JAPAN P& I CLUBVol.49 December 2020

P&I Loss Prevention Bulletin
The Japan Ship Owners'Mutual Protection & Indemnity Association Loss Prevention and Ship Inspection Department         

P&I Loss Prevention Bulletin
 

........................................................................ 2        

    ....... 5

2-1

Building up a trustful relationship among engine team members................ 6

2-2
2-3

Why is repair/inspection/maintenance necessary?................................. 11
Harmony between technology and human beings:
4M management ............................................................................. 13

2-4

Limitation of human capacity ............................................................. 15

2-5

Error chain: example of an engine accident .......................................... 19

2-6
2-7

What to careful of with repair/inspection/maintenance ........................... 22
When and what should crewmembers evaluate andjudge on board? .............................................................................. 24

2-8

Summary ....................................................................................... 27         
3-1........................ 31

Common recognition of the state of loss of propulsion
and loss of power ............................................................................ 32

3-2

Cases of loss of propulsion and loss of power ...................................... 34

3-2-1 Incident case of loss of propulsion in the US: Incorrect operationof the main engine in the wheelhouse ................................................. 34
3-2-2 Incident case of loss of power in Norway: Inadequate replenishing of systemlubricating oil to diesel generators on an electric propulsion vessel ........... 35
3-2-3 Transport Safety Board investigation reports for Japan: Cases of loss of
power ............................................................................................ 38
3-3

Response to be taken by a ship in the event of an emergency ................ 40

3-3-1 Diesel Engine Plant System ............................................................... 40
3-3-2 Analysis of loss of propulsion ............................................................. 41
3-3-3 Emergency response when loss of power occurs (blackout) ................... 43
3-4

Summary ....................................................................................... 55         !"        

 # $ ........... 56

4-1

Importance of preserving evidence in time of bunker trouble ................... 56

4-2

Summary ....................................................................................... 63 %&& '(     

 ....................................... 65

5-1
IMO 2020 compliant fuel oil concerns ................................................. 66
5-1-1 Production of marine fuel oils ............................................................. 66
5-2
Precautions and countermeasures for safe usage of 2020 IMO
5-2-1
5-2-2
5-2-3
5-2-4
5-2-5
5-3
5-4
5-4-1
5-4-2
5-4-3
5-5

compliant fuel oil.............................................................................. 69① Compatibility ............................................................................... 71② Low viscosity .............................................................................. 75③ Cold flow properties ..................................................................... 82④ Cat-fines (FCC catalyst particles) .................................................... 88⑤ Ignition and combustion quality ...................................................... 92
Countermeasures for the safe use of cylinder oil ................................... 97
Onboard check ............................................................................... 99
Diagnosis of Compatibility ............................................................... 100
Diagnosis of cold flow properties ...................................................... 101
Assessment of ignition quality .......................................................... 102
Summary ..................................................................................... 103

 )  ...................................................................... 104*  '  ......................................................................... 106
Reference Material 01:
Ability diagnosis of onboard work performance: Main Text P. 7 ........................ 106
Reference Material 02:
Under what circumstances does an error occur?: Main Text P. 16 ................... 108
Reference Material 03: Problem Solving Method: Main text P. 21, P. 42 ............ 111
Reference Material 04: Details of Power Loss Accident in Norway:
Main Text P. 35 ........................................................................................ 116
Reference Material 05:
The investigation reports of the Japan Transport Safety Board: cases of loss of
power: Main Text P. 39 ............................................................................ 119
Reference Material 06:
Emergency response checklist immediately after loss of propulsion and loss of
power: Main Text P. 45 ............................................................................. 125
Reference Material 07: How to prevent panic: Main text P. 55 ......................... 127= References = ...................................................................................... 131
Author ................................................................................................... 140

1

Chapter1

Introduction

In previous seminars and loss prevention bulletins, we introduced the following themes:
・the causes of marine casualties/incidents,
・the reasons why similar types of marine accidents continue, and・the recommended measures needed to prevent a reoccurrence.
A brief outline of each is given below.

