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教训:在操作上走捷径会导致事故

来源: 2019-11-03 22:11:40 责任编辑:国际海员服务中心网 人气:

英国MAIB在其最新的《安全摘要》中着重探讨了轮渡上的系泊缆线会容易缠绕上螺旋桨,在没有船上人员与岸上之间进行正确的沟通的情况下。基于此事故,MAIB建议始终遵循安全系统的指示,并牢记常规操作并对安全做法进行测试。

 事件

一艘渡轮正试图离开港口,此时系泊缆缠绕住了螺旋桨。

按照从船桥上“单绑”的命令,渡轮已经成功完成装载,并且系泊线已经松开。当缆绳变得松弛时,码头的巡视员误解了这个信号,并认为该船只将出发。随后,他将系缆从系缆柱上卸下,然后缆绳掉入水中。

几分钟后,他沿着码头走过缆绳线路,握住连接的一端,然后等待将缆绳拉上船。(见图1)至于船上,系泊站没有有人操纵。一名船员在绞盘控制装置上,另一名船员正在处理转轮端的绳索。

甲板上的一名高级船员通常负责监督当地的运营,仍在关闭水密门以准备航行,而本应参与缆绳处理的三副正在完成绑扎。

在转轮的末端,有一个水手将转轮排成三圈,排成一列,剩下的锚尾上的尾巴缠绕在托盘上。然后,他将绳索保持在面对托盘和海上绞车的手中,并将其松开,等待船员的指示停止。但是他没有听到绞车操作员的命令。

同时,在码头上,巡视员不知道这条缆绳的额外松开了,因为船会定期放出一条额外的缆绳以消除会存在扭曲。他一直握着缆绳,等待缆绳被拖上船。那时,松弛缆绳在船的螺旋桨中缠绕(见图2),缆绳从巡视员的手上拖了下来,其余的系泊缆线则从渡轮甲板上迅速拉出。

没有报告海岸或船上人员受伤。轮渡在船长不知情的情况下驶过,他不得不返回港口,因为螺旋桨轴上缠绕的绳索引发了强烈的震动。

最后,没有发现渡轮有任何损坏,潜水员成功地从螺旋桨上取下了绳索。为确定事故情节而进行的检查表明,大约有10m的松弛缆绳被带入水中。

得到教训

轮渡和港口均具有安全管理系统,该系统详细介绍了有关停泊和下泊作业的安全操作。在这种情况下,船与岸之间没有通信,轮渡人员配置不足,并且岸线巡逻员在没有船指示的情况下采取了行动。通过风险评估,识别危害和实施风险降低措施来开发安全系统。走捷径和绕过安全流程是造成事故的原因。

例行操作允许制定,实施和测试安全实践。但是,当熟悉和对效率的渴望导致偏离安全实践时,常规操作也会变得很危险。

船舶程序应是现实可行的。在同时执行任务(水密准备,货物系固和下泊)的情况下,至关重要的是要么有足够的适当人力,要么将操作延迟到此为止。

image006.jpg 

Lessons learned: Taking shortcuts on an operation leads to accidents

In its latest Safety Digest, UK MAIB focuses on how a mooring line from a ferry, can easily be tangled in the propeller, without the right communication between the ship personnel and the shore. Based on this accident, MAIB advises to always follow the directions of the safety system and keep in mind that routine operations allow safe practices to be tested.

02/11/19

The incident 

A ferry was attempting to leave port, when a mooring line became entangled in propeller.

The ferry had already successfully completed loading, following the order to 'single up' from the bridge, and the spring line had been slackened off. When the line became slack, the linesman on the jetty misunderstood this signal and thought to let go. He afterwards removed the line from the mooring bollards and dropped it into the water.

Minutes later, he walked the line along the jetty, holding onto the attached messenger, and waited for the line to be lifted on board. (see figure 1) As for the ferry on board, the mooring station was not manned to its usual level. The one boatman was on the winch controls and the other one was handling the rope from the drum end.

image007.jpg 

The senior crewman at the deck,who usually supervised local operations, was still closing watertight doors in preparation for sailing and the third crewman, who should have been involved in line handling, was finishing the cargo lashing.

At the drum end, there was a seaman who had set the line up with three turns on the drum and the remaining tail from the anchorage bitts coiled on a pallet. He then kept the line in his hands facing the pallet and the marine winch and slackened it out, waiting for the seaman's instructions to stop. But he had heard no orders from the winch operator.

Meanwhile on the pier, the linesman had no idea about the additional slack in the line, as the ship periodically let out an extra line to remove any twists. He kept holding the messenger and waiting for the line to be dragged on board.  At that moment, the slack line twisted in the vessel's propeller (see figure 2),  the messenger was hauled from the linesman’s hand and the remaining mooring line was pulled rapidly from the ferry’s deck.

image008.jpg 

No injuries to the shore or to the cabin crew were reported. The ferry sailed without master's knowledge that the incident was accursed, and he had to return back to the port station, since there was an intense vibration coming from the tangled rope in the propeller shaft.

Concluding, there was no any damage noticed to the ferry and the divers successfully removed the rope from the propeller. Examinations to establish the circumstances of the episode,  indicated that about 10m of slack line had been allowed to enter the water.

Lessons learned

1.Both the ferry and the port had safety management systems that detailed safe operations concerning work for berthing and unberthing operations. On this occasion there was no communication between ship and shore, the ferry manning was insufficient and the shore linesman had acted without instruction from the vessel. Safe systems are developed through risk assessment, identifying hazards and implementing risk reduction measures. Taking shortcuts and bypassing safe processes is a sure way to create an accident.

2.Routine operations allow safe practices to develop, be implemented and to be tested. However, routine operations can also become hazardous when familiarity and a desire for efficiencies lead to a deviation from safe practice.

3.Ship procedures should be realistic and achievable. Where concurrent tasks (watertight preparation, cargo securing and unberthing) are being conducted, it is essential either that sufficient and appropriate manpower is available, or operations are delayed until it is.

 
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