Providing learning through confidential reports – an international co-operative scheme for improving safety
MARS – Lessons
Learned
MARS Report No 388 February 2025
MARS 202505 MARS 202506
Fingers crushed by heavy equipment Tug capsizes with two fatalities
An engineer and a helper needed to inspect the spare impeller blade As edited from MAIB (UK) report 17/2024
assembly for the inert gas generator. This spare was kept in a plywood [Link]
box, and was underneath a spare flame shield, which was quite heavy. f2b5613525/[Link]
With no further planning, the crew attempted to lift the heavy flame A small passenger vessel was approaching port after conducting
shield off the impeller box by hand. Both crew were wearing cotton post-refit sea trials and a pilot had embarked for the docking. The plan,
gloves for the task. as discussed between the Master and the pilot, was to turn the vessel
The plywood cover of the impeller box was only loosely installed. 180 degrees and enter the confined dock area with the assistance of one
While shifting the flame shield, the loose plywood cover also moved, tug forward and one aft, berthing the vessel starboard side to. The pilot
and one corner of the cover slid and fell inside the box. The flame shield took the con, and slow ahead on both engines was ordered. The Master
was too heavy for the crew to support the weight, and the engineer’s inquired what speed was required for the aft tug to connect; the pilot
right index and middle finger were trapped between the flame shield responded that they could go up to 7kts and noted that slow ahead had
and the wooden box. The victim received a deep cut on the index finger just been ordered.
and a swollen middle finger. The passenger ship passed Number 1 Buoy and entered the main
navigational channel at a speed of 6 knots. The pilot called the Master
of the aft tug on VHF radio, directing them to approach and pass the
tug’s bridle to the aft mooring party on the passenger vessel. The pilot
remained on the bridge, and the Master went to the starboard bridge
wing to watch the tug make its approach. The aft tug matched the
passenger vessel’s speed, and the mooring party pulled the towlines on
board.
About three minutes later, dead slow ahead on both engines was
ordered on the passenger vessel. Shortly afterwards, it was reported
that the two lines of the aft tug’s bridle had been made fast on the port
and starboard side of the passenger vessel’s poop deck. The forward tug
began approaching for their connection. The passenger vessel was now
making 4.6kts.
Once the forward tug was connected, the pilot directed ‘After tug
minimum dead astern’ on VHF. The aft tug’s Master responded, ‘Do you
want me swinging off pilot and go dead astern?’, to which the pilot
replied ‘Yeah, dead astern minimum please’. Closed-circuit television
images show the aft tug now turning to starboard and peeling away
from the passenger vessel’s starboard side then dropping astern.
On the aft tug’s deck, the starboard bridle became taut. The tug’s turn
stalled with its heading now approximately 45 degrees to the right of
Lessons learned the passenger vessel’s track. The tug was quickly pulled sideways by
l Before carrying out any job, carry out an informal risk assessment the bridle and almost immediately heeled to port. It capsized within
which involves inspecting the job and the surrounding area. Ask 10 seconds. Some of the aft mooring party on the passenger vessel
yourself, what are the hazards? threw lifebuoys overboard and looked for survivors, while one crew
l Whenever handling a heavy object, evaluate whether lifting rushed to the galley for a knife to cut the tug’s bridle.
appliances can be employed or alternate methods used to lift or The rescue efforts notwithstanding, the inverted tug sank within
handle the object. Use common sense before brute strength! 30 minutes, taking the two crew with it. The victims were later recovered
l Alternatively, if space constraints prevent the use of lifting appliances, but were deceased.
it is crucial to ensure an adequate number of crew members are The investigation found that, considering the speed (4.6kts), the
available for the task. tug had just over 10 seconds to reverse direction into its new position
l Never put your hands below a heavy object or take a position which astern of the passenger vessel before its weight came onto the towlines.
might lead to a crush injury. Instead, the tug’s turn stalled and the bridle came under tension. The
l Use appropriate PPE. Debatably, leather gloves would have been tug was using a gob rope, but this did not prevent the tug being towed
more appropriate for this task and would have probably reduced the sideways. The tug’s emergency tow hook release was found to be
severity of the injuries. Yet, no injuries would have been sustained had operating correctly after the accident, but it is hypothesised that the
the above lessons been applied prior to working. crew did not have enough time to operate it before capsizing.
