TU3-7-11-0160
Contents
1. When VDR data in particular bridge audio recordings are not available to an investigation this may preclude the identification and communication of safety deficiencies to advance transportation safety 14 Conclusions Findings as to Causes and Contributing Factors 1 Steering control was lost when the port steering system potentiometer failed while the rudder angle was at 10 to starboard causing the vessel to veer to starboard and leave the dredged channel The bridge crew members were not familiar with the use of the non follow up mode or with switching the steering system selector switch from port to starboard to regain steering control The master switched the steering system selector switch from port to starboard which restored steering control but it was too late to prevent the vessel from running aground Findings as to Risk 1 Without the regular replacement of potentiometers there is an increased risk that they will fail in service Crew may be unfamiliar with the steering control methods of the non follow up mode or switching steering systems in cases of steering failure if this information is not incorporated into technical manuals familiarization and drills or adequately described and posted near the steering stand When data from the voyage data recorder in particular the bridge audio recordings are not available to an investigation this may preclude the identification and communication of safety2. the steering stand instruction booklet on board the vessel the Sperry Helm Steering Assembly Operation and Service Manual made no reference to the need to replace potentiometers The manual advised the crew to perform monthly tests of the steering to verify the functioning of the potentiometer by positioning the steering wheel to one third of a full turn two thirds of a full turn and then a full turn on both sides each time ensuring that the rudder indicator matches the wheel order By comparison another manufacturer Litton Marine issued in 1999 the Steering Gear Tests Drills and Preventative Maintenance notice for the C Plath steering stand type in which it recommended the replacement of potentiometers in steering stands at minimum intervals of 5 years Inspection of Steering Stand On 10 December 2011 an authorized representative of Sperry Alliance Nav visited the Orsula in the Port of Contrec ur at the request of the master While the work order was to inspect the gyro the master also requested that the technician perform a general test of the steering console During this general test the technician did not specifically inspect the potentiometers The technician was aware of the recommendation from the other manufacturer to replace the potentiometer after a period of time but found no defects on the steering console The potentiometer that failed on board the Orsula was manufactured in 1994 The potentiometer did no
3. ISM Code 8 Crew Certification and Experience The crew of the Orsula were all properly certified for their positions on board The master held a Master Mariner certificate of competency endorsed by the Marshall Islands Maritime Administrator and had sailed as a master on various vessels belonging to the same company since 2004 He joined the Orsula in September 2011 having served on board as master several times since 2005 The OOW held an Officer of the Watch certificate of competency issued in April 2011 and endorsed by the Marshall Islands Maritime Administrator and had been sailing on different vessels in that position since July 2011 He joined the Orsula on 12 December 2011 The helmsman had been sailing since 1981 and obtained his Bridge Watchman certificate in 1987 in Croatia He had been with this company since 2006 and joined the Orsula in October 2011 7 The SMC was subject to at least 1 intermediate verification to be carried out between the second and third anniversary dates of the SMC in accordance with regulation IX 6 1 of the International Convention for the Safety of Life at Sea SOLAS and paragraph 13 8 of the ISM Code International Management Code for the Safe Operation of Ships and for Pollution Prevention The pilot held a Master Inland Waters certificate and obtained his District 1 Class B2 pilot licence in April 2011 The apprentice pilot held a Master Near Coastal certificate and obtained his District 1 Clas
4. e ANCILLARY BRIDGE EQUIPMENT E G BINOCULARS WINDOW WIPERS STEERING GEAR TESTED INCLUDING HARD OVER PORT HARD OVER STARBOARD STEERING GEAR NO HARD OVER PORT HARD OVER STARBOARD STEERING GEAR NO 2 ri AUTO PILOT ae TEST OF MANUAL OPERATION aa Le TEST FUNCTION OF STEERING GEAR TO BRIDGE COMMUNICATIONS e CONFIRMATION OF CORRECT FUNCTION OF RUDDER INDICATORS e WATER INGRESS DETECTION SYSTEM e DEWATERING SYSTEM 4 IS THE SHIP SECURE FOR SEA e CARGO AND CARGO HANDLING EQUIPMENT SECURED e ALL HULL OPENINGS SECURED AND WATERTIGHT e CARGO PASSENGERS DETAILS AVAILABLE e STABILITY AND DRAUGHT INFORMATION AVAILABLE ALL THE CREW ON BOARD AND ALL SHORE PERSONALL ASHORE 6 ISTHE VESSEL THROUGHLY SEARCHED FOR STOWAWAYS ee 8 ISTHE CREW AT STATIONS FORLEAVINGHARBOUR 9 ARE THE PILOT DISEMBARKATION ARRANGEMENTS IN PLACE i i CONFIRMATION FROM E R THAT CHECK LIST TEC20 IS SATISFACTORILY COMPLETED AND BRIDGE CONTROL ACCEPTED PORT SIGNED MASTER cescseccccen ec tessseeessneee OFFICERIOP WATER sus serons To be filed on board for inspection purposes Revision date 2008 08 01 Issued by Fleet Teams Revision 1 Annroved hw CFO Shinmanacement
