When the main engine was operated in engine room control mode, there was no automatic interlock to prevent ‘wrong way’ operation of the engine and no audible alarm to indicate when it was running the ‘wrong way’. As a result, the only system protections to warn the crew of ‘wrong way’ running of the engine were the bridge and engine control room console mounted flashing light indicators.
The company put procedures ain place and installed an audible alarm on the bridge and in the control room.
Newlead Bulkers have advised the ATSB that before the ship departed Port Lincoln, audible alarms were fitted in engine control room and on the bridge to alert the crew to wrong way running of the main engine.
Also, in order to overcome for the lack of system defences, additional standing orders were developed and posted on the bridge requiring the crew member who is in control of the main engine telegraph to not only clearly repeat telegraph orders but also inform the master and pilot of the main engine response in terms of directions and RPM. Additional standing orders were placed in conspicuous place in engine control room requiring an engineer officer to stand at the local controls of main engine (engine side) when entering ports, leaving ports, under pilotage or every time main engine is to be manoeuvred, in order to monitor the visual indicators that confirm the correct engine rotation and report immediately any abnormalities to engine control room.
A thorough investigation was also undertaken by the company’s technical department to examine if similar circumstances existed on other ships in our fleet, e.g. equipped with same or similar type of engine and controls, with the purpose of identifying whether there was a risk of reoccurrence and to introduce the appropriate preventive measures.
The ATSB is satisfied that the safety action taken by Newlead bulkers adequately addresses the safety issue.
