  |
|
|
| Recommendation Reference # | Recommendation Text |
| 2010-018 | Calibrate the fuel tank volume percentage monitor board (located just aft of the fuel oil transfer pump) to ensure it is accurate. |
| 2010-017 | Inspect the fuel tank sounding tubes, fitted within the fuel tanks, to determine why these tubes cannot be used to determine fuel tank height and corresponding fuel tank volumes. |
| 2010-016 | Investigate the fuel tank sounding tables and correct them as necessary to ensure that these tables give accurate fuel tank heights and corresponding fuel tank volumes. |
| 2010-015 | Adhere to the applicable vessel oil transfer procedures, at any time, a fuel transfer is conducted; specifically that a minimum of two persons are to be available prior to any internal transfer. |
| 2010-014 | In consultation with the U.S. Coast Guard, District 13, fishing vessel inspection program, consider requiring {fishing vessel company} to implement one or more of the recommendations made to them in this report via an Administrative Order. |
| 2010-013 | Though they are not required for a vessel of the size of the {fishing vessel}, use appropriate section of the Washington State requirements for safe bunkering (Washington Administrative Code 317-40) to further enhance the safety of fueling operations aboard the {fishing vessel}. |
| 2010-012 | Use the January 2009 Washington State publication “Focus on Internal Oil Transfers” (Publication Number: 99-1307 (Rev. 1/09)) as a guide to develop internal oil transfer procedures appropriate to the {fishing vessel}. |
| 2010-011 | In consultation with the U.S. Coast Guard and the Department of Ecology develop a work schedule for implementing the changes to the {fishing vessel’s} fuel system outlined in the Captain’s letter of April 16, 2010. |
| 2009-047 | Modify {Towing vessel Company} Operating Procedures Manual, Tug Fueling and Fuel Transfers,... to require that a minimum of two persons are assigned when conducting an internal fuel transfer – a PIC and a deck rover watch. |
| 2009-046 | Provide an addendum to the oil transfer procedures for the tug {towing vessel} to highlight the possibility of overflowing the port day tank when loading it above 90 percent in a starboard list condition. If there are other known peculiarities of the fuel system of the {towing vessel}, include them in the addendum as well. |
| 2009-040 |
Modify the Responsible Carrier Program (RCP) to
require that participating companies address in their operations manuals
mobile telephone use by on-duty watch standers. RCP participants should: • restrict mobile telephone use (for voice and text messaging) by on-duty watch standers to operations-related calls; • should set time limits for those calls; • should identify locations and circumstances when mobile telephone calls are permitted; and • should outline procedures for on-duty personnel to get relief should they receive a personal mobile telephone call of an emergency nature. |
| 2009-039 | Modify the Responsible Carrier Program (RCP) wording to require a participating company’s procedures state that a qualified navigation watch stander needs to be present in the tug’s wheelhouse at all times while underway. |
| 2009-038 | Consider modifying your marine operations manual to restrict internal fuel transfers to daytime only unless specific safety considerations dictate otherwise. |
| 2009-037 | Commend the author of your internal company report of this spill for identifying systemic issues at {towing vessel company} that require correction. |
| 2009-036 | In light of spills involving breaches of company procedures, consider undertaking a company-wide “safety, quality, and environment (SQE) stand-down.” Re-emphasize the company’s commitment to safety, environmental protection, and quality during the SQE stand-down. Review with, take comments from, and answer questions from, personnel regarding procedures contained within the company’s operations manuals. |
| 2009-035 | If high level alarms on each diesel fuel tank in the fleet are not feasible, consider as an alternative modifying the fleet’s fuel venting systems to a common vent. Consider incorporating a small tank into the common vent piping, and fitting the tank with a float-switch alarm; OR, fit the common vent pipe with a flow-activated alarm. Such modifications should be done only after careful review by your engineering staff and, if necessary, with concurrence of your classification society and the U.S. Coast Guard. |
| 2009-034 | Audit your document control system to ensure that the system gets up-to-date information to those who need it, and that it removes outdated information from circulation. |
| 2009-033 | If your marine operations manual does not already require a formal face-to-face handoff between off-going and on-coming Masters and Chief Engineers, modify it to include the requirement and to specify required points of discussion. |
| 2009-032 |
If you do not explicitly address mobile telephone
