ANDREA S

Each towing vessel must have reliable means to provide notification when an emergency condition exists or requires attention. Attending IO/MI's confirmed that no alarm for main engine and auxiliary generator low lube oil pressure and high cooling water temperature was observed from the operating station or the engine room on 15MAR2022. Additionally attending IO/MI's witnessed the on-line running generator with all alarms disabled. 46 CFR 143.230

The company's Towing Vessel Planned Maintenance Procedures, (VMP-003) Paragraph R, requires vessel personnel to notify the Operations Department and complete a Risk Assessment Form prior to systems shut-down, bypass or otherwise taking a critical system out of service. Objective evidence attained by the attending IO/MI's concluded that this dialog between the vessel crew and operations never occurred. Additionally, the crew interviewed were unfamiliar with this company instruction and the terminology of "Critical Equipment" and "Risk Assessment Form" confirming that the crew is unfamiliar with the Towing Vessel Safety Management System (TSMS). 46 CFR 138.205, 46 CFR 138.510

Immediately after addressing the resultant safety concerns, the owner, agent, master, operator or person in charge, shall notify the nearest Coast Guard Marine Inspection Office whenever the vessel is involved in a marine casualty consisting of an occurrence causing property damage in excess of $75,000. This marine casualty scenario began to unfold around 0830 on March 15th and notification was made to the Coast Guard at 2038 of the same day. 46 CFR 4.05-1

The Company has a Safe Work Instruction titled "Main Engine Oil Change" that outlines engine Operational Status, Safe Temp, and PPE required. The crew member who changed the engine oil failed to adhere to this SWI, causing a catastrophic failure of the STBD main engine. 46 CFR 138.510

The TSMS must contain a method to ensure all levels of the organization are working within the frame work: Procedures for an owner or managing operator to evaluate that they are following their own policies and procedures and complying with the requirements of this sub-chapter. Crew is familiar with the "TAKE 5" risk analysis tool, however it hasn't been used consistently and tracked. One crew member interviewed has transited through locks on the river more than 20 times and never reviewed the procedure for locking located in the TSMS.46 CFR 138.205 (b)(3)

Machinery and electrical systems must be designed and maintained to provide safe operation of the towing vessel and safety of persons on-board under normal and emergency conditions. The starboard main engine tachometer pick up is being held in place by a pair of vise grips. 46 CFR 143.205 (a)

Vessels Port MDE shut down due to something getting caught in the wheel.