5. familiar with the proper response to a steering failure in restricted waters It is also recommended that the operator use the lessons learned from this occurrence as a case study for enhanced bridge team management training for its crews Safety Concerns Familiarity with Steering Control Modes Steering is a critical aspect of operating a vessel Vessels that are compliant with the International Convention for the Safety of Life at Sea SOLAS are required to have at least 2 independent steering control systems designed so that there is a built in redundancy In this occurrence when the rudder did not respond the on watch personnel did not know why and did not select the alternate steering system A quick response would have allowed the vessel to regain steering control before it departed the channel and grounded As such familiarity with and use 17 of these steering systems is of the utmost importance in situations where a steering system fails and there is limited time available to regain steering control SOLAS Chapter V Regulation 26 states the following all ships officers concerned with the operation and or maintenance of steering gear shall be familiar with the operation of the steering systems fitted on the ship and with the procedures for changing from one system to another The information can be conveyed through technical manuals familiarization drills and posted procedures When the potentiometer failed on the
6. of an emergency stop putting the telegraph from full ahead to full astern the vessel can be stopped in 5 minutes and 21 seconds 1 This information was posted on a bulkhead in the wheelhouse Crew Familiarization Checklist The managing company established different checklists to account for different aspects of safety maintenance verification and training for the crew Among these form NAV09 entitled Familiarization with Bridge Equipment lists navigation equipment and controls to be studied and understood by the bridge crew member When all of the items are checked off to indicate completion of familiarization the form is signed by the crew member and the master On the Orsula this form was found to be completed and signed Also form NAV10 entitled Bridge Preparation for Departure lists a series of verifications of bridge equipment to be completed prior to departure Appendix C Among these the steering gear is to be verified in several ways Neither NAV09 nor NAV10 contained any information regarding the operation of the NFU mode or the option to switch from the port to the starboard steering system for steering control 1 Data based on information collected during sea trials of the Orsula prior to delivery to owner 10 Drills In Chapter V Regulation 26 of the International Convention for the Safety of Life at Sea SOLAS there is a description of the tests and drills that must be performed on a steering g
7. port steering system of the Orsula the use of the alternative remote steering systems on the bridge was the fastest method of regaining steering control On the Orsula the steering systems available on the bridge were as follows Remote full follow up FFU mode using the helm wheel on the port steering system Remote FFU mode using the helm wheel on the starboard steering system Remote non follow up NFU mode using the hand lever However the on watch personnel were not familiar with the use of these systems and as such did not make use of them during this occurrence During the investigation the TSB visited 8 vessels to verify the crew s familiarity with steering systems The TSB found that the lack of awareness of alternative steering systems was not limited to the Orsula which indicates a broader problem In the past 10 years the TSB has recorded approximately 180 occurrences related to steering failure While most of these did not result in groundings steering failures nonetheless present significant risks to a vessel s operation In one of these occurrences involving the vessel Fossnes occurrence number M00L0114 similar safety concerns as that of the occurrence involving the Orsula were identified Furthermore the Australian Transport Safety Bureau ATSB in its report on the 31 July 2008 grounding of the bulk carrier Iron King at Port Hedland Western Australia identified as a safety issue a lack of drills a
8. then ordered the engine to be stopped that somebody be ready to drop the anchor and that emergency steering be activated At this time the vessel was more or less steady on a course of approximately 050 The OOW called the master and moved the engine telegraph handle from full ahead to stop at which time the vessel s speed was approximately 15 knots speed over ground SOG The OOW then went and stood by the steering stand At the same time the pilot called Marine Communication and Traffic Services MCTS informing them that the vessel was out of control and would soon exit the channel At about 0 5 nm east of buoy C21 the vessel started exiting the channel with a slow turn to starboard The pilot ordered the main engine full astern and the OOW set the engine telegraph to full astern 6 Speed through the water is a measure of speed that does not take into account current or wind On the other hand speed over ground SOG accounts for the current and wind speed 4 All courses are gyro compass headings unless otherwise specified 5 Midship is when the rudder angle is at 0 To be able to reverse the engine and apply full astern thrust the main engine revolutions per minute need to reach a low enough level to apply braking air in order to expedite the slowing and reversing of the engine By the time the main engine was reversed and full astern was available the vessel had already grounded At 1327 the pilot reported to MCTS that