use in your marine operations manual, modify the manual to set
requirements for mobile telephone use by on-duty watch standers. The
requirements should: • restrict mobile telephone use (for voice and text messaging) by on-duty watch standers to operations-related calls; • set time limits for those calls; • identify locations and circumstances when mobile telephone calls are permitted; and • outline procedures for on-duty personnel to get relief should they receive a personal mobile telephone call of an emergency nature. |
| 2009-031 | Ensure your marine operations manual requires that a qualified navigation watch stander needs to be present in the tug’s wheelhouse at all times while underway. |
| 2009-030 | Label all fuel transfer system valves fleet wide. |
| 2009-029 |
Complete the corrective actions and consider the
recommendations described by your investigator, including: • Ensure vessel orientation and unlicensed engineer qualification checks are completed • Develop and maintain a matrix to track crew qualification needs for equipment • Conduct training for Masters concerning fuel transfer policies • Modify the {towing vessel's} fuel system to include high-level alarms and a common vent • Conduct an audit of all field personnel documentation regarding qualifications for their vessel • Develop and implement a formal engineer training program • Conduct remedial training for the Master and Chief Engineer • Training schedulers and operations personnel in identifying necessary requirements for vessel personnel when making assignments • Fit high level alarms on all fuel tanks fleet wide |
| 2008-107 | Implement the two corrective actions identified by your Director of Safety in his internal report on this spill. |
| 2008-073 | Consider not allowing internal transfers to occur while bunkering/fueling is occurring, or requiring additional personnel assigned to the internal transfer. |
| 2008-072 | Take a lessons-learned approach to {fishing vessel} tank arrangement. Determine if other vessels in Trident’s fleet could have their overboard vents piped to “overflow” tanks. |
| 2008-071 | Require your vessels’ engineering crews to keep detailed hand-over notes, so that a vessel taken out of lay-up has historical notes on its operation that the new crew can refer to. |
| 2008-070 | Clarify your bunkering checklist to require the draining and plugging of all fuel tank vent containments, including those for fuel tanks not listed on the pre-load plan. |
| 2008-069 | Review your oil transfer procedures for internal oil transfers and determine if some of the requirements for external transfers should be applied to internal transfers. Examples include: sounding the tank you intend to transfer fuel to, plugging the containment and/or scuppers, filling out a pre-transfer checklist, and having a deck rover watch assigned. |
| 2008-053 | Ensure Trident’s vessel engineers are communicating closely with the engineering manager and evaluating pollution risks during times vessels are being worked on at the dock. |
| 2008-052 | Review your oil transfer procedures fleet-wide. Ensure the procedures clearly define “oil transfer” to include all internal and external oil transfers aboard your vessels. |
| 2007-007 | Examine company procedures for collecting oiled materials recovered as part of an oil spill response. Consider, if necessary, revising procedures to ensure that these materials are segregated by the individual spill and by use (i.e. on deck, water, or shore recovery). |
| 2007-006 | Examine company procedures for determining if outside contractor assistance is necessary for the cleanup of oil spills from vessels not covered by the company’s contingency plan. Ensure that these procedures, if followed, provide the quickest call for assistance possible. |
| 2007-005 | Examine company procedures for notification of the USCG (through the National Response Center) and of Ecology (through the Washington Emergency Management Division) to ensure that, if followed, they provide the quickest and most accurate notification of these agencies possible. |
| 2007-004 | Revise the information contained within the company’s Marine Operations Manual for the {towing vessel} to include maximum fill levels or maximum percentage of full for all fuel tanks. If there are vessel list or trim conditions that significantly impact these fill levels, they should be documented as well. Ensure that such maximums are similarly established and documented for other vessels in the company’s fleet. |
| 2007-003 | Revise the information contained within the company’s Marine Operations Manual for the {towing vessel} to ensure the fuel tank volume figures are internally consistent, and correspond with the actual tank volumes. Ensure that information for other company vessels in the Manual does not contain similar inconsistencies. |
