Marine Accident Investigation Branch (MAIB) - Safety Digest Contents 1. FAILURE OF A LIFEBOAT WINCH ....................................................................3 Narrative .........................................................................................................................3 Observations ...................................................................................................................3 Comment.........................................................................................................................3 2. FOUNDERING OF TUG HIGHLIGHTS POOR MANAGEMENT PRACTICES 4 Narrative .........................................................................................................................4 Observations ...................................................................................................................4 Comment.........................................................................................................................5 3. ENGINE-ROOM FIRE DUE TO FUEL OIL LEAK.............................................6 Narrative .........................................................................................................................6 Observations ...................................................................................................................6 Comment.........................................................................................................................6 4. CREWMAN INJURED BY REVERSING TRAILER ON RO-RO VEHICLE DECK 7 Narrative .........................................................................................................................7 Observations ...................................................................................................................7 Comment.........................................................................................................................7 5. GROUNDING CAUSED BY SLEEPING WATCHKEEPER ..............................8 Narrative .........................................................................................................................8 Observations ...................................................................................................................8 Comment.........................................................................................................................8 6. ENGINE-ROOM FIRE ONBOARD A SMALL BULK CARRIER...................10 Narrative .......................................................................................................................10 Observations .................................................................................................................10 Comment.......................................................................................................................10 7. INEXPERIENCE LEADS TO FINGER INJURY OF ENGINEERING CADET11 Narrative .......................................................................................................................11 Observations .................................................................................................................11 Comment.......................................................................................................................11 8. BATTERY EXPLOSIONS CAUSE INJURY TO SHIP'S OFFICER ...............12 Narrative .......................................................................................................................12 Observations .................................................................................................................12 Comment.......................................................................................................................12 9. FATAL ACCIDENT ON A SMALL PASSENGER VESSEL ............................13 Narrative .......................................................................................................................13 Observations .................................................................................................................13

Comment.......................................................................................................................13 10. DANGEROUS OCCURRENCE CAUSED BY TOW ROPE PARTING ........14 Narrative .......................................................................................................................14 Observations .................................................................................................................14 Comment.......................................................................................................................14 11. ENGINE-ROOM FIRE ON SMALL PASSENGER VESSEL..........................15 Narrative .......................................................................................................................15 Observations .................................................................................................................15 Comment.......................................................................................................................15 12. OFFICER KILLED BY LACK OF OXYGEN...................................................17 Narrative .......................................................................................................................17 Observations .................................................................................................................17 Comment.......................................................................................................................17 13. EXPLOSION AND FIRE IN BOILER WHILST ALONGSIDE LOADING FUEL OIL CARGO.........................................................................................................................18 Narrative .......................................................................................................................18 Observations .................................................................................................................18 Comment.......................................................................................................................18 14. DIVING EQUIPMENT FIRE...............................................................................19 Narrative .......................................................................................................................19 Observations .................................................................................................................19 Comment.......................................................................................................................19 15. ACCIDENT WHILST MOORING ALONGSIDE A VESSEL ........................20 Narrative .......................................................................................................................20 Observations .................................................................................................................20 Comment.......................................................................................................................20 16. LOSS OF OLDER WOODEN FISHING VESSEL............................................21 Narrative .......................................................................................................................21 Observations .................................................................................................................21 Comment.......................................................................................................................21 17. FATIGUE CAUSES GROUNDING OF TRAWLER ........................................22 Narrative .......................................................................................................................22 Observations .................................................................................................................22 Comment.......................................................................................................................22 18. MAJOR INJURIES TO FISHERMEN DURING HEAVY WEATHER.........23 Narrative .......................................................................................................................23 Observations .................................................................................................................23 Comment.......................................................................................................................23 19. LIFERAFT AND FLARES SAVE A 10 METRE FISHING VESSEL CREW24

Narrative .......................................................................................................................24 Observations .................................................................................................................24 Comment.......................................................................................................................24

1. FAILURE OF A LIFEBOAT WINCH

On completion of a routine lifeboat drill the lifeboat was being raised using the winch motor. A total of five persons remained in the boat. It was decided to stop the operation before the lifeboat reached the housed position to allow some adjustments to be made to the bowsing tackles which were made fast at both ends. Tricing pendants were not used.