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Providing learning through confidential reports – an international co-operative scheme for improving safety
MARS 202507
Ladder deficiency allows fall to quay
As edited from SKH (Sweden) report SHK 2024:16e
[Link]
authority/search-investigation/maritime-transport/2024-01-17-
roerborg---fall-accident-in-oxelosund
A general cargo ship was berthed to load steel products. The ship
had a gantry crane which ran on rails on the coaming each side of the
holds and was used to lift or replace the hatch covers.
A crew member was climbing down from the gantry crane control
area to the deck. While proceeding down the ladder, the crew member
lost their footing on one of the upper rungs. They initially fell to a
platform on the lower part of the gantry crane, but the momentum from
the initial fall carried them over the platform railing and then down over
the ship’s side railing before finally landing on the quay.
The ladder in question was equipped with a protective cage and
the platform under the ladder was equipped with a railing. Between
the platform railing and the ladder’s protective cage there was an
unprotected space measuring just over 1m. The crew member fell
through this space and down onto the quay. The total height of the
fall was just over 11m.
Other crew members saw the fall and rushed to the quay to
administer first aid and call for external assistance. An ambulance soon
arrived and took the victim to a local hospital. The crew member was
seriously injured by the fall, but did not suffer permanent injuries. At the
time of the accident the victim was wearing several layers of clothing
and a helmet with a chinstrap. The clothing and the personal protective
equipment probably mitigated the consequences.
Lessons learned
l Research shows that the heeling force exerted on a tug is
proportional to the square of the towing speed. As such, the heeling
moment generated at 4.6kts was more than twice that generated at
3kts and five times that generated at 2kts.
l The passenger vessel’s speed at the time of the manoeuvre exceeded
the 2-3kts recommended by both industry and the local port towing
guidelines.
l Investigations into similar girting accidents found that it was essential
that conventional tugs use a gob rope during towing operations to
ensure the safety of the tug. To be fully effective, this rope must be
correctly set and secured. A gob rope must be as low in the vessel as
possible and as close as possible to the tug’s transom.
l The gob rope in this case was led through a bow shackle 2.8m behind
the towing hook, about 0.5m above the deck and over 1m from
the tug’s transom. This gob rope arrangement was unlikely to be as Lessons learned
effective as one rigged closer to the transom. It is therefore possible l This accident again illustrates the benefit of doing the rounds of
that this arrangement left the tug more vulnerable to being towed your vessel with ’new eyes’. Try and see where hazards exist but have
sideways and girted. always been in plain sight. We become too accustomed to hazards in
l It is essential for safe operations that the Master, pilot and tug plain sight; we see them as ‘normal’.
Masters agree and share a common understanding of the planned l The victim had used a protective helmet with chin strap. The chin
manoeuvre. In this case there was ambiguity and lack of information strap, an often-maligned PPE detail, was instrumental in keeping the
amongst the team. helmet on their head during the multiple impacts of the fall and may
l Cutting the tug bridle may have changed the outcome had it been have saved their life.
done before the tug capsized. As it was, a crewmember on the
passenger vessel had to run to the galley for a knife.