| 2007-002 | Conduct an internal audit of oil use, handling, transfer, and storage aboard company vessels to ensure that oil spill risks have been adequately identified and addressed by company policies and procedures, and by the company’s employee training program. |
| 2007-001 | Ensure that initial and refresher training provided by the company to seagoing personnel adequately emphasizes the importance of reading, understanding, and following all federal, state, and company procedures for both internal and over-the-rail oil transfers. |
| 2006-022 | Closely monitor main engine day tanks for water content or water ingress to ensure no fracture has reoccurred. |
| 2006-021 | Ensure that the ship’s crews, and especially the master and persons-in-charge, are aware of, and follow, the procedures outlined by their contingency coverage provider (the Washington State Maritime Cooperative, WSMC), with special attention to the requirement to notify the contingency coverage provider of any spill from the ship. |
| 2006-020 | Implement a lock-out/tag-out program for ship’s systems that are secured. Ensure the procedures for implementing the program include a comprehensive review of each system to ensure that it is verifiably isolated and not a danger to ship’s personnel or the environment. |
| 2006-019 | Ensure that persons-in-charge complete a transfer plan and comply with federal and state regulations prior to transferring oil. |
| 2006-018 | Post, or make readily available, a comprehensive and updated line diagram of the ship’s oil transfer system for use by those involved in oil transfers. |
| 2006-017 | Develop a checklist outlining the internal transfer procedures developed and post them in a location readily accessible for use in preparation for an internal oil transfer. |
| 2006-016 | Adopt procedures for internal transfers of oil that are comprehensive, and are understood and used by crew members with transfer duties. |
| 2006-015 | Review the ship’s planned maintenance program to ensure that it addresses the need to promptly repair indicator lights. |
| 2006-014 | Repair the “GEN TANK” light on the purifier controller panel. |
| 2006-013 | Ensure that there is adequate overlap between departing crew members and arriving crew members during crew rotations. Special attention should be given to cases where an arriving crew member has not sailed on the vessel before. |
| 2006-012 | Review the company’s procedures for familiarizing the ship’s personnel with their duties to ensure that all procedures that have a significant chance to impact safety or the environment are identified and incorporated into the familiarization process. Until procedures so identified have been performed by the crew member receiving familiarization training under supervision of an experienced crewmember, the familiarization checklist should remain in an “incomplete” status. |
| 2006-011 | Incorporate the procedures for engine room slops transfers and other internal transfers of oil (including oily wastes) into the Oil Transfer Procedures contained in the ship’s Vessel Specific Manual. |
| 2006-010 | Implement a requirement that a procedural checklist be completed, signed, and logged prior to the initiation of a engine room slops transfer. Ensure that compliance with the requirement be included in Safety Management System audits. |
| 2006-009 | Install remote gauging for the engine room slop tank to allow engineering personnel in the engine control room to monitor the tank’s level when a slops transfer is initiated, and shut down the transfer immediately should an unexpected change in the tank’s level occur. |
| 2006-008 | Lower the high level alarm set point on the engine room slop tank to allow more time for engine room personnel to react to a high level alarm indication. |
| 2003-89 | Establish quality control/quality assurance procedures to ensure that any modification or repair done on the fuel delivery systems is verified and certified by a qualified engineer before returning the systems to operational status. |
| 2003-091 | Consult the manufacturer of the day tank to find out if the tank top opening with a cap that has a center vent hole should be removed or modified. |
| 2003-090 | Establish an equipment inspection and maintenance schedule based on the manufacturers’ recommendations and specific operating conditions. |
| 2003-088 | Establish a process to ensure that any future design or modification of the fuel delivery systems is evaluated and certified by a professional engineer. |
| 2002-003 | It was noted during this investigation that the form pasted to the paddle board which the oiler used to record his sounding levels on when making rounds in the engine room, was cramped and hard to read. Although the error in the log book record indicating that the levels in both the waste oil tank and holding tanks were 4’ 9” probably didn’t directly lead to the spill, we recommend that the engine room personnel re-examine the method the oiler uses to record soundings in order to reduce the chance of an incorrect entry by either the oiler during the initial recording, or the duty engineer during transfer to the log books. |
