# Danish Maritime Accident Investigation Board Report - Maersk Shipper and Searcher Su



## Andrew Craig-Bennett (Mar 13, 2007)

This report repays careful study:

http://www.dmaib.com/Ulykkesrapporter/Marine accident report - Loss of tow - MAERSK BATTLER.pdf


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## NoR (Mar 24, 2008)

Pathetic. All that bullsh1t and paperwork and they do something as stupid as that.


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## Stephen J. Card (Nov 5, 2006)

Andrew, many thank for the report. A bit of an eye opener!

I can see towing two vessels... in a river, or very short distance and the weather was likely to be good. Two side by said...in December... for three weeks? No way!

Stephen


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## Barrie Youde (May 29, 2006)

About twenty years have now passed since I first heard the term "Risk Assessment". This was about ten years after I had left my last ship, after almost thirty years in pilotage.

The new words (risk assessment) were drawn to my attention as though they were holy writ; and my reaction was to wonder how on earth any of us had survived before this jargonistic expression was coined. That is a thing which I still wonder, in light of the knowledge that any assessment of risk, if relied upon as a guarantee - or holy writ, as might be urged - is in point of fact complete bullsh1t, as the Conclusions in the Report make clear.

The truth is that a mariner spends his entire life assessing risk - and there simply isn't time available to commit every single thought to paper.

Thank you Andrew, for posting!


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## valvanuz (Feb 4, 2012)

Common sense and basic seamanship will beat risk assessment by a mille


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## woodend (Nov 23, 2009)

Thanks for posting the report Andrew, it made interesting reading.


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## Robert Hilton (Feb 13, 2011)

"Risk Assessment" has always puzzled me. It appears to assume that we were all taking wild and unconsidered risks before it was introduced.


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## woodend (Nov 23, 2009)

One question I meant to ask is in the dark ages when I was a tug master we had to have a 'towage certificate' issued by a Department of Transport Marine Division surveyor before the tow started. Do they still as I saw no nmention of it in the report? This accident would not have happened had their been some experiencen somewhere in the decision making train.


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## D1566 (Sep 7, 2009)

Robert Hilton said:


> "Risk Assessment" has always puzzled me. It appears to assume that we were all taking wild and unconsidered risks before it was introduced.


It just formalises a process that most people have been going through since the year dot. Look on it as being a useful tool, a memory jogger, what you will, but it has stopped the routine taking of many stupid risks, which are usually put down to 'we have always done it like that'.


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## John Dryden (Sep 26, 2009)

The final words of the conclusion tell us a lot:

''In fact, the risk management system instead tends to facilitate the carrying out of risk prone operations''


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## D1566 (Sep 7, 2009)

John Dryden said:


> The final words of the conclusion tell us a lot:
> 
> ''In fact, the risk management system instead tends to facilitate the carrying out of risk prone operations''


It is about management of those risks.


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## NoR (Mar 24, 2008)

woodend said:


> One question I meant to ask is in the dark ages when I was a tug master we had to have a 'towage certificate' issued by a Department of Transport Marine Division surveyor before the tow started. Do they still as I saw no nmention of it in the report? This accident would not have happened had their been some experiencen somewhere in the decision making train.


These days lack of practical experience seems to be the rule rather than the exception. Look at the MSC Napoli screw up.
We seem to be run either by academics with liberal arts degrees or morons with MBAs. 'Uneducated' practical folk and their opinions are ignored and this incident is just another symptom.

Rant over !! (Cloud)


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## BOB.WHITTAKER (Dec 3, 2008)

I read this report on 4th September already being aware of the incident .
The final paragraph on page 37 of the report sums up the situation and highlights the failings of the so called " Risk Assessment " where it appears the intention was to " reverse engineer " the assessment to
ensure targets were met . This additional to the personnel movements, the " desk top " level of the planning , possibly the level of expertise of some involved , the final selection of the equipment to be used , in particular the fenders etc. etc . It appears to have been a catalogue of errors from the start .
Not what would have been expected from MAERSK


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## NoR (Mar 24, 2008)

It's so obviously a stupid thing to do. 30 seconds thought tells you that. You can tow barges abreast on rivers but not at sea.


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## Ian Lawson (Apr 30, 2017)

NoR said:


> These days lack of practical experience seems to be the rule rather than the exception. Look at the MSC Napoli screw up.
> We seem to be run either by academics with liberal arts degrees or morons with MBAs. 'Uneducated' practical folk and their opinions are ignored and this incident is just another symptom.
> 
> *Rant over !!* (Cloud)


I don't look on it as a rant at all. You will recall Barrie Youde's recent post wrt to an individual with all the qualifications etc, and he had never been south of Ushant. Let's face it 'things ain't like they used to be'.


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## Robert Hilton (Feb 13, 2011)

D1566 said:


> It just formalises a process that most people have been going through since the year dot. Look on it as being a useful tool, a memory jogger, what you will, but it has stopped the routine taking of many stupid risks, which are usually put down to 'we have always done it like that'.


In the days when we were taught seamanship we were also taught to think and to avoid stupid risks. More thought than could be put on paper in many hours would pass through the mind. Risk assessment is meant to place the responsibility on those carrying out the orders and to leave those giving the orders free of all blame should a mishap occur. 

It must be obvious from the case in hand that a written risk assessment can also permit unacceptable risks to be taken.


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## Barrie Youde (May 29, 2006)

#15 

Thank you, Ian.

