Human Error to Blame for ‘Majority’ of Auxiliary Engine Damage Claims -Marine Insurer


#1

Human Error to Blame for ‘Majority’ of Auxiliary Engine Damage Claims -Marine Insurer

the majority of all damage takes place immediately after maintenance work. A key finding is that 55% of casualties occur within only 10% of the time between overhaul (TBO), corresponding to the first 1,000 hours or so of operation after overhaul. In most cases the damage occurs only a few hours after start up.

The human that makes the error is the PE that failed to send a qualified tech to the ship if required.


#2

Looks like the insurer has rediscovered the phenomenon known as “infant mortality” in the aviation business. Extensively studied; see:

www.faa.gov/aircraft/air_cert/design_approvals/csta/publications/media/risk_analysis_corres_course.doc

or google on “infant mortality aircraft engine”

Often used as a justification for a “run it until it breaks” policy by corner-cutters.

Cheers,

Earl


#3

In most cases the damage occurs only a few hours after start up.

Need to know the percent of failures a few hours after start up when the overhaul is done by crew compared to percent when done by qualified techs.

startup failures with overhaul by crew / by qualified techs = somewhere between 10 and 100


#4

Agreed. I was just a bit surprised that an insurance company would appear unfamiliar with the phenomenon of infant mortality in engines.

Cheers,

Earl


#5

It’s a new one on me, it’s a good one. Can’t wait to use it on the chief and then feign surprise when he doesn’t know what it means. My chief is pretty quick however, he might turn the tables on me.


#6

There’s also a “bathtub curve” of failures in electronics, where a high rate of early failure falls to a low stable rate and then increases again at end of life.


#7

Ah, behold the capacitor and the effects of heat and time.


#8

True, but also conditions inside integrated circuits can be much more severe than people realize. I seem to remember current densities of one hundred kiloamps per square centimeter being mentioned.


#9

@dbeierl you just blew by over my head. The only current densities I know about are in the carbon brushes on my DC motors! I am fortunate enough to work with some gifted ET’s who can troubleshoot and repair down to the component level on old analog type boards - think Baylor Thyrig units. It has become somewhat of a running joke that the failures are in large proportion related to capacitors (even on the fancy newfangled electronic equipment). So much so that no matter what we are working on electrical or mechanical, someone is sure to blame a capacitor. Guffaws ensue. Well maybe you had to be there.


#10

Electrolytic capacitors are always a weak link, and some years ago there was also a severe problem with faulty and/or counterfeit small electrolytics on computer boards.

A hundred kiloamps/cm^2 is the same as putting 825 amps through your table lamp cord.


#11

During one of my ill-fated attempts at shoreside employment I was associated with the effort to bring a CMMS to the great good MSC fleet. This was when their computers were Zeniths and discs were actually floppy. Part of that experience was attending some conferences of maintenance managers and early developers of CMMS software and once such talk presented as fact that 80% of corrective maintenance was caused by preventive maintenance. In other words maintenance induced failures. I don’t know if they got the proportion correct or not (it appears very high to me) but it appears the phenomenon is measurable.

That appears to be the gist of infant mortality described above. For example changing a bearing in advance of its expected life and thinking that you will automatically reset the expected life to the maximum is not something you should count on for wide range of reasons including the quality of the replacement part and the quality of the workmanship. That is assuming you are basing your planned action only on running hours or other interval. For the most part (and I can think of very specific counter examples) unless you are basing your action on some vibration or noise measurements you may be disappointed in the results.

This is not meant to devalue all calendar or running hour maintenance. Just that experience should temper the default “manufacturers recommendations” or bright ideas from the office. In certain quarters the initial maintenance plans are taken as gospel and even suggesting changes is met with irrational push back and essentially wasted man-hours either pencil whipping tasks or rote performance of meaningless tasks (if its not broke now it will be soon after some well intentioned crew member tightens a foundation fastener to its yield strength) while for example, fire dampers go under-maintained.

Returning to the article in the OP and downloading the “investigation report” does little to technically enlighten either shipboard or experienced port engineer. It does seem well suited for the new generation of shoreside support staff to justify any of tens (hundreds?) management of change documents to add to shipboard misery. I’m sure it made the technical section at the Swedish Club feel better about things too.

Honestly, reading the “essentials” on page two is about as far as you need go to see where its headed. Aw heck here it is to save you wasting your bandwidth downloading it.

How to avoid auxiliary engine damage

Ensure you have the necessary knowledge and experience
before commencing any overhaul work.

If you have not received training on the specific engine
model, consider engaging an expert from the manufacturer.

Always strictly follow manufacturer’s instructions.

During overhaul, check and double check that stud bolts for
connection rods and bearing keeps are tightened 100% in
accordance with manufacturer’s instructions.

Ensure that required tools are available and calibrated as
necessary.

Regularly monitor the quality of your lubrication oil and take
prompt action when irregularities are detected

Here is another gem.

Whilst prevention is always the best cure, steps can be taken to mitigate the damage caused by failure of the auxiliary engine. Most modern auxiliary engine installations can be started and stopped remotely from the engine control room. It is good practice to always be present at the engine when starting same, especially after longer periods of still-stand and after overhaul. During start-up, if anything goes wrong, it usually happens very quickly. If someone is present at the engine there is at least a possibility to intervene and shut down the engine manually.

Again, honestly who is going to sea these days?

What is the bar set at for publishing this sort of thing?