| 2002-002 | {Ship operating company} policies and procedures should ensure that all devices installed to alert the vessel crew of a potential spill, ie. high level alarms, are tested and kept in working order whether or not the device is covered by the US Coast Guard’s list of alarms to be tested. |
| 2002-001 | {Ship operating company} policies and procedures should specify that any system which is built with redundancy, ie. two valves in a line, etc., should utilize that redundancy. This particular spill could have been avoided if both valves in the line had been closed. |
| 2001-057 | Review this case with the {classification society} to ascertain what improvements may be made in the shipboard system design review process, taking special note of any opportunities for improvements in communication between the two organizations when proposals for unusual or ‘non-standard’ shipboard systems are being reviewed. |
| 2001-056 | Ensure that temporary system tag-outs required as a condition of class or as a requirement for a document are highlighted (red-flagged) for continued inspection during follow-up class inspections. |
| 2001-055 | Review {classification society} procedures for design review of ship modifications. Ensure that issues that are identified for additional review/discussion with the USCG are fully documented and copied to appropriate USCG personnel in a timely manner. Ensure that local {classification society} representatives are not reticent about refusing approval of systems that are installed without adequate time for review by {classification society}. |
| 2001-054 | Communicate lessons-learned from this oil spill throughout the company’s fleet. |
| 2001-053 | Emphasize the importance of the Oil Record Books as a legal document to those aboard {tank ship company} ships required to make entries in them. Ensure that {tank ship company} Chief Engineers and Chief Mates regularly and carefully review entries made in the books and take corrective action with personnel making inaccurate or incomplete entries. Emphasize to Masters their role in, and ultimate responsibility for, maintaining Oil Record Book accuracy. |
| 2001-052 | If the main deck drain system is put back into use, ensure that the drains are attended at all times while open and that their opening and closing is noted in the deck log book. |
| 2001-051 | Revise the “Day/Night Orders” for loading/unloading operations aboard the {tank ship} to accurately reflect the status of the main deck drain system and, assuming it is put back into use, special instructions for its use in relation to the ullage of the slop tanks. Ensure that signature of these orders by the mates is not, and does not become, perfunctory. |
| 2001-050 | Commend the crew of the {tank ship} for their quick and professional response to the spill, once discovered. |
| 2001-049 | Review standing orders for deck security rounds. Ensure that the rounds are conducted regularly (preferably at a minimum of hourly) and that all rounds are accurately and consistently logged. |
| 2001-048 | Review the standing orders for pumping the bilge collection tank to the slop tanks aboard the {tank ship} and compare it to industry guidance provided in “Towards Safer Ships and Cleaner Seas.” Clarify which engineering watch or watches are to conduct that operation. Ensure that any revision of the standing order is coordinated between the deck and engine departments. Ensure that the standing order adequately addresses slop tank valve discipline and communications between the deck and engine departments. Add a requirement that the Mate on watch also be notified of the operation before it is conducted. |
| 2001-047 | Review {tank ship company's} SMS to ensure that adequate audits are accomplished on all safety and pollution prevention activities in compliance with ISM Code, Section 12.1. |
| 2001-046 | Review {tank ship company's} SMS regarding the availability of documents relating to shipboard systems to shipboard personnel. Ensure that relevant documents are maintained aboard the vessel in a systematic manner in compliance with the ISM Code, Section 11.3. |
| 2001-045 | Review {tank ship company's} SMS to ensure that there are plans and instructions for key shipboard safety and pollution prevention operations in compliance with ISM Code, Section 7.0. |
| 2001-044 | Ensure that temporary system tag-outs required as a condition of class or as a requirement for a document are highlighted (red-flagged) for continued inspection during follow-up inspections or audits. |