My reference to the fact that it is now possible to acquire a Class 1 STCW Certificate applicable world-wide without going beyond Ushant should more accurately have said that it is now possible to hold the modern equivalent of the former Foreign Going Master's Certificate without ever going beyond Home-Trade limits (the Elbe and Brest). There has very clearly been a significant reduction in standards in maritime matters at UK governmental level, whereby experience beyond those limits is no longer required in order to claim world-wide qualification.

Does the general public appreciate the point? Of course it doesn't. Should the point be well known? Of course it should, particularly when clownery of this kind arises.


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## Barrie Youde (May 29, 2006)

#11 and #10 

#11 speaks up for the philosophy of "Risk Assessment" whereas #10 (and the Report in the present case) speak the truth that reliance upon a new-fangled philosophy is highly dangerous when rational experience warns against it.

It would appear that worship of the philosophy of "Risk Assessment" in all things was a harbinger of what is now becoming known as the "post-truth" era. Far more sensible is the ancient folk-lore that "If it looks like a duck and quacks like a duck, it probably is a duck." 

To cross the English Channel with bow-doors wide open never did look right, did it? (Herald of Free Enterprise, 1987.)


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## Barrie Youde (May 29, 2006)

A further basic thought on Risk Assessment is that most of us here in SN will recall the obligation to ensure that hatch-beams were in place before even crossing any harbour. Today, many mariners might ask "What are hatch-beams?"

I might well be wrong, but I'd guess that such things had disappeared long before any jargonist coined the term "Risk Assessment".


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## Barrie Youde (May 29, 2006)

#16 

Robert, 

I have responded to your PM but it does not seem to show in my outbox. Please would you kindly confirm receipt? Many thanks.

Barrie


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## Andrew Craig-Bennett (Mar 13, 2007)

woodend said:


> One question I meant to ask is in the dark ages when I was a tug master we had to have a 'towage certificate' issued by a Department of Transport Marine Division surveyor before the tow started. Do they still as I saw no nmention of it in the report? This accident would not have happened had their been some experiencen somewhere in the decision making train.


To some extent one has to read between the lines of the report, this is after all a report by the Danish Maritime Accident Investigation Board into a casualty which was 100% Maersk, but as I understand it there was a towage approval issed by the Danish authorities for the tows to be towed unmanned and "dead ship" but the shore based people in charge of the operation thought that the Class Towage Approval was the same thing as a warranty surveyor's Towage Approval and nobody on the tug thought to ask for it...

I can say rather categorically, having been a junior shore wallah in a position that had to do with deepsea towage, in the early 70's, that that is not a mistake that I would have made, nor would I have tried to suggest to anyone that they could tow two 5,000 ton ships side by side across Biscay, and if I had done either of those things I would have been on the end of a severe bollocking as a result of the tug master getting on the phone to my boss.

There's something rotten in the state of Denmark, here...


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## Stephen J. Card (Nov 5, 2006)

Andrew,

Would you have done this as in 'series'... shown in the diagrams? It would have been a relatively job to connect the two dead ships. Weld a Smit bracket on the after deck of the first dead ship and use cable from the second dead ship. The towing vessel connect his wire to the cable from the bow of first dead ship. Perhaps a bit of manpower to connect up in the beginning, but I can see that it would not have taken much time probably less than setting up the Yokohama fenders and could have saved that cost completely. 

What was the purpose of the tyres on the bridge wings of the two dead ships? Did someone really think that it would do anything at all? Wishful thinking!

Stephen


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## jimthehat (Aug 5, 2006)

I thought that the herald only went round the zeebrugge breakwater with the bow doors open-end that was a error on the duty bosuns part, he should have closed the doors but fell asleep.\
On townsends one of the duty mates stayed on the vehicle deck until bow and stern doors were closed and secured before proceeding to the bridge.


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## roddy (Mar 5, 2006)

https://www.shipownersclub.com/medi...-Tow-Safety-and-Operational-Guide_A5_0715.pdf

The above referenced operational guide might well be of interest, to anyone wishing to learn about the complexities of twin towing


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## Andrew Craig-Bennett (Mar 13, 2007)

roddy said:


> https://www.shipownersclub.com/medi...-Tow-Safety-and-Operational-Guide_A5_0715.pdf
> 
> The above referenced operational guide might well be of interest, to anyone wishing to learn about the complexities of twin towing


Thanks for posting that. 

It's comprehensive and, I think, very good, apart from the "calculation of bollard pull section", which is a bit iffy I think. The horsepower of tugs is a Dark Art, and their Bollard Pull doubly so...

Edited to add: I see - after reading to the end - that it's largely the work of Chris Spencer. Well done, Chris.

Pity Maersk didn't read it!


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## NoR (Mar 24, 2008)

Robert Hilton said:


> In the days when we were taught seamanship we were also taught to think and to avoid stupid risks. More thought than could be put on paper in many hours would pass through the mind. Risk assessment is meant to place the responsibility on those carrying out the orders and to leave those giving the orders free of all blame should a mishap occur.
> 
> It must be obvious from the case in hand that a written risk assessment can also permit unacceptable risks to be taken.


That's right ! When does a risk assessment morph into an exercise to justify something stupid ?


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## Varley (Oct 1, 2006)

It became clear to me that some of the motivation, at least, behind a switch from type approval to risk based 'shipbuilding' (ie from sheer strake to masthead lantern) is to avoid proving the gadgetry or technique as far as possible before it gets approved. This was over the course of two presentations by LR to IMarEST branch here.

I don't know about the body of SN (especially as it seems content to rely on GPS - ALONE - for navigation) but I would be considerably more content if the kit I was tasked to supervise was tried, tested and its foibles already discovered than simply chewed over on paper.

Perhaps not when I was at sea when the more and more complicated the kit the more fun it was to play with. But certainly from behind a desk.

