| Recommendation Reference Number | Recommendation Text |
| 2008-037 | Emphasize the dangers of complacency during oil transfers to crews by publicizing lessons-learned from this spill throughout the company’s fleet. |
| 2008-036 | Emphasize to the bunkering team members during pre-bunkering training, the importance of closely monitoring the tank vents of tanks that are being topped-off. |
| 2008-035 | Ensure vessel crews that receive pre-bunkering training required by Washington’s procedures for safe bunkering, fully understand these requirements, and are prepared to carry out their duties as part of a bunkering team. |
| 2008-034 | Ensure your vessel crews are aware of and fully comply with Washington’s requirements for safe oil transfer. |
| 2008-033 | Ensure that pre-loading plans that are prepared are followed. |
| 2008-032 | Develop a means to more completely close-off the {ship's} freeing ports during fueling operations to prevent any spilled oil from reaching the water. Ensure those means are incorporated into the {ship's} oil transfer procedures. |
| 2008-031 | Modify your oil transfer procedures to prohibit simultaneous transfers (such as lube and fuel oil) when tanks are being topped-off, unless additional personnel are used to ensure both transfers can proceed safely. |
| 2008-030 | Regularly monitor the fueling operations of vessels in your fleet to ensure that Persons-in-charge are complying with the oil transfer procedures, especially with regard to the maximum tank fill levels that are established. |
| 2008-029 | Determine the safe fill level for each of the {ship's} tanks and ensure these levels are reflected in the ship’s oil transfer procedures. Consider marking the safe fill level on the sight glasses or on the bulkhead adjacent to the sight glasses. |
| 2008-026 | Consider revision of WAC 173-180-245 (4) to make allowance for instances where the design of the vessel is neither amenable to fixed vent containment nor automatic shut-off nozzles (as in the case of many tug boats). In the meantime, provide guidance to Ecology oil transfer inspectors as to how to handle such conditions when they observe them during inspections. Also consider approving facility operations manuals that do not incorporate the requirements of WAC 173-180-245 (4) as an interim measure. |
| 2008-025 | Ensure the tank truck Person-in-charge coordinates closely with vessel Person-in-charge to ensure that the hose is adequately cleared at the end of the transfer while preventing air from unnecessarily entering the tank. |
| 2008-024 | Ensure that your tug crews are aware of and fully comply with Washington’s requirements for safe oil transfer. |
| 2008-023 | Ensure the vessel Person-in-charge coordinates closely with tank truck Person-in-charge to ensure that the hose is adequately cleared at the end of the transfer while preventing air from unnecessarily entering the tank. |
| 2008-022 | Regularly monitor the fueling operations of tugs in your fleet to ensure that Persons-in-charge are complying with the oil transfer procedures, especially with regard to established maximum tank fill levels. |
| 2008-021 | Determine the safe fill level for each of the {ship's} tanks and ensure these levels are reflected in the tug’s oil transfer procedures. |
| 2008-020 | Develop a means to more completely close-off the {ship's} freeing ports during fueling operations to prevent any spilled oil from reaching the water. Ensure those means are incorporated into the {ship's} oil transfer procedures. |
| 2008-019 | Revise the oil transfer procedures for the {ship} so that they require the Person-in-charge to place containment under every fuel oil tank vent prior to fueling. |
| 2008-018 | Revise the oil transfer procedures for the {ship} to indicate correctly that the tug has no fixed containment around the tank vents |
| 2008-011 | Examine your inspection program under the Responsible Carrier Program; determine why the potential need for removal or tag-out of the cross-over valve was not identified under that program despite annual inspections. |
| 2008-010 | Examine your lock-out/tag-out procedures in light of this spill; determine why they were not applied to the barge day tank cross-over piping, and whether any improvement of lock-out/tag-out criteria can be made. |
| 2008-009 | Develop a means to more completely close-off the {ship's} freeing ports during fueling operations to prevent any spilled oil from reaching the water. |
| 2008-008 | Ensure that your tug crews are aware of the Washington State requirement to notify both the U.S. Coast Guard’s National Response Center and the Washington State Emergency Management Division in the event of a spill. |
| 2008-007 | Ensure that your tug crews are aware of and fully comply with Washington’s requirements for safe oil transfer. |
| 2008-006 | Ensure Persons-in-charge of oil transfers aboard your tugs complete an accurate pre-loading plan prior to the start of an oil transfer. |
| 2007-072 | Work with tank truck companies delivering oil at your facilities to ensure that they understand the port’s requirement to receive permission prior to starting an oil transfer at a port facility. |
| 2007-071 | Commend {personnel} for their efforts, in conjunction with the crew of the {ship}, to respond to contain and clean up the oil spill. |
| 2007-070 | Ensure your Persons-in-charge remain at the scene of an oil transfer from which a spill occurs until receiving approval to depart by the state on-scene coordinator. |
| 2007-069 | Ensure your Persons-in-charge provide an air horn to the vessel receiving oil during the pre-transfer conference as a back up to radio and voice communication. |
| 2007-068 | Ensure that your Persons-in-charge are aware of the Washington State requirement that a transfer shut down due to a spill not be restarted until after receiving approval from the state on-scene coordinator. |
