Lack of safety management system highlighted in the case of the Peter F Gellatly

Peter F Gellatly image source: NTSB. Photo by John Skelson
Peter F Gellatly image source: NTSB. Photo by John Skelson

The National Transportation Safety Board (NTSB) has issued its accident report into the case of the Peter F Gellatly in New Jersey that caused an estimated $2.7 million of damage, which could have been mitigated had there been a safety management system in place. The tank barge Double Skin 501 collided with the International Matex Tank Terminals (IMTT) Bayonne Pier A whilst being pushed by the uninspected towing vessel. In addition, further damage was caused to an adjacent ship, the Isola Bianca. Furthermore, pipelines on the pier were damaged, resulting in the discharge of 630 gallons of fuel oil into the water.

The incident
About 2012 on the evening of the accident, the Peter F Gellatly got under way from the Global Container Terminals (GCT) Bayonne pier en route to IMTT Constable Hook (New Jersey) to pick up the loaded tank barge Double Skin 501. According to crew statements, the towing vessel’s starboard engine was “surging” during the transit, so the captain asked the engineer to investigate the problem. The engineer diagnosed the problem as low fuel pressure and requested to change out the engine’s fuel and air filters while the vessel was stopped in Constable Hook. The captain agreed.

The vessel arrived at Constable Hook about 2026. Over the next 55 minutes, the engine fuel and air filters were replaced and the Peter F Gellatly was made up to the Double Skin 501. The captain told investigators that, during this time, he called the operating company’s port engineer to inform him of the engine problem. The captain was unable to reach the port engineer, so he left him a voice mail.

About 2121, the tow got under way bound for IMTT Bayonne, less than a mile and a half away. As the tow was backing away from the IMTT Constable Hook pier, the captain noted that the tugboat Houma, an assist tugboat owned by the same company, was just finishing a job at a nearby pier. The Peter F Gellatly captain asked the Houma captain if the tugboat could assist with the transit, to which the Houma captain agreed.

The Peter F Gellatly captain told investigators that, after backing out of the berth, the vessel’s starboard engine would not engage in the forward position. At the direction of the captain, the mate informed the engineer, who proceeded to the engine room to investigate the starboard engine control unit. The engineer found the electronic propulsion solenoid switch indicator light oscillating between forward and astern. Normally, only one solenoid would light, depending on whether the engine’s gearbox was engaged ahead or astern.

The engineer told investigators that he examined the solenoid valves but could not identify a problem. He also pushed both control knobs on the end of the solenoid valves with his hand to see if they were stuck.

As the engineer was on his way to report his findings to the captain, he heard and felt the starboard engine re-engage. He assumed that the problem had “worked itself out,” so he did not go to the bridge to report to the captain as originally planned. Instead, he went to the galley to watch television. The captain noticed he had control of the starboard engine and assumed the engineer had fixed the problem.

The captain intended to moor the Double Skin 501 at IMTT Bayonne Pier 1. Just beyond, or to the west, of Pier 1 was Pier A, where the tank vessel Isola Bianca was discharging no. 6 fuel oil. The tanker was moored roughly parallel to the channel at the end of Pier A, with its stern facing east.

At 2140, as the Peter F Gellatly approached the terminal, the captain attempted to slow the tow for its approach to Pier 1. He moved both engine throttles astern, but the starboard engine did not disengage from forward propulsion. The captain told investigators that he did not look at instruments in the wheelhouse, such as the shaft tachometers, that would have showed him both the revolutions per minute of the propeller and the ahead, astern, or neutral position of the propeller shafts. Thus, he did not understand why the tow did not slow as expected. The captain radioed the Houma captain, asking him to place a line on the towing vessel’s stern and to back his vessel down in order to assist with slowing down the tow.

With the assistance of the Houma, the speed of the Peter F Gellatly was reduced to 3 knots as the tow neared the head of Pier 1 at 2144, but the tow was still in danger of colliding with the Isola Bianca directly ahead. In response, the Houma detached from the stern of the Peter F Gellatly, raced ahead, and began pushing on the port bow of the Double Skin 501 to keep the barge from making contact with the Isola Bianca stern.

At 2146, the Peter F Gellatly captain sounded the danger signal. The crew of the Isola Bianca responded with the same signal and shut down oil discharge operations. At 2147, the Double Skin 501’s forward mast caught the two stern lines on the starboard quarter of the Isola Bianca when the barge passed between the tanker and the catwalk that connected mooring stations at the head of Pier A.

When the Peter F Gellatly captain saw the mooring lines snap, he directed the Houma captain to move to the port side of the Isola Bianca and push to keep the tanker alongside the dock. As the Houma backed away, the assist tugboat captain told the Peter F Gellatly captain that he still had prop wash coming from the starboard engine, indicating that the starboard shaft was propelling the Peter F Gellatly forward.

The Peter F Gellatly tow came to a stop after the Double Skin 501 went through the mooring catwalk adjacent to Pier A and hung up on the pier’s main structure. At 2150, the Peter F Gellatly captain shut down his vessel’s engines, stopping the forward force of the tow. Damaged pipelines leading to loading arms on IMTT Bayonne Pier A.

The force of the allision caused pipelines on the west side of the pier to rupture, with one of the ruptured pipelines discharging 630 gallons of no. 6 oil into Kill Van Kull. Damage to the pier, catwalk, and pipelines totaled about $2.7 million. Repairs to the Double Skin 501 foremast, which toppled when it struck the Isola Bianca mooring lines, totaled $10,000. The Peter F Gellatly was undamaged.

Probable Cause
The National Transportation Safety Board determines that the probable cause of the allision of the Peter F Gellatly tow with IMTT Bayonne Pier A was the captain and the engineer’s poor communication, their inadequate assessment of the hazardous condition posed by the starboard engine control malfunction, and the captain’s decision to continue operations without ensuring that the malfunction had been adequately corrected. Contributing to the accident was the crew’s unfamiliarity with the provisions of the company’s safety management system that addressed actions in response to hazardous conditions.

The NTSB has investigated numerous accidents across all modes of transportation where a safety management system (SMS) or similar program could have prevented injuries, loss of life, or material damage. As a result, the NTSB has recommended that marine, aviation, railroad, and highway organizations establish safety management programs.

The key to a functional SMS is a systematic way to identify hazards and control risks while maintaining assurance that these risk controls are effective. The major components to an SMS include the following:
– Safety policy – management’s commitment to continually improve safety; the policy defines the methods, processes, and organizational structure needed to meet safety goals.
– Safety risk management – the determination of the need for, and adequacy of, new or revised risk controls based on the assessment of acceptable risk.
– Safety assurance – management’s system of internal evaluation intended to assure the execution of safety-related measures and to make certain that employees understand their roles.
– Safety promotion – the organization’s promotion of safety as a core value using practices that support a sound safety culture.

Read the National Transportation Safety Board’s report in full: NTSB-Allision-of-Peter-F-Gellatly-Tow-with-IMTT-Pier-A-2017_06

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