Tried and tested safe but expensive. Risk assessed, cheep, until proven unsafe.


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## Blackal (Jan 29, 2008)

Barrie Youde said:


> About twenty years have now passed since I first heard the term "Risk Assessment". This was about ten years after I had left my last ship, after almost thirty years in pilotage.
> 
> The new words (risk assessment) were drawn to my attention as though they were holy writ; and my reaction was to wonder how on earth any of us had survived before this jargonistic expression was coined. That is a thing which I still wonder, in light of the knowledge that any assessment of risk, if relied upon as a guarantee - or holy writ, as might be urged - is in point of fact complete bullsh1t, as the Conclusions in the Report make clear.
> 
> ...


The mariner *does* spend his life doing risk assessments, and in the past - many were prepared to 'play the odds' with their own and with others' lives. Risk assessments 'should' encapsulate those mariners' experience and knowledge, and when done correctly in a forum - should produce an appraisal with integrity. The recording of that risk assessment has more than one benefit:

It remains as a working do***ent for others to build on (gaining the experience and knowledge of those conducting the first RA) 

It encourages openness and forces any contributors with an 'agenda' to explain that train of thought (sometimes you have to point this out to some)

It becomes a written record which does force some 'decision-makers' to think twice about what they are recommending.



valvanuz said:


> Common sense and basic seamanship will beat risk assessment by a mille


I see the Risk Assessment process as being built upon those qualities/attributes. It doesn't replace them, but your "common sense and basic seamanship" was/is not sufficient. 

I posted a photo on this site of a deck cadet, climbing over a crane jib about 15ft above deck level. No PPE. Several 'experienced' seafarers commented that it was admirable - "one hand for the ship" etc. But - any risk assessment would highlight that the probability of a fall was 'possible' and the result 'death or severe injury'? Apparently the use of a fall-arrestor was deemed to be 'nanny'. 

Things *had* to change.



Robert Hilton said:


> "Risk Assessment" has always puzzled me. It appears to assume that we were all taking wild and unconsidered risks before it was introduced.


Not "all" - that is ridiculous. But - sufficient to demand a change in the MO.



woodend said:


> One question I meant to ask is in the dark ages when I was a tug master we had to have a 'towage certificate' issued by a Department of Transport Marine Division surveyor before the tow started. Do they still as I saw no nmention of it in the report? This accident would not have happened had their been some experiencen somewhere in the decision making train.


Towing Approval is generally demanded by the underwriter for the operation. The procedure is reviewed by a warranty survey company (e.g. Noble Denton etc), and any shortfalls identified and asked to be addressed. From that - they will produce a checklist for the Warranty Surveyor to complete when he attends the towing vessel(s) prior to the tow commencing. A good Warranty Surveyor - will use the checklist as an aide-memoire and look at more than the checklist - lists. 



D1566 said:


> It just formalises a process that most people have been going through since the year dot. Look on it as being a useful tool, a memory jogger, what you will, but it has stopped the routine taking of many stupid risks, which are usually put down to 'we have always done it like that'.


That is it - in a nutshell. It also assists others in the future, when carrying out 'similar' operations.



John Dryden said:


> The final words of the conclusion tell us a lot:
> 
> ''In fact, the risk management system instead tends to facilitate the carrying out of risk prone operations''


It can- if you let it. I have sat on many HIRAs, HAZIDs and Task Risk Assessments, and there are often project personnel who do not approach the process with the 'integrity' required. But - there is the opportunity to steer it back on course. One thing is certain - the Risk Assessment process beats the 'Ad Hoc' method any day. I have also carried out Towing Approvals on behalf of the operation underwriters.



Robert Hilton said:


> In the days when we were taught seamanship we were also taught to think and to avoid stupid risks. More thought than could be put on paper in many hours would pass through the mind. *Risk assessment is meant to place the responsibility on those carrying out the orders and to leave those giving the orders free of all blame should a mishap occur.
> *
> It must be obvious from the case in hand that a written risk assessment can also permit unacceptable risks to be taken.


I can't agree with that sentiment. The Risk Assessment isn't the final visit to the task - the Toolbox talk allows for the explanation of all the risks identified and the proposed mitigation and for the work party to contribute their experience/knowledge and also to question the assessment.

Yes, sometimes Risk Assessments can be lacking in integrity - some people continue to take shortcuts, and in a previous generation - would have been the cowboys, I reckon. I sense that a lot of the responses above are 'latching on' to the occasions when Risk Assessment fail - as if to prove a point.

Back to the Maersk operation - without going back to the report which I have just skimmed over - I am not sure if the operation had any external indemnity - it may have been self-insured by Maersk, who would naturally be more interested in the operation going ahead than "challenging" every aspect.

Al


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## NoR (Mar 24, 2008)

In sixteen years at sea and twenty five years in aviation I never carried out a risk assessment and I never had a serious accident although there was plenty of opportunity for such. I guess my experience replicates that of many others on this site.
IMHO the main purpose of risk assessments is to provide a 'get out of jail card' for management.


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## Barrie Youde (May 29, 2006)

#28 

Nobody appreciates more than I do the benefits of learning from the experiences of other people; and I do not question for a moment the good intentions of the philosophy of preparing a written risk assessment. A risk assessment, however (by definition) precedes the running of any risk; and if the proposed event then proceeds and occurs without incident then it seems unlikely that any of us will ever see the preceding risk assessment or gain any benefit from it.

As to giving (or gaining) benefit from the experiences of others, it seems quite clear that MAIB Reports and Law Reports (both of which are reports ex-post facto) are of far greater benefit than any preparatory risk assessment, based largely on wishful thinking. I have been present at the taking of evidence for more MAIB reports than I care to remember and can confirm without hesitation that they are based on hard fact rather than supposition, however expert the supposition might or might not be.

