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and indentations in the hull plating in the bow area. There was no pollution and the ship later re-entered the port where it underwent temporary repairs before resuming its voyage. It later entered a dry-dock in China to effect permanent repairs. COMMISSION FINDINGS The Commission in its findings reported: • The automatic main engine slow down and shut down events were caused by a high cooling-water temperature that was most likely caused by a malfunction of a three-way valve used to regulate the temperature of the cooling water. • The Hanjin Bombay's main engine automatically shut down after the vessel was established in a turn into the No.2 Reach, which left the vessel with insufficient steering control to overcome the momentum of the turn and prevent it leaving the channel and grounding. • The facility was available both on the bridge and in the engine room to override the automatic main engine shut down, which might have resulted in damage to the main engine but would probably have prevented the vessel running aground. • Better communication about the developing situation within the bridge team and between the bridge and engine room could have prevented the Hanjin Bombay grounding; through better use of engines, tugs and anchors. • Damage sustained: The hull of the vessel set in and penetrated in way of No.1 port-side water ballast double-bottom tank between frames 179 and 181. The vessel's hull and internal framing was damaged between frames 174 and 195. Key lessons from the inquiry included: • Vessel crews must have a thorough knowledge of their vessels' operating systems if they are to deal effectively with abnormal situations. • The concept of crew resource management must extend to all operational areas on a vessel, and in particular must result in a common understanding of the voyage plan and good communication between bridge and engine room. • The level of tug assistance given to vessels when transiting narrow channels needs to be commensurate with the level of risk and should be decided on the basis of reducing the risk to as low as reasonably practicable. • Shipboard operations must be conducted using an agreed common language that everyone can understand. Crew members lapsing into their native tongue during an emergency is a breakdown in communication that can seriously hinder any response to deal with the emergency. The Commission made recommendations to the director of Maritime New Zealand that the number of defects causing incidents and accidents in the New Zealand pilotage waters was of concern. The Commission stated that minor technical defects and human performance issues are often lead indicators of deeper systemic safety issues on board a vessel. If these issues of mechanically unreliable vessels and substandard crew resource management on vessels operating in New Zealand ports are to be addressed it would need to be done at a national level. The Commission recommended that the director of Maritime New Zealand consult port and harbour authorities and the New Zealand Maritime Pilots Association to develop a formal system for port and harbour authority employees to report vessel defects and crew performance issues. The purpose of the system would be to make information immediately available to maritime employees who can use the information to improve the safety of pilotage operations at subsequent ports – but not to replace the mandatory reporting of accidents and incidents. Maritime New Zealand responded that it had previously commented on the distribution of notifications and has monthly accident and incident summaries which are posted on the MNZ public website. MNZ understands that information about incidents is routinely passed on to pilots and MNZ personnel at the next port of call and that there is no need to formalise the process. The Commission also recommended that as vessels' machinery installations and control systems are complex, there is always the possibility that some part may fail. For a vessel like Hanjin Bombay with only one propulsion system, the risk of losing control of the vessel caused by a single-point failure is higher than for other vessels. These types of vessels rely heavily on tug services when operating in confirmed pilotage waters. Port of Tauranga Limited's Port and Harbour Safety system policy on the level of tug service did not adequately manage the risk of single-point failures leading to the loss of control of a vessel. The Commission believed this is to be a safety issue that could be relevant to other New Zealand ports. VIP.S69 V VI S94 VIP.S94 Specialist manufacturers of marine aluminium windows and doors www.skipper.co.nz 11 Finlayson St, Whangarei. www.seamac.co.nz Ph 09 438 6884, Fax 09 438 6852, Email sales@seamac.co.nz September/October 2013 Professional Skipper 81