università degli studi di genova corso di laurea

Learning from marine accidents

Learning from marine accidents.

A design method based on formal assessment and

past experience.

Università degli Studi di Genova

Corso di Laurea Magistrale in Ingegneria Navale

Prof. Ing. Massimo Figari


RMS Titanic, 1912

Estonia, 1994

Moby Prince, 1991

Haven, 1991

Amoco Cadiz, 1978

Prestige, 2002

Braer, 1993

Star Princess, 2006 MSC Napoli, 2007


Recently…

Anversa, 13-03-2007

Repubblica di Genova

Grimaldi Lines


Safety

• Persons,

• Environment,

• Property

• Safety vs. Security : two different concepts


Management of Safety issues

in the ship design process

• Design

•Construction

•Operation

•Accident Investigation

Shipyard, Class Society

Class Society, Shipowner

Administration

All

parties


International Conventions

• SOLAS

• MARPOL

• STCW

• Load Lines

Code

• FSS Code

• HSC Code

• IBC Code

• ICS Code

• IGC Code

• IMDG Code

• ISM Code

• ISPS Code

Safety issues Management at international

level


Sicurezza in campo navale

• Normativa europea (Direttive)

• EMSA (European Maritime Safety Authority) sede a

Lisbona

• Leggi italiane

• Amministrazione di Bandiera (Autorità Marittima

Italiana)

– Ministero dei Trasporti

– Capitanerie di Porto – Guardia Costiera

• VI Reparto Sicurezza della Navigazione


• Flag State Control

• Port State Control

• Convenzioni e Risoluzioni IMO

• Convenzioni ILO

Controllo della sicurezza

• Diritto all’auto protezione

• Rispetto delle leggi nazionali


Memorandum of Understanding

on Port State Control

• Paris MOU • Black Sea MOU

• Caribbean MOU

• Tokyo MOU

• Viña del Mar Agreement

• Indian Ocean MOU

• Mediterranean MOU

• Persic Gulf MOU

• African MOU


Copertura geografica del Paris MOU


Technical investigation of marine accidents

Technical comments and operational procedures

to avoid the repetition of the same accident

• New design procedures

• Improvements of the Rules

Causes Effects

INVESTIGATION REPORT


MARINE TECHNICAL INVESTIGATIONS - IMO PROCEUDURE

MARITIME SAFETY COMMITTEE

MARINE ENVIRONMENT PROTECTION COMMITTEE

MSC/Circ.953

MEPC/Circ.372

REPORTS PROCEDURE


MARINE TECHNICAL INVESTIGATIONS - IMO PROCEUDURE

10 ANNEXES

• Serious casualties • Marine incidents

• Very serious casualties • Less serious casualties

Preliminary classification

in casi particolari in casi

particolari in casi

particolari

in casi

particolari

Marine incident

in casi particolari in casi

particolari in casi

particolari

in casi

particolari

Less serious casualty

in casi particolari Serious casualty

sempre Very serious casualty

Report completo Altri Annex 3 Annex 2 Annex 1


IMO Taxonomy

• Initial event: 1. capsizing/ listing

2. collision

3. contact

4. damages to ship or equipment

5. stranding/ grounding

6. fire or explosion

7.

8. hull failure/ failure of watertight doors/ports, etc.

9. machinery damage (loss of control)

10. missing: assumed lost

11.

12. accidents with life-saving appliances

13. other


IMO Taxonomy

• Consequences

– total loss of the ship

– ship rendered unfit to proceed

– ship remains fit to proceed

– pollution

– loss of life

– serious injuries


HUMAN RELATED

CAUSES

• OPERATIONAL ERRORS (CREW)

• DESIGN ERRORS (DESIGNER)

• CONSTRUCTION ERRORS (BUILDER)

• MANAGEMENT ERRORS (OWNER, TECHNICAL MANAGER)


EU Directive 2009/18/EC

• improve maritime safety and the prevention of pollution

by ships, and so reduce the risk of future marine

casualties by:

– safety investigations and proper analysis of marine casualties

and incidents in order to determine their causes;

– ensuring the timely and accurate reporting of safety

investigations and proposals for remedial action.

• Investigations shall not be concerned with determining

liability or apportioning blame.