As to the Law Reports, their records bind us all, precisely because their contents are factual and not merely estimated or assessed.


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## Chillytoes (Dec 9, 2006)

However one views 'risk assessments' and other manifestations of managementese, I think we can all agree that experience and awareness are the most valuable assets for any seafarer. It is a source of great concern that there is such a headlong rush to be the first to introduce 'autonomous' or unmanned ships, that if there are to be no seafarers, how can anyone get the required experience?


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## Barrie Youde (May 29, 2006)

#31 

A fundamental point which is overlooked only at the peril of all mankind.


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## Blackal (Jan 29, 2008)

Barrie Youde said:


> #28
> 
> Nobody appreciates more than I do the benefits of learning from the experiences of other people; and I do not question for a moment the good intentions of the philosophy of preparing a written risk assessment. A risk assessment, however (by definition) precedes the running of any risk; and if the proposed event then proceeds and occurs without incident then it seems unlikely that any of us will ever see the preceding risk assessment or gain any benefit from it.
> 
> ...


On major project or constituent parts - the task is reviewed upon completion, where lessons learned are explored (on a well-run project, at least)

In a system using Task Risk Assessments - there are "usually" the requirement for the TRA to remain in the system, to be utilised as a framework for future similar tasks (with the caveat that it must be reviewed to ensure that the cir***stances are the same - and adjusted to suit). Of course - there are some who will shortcut the process, by grabbing a TRA and thinking "this will cover it" - and wade in.
Most companies will require within their SMS that a TRA can only remain valid for a period of 12 months, after which it must be reviewed by the appropriate disciplines.
TRAs also have the facility for review after the task has been carried out - for issues or any additional safeguards which have been noted as being worthwhile.


"A risk assessment, however (by definition) precedes the running of any risk"

Every task has a risk, albeit (hopefully) the risk is 'negligible' or 'zero'. The RA allows operators to see the steps involved in the task, in a tabular fashion - which to me is of great assistance to ensure that the whole task is considered f- prior to commencement.

I've seen a few operations where I would be very surprised if the formalising of the risk assessment - didn't bring the operators to their senses.

Acting on Law Reports and MAIB reports - Yes, when severe incidents occur- then quite rightly, there may be a requirement for a whole industry to change, but I am a firm believer that the Risk Assessment Process assists in minimising the LRs and MAIBRs.

I fully recognise that the experience and knowledge are principal inputs to the RA process, but I've seen too many cases of "We've always done it like that" and "It'll be alright".......... Often with disastrous consequences.

Al


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## NoR (Mar 24, 2008)

Blackal said:


> On major project or constituent parts - the task is reviewed upon completion, where lessons learned are explored (on a well-run project, at least)
> 
> In a system using Task Risk Assessments - there are "usually" the requirement for the TRA to remain in the system, to be utilised as a framework for future similar tasks (with the caveat that it must be reviewed to ensure that the cir***stances are the same - and adjusted to suit). Of course - there are some who will shortcut the process, by grabbing a TRA and thinking "this will cover it" - and wade in.
> Most companies will require within their SMS that a TRA can only remain valid for a period of 12 months, after which it must be reviewed by the appropriate disciplines.
> ...


Bureaucratic BS. Anything to generate another piece of paper and codify stuff that should be common sense.


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## Blackal (Jan 29, 2008)

NoR said:


> In sixteen years at sea and twenty five years in aviation I never carried out a risk assessment and I never had a serious accident although there was plenty of opportunity for such. I guess my experience replicates that of many others on this site.
> IMHO the main purpose of risk assessments is to provide a 'get out of jail card' for management.





NoR said:


> Bureaucratic BS. Anything to generate another piece of paper and codify stuff that should be common sense.


You'll never be convinced by reason.

But - this is, after all...... a site for 'nostalgia'.


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## Varley (Oct 1, 2006)

I agree that we are trying to replace expertise and experience with operational procedures however in the case of risk assessments I do not see why one should shy away from demonstrating one's common sense by recording it. 

No one else is going to blow your trumpet for you (and it gives the Coroner something to read in your absence if one is too short of the rare commodity in question).


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## Barrie Youde (May 29, 2006)

An improvement in anything is to be welcomed.

But there can be no doubt that the Report which started this thread identifies the dangers of relying upon supposition, simply because it has been written down. Such a philosophy is absurd, as any practical person knows.


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## Blackal (Jan 29, 2008)

Barrie Youde said:


> An improvement in anything is to be welcomed.
> 
> But there can be no doubt that the Report which started this thread identifies the dangers of relying upon supposition, simply because it has been written down. Such a philosophy is absurd, as any practical person knows.


I suspect that there was little money to be made out of the disposal of the vessels, therefor safety was perhaps lower down the priority list than a client-driven project.


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## Barrie Youde (May 29, 2006)

# 38

That sounds very much like further supposition.


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## Binnacle (Jul 22, 2005)

Blackal said:


> I posted a photo on this site of a deck cadet, climbing over a crane jib about 15ft above deck level. No PPE. Several 'experienced' seafarers commented that it was admirable - "one hand for the ship" etc. But - any risk assessment would highlight that the probability of a fall was 'possible' and the result 'death or severe injury'? Apparently the use of a fall-arrestor was deemed to be 'nanny'.
> 
> Things *had* to change.
> 
> Al


Without success I have been trying to sight your photograph of a cadet on a crane jib and the responses posted, I would be grateful if you could point me in this direction. As a former crane boy who has shinned up a crane jib to retrieve the hook, the subject is obviously of interest to me. I understand crane boys may now be an extinct maritime species, I may be among the last.
Thank you.


