

A bulk carrier, “Odaeyang”, was conducting a cleaning operation inside the economizer of the

engine while being moored in Brazil when the third engineer staggered and cried out due to

dizziness. The first engineer who was taking turns at the operation nearby found him and with the

help of other crew in the engine department, moved the third engineer to the medical center on

board and had him breathe in fresh air.

Mr. first engineer!I am dizzy.


Chapter 4. Risk of Casualty ㅣ 33

Conduct operations in enclosed spaces in pairs, and take sufficient time for ventilation before and after the operation.

I t 's dangerous to enter an enclosed space alone during operation.

I should have checked the concentration using the portable gas detector before entering the economizer...

● Lack of sufficient ventilation during operation in enclosed spaces● Lack of sufficient cooling during operation in enclosed spaces● Lack of oxygen and gas concentration detection using portable gas detector prior to engineering the

economizer● Third engineer working alone without a watchman nearby


● Conduct operation while using a checklist containing the following points- Sufficient ventilation prior to operation in enclosed spaces- Check oxygen and gas concentration by using a portable gas detector before entering the economizer- Work in pairs in enclosed space with one person as a watchman- Promptly respond to emergency situations by working in pairs- Conduct operation in enclosed spaces after becoming fully aware of communication equipment and emergency guidelines

Preventive Measures

<Entrance> <Operation in an enclosed space>

34

Chapter 4.

Risk of Casualty


Eek! That surprised me!

2. Risk of Injury due to Internal Pressure of Fire Hydrant

Situation of Danger

The third officer and the apprentice officer tried to open the cap of the fire hydrant to test the

fire hose and the fire hydrant but it did not open. When they opened the cap forcefully by using

tools, the cap flew open from the pressure that built up inside the hydrant. Fortunately, both were

standing on the side, avoiding any injury. However, with even the wire of the cap having been

swept away before the crew opened the cap forcefully, it could have led to a serious injury.



If the cap of the fire hydrant is not opening well, open the valve to lower the internal pressure.

Inspect the fire equipment regularly to prevent accidents.

● Lack of fire equipment management- Loss of connecting wire- Faulty cap of the fire hydrant

● Inexperienced inspector- The internal pressure of the fire hydrant was not lowered after discovering the cap could not be opened easily - Resume operation after connecting the wire that got swept away


● Inspector training- Open the hydrant valve to lower internal pressure when the cap does not open well- Resume operation after re-connecting the wire that got swept away

● Implement regular inspections and maintenance of fire equipment

Preventive Measures

HydrantCap

Wire

Pressureaction

36

Chapter 4.

Risk of Casualty


3. Risk of Injury from a Mistake with Winch Operation

Situation of Danger

After assigning crew at the stern for departure, the crew began to prepare for the departure under

the command of the second officer. After berthing the tugboat, the anchoring rope hung around

the bitt was let loose so that the winch could be operated to reel it in. However, as the operator

on land could not let loose the anchoring rope, the second officer was using his hands to release

the rope. Suddenly, the operator working the winch began to reel in the rope. The second officer

immediately stopped the operation and escaped serious injury.

The anchoring rope can’t be loosened easily.

Oh, no! My hand will get stuck between the anchoring rope soon.



Use mutually agreed hand signals and confirm the level of understanding of operators.

•Communication such as delivery and understanding of signals for winch operation is important.

Additional Information (related to winch operation)

<Shore> <Ship>

Winch operator - Operate winch at the command of the second officer using hand signals

Second officer - Order winch operation usinghand signals by checking status on land

Operators on land - Tie and loosen the rope on bitt on land

Comply with the command of the officer in charge at entry and departure. Confirm the instructions by repeating the order.

● Act according to the command of the officer in charge of each department at arrival and departure● Control of situation based on clear command and confirmation of command (repeating back the order)● When using mutually agreed hand signals, confirm the understanding of the operator

Preventive Measures

● The officer in command moved out of sight of the operator ● Unclear commands, lack of communication● Winch operator operated the winch at his own discretion without the command of the officer in charge


Chapter 5.