Naval Architecture & Marine Engineering


DL165_06/09/2011

• Attuazione Direttiva 2009/18/EC

• Traduzione della direttiva



GOVERNAMENTAL AGENCIES

incidents reports • http://www.amsa.gov.au/Shipping_Safety/Incident_Rep

orting/Index.asp

• http://www.ntsb.gov/Surface/marine/marine.htm

• http://www.emsa.europa.eu/

• http://www.maib.gov.uk/home/index.cfm

http://www.amsa.gov.au/Shipping_Safety/Incident_Reporting/Index.asp

http://www.amsa.gov.au/Shipping_Safety/Incident_Reporting/Index.asp

http://www.ntsb.gov/Surface/marine/marine.htm

http://www.emsa.europa.eu/

http://www.maib.gov.uk/home/index.cfm


Accident Taxonomy

• Capsize / Listing

• Collision

• Contact

• Fire / Explosion

• Flooding / Foundering

• Grounding

• Machinery Failure

MAIB

• Capsize

• Collision

• Contact

• Fire / Explosion

• Flooding / Foundering

• Grounding

• Machinery Failure

• Multiple Accidents

• Collision

• Contact

• Fire

• Flooding

• Grounding

MAIA Hong Kong

different agencies use different taxonomy


Capsize/Listing

Collision

Contact

Fire/Explosion

Flooding/FounderingGrounding

Machinery Failure

Not Considered

MAIB MAIA

Hong Kong

Collision

Contact

GroundingMachinery Failure

Multiple Accidents

Not Considered

Fire/Explosion

Flooding/Foundering

Capsize

Fire

Flooding

Grounding

Collision

Contact

Not Considered

Accident Statistics 2000 - 2005

42%

57%

15%

18%

7%

32%

16%

12%

11%

Accident statistics of different Agencies are very difficult to compare

due to the different taxonomy

Learning from marine incidents

DINAV - Naval Architecture and

Marine Engineering Department

STUDIED CASES

MAIB:

1. P&OSL Canterbury

2. Elhanan T

3. Sharona

4. Star Princess

TAIC:

1. Arahura

2. Kent

3. Lady Ann

Office of the Maritime Administration of Marshall Island

1. Eliza

http://upload.wikimedia.org/wikipedia/commons/thumb/3/3e/Flag_of_New_Zealand.svg/800px-Flag_of_New_Zealand.svg.png

http://images.google.it/imgres?imgurl=http://www.rbvex.it/oceaniagif/marshall.gif&imgrefurl=http://www.rbvex.it/oceanpag/pacifiche.html&h=201&w=383&sz=8&hl=it&start=8&um=1&tbnid=xwGHKhWcEMdGcM:&tbnh=65&tbnw=123&prev=/images?q=bandiera+isole+marshall&svnum=10&um=1&hl=it&rlz=1T4ADBS_itIT240IT241&sa=N




SHIP NAME INITIAL EVENT CONSEQUENCES

ARAHURA OTHER SHIP REMAINS FIT TO

PROCEED

ELIZA FIRE OR EXPLOSION TOTAL LOSS OF THE SHIP

KENT CONTACT SHIP RENDERED UNFIT TO

PROCEED

LADY ANN COLLISION TOTAL LOSS OF THE SHIP

P&OSL CANTERBURY OTHER SHIP REMAINS FIT TO

PROCEED

ELHANAN T DAMAGES TO

EQUIPMENT

TOTAL LOSS OF THE SHIP

SHARONA DAMAGES TO

EQUIPMENT

TOTAL LOSS OF THE SHIP

ANNEX I – STUDIED CASES


Arahura – Engine Rooms Layout


Arahura – factual information

(Ro-ro pax, Australia, Det Norske Veritas, 7 Giugno 2001, Wellington)

• Bilge high-level alarm forward propulsion motor room (fire zone 32)

• Alarm cancelled three times, without inspection

• Bilge high-level alarm aft propulsion motor room

• Bilge high-level alarm aft engine room

• Switch on bilge pump from aft engine room to bilge tank

• Fire alarm forward propulsion motor room

• Inspection: flooded compartment (2.1 m water) forward propulsion motor room

• Shutdown port shaft

• Shutdown bilge pump from aft engine room and switch on bilge pump from

forward propulsion motor room to overboard

• Water ingress aft propulsion motor room from a vent pipe. Bilge pump on.


Arahura – final condition

• Water ingress 177 ton in forward propulsion motor room

• 3 compartments flooded

• GM=0.55 m (at departure GM= 1.3 m)


Arahura – bilge system

• 4 bilge/fire pumps (1 submersible)

• Port and starboard bilge main

• Bilge tank 102 (9 ton)

• Tank 102 overflow inside ship


Arahura - analysis

Sea suction valve 90 misaligned, remained open

Valve tank 102 remained open

Sea Water flood in tank 102 up to sea level

When Bilge pump switched on, tank 102 vent pipe overflowed in the

forward propulsion motor room

Oil separator valve flooded aft prop motor room


Arahura

INITIAL EVENT CONSEQUENCES

OTHER SHIP REMAINS FIT TO PROCEED

PORT SHAFTLINE UNAVAILABLE

PORT MOTOR SHUT DOWN

ENGINE ROOM FLOODING

CREW ERROR

MANAGEMENT ERROR

FABRICATION ERROR &

DESIGN ERROR




P&OSL Canterbury - Narrative

(Ro-ro pax, UK, Lloyd’s Register, 18 Maggio 2002, English channel)