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## Varley (Oct 1, 2006)

But a risk assessment is something we all do do. That does not necessarily sitting down with a checklist but perhaps just simply thinking about the task and making sure one has the tools and instruments required to hand, certainly if one might inconvenience another (killing the galley for instance), considering if one should poll others on what one is doing and potentially moving on to a more formal RA or even permit to work. It DOES mean to some "auditable **** cover" however it can certainly serve a useful purpose as well.


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## NoR (Mar 24, 2008)

Blackal said:


> You'll never be convinced by reason.
> 
> But - this is, after all...... a site for 'nostalgia'.


Reason is what I gave you. Moreover backed up with lots of experience. Not my fault if you can't see that.


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## Barrie Youde (May 29, 2006)

At its best, a risk assessment is a statement of expectation, from which two further thoughts follow:

1. Of great expectations are disappointments born.

2. Blessed are they who expect nothing, for they shall not be disappointed.


PS

I'll even offer a third:-

The best laid plans of mice and men gang aft agley. I wonder if Burns drafted a risk assessment before he published Auld Lang Syne? Did he realise what riotous encouragement it might give to the debauchery of Hogmanay - once described as people being sick on the pavements in Glasgow? Dreadful behaviour, of course. Was he a public nuisance?


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## NoR (Mar 24, 2008)

Barrie Youde said:


> At its best, a risk assessment is a statement of expectation, from which two further thoughts follow:
> 
> 1. Of great expectations are disappointments born.
> 
> ...


How about having to fill in a Risk Assessment every time you lit a cigarette ? That would keep you occupied for a while.


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## jimthehat (Aug 5, 2006)

Blackal said:


> I suspect that there was little money to be made out of the disposal of the vessels, therefor safety was perhaps lower down the priority list than a client-driven project.


Are you then saying that the safety of the crew on the towing vessel was lower down on Maersks list?

I feel that the master and crew did a very good job in breaking away from the second of the sinking ships,


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## Robert Hilton (Feb 13, 2011)

The more attacks on, and defences of, risk assessments I read here the more uncomfortable I feel about the whole scenario. I'd rather get on with the job. 

I once took a vessel from the Irish Republic to Belfast. The Irish Department of Marine were anxious to ensure that all was in order with the vessel and in particular with the do***ents. Three personages were seeing to this, two from the D of M, and the other from the owners, or perhaps the other way round. 

My own preoccupation was a doubtful weather forecast that threatened to make the harbour entrance at least difficult. It emerged that we sailed with one of the do***ents still in the boot of a superintendent's car. 

When we were examined at Belfast I was asked for a statement as to why this I had sailed without the missing do***ent . I stated that I was more concerned with the weather and the passage. I said I had assumed that three men in senior capacity would be more able than I to deal with the modern plethora of do***entation. (I had to spell 'plethora' for them). Afterwards they told me I might hear further, or I might not. I guessed I'd hear nothing as they had got my address wrong when they wrote it down. This was years ago and I've heard nothing.

I conclude that bureaucracy and all do***entation relating to safety needs to have intelligence applied to it.


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## NoR (Mar 24, 2008)

Robert Hilton said:


> The more attacks on, and defences of, risk assessments I read here the more uncomfortable I feel about the whole scenario. I'd rather get on with the job.
> 
> I once took a vessel from the Irish Republic to Belfast. The Irish Department of Marine were anxious to ensure that all was in order with the vessel and in particular with the do***ents. Three personages were seeing to this, two from the D of M, and the other from the owners, or perhaps the other way round.
> 
> ...


Good to hear of somebody getting their priorities right. The trouble is that we've come under the thrall of a bunch of pen pushers and graduates.

IMHO practical experience is paramount and there is no shortcut to gaining it. Perhaps that is a lesson that has to be re learned ?


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## Barrie Youde (May 29, 2006)

#47 

I have a vivid recollection of being told of some coastal shipmasters (well within living memory) who could neither read nor write but could find their way around the Irish Sea.

Plainly, literacy is a useful thing; and I'm as steeped as anybody else is in the philosophy that to place things on record helps to protect oneself.

But to be obliged to record one's personal expectations, in the full knowledge that they are nothing more than expectations - and therefore vacuous at best - still seems to be absurd. To be obliged to record what has actually happened is a very different matter; and makes perfect sense.


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## 5036 (Jan 23, 2006)

jimthehat said:


> Are you then saying that the safety of the crew on the towing vessel was lower down on Maersks list?
> 
> I feel that the master and crew did a very good job in breaking away from the second of the sinking ships,


What utter b**l****.

https://youtu.be/F_fLBjk5TcQ

The only customer they did not know was themselves.

This thread should be combined with the thread I started on "The Bridge."

"I am amazed that this side by side tow ever got approved and that the tow continued after the fenders failed and the ships started battering lumps out of each other on the 20th leading to the carnage of the 21st and the initial capsize on the 22nd. It seems a lot of opportunities were either missed, lost or ignored.
"

"RELEVANT SHIP CREW ON MÆRSK BATTLER (The tow ship)

Master: STCW II/2 Master unlimited
60 years old, had served the company for 40 years and had been at
sea for 44 years. Served as a master in the company since 1997, 10
weeks of which on MÆRSK BATTLER.

Chief officer: STCW II/2 Master unlimited
34 years old and had been at sea for a total of 7 years, all of which
with the company. Had served as a chief officer on MÆRSK BATTLER
for 2 years.

Able seaman: 43 years old. Had served the company since 2009, approx. 7 months
of which on MÆRSK BATTLER.