9. 1 and 2 are carried out and the date and details of emergency steering drills carried out under paragraph 4 shall be recorded 22 Appendix C Form Number NA V10 ATLANTSKA PLOVIDBA d d Form Number NAV10 Page l of BRIDGE PREPARATION FOR DEPARTURE Ship s Name TICK 1 HAS A PASSAGE PLAN FOR THE INTENDED VOYAGE BEEN PREPARED a ARE ALL RELEVANT CHARTS AND NAUTICAL PUBLICATIONS CORRECTED UP TO DATE AND COURSES LAID OFF 3 HAS THE FOLLOWING EQUIPMENT BEEN CHECKED AND FOUND READY FOR USE e ANCHORS INCLUDING CLEARED AWAY MOORING WINCHES AND LINES INCLUDING HEAVING LINES BRIDGE MOVEMENT BOOK COURSE AND ENGINE MOVEMENT RECORDER e SIMPLIFIED VOYAGE DATA RECORDER p e AUTOMATIC IDENTIFICATION SYSTEM AIS UPDATED ECHO SOUNDER ELECTRONIC NAVIGATIONAL POSITION FIXING SYSTEMS e GYRO MAGNETIC COMPASS AND REPEATERS e RADARS AND ASSOCIATED PLOTTING AIDS e SPEED DISTANCE RECORDER e CLOCKS SYNCHRONISED e BRIDGE AND ENGINE ROOM TELEGRAPHS INCLUDING RPM INDICATORS EMERGENCY ENGINE STOPS THRUSTER CONTROLS AND INDICATORS IF FITTED e CONTROLLABLE PITCH PROPELLER CONTROLS AND INDICATORS IF FITTED e COMMUNICATION FACILITIES INTERNAL EXTERNAL AND PORTABLE e NAVIGATION AND SIGNAL LIGHTS SHAPES INCLUDING SEARCHLIGHTS SIGNALLING LAMP MORSE LIGHT NOT UNDER COMMAND AND AT ANCHOR e SHIP S WHISTLE e DECK LIGHTING PRESSURE ON FIRE MAIN e WINDOW WIPER CLEARVIEW SCREEN ARRANGEMENTS
10. Bureau de la s curit des transports du Canada Transportation Safety Board of Canada MARINE INVESTIGATION REPORT M11L0160 si z Cae GROUNDING BULK CARRIER ORSULA BATTURES DE GENTILLY BECANCOUR QUEBEC 15 DECEMBER 2011 isi Canada The Transportation Safety Board of Canada TSB investigated this occurrence for the purpose of advancing transportation safety It is not the function of the Board to assign fault or determine civil or criminal liability Marine Investigation Report Grounding Bulk Carrier Orsula Battures de Gentilly B cancour Quebec 15 December 2011 Report Number M11L0160 Summary On 15 December 2011 at 0910 Eastern Standard Time the bulk carrier Orsula departed Contrec ur Quebec in ballast for Baie Comeau Quebec While proceeding downbound on the St Lawrence River under the conduct of a pilot the vessel lost steering control and ran aground at 1329 on the Battures de Gentilly 1 25 miles northeast of B cancour wharf Quebec About 48 hours later it was refloated on the first attempt using tugs The vessel sustained hull damage which required repairs There were no injuries or pollution as a result of this occurrence Ce rapport est galement disponible en fran ais Factual Information Particulars of the Vessel Name of vessel Orsula IMO number 9110901 Port of registry Majuro Flag Marshall Islands Type Bulk carrier Gross t
11. ations societies of the circumstances of the steering failure IACS considers that it is the responsibility of the manufacturer of the steering system or potentiometer to identify the vessels fitted with this equipment and to inform the concerned owners operators of all updated instructions and recommendations for the equipment Marshall Islands Maritime Administrator The Marshall Islands Maritime Administrator recommends that the operator of the Orsula reviews and revises as appropriate its procedures and checklists for documenting the familiarization of on signing officers of the watch with the vessel s bridge equipment It also recommends that the officer be required to demonstrate to the master and or chief officer their ability to operate the steering gear in all modes of operation In addition it is recommended that these procedures include ensuring that the on signing officer is familiar with how to respond to a steering failure when navigating in restricted waters without intervention from the master Also it is recommended that these familiarization requirements be included as a pre requisite for crew members serving as helmsmen Furthermore the Maritime Administrator recommends that the operator ensure that all officers of the watch and helmsmen currently serving on vessels in its managed fleet receive hands on training that they are able to demonstrate proper operation of the steering gear in all modes of operation and that they are
12. deficiencies to advance transportation safety 15 Safety Action Action Taken TSB On 03 January 2012 the TSB issued a Marine Safety Advisory Letter MSA 07 11 to the International Association of Classification Societies IACS a copy of which was also sent to Transport Canada Fednav Limited as sister vessel owners Anglo Eastern Ship Management as sister vessel manager Sperry Marine and Det Norske Veritas DNV Republic of the Marshall Islands for it to consider informing its member classification societies of the circumstances of this steering gear failure and of the necessity to replace potentiometers in similar Litton Marine System Sperry Marine steering systems at or before the recommended interval of 5 years The letter also requested that IACS consider verifying that the manufacturer s service instructions are on board vessels fitted with similar systems Owner After this occurrence the owner instructed all vessels in its fleet to perform an Emergency Steering Drill on Sundays During the drill the master is to explain to all deck officers and helmsmen how to change from the follow up to the non follow up steering mode After this explanation the crew must demonstrate these techniques to the master The owner also included emergency changeover arrangements for steering gear in the Familiarization with Bridge Equipment and Bridge Preparation for Arrival Departure checklists The understanding of these checklist
