Marine Accident Investigation Branch (MAIB) - Safety Digest

Contents 1. MOVEMENT OF TRAILER UNITS DUE TO HEAVY WEATHER.................4 Narrative .........................................................................................................................4 Observations ...................................................................................................................4 Comment.........................................................................................................................4 2. ENGINE-ROOM FIRE WHILST ALONGSIDE ...................................................5 Narrative .........................................................................................................................5 Observations ...................................................................................................................5 Comment.........................................................................................................................6 3. INCORRECT INSTALLATION OF LIFEBOAT DAVIT WINCH MOTOR ...7 Narrative .........................................................................................................................7 Observations ...................................................................................................................7 Comment.........................................................................................................................8 4. NO LOOKOUT ON EITHER VESSEL ..................................................................9 Narrative .........................................................................................................................9 Observations ...................................................................................................................9 Comment.......................................................................................................................10 5. COLLISION WITH DISCHARGING CHEMICAL TANKER .........................11 Narrative .......................................................................................................................11 Observations .................................................................................................................11 Comment.......................................................................................................................11 6. SNAGGING LEADS TO LOSS OF FISHING VESSEL AND SKIPPER.........12 Narrative .......................................................................................................................12 Observations .................................................................................................................12 Comment.......................................................................................................................12 7. FISHING VESSEL SINKS WITH LOSS OF TWO LIVES................................13 Narrative .......................................................................................................................13 Observations .................................................................................................................13 Comment.......................................................................................................................14

8. FISHING VESSEL SINKS AT ANCHOR ............................................................15 Narrative .......................................................................................................................15 Observations .................................................................................................................15 Comment.......................................................................................................................15 9. BILGE PUMPING FAILURE CAUSES LOSS OF FISHING VESSEL ...........16 Narrative .......................................................................................................................16 Observations .................................................................................................................16 Comment.......................................................................................................................16 10. CRUSH INJURY TO FISHERMAN WHILST OPERATING WINCH .........17 Narrative .......................................................................................................................17 Observations .................................................................................................................17 Comment.......................................................................................................................17 11. POOR BILGE PUMPING PRACTICES CAUSE ACCIDENTS .....................18 Narrative .......................................................................................................................18 Observations .................................................................................................................18 Comment.......................................................................................................................19 12. FISHING VESSEL CAPSIZES IN HARBOUR .................................................20 Narrative .......................................................................................................................20 Observations .................................................................................................................20 Comment.......................................................................................................................21 13. SUBMARINE SNAGGED WARPS OF PAIR TRAWLERS............................22 Narrative .......................................................................................................................22 Observations .................................................................................................................22 Comment.......................................................................................................................23 14. CAPSIZE OF OPEN FISHING BOAT IN ADVERSE WEATHER ................24 Narrative .......................................................................................................................24 Observations .................................................................................................................24 Comment.......................................................................................................................25 15. FATALITY DURING LIFEBOAT RELEASE GEAR TEST...........................26 Narrative .......................................................................................................................26 Observations .................................................................................................................26 Comment.......................................................................................................................26

16. OVERTURNING OF CRAWLER CRANE........................................................27 Narrative .......................................................................................................................27 Observations .................................................................................................................27 Comment.......................................................................................................................28

1. MOVEMENT OF TRAILER UNITS DUE TO HEAVY WEATHER

A passenger/cargo Ro-Ro vessel, of about 21,000 Gross Tons (GT), was employed on a short/medium sea crossing between the UK and Continental Europe; one return voyage being made each 24 hours. The vessel had three vehicle decks, the uppermost being open, all of which were loaded via the stern door or, for non Ro-Ro units, lifted directly onto the open deck using shore cranes.

On three consecutive crossings very poor weather was experienced which caused the vessel to roll heavily. Estimates of conditions suggested that winds were of Force 9 - 10 together with very rough seas and a heavy swell. During the first two of these crossings several cargo units broke free from their securing arrangements. Other cargo units were damaged and broke free, and the vessel was also damaged. On the third crossing no cargo units moved significantly. However, on inspection shortly before berthing it was found that heavy items of cargo had shifted from open trailers and fallen to the deck, puncturing it in several places.