| 2007-067 | Ensure that your response plan gives adequate information regarding the source of response materials and how to gain access to those materials in the event of a spill, when the transfer operation is dependent on a third-party source for those response materials. |
| 2007-066 | Ensure your operations manual requires that the Person-in-charge make positive contact with the owner of, or operator of, or local authority responsible for the location at which a transfer will take place to ensure that they have permission to conduct the transfer operation. |
| 2007-065 | Ensure your Persons-in-charge are adequately trained on the use of the company’s operations and response manuals, and are prepared to implement the manuals’ requirements. |
| 2007-064 | Ensure your operations and response manuals are kept up to date and that a copy of each is available in each tank truck for reference by your Persons-in-charge. |
| 2007-063 | Ensure your Persons-in-charge notify the U.S. Coast Guard and Washington Emergency Management Division when a spill occurs during an oil transfer involving one of your tank trucks. |
| 2007-062 | Ensure that your Persons-in-charge are aware of the Washington State requirement that a transfer shut down due to a spill not be restarted until after receiving approval from the state on-scene coordinator. |
| 2007-061 | Ensure that any facility from which the vessel takes fuel is aware that the ship’s fuel capacity is above the 10,500 gallon threshold above which federal and Washington State oil transfer regulations apply, by providing the ship’s fuel capacity to the facility Person-in-charge during the pre-transfer conference. |
| 2007-060 | Consider using the Washington State requirements for safe bunkering (Washington Administrative Code 317-40) as a guide to further enhance the safety of fueling operations aboard the {ship}. |
| 2007-059 | Ensure that Persons-in-charge of fueling operations aboard the ship carefully and completely prepare a pre-loading plan for discussion with the delivering Person-in-charge during the pre-transfer conference. |
| 2007-058 | Ensure that Persons-in-charge of fueling operations aboard the {ship} utilize the communication systems available to them to make immediate and positive notification to the delivering Person-in-charge when an oil spill occurs. |
| 2007-057 | Ensure that crew members that have assigned bunkering duties, including the Person-in-charge, get sufficient time off to get adequate rest prior to conducting fueling operations, and that they understand the importance of adequate rest and the dangers of working while fatigued. |
| 2007-056 | Review the {ship's} fuel system design to determine exactly why the bow-down starboard-list condition contributed to this spill despite the four-foot vent height, and, if necessary, undertake additional steps to prevent recurrence of a fueling spill under similar circumstances. |
| 2007-055 | Ensure the changes to the {ship's} oil
transfer procedures proposed by the Captain are implemented. That is: Take care when loading the vessel with fuel to avoid a list. Station a crew member near the fuel tank vents. |
| 2007-054 | Ensure the ship’s Captain and Person-in-charge of an oil transfer is aware of the Washington State legal requirement for them to call the U.S. Coast Guard and Washington Emergency Management Division in the event of a spill from their vessel. |
| 2007-053 | Ensure ship’s crews visiting Washington waters are aware that they must conduct bunker training within 48 hours of the scheduled bunkering operation, and encourage them to conduct refresher training within 48 hours of any delayed bunkering operation. |
| 2007-052 | Evaluate the usefulness of the vent valves at each of the bunkering stations aboard ships of this class, and determine if they should be maintained or removed. [Ships typically break the vacuum in a fuel transfer hose for draining back oil to the delivering barge or shore facility by loosening the bolts at the flange, not by opening a vent valve.] |
| 2007-051 | Check other vessels of the same class to ensure that the vent valve spindles at the port and starboard bunkering stations are not painted in such a way to prevent them from being fully closed. |
| 2007-050 | Review the deck rover procedures to ensure the rover is frequently checking all possible locations for a spill, i.e. tank vents, opposite bunker station, water around the ship. |
| 2007-049 | Commend the crew of the {ship} for promptly reporting the spill of oil to authorities. |
| 2007-048 | Ensure that facility Persons-in-charge (PICs) work closely with their vessel counterparts to ensure that the transfer system alignment has been correctly made and independently checked. |
| 2007-047 | Review your procedures for inputting Advance Notice of Transfers (ANTs). Ensure it is reliable and has redundancy so if an entry is forgotten, the oversight is caught and fixed as soon as possible. |
| 2007-046 | Install lights to properly illuminate the valves and manifold system. |
| 2007-045 | Post a permanent line diagram of the oil transfer system at the valve location. |
| 2007-044 | Ensure all (oil transfer system) markings are kept clean and conspicuous. |
| 2007-043 | Mark all oil transfer system valves, manifolds, and piping with large and contrasting letters or numbers. |
| 2007-042 | Review {company's} spill notification procedures. Ensure the contingency plan is activated before other state and federal notifications are made. |
| 2007-041 | Ensure company procedures require tanks are sounded with sufficient frequency at the start of bunkering operations to verify that fuel is being received by the intended tanks. |
| 2007-040 | Ensure that personnel assigned duties during bunkering know what is expected of them and understand the importance of their role in preventing oil spills. |