Once the boat had reached the desired position the winch motor was stopped. The winch immediately started to run back, lowering the boat until it came to rest against the ship's side with its weight taken only by the bowsing tackles.

All five persons in the boat were evacuated without injury.

A test was later performed, with no personnel in the lifeboat, during which the winch again ran back after the hoist motor was stopped and despite the application of the manually operated brake. This time the lifeboat continued to lower, under the influence of the centrifugal brake, until it reached the water.

Subsequent inspection of the winch established that the one way clutch unit showed signs of damage due to overheating and had been filled with oil of too high a viscosity.

Observations The one-way clutch in this type of winch is required to lock during boat lowering operations in order to connect the manual brake to the rotating parts of the winch. A defective clutch renders the manual brake ineffective. However, while the lifeboat is being hoisted using the winch motor the one-way clutch is intended to run free. Hence a slipping one-way clutch is apparent only when attempting to apply the manually operated brake during a lowering operation.

Comment The type of one-way clutch employed in this winch consisted of spring loaded rollers, trapped in converging channels, within a cylindrical casing. Oil of excessive viscosity would have the tendency of generating a dynamic film of lubricant between the rollers and cylindrical casing, so preventing the rollers from "locking". Further, should the clutch be operated for any significant time in this way, overheating could occur causing damage to the unit.

Manufacturer's recommendations on the grade of lubricating oil for these units should always be followed.

2. FOUNDERING OF TUG HIGHLIGHTS POOR MANAGEMENT PRACTICES

A tug of 22 metres registered length was towing a crane barge on the ebb tide downriver towards an anchorage. A flat top barge was secured alongside the crane barge. Both barges were unmanned. The weather conditions were fine and clear and the wind was force 4. A small workboat was secured alongside the tug.

The Skipper of the tug intended to anchor the crane barge using a running moor. On approaching the anchorage, the workboat transferred crewmen from the tug to the crane barge and then stood by to render assistance as required. The Skipper turned the tug and tow around in order to stem the tide on a north-westerly heading and then ordered the crane barge crew to let go a stern anchor. Although the engine of the tug continued to run at full ahead, the vessel lost steerage way against the tide and was pushed around onto a more westerly heading.

As the Skipper attempted to turn the tug to starboard, the angle of the tow rope from the centreline increased to such an extent that the tow rope caused the tug to heel heavily to starboard and to take water on the starboard side of her main deck. The Skipper ordered the crane barge crew to let go the towing bridle but this proved to be impossible with the tow rope under tension. In an unsuccessful attempt to slacken the tow rope, the Skipper ran the engine full astern. He then applied port helm and returned the engine to full ahead in an attempt to reduce the angle of the tow rope from the centreline. By this time water had entered the engine-room through the open engine-room skylights and the tug progressively heeled further to starboard. The Skipper managed to kick two turns of the tow rope off the towing post before he and his crewman transferred to the workboat, which had been manoeuvred alongside the tug. The tug continued to flood and finally sank. There were no injuries to personnel.

Observations 1. The main contributory factors to the accident were: o The tug was insufficiently powered to manoeuvre the tow effectively in the prevailing tidal conditions; o No means were provided on board the tug or the tow to release the tow rope quickly and safely while it was under tension; o The engine-room skylights and access door from the main deck were neither shut nor effectively secured prior to the start of the towing operation. 2. Because of the lack of any stability information relating to the tug, it is unknown to what degree its stability was a contributory factor. 3. Merchant Shipping Notice No M.1531, provides recommendations aimed at preventing the capsize of tugs while engaged in towing operations. The recommendations include: o the provision of a towing hook having a positive means of quick release; o the provision and use of weathertight fittings for openings which provide access to spaces below the weather deck; and o minimum stability criteria. 4. The management company failed to provide its employees with appropriate instructions or with published advice pertaining to safe towing operations.

Comment Appropriate advice for promoting good management practices is contained in Merchant Shipping Notice No M.1616, which provides a brief introduction to the International Safety Management (ISM) Code. Although the provisions of the Code are aimed primarily at seagoing vessels, their application to non-seagoing vessels is equally appropriate for the purpose of promoting good management practices. The Code states that:

the safety-management system should ensure compliance with mandatory rules and regulations; and that applicable codes, guidelines and standards recommended by the International Maritime Organization, Administrations, classification societies and maritime industry organisations are taken into account.