Observations 1. At each loading port all the cargo units were secured with suitable lashings for the forecasted poor weather conditions. The lashing system used was well proven.

2. Also, as far as was possible and practicable, all cargo units were inspected by ship's staff who rejected any which were judged to be unsuitable for carriage.

Comment 1. Very prudently no attempt was made to re-lash the cargo units at sea. However, their situation was monitored on CCTV.

2. Having decided to make the first of the three crossings with poor weather forecast, and seeing the effect of the conditions on his vessel and her cargo, it is a little surprising that the Master did not give greater consideration to postpone sailing on the following two crossings until the weather improved. 3. The damage which occurred on the third crossing serves to demonstrate that operators need to pay more attention to properly securing loads carried on their vehicles before boarding Ro-Ro vessels. The guidance contained in the Department of Transport's publication "Code of Practice: Safety of Loads on Vehicles" will be of assistance to the vessel's staff when assessing the safety of its load securing arrangements, before loading the vehicle.

2. ENGINE-ROOM FIRE WHILST ALONGSIDE

This 9000 GT cable layer was alongside for maintenance and repair, with the crew assisting as required. Work started as usual and continued through the morning apart from a brief interruption when the fire alarm sounded. This alarm was caused by welding fumes in the engineers workshop. To prevent further alarms, this zone was isolated until the working day ended. At 1700 work finished for the day, all fire detector zones were activated and hourly fire patrols started.

At 2135, the fire alarm sounded indicating a fire in the engine-room. The local fire brigade were called and the ship's crew mustered on the cable deck. Shortly afterwards blackout occurred whilst the engine fire party were donning breathing apparatus. The engine space was closed down, all emergency stops operated and non essential crew sent ashore. The fire brigade arrived, were briefed on the situation, and a fire party entered the engine space at the lower level. A number of small fires were dealt with but intense heat was found in the engine control room area and the party withdrew. It was decided that CO2 total flooding of the engine space would be carried out, this being activated by the Chief and Second Engineers at 2238. Two pulls were necessary before the sound of escaping gas was heard and both men left the vessel. From 2300, regular checks were made for local hot spots until 0500 the next day, when the engine- room was entered. The fire brigade found and put out a fire inthe main propulsion switchboard and subsequently vented the engine space. The engine-room was available for inspection at 0545. The seat of the fire was found by the starboard auxiliary generator with heavy fire damage extending upwards into the engine control room. An inspection of the CO2 room confirmed that the bottles had not been discharged due to a fault in the cable operating mechanism. By 1500 the fire was declared out and the vessel safe.

Observations 1. The impingement of a spray of warm lub oil onto the hot exhaust of the starboard auxiliary generator, caused the generation of a vapour cloud and subsequent ignition. Flame and soot markings on the side of the generator, showed the source of that lub oil spray as being due to the loss of a venting valve fitted on the generator Duplex lub oil filter. The original vent cock had been replaced by a non standard valve at some time. The thread on the valve connection to the filter block was worn and with fluctuating oil pressures; it eventually worked loose.

2. The fire spread from the top of the generator to the main power cables carried on deck head cable trays. The fire burnt along the cable insulation, helped by oil impregnated dust and dirt, eventually travelling up into the underside of the switch gear in the control room above via unsealed cable entries - no cable transits being fitted due to the date of construction. The steel casing of the switch gear cabinet contained the fire although the considerable heat generated caused heat distortion and paint blistering at deck head level. 3. Despite having been inspected and serviced some four months earlier by the manufacturers agents, the CO2 system failed due to the disintegration of the bulldog locking mechanism fitted to the operating pull wire. Subsequent examination showed that only one of the pilot cylinders had discharged, the second pilot bottle remained intact. The first stage alarm, indicating either a gas leak or that the main system was about to be operated, had tripped. The second pilot valve seal disc was found intact with no evidence of any attempted rupture. This suggests that the operating pull wire was not secure in the clamping pin

allowing the wire to move within the pin without operating the arm. Dismantling of the safety valve showed that although the operating arm had moved towards the maximum piercing position, causing an indentation in the disc, no rupture had taken place. 4. The CO2 room adjacent to the operating station was kept locked, with the two emergency keys being kept in the engine control room and bridge respectively.