The root cause of marine casualties/incidents:
A Chain of Human Errors.

The reasons why similar types of marine casualties/incidents continue:
While it is impossible to prevent human errors completely, in the past, those involvedin safety management and many shipowners/management companies have taken
measures to prevent recurrence from a technical perspective because they assumed
that the cause of casualties/incidents was mainly due to the chain of errors that
surfaced as a result of technical issues. Previously, the parties who were directly
related to the casualties/incidents were punished and the case was closed.
However, with this method, the possibility of the same kind of accident reoccurring
is apparent, since we have not analyzed the root cause as to why experienced
crewmembers and marine engineers generated human errors that could lead tocasualties/incidents.

2

Recommended measures to prevent a reoccurrence:
We need to analyze the human behavior characteristics of the person who causedsuch errors: the root cause, the psychological factors, and human capability/
limitation, to establish an environment that eliminates them.
When focusing on the root causes of a ship’s machinery failure and incidents, itappears that most cases are the result of management problems regarding oils (fueloil and lubricating oil) and inspection/repair/maintenance work that was not properly
performed. However, the engineers and their crewmembers in the engine department
tend to pursue the cause as to whether there is any abnormality regarding mechanical/
electrical engineering integrity and soundness in design/manufacturing, such aswhether the engine machinery/equipment itself is working and running normally or not.
Regrettably, it is often the case that reoccurrence preventive measures, such as thosementioned above, tend to get neglected or forgotten.
In this guide “Tips for Effective Engine Management and Maintenance” we haveincluded all of the key elements taken from our open seminars that were held in Japan in
2019.
Mr. Osamu Hayashi, a yobikō (university prep. school) lecturer, known for his famousphrase “Ima desho! (Do it now!)” explains that the common causes of historical failuresand defeats are “conceit, preconception, and a lack of information”. We should view
them as human behavioral characteristics. Therefore, we recommend that ship owners/
ship management companies, in particular, recognize human behavioral characteristics
as a threat. We wish to emphasize the importance of ① “supporting human resources”
and② “being prepared for panic”. By cooperating with the vessels and those who

man them more eﬀectively will lead to successful teamwork. It is hoped that the key
points raised in this bulletin will assist and promote prevention and the reoccurrence of
casualties/accidents.
Please refer to the following loss prevention bulletins on human behavioral

3characteristics, psychological factors, and human capability/limitation that contribute to
the root causes.

JAPAN P& I CLUBVol.35 July 2015

P&I Loss Prevention Bulletin
The Japan Ship Owners Mutual Protection & Indemnity Association Loss Prevention and Ship Inspection Department

Thinking Safety
Bridge Resource Management and Engine Room Resource Management+ ,%Thinking Safety – Bridge Resource Management andEngine Room Resource Management(Issued in July 2015)

JAPAN P& I CLUBVol.46 November 2019

P&I Loss Prevention Bulletin
The Japan Ship Owners'Mutual Protection & Indemnity Association Loss Prevention and Ship Inspection Department

A Psychological Approach
to Safety Behaviour+ ,)A Psychological Approach to Safety Behaviour(Issued in September 2019)

JAPAN P& I CLUBVol.47 March 2020

P&I Loss Prevention Bulletin
The Japan Ship Owners'Mutual Protection & Indemnity Association Loss Prevention and Ship Inspection Department

A Psychological Approach
to Safety Behaviour
Continued...

+ ,-A Psychological Approach to Safety Behaviour Continued(Issued in March 2020)

4

Chapter2

The importance of repair/inspection/maintenance

The following are the fundamentals of repair/inspection/maintenance and are
empirically said to be the lifelines of the engine department.