1. Risk of Detachment of Crankshaft Counter Weight

2. Failure of Main Engine in the Exchange of Fuel Oil

3. Engine Failure of Lifeboat

4. Hole in the F.O Tank Ventilator inside Cargo Hold

5. Navigation Risk from Detachment of Container Equipment during

Cargo Work

Danger of Engine and Vessel Equipment Accident

40

Chapter 5.



Crankshaft Counter weight can be moved easily by hand.

1. Risk of Detachment of Crankshaft Counter Weight

Situation of Danger

While inspecting the crank chamber after cleaning the No.3 G/E L.O. sump tank, the chief

engineer noticed that the crankshaft counter weight of No.2 Cyl. could be moved easily by

hand and immediately ordered the second engineer to inspect the condition of all cyl. counter

weight screws. After inspecting the tightness of the counter weight screw of all No.3 G/E cyl. as

commanded, the second engineer found that the no.3 cyl. crankshaft counter weight screw was

also loose and tightened the counter weight screw.

If they had continued to sail without noticing it, the counter weight could have become loose,

which then could have led to a large G/E accident such as G/E crankshaft deformation and

engine block damage.


Chapter 5. Danger of Engine and Vessel Equipment Accident ㅣ 41

It is important to conduct maintenance and inspection in accordance with PMS period.

The officer in charge of equipment should enhance expertise and perform maintenance thoroughly.

● Non-compliance with PMS *PMS: Planed Maintenance System

- Counter weight of the generator was not inspected regularly

● Lack of expertise in equipment- Did not tighten the counter weight torque of the generator sufficiently- Did not check the type of counter weight screw when installing the generator- Previous maintenance operation was flawed (the use of genuine product)

● No meeting before important equipment maintenance operations- The chief officer did not speak about important matters to the operators before undertaking maintenance operations on

important vessel equipment


● Compliance with the maintenance standards based on PMS- Improve appropriate maintenance and inspection standards based on the PMS period- Add specific instructions and inspection manuals in the PMS inspection checklist

● Enhance expertise in equipment- Familiarize the operator with the instruction manual of each equipment- Check whether the counter weight screw is a type that comes loose after installing the generator- Tighten the counter weight torque of the generator with a torque wrench

● Other - Inform the status of important equipment to the next crew on duty- Inspect other vessels using the same brand and type of equipment

Preventive Measures


Engine Damage of Fishing boat “Gireogi”

The fishing boat “Gireogi” departed from Incheon Port to fish for the day. After the boat was loaded with fish, it was returning to Incheon Port on the same day, when the main engine stopped with a loud noise. The connecting rod bearing of the main engine was damaged due to dry friction. The ship had been running for a long time with insufficient lubricating oil, as a result of negligence in maintenance and inspection of the lubrication system of the main engine.

00:00. April 26, 2012. approximately 38 miles to the south-southeast, Socheong-do, Ongjin-gun, Incheon

42

Chapter 5.



Huh? What’s wrong? The boiler is not working.

2. Failure of Main Engine in the Exchange of Fuel Oil

Situation of Danger

While preparing to use the engine to heave up the anchor at the waiting anchorage of Port OOO

in order to proceed to berth, the boiler malfunctioned so it was replaced with MGO fuel oil before

using the main engine.

Once the pilot boarded the ship, the ship was manuvered using the astern engine with the help

of two towing boats but as the engine failed, it had to lay anchor in an emergency in front of Pier

OOO around 20:23.

The results of the inspection suggested that the engine failed because compression pressure

did not form due to the deterioration of the spindle bush of the EXH valve and the abrasion of the

CYL liner. FO that was heated with the steam generated by the economizer of the main engine

could be used to replace the MGO, however, the berthing was delayed for about an hour due to

the process of replacing the MGO with FO.

The FO had been replaced with MGO as fuel oil as the boiler could not be set off, but with the

failure of the main engine, it was able to contact the pier or other ships at berth.



Change the fuel oil from F.O. to M.G.O. so we can use the main engine.