13. der according to the required capabilities of the steering gear 2 a visual inspection for the steering gear and its connecting linkage and 3 the operation of the means of communication between the navigation bridge and steering gear compartment Simple operating instructions with a block diagram showing the change over procedures for remote steering gear control systems and steering gear power units shall be permanently displayed on the navigation bridge and in the steering compartment All ships officers concerned with the operation and or maintenance of steering gear shall be familiar with the operation of the steering systems fitted on the ship and with the procedures for changing from one system to another In addition to the routine checks and tests prescribed in paragraphs 1 and 2 emergency steering drills shall take place at least once every three months in order to practice emergency steering procedures These drills shall include direct control within the steering gear compartment the communications procedure with the navigation bridge and where applicable the operation of alternative power supplies The Administration may waive the requirements to carry out the checks and tests prescribed in paragraphs 1 and 2 for ships which regularly engage on voyages of short duration Such ships shall carry out these checks and tests at least once every week 21 6 The date upon which the checks and tests prescribed in paragraphs
14. ear Appendix B The series of verifications stated in SOLAS are the same as those in the safety management system documentation on board the Orsula Appendix C Neither is specific about the use of the NFU mode or switching from the port to the starboard steering system or how these technical means of steering can be used in cases where steering control is lost Voyage Data Recorder In addition to bridge audio a simplified voyage data recorder S VDR is capable of recording such items as time vessel heading and speed gyrocompass alarms very high frequency VHF radiotelephone communications radar echo sounder wind speed and direction and rudder engine orders and responses SOLAS requires that annual performance tests of the S VDR be conducted by an approved testing or servicing facility 12 The last annual performance test certificate on board the Orsula was dated 02 May 2011 The Orsula had a valid safety management certificate as required by the ISM Code therefore there was a safety management system on board the vessel The safety management system included a pre departure checklist NAV10 which required verification of the readiness of the S VDR The pre departure checklist indicated that the S VDR had been verified by the bridge crew before leaving Contrecceur On the Orsula the S VDR was not recording at the time of the occurrence and had not recorded any data since May 2011 The S VDR started recording 3 hours after the
15. eering control a crew must be aware of the means to regain that control This is especially crucial when the vessel is sailing in restricted waters That awareness can come from technical manuals familiarization drills and posted procedures Steering control was lost on the Orsula when one of the potentiometers failed Using the NFU mode in situations such as these is an efficient and effective way to try to regain control of the vessel s steering Also another effective method is to switch from the port to the starboard steering system However neither the helmsman nor the OOW tried the NFU mode or switched the steering systems to regain control The helmsman and OOW were not familiar with these methods and they did not make use of them in this occurrence Neither method was specifically addressed in Orsula s on board familiarization as they were not included in the NAV09 or NAV10 checklists There was no specific information on these methods posted near the steering stand or specified in the on board Sperry Helm Steering Assembly Operation and Service Manual The procedure for emergency steering drills in compliance with SOLAS also did not include the testing and use of the NFU mode or switching steering systems As such there were limited opportunities for the bridge crew to become familiar with these 2 means of regaining steering control on board the Orsula Furthermore the TSB s review of 8 vessels found that the lack of a
16. gency measure to detach the 2 telemotor receivers from the floating lever arrangement and connect a hand trick wheel to directly and manually operate the variable delivery main steering pump However in order to do this an operator must be situated locally in the steering gear compartment to operate the trick wheel and follow orders given by bridge personnel through a communication device 3 A wheel located in the steering gear compartment which in an emergency manually drives the telemotors operating the rudder Bridge Helm Unit The Orsula is fitted with a Sperry Marine steering control system model ADG 3000 This system fitted during the construction of the vessel and approved by the classification society includes an all electric helm unit that incorporates hand steering capabilities and autopilot functions Gyro repeater Steering system A steering control mode selector switch Steering control selector switch located on the upper left hand side of the PEN steering stand is used to select 1 of 3 different means of steering the vessel autopilot hand or non follow up NFU When the steering mode selector switch is set to the hand position the helm wheel is activated permitting the helmsman to operate the steering in FFU mode In FFU mode when the operator changes the position of the helm wheel the rudder begins to move and keeps moving until it reaches the ordered position indicated on the helm To