| 2007-039 | Ensure the PIC of the transfer understands how to correctly fill out the forms provided by {company} to help ensure a safe fuel transfer. |
| 2007-038 | Amend the {ship's} pre-transfer checklist to include verification of the valve alignment by another person before beginning any fuel oil transfer. |
| 2007-037 | Commend the Tankerman-PIC and the crew of the {tug} for quickly making notifications and initiating response efforts once the oil spill was discovered. |
| 2007-036 | Ensure that company policies and procedures require tankermen to consider any unexpected shutdown during an oil transfer as a potential emergency and, if unable to safely and quickly gather additional information from the receiving or delivering party as to the cause, request assistance from the tug’s crew. |
| 2007-035 | Undertake a special International Safety Management (ISM) Code audit to ensure {company's} Safety Management System (SMS) is effective in light of the failures to conform to various standards, including the company’s own standards, found aboard the {ship}. |
| 2007-034 | Emphasize the dangers of complacency during oil transfers by publicizing lessons-learned from this spill throughout the company’s fleet. |
| 2007-033 | Ensure that crews aboard company ships are aware of their obligations to quickly notify their contingency plan provider, the U.S. Coast Guard, and Washington State, when oil spills occur in Washington State. |
| 2007-032 | Ensure, through regular internal auditing procedures incorporated into the company’s Safety Management System (SMS), that the Oil Record Book of vessels in the company’s fleet fully and accurately reflect activities that must be recorded under MARPOL, Annex I. |
| 2007-031 | Investigate the reason(s) that the oil spill at Seattle, Washington on {date} was not logged in the {ship's} Oil Record Book in accordance with MARPOL, Annex I requirements. |
| 2007-030 | Ensure that crew members are given sufficient time off to get adequate rest prior to conducting bunkering procedures, that they understand the importance of adequate rest and the dangers of working while fatigued, that they comply with work hour limitations, and that sufficient personnel are available to allow for compliance. |
| 2007-029 | Ensure crew members conduct soundings and record innages at regular intervals and that Persons-in-Charge use the information to calculate and record the rate of transfer. Ensure that the calculated rate is compared to the planned rate, and if the rate of transfer is not what is expected, that Persons-in-Charge of a bunkering operation are instructed to investigate the discrepancy immediately. |
| 2007-028 | Ensure that the company’s bunkering procedures emphasize quick communication with Persons-in-Charge of delivering vessels or facilities in the event of a discharge or other unexpected event during bunkering. |
| 2007-027 | Review your maintenance program to ensure that it requires adequate oversight of repairs and testing of any equipment that may impact the safety of the ship and the marine environment. |
| 2007-026 | Ensure the company’s bunkering procedures and all federal and state regulations regarding bunkering and oil transfers are understood and complied with by ships’ crews. |
| 2007-025 | Review the Pre-Fueling Checklist for the {ship} to ensure it is correct and consistent. |
| 2007-024 | Undertake a fleet-wide survey to identify “problem” fuel oil tanks. Identify the cause of the problems observed by ship personnel, and undertake steps to fix the problems or reduce the possibility they will result in a spill. |
| 2007-023 | Ensure that personnel assigned duties during bunkering know what is expected of them and understand the importance of their role in preventing oil spills. |
| 2007-022 | Amend the vessel’s pre-loading plan and/or oil transfer procedures to have detailed policies and procedures regarding monitoring the tanks levels. |
| 2007-021 | Ensure that any Person-in-Charge (PIC) has had adequate time to familiarize (or re-familiarize) themselves with the ship’s oil transfer procedures (OTPs), fuel piping system, and fuel piping system status prior to undertaking an oil transfer. |
| 2007-020 | Ensure that you are consulted on any modification made to the {ship's} light oil transfer system to make the transfer of diesel or marine gas oil easier. |
| 2007-019 | Ensure that any modification made to the {ship's} light oil transfer system to make the transfer of diesel or marine gas oil easier, be in consultation with your classification society. |
| 2007-018 | Ensure crew members conduct soundings and record innages at regular intervals and that Persons-in-Charge use the information to calculate and record the rate of transfer. Ensure that the calculated rate is compared to the planned rate, and if the rate of transfer is unacceptable, ensure Persons-in-Charge of the bunkering operation are instructed to contact the delivering vessel or facility immediately to adjust the transfer rate as appropriate. |
| 2007-017 | Commend the crew of the {ship} for promptly reporting the spill of oil to water to authorities. |
| 2007-016 | Ensure your company policies, procedures, and training materials place safety over commercial considerations in order of precedence. |
| 2007-015 | Review the use of camlock couplings aboard your tank barges, and ensure your procedures and tankermen training adequately address any special considerations regarding their use. |
| 2007-014 | Ensure that supervisors and more experienced personnel actively assist less experienced personnel to ensure safe operations when indicators are present that such assistance is called for. |