Who:

"The crew on MÆRSK BATTLER did not perceive
the direct contact between MÆRSK SEARCHER
and MÆRSK SHIPPER as an emergency situation.
The crew expected that the fenders of the side-by-side
towing setup could fail during the tow and that
the ships would suffer some damage to the accommodation
on each of the ships under tow, but as they
were to be recycled, damage above the waterline
was accepted. This perception blurred the line between
a successful operation and a critical situation
and therefore the emergency situation was not evident
to the crew until 10 minutes before the capsizing
of MÆRSK SEARCHER though both ships
under tow had shown signs of significant structural
damage 24 hours earlier""

As I said. WTF?


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## ART6 (Sep 14, 2010)

On the subject of risk assessments and diverting from the maritime point of this thread, my last major project as project director was building a very large biofuels processing plant in London. As always the jobsworths clustered, and as we were setting up the site, installing the site offices, and all the other hundreds of things that had to be done, I was asked if we had prepared risk assessments and method statements for every job in the construction and installation of machinery, and if they had been submitted (to whom? That was never explained, but I assume they should have been submitted to a filing cabinet in the basement of some government office from where they would never, ever, again see the light of day).

Right so: Once operations commenced there would be at least five crews each doing half a dozen tasks per ten-hour day, and often many more peripheral jobs. There was a fabrication bay where welders were busy fabricating steel columns and girders on a just-in-time process as my site office turned out the necessary drawings. There were the daily deliveries of steel that had to be received and unloaded by the riggers, and later the deliveries of thirty-tonne machines. And a risk analysis and a method statement for every task?? FFS! Yet over the years I had built six such plants and had never had to deal with any accident more serious than a cut finger! I refused to do any of those things.

That was my experience of the new regulations that seemed to be designed to stop anyone doing anything any time, and that experience was small scale in heavy engineering. So what would be required by the H&S laws when the new UK aircraft carriers were being built is beyond my imagination. I can only imagine that for every man welding steel there would be six others preparing written directions on how he should do so without having ever done it themselves. As always, bureaucrats reign supreme!


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## jimthehat (Aug 5, 2006)

nav said:


> What utter b**l****.
> 
> https://youtu.be/F_fLBjk5TcQ
> 
> ...


it is quite obvious that you do not have a clue and it is you who are talking Bulls**t.


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## 5036 (Jan 23, 2006)

jimthehat said:


> it is quite obvious that you do not have a clue and it is you who are talking Bulls**t.


So, you as a 60 year old master with 40 years experience working with Maersk would not have considered questioning towing two vessels side by side through the Bay of Biscay in December. Look at the opening picture to the report. Would you not have questioned the situation where two tyres are mounted on the bridge wings? What genius came up with that one? Obviously the project management expected damage but what type of solution is that?

20th December you are proceeding through the English Channel when the separating fenders disappear but do not consider that a threat to the tow? An opportunity missed.

On the 21st December you continue on towing two ships battering lumps out of each other into the Bay of Biscay under the naive illusion that the damage is only occurring above the waterline. An opportunity missed.

On 22nd December you watch lists develop and are happy to do so until one vessel capsized. Only at that point do you consider breaking the tow. How on earth did you get yourself into that situation? You are the master. You have 40 years experience. You are responsible for the safety of the vessel and, more importantly, the crew.


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## Robert Hilton (Feb 13, 2011)

#51 & #52 I'd like to bang your heads together so you'd stop squabbling.


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## Varley (Oct 1, 2006)

You mustn't do that. They might sink.


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## 5036 (Jan 23, 2006)

Varley said:


> You mustn't do that. They might sink.


(Ouch)

Brilliant V!


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## Ian Lawson (Apr 30, 2017)

Robert Hilton said:


> [URL=http://www.shipsnostalgia.com/usertag.php?do=list&action=hash&hash=51]#51 [/URL] & #52 I'd like to bang your heads together so you'd stop squabbling.


Before you do that would you please allow #51 to explain to the elder members what is this STCW ll/2 actually mean.


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## ian keyl (Nov 28, 2005)

They maersk tend to know everything or so they think .
Keep her steady.


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## Andrew Craig-Bennett (Mar 13, 2007)

*how to sink two perfectly good ships, in good weather, due to toxic management*

There is a phenomemenon known as “regulatory capture”. This happens when a Government agency, charged with regulating some commercial activity, starts to advance the interests of special interest groups involved in that activity, against the public interest.

There are those who say that a nation as small as Denmark surely cannot have, as a corporate citizen, a company as large as the AP Moller Group, without suffering regulatory capture. That is not what this posting is about. It may well be, as we are often told, that Maersk is a model corporate citizen of Denmark. 

What this is about is the capture of large and famously excellent shipping companies by their own accountants, at the cost of what the Admiralty Court in London calls “the ordinary good practice of seamen”. Shipping companies are prone to this because their needs for large sums of capital whilst operating in a highly volatile financial environment put their money men in an unusually powerful position.

We could all see this happening to the AP Moller Group of companies, starting in the 1980s, by which time it was already impossible for a Maersk staffer to explain the AP Moller group without the aid of a “wiring diagram” to illustrate the relationship between DS Svendborg, DS 1912, the Partnership, the gas field, the leases, the supermarkets and the Danish tax man, and culminating at the moment when Maersk McKinney Moller retired and handed over to Jess Soderberg, since the Finance Director was by by then the only person who could understand it.