Make a port entry after checking the maintenance and exchange cycles and exhaust gas temperature of the equipment or components of the boiler.

The boiler is not working.

● Thorough maintenance and inspection according to PMS (the shipping company should also monitor and support implementation of PMS)

● Planning for risk (implement risk assessment and risk reduction)● Due to the strengthening of international air pollution regulations on exhaust gas, there are many cases

where it is exchanged with low sulphur diesel or M.G.O. during entry and exit. Therefore, it is necessary to thoroughly inspect the maintenance of the fuel oil injection system to prevent the use of light oil.

Preventive Measures

● Tried to enter port without boiler maintenance (attempt at entry despite risk)● Negligent in inspecting maintenance and exchange cycles and exhaust gas temperature of equipment or

components of the boiler



Cargo Ship, “Jijunghae”, Crash into Pier

In order to reduce fuel costs, the fuel pipe of the generator was modified at the shipyard.(A new boiler pipe was connected to the generator oil fuel pipe.) However, the generator suddenly stopped when the ship was sailing to the port because fuel oil was not being supplied to the generator appropriately, rather the fuel oil was being supplied to the boiler. Other main functions such as the main engine and the steering gear were also shut down and the bulbous bow on the starboard side came into contact with the inner wall of the dock, which resulted in a crack of approximately 50cm at the outer surface of the bulbous bow.

10:36. November 22, 2014. Berth 14, Sam-hak dock, Mokpo Harbor

44

Chapter 5.



Oh, this is strange. Only air is being generated and no fuel is being supplied.

3. Engine Failure of Lifeboat

Situation of Danger

During an inspection of the life boat engine system by the lifeboat inspector (2/O), the engine

worked normally for more than 4 minutes when it suddenly stopped and did not restart. The chief

engineer inspected it and found no problem with the engine system so he initiated an interim

check of the fuel oil system. He opened the fuel drain nipple and continued fuel priming for over

10 minutes but it only created air and did not supply any fuel. Then, while inspecting the entire

line of the fuel oil system, it was found that the fuel oil supply line and the drain line had been

changed (The engine line is assumed to have been changed from the beginning).



Oh, this is strange. Only air is being generated and no fuel is being supplied.

During emergency training that includes launching lifeboats, the engine should be checked to ensure it starts.

● When installing a lifeboat, check carefully that it starts and operates properly● Carry out regular emergency response training including the launch of the lifeboat ● Make sure that the lifeboat operates for at least 5 minutes after start-up● Check whether fuel is being supplied to the lifeboat and check with the engineer whether fuel is

being injected

Preventive Measures

● Installation of a defective lifeboat manufactured by the lifeboat manufacturer● Failure to conduct emergency response training such as the launch of a lifeboat● Turning off the engine immediately after only checking that it starts● No confirmation of whether the fuel oil is being supplied to the lifeboat


46

Chapter 5.



There is a hole near the bottom of the pipe.

4. Hole in the F.O Tank Ventilator inside Cargo Hold

Situation of Danger

During the unloading of cement at Samcheok Port, cement dust was found being discharged

from the no.2 F.O tank ventilator and the cargo operation was put on hold immediately. After

inspecting the no.1 cargo hold and void space, a hole was found in the lower part of the no.2 F.O

tank ventilator pipe inside NO.1 cargo hold (P). The hole was covered quickly with a rubber band

and tape before resuming the operation.



To prevent cement dust from setting, it is necessary to airwash afterwards!

A protective film should be installed around the ventilation pipe to prevent cement from setting in.

● As a result of the hole created near the bottom of the fuel tank air pipe, cement dust was discharged on deck through the air pipe.

Additional Information (Related to dangerous situation)

● Airwash after cargo operation to prevent cement and cement dust from setting in● Measure the thickness of each part during regular dock repair● Prevent cement from setting in by installing a protective film around the ventilation pipe

(Replace the protective film after a set period of use)

Preventive Measures

● Difficulties in detecting the hole with the naked eye as cement and cement dust had set in the ventilation pipe within the hold


Cargo hold(cement)

F.O Tank

Hole

Dischargedcement dust

48

Chapter 5.