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MARS 202508 the wind to permit a check in the windlass motor room. There was once
again water in the compartment, and the level had reached the top of
Damage to accommodation ladder the entrance stairway. Pumps were employed for about two hours, but
A tanker had arrived at berth to load a fuel parcel. Once mooring was were not able to lower the water level.
completed, the starboard accommodation ladder was prepared for the Given the weather forecast and his sailing experience in the area,
embarkation of local authorities, including the agent and the terminal the Master determined that the weather would improve so he resumed
personnel. Upon embarkation of the first group of terminal workers, sailing toward the destination port. Later that day the vessel heeled
they requested that the vessel lower the ladder somewhat to reduce the a few degrees to port. Some hours later, the vessel was heeling five
gap from the dock. The ladder was subsequently lowered, but now was to seven degrees to port. It was later posited that port side ballast tanks
below the level of the jetty. one and two were taking water due to damaged air pipes caused by the
As the vessel was moving somewhat, both vertically (15 cm) and continuous blue water on deck.
horizontally (30 cm), the ladder hit the dock and suffered damage To correct the heeling, ballast water was loaded into the ballast water
before it could be raised above the level of the jetty. tank on the starboard side, but this did not bring the vessel upright. The
vessel was now dangerously overloaded and lacked sufficient reserve
buoyancy. The Master then attempted to alter the tanker’s course over
a three-hour period with varying success. With the tanker now heeled
to port and with negative trim, and given the wind and waves, the
manoeuvres did not have the desired effect.
Finally, at 2:40 the following morning, it was decided to abandon
ship. A distress signal was sent and a rescue helicopter arrived on scene
about 2.5 hours later. Other rescue resources followed, and all crew
were recovered. The tanker capsized and sank about six hours later.
All crewmembers were rescued, but the chief officer died while being
transported to hospital.
The investigation determined from witness testimony and the
salvaged vessel, among other things, that the sequence of flooding was
as follows: as the weather conditions worsened seawater constantly
washed over the forecastle. The seawater inundating the forecastle deck
Lessons learned flowed into the chain locker through the spurling pipe, which was not
l Consider your actions before executing them – bad consequences are plugged. When the chain locker was full, it flowed through the opened
a possibility so be situationally aware. chain locker hatch into the motor room and from there through the
l Sometimes we rush to please others. Stay focused on safety. open door into the bow thruster room.
Additionally, the investigation found that the three flooded areas
(windlass motor room, the bow thruster room, and the chain locker)
MARS 202509 are excluded from the vessel’s Loadcom program. The simulation
Progressive flooding sinks tanker conducted by the Master earlier in the voyage to determine the vessel’s
seaworthiness was mistaken and gave a false sense of security.
As edited from KMST (South Korea) report MSI 2024-003
[Link]
A fully loaded tanker left port despite a bad weather forecast for the
following days. As a precaution, the Master chose a route relatively close
to the coast in the event of an emergency.
Some 11 hours after departure, the bilge alarm sounded in the bow
thruster room. The OOW considered it to be a malfunction and silenced
the alarm. The next morning the bilge alarm in the bow thruster room
sounded again. The bilge pump was started for that space, and the
alarm soon ceased.
The weather remained relatively fair during the first day of the
voyage. By the afternoon of the second day, a strong northeasterly
wind was blowing, with waves increasing from four to six metres. In the
afternoon of the same day, a 440V low insulation warning alarm was
detected in the windlass motor room.
Given the alarms, the Master wanted to check the extent of the
problems forward. He altered the tanker’s course to reduce wave
impacts at the bow. Crewmembers, including the chief engineer, then
went forward and found that there was about one metre of water inside
the windlass motor room. The windlass motor room was emptied of
seawater using the general service pump and portable air pumps, Lessons learned
but the operation was hampered by the ship’s heaving and rolling. l It is best practice to plug spurling pipes prior to bad weather and
The Master checked the cargo stowage programme on the vessel’s keep chain locker access hatches closed and dogged.
loading computer (Loadcom) to determine the tanker’s safety and l Ensure your vessel is 100% seaworthy – battened down doors and
seaworthiness in the event of a flooded windlass motor room. The result hatches for all seas.
appeared good, so he decided to continue sailing to the destination l Know your ship and the tools available to you, among others the load
port. The next morning, the Master again turned the vessel away from computer.
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