17. indows C Wheel 4 Telephone 9 Doors D Non follow up controller 5 Chair Figure 1 Bridge layout diagram not to scale History of the Voyage On 15 December 2011 the Orsula departed Contrecceur Quebec for Baie Comeau Quebec in ballast condition At 1230 2 the vessel arrived at the Pointe des Ormes pilot station The pilot assigned from Trois Rivi res Quebec to Qu bec Quebec boarded the vessel along with an apprentice pilot to relieve the pilot assigned from Contrecceur to Trois Rivi res At this point a pilot pilot exchange took place During the exchange between the master and the new pilot the pilot told the master that he would begin the passage at slow speed to allow sufficient time for 2 All times are Eastern Standard Time Coordinated Universal Time minus 5 hours unless otherwise noted another vessel to manoeuvre in the port of Trois Rivi res The pilot also informed the master of his intention to keep the engine in the manoeuvring speed mode of 12 knots through the water 3 throughout the passage to Qu bec The engine control was set to bridge control The bridge team was comprised at this time of the master the second officer acting as officer of the watch OOW a pilot an apprentice pilot and a helmsman The helmsman responded well to the helm orders using the helm wheel in full follow up FFU mode and that he steered the vessel steadily At this time the pilot connected his portable pilot unit PPU a
18. ing thus making important information inaccessible to the TSB Likewise in other occurrence investigations M10H0006 Clipper Adventurer M09C0051 Federal Agno and M05L0205 Cast Prosperity and tanker Hyde Park the VDR data was unavailable for different reasons which impeded the work of the TSB In addition numerous marine occurrence investigations worldwide have identified a similar problem regarding malfunctioning or non operating vessel VDRs Given this history and the occurrence of the Orsula the Board is concerned that when VDR data in particular bridge audio recordings are not available to an investigation this may preclude the identification and communication of safety deficiencies to advance transportation safety The Board will be monitoring the situation with a view to assessing the need for further safety action on this issue This report concludes the Transportation Safety Board s investigation into this occurrence Consequently the Board authorized the release of this report on 23 January 2013 It was officially released on 07 February 2013 Visit the Transportation Safety Board s website www bst tsb gc ca for information about the Transportation Safety Board and its products and services You will also find the Watchlist which identifies the transportation safety issues that pose the greatest risk to Canadians In each case the TSB has found that actions taken to date are inadequate and that industry and regulators need t
19. nd training on the procedures to be used when steering is lost In the Iron King incident the vessel s SMS procedures stated that emergency steering drills should be carried out but did not explain how to do so In light of the potential hazards associated with the loss of steering control on vessels the Board is concerned that shortcomings in the familiarization and training of crew members with regards to steering systems may result in risks to life property and the environment The Board will be monitoring the situation to determine if appropriate remedial action is being taken and will assess the need for further action on this issue Availability of Voyage Data Recorder Data The purpose of a voyage data recorder VDR is to create and maintain a secure retrievable record of information related to the position movement physical status command and control of a vessel Objective data voice data in particular are invaluable to investigators seeking to 18 understand the sequence of events leading up to an occurrence In this investigation voice data recorded by VDR would have been a highly effective means of gathering information about the activities of the bridge team Upon reviewing past occurrences investigated by the TSB it was determined that the failure of VDRs to function as intended is not uncommon For example on 31 March 2011 the VDR on the BBC Steinhoeft 14 was found to have ceased functioning prior to the ground
20. nd used his own global positioning system GPS antenna to feed the PPU The pilot then allowed the apprentice pilot to conduct the vessel while still supervising him At around 1315 the vessel approached Course de B cancour and the apprentice altered course to 050 gyro G 4 to steer on the next set of ranges At around this time the master left the bridge At 1324 the vessel passed 0 4 nautical miles nm abeam B cancour wharf while still in line with the ranges At around 1326 the vessel was near buoy C21 and had reached the point at which the pilot was to initiate a turn to port The apprentice ordered the helmsman to bring the vessel to a heading of 045 and the helmsman confirmed this order by repeating the heading However the rudder angle indicator showed 10 to starboard The apprentice then ordered the heading 045 again and the helmsman confirmed by repeating it With the rudder angle indicator still showing 10 to starboard the apprentice ordered the helmsman to put the helm at midship but there was still no rudder movement showing on the rudder angle indicator The apprentice then advised the pilot of the situation The pilot took over the conduct of the vessel and ordered 20 of port rudder The rudder angle indicator remained at 10 to starboard The pilot then ordered hard to port but upon seeing no result ordered 10 of starboard rudder No rudder movement could be observed on the rudder angle indicator The pilot