The containers have bumped into each other. Did the semi-auto cone fall out?

5. Navigation Risk from Detachment of Container Equipment during Cargo Work

Situation of Danger

During loading and unloading work at Manila Port in the Philippines, a worker on land installed

a semi-auto cone at the bottom of the container to load a 40ft container. In the attempt to load

it on top of a container that was already loaded, a crew member on deck discovered that the

semi-auto cone had been detached as a result of the impact with the container. It was reported

immediately to the worker on land and the checker. After moving the container back to land, the

detached semi-auto cone was replaced and the container was safely loaded. If the container had

been loaded without the cone attached properly, it could have led to a navigation accident.



Meet with the worker on land before loading and inspect according to the checklist after loading.

Inspect the shipment equipment regularly and make marks on the cone so that it can be checked with the naked eye.

● Inspect according to the checklist during and after loading● Have a meeting with the worker onshore before operation to discuss working rules, precautions,

etc.● Need to inspect loading equipment regularly and repair and exchange accordingly● Make sure that cones are visible with the naked eye by making marks

Preventive Measures

● Semi-auto cones may fall out due to impact from collision of containers during the container

loading process● No inspection by the worker on land and negligence of crane worker● Failure to identify faulty semi-auto cone in the inspection of loading equipment


Chapter 6.

1. Heeling before Departure due to Inadequate Ballast Operation

2. Risk of Stranding due to Inaccurate Nautical Chart

Risk of Stranding

Chapter 6.

Risk of Stranding


The hull is listing to port.

What’s going on?

1. Heeling before Departure due to Inadequate Ballast Operation

Situation of Danger

During the cargo operation at berth of Port OOO, the first officer felt that the hull was continuously

listing towards port at 18:30, about 30 minutes before the planned departure time. He found

this strange and checked the situation at CCR during deck inspection. The apprentice officer

was operating the anti-heeling system instead of the third officer who was busy inspecting the

navigation equipment before departure. The hull was tilting more to the port due to a mistake in

operating the valve of the upper tanks on the ballast line. The first officer revised the valve status

after identifying the problem and promptly recovered the incline by operating two ballast pumps.

Fortunately, the hull was restored to its normal heeling before departure and the ship departed on

time at 19:00.


Chapter 6. Risk of Stranding ㅣ 53

I have an urgent task to attend to. Could you replace me while I am gone?

Yes. I will make sure that there is no disruption in the cargo work.

● Solo operation by the apprentice officer (absence of responsible officer)● Unclear reporting procedure (notify the person in charge if any abnormality is found)● Inappropriate number of people stationed (30 minutes before departure)


● Assign a substitute officer when leaving the cargo control room for a long time

● Undertake operation under the command of a responsible officer

● Distinguish clear reporting procedures when abnormality above a certain standard is found EX) List 10°: C/O, List 20°: CAPT

Preventive Measures

•Heeling: longitudinal slope of the hull • Anti-Heeling System: equipment to maintain balance by

moving ballast water to prevent heeling

When leaving the cargo control room for a long time, the position must be substituted with another officer.

Chapter 6.

Risk of Stranding


2. Risk of Stranding due to Inaccurate Nautical Chart

Situation of Danger

While sailing near Hong Kong, the ship left its planned course to avoid the fishing fleet. While

checking its position with a nautical map, a no-go area was found about 5 miles ahead. There

was no special mark or explanation on the chart and no particular barrier could be seen with the

naked eye. So, the ship continued to sail while being mindful of nearby ships only. Then, it saw

a marine structure that looked like a power transmission tower about 2 miles ahead. Fortunately,

it was able to avoid it but if it had not been able to spot it early or if there had been marine

structures, the ship could have been stranded considering its draft.

Huh? There was no power transmission tower on the chart. I should have brought the updated version.


Chapter 6. Risk of Stranding ㅣ 55

● Identify navigation risk factors by checking the chart and radar before veering

● Before navigation, update all sea charts and publications

● Check dangerous situations that could take place during duty at the time of taking the shift (checking sea chart etc.)

