Ecology Prevention Recommendations on Loss of Propulsion Incidents

1998-2005

The table below contains recommendations made by the Washington State Department of Ecology to ship operators, Classification Societies, and government agencies following investigations of loss of propulsion incidents. Some recommendations have been made in more than one case and no attempt was made to remove duplicate recommendations.  Readers will note that some recommendations were broad, while others were very specific to the circumstances of the incident.
Recommendation Reference Number Recommendation to Recommendation Text
2003-087 USCG Ensure that the Washington State Department of Ecology is notified immediately of vessel casualties per Protocols, so that the use of the Neah Bay Rescue Tug can be initiated under State auspices even when the Captain of the Port chooses not to.
2003-086 Vessel Operator Whenever motors or generators are turned or worked on, have vessel personnel visually inspect for metallic dust before equipment is used.
2003-085 Vessel Operator Visually inspect all original vessel main propulsion wire every five years during drydock, where feasible.
2003-078 Transport Canada The Puget Sound Harbor Safety Plan requirements for the use of tug assistance in mitigating risk posed by casualties be implemented for vessels transiting Canadian waters of the Cooperative Vessel Traffic System (CVTS).
2003-077 Vessel Operator Ensure that all critical sub-systems serving the main engines of ships in your fleet have been identified, that adequate procedures are in place to test the operational status of each critical sub-system, that criteria for overhaul or replacement of each critical sub-system have been established, and that adequate spares or components are available aboard to facilitate overhaul or replacement. Publicize this incident within your fleet, emphasizing lessons-learned.
2003-076 Vessel Operator Compare the damage found in the No. 2 main seawater pump of the {container ship} when it was repaired or replace at Hong Kong with that found in the No. 1 main seawater pump at Port Angeles to determine if the mode of failure was the same.
2003-056 Vessel Operator Engine Room Emergency Procedures Checklists - {the ship's operating company} should develop vessel specific checklists for engineering procedures like “splitting the plant”.
2003-055 Vessel Operator Policy - {the ship's operating company} should develop fleet-wide policy regarding acceptable engineering procedures when the vessel is underway in confined waters or in pilotage waters.
2003-054 Vessel Operator Emergency Procedures – {the ship's operating company} should develop vessel specific checklists for each vessel in its fleet for engine room emergency procedures. One checklist should address loss of the steam generating plant.
2003-036 Ecology Develop additional protocol with the Neah Bay Rescue Tug so that Ecology is notified immediately of any call they receive concerning an incident from the U.S. Coast Guard (USCG) or any radio traffic they overhear regarding an emergent vessel casualty.
2003-035 USCG Ensure that the Washington State Department of Ecology is notified immediately of vessel casualties, so that the use of the Neah Bay Rescue Tug can be initiated under State auspices even if the Captain of the Port chooses not to.
2003-034 Vessel Operator In light of this incident and the subsequent detention of the ship in Canada for multiple deficiencies, conduct a special audit of the company’s Safety Management System (SMS) and its implementation.
2003-033 Classification Society Determine, in conjunction with {the ship's operating company}, how this apparent non-conformity regarding a lack of maintenance records for a safety-critical piece of equipment continued without detection by the company’s audit system for a period of approximately 20 months.
2003-032 Vessel Operator Ensure that vessel Master’s calling in waters covered by the Puget Sound Harbor Safety Plan are familiar with, and are prepared to comply with, its requirements.
2003-031 Vessel Operator Determine, in conjunction with {ship's classification society}, how this apparent non-conformity regarding a lack of maintenance records for a safety-critical piece of equipment continued without detection by the company’s audit system for a period of approximately 20 months.
2003-030 Vessel Operator Ensure that information regarding this incident receives the widest distribution possible amongst the company’s personnel, particularly engineering personnel.
2003-029 Vessel Operator Ensure, via special audit, that other vessels in the company’s fleet are properly maintaining their main engine lubricating oil cylinder pumps.
2003-028 Vessel Operator Ensure that safety-critical systems such as the lubricating oil cylinder pumps are properly identified and properly maintained under the company’s Safety Management System (SMS) in accordance with Section 10.3 of the International Safety Management (ISM) Code.