| 2006-036 | Ensure that personnel assigned duties during bunkering know what is expected of them and understand the importance of their role in preventing oil spills. |
| 2006-035 | Amend the vessel’s pre-loading plan and/or oil transfer procedures to have detailed policies and procedures regarding monitoring the tanks levels. |
| 2006-034 | Amend your company’s vessel pre-transfer checklist to include a test of any fuel tank high-level alarms. |
| 2006-033 | Amend your company’s vessel pre-transfer checklist to include a visual check of the piping alignment before beginning any fuel oil transfer. |
| 2006-032 | Ensure that tankermen inform the receiving vessel’s person-in-charge of any non-conformities with Federal or State regulations for bunkering they observe while conducting the pre-transfer conference and signing the Declaration of Inspection (DOI). |
| 2006-031 | Implement the plan developed in consultation with USCG Sector Portland pollution investigators and Ecology investigators to have the tankerman aboard the barge calculate the transfer rate based on soundings of the barge and convey that transfer rate to the ship’s person-in-charge via posting on a white or chalk board. |
| 2006-030 | Emphasize the dangers of complacency during oil transfers to crews by publicizing lessons-learned from this spill throughout the company’s fleet. |
| 2006-029 | Ensure your company policies and procedures place safety and environmental protection over commercial considerations in order of precedence. |
| 2006-028 | Emphasize teamwork during bunkering training to help maintain situational awareness. |
| 2006-027 | Undertake a special International Safety Management (ISM) Code audit to ensure your company’s Safety Management System (SMS) is effective in light of the failures to conform to various standards, including the company’s own standards, found aboard the {ship} on two separate occasions. |
| 2006-026 | Ensure Persons-in-Charge of bunkering are aware of the Washington State requirement that the training session occur within 48 hours prior to the start of the bunkering operation. |
| 2006-025 | Ensure Persons-in-Charge of bunkering are aware of the U.S. Federal requirement that each item on the Declaration of Inspection (DOI) form must be initialed prior to starting a transfer. |
| 2006-024 | Modify the {company's} checklist ‘Intake of Hydrocarbons in Bulk - Safety Verification List’ to include a requirement that the transfer rate be periodically calculated, recorded and monitored by the Person-in-Charge during the transfer. |
| 2006-023 | Ensure crew members conduct soundings and record innages at regular intervals and that Persons-in-Charge use the information to calculate and record the rate of transfer. Ensure that the calculated rate is compared to the planned rate, and if the rate of transfer is unacceptable, ensure Persons-in-Charge of the bunkering operation are instructed to contact the delivering vessel or facility immediately to adjust the transfer rate as appropriate. |
| 2006-007 | Emphasize the dangers of complacency during oil transfers to crews by publicizing lessons-learned from this spill throughout the company’s fleet. |
| 2006-006 | Ensure that personnel involved in an oil transfer are aware of, and fully understand, their duties and duty stations. |
| 2006-005 | Undertake a special International Safety Management (ISM) Code audit to ensure your company’s SMS is effective in light of the failures to conform to various standards, including the company’s own standards, found aboard the {ship}. |
| 2006-004 | Ensure that work hour records are maintained up-to-date for all bunkering team members, including the Chief Engineer, and that they accurately reflect the hours actually worked and rest periods. |
| 2006-003 | Ensure the company’s procedures for bunkering contained within the company’s Safety Management Manual and all federal and state regulations, are understood and complied with by ships’ crews. |
| 2006-002 | Ensure that bunkering personnel understand the importance of following procedures, and do not become complacent about using standard checklists. |
| 2006-001 | Ensure crew members conduct soundings and record innages at regular intervals and that Persons-in-Charge use the information to calculate and record the rate of transfer. Ensure that the calculated rate is compared to the planned rate, and if the rate of transfer is unacceptable, ensure Persons-in-Charge of the bunkering operation are instructed to contact the delivering vessel or facility immediately. |
| 2005-054 | Ensure the company’s “Procedures for Bunkering and Internal Oil Transfers” contained within the company’s Safety Management Manual and all federal and state regulations are understood and complied with by ships’ crews. |
| 2005-055 | Modify item 18 under “Preliminary Arrangements” of the {company's} checklist “Checklist for Bunkering Reception During Port Stay” to clearly reflect the requirement of Section 5.3.1 of the {company's} Safety Management Manual section “Procedure for Bunkering and Internal Oil Transfers.” Section 5.3.1 requires that “containment trays” be empty and “plugged” (or in this case secured by closing the valves) prior to starting the bunkering operation. |
| 2005-056 | Ensure crew members conduct soundings and record innages at regular intervals and that Persons-in-Charge use the information to calculate and record the rate of transfer. Ensure that the calculated rate is compared to the planned rate, and if the rate of transfer is unacceptable, ensure Persons-in-Charge of the bunkering operation are instructed to contact the delivering vessel or facility immediately. |
| 2005-057 | Emphasize teamwork during bunkering training to help maintain situational awareness. |
| 2005-058 | Ensure that crew members that have assigned bunkering duties, including the Chief Engineer, are given sufficient time off to get adequate rest prior to conducting bunkering operations, and that they understand the importance of adequate rest and the dangers of working while fatigued. |