• High level bilge alarm catering store

• Emergency bilge pump in forward machinery space activated

• High level bilge alarm forward machinery space

• Suction from forward machinery space with the emergency bilge pump

• Inspection in the f. m. s. , flooded

• Failure of the emergency bilge pump in the flooded space

• Bilge pumping continued with the other bilge pumps in Engine Room

• Fire alarm activated in the f. m. s. , no real fire, fire party on stand by

• Another fire alarm in the f. m. s. , no real fire,

• Total water depth in f. m. s. about 1.4 metres

• Water pumped out in a road tanker at berth





(Ro-ro pax, UK, Lloyd’s Register, 18 Maggio 2002, English channel) NON return

Valve

NOT PRESENT




P&OSL Canterbury - Analysis


• 4 bilge pumps, 2 in f.m.s. (no bilge holding tank), 2 in engine room,

• Bilge Test line on the discharge line of the bilge pumps to direct the output

in the bilge space of the f.m.s. . Allow to test the bilge pumps without

discharging polluted water overboard.

• test line valve left open • Overboard NON RETURN valve not present, sea water backflooded from

overboard (not compliant with Load Line Convention)




P&OSL Canterbury


EVENTO INIZIALE CONSEGUENZE

OTHER SHIP REMAINS FIT TO PROCEED

TEST LINE VALVE OPEN

SAFETY SYSTEMS NON AVAILABLE

DESIGN ERROR

NON RETURN VALVE

NOT FITTED

CREW ERROR

FLOODING


Star Princess – Fire on board

23/03/2006, Montego Bay, Jamaica

L=290 m.

GT=108977 t.

Passengers 2700

Crew 1123


Star Princess – Factual information

• Burning smelled amidship by a security patrol

• 20 minutes later manual call point alarm from fire zone 2 deck 11

• 03.09 fire on superstructure, port side, confirmed by the bridge lookout

• 03.12 fire party on scene

• 03.13 staff captain in ‘safety centre’,

• 03.14 fire doors closed in fire zones 1, 2, 3


Star Princess – factual information

• 03.14 ventilation stopped

• 03.17 speed reduction, course changed to reduce relative wind

• 03.20 General Emergency , passengers to muster station

• 03.26 Fire party entered in zone 3 from forward

• 03.40 Fire in zone 4 and 5

• 04.36 Fire out.

• 09.54 Ship at berth, muster stations off


Star Princess - Analysis


Star Princess - Damages

• Fire damage extended over 3 Main Vertical Fire Zone and 5 decks

• Damage to balconies and staterooms

• 1 fatalty, 14 casualties


Star Princess


Star Princess – Mode and Cause

• Fire started on the balconies

• Glass balcony door collapsed and internal curtains ignited

• Fire spread very rapidly due to :

– Balcony furniture and partition of ignitable material

– Large amount of heat generated by the fire

• Smoke penetrated accomodations via balcony collapsed doors,

difficult evacuation, death of 1 passenger

• The balconies crossed main zone fire boundaries, without

structural or thermal barriers at the zone or deck boundaries

• No fire detection or fire suppression systems were fitted on the

balconies

• Fire fighting difficult due to non accessible areas

• Water mist system prevented fire spread further inside ship

• Water mist operated beyond minimum regulatory requirement


Water mist effectiveness

Water mist head failure

Water mist head normal operation


Lessons learnt

• Perform fire risk assessment of external areas

• Materials : furniture, partition

• Fire detection and fire fighting systems

• Accessibility of external areas

• Crew’s onboard training

• SOLAS revised




Incidenti considerati

(8) (10) (3)

• Border Heather

• Braer

• Canberra Pub

• Elegance

• Norsea

• Queen Elizabeth 2

• Savannah Express

• Sonia

• Star Princess

• Toisa Gryphon

• ANL Purpose

• Aurora Australis

• Hajin Dampier

• Harmonic Progress

• Helix

• Leonardo da Vinci

• MSC Katie

• Opal Naree

• Columbia

• Nieuw Amsterdam

• Port Imperial Manhattan


Queen Elizabeth 2

(Cruise Ship, United Kingdom)

22/05/2002, Atlantic Ocean • Corrosione sulla linea principale

della presa a mare

• Foro nel tubo, assenza valvola,

allagamento del locale

• Spegnimento motori dei

propulsione per l’allagamento

• Contaminazione del carburante

• Acqua pompata all’interno delle casse sludge attraverso le pompe di circolazione SW

• Livello dell’acqua in ER in aumento

• Provvidenziali riparazioni da parte dell’equipaggio

• Utilizzo delle pompe di sentina emergenza (lupa) per scarico fuori bordo

• Messa in sicurezza della nave


Engine Room compartments

Fore E.R.