2003-021 Ecology Develop additional protocol for the Neah Bay Rescue Tug so that Ecology is notified immediately of any call the tug receives concerning an incident or any radio traffic they overhear regarding an emergent vessel casualty.
2003-020 USCG Encourage the Puget Sound Vessel Traffic Service (VTS) to continue to provide early notification of potential deployment to the Neah Bay Rescue Tug.
2003-019 USCG Ensure that the Washington State Department of Ecology is notified immediately of vessel casualties, so that the use of the Neah Bay Rescue Tug can be initiated under State auspices even when the Captain of the Port chooses not to.
2003-018 USCG Ensure that the Puget Sound Harbor Safety Plan requirements for the use of tug assistance in mitigating risk posed by casualties is implemented consistently and in a timely fashion.
2003-017 Vessel Operator Ensure all appropriate personnel in the company’s fleet are aware of the incident and have information regarding proper lube oil levels for their vessels.
2003-016 Vessel Operator Ensure that vessel Masters calling in waters covered by the Puget Sound Harbor Safety Plan are familiar with, and are prepared to comply with, its requirements.
2003-015 Vessel Operator Incorporate any information developed above into the ship’s engineering standard operating procedures, and create a special circular on the matter for similar vessels in the fleet informing them of the incident and any required corrective measures.
2003-014 Vessel Operator Review the main engine design operating parameters with the engine manufacturer {manufacturer's name} to determine what level of lube oil in the main engine will ensure adequate supply of lube oil to the pumps under various assumed angles of heel, roll and/or list.
2000-063 Vessel Operator The crosshead gland should be repaired in short order to prevent further lube oil contamination and resultant potential damage associated with it
2000-054 Vessel Operator Ensure that reduced turbocharger performance is given immediate attention to avoid related main engine problems that can arise as a result.
2000-053 Vessel Operator Contact {main engine manufacturer} and work with them to determine the cause of the low scavenging air pressure that was experienced following the July 2000 turbocharger overhaul.
2000-052 Vessel Operator Ensure that outstanding problems aboard a vessel in the company’s fleet following shipyard work are satisfactorily resolved before it is returned to service.
2000-051 Vessel Operator Ensure that possible collateral damage to ships’ engineering systems is assessed and accounted for when mechanical failures occur in related systems.
2000-050 Vessel Operator Ensure that ‘mystery’ engineering occurrences are thoroughly investigated and resolved before a ship returns to service.
2000-049 Vessel Operator Ensure that shipyard specifications include redundant inspections of all installations/repairs and full testing before an installation/repair is approved/accepted.
1999-027 Vessel Operator Ensure that planned maintenance procedures for critical main propulsion systems are in place, adequate and fully implemented.
1999-004 Vessel Operator Ensure the Master has guidance from the company for making a determination of when towing assistance will be accepted. Ensure the guidance includes a discussion of the uncertainties of counting on anchorage on a lee shore as an option.
1999-003 Vessel Operator Improve communication between the Master and Chief Engineer so that Master will have adequate information regarding anticipated repair times to pass to authorities in the event of a casualty.
1999-002 Vessel Operator Ensure that their preventive maintenance policies and procedures address main engine exhaust valve overhaul intervals.
1998-046 Vessel Operator Ensure that any maintenance, repair or reconditioning performed on equipment that will be used as spares is checked by a crew member other than the one that performed the work. This check should be performed before the spare is put back into use.
1998-045 Vessel Operator Implement the step by step exhaust valve maintenance procedures outlined in your Event Report, and consider developing a checklist to prevent any steps on the process from being missed.
1998-023 Vessel Operator Ensure that electrical equipment is properly installed in engine spaces to prevent it from becoming a potential ignition source.
1998-022 Vessel Operator Ensure that engine rooms are kept as clean as possible to avoid accumulations of oil.
1998-021 Vessel Operator Ensure that fuel oil piping systems are properly shielded to prevent leaks from reaching ignition sources.
1998-020 Vessel Operator Ensure that, if inexperienced personnel conduct maintenance, they are properly supervised.
1998-019 Vessel Operator Ensure that maintenance procedures include measures to check the quality of all maintenance and repairs.

For additional information contact:  Michael Lynch, (360) 407-7482