3. ENGINE-ROOM FIRE DUE TO FUEL OIL LEAK

A vessel was alongside a container berth when the alarm sounded for a fire in the engine-room. A fire had broken out on top of No 2 diesel alternator engine, flames having been observed at the aft end in the area of the exhaust trunking. The Engineers in the vicinity immediately returned to the control room, took the engine off load and stopped it.

The fire was tackled using local foam extinguishers, and several attempts to put the fire out had to be made as re-ignition continued to occur until contact surfaces in the area had cooled below ignition temperature.

Observations 1. Subsequent investigation showed that a two bolt Low Pressure (LP) fuel pipe flange had become displaced on the fuel rail due to a fracture of one of the securing bolts. This allowed fuel oil to leak into the hot box surrounding the cylinder heads and eventual ignition of oil fuel fumes by contact with the exhaust trunking. 2. Further investigation failed to establish the exact cause of the bolt failure. It was also noted that the LP fuel oil rail operated at a pressure of about 10 Kg/cm2 (or 10 bar). At this pressure, any displacement of the joint seal will result in a substantial leak.

Comment 1. As a result of this incident, the company have modified the LP fuel rail to allow a four bolt flanged connection to be fitted in place of the original two bolt flange. This modification had already been carried out by the engine manufacturers on later models in this product range. 2. Good communication between ship and shore staff immediately after this incident led to early identification of the real problem and subsequent modification of the system.

4. CREWMAN INJURED BY REVERSING TRAILER ON RO-RO VEHICLE DECK

A Ro-Ro passenger/freight ferry of 1,250 gross registered tonnage, employed on a short sea crossing, had arrived at one of its terminal ports. Vehicle unloading operations were in progress. Some of the freight vehicles were trailers which required the use of shore based tractor units for their movement around and from the vessel.

Members of the ship's deck crew had the task of removing vehicle lashings and trailer support trestles. These crewmen usually worked in pairs. Eventually, all vehicles had been unloaded except one trailer. A tractor unit was driven onto the vehicle deck, reversed into position and coupled to the last trailer. One member of the deck crew attended this vehicle to remove the trestle. All other crew had moved to the other end of the vehicle deck to prepare for the next loading operation.

This last trailer was being reversed along the centre lane of the vehicle deck towards the stern door when the crewman who had been in attendance attempted to cross this centre lane. He was knocked over by the reversing trailer and suffered a leg injury.

Observations 1. The driver of the tractor unit/trailer had no clear view behind the trailer while reversing. 2. The injured crewman was disorientated and unaware of the direction from which any vehicle may have been moving when he crossed the deck.

Comment 1. Although company instructions required crew working on the vehicle deck to do so in pairs, the injured man's partner had left the immediate area to perform other tasks. 2. Operating in pairs, with one man signalling the vehicle's driver and the other sighting his "blind areas", would allow reversing to be accomplished much more safely. 3. The company accepted a recommendation to make their instructions more explicit, by introducing a clear direction that whenever vehicles or freight trailers are being moved in reverse, one member of each two man team must act solely as lookout and signaller for the drivers. 4. Merchant Shipping Notice No M.1507 gives guidance on the precautions required when conducting cargo operations on vehicle decks of Ro-Ro vessels.

5. GROUNDING CAUSED BY SLEEPING WATCHKEEPER

A tug left port at 0200 hrs and proceeded on a coastal passage in fine weather with good visibility. The wheelhouse was manned by the Mate and a helmsman, with the tug on hand steering.

During the watch, the Mate periodically sat on a seat provided in the vicinity of the chart table, which was situated in an aft corner of the wheelhouse.

At approximately 0400 hrs, the Mate instructed the helmsman to alter course 10º to port with the intention of passing three cables off a shore light, which was then fine on the starboard bow at a range of four miles. He then sat down in the seat and soon fell asleep.

About 20 minutes later, the helmsman suddenly became aware of the close proximity of the shore light, instinctively shouted to the Mate and applied full port helm. The Mate awoke and saw the light dead ahead at close range. Although he immediately pulled the engine control lever back to Full Astern, the vessel grounded on rocks a few seconds later.

There were no injuries but the vessel was a constructive total loss.