● Continue to keep watch and check not only nearby ships but also nearby risk factors

Nautical charts and publications must be replaced with the updated version. By using the revised version, all risk factors should be identified in advance.

Check to see if there are any risk factors such as barriers with nautical charts and radar before veering.

● Inadequate identification of risk factors such as barriers before veering● Unclear small corrections to nautical charts by second officer● Inappropriate watch-keeping


Preventive Measures

▲ Areas where temporary barriers have been seen or where water level is low are marked as no-go areas with a pencil as the image shows. In general, ships should not approach or enter marked waters even when there are no separate explanations.


What is a Marine Incident Management System?

Legal BasisArticle 2:1(2) and Article 31(2) of the 「Act on the Investigation of and Inquiry into Marine Accidents」

Purpose- By drawing and spreading potential factors of accidents and lessons through voluntary

participation of the shipping industry, promote a culture of pre-emptive measures for marine

accident prevention

Operational Method- the ship owner or ship operator voluntarily reports marine incidents to the Korea Maritime Safety

Tribunal who then analyzes them and selects cases that provide lessons. The Korea Maritime

Safety Tribunal provides regular publications for the public.

Annually published maritime incident cases since 2012 with lessons using illustrations

production and distribution of (Total Commitment of Captain “Na Choi Go” to Safe Sailing)

→ Post-delivery, website (www.kmst.go.kr → Resources → Educational Resources Board)

Notification Method for Marine Incidents ■ Send official document, fax or post, write on website

■ Address: Korea Maritime Safety Tribunal, Government Complex Building #5, Sejong, #94,

Dasom 2-ro, Sejong Special Self-governing City, 30103, Republic of Korea

■Phone number: 044-200-6128

■Email/fax: [email protected] / 044-200-6139

■Website: www.kmst.go.kr → participation sea → marine incident notification board

* There is no limit on the notification format

■ Band registration: Council for Marine Incident System Development

(www.band.us/n/aaaT8g6bb112)

What is a Marine Incident Management System?


What is a Marine Incident Management System? ㅣ 57

Activities of the Marine Incident Council in 2016

■ Launch of the Council for Marine Incident System Development: 2016.3.22. / Panocean Building, Busan

- (Purpose) To prevent the recurrence of marine accidents and reduce marine accidents by

promoting the Marine Incident Council through voluntary participation of the private sector

- (Participants) Shipping companies, shipping related institutions etc.

- (Discussion topics) Formation and operation of the Marine Incident Council, data collection of

marine incidents, ways to spread lesson cases

■ Council for Marine Incident System Development Workshop: 2016.10.27.–28 / Cheonan Human Resources Development Institute

- (Participants) Shipping companies, shipping related institutions etc.

- (Topic) Presentation on application cases of marine incidents, case analysis and direction for

development, group discussions

When the ship came close to another ship due to navigation negligence and almost ended up in a crash but closely avoided it

Example 1When the ship left its course during entry or departure from port and almost got stranded but narrowly escaped to safe waters

Example 2When the ship almost capsized or sank due to bad stowage or a faulty securing device but closely avoided it

Example 3Contaminants were almost discharged at sea due to negligence in operating marine pollution prevention equipment but crew managed to take appropriate preventive measures

Example 4

Marine incidents involve all situations that could pose harm to the safety of the vessel, people or the marine environment without a revision or improvement in the structure, equipment or management of a vessel. It excludes marine accidents.

Marine Incident

Published by : Korea Maritime Safety Tribunal

- Editorial Member : Chief Investigator Lee Yong

Investigator Bag Jang-ho

- General Editing : Kim Gu-jong

- Practical Editing : Yeo Sil-jung

Registration for publishing : 11-1192251-000011-10

Date of publication : January, 2017

Design and printing : Cree Communication, +82-2-2273-1775

● Contents of this booklet may be freely quoted if the source is accurately acknowledged,

but it is a legal violation if it is quoted or reproduced without authorization.

total commitment of captain “na choi go” safe sailing

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