Potential High Impact Incidents - Pilbara Ports Authority · Potential high impact incidents and...

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Potential High Impact Incidents Ports of Port Hedland and Dampier

Transcript of Potential High Impact Incidents - Pilbara Ports Authority · Potential high impact incidents and...

Page 1: Potential High Impact Incidents - Pilbara Ports Authority · Potential high impact incidents and trends ... safe mooring operation Lighting on deck Lighting on deck and at the mooring

Potential High Impact Incidents Ports of Port Hedland and Dampier

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Session 2 Potential high impact incidents and trends

Myron Fernandes, Pilbara Ports Authority

Pilbara Ports Authority incident statistics and trends

Port of Port Hedland potential high impact incidents

Reza Vind, Australian Maritime Safety Authority

Port state control statistics and risk assessments

Port of Dampier potential high impact incidents

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WHY ARE WE SHARING

THIS INFORMATION

Culture of transparency

Incident prevention Continuous

improvement

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PPA Marine Incidents 1 September 2016 – 31 August 2017

172 Port Hedland

51 Dampier

3

Ashburton Types of Marine Incidents

Mechanical - Main Engine

Mechanical - Other

Mooring

Towage

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36 Marine Events

18 Other

6

5

7

3

15 Other

Main Engine

Mechanical

Other

Mooring

Towage

Dampier Incidents

Port Hedland

Incidents

150 Marine Events

22 Other 46

12 42

12

38 Main Engine Other

Towage

Mooring

Mechanical

Other

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FMG GRACE (renamed) 17 September 2016

Vessel Details • 300m LOA and 50m Beam

• 205,000 DWT

• 18.41m Draft

Weather & Tide • Light airs – South 3-4 knots

• 6.10m flood tide range

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Berth Details and Location

General Statistics September 2014 – September 2016

• Total departures - 378

• Total departures > 200,000 DWT - 168

Berth Details • Commissioned July 2013

• Declared depth 19.7m

• Layby berth configuration

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Incident Summary

2154 Last Line FMG Grace – AP4 Outbound (DUKC window closes 2300hrs)

2215 Port Emergency declared. VTS noted vessel was not in it’s normal departure position

2217 5 extra tugs supplied to FMG Grace – total 9 tugs attending vessel

2232 Adjacent vessel reported coming off the berth (due to interaction). 2 tugs diverted to

hold vessel in position

2238 FMG Grace repositioned in inner harbour turning circle

2239 FMG Grace departs outbound with 6 accompanying tugs

2244 Following vessel departure cancelled to allow safe outbound passage of FMG Grace

with allocated resources

2309 FMG Grace passing Hunt Point outbound, no further issues reported by pilot

throughout channel transit

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Standard departure from AP4 berth

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FMG Grace departure from AP4 berth

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Comparison with other departures

Assessment of 37 previous departures from berth (October 2014 – January 2016) • 90% of departures logged a true heading at low speed in SWC of between 000o and 020o

• Most easterly heading in the 37 departures is 028o

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Allocation of tugs Opportunity to make better use of the

allocated tugs based on tug capability

Departure heading Highly unusual north easterly heading

Reduction of UKC Reduced UKC impacted bow movement

towards port side

Pilot Training Mentoring a trainee pilot and pilot training

methodology

Towage Performance Port bow tug had little or no effect for at least

three (3) minutes

INVESTIGATION OUTCOMES

Bridge Team Communication between the bridge team

was positive and outcome based.

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Communication Marine pilot to be immediately informed

when tug performance is not to plan

Allocation of tugs Appropriate positioning of tugs based on

their capability

Towlines Adequate length of towline to be deployed

prior to the manoeuver commencing

Pilot training Clear guidelines on mentor and trainee

interaction

Incident was incorporated in the pilot training

simulator

Tidal flow model Tidal flow data for the port was updated in

training simulator

ACTIONS ARISING

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Actual Impact ACTUAL IMPACT

Safety (No injuries)

Environment (No impact)

Infrastructure (No damage)

Operations (minor scheduling impacts)

Resources (tugs allocated)

POTENTIAL IMPACT?

