The Weekly Reflektion 10/2024

In all operations there are some tasks that are more important than others since they can have serious consequences if mistakes are made. We need to differentiate between critical and non-critical tasks and have processes in place to ensure critical tasks are carried out properly.

MV Golden Ray after capsize

In your operation are you conscious of what is critical and non-critical?

The MV Golden Ray was a 200-metre long (660 ft) roll-on/roll-off cargo ship designed to carry automobiles. Golden Ray capsized on 8 September 2019 in St. Simons Sound near the Port of Brunswick in Georgia, United States. When she left Brunswick, the vessel was carrying approximately 4,300 brand new Kia and Hyundai cars. After the cargo was loaded the chief officer transferred water from a port water ballast tank in the ship’s double bottom to a starboard water ballast tank, correcting a list from 0.42° to port to 0.03° to starboard.Leaving the port, the pilot ordered a starboard turn and noted the vessel “felt directionally unstable … when I started the turn, she wanted to keep turning” and ordered the rudder be returned to centre, but the vessel continued to turn to starboard and heel over. The vessel’s list reached 60° within a minuteand the ship ran aground. 

The ship’s master previously had ordered the portside pilot door to be opened to prepare for the departure of the pilot. Water began to enter the vessel through the open pilot door, flooding the engine and steering gear rooms, as tugboats pushed the ship out of the deep channel, she came to rest on her port side. All 24 on board survived, four of whom were rescued the day after the capsize by rescuers cutting a hole in the ship’s hull after hearing tapping sounds. Two were seriously injured.

The NTSB (National Transportation Safety Board) held an investigation and found that the probable cause of the capsize was incorrect data entered by the chief officer when he inputballast quantities into the stability calculation program. Thisled to his incorrect determination of the vessel’s stability and resulted in the Golden Ray having an insufficient righting arm to counteract the forces developed during the turn when leaving the harbour. There was no procedure for verification of stability calculations for the vessel. It was also found that two watertight doors had been left open in addition to the open pilot door and it was not ensured that the doors were closed before departing the harbour. The open watertight doors did not play a role in the capsize, but the resultant flooding trapped the four men in the engine room.

The two main recommendations from the NTSB were, the establishment of procedures for verification of stability calculations before leaving harbour, and to ensure adherence to an Arrival/Departure checklist regarding the closure of watertight doors. Both of these were critical tasks and that should have had an independent verification to ensure the safe operation of the vessel.

For critical tasks, do you have a two-barrier philosophy to ensure one mistake cannot cause a disaster?

Reflekt AS