Anything else you want to add? Don’t run with scissors? Don’t stick screwdrivers in electrical outlets (Sorry Mr. Cavo)

It’s not that any of this is not true, it’s that they seem to aim it squarely at shipboard staff and frame it as a deficiency of theirs. What about ship management? Who hires such a unqualified crew then keeps them in place when not performing adequately? Who implements and monitors a lube oil analysis program? Who approves or even insists on calibration of instruments and tools? You’re a ship manager how about git to managing.

The analysis is an inch wide and a millimeter deep (to intentionally mix system of units). Do tell us more. How about claims by owner, fleet, class of ship. Or by make/model of engine. Maybe this uptick was all due to one or two substandard owners or poor selection of equipment.

Now on the other hand perhaps it can be used jujitsu style to use their own weight against them to recommend advanced makers training for all hands in order save them cost of future deductibles on future claims. Road trip!


#12

They forgot “Do not put damage control plugs in pump weep holes” and “If you did put a damage control plug in a pump weep hole, take it out”.


#13

I have to say KPC that sometimes this stuff is very valuable. In the real world the signal to noise ratio is sometimes not so good.

One thing the chief and I have learned is you have to have a simple message and keep pounding it home. Short and true makes a potent tool. Works both crew side and shoreside.

  1. the message
  2. the story of the screw-up
  3. the message again

#14

Well I’ll take your point that there is something to having a simple message but even that depends on your audience. Having a simple message is one thing and having a useless one is another. So the way I’m looking at this particular “announcement” and “repot” is like this.

These guys have 2295 ships under cover of H&M. They have some kind of in-house technical department, loss control people and no doubt access to various experts. And my opinion is they could have done better than this. In fact they could take their own advice at section 6.2, Do it right - or don’t do it at all.

Even using your guidance for lessons learned type transfer of experience might a better format have been to publish individual bulletins per claim (or a few representative claims) showing clearly what went wrong? And maybe even look at it with a systems approach and not a swiss cheese approach?

Of the 192 AE claims they state:
58 cases of conn rod bolts not assembled correctly
27 cases LO contamination
25 cases incorrect maintenance and procedures
16 cases Overspeed
4 cases due to latent defects
(yup that only adds up to 130 but presumably the 62 other cases are so widely varied as to not be deemed worthy of analysis)

58 cases of not assembling a connecting rod correctly is indeed a sobering statistic. These are the points they raise under that topic:
*Improper tightening of bolts
*Hydraulic tool/pump not calibrated
*Lack of crew training and adherence to procedures

So far so good. Now it would be nice to have some detailed bulletins about not only what went wrong on the deck plates but looking all the way back up the technical chain of command, ISM system in place and corporate engineering culture. Were all the resources available to the CE at the time? Did he request items not delivered? Were these emergency repairs or part of routine overhaul? Under what conditions (rushed by schedule, in heavy weather) were the repairs carried out? How rushed or complete was the planning for the job? Oh I’m a big one for planning, don’t get me started.

Might it be better to present a few cases examined thoroughly and presented capably. The old " tell them what you’re going to tell them - tell them - tell them what you told them" model.

The 30,000 foot view they put out is aimed at the office. Once they get it (and especially if they were one of the companies with a claim) stuff will start to roll down hill. I’d be willing to bet they are not going to have a ah-ha moment become self-actualized do some soul searching and ask themselves how did we go wrong in supporting the ship. True I’m just speculating but I’m inclined to think the office thought process will be - look what went wrong on the ship, how can things be so wrong on the ship, can I develop (in a vacuum) a new set of constraints, warnings, cautions, revise documents on the ship to prevent this?

Will they ask did I set the CE up for success or just set him up? Not sure that will cross their mind. Doesn’t seem to work that way anymore.

EDIT: I’m spending more time on the Swedish Club website trying to find information about the ships they cover, flag, operating companies etc, but that doesn’t seem to be public information. At any rate would like to make it clear my comments are applicable to the report in question, its utility and the way it is presented by other sites not on the effectiveness of the club in general.


#15

I agree 100% with your post.

Of course you and I are on vastly different levels regarding what we know about generator overhauls as well as the nature of what we know.

However I still sometimes have a requirement to communicate what I know about generator overhauls. But if I tried to tell you what I know, it’d be ugly.

But if I can start with this, I can say this matches what I know almost exactly. I, as captain, couldn’t do better than this.

So when the chief and I fight with the PE about this, this represents shared agreement, at least it’s a place to start.


#16

There are some people good at wrenching and some not.
There are some who’ll know they may be in over their head and ask for help and those that won’t.
some got “the right stuff”… others never will.
everybody is good at at least one thing!


#17

I think in terms of crew and probability, are the chances of this crew successfully doing a job acceptable or not? What can I do to improve the odds?

Good chief will give me good advice, bad chief will bullshit me.


#18

If you can’t dazzle 'em with brilliance, baffle 'em with bullshit.


#19

That’s why info like this is helpful for me, maybe not so much for an experienced chief.


#20

These types of documents and “reports” are written by office people, for office people. The need to justify travel and time to go to some fancy “conference” to get out of the cube farm and present “amazing” information like these figures of aux engine damage. Mind you, these figures and failures are readily known to a competent operator that has “done the time” with real experience and also keeps up on industry trends/technology/standards/findings.

I’ve read nearly identical articles to this over the last 20 years. Infant mortality and failure after maintenance activities are well known to be a major cause of extensive equipment damage. But these bureaucrats that sit in the office need to justify their duties and pat themselves on the back for “discovering” new data…just like millions of masters and PHD students write dissertations each year regurgitating well known information…it’s all merely entropy of information.