The Maersk brand - assiduously promoted to its customers - started to get ”_hollowed out”_, in the eyes of seafarers, as Mr Moller’s shipownerish eccentricities, like putting all his ships in the West of England P&I Club, classing all his ships with LR, building all his ships at Odense, making all the small fittings on deck out of bronze, and employing stewardesses to keep life on board civilised, were reduced to a simple matter of painting them all blue. As Maersk went from strength to strength, the blueness started to get stretched thinner and thinner, to the point where people could watch the 1967 Danish comedy film “MARTHA” – a classic of the Ealing genre, -and I will be eternally grateful to Cisco for introducing me to it - and not recognise that it is a gentle skit on the late Mr Moller and his already growing empire.

And now – oh, dear – the AP Moller Group have got their label on a spectacular example of bad seamanship – so bad that “gross incompetence” barely starts to describe it, which took place, not anywhere obscure, not involving anyone else, but entirely “in house”, starting in Denmark itself and ending with the sinking of two perfectly good ships, in fine weather, in the Western Approaches to the English Channel. 

Luckily, nobody was hurt, which means we can all enjoy a good dose of _schadenfreude_ – taking pleasure in the misfortunes of others – at Mollers’ expense. Bad seamanship always has its origins ashore, in the Board Rooms of shipowners, because companies with a healthy corporate culture do not tolerate poor seamanship, and they recognise and reward good seamanship. It is, after all, what we do – it’s what we are all here for – to carry people and their goods by operating ships as well as possible, using the expert knowledge bequeathed to us by our forebears.

To say, with Shakespeare, that “there is something rotten in the state of Denmark” hardly does justice to this case. The full panoply of modern, systematised, ship management and ship operation was paid lip service to – there is hardly a jargon phrase, from “Management of Change” through “Risk Assessment Procedure”, that does not feature prominently in the report, and which was not abused, in broad daylight. 

The DMAIB report correctly states that _this was a system failure_. It was a failure of the whole system, starting with the sacking of the man charged with preparing the operation without giving him time to clear his desk or to hand over, continuing with a whole string of unwarranted assumptions made by non-seamen, who had been required to take over the simple operation of delivering several ships to a breaker’s yard in Turkey after all those who had started the planning were fired and extending to the curious case of the professional seamen aboard the towing vessel , who calmly assumed that everything was OK – when the operation that they were being told to carry out was obviously preposterous – and never said a word.

The new team – a manager and a trainee – must have been a good deal cheaper, because their ignorance of their own industry was breathtaking. They assumed that approval for each vessel to be towed unmanned by the Danish Maritime Authority was an approval of the towing procedure. They assumed that a class approval for a dead ship tow was the same thing as a warranty surveyor’s approval of the towing procedure. (I’ll just remind you, at this point, that this is a company which claims to be “the market leader” in the offshore industry!) 

Outrageously, to the mind of any seaman, they – _and the tug’s crew_ – saw nothing wrong in trying to tow two ships alongside each other, lashed together with chains fore and aft but with no springs and separated by small Yokohama fenders, chained on in a manner which invited chafe, from Denmark to Turkey,across the Bay of Biscay, in winter. Towing the ships separately with a single tug would, they thought, have required a double winch, which ythe _Maersk Chancellor_ did not have,m but in fact the _Maersk Battler_, the tug used, had a double winch, as is rather common in the industry. At no point did anyone notice that the original reason for the unsafe proposal no longer applied.

Why didn’t the crew of the tug object? To cite the report, again,_ “The crew on MÆRSK BATTLER were aware that the side-by-side towing method was untraditional for this type of voyage. However, the crew strongly identified themselves with the company’s image of being industry frontrunners and capable of solving difficult and novel tasks. Therefore, the crew did not question the towing method, but relied on their professionalism to manage the situation”._

Or, "being translated" as the Good Book has it, the crew either believed the company’s own bull.... or they were too scared of redundancy to speak up.
In looking at that Holy Grail of modern shipping company management, the Risk Assessment System, the report says:

_In the risk management process preceding the towing operation, the risk of losing the fenders, the risk of collision between MÆRSK SHIPPER and MÆRSK SEARCHER, and the risk of the ships under tow being flooded were all identified. The risk factors and risk mitigating initiatives were all identified on the basis of the “Management of Change” meeting participants’ experience and conceptions of what type of risk scenarios would be relevant. As no participant in the MoC meetings had experience with the side-by-side towing method, they relied solely on their ability to imagine which scenarios could occur. When observing the risk_ _assessment and the applied risk mitigating strategies, two issues regarding the participants’ risk perception can be observed:

i) Underestimation of acting forces The forces acting between the ships under tow were underestimated. The mooring ropes mounted to keep the ships close together and the mounted tyre fenders on the bridge wings indicate that nobody had imagined that the ships were able to move individually and to interact to the extent that they did. Mooring ropes and tyre fenders are not able to withstand this type of forces. The choice of downscaling the fenders also indicates that the forces acting between the ships under tow were underestimated._

(Note: Two ships of five thousand tons each, alongside each other, in the Bay of Biscay.. as Homer Simpson might say... duh!)

_ ii) Absence of mitigating strategies for acutely emerging incidents The risk mitigation focused on preventive measures to be carried out or mounted prior to arrival. These measures were assessed to reduce the risk of the operation, but a residual risk was maintained. If these preventive measures failed, no strategies to redress the consequences were in place, which effectively left the crew without any possibility of acting on these consequences._

_ Furthermore, as each risk factor was handled separately, the risk assessment did not address the fact that the risks could be connected, e.g. that the failing fenders could lead to collision and subsequent flooding. Hence, the preventive control measures did not correspond to the acute potential of the consequences of the residual risks coming into effect and the interaction between the risk factors.
_

Well, quite. Now I want to be serious. Please read the next bit carefully, because this applies to you, even if you don’t work for Maersk. The Report concludes:

_The towage was configured as a side-by-side setup where the ships under tow were connected and considered to be one unit. When the towage was confronted with swell and waves causing increased motions of the ships, they did not behave as one unit, but as two individual units interacting. 

