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.
#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.
#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.
#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.
#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.
#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.
#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.
#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.
#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.
#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.
#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.
#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.
The full report may be downloaded at,
https://www.ntsb.gov/investigations/AccidentReports/Reports/SPC1701.pdf
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