Marine Accident Investigation Branch (MAIB) - Safety Digest

Contents Part 1 - Merchant vessels...............................................................................................3 Case 1: Grounding of Panamanian Bulk Carrier......................................................................3 Case 2: Bridge Management Failure........................................................................................6 Case 3: Collision between a Fast Ferry and a Fishing Vessel..................................................7 Case 4: Coaster Collides with Fishing Vessel..........................................................................9 Case 5: Oil Tanker Drags Anchor and Grounds.....................................................................12 Case 6: Defective Gangway Platform Design........................................................................14 Case 7: Fall from Ladder........................................................................................................15 Case 8: Complacency during Routine Operation...................................................................15 Case 9: Ship's Fires during Refit ............................................................................................16 Case 10: Engine Room Fire in General Cargo Vessel ...........................................................18 Case 11: Fire in Engine Room of Ro-Ro Vessel....................................................................19 Case 12: Accident caused because No Gangway Provided ...................................................21 Case 13: Overtaking Ferry fails to Give Way ........................................................................22 Case 14: Mistaken Identity.....................................................................................................23 Case 15: Interaction during Tow Line Connection ................................................................24 Case 16: Bow Visor Damage on Large Ro-Ro Passenger Ferry............................................25 Case 17: Seaman Trapped when Handling Screens on board a Suction Dredger ..................27 Case 18: Crew Member Lost Overboard from a Small Coaster.............................................28 Part 2 - Fishing vessels.................................................................................................31 Case 19: Small Angling Boat Overturned in Waves..............................................................31 Case 20: Loss of Life Close Inshore ......................................................................................33 Case 21: Poor Design of Working Arrangements Led to Death of Skipper ..........................34 Case 22: Fishermen Struck by Seas on Deck.........................................................................35 Case 23: Lifesaving Appliance Shortages Cost Lives Again.................................................36 Case 24: Discharged EPIRB and VHF Batteries cause Problems..........................................37 Case 25: Rapid Capsize Following Flooding.........................................................................38 Case 26: Defective Bilge Alarm Delays Discovery of Flooding ...........................................39 Case 27: Dirty Fuel Disables a Fishing Vessel ......................................................................41

Part 3 - Leisure craft....................................................................................................43 Case 28: Diabetic Not Fit for Sea...........................................................................................43 Case 29: Yacht Owner Loses Life after Failing to Wear Safety Harness ..............................45 Appendix A: Investigations Commenced in the Period 01/01/98 31/08/98 .............48 Appendix B: Inspector's Inquiries..............................................................................50 Appendix C: Reports Issued in 1998 ..........................................................................51 Appendix D: Stationery Office Stockists and Distributors Overseas......................52

Part 1 - Merchant vessels This edition of the Safety Digest contains a variety of incidents with lessons for both deck and engine room personnel. There is no common theme among the accidents described but we believe they all contain food for thought and should heighten an awareness of what can go wrong at sea. With the increasing use of fast ferries around our coasts we publish an account of an accident involving a fast ferry colliding with a fishing vessel and are grateful to the Danish Maritime Authority for allowing us to précis their more detailed version. The use of high speed craft adds an extra dimension to seafaring and this incident should focus attention on how propelling at 35 knots requires a special relationship between man and machine. Given the relatively small number of UK merchant ships on our database, analysis of accident trends is, to an extent, subjective. On the other hand the MAIB is in a position to note certain features in many accident reports which continue to concern us. The issue of fatigue among mariners is not new but it occurs again and again and is an undisputed factor in many of the accidents we investigate in both UK registered and foreign flagged vessels. Identifying the root cause is equally subjective but two trends are developing which require attention; the lack of proper rest between periods of duty and a tendency to use watchkeeping time to attend to matters that distract the watchkeeper from his or her principal duty. We do not yet have sufficient data to make any authoritative comment on minimal manning standards but it seems to us that some ships are so short handed that proper rest becomes impossible and many of the tasks of todays seamen can only be carried out by the person on watch. We have, for instance, reports of officers who spend much of their time keeping volumes of new regulations up to date, while on watch. At the heart of the problem are the commercial pressures arising from too many ships chasing too few cargoes. Some owners cut costs which invariably means savings in manpower. Investment in safety and training is reduced and the potential for accidents increases. This is not a new problem. While it is always very easy to criticise seamen for mistakes made at sea, and owners for not providing them with the necessary resources, responsibility also lies with flag states to implement the various international agreements on standards. The advent of the ISM Code provides an opportunity for every port state to be unrelenting in its determination to detain substandard ships and identify the rotten core of equally substandard ship operators, classification societies, charterers, insurers and financial institutions. We do not require more regulations, only implementation of the existing ones. Once these substandard ships have been eradicated, the good operators will have a much better opportunity to compete on a sound basis, invest in manpower and training, and man their ships with dedicated crews. Those at sea will, hopefully, be able to carry out their duties more effectively without being permanently tired. This should, in turn, lead to a reduction in the number of accidents.