21. not familiar with either option By the time the master returned to the bridge and switched the steering system selector switch from port to starboard restoring control of rudder movement it was too late to prevent the grounding Potentiometer Failure Potentiometers send signals to a steering system amplifier and corresponding telemotors and are mechanically connected to the helm wheel with gearwheels As critical components of the steering gear control potentiometers require adequate testing and record keeping to ensure that they continue to function effectively In this occurrence the potentiometer connected to the port steering system failed disrupting the link between the steering stand and the port telemotor in the steering gear compartment resulting in the loss of control of rudder movement The potentiometer had failed due to the consequences of contamination however the investigation was not able to determine the origin of this contamination The instruction manual for the Sperry Marine steering stand on board the Orsula the Sperry Helm Steering Assembly Operation and Service Manual advised the crew to perform monthly verifications of the steering that would test the potentiometer This is done by positioning the steering wheel to one third of a full turn two thirds of a full turn and then a full turn each time ensuring that the rudder indicator matches the wheel order While the NAV10 checklist that contains the proced
22. o take additional concrete measures to eliminate the risks 14 TSB Occurrence M11C0001 19 Appendix A Area of the Occurrence 1325 30 Approximate time of steering 1323 45 Vessel abeam B cancour wharf 15 December 2011 1329 30 Vessel aground Lat 46 25 4 N Long 072 21 6 W Heading 079 G THE INFORMATION ON THIS SKETCH WAS COMPILED BY THE TSB MARINE INVESTIGATIONS BRANCH AND IS NOT TO BE USED FOR NAVIGATION ALL TRACKS AND POSITIONS ARE APPROXIMATE BASED ON AN ELECTRONIC NAVIGATION CHART ENC PROVIDED BY THE CANADIAN HYDROGRAPHIC SERVICE CHART No 1313 20 Appendix B SOLAS Chapter V REGULATION 26 Steering Gear Testing and Drills 1 2 3 1 3 2 Within 12 hours before departure the ship s steering gear shall be checked and tested by the ship s crew The test procedure shall include where applicable the operation of the following 1 the main steering gear 2 the auxiliary steering gear 3 the remote steering gear control systems 4 the steering positions located on the navigation bridge 5 the emergency power supply 6 the rudder angle indicators in relation to the actual position of the rudder 7 the remote steering gear control system power failure alarms 8 the steering gear power unit failure alarms and 9 automatic isolating arrangements and other automatic equipment The checks and tests shall include 1 the full movement of the rud
23. onnage 20 837 Length 200 m Draught Forward 4 18 m Aft 6 8 m Built 1996 Yiangnan Shipyard Shanghai China Propulsion B amp W 6S50MC 2 stroke single acting engine developing 8562 kW at 127 rpm Cargo Ballast 9362 metric tons Crew 20 Registered owner Atlant Bulkers Corp Majuro Marshall Islands Manager Atlantska Plovidba d d Dubrovnik Croatia Description of the Vessel The Orsula is a bulk carrier cargo vessel built of steel with machinery spaces and accommodations located aft The 6 cargo holds and hatches are serviced by three 30 tonne electrical hydraulic cranes mounted on the centreline of the vessel The bridge is equipped with all the required navigational equipment including both 3 cm and 10 cm radars distributed on either side of the centreline Figure 1 The steering stand is situated off to the starboard side of the centreline of the bridge and an indication is in place at the starboard window to enable Photo 1 Orsula 1 Units of measurement in this report conform to International Maritime Organization IMO standards or where there is no such standard are expressed in the International System SI of units visual alignment with the steering light The engine controls and the communication system are located on the starboard console Centreline 1 Radar 6 Navlights console A Steering control mode 2 Steering stand 7 Chart table B Telemotor control mode 3 Telegraph 8 W
24. return the rudder to the neutral 0 position the helm wheel must be manually positioned to 0 The helm order data signal to the steering gear telemotors is provided by 2 potentiometers that are mechanically linked to the helm wheel and electrically linked to each telemotor 1 potentiometer per telemotor Displa assembly Non follow up controller Typically when the NFU mode is selected the NFU controller becomes operational and the helm wheel is deactivated However on the Orsula once the NFU controller is used it overridesall Figure 2 Bridge helm unit arrangement other steering controllers without the need to set the steering mode selector switch to NFU The NFU controller is a spring loaded lever that must be held to one side or the other for a signal to be sent to the steering gear telemotors Operating the NFU control causes the rudder to rotate left or right for as long as the control is held in the left or right position On releasing the control the rudder stops rotating and holds its position until the NFU controller is again operated A steering system selector switch is located on the upper right hand side of the steering helm unit The steering selector switch selects either the port or starboard steering system Each of these systems controls the steering gear telemotor Replacement of Steering Stand Components The steering stand on the Orsula was manufactured by Sperry Marine At the time of the occurrence
