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National Transportation Safety Board: Lessons Learned from Marine Accident Investigations


Posted in Get To Know Maritime Law, News and Events on January 1, 2019


It is said it is necessary to study the past if we wish to plan for the future.

The National Transportation Safety Board released their “Safer Seas Digest 2017” in November of 2018 and highlighted major accidents that had occurred in recent years as well as lessons learned from the incidents.

With the new year upon us, it is important to revisit these unfortunate maritime accidents in hopes that they can be avoided in the years to come.

As attorneys, the Houston maritime lawyers at Lapeze & Johns know the importance of precedents as sources of information and guidance. With this in mind, we hope the lessons learned from the following maritime accidents serve as a means to develop a safer industry for maritime workers in 2019.

2017 Maritime Accident Reports to Learn From

1. Capsizing and Sinking of Towing Vessel Ricky J. LeBoeuf
On April 19, 2016, the Ricky J. LeBoeuf tried to remove a barge from a fleeting area on the San Jacinto River, located in Channelview, Texas. Alerts had already been issued warning vessels about unusual high water levels caused by rainfall.

The towing vessel’s company advised the captains against maneuvers like downstreaming, which required using the river’s current to approach an intended object. However, the relief captain of the Ricky J. LeBoeuf decided downstreaming was the best option to approach the barge they needed to remove.

Unfortunately, the current was too strong for the vessel, which was badly positioned, and ended up causing it to be pinned against the barges. The vessel tipped and water entered through open doors causing it to capsize and sink.

The captain’s decision cost the life of one of the five deckhands present.

2. Collision of Cargo Vessel Ocean Freedom with Tank Barges
On October 29, 2015, at the port of Corpus Christi, Texas, the Ocean Freedom was carrying several steel pipes. Once underway, the compulsory pilot indicated that the vessel was “a little bit too much to handle” and would need “a lot of rudder.” This prompted him to ask the mate and bridge team to let him know if he oversteered, since the vessel was a “specialty ship,” having its wheelhouse on the bow instead of the stern.

However, the captain steered the boat in the wrong direction, setting the Ocean Freedom in a collision course with barges being pulled by tugboats. The crew members failed to give warning. The captain realized his mistake too late but was still able to announce through VHF radio of the impending collision.

The incident resulted in structural damage and a tugboat crew member suffered injuries including a broken rib and knee injury.

3. Engine Explosion and Fire Aboard Towing Vessel The Admiral
On July 14, 2016, near Ingleside, Texas, The Admiral, was working on a construction site monitoring a fleet of hopper barges. The vessel was using a 12-cylinder, 2-cycle, diesel EMD manufactured engine, which was overhauled and converted from 567C to 645E. For this reason, the vessel’s company had a very strict manual regarding the engine’s proper maintenance.

Finishing proper procedures for the engine, the first engineer was relieved from his shift by the second engineer. After providing the prescribed care, the second engineer noticed a ticking noise coming from the engine. He waited for the first engineer to return, so he could also examine it.

Both engineers decided to shut down the engine by using the emergency stop button. The engine initially slowed down, then the tachometer went up to 2,452 rpm. They tried cutting the fuel supply, which didn’t stop the engine either. This prompted the first engineer to head for the stairs to halt the emergency fuel supply. Unfortunately, the engine ended up exploding before he was able to do so.

Both engineers were taken ashore to receive medical attention. It was later discovered that the engine explosion was generated by a misfiring cylinder which ignited the engine’s lubricant oil.

The first engineer died from severe burns, the second engineer suffered some severe burns, as well, but survived.

4. The Sinking of the US Cargo Vessel El Faro
On September 29, 2015, El Faro and its 33 crew members cast off from Jacksonville, Florida, heading towards San Juan, Puerto Rico, with vehicles and cargo containers. At the same time, the tropical storm Joaquin was expected to be close to the vessel’s course. The captain had planned to navigate south of the storm in order to avoid it.

However, the weather reports received by the vessel lagged, and the captain favored an incomplete report of the weather conditions. When the tropical storm became a hurricane, the crew continued onward unaware. The first, second, and third mate explained their concerns to the captain about the storm and the weather reports, all suggesting to change course, but the captain rejected their input.

On October 1st, the engineers reported a problem with the main propulsion lube oil pump, causing the vessel to lose propulsion. Then, due to the hurricane generating waves over the usual water level, water came in through an open scuttle, draining all the way down to where the vehicles were, tipping the vessel. The tipping caused the vehicles to shift and get loose, breaking the emergency fire pump, allowing more water to come in.

At 7 a.m., local time, the captain reported to DP a maritime emergency; at 7:30 a.m. the captain ordered everyone into the liferafts. The ship’s record ended at 7:39 a.m.

No crew member was recovered from the incident.

Lessons Learned From These Maritime Accidents

1. Watertight Integrity
Failing to maintain watertight integrity was the leading cause of vessel losses in the 2017 reporting year. In order to protect ships, crew and the environment, vessel owners should always revise and give maintenance to hulls and watertight bulkheads, even during layup periods. Revisions should include the hull thickness, marine coatings, and the use of cathodic protection systems.

If any faults are found, they should be fixed by permanent means. It is also important to make sure all alarms and watertight doors work as they should.

2. Heavy-Weather Operations
Seamen should always be cautious when harsh weather conditions are expected offshore. Even when traveling in a large vessel, mariners must take heavy-weather seriously. An emergency during strong winds, heavy rain, and a stormy sea can risk the lives of the crew.

When dangerous conditions are expected, delaying to get underway and arriving early to port should be strongly considered.

3. Bridge Resource Management
Bridge resource management (BRM) is the proper use of all resources to safely operate a vessel. This includes but is not limited to:

  • Radars
  • Charting systems
  • Watchstanders

One person’s visual cues are not enough to securely guide a vessel. Different weather conditions and hidden dangers like shoal water can mean problems. The collective effort of the watch team and data from equipment reduce any oversight or possible weaknesses.

It should also be noted that the presence of a pilot does not relieve the rest of the crew from their responsibilities and roles dedicated to safely navigate seas. Individual crew members must look over the ship’s position and communicate closely with the pilot and take action to avoid an accident if necessary.

4. Preventive Maintenance
Preventive maintenance is necessary for equipment to continue working properly. Reviewing the equipment often and providing necessary maintenance according to the manufacturer’s manual is important to keep a boat seaworthy.

Ship owners should replace any equipment when needed, and along with operators, must make sure personnel performing the maintenance are well trained.

5. Safety Management Systems
Safety management systems (SMS) are meant to prevent most accidents, injuries, and loss of life aboard vessels. According to the National Transportation Safety Board “an effective SMS has a company safety policy, a risk management program, a safety assurance system, and a safety promotion program.”

  • The safety policy is meant as a commitment to continuously improve safety measures
  • The risk management program is designed to keep up with risk controls depending on the assessment of acceptable risk.
  • The safety assurance system is intended to let crew members know of their roles in case of an emergency.
  • The safety promotion program advances the principle of safety as a core value and ensures every team member works to support it.

Unfortunately, accidents maritime accidents do happen. Our Gulf Coast maritime lawyers want victims of maritime accidents to know that they are not alone.

If you have been injured in a maritime accident contact Lapeze & Johns today at 713-739-1010 for a free case review.