| 2001-043 | Maintain the main deck drain systems aboard the {tank ship}, {tank ship} and {tank ship} in an out-of-service status until a joint design safety review by {tank ship company} and {classification society} is complete. Institute a formal tag-out for the systems until they are cleared for return to service or rendered permanently inoperable. If the systems are cleared for a return to service, ensure that adequate design safety measures are implemented (i.e. overflow/back-flow prevention and high level alerts commensurate with the tanks’ overflow points). Ensure that revised design specifications are made available to shipboard personnel and that clear operating procedures are developed. Ensure that the crew receives training in the safe operation of the main deck drain systems. Make audits of compliance with main deck drain system operating procedures part of the company’s SMS. |
| 2001-042 | Ensure company procedures for development of plans for ship system modifications include a full review by company engineering staff prior to installation. Such reviews, whenever possible, should take place well in advance of the proposed date of modification. Incorporate these procedures into the company’s SMS to ensure that the design review and acceptance process is regularly audited. |
| 2001-041 | Communicate lessons-learned from this oil spill to ships operated by the company. |
| 2001-040 | Ensure company procedures for development of plans for ship system modifications include a full review by company engineering staff prior to installation. Such reviews, whenever possible, should take place well in advance of the proposed date of modification. Incorporate these procedures into the company’s safety management system (SMS) to ensure that the design review and acceptance process is regularly audited. |
| 2001-023 | Ensure that the company’s SMS fully complies with Section 10.3 of the ISM Code. |
| 2001-022 | Install adequate containment for the Stack House (funnel) vents in the event of overflow. |
| 2001-021 | Create vessel Oil Transfer Procedures (OTP) to address the generator internal fuel oil/diesel oil change over. Ensure the OTP meets the requirements of 33 CFR 155.750. |
| 2001-020 | Ensure that new engineering officers are supervised during critical operational procedures until they are adept at performing them alone. |
| 2001-019 | Ensure that new engineering officers are adequately familiarized with critical operational procedures. |
| 2001-009 | Ensure that all PIC’s 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. |
| 2001-008 | Provide the {fishing vessel} with tank sounding tables that allow for adjustment of tank capacity calculations for trim and list. |
| 2001-007 | Ensure that PIC’s complete a transfer plan and comply with federal and state regulations prior to transferring oil. |
| 2001-006 | Fully document all critical ship systems and ensure the documentation is available to those crew members using those systems. |
| 2001-005 | Ensure that PIC’s of oil transfers are fully trained and sufficiently experienced with the vessel to safely carry out their duties. |
| 2000-048 | Consider having the WSMC Covered Vessel Field Guide translated into a language understood by ships’ officers. |
| 2000-047 | Ensure ships’ crews are aware of and follow the procedures outlined by their contingency coverage provider (Washington State Maritime Cooperative, WSMC). |
| 2000-046 | Update the company’s oil spill emergency procedures to ensure that port, state and federal authorities are always notified of an oil spill. |
| 2000-045 | Update company’s oil transfer procedures to reflect Washington’s Safe Bunkering Procedures. |
| 2000-044 | Adopt procedures for internal transfers of oil that are comprehensive, and understood and utilized by crew members with transfer duties. |
| 2000-043 | Determine the reason that residual oil was contained in the vent pipe to DBT 2.10, and ensure the condition is corrected. |
| 2000-042 | Ensure the malfunctioning valve is replaced and that hydraulically actuated valves of similar design be checked for proper operation. |
| 2000-006 | Ensure that all persons-in-charge of oil transfers have access copy of the required Field Document which describes steps to take in event of a spill. |
| 2000-005 | Ensure that all persons-in-charge of oil transfers are aware of the need to activate their contingency plan (WSMC in this case) in case of a spill. |
| 2000-004 | Ensure that all persons-in-charge of oil transfers are aware of the need to make notification to the USCG and Washington State in case of a spill. |
| 2000-003 | Ensure all personnel involved in transferring of oil products are aware that high-level cut-off switches are a safety measure, and not a reason to reduce attention to fuel transfers. |
| 2000-002 | Ensure that all installed high level switches on fuel tanks are properly installed and operational. |
| 2000-001 | Take immediate steps to ensure all persons-in-charge of oil transfers are fully trained in and are aware of their responsibility to utilize the ship’s oil transfer procedures. |
| 1999-001 | Ensure maintenance procedures include post maintenance operation checks of all systems that may have been disabled in order to accomplish maintenance. |