25. s D apprentice licence in April 2011 Environmental Information On 15 December 2011 in the region of Trois Rivi res B cancour the visibility was about 2 miles and the sky was overcast with light rain High tide was at 1351 in Trois Rivi res and at 1330 in B cancour The water level in B cancour was predicted to be 1 2 m above chart datum at high tide Damage to the Vessel On 17 December 2011 an underwater survey of the Orsula was conducted at the Port of B cancour The survey revealed the following e 2cracks one 1500 mm x 50 mm and the other 500 mm x 40 mm in way of the bow thruster e long indents 8 m x 70 mm deep found on the port and starboard bow e starboard bulkheads between the bow thruster room and forepeak tank were found buckled and detached at the bottom e numerous transverse floors were found buckled and detached at the bottom over a length of 1 m Steering Gear The Orsula is equipped with an electro hydraulic Rapson Slide type FM21 072 steering gear with 2 rams and 4 cylinders manufactured by Kawasaki Wuhan The hydraulic cylinders are supplied by 2 variable delivery main steering gear pumps operated through a floating lever arrangement driven by a set of 2 telemotor receivers Only 1 telemotor receiver can be used at a time but it can drive either 1 or 2 variable delivery main steering pumps at the same time In case of failure of all remote steering gear control systems it is possible as an emer
26. s should be demonstrated by all navigating officers and helmsmen during each emergency drill Furthermore the owner revised the safety management system for the Orsula and other vessels with the same equipment to include the requirement to replace potentiometers every 5 years for preventative maintenance Sister Vessel Owner On 07 February 2012 the FedNav Owned Fleet department forwarded a copy of the MSA to its technical managers requesting that they follow up with the FedNav vessels under their management Lloyd s Register On 22 February 2012 Lloyd s Register issued Classification News No 07 2012 to all vessel owners and operators strongly recommending that they ensure that all service bulletins are maintained up to date with a copy retained on board and that necessary maintenance procedures are adhered to on steering control potentiometers 16 China Classification Society On 17 April 2012 the China Classification Society CCS issued Classification Information notice No 196 to distribute the MSA to relevant shipping companies The information has also been published on the CCS website International Association of Classification Societies Limited On 06 June 2012 IACS responded to the TSB stating that it had distributed the MSA to its members and that it would officially reply to the MSA once it had received feedback On 02 July 2012 IACS responded to the TSB stating that it had informed individual member classific
27. t have any physical label to identify the manufacturing date Instead it was marked with a serial number that an individual could use as a reference when calling the manufacturer to determine the manufacturing date Laboratory Analysis Upon examination of the potentiometer visible contamination was found on the lower bearing resembling a powder of a brown hue The balls and races had been affected by some deterioration likely due to the abrasive action of that contamination The deterioration of the surfaces likely resulted in the need for additional force to rotate the shaft of the potentiometer which in turn deformed and cracked the bearing cage The examination concluded that the potentiometer did not turn freely due to the failure of its lower bearing which had seized due to the deformation and cracking of its cage 10 The investigation was not able to determine the origin of the contamination Review of Alternative Steering Methods The TSB conducted a review of 8 vessels from different owners and flag states in the Port of Qu bec to determine the general knowledge and use of the NFU mode by bridge crew members This revealed that on 6 out of the 8 vessels reviewed the crew members were not 19 TSB Laboratory report LP 180 2011 available upon request fully familiar with the use of the NFU mode In general it was found that when they first boarded the vessel helmsmen were only given brief explanations of the different steering s
28. tand components and their use including the NFU mode Furthermore the procedures for dealing with situations involving steering failures refer primarily to the local emergency steering in the steering gear compartment Use of the NFU mode if it is referred to is usually listed as a secondary or tertiary method to regain control On the Orsula 1 steering system is used to control the steering when in hand steering mode In the event of a steering failure switching to another steering system can be a solution to regain control The deficient potentiometer was linked to the port telemotor When the master came back on the bridge he switched the steering system selector switch from port to starboard which restored steering control Reversing the Main Engine The vessel is fitted with a direct drive reversible low speed engine The engine drives 1 fixed pitch propeller and the vessel service speed is approximately 15 knots The bridge control of the engine enables a crew member to start the engine ahead or astern and choose different speed settings To switch from ahead to astern movement the engine must be allowed to slow down to a designated revolution 37 rpm to prevent excessive stresses and forces before it can then be set into reverse mode and restarted astern When the main engine is set to full ahead 127 rpm and the vessel speed is 14 8 knots it takes 155 seconds for the engine to set into astern starting mode As well in the case