The management of Oils (fuel oil and lubricating oil)
The grasping of machinery working status/appropriate maintenance(especially the fuel supply system)

ERM (Engine Room Resource Management) was stipulated as a requirement
following the revision of the STCW Convention (International Convention
on Standards of Training, Certification and Watchkeeping for Seafarers) in2010. The requirement specifies the standards of navigational watchkeeping
needed in accordance with the Mariners Act in Japan. The standard goes on to
explain that crewmembers must surely implement what has been traditionally
important/necessary regarding technical knowledge and maintenance methods
that are the fundamentals of engine management. To reliably realize this, crew
members must utilize all of the engine department’s resources and cooperatewith one another, communicate with the engine team effectively, and makesure that work on planned maintenance is carried out along with continuous
condition monitoring while keeping up to date with training. Therefore, repair/inspection/maintenance is closely linked to ERM.

5

It is also recommended that not only the crewmembers on-board, but also thatthe shipowner/ship management company consider the following to achieveeﬀective engine management in addition to mechanical/electrical engineering
technical theory:
It is essential to respect the “positiveness and faithfulness” of humans.
It is necessary to be mindful of “supporting human resources” paying particularattention to the fact that “people have limitations”.

2-1 Building up a trustful relationship among
engine team members
Figure 2-1 is one of the posters that we
issued in early 2019 to promote safety.
There may be a gap between what
the “boss” expects (conceit and thepreconception) and what the “younger
crewmember” may understand (a lackof information). The poster reminded
the author of one day when he waslooking around the engine room forsomething, about 30 years ago when
he first boarded a ship. Have you everexperienced something similar to thescene in this poster?
Social and economic development
is now stable following a period of
rapid economic growth after world

6

Figure 2-1 4th Engineer gets lost and struggles

war II, the collapse of the bubble boom economy in 1991 in Japan, and the 2008 Global
Financial Crisis. As a result, while our freedom to think and diversity, and ability tochoose are respected, there is the concern that humans have become vulnerable to stressin social situations due to such respect and sensitivity towards individual rights.
However, life onboard a ship is still sometimes considered backward with a system thatremains straitjacketed and hierarchical. If experienced crewmembers teach younger
crewmembers in an old-fashioned manner with conceit and preconception, it may be
too overwhelming for younger crew members. This may scar them mentally and it
may take some time for them to recover. Therefore, to create a sustainable workplace,experienced crewmembers should be aware of the fact that younger crewmembers are
more vulnerable to a stressful environment, particularly when under the supervision ofexperienced crewmembers. Given these circumstances, experienced crewmembers alsoneed to acknowledge this and take a more flexible approach, for example:① To compliment younger crewmembers whenever possible② To not give ambiguous instructions to younger crewmembers③ To create a safe space and environment where younger crewmembers canconcentrate④ In order to support younger crewmembers, experienced crewmembers
need to be aware of what they need to know, and not pressure them

It is recommended that the senior engineers conduct an extensive and comprehensive
diagnosis of each crewmember in the engine department as early as possible, so as tobe able to approach younger crewmembers appropriately. Please refer to “Referencematerial 01: Ability diagnosis of onboard work performance” (Page 106).
It is difficult to build up a trustful relationship in the engine team under vague
circumstances, i.e. an attitude of conceit, preconceptions, and a lack of information
will hinder a trustful relationship. To prevent this, as shown in Figure 2-2, experienced
crewmembers and younger crewmembers should establish a sense of unity.

7

・&  " 
・&  " 0  " "    ・        ・.    ・.1      


⇨



       

  ⇨ 

・#        ・$  ・%       "    ・&  '  ・(     ・) *   ・& + * ・,      " ・  *     "  " " ・&   "   "
・.    ・/       ⇨  

" -           

                  !   "   "    "    "   "
            Figure 2-2 On building a better team

Therefore, the experienced crewmembers need to utilize 6 capabilities effectively tobuild a trustful relationship with younger crewmembers who have a diverse way of
thinking, especially when they work on onboard operations that require organizational
control and discipline.
The 6 capabilities are “trustworthiness, principles, ability to evaluate, ability tocommunicate, achievement, and autonomy”.