| 2005-059 | Examine your procedures for transferring oil (internal and over-the-rail) to ensure that tank vent containment is checked prior to transfers. |
| 2005-060 | Ensure that work hour records are maintained up-to-date for all bunkering team members, including the Chief Engineer, and that they accurately reflect the hours actually worked and rest periods. |
| 2005-061 | Ensure your company policies and procedures place safety and environmental protection over commercial considerations in order of precedence. |
| 2005-062 | Emphasize the dangers of complacency during oil transfers to crews by publicizing lessons-learned from this spill throughout the company’s fleet. |
| 2004-001 | Ensure the company’s bunkering procedures and all local regulations regarding bunkering and oil transfers are understood and complied with by ships’ crews. |
| 2004-002 | Emphasize teamwork during bunkering training to help maintain situational awareness. |
| 2004-003 | Ensure that bunkering personnel understand the importance of following procedures, and do not become complacent about using standard checklists. |
| 2004-004 | Investigate, in cooperation with {the ship's Classification Societies, the revision of the set point for the high-level alarm on the upper portion of the {automated engineering status} display for the port fuel oil storage tank and determine how the improper setting occurred and how it apparently went un-corrected despite a requirement that it be checked prior to a transfer. Take steps, if necessary, to modify the company’s Safety Management System (SMS) to ensure proper functioning of {automated engineering status} alarms following any maintenance or testing. |
| 2004-005 | Ensure your company policies and procedures place safety and environmental protection over commercial considerations in order of precedence. |
| 2004-006 | Ensure crew members that act as Persons-in-Charge (PICs) of oil transfers manually record innages/ullages at regular intervals and do not rely solely on automated fuel oil tank alarms or displays during bunkering. |
| 2004-007 | Ensure that work hour records are maintained up-to-date for all bunkering team members and that they accurately reflect the hours actually worked and rest periods. |
| 2004-008 | Emphasize the dangers of complacency during oil transfers to crews by publicizing lessons-learned from this spill throughout the company’s fleet. |
| 2004-009 | Investigate, in cooperation with {the ship's operating company}and {the ship's other Classification Society}, the revision of the set point for the high-level alarm on the upper portion of the {automated engineering status} display for the port fuel oil storage tank and determine how the improper setting occurred and how it apparently went un-corrected despite a requirement that it be checked prior to a transfer. |
| 2004-010 | Undertake a special International Safety Management (ISM) Code audit to ensure {company's} SMS is effective in light of the failures to conform to various standards, including the company’s own standards, found aboard the {ship}. |
| 2004-011 | Investigate, in cooperation with {the ship's operating company} and {the ship's other Classification Society}, the revision of the set point for the high-level alarm on the upper portion of the {automated engineering status} display for the port fuel oil storage tank and determine how the improper setting occurred and how it apparently went un-corrected despite a requirement that it be checked prior to a transfer. |
| 2004-026 | Ensure that the revised ship’s Oil Transfer Procedures (OTPs) are available to the crew in the crew’s working language, and that they reflect the current vessel bunker piping configuration. |
| 2004-027 | Ensure that the revised ship’s plans showing any changes made in the shipyard, are available to the crew, including plans showing details of various critical systems and safety subsystems. |
| 2004-028 | Ensure that all shipboard crew receive familiarization training, including training in bunkering procedures, when they report to the ship. |
| 2004-029 | When familiarization training cannot be accomplished because of crew turnover, ensure that newly hired crew have sufficient time and documentation to familiarize themselves with the ship, before they undertake duties that may pose a risk to personnel, property, or the environment. |
| 2004-030 | Emphasize to crew that items on checklists such as the Declaration of Inspection (DOI) must not be checked and signed as completed until all tasks on the checklist are, in fact, completed. |
| 2004-031 | Ensure that maintenance policies require that all system labels and ship’s placards are protected during maintenance painting.. Establishing a policy to temporarily mask labels and placards prior to painting may suffice. |
| 2004-032 | Ensure that any vessel 300 gross tons or larger which you own or manage is covered under the Washington State Maritime Cooperative (WSMC) or covered under an approved Washington State contingency plan on file with the Department of Ecology before the vessel enters Washington State waters. |
| 2004-033 | Ensure appropriate personnel are trained to report spills and utilize the ship’s contingency plan in the event of an oil spill. Ensure they know the location of, and have read and understood, the Washington State Maritime Cooperative’s (WSMC) “Covered Vessel Field Guide.” |
| 2003-037 | Ensure the company’s bunkering procedures and all federal and state regulations regarding bunkering and oil transfers are understood and complied with by ships’ crews. |