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FPMC 26 Near Miss Incident 30 January 2017

Vessel Details • 182.5 LOA and 32.2m Beam

• 50,076 DWT

• 10.8m arrival draft (loaded tanker)

Metocean • NW x 7/10 kts

• Tide range 5.42m

• Low water 18:38 – 1.42m

• Slack water at time of incident

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Tanker statistics and incident location

General Statistics 1 January 2015 – 31 December 2016

• Total tanker arrivals – 86

• Total tanker deadweight > 50,000 - 19

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Metocean – Wind and Tidal height Monday 30 January 2017

Wind Gust: 9.5kts

Tidal height: 1.5m

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Shipping Schedule Monday 30 January 2017

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17:30 POB – extended arrival passage for draft of 10.9m (beacon 15/16 entry)

17:30 – 19:00 Inbound passage with no reported steering issues

19:04 Passing hunt point (speed 8.5kts)

19:05 Pilots both commented that the vessel was exactly on the normal check headings for

a flood tide arrival

19:06 Vessels ROT is increasing rapidly and hard to starboard rudder is applied with

engine full ahead

19:06 Stern tug ordered to pull back on emergency full. Vessel engine and rudder still

applied to attempt to regain heading

19:07 ROT under control. Vessel passes at close quarter to tug haven. Port shoulder tug

lets go tug line to prevent collision with another tug moored outside the tug haven.

19:09 Vessel clears tug haven and berth 1 infrastructure and moves towards a safe

location in the inner harbour (swing basin)

Incident Summary

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PPU Footage

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CCTV Footage

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Positive pilot action Decisive action taken by the unrestricted

pilot to regain control of the situation

Effects of tug wash Tug wash from the berthing ship was a

contributing factor

Unstable vessel dynamics The vessel’s manoeuvrability when at even

keel and potential squatting by the head

INVESTIGATION OUTCOMES

Shipping Schedule The tanker arrived into the harbour earlier

than scheduled

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ACTIONS ARISING

PPA investigation methodology Use of the simulator to understand possible

contributing factors

Vessel evidence The vessel did not take any measures to

download the VDR data post incident

Pilot training Effects of tug wash incorporated in the pilot

simulator training

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Actual Impact ACTUAL IMPACT

Safety (no injuries)

Environment (no impact)

Infrastructure (towline)

Operations (no impact)

Resources (minor impact)

POTENTIAL IMPACT?

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Braverus – Main Engine Failure 9 July 2017

Vessel Details • 287.5m LOA and 45m Beam

• 170,015 DWT

• 17.7m Draft

Weather & Tide • South east 5 knots

• 4.16m flood tide range

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Incident Location – AP1

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Shipping Schedule and Metocean Sunday 09 July 2017 First of 5 outbound vessels

Wind Gust: 9.5kts

Tidal height: 3.8m

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Incident Summary

07:20 Pilot on board, preparations made for departure.

07:42 Vessel departed berth (AP1), first movement dead slow astern – no issues

experienced.

07:48 Engine ordered to slow ahead. Fluctuation in engine RPM’s noticed by pilot. Dead

slow to slow was within critical RPM range.

07:54 Main engine unable to increase RPM. Pilot decides to stop vessel in the Inner

Harbour area.

08:00 Port emergency declared, additional towage assistance requested. Assessment

made on re-berthing the vessel at AP1.

08:17 Pilot informed by Master that the vessel requires 1 hour to fix the main engine

problem.

08:25 Second pilot boarded the vessel to assist with re-berthing. 7 tugs allocated.

09:15 Vessel re-berthed at AP1.

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PPU Footage

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Re-berthing fully loaded

vessels Managing the berthing of a fully loaded

vessel due to the design capacity of wharf

infrastructure

Ships equipment • Defective puncture valves on two main

engine cylinders

• Excessive carbon deposits in the main

engine air chamber

INVESTIGATION OUTCOMES

Periodic Maintenance Puncture valves overhauling periods were

not specified in vessel’s PMS

Communications Prompt and accurate communication

between bridge team to ensure a safe

outcome

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Actual Impact ACTUAL IMPACT

Safety (no injuries)

Environment (no impact)

Infrastructure (no damage)

Operations (minor impact)

Resources (minor impact)

POTENTIAL IMPACT?