8          


 





 



 ：Self-protection makes for a weak leader.

Don’t be dismissive.
Support those under your leadership.
Be true to your word.

    ：Rules that follow a vision are strong.
Have a clear vision.
Decide how the team should be.
Breaking the rules is a joint responsibility.
Create rules to prevent mistakes and gaps.
Eliminate the contradiction between words and actions.

9    ：An absolute appreciation of roles is motivating.
It is not necessary to be biased (unfairly kind).
It is important that everyone develop strong resilience.
It is necessary that everyone be aware of their role.
Investing in the education of younger personnel under your leadership is
ideal.

    ：Was the information “understood” rather

than simply “transmitted”?
Always encourage them to leave their comfort zone and make sure thateverything is absorbed.
Use repetition if you want to be understood.
Don’t communicate with uncertainness.
Share the best and ultimate achievements.



 

 ：A mechanism that allows a team to exert its

greatest performance.
Leaders must work harder than anyone else.
Keep going no matter the outcome.
Consider the result an “opportunity to learn” that will strengthen younger
personnel under your charge.
Face and respect your younger personnel as individuals.
Create an updatable and readily accessible manual.

  ：Create an environment that encourages those under

your charge to act of their own accord.
Create a safe work environment.
Encourage newcomers to emulate others.
Real leaders win over both superiors and those under their charge.
Endurance is key to success.
10

If you try to control your those under your charge by downplaying them, you will likely be
repulsed and may face diﬃculties in building a strong team. In other words, if you do notrespect those working for you, they may never listen to you and may never cooperate.
In short, it is important that “one does not lie, does not make excuses, and does notbetray their team”. Namely, “do not betray others to save face”.
Based on this, if the mutual understanding of values between the two parties createscooperation and empathy, the engine department can build the most robust teamwork
and obtain high-quality work results.
Shipowners and ship management companies tend to tighten the SMS (Safety
Management System) as a countermeasure for casualties/accidents. However, it should
not interfere with the teamwork of the crewmembers.

2-2 Why is repair / inspection / maintenancenecessary ?
The author attended a seminar on the human factors surrounding aeronautical engineers,which included many hints that could be considered applicable for onboard work in aship’s engine department.

Tips that can be applied to a ship’s engine department
The aviation field considered human characteristics and capabilities carefully in aircraft
design to eﬀectively improve manoeuvring operations. This is where an understanding of
human factors first began. Besides, even in recent years, even though aircraft technology
has advanced to a high degree, it is dependent on humans to a large extent, so it isextremely important to understand human behavior characteristics and to align themwith machines to improve overall system safety. The author would like to focus on the
background of a more profound recognition of human factors.
Figure 2-3 shows the “biggest threat” to aircraft and ships, two main forms of transportation.
11

On an aircraft, if the aircraft gets damaged or there is engine failure due to “human” error
with repair/inspection/maintenance or if it is manoeuvred incorrectly, “gravity” will cause it
to crash.
On a ship, if a ship sustains damage to the hull or the main engine stops because of “human”
error similar to the above, a marine casualty/accident occurs because the “water (sea)”causes instability, inconvenience, and isolation.
Therefore, both forms of transportation have the same phenomena in common, that is, thebiggest threat is “human beings”.
Aircraft and ships are inspected before commencement of operation to ensure that they
have been designed and built in accordance with the rules and regulations and that they areoperated correctly. On passing, a certificate is issued. This is then proof that an aircraft is
airworthy or that a ship is seaworthy.

        
          
  
Figure 2-3 What is the beings threat?

The carrying out of repair/inspection/maintenance is to “maintain the inherent
airworthiness and seaworthiness” of an aircraft or ship. Besides, it is just this “essential
positive action” that enables “humans” to discover defects or problems within
machinery. However, because “humans” work on this machinery directly, and let us
remember that “humans” pose the greatest threat, it is recommended that experienced
crewmembers always reconfirm just what “repair/inspection/maintenance” is and make12