| 2003-038 | Ensure crew members that act as Persons-in-Charge (PICs) of oil transfers conduct soundings and record innages at regular intervals and use the information to calculate and record the rate of transfer. If the rate of transfer is unacceptable they should be instructed to contact the delivering vessel or facility immediately. |
| 2003-039 | Emphasize teamwork during bunkering training to help maintain situational awareness. In particular, ensure that the engine room watch is given a role in monitoring tank levels where high level alarms are fitted to alert in the engine control room. |
| 2003-040 | Ensure that the crewmember stationed in the engine control room has an effective means of communication with the rest of the bunkering team. |
| 2003-041 | Ensure that bunkering personnel understand the importance of following procedures, and do not become complacent about using standard checklists. |
| 2003-042 | Ensure that crew members are given sufficient time off to get adequate rest prior to conducting bunkering procedures, that they understand the importance of adequate rest and the dangers of working while fatigued, that they comply with work hour limitations, and that sufficient personnel are available to allow for compliance. |
| 2003-043 | Ensure that work hour records are maintained up-to-date for all bunkering team members and that they accurately reflect the hours actually worked and rest periods. |
| 2003-044 | Develop standard procedures for the {ship} to ensure that the possibility of a cold plug developing in the on-deck fuel oil piping is minimized. |
| 2003-045 | Investigate the maintenance history of the on-deck fuel oil pressure relief valve and determine how the improper assembly apparently went un-detected for about ten months. Take steps, if necessary, to modify the company’s Safety Management System (SMS) to ensure proper oversight and documentation of equipment repair, maintenance and regular testing. |
| 2003-046 | Investigate, in cooperation with {the company's Classification Societies}, how the addition of the on-deck fuel oil piping for the forward fuel oil tank went undocumented in the ship’s fuel system diagrams. |
| 2003-047 | Investigate the reason(s) that the oil spill at Port Angeles, Washington on {date} was not logged in the {ship's} Oil Record Book in accordance with International Convention for the Prevention of Pollution from Ships (MARPOL), Annex I requirements. |
| 2003-048 | Ensure, through regular auditing procedures incorporated into the company’s Safety Management System (SMS), that the Oil Record Book of vessels in the company’s fleet fully and accurately reflect activities that must be recorded under International Convention for the Prevention of Pollution from Ships (MARPOL), Annex I. |
| 2003-049 | Ensure that crews aboard company ships are aware of their obligations under International Convention for the Prevention of Pollution from Ships (MARPOL), and that they are given the support necessary to meet those obligations. |
| 2003-050 | Emphasize the dangers of complacency during oil transfers to crews by publicizing lessons-learned from this spill throughout the company’s fleet. |
| 2003-051 | Undertake a special International Safety Management (ISM) Code audit to ensure {the company's} Safety Management System (SMS) is effective in light of the failures to conform to various standards, including the company’s own standards, found aboard the {ship}. |
| 2003-052 | Investigate, in cooperation with {the ship operator} and {the other Classification Society involved}, how the addition of the on-deck fuel oil piping for the forward fuel oil tank went undocumented in the ship’s fuel system diagrams. |
| 2003-053 | Investigate, in cooperation with {the ship operator}and {the other Classification Society involved}, how the addition of the on-deck fuel oil piping for the forward fuel oil tank went undocumented in the ship’s fuel system diagrams. |
| 2003-059 | Immediately undertake measures to ensure the {ship}, and other vessels in the {company's} fleet, conduct bunkering operations in compliance with Washington’s Safe Bunkering Procedures contained in Washington Administrative Code (WAC) 317-40. |
| 2003-060 | Ensure that the ship’s bunkering procedures clearly specify that the Person-in-Charge (PIC) of the operation is to have no other duties during the bunkering process. |
| 2003-061 | If using a vacuum truck for the transfer of fuel oil to the ship, consider additional precautions to offset the increase in risk posed by the potential addition of compressed air from the vacuum truck into the ship’s tanks (i.e. in additional to the required personnel for the transfer, add an additional deck rover watch). |
| 2003-079 | Ensure the company’s bunkering procedures and all federal and state regulations regarding bunkering and oil transfers are understood and complied with by the ship’s crew members. |
| 2003-080 | Ensure that crew members are given sufficient time off to get adequate rest prior to conducting bunkering procedures, that they understand the importance of adequate rest and the dangers of working while fatigued, that they comply with work hour limitations, and that sufficient personnel are available to allow for compliance. |
| 2003-081 | Ensure that work hour records are maintained up-to-date for all bunkering team members and that they accurately reflect the hours actually worked and rest periods. |
| 2003-082 | Consider taking additional precautions whenever the {ship} is bunkering to minimize the potential for spill (i.e. add additional personnel to monitor for spills during the transfer) and to minimize impact should a spill occur (i.e. routinely request that the ship be boomed prior to transfer and remain boomed throughout the transfer operation). |