Case 1: Grounding of Panamanian Bulk Carrier Narrative

The Panamanian registered bulk carrier WESTERN WINNER of 30,396 tonnes dead-weight was on passage from Singapore to the east coast of Australia. During the voyage her destination was changed twice, first to Port Adelaide for which she had appropriate charts, and then to Wallaroo in the Spencer Gulf. Her chart portfolio did not, however, include two crucial charts covering the Southern part of the Gulf which she required for safe navigation. To overcome the problem one of the officers attached some plain paper to the bottom of a chart already held and used this extension for navigation. In lieu of a chart, reference was made to the port entry guide rather than the Admiralty sailing directions and a course plotted towards the pilot boarding area. Its charted position happened to fall on the plain paper. The Master had meanwhile telexed the vessels agents requesting charts for the waters in question but did not give any reasons as to why he needed them. The vessel continued on passage with positions being plotted at regular intervals on the charts available. The last position, prior to the accident, was plotted on the makeshift chart and some two hours prior to embarking the pilot. The portion of the chart in use was devoid of any detail. At the time the last position was plotted, the watch was handed over to the Third Officer with the Master in attendance on the bridge. Both radars were in operation, one of which was equipped with

ARPA. A lookout/helmsman was also on watch. The weather was overcast, with moderate visibility and occasional rain showers. Some one and a half hours later, visibility was reduced in a heavy rain shower and a radar echo was detected fine on the starboard bow. It was assumed to be a small vessel and course was altered to keep clear of it. After steaming a further mile, a light was seen on the same bearing as the radar echo which prompted a further alteration of course. Shortly afterwards, the ship ran aground. It was then discovered that the echo the Master had assumed to be another vessel was in fact the Tiparra Reef light beacon which was very clearly marked on the appropriate charts but not on the makeshift version being used onboard WESTERN WINNER.

The Lessons

1.All appropriate charts for the required trading area should be carried to ensure that a detailed passage plan can still be constructed should the destination port be changed while the vessel is on passage. 2.Admiralty or other approved sailing directions should always be consulted when planning a passage. 3.Owners should maintain records of charts carried on board the vessels. 4.Masters can never assume the port of destination will remain unchanged. If, as in this case, charts are not held for the area in which the ship is intending to sail and they are ordered by fax, telex or other means, the reasons for demanding them should be given. 5.The largest scale chart should always be used. 6.No Master should ever take his ship into water for which he has no chart of a scale suitable for safe navigation. When the relevant charts are not held, both owner and charterer should be informed without delay. 7.Course alterations based on imprecise or incomplete information can result in vessels being placed in dangerous situations. Stationary targets should be cross-checked against charted objects. 8.When doubt exists as to whether a vessel is in safe water, Masters should proceed with extreme caution until an accurate position has been obtained. The echo sounder should be switched on and monitored. Depending on the circumstances, taking the way off and even anchoring is preferable to running aground. The anchors should be cleared away when entering shallow water and when there is any doubt about the vessels position. 9.When ordering an item to meet an urgent requirement, the demand should include a statement as to why it is required and the date by which it should be delivered.

Footnote

Although the SOLAS Convention requires ships to carry paper charts, the advantages in having digital navigation systems and electronic charts should not be underestimated. These include the facility of being able to carry an extensive portfolio on board, a reliable means of maintaining charts up to date and the ability to access a chart not normally used by entering a special code. In extremis, a new chart can be transmitted via INMARSAT. With grateful acknowledgement to the Australian Marine Incident Investigation Unit

Case 2: Bridge Management Failure Narrative

The offshore supply vessel HIGHLAND STAR was leaving Peterhead Harbour in restricted visibility on 16 August 1997. The bridge was manned by the Master, Chief Officer and Second Officer. Two radars were operating on a range scale of 0.75 mile.

After manoeuvring the vessel clear of her berth at the southern end of the harbour, the Master retained the con and steered a course approximately parallel to the south breakwater. He intended turning the vessel to starboard at the appropriate moment to pass between the north and south breakwaters and exit the harbour on the charted leading line. While proceeding across the harbour, the vessel entered a fog bank with visibility reduced to about 20 metres. The Chief Officer, monitoring progress on the starboard radar, informed the Master they were two cables from the south breakwater. The Master engaged the autopilot and moved to the port radar to determine the range of the quay wall ahead of him. He was surprised to find it was only 1.4 cables dead ahead, much less than he had anticipated. An immediate course alteration to starboard was necessary but several things then occurred at once. The mobile phone rang on the bridge and was answered by the Second Officer who passed a message to the Master. At almost the same time the Harbour Office called on VHF radio to advise that the vessel was only one cable from the quay and closing it. The transmission was acknowledged by the Chief Officer. The Master found himself in poor visibility, deluged with information at a critical moment, closing a wall he couldn't see and responsible for taking immediate action with the steering in auto. He changed back to manual steering, applied full starboard helm and put both engines to full astern

before placing the helm amidships. Although this significantly reduced headway, it failed to prevent the vessel hitting the sea defences of the quay wall.