Comment 1. This incident illustrates the importance of structural fire protection and the maintenance of both fire integrity and insulation standards of bulkheads. Current regulations require the installation of approved cable transits for cable penetration of Class "A" and "B" bulkheads. The fitting of approved cable transits would have significantly restricted the spread of fire and the extent of the damage sustained.

2. The failure of the CO2 system in itself was due to poor maintenance procedures by the contractor. It does show however the continual need to supervise and monitor contractors, particularly in respect of safety equipment maintenance carried out aboard the vessel. 3. The presence of a local emergency key to the CO2 room would have allowed a visual check to be carried out on the operating mechanism when difficulties were experienced on the initial pull.

3. INCORRECT INSTALLATION OF LIFEBOAT DAVIT WINCH MOTOR

A davit winch motor burnt out during the recovery of a lifeboat on a 37,583 GT ferry when she was alongside in port. Although a spare motor was fitted just before the vessel sailed, it was considered impracticable to test the motor at sea with the lifeboat stowed.

Three days later arrangements were made to test the motor when the vessel had returned to her home port. The lifeboat was lowered approximately one metre from its stowed position and the motor was tested by the raise control button. The winch drum failed to move and a clunking/clicking noise was heard to come from the winch housing. The raise button was depressed a further two or three times with the same result. The Electrical Officer was called and the raise button was again depressed. This time the winch started to lower the lifeboat and continued to do so, even after the power supply to the motor was isolated. The lifeboat eventually landed on the quay and was damaged. There were no injuries.

Observations The power supply to the replacement motor had been incorrectly connected and caused the motor to rotate in the reverse direction.

1. The reverse direction of the motor damaged the locking pawls of the sprag clutch and rendered them ineffective. 2. No information was available on board regarding the required procedure for changing a lifeboat winch motor and staff were not conversant with the principles of operation of the drive/clutch/brake arrangement.

Comment 1. Immediately after the accident, the vessel's managers implemented the following procedures for changing lifeboat winch motors, which should prevent similar accidents occurring.

1. The winch motor direction of rotation should be established and a suitable mark made on the gearbox casing adjacent to the motor.

2. Before replacing the winch motor, the lifeboat should be securely stowed with the davit arms retained by the harbour pins. 3. After fitting the motor, the correct electrical connections should be made. The lifeboat should then be lowered from its fully stowed position in order to enable a full function test to be undertaken. Suitable arrangements should be made to ensure that the quay area below the lifeboat is kept clear of personnel. 4. Precise instructions should be given to ensure that all persons involved are fully aware of the schedule and requirements of the test. Appropriate information should be made available on board with regard to the operation and maintenance of lifeboat launching and recovery equipment.

4. NO LOOKOUT ON EITHER VESSEL

A general cargo vessel of 1200 GT was on passage at night in the English Channel and correctly exhibiting the navigation lights for a power-driven vessel underway. The Master was the sole watch keeper. The vessel was being steered by auto-pilot on a heading of 279º(T) and an operational radar was set on the 6-mile range scale.

A 12-metre twin-hulled trawler had just hauled her net and was proceeding a head at reduced speed with the net trailing astern and clear of the twin propellers. She was showing the navigation lights for a vessel engaged in trawling and making way through the water. An operational radar was set on the 3-mile range scale and the vessel was being steered by autopilot on a heading of approximately065º(T). The Skipper was the only person on board. Both vessels had their VHF radios switched on to Channel 16. The wind was westerly Force 2, with a slight sea and excellent visibility. The Master of the cargo vessel observed what he considered to be the stern light of a vessel about 15º on the port bow, on a similar heading to his own. He decided that his vessel would overtake the other at a safe distance. He then went to the chart room in order to familiarise himself with the arrival procedures for his next intended port of call. Meanwhile, the trawler Skipper had been checking the engine spaces and had found some water in the starboard compartment. He started the bilge pump and remained in the starboard engine space in order to check the machinery, grease the stern tube and tighten the stern gland. After about five minutes, the Master of the cargo vessel returned to the wheelhouse from the chart room and saw a green light at close range fine on the port bow. He immediately turned the auto- pilot setting to starboard but the vessels collided. The trawler passed the cargo vessel's port bridge wing about two metres off heading at right angles to the cargo vessel. The trawler Skipper, having felt the impact, returned to the wheelhouse and immediately pulled the engine control levers to astern before he realised that the nets would become fouled as a result. Although both vessels were damaged, there was no ingress of water. The trawler Skipper called HM Coastguard and reported the incident, but the cargo vessel continued her passage until HM Coastguard, calling on VHF Channel 16, managed to get her Master to respond and identify his vessel. The trawler was subsequently towed into port by an RNLI lifeboat.

