94034 Equipment Failure CPP Master Error
Mistakes Made by Master
- South America. Daytime. Clear and Calm.
- Report No. 94034.
The vessel, a large chemical tanker carrying a mixed cargo which included a cocktail of various ethanols and phenols, benzene, and ethyl acetate was entering a port in South America. An ETA of 1200 had been given for arrival at the pilot station and, being late, full speed was maintained to within 2 - 3 miles of the Pilot Station. The engine room was given 1 hours notice at 1200.
At around 1300 the vessel was 2 miles from No 1 buoy, the pilot called and agreed to meet vessel in the channel just past No 1 buoy. The vessel had a controllable pitch propeller and the Master started reducing the pitch.
At a distance of 1 mile from the buoy the vessel was setting east towards No 1 buoy and up to 100 of set was applied to the course to counteract the set. Another vessel was leaving the harbour and had just passed the breakwater and was in the main channel. Own vessel's speed of about 8 knots was too high, so Master continued reducing pitch to zero. The time was now about 1310. The Master's attention was on No 1 buoy, the outward bound vessel, the pilot boat, and not on the propeller pitch indicator.
At about 1315 own vessel was 1/2 a mile from No 1 buoy and was still setting east, passing close to the buoy and making too much speed (5 - 6 knots). The Master ordered another 10 degrees to port to allow for the set and moved the pitch control to half astern. The Master then noticed that the propeller pitch feedback still showed slow ahead despite the pitch control being at half astern. The Master moved the pitch/engine control to full astern. Nothing happened to the pitch feedback indicator. The Master ordered the engine room to stop the main engine and check out the problem with controllable pitch propeller not responding to bridge pitch control.
At about 1320, with the engine stopped and the vessel still swinging to port, the steering became ineffective. The port swing could not be stopped and the vessel, which was still making about 3 knots, swung right across the channel in front of the oncoming outward bound vessel. The Master advised the other vessel and Pilot that his vessel had lost power and steering. At 1325 the vessel was heading 2700 T with the bow close to No 4 buoy and the stern by No 3 buoy. The main engine could not be re-started and after several tries, ran out of starting air.
The oncoming outward bound vessel left the channel and passed outside No 4 buoy. Fortunately, there was sufficient water and she was light. At about 1330, the outbound vessel passed clear and was able to return to the channel. From 1330 to 1350 the vessel drifted in the channel, still heading west, and narrowly missed touching the channel buoys.
At 1350 the Pilot was aboard and had ordered tugs to assist. At about 1400 the main engine was started and the controllable pitch propeller was fully operational, but operating on a back-up hydraulic system. The vessel proceeded inbound without any further incident. The Chief Engineer found a fault with the CPP hydraulic pump unit which had caused the pitch control to fail. The Master learned to pay more attention to the indicators and instruments on the bridge.
Conclusion:
A potentially very serious incident could have occurred which could have resulted in severe damage to two vessels, a major pollution incident, an explosion and fire with major loss of life, if the two vessels had collided. The incident was caused by:
1. The Master proceeding too fast to try and maintain an ETA.
2. Failure of the Master to properly monitor his bridge indicators and instruments.
3. Blind faith in the vessel's controls without considering that they could fail at a critical time.
4. Too much for one person to do all at once when the situation got out of control.
The Master was trying to communicate with the other vessel, the Pilot, the Engine Room, give helm orders and monitor the situation all at the same time. This was because the Officer of the Watch had left the bridge to meet the Pilot, the bridge watchmen was assisting the OOW with the pilot ladder and the Chief Officer was preparing the vessel for cargo operations. There was also a trainee Officer on the bridge, filling in the bell book, but he was insufficiently experienced to assist. The 2nd watchman was the helmsman.
Subsequent to this incident, the Master has learned a good lesson, fortunately without serious cost, and hopefully will be the better and safer for it in the future.