| 2003-083 | Undertake a thorough review of the maintenance status of the {ship}, engaging both the deck and engineering departments in the review. Consider using the results of the review as the basis for a comprehensive planned maintenance program that: identifies critical systems and equipment; assesses the present condition of systems and equipment; identifies an appropriate maintenance interval; establishes a process for scheduling maintenance; creates a permanent record of maintenance accomplished; and, incorporates a mechanism for acting on unanticipated maintenance issues as they arise. |
| 2003-084 | Emphasize the dangers of complacency during oil transfers to crews by publicizing lessons-learned from this spill throughout the company’s fleet. |
| 2001-003 | Incorporate a second check of oil transfer system alignment, by a second qualified engineer, following changes to the system alignment. |
| 2001-004 | Ensure that oil transfer procedures include the requirement that fuel tanks already filled continue to be sounded for some time to ensure that tank levels do not change as additional fuel is transferred. |
| 2001-010 | Bring company vessels into compliance with Washington State Procedures for Safe Bunkering (Washington Administrative Code [WAC] 317-40). |
| 2001-011 | Update the ship’s Oil Transfer Procedures (OTPs) to comply with State and Federal regulations, and to ensure adequate deck containment for any oil spilled during fuel transfers. |
| 2001-012 | Ensure that all Persons-in-Charge are aware of the requirement to report all spills to State and Federal authorities. |
| 2001-013 | Ensure that any Person-in-Charge (PIC) has had adequate time to familiarize (or re-familiarize) themselves with the ship’s Oil Transfer Procedures (OTPs), fuel piping system, and fuel piping system status prior to undertaking an oil transfer. |
| 2001-014 | Ensure that personnel involved in an oil transfer are aware of, and fully understand, their duties and duty stations. |
| 2001-015 | Consider the installation of containment under the settling tank vent. |
| 2001-016 | Consider re-attaching the sight glass tops for the settling tank and lube oil tank back to the tanks to limit the potential for oil to spray/splash on hot equipment in case of a tank over-flow. |
| 2001-059 | Implement the Oil Transfer Procedures (OTPs) developed for the ship and approved by the U.S. Coast Guard. |
| 2001-060 | Ensure that Persons-in-Charge (PICs) are fully aware of their responsibilities under the new Oil Transfer Procedures (OTPs). |
| 2001-061 | Bring the ship into compliance with Washington’s Procedures for Safe Bunkering (Washington Administrative Code [WAC] 317-40). |
| 2001-062 | Bring the ship into compliance with Washington’s Contingency Planning requirements (Washington Administrative Code [WAC] 317-10). |
| 2001-063 | Ensure Persons-in-Charge (PICs) are trained in the use of their contingency plan and are aware of their responsibility to implement it in case of a spill. |
| 2001-064 | Ensure Persons-in-Charge (PICs) are aware of their responsibility to notify Washington State authorities (specifically Washington Emergency Management Division) in the event of a spill. |
| 2001-065 | Ensure tanks are sounded before, during, and after loading to confirm available tank capacity, transfer rate and remaining capacity, and a static tank condition, respectively. |
| 2001-066 | Avoid scheduling bunkering operations immediately upon arrival in port, especially following difficult sea passages and prolonged passages in pilotage waters, in order to allow the crew sufficient rest to comply with work hour restrictions. |
| 2001-067 | Incorporate good ergonomic principles, to the maximum extent possible, in ship system design decisions, and carefully consider the influence of design decisions on operations safety. |
| 2000-060 | Ensure that Persons-in-Charge (PICs) complete a pre-loading plan and comply with other federal and state regulations prior to bunkering. |
| 2000-061 | Provide the {ship} with tank sounding tables that allow for adjustment of tank capacity calculations for trim and list. |
| 2000-062 | Ensure that all Persons-in-Charge (PICs) understand the importance of taking soundings to determine remaining tank capacity, and that fuel metering systems are not a substitute for accurate tank sounding information. |
| 1999-040 | Ensure that work hour limitations are complied with, and that sufficient personnel are available to allow for compliance. |
| 1999-041 | Ensure that bunkering personnel understand the importance of following procedures, and do not become complacent about using standard checklists. |
| 1999-042 | When switching bunker tanks, ensure that tanks are sounded after being filled to confirm that oil is no longer flowing to them. |
| 1999-043 | Consider options for making the starboard diesel oil tank valve more accessible, or, at least, less likely to be overlooked. |
| 1998-001 | Ensure the company bunkering procedures, and all applicable regulations, are understood and complied with by ships’ crews and complied with. |
| 1998-002 | Ensure the Bunkering Procedures Manual is available on every company vessel and that the crew is familiar with it and its contents. |
| 1998-003 | Ensure crew members conduct soundings and record innages at regular intervals and use the information to calculate and record the rate of transfer. If the rate of transfer is unacceptable, crew members should be instructed to contact the delivering vessel or facility immediately. |
| 1998-004 | Emphasize teamwork during bunkering training to help maintain situational awareness. |
| 1998-005 | Emphasize the dangers of complacency during oil transfers to crews by publicizing lessons-learned from bunkering spills and near-spills. |
| 1998-006 | Ensure that all Persons-In-Charge (PICs) complete the Declaration of Inspection (DOI), not as a matter of routine, but as an important check on transfer readiness. |