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Personnel injury Ports of Dampier and Port Hedland

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Failure of pilot ladder Port of Dampier

Bottom rung failed when pilot stepped

on ladder

Point of failure

Pilot fell approximately 1m to the deck

of the pilot boat

Minor superficial injury to the boarding

pilot

Incident Summary

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Assurance process Failure to identify deficiencies associated

with the pilot ladders within the ship

operators assurance process

INVESTIGATION OUTCOMES

Planned maintenance Ship board pilot ladders were not maintained

in accordance with ISO 799: 2004

Pre arrival process Information on pilot ladder condition to be included

as part of the pre arrival documentation

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Approved design

Bottom terminations of newly purchased replacement pilot ladder (alternative design using continuous loop arrangement)

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Vessel inbound to berth during

hours of darkness

Tugs line was being let go in

preparation for reconfiguration

Crew member’s leg got caught

between the messenger line and

ship’s fairlead

Injury during mooring operations Port of Port Hedland

Crew member suffered two broken

ribs and soft tissue leg injury

Incident Summary

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Crew member standing between the tug

line and messenger line (Note deck equipment configuration and positioning of

ships crew)

Officer assisting crew member with letting

go the tug line

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Tug line not connected. Crew member

positioned between the messenger line, tugs

line and with weight on the rope stopper. Tow

line is being lowered, messenger is

connected to the ships warping drum. Crew

members legs gets entangled with the

messenger line.

Due to the weight of the tow line, the crew

member is dragged towards the roller

fairlead. His leg is caught between the

fairlead and messenger line. The

messenger line has to be cut to free the

crew members leg.

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Handling of towline • Towlines on new tugs are significantly heavier

• Use of mechanical means to handle towlines

• Use of rope stoppers to handle tow lines

INVESTIGATION OUTCOMES

Deck equipment configuration Configuration did not lend itself to an inherently

safe mooring operation

Lighting on deck Lighting on deck and at the mooring location was

reported to be inadequate

Manning requirements Officer in charge was required to physically support

the operation – may not have allowed him to focus

on the bigger picture

Note: investigation is ongoing at the time of the presentation

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Unannouced severe weather event 23 March 2017

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Tropical System 22U Bureau of Metrology Track Maps issued for Port of Port Hedland

Update 1 – 20 March Update 2 – 21 March

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Tropical System 22U Bureau of Metrology Track Maps issued for Port of Port Hedland

FINAL Update – 22 March

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Bn16 – Recorded Wind, Gusts, Swell & Waves 23 March: 0600 – 1800

Maximum Wind Gust: 61 kts

Wind: 48 kts Swell: 2.1 m

Waves: 2.2 m

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Shipping Schedule

15 vessels in the Inner

Harbour

40 vessels

at anchorage

0900 to 1500

Shipping suspended

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DUKC – Predicted Plan

0920 – 1020: continuously reducing DUKC window for the vessel’s departure

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INVESTIGATION OUTCOMES

Data analysis Actual wind data

recorded by PPA

analysed post event

indicated a category

1 cyclone event

impact on Port

Hedland

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Actual Impact ACTUAL IMPACT

Safety (no injuries)

Environment (no impact)

Infrastructure (no damage)

Operations (6 hour suspension of shipping)

Resources (15 tugs strategically positioned to

respond to berthed vessels needs)

POTENTIAL IMPACT?

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Past 40 years Tropical Cyclone Formation North West Australia

Port Hedland

Dampier

Ashburton

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Cyclone Response Plan

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Response Stages

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VESSEL PREPAREDNESS

Local Knowledge (PPA cyclone plan, local port traffic

and local metocean conditions)

Awareness (VTS communications on

evacuation plans)

Commercial Impact (vessel does not lose it’s position in

berth line up if departing due to

cyclone avoidance)

Vessel fitness (Management of loading operation

to ensure vessel can depart berth at

short notice)

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KEY MESSAGES

Any vessel can have an

incident

All incidents can impact

the port and the vessel

Local knowledge helps

with managing an

incident

Culture of transparency

when dealing with

incidents