29. the vessel was leaving the channel and would soon ground At approximately 1328 the master came on the bridge He went directly to the steering stand and transferred the steering system actuator switch from port to starboard restoring control to the steering Nonetheless at 1329 as the bosun and OOW were out on deck on their way to attend the anchors the vessel ran aground at an estimated speed of 8 knots SOG At 1331 the pilot called MCTS to report that the vessel was aground in position 46 25 4 N and 072 21 6 W with a heading of 079 Post Occurrence Examination of Steering Stand Following the grounding when the vessel was towed to the Port of B cancour a call was made to an authorized representative of Sperry Marine to examine the bridge steering stand components The examination determined that the port steering system helm potentiometer had failed As part of the service call the 3 potentiometers in the steering stand were replaced and the system was found to be functional Vessel Certification The Orsula carried all appropriate certificates for a vessel of its class and for the voyage A Safety Management Certificate SMC had been issued to the vessel by Det Norske Veritas DNV in Norway on 13 November 2008 and was valid until 27 September 2013 This certificate was endorsed after an intermediate verification 7 on 06 August 2011 The vessel was thus in compliance with the requirements of the International Safety Management
30. ures that the crew of the Orsula performed before each departure does require a steering test this steering test does not fully correspond to the procedure stated in the manual Referring to Appendix C the checklist requires a steering gear test where the wheel is 12 turned hard over to port and hard over to starboard Therefore this procedure may not have adequately served to test the potentiometer in accordance with the manufacturer s instructions The regular testing of steering merely verifies that the potentiometer is functional at the specific time of a given test If one of the potentiometers fails the bridge operator can either switch to the alternate steering system or regain steering control using the NFU mode The effectiveness of these 2 options available to the bridge operator depends on the operator s awareness of and ability to use these options in the event of a failure The Sperry Marine instruction manual on board the Orsula did not contain any reference to the need to replace potentiometers The potentiometer that failed in this occurrence had been manufactured in 1994 Other manufacturers such as Litton Marine recommend that potentiometers in steering stands be replaced at minimum intervals of 5 years Without regular replacement of potentiometers there is an increased risk that they will fail in service Familiarity with Steering Control Modes To react effectively in emergency situations where there is a loss of st
31. vessel went aground on 15 December 2011 13 12 Regulation V 18 8 13 TSB Laboratory Report LP182 2011 available upon request TI Analysis Events Leading to the Grounding When the helm follow up potentiometer of the port steering system failed the electrical link between the steering stand and the telemotor in the steering gear compartment ceased to function and control of rudder movement was lost At this time the rudder angle indicator was showing 10 to starboard The vessel veered to starboard when it was intended to alter course to port When the vessel s crew members on the bridge became aware that the rudder was not responding 3 options were available on the bridge to rectify the situation taking over the steering control with the non follow up NFU mode changing over from the port to the starboard steering system to also regain steering control or stopping the vessel However stopping the vessel was not a viable option because of the vessel s proximity to the shore and the length of time required to put the engine at full astern and stop the vessel Thus while in this case the engine was ordered full astern the engine went astern only after the vessel had grounded The other 2 options in this situation involved regaining control of steering There was no attempt made by the officer of the watch OOW or the helmsman to use the NFU mode or to switch from the port to the starboard steering system because they were
32. wareness of the NFU mode is not limited to the Orsula and may be an indication of a broader problem Therefore if information on steering control methods such as the NFU mode or switching steering systems is not adequately incorporated into technical manuals familiarization and drills or adequately described and posted near steering stands crew may be unfamiliar with these methods As in the Orsula a lack of familiarity with either method can put the vessel and its crew at risk when a means of regaining steering control is needed in an emergency 13 Voyage Data Recorder The purpose of a voyage data recorder VDR is to create and maintain a secure retrievable record of information indicating the position movement physical status and control of a vessel for the period covering the most recent 12 hours of operation Objective data is invaluable to investigators when seeking to understand a sequence of events and identify operational problems and human factors The pre departure checklist on board the Orsula NAV10 indicated that the simplified voyage data recorder S VDR had been verified by the bridge crew prior to departure the crew did not see any indication that the S VDR was malfunctioning Furthermore the investigation did not determine why the VDR was not recording at the time of the occurrence nor why it had not recorded data since May 2011 The VDR started recording 3 hours after the vessel went aground on 15 December 2011
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