Observations 1. The Master of the cargo vessel failed to assess whether a risk of collision with the trawler existed and failed to keep a proper lookout.

2. The trawler Skipper, who was the only person on board, failed to keep any lookout because he was in the engine-room.

3. Insufficient use was made of the radar on both vessels for the purpose of identifying the possibility of a risk of collision. 4. The extent of damage to both vessels was substantial.

Comment 1. Following the collision, the Master of the cargo vessel made no attempt to stop or to communicate with the trawler as obliged to by Article 8 of The Collisions Convention 1910. Similar obligations, prescribed in Section 92 of the Merchant Shipping Act 1995, apply to UK vessels and other vessels in UK waters.

2. The trawler Skipper had been fishing at sea and had had no sleep for nearly 24 hours. It is possible that fatigue could have been a contributory factor in his not maintaining a lookout. 3. The absence of a crewman cannot excuse a Skipper, who chooses to operate his vessel alone, from the consequences of self-imposed fatigue, or the failure to maintain a lookout.

5. COLLISION WITH DISCHARGING CHEMICAL TANKER

A 22,400 GT bulk carrier carrying a mixed cargo of 33,000 tonnes of grain and animal feeds was under port pilotage to her discharging berth with one tug made fast aft and two others in attendance. The weather conditions were good and, as the bulk carrier had a bow thruster and good manoeuvrability, the Master and Pilot had agreed that it was not necessary to make a tug fast forward to assist with a planned turn to starboard. The size of the bulk carrier and the usual preferred turn position meant that her bow would swing close to a chemical tanker which was moored at a berth adjacent to the turning basin. Partly because the forward tug had not been connected the Pilot chose to keep power and headway on to help with the turn. The vessel was turning to starboard and still making headway when the bulbous bow came into contact with the side of the chemical tanker, which was discharging a cargo of 4291 tonnes of sulphuric acid.

Although the chemical tanker was holed below the waterline which caused her to list rapidly to about 35º there were no injuries and there was no pollution as a result of the accident.

Observations 1. The port and its turning area had been laid out in times when vessels were smaller and the proximity of berths, now used for chemical and gas carriers, was not considered to present an undue hazard.

2. It had become common practice for large bulk carriers to swing on the edge of the designated turning basin and close to the chemical berths in order to better facilitate manoeuvring alongside the grain berths. 3. The Pilot misjudged the amount of headway. The misjudgment was not noticed by the Master who was monitoring the pilotage on the bridge. Both the Pilot and the Master thought that the situation was under control until the last moment and, despite full astern power being applied, they were unable to avoid the collision. The Chief Officer on the forecastle had warned the Bridge about the decreasing clearance from the other vessel. 4. Serious pollution and/or loss of life was only narrowly averted. One of the tanker's wing ballast tanks and the ballast pump room was holed and the bulkhead of one of the full cargo centre tanks was distorted. The cargo containment was not affected.

Comment 1. The manoeuvring of large vessels intentionally close to moored tankers or gas carriers should be avoided if practicable to do so. The Harbour Master of the port where this accident occurred has now instigated a 150 metres safety zone around all moored chemical tankers adjacent to the turning area.

2. It should be recognised that tugs which are already made fast can quickly provide assistance in emergency situations. In deciding on the number of tugs to make fast Masters and Pilots should consider all possible contingencies.

6. SNAGGING LEADS TO LOSS OF FISHING VESSEL AND SKIPPER

A 24.35 metre long fishing vessel, with a crew of six, snagged her fishing gear on an underwater obstruction whilst bottom trawling. The