Observations 1. The Master had instructed his crew to return to the vessel at midnight with the intention of departing at 0200 hrs. 2. The Mate duly arrived on board the vessel at midnight, having spent the day at home, but he had not slept since the previous night. The helmsman arrived on board at about 0120 hrs. 3. The Master was of the opinion that both the Mate and the helmsman were fit for duty. However, he made no specific enquiries as to the quantity or quality of rest each of them had gained prior to their arrival on board. 4. The Master had made no attempt to ensure that he was adequately rested himself and had assumed that the Mate would be in a fit state to take charge of the first watch. 5. Prior to the grounding, there was little conversation between the Mate and the helmsman. The wheelhouse was in darkness and the heating was on, with the wheelhouse doors and windows closed. 6. The wheelhouse was not equipped with a watch alarm.

Comment 1. A major contributory factor to the Mate falling asleep was fatigue due to lack of adequate rest. However, any tendency for him to feel drowsy would have been exacerbated by him sitting down in the warm, dark and quiet atmosphere of the wheelhouse. 2. By instructing his crew to return to the vessel at midnight, the Master allowed insufficient time to ensure that they were adequately rested for the passage. In this regard, each crew member also had an individual responsibility under The Merchant Shipping (Health and Safety: General Duties) Regulations 1984 to ensure his own fitness for duty. 3. The helmsman was under no obligation to maintain a lookout while steering the vessel. However, it is probable that had he been less fatigued, he would have realised the close proximity of the shore light at an earlier stage, in time for avoiding action to be taken.

4. If a watchkeeper is allowed to sit in a chair during the hours of darkness, with few navigational duties to perform, there will always be a tendency for him to fall asleep. He does not necessarily have to be fatigued or otherwise impaired for this to happen.

6. ENGINE-ROOM FIRE ONBOARD A SMALL BULK CARRIER

A small bulk carrier of 3,890 gross registered tonnage was on passage in the English Channel with a cargo of coal. Shortly after dawn the fire detection system activated, indicating a fire in the engine-room. The Chief and Second Engineers made their way to the engine-room to investigate and discovered large quantities of smoke. The engines were stopped from the bridge and the quick closing fuel valves were tripped.

A fire fighting party was mustered and made an attempt to enter the engine-room to tackle the fire. Unfortunately these attempts were thwarted by very dense smoke. All ventilators and dampers to the engine-room were then closed and, after all personnel were accounted for, the CO2 flooding system was discharged. This was some 30 minutes after the fire alarm was first heard.

About five minutes later the Master made contact with the Coastguard requesting fire fighting assistance. After the arrival of shore based fire fighters it was established that the fire had been extinguished and the vessel was safely towed to port.

Observations 1. During the subsequent inspection only very limited damage was found, which would suggest that little heat had been generated and that most of the fire fighting problems had been caused by the dense smoke generated. Also at that time a small bore fuel pipe beneath a main engine turbocharger casing, and adjacent to a compression fitting, was found to have been fractured. 2. It is noted that a significant period of time elapsed between the activation of the fire alarm and the discharge of the CO2 smothering gas. Similarly, the Master delayed contacting the Coastguard until after the CO2 had been deployed. It is fortunate that the fire did not intensify and spread during this time.

Comment The importance of screening oil pipes from possible sources of ignition is well set out in Merchant Shipping Notice No M.1456, and in its Appendix there are several examples of machinery space fires, one of which was due to the failure of a compression fitting on a fuel line. The vulnerability of this type of fitting, especially when subject to vibration, should be carefully considered when selecting pipe joining techniques.

7. INEXPERIENCE LEADS TO FINGER INJURY OF ENGINEERING CADET

An engineer was being assisted by a cadet in reassembling a heavy oil purifier. The purifier was of the self cleaning type, having a sliding bowl within a main bowl around the periphery of which are sludge discharge ports.

The sliding bowl had been lifted, using lifting gear, into the main bowl. The lifting gear remained in place in order to position the sliding bowl correctly. Difficulty was experienced in accurately positioning the sliding bowl due to it sticking. In order to assess the position of the sliding bowl the cadet put his finger into a sludge port; at the same time the sliding bowl jumped slightly due to the residual load on the lifting gear. The cadet's finger was trapped between the edge of the sludge port and the sliding bowl causing a painful injury.

Observations 1. Careful supervision of young trainees, such as this cadet, is the immediate responsibility of the supervising engineer officer. 2. The acquisition of