Failure

Aft E.R.

D/G E.M. D/G


Queen Elizabeth 2 - II


Sea Water cooling system




Sonia

(General Cargo, St. Vincent & Grenadine)

05/09/1999, Isle of Wight, United Kingdom

• Corrosione sulla linea principale della

presa a mare

• Foro nel tubo ed allagamento del locale

• Acqua pompata nelle casse morchie

• Spegnimento dei motori

• Intervento altre navi ed installazione di

altre pompe

• Black out dovuta all’avaria dei generatori elettrici

• Riavvio del sistema ed installazione di ulteriori pompe di emergenza

• Riparazione provvisoria del foro di entrata dell’acqua

• Nave messa in sicurezza


Harmonic Progress

(Bulk Carrier, Panama)

16/04/2004, Coral Sea, Australia • Corrosione sulla linea principale

di zavorra

• Foro nei tubi all’interno della sala

macchine

• Procedure non corrette da parte

dell’equipaggio

• Allagamento del locale

• Acqua inizialmente scaricata all’interno delle casse morchie attraverso l’OWS

• Corto circuito e spegnimento del motore principale dovuto al livello d’acqua

• Deriva per ore

• Nave rimorchiata in porto

• Equipaggio poco familiare con l’impianto di zavorra


Harmonic Progress - II




Modello deterministico del danno (ALLAGAMENTO)

Queen Elizabeth 2 • Flooding of Aft Engine Room

• Complete loss of main propulsion

• Damages on the main engine cooler due to sea water

Sonia • Flooding of the Engine Room

• Manual stop of propulsive power

• Shut down of electrical system caused by sea water level

• Loss of any pumping capacity

Harmonic Progress • Flooding of the Engine Room

• The water led to the main engine lubricating oil pump motors short circuiting

• Loss of propulsive power due to blockage of the main engine




Modello deterministico del danno

Sezione circolare

A

Qvreale

gH2cvvteorico

• Confronto tra caso reale e

teorico di ingresso d’acqua

Formula idrodinamica

d

teorico

realev

v

vc




e = 13 % (Sonia)

e = 33 % (Harmonic Progress)

e = 40 % (Queen Elizabeth 2)

d

D

D

d100e

• Stima della portata di acqua in

ingresso

Modello deterministico del danno




0

50

100

150

200

250

300

350

0 50 100 150 200 250 300 350 400 450 500

Diametro del tubo [mm]

Po

rtata

[m

3/h

]

13% 33% 40%

Andamento della portata in ingresso




Applicazione del modello

Nave da crociera Nave traghetto

• Individuazione del locale più a rischio

• Stima dell’estensione del foro ( e )

• Valutazione della portata in ingresso grazie al grafico

• Calcolo del volume in ingresso al variare del tempo




Andamento del volume in ingresso

0

50

100

150

200

250

300

350

400

450

500

0 120 240 360 480 600 720 840 960 1080 1200 1320 1440

tempo [min]

vo

lum

e [

m3]

nessun intervento ritardo di 30 minuti ritardo di 60 minuti




Calcolo del battente interno

*S

Vh

0,00

0,50

1,00

1,50

2,00

2,50

3,00

0 120 240 360 480 600

tempo [min]

alte

zza

[m]

nessun intervento ritardo di 30 minuti ritardo di 60 minuti




Calcolo del battente interno

Danneggiamento dell’impianto elettrico

• Black out

• Perdita della propulsione

• Spegnimento impianti ausiliari e di governo




Conclusione dello studio

• Frequenze di accadimento

• Relazioni cause - effetti

• Modello delle conseguenze




Analisi di rischio

Rischio = probabilità di accadimento * conseguenze

Frequent

Reasonably probable

Remote

Extremely remote

Insignificant Minor Major Catastrophic

ALARP

Intolerable

Neglegible

Matrice di rischio


Bourbon Dolphin


https://www.youtube.com/watch?v=ZlX-

VVxNcn4

https://www.youtube.com/watch?v=ZlX-VVxNcn4




SUPREME


https://www.youtube.com/watch?v=jQJ-

nW49VFc

https://www.youtube.com/watch?v=jQJ-nW49VFc




Costa Allegra


https://www.youtube.com/w

atch?v=uatCWmKukTs

https://www.youtube.com/watch?v=uatCWmKukTs

https://www.youtube.com/watch?v=uatCWmKukTs


Costa Concordia accident


https://www.youtube.com/w

atch?v=4MtWxnRBVvg

https://www.youtube.com/watch?v=4MtWxnRBVvg

https://www.youtube.com/watch?v=4MtWxnRBVvg

università degli studi di genova corso di laurea

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