| 1998-007 | Ensure that the crewmember tasked with controlling tank valves has an effective means of communication with the person on deck conducting soundings of tanks. |
| 1998-008 | Ensure that crew members are given sufficient time off to get adequate rest prior to conducting bunkering operations, and that they understand the importance of adequate rest and the dangers of working while fatigued. |
| 1998-009 | Ensure that spill investigators request drug and alcohol tests of involved personnel as soon as possible following a spill that has a potential to be a serious marine incident. [It was noted that no drug or alcohol tests were conducted following the spill in this case.] |
| 1998-010 | Consider modifying Washington Administrative Code [WAC] 317-40 to require that the Declaration of Inspection (DOI) is reviewed jointly, and re-initialed, by the receiving vessel and delivering vessel Persons-in -Charge (PICs) before each change of watch. Requiring such a meeting would provide a second opportunity for information exchange, ensure that personnel involved in the bunkering are introduced, and prevent miscommunication. |
| 1998-011 | Ensure crew members conduct bunkering operations in accordance with special instructions established by the Chief Engineer. |
| 1998-012 | Adopt a policy that requires a Person-in-Charge (PIC) coming on shift to personally check the transfer rate before taking over the transfer watch. |
| 1998-013 | Ensure that the crewmember designated as the deck-rover watch is equipped with a radio, is fully involved in the bunkering process, and understands the importance of his/her participation. |
| 1998-014 | Ensure that crew members are given sufficient time off to get adequate rest prior to conducting bunkering operations, and that they understand the importance of adequate rest and the dangers of working while fatigued. Consider the effect of changes in work / rest patterns on personnel assigned to the bunkering team. |
| 1998-015 | Consider modifying Washington Administrative Code (WAC) 317-40 to require that the Declaration of Inspection (DOI) is reviewed jointly, and re-initialed, by the receiving vessel and delivering vessel Persons-in-Charge (PICs) before each change of watch. Requiring such a meeting would provide a second opportunity for information exchange, ensure that personnel involved in the bunkering are introduced, and prevent miscommunication. |
| 1998-024 | Consider appropriate enforcement actions based on the violations of State and Federal regulations cited in this report. |
| 1998-025 | Following completion of any enforcement and Natural Resource Damage Assessment (NRDA) actions, consider publication of a Prevention Bulletin to publicize the lessons-learned from this spill. |
| 1998-026 | Adopt procedures to require that a tankerman coming on watch review and sign the Declaration of Inspection (DOI) with the receiving vessel’s Person-in-Charge (PIC) before taking over the transfer watch. |
| 1998-027 | Modify the company’s Oil Spill Prevention Plan, Chapter 3, to indicate that the “Fueling Precaution Guidelines” have replaced the “Safety Transfer Bunkering Procedures.” |
| 1998-028 | Ensure that any information provided to the ship explicitly states that transfer rates may vary from the agreed upon rate and that the receiving vessel should contact the tankerman immediately if they note any problem with the transfer rate. |
| 1998-029 | Ensure that any problems experienced with very-high frequency (VHF) radios used for transfer operations are reported and corrected promptly. |
| 1998-030 | Ensure tankermen take precautions to ensure at least one reliable means of being contacted by the vessel is always available. |
| 1998-031 | Emphasize the dangers of complacency during oil transfers to barge personnel by publicizing lessons-learned from bunkering spills and near-spills. |
| 1998-032 | Ensure the company’s Bunkering Procedures Manual and all federal and state regulations are understood and complied with by ship’s crews. |
| 1998-033 | Adopt a policy that requires a tankerman coming on shift review and sign the Declaration of Inspection (DOI) with the receiving vessel’s Person-in-Charge (PIC) before taking over the transfer watch. |
| 1998-034 | Adopt a policy that requires a tankerman coming on shift to personally check the transfer rate before taking over the transfer watch. |
| 1998-035 | Ensure that tankerman understand the importance of adequate rest and the dangers of working while fatigued. Consider the effect of changes in work / rest patterns on personnel assigned to bunkering operations, and endeavor to notify tankermen of upcoming bunkering assignments as early as possible to allow them to adjust their sleep schedule in advance. |
| 1998-036 | Publicize lessons-learned from this spill throughout the company’s fleet. |
| 1998-037 | Consider appropriate enforcement actions based on the violations of State and Federal regulations cited in this report. |
| 1998-038 | Ensure that the Chief Engineer is satisfied that the fill valve for number 4 port double bottom tank no longer leaks. |
| 1998-039 | Ensure that all tank vents match the piping color coding scheme posted aboard the ship. |
| 1998-040 | Place fixed containment beneath all fuel oil tank vents. |
| 1998-041 | Update the diagram of the ship's fuel oil system and ensure copies are available to the ship's crew. |
| 1998-042 | Update your oil transfer procedures to cover bunkering operations. |
| 1998-043 | Review your engineering policies to ensure they require the maintenance of complete and current documentation (diagrams and procedures) for all ship's systems. |
| 1998-044 | Examine your procedures for transferring oil (internal and over-the-rail) to ensure that tank vent containment is checked prior to transfers. |
For additional information contact: Michael Lynch, (360) 407-7482