The only buffer separating the ships consisted of three fenders, which were unable to withstand the force of the coupled and interacting ships and hence failed. When MÆRSK SEARCHER and MÆRSK SHIPPER had been in direct contact and had collided continuously for 36 hours, structural damage compromised the watertight integrity of MÆRSK SEARCHER. _

_The side-by-side setup rendered no contingency to disconnect MÆRSK SHIPPER from MÆRSK SEARCHER. Hence, when MÆRSK SEARCHER capsized and sank, the crew had no option to recover MÆRSK SHIPPER, which capsized shortly after and subsequently sank. The crew on MÆRSK BATTLER did not perceive the direct contact between MÆRSK SEARCHER and MÆRSK SHIPPER as an emergency situation. 
_
_The crew expected that the fenders of the side-by-side towing setup could fail during the tow and that the ships would suffer some damage to the accommodation on each of the ships under tow, but as they were to be recycled, damage above the waterline was accepted. This perception blurred the line between a successful operation and a critical situation and therefore the emergency situation was not evident to the crew until 10 minutes before the capsizing of MÆRSK SEARCHER though both ships under tow had shown signs of significant structural damage 24 hours earlier. 

The cause of the capsizing and foundering of MÆRSK SEARCHER and MÆRSK SHIPPER might seem simply to be the result of two ships being allowed to collide multiple times and a wrong choice of towing method. _

_However, this assumption is oversimplified. Instead, this accident calls for understanding the complex cir***stances of the lengthy preparation process during a period of organisational changes, which resulted in the decision to use an unconventional towing method. 

In this case, the choice of towing method was made on the basis of the limitations of another tug than MÆRSK BATTLER, and there was no reason to change the towing setup to the setup recommended by external experts as the risk connected to the side-by-side tow had been handled in the risk management system and was thereby reduced to an acceptable level. The risk of loss of fenders, collision and flooding of the unmanned ships under tow was addressed in the risk assessment carried out by the shore management. The risk assessment formed the basis of the decision whether the side-by-side towing setup was feasible and was perceived as a tool which would indicate whether the operation should be aborted as being too risky. _

_However, the logic of the risk management system was to introduce risk mitigating initiatives for each risk factor so that the risk was assumed to be reduced to an acceptable level. However, the occurrence of the accident proves that these initiatives were ineffective. DMAIB concludes that the risk mitigating strategies were mainly focused on preventing risk factors in isolation and left little or no contingency for acute interaction between the risk factors.

*The risk management system used by Maersk Supply Service is one of the most common in the shipping industry *and the problems connected to the risk management system which led to the insufficient risk mitigation of the towing operation are hence not *out of the ordinary. The risk management system offers to handle risk as an objective value and to provide a structure for handling risk. However, there is no aid or control of what is put into the system when it comes to which risk factors are identified. *
_
_The numeric risk value is based solely on how imaginative the involved persons are, and the system does not provide a structure for how to reflect on what risk mitigating strategies are applied. This means that the risk management system does not help its user to manage risk, and that the assessment of the risk reduction is highly sensitive to one or more individuals’ subjective risk perception, which will be strongly influenced by the desire to make the operation possible. *Thereby, the risk management system will rarely limit activities prone to risk. In fact, the risk management system instead tends to facilitate the carrying out of risk prone operations.*”_


In other words, it’s all twaddle. Garbage in; garbage out, and the value of what goes into the Risk Assessment is wholly dependent on the professional knowledge of the people making the assesssment and on their willingness to contribute honestly and to the best of their ability.

These factors depend on the company culture, and a company in which experienced people are fired with no notice and not even permitted to clear their desks is a toxic company culture, in which nobody will speak out of turn. The Emperor had no clothes. 

This point is not made in the DMAIB report – perhaps due to “regulatory capture” by Maersk – who knows? It is why I want to hold what is now the rotten husk of a once great company up to the contempt and ridicule which its managers have come to deserve. 

I think that at this point I can do no better than to use Maersk’s own words and to quote the Maersk press release announcing the appointment of the Chief Operating Officer responsible for this utter shambles, three months before the event:

_“Claus Bachmann will assume the position of COO after Claus Tafteberg Sørensen, who will leave Maersk Supply Service and the A.P. Møller Maersk Group.
“I am pleased to announce Claus as the new COO of Maersk Supply Service. With almost25 years of experience in the oil and gas industry, *I am confident that he will drive operational efficiency in the current challenging markets*. Claus has a proven track record of leading high performing teams and managing global assets in Maersk Drilling, and he will be instrumental in further optimizing our operation,” says CEO Jørn Madsen..._

(We can all translate _*“drive operational efficiency”*_, can’t we...)

_“About Maersk Supply Service
“Maersk Supply Service provides marine services to the oil and gas industry worldwide. *Maersk Supply Service is the market leader in deep-water services such as anchor handling in ultra-deep water, mooring installations, rig moves and transport of equipment to drilling rigs and production units. *Maersk Supply Service employs an international staff of around 1450 offshore and 260 onshore people. Headquartered in Lyngby, Denmark, Maersk Supply Service is represented globally with offices in Aberdeen, St. John's, Rio de Janeiro, Lagos, Luanda and Perth... In 2015 Maersk Supply Service delivered a profit (NOPAT) of USD 147 million.”_



Anyone know the Danish for “Yeah, right..."?


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