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Precis File
SHIP NAME: Iron King KEY: NUM. ENTRIES: 2
source ATSB
type A
volume
material
dead 0
link http://www.atsb.gov.au/publications/investigation_reports/2008/mair/256-mo-2008-008.aspx#tab_1

At 2142 on 31 July 2008, the fully laden cape-sized bulk carrier Iron King departed from its berth in Port Hedland, Western Australia, with a harbour pilot on board.

Iron King made its way through the harbour and while the assisting tugs had been let go by 2217, just before the ship reached Hunt Point, they continued to escort it. Shortly afterwards, at 2219 and again at 2221ΒΌ, the ship's rudder failed to respond to port helm orders as the pilot attempted to steady the ship's heading on the Spoil Lead.

The master switched the steering control switch between the two follow-up control systems and informed the pilot that steering control had been restored. The ship was still turning to starboard, so the pilot ordered full ahead and hard-to-port in an attempt to keep the ship in the channel and thus avoid grounding. He also directed the tugs to make fast to the ship as soon as possible. However, the tugs were unable to provide much assistance and by 2225, the ship had collided with Beacon 44 and grounded.

The ship remained aground until the next high tide, when it was successfully refloated.

The investigation found that the steering gear failed to respond to the helm orders because a leaking actuator relief valve was limiting the steering system hydraulic pressure. It was also found that; it was normal practice for assisting tugs to be let go before departing ships reached Hunt Point; the pilot directed the tugs to make fast to the ship again, but they were unable to do so before it grounded; the master was not aware of the appropriate emergency steering system change-over procedure; and the pilot had not been provided with training in the implementation of a suite of 'risk analysed' responses to predictable emergency scenarios in a simulated environment. 9108300,161167,81203,IoM,BV,9 holds, Sulzer


source CTX
type C
volume
material
dead 0
link

Usual thorough ATSC report including great graphics and explanation of the rotary vane type steering gear, and why the fact that a single leaking valve could keep the rudder from turning port.

The steering gear is supposed to be totally redundant, but it is not. What interesting about this Porsgrunn steering gear is that the failure --- or just a leak --- of any either of two relief valves can immobilize the system, no matter what the crew does. And there are a bunch of other single component failure modes which at a minimum require the immediate, right response from the crew.

The ATSB makes no real comment or complaint about an inherently flawed design. Nor does it talk about the lack of redundancy associated with single screw/single rudder. Instead we attempt to blame the crew.

The ATSB blamed the Master for only trying to switch between the two control systems, when he should have also tried the non-follow up system, and then shutting down each of the two pumps. But they also admit it would not have made any difference. The Master's error, if it was that, was non-causal.

The ATSB blamed the pilot for not ordering the tugs to reattach at 2219 on the first steering problem even tho at 2219.5 it looked like steering had been restored by switching pumps. The pilot actually ordered the tugs to make fast at 2222.5. The ATSB admit that simulations showed the 3.5 minute difference would not have kept the ship from grounding. The pilot's actions were non-causal.

CTX has no idea what the technobabble about "training in the implementation of a suite of 'risk analysed' responses to predictable emergency scenarios in a simulated environment." means, but it is hard to see what the pilot (or for that matter the Master) could have done differently. Yet the popular press picked this up as an "inadequate training" casualty. This was a mechanical failure, plain and simple.