The Lessons

1.Ship handling and pilotage in restricted visibility requires additional care. Not only should the entire manoeuvre be planned in advance but there must be a clear delineation of responsibility and established procedures for who does what. 2.The Master, having taken the decision to sail in conditions where the visibility might change suddenly, should have ensured that both the Chief and Second Officers were totally dedicated to supporting him in what was clearly a difficult manoeuvre once fog had descended. Primarily, this would entail providing him with relevant and accurate information to enable the vessel to proceed safely and for the wheel to be applied at precisely the right moment to alter course to starboard. 3.Anyone handling a vessel in such a situation will normally focus his, or her, total concentration on the matter in hand. Any distraction can be very disconcerting and potentially dangerous. Few people are able to absorb additional, or superfluous, information in such circumstances without losing concentration. Every effort must be made to identify the sources of potential distractions with the aim of either managing them sensibly or removing them altogether. Mobile phones, for instance, can present unwelcome distractions and consideration should be given to switching them off or placing them in the care of personnel not involved in navigation at the time. 4.The need for detailed passage planning and execution applies to harbour transits as well as sea passages and should cater for both visual and blind conditions. It should be possible to change from one plan to the other in the event of sudden changes invisibility. Wheel-over positions should be calculated in advance, using radar information alone. Blind pilotage techniques should be practised regularly so those involved can gain confidence in their ability to navigate safely in poor visibility and to establish the best allocation of responsibilities among those on the bridge. 5.The autopilot should not be used when underway within harbour limits. In blind pilotage conditions Masters will generally find it easier to maintain a better overview of events when they delegate the steering to someone else. 6.Crew resource management training is strongly recommended to assure that divisions of responsibility, pre-planning, equipment failure and unexpected developments can be accommodated and effective procedures established.

Case 3: Collision between a Fast Ferry and a Fishing Vessel Narrative

On 13 March 1997, the Tasmanian-built, wave piercing catamaran CAT LINK II, with a maximum top speed of 36 knots and a carrying capacity of 125 cars and 583 passengers, was on her regular service between the Danish ports of Kalundborg and Arhus. At 0942 that day, with visibility assessed at between 0.5 to 0.75 of a mile, she collided with, and sank, the 13.4 GT wooden fishing vessel LISSI. The Skipper, who was the sole occupant of the fishing vessel, survived and was picked up by the catamaran. The catamaran's modus operandi at sea was for Master and Mate to man the bridge control desks with the vessel being steered from the centre seat. Two radars were fitted. On the day of the accident the Master used a gyro stabilised, true motion, X-band set at 1.5miles but off-centred so that he could detect contacts at a range of 2.5 miles ahead. The Mate had a DGPS stabilised S-band

radar set to a range of three miles and off-centred so that it was possible to see five miles ahead. The Chief Engineer was also on the bridge; seated behind, and to port of, Master and Mate. The catamaran was proceeding at 34.5 knots. Fog signals were not being made. Ahead of them LISSI was moving through the water at about three knots, showing lights and shapes to signify she was trawling. In addition a floodlight was shining astern towards the trawl. The Skipper was in the wheelhouse with the radar switched on as an aid to navigation. He was unaware of the catamaran's high speed approach from astern. LISSI was fitted with a radar reflector constructed of plates at right angles which had limited reflective properties for X-band radars and virtually none for S-band. CAT LINK II's Mate detected two echoes on the radar at a range of four miles and reported them to the Master. Shortly afterwards the Master became aware of a collision warning on his radar from one of the two contacts and altered course to port to avoid them. The avoiding action having been taken, the Mate sought the Master's approval to leave the bridge to visit the toilet. The Master gave his permission. The Master, now watchkeeping alone, continued to monitor the very clear computer generated plotting symbols superimposed on the synthetic radar echoes and assessed he was passing clear. Meanwhile he divided his lookout responsibilities between monitoring both radar displays and keeping a visual lookout. Each time he looked up he automatically switched on the wipers to remove spray settling on the bridge windows. An independent witness states LISSI became visible at a range of 1000 metres. Neither Master nor Chief Engineer saw it until it had closed to less than 100 metres. Despite taking immediate corrective action, it proved impossible to take the way off, or alter course sufficiently, to avoid a collision. The catamaran's starboard pontoon hit the fishing vessel. The first that LISSI's Skipper knew of impending disaster was hearing the noise of the catamaran when the range had closed to about100 metres. Although he then saw the catamaran approaching from astern, it was too late to do anything. He was thrown into the water on impact. The catamaran can stop from full speed in 270m within 48 seconds. The man overboard boat was successfully launched in two minutes and the Skipper recovered. Although LISSI was fitted with a four-person life raft and the hydrostatic release had correctly activated, it failed to break free from the sinking vessel because a tarpaulin had been secured on top of it to protect it from the weather. The investigation showed that the X-band radar's relatively slow rotational speed (24 rpm), together with delays and in accuracies in the gyro and log inputs, led to large errors in the calculated position and speed of the echoes, so much so that they could not be followed automatically at times. It was found to work more effectively when functioning without the various data inputs. The performance of the S-band radar was also affected by a number of vertical surfaces in the vicinity of the antenna and the presence of an aluminium box which had been specially installed forward of the antenna. The display suffered from excessive clutter