Marine Accident Investigation Branch (MAIB) - Safety Digest

Contents About the Marine Accident Investigation Branch ......................................................4 Glossary of Terms and Abbreviations .........................................................................5 Introduction ....................................................................................................................6 Part 1 Merchant Vessels ................................................................................................7 Case 1 Lift Failure due to Poor Loading......................................................................8 Narrative...................................................................................................................................8 The Lessons..............................................................................................................................8 Case 2 The Timing of Trips! .........................................................................................9 Narrative...................................................................................................................................9 The Lessons..............................................................................................................................9 Case 3 Engineer Superintendents Nightmare! ..........................................................11 Narrative.................................................................................................................................11 The Lessons............................................................................................................................11 Case 4 Alteration of Passage Plan leads to Cargo Vessel Running Aground.........12 Narrative.................................................................................................................................12 The Lessons............................................................................................................................13 Case 5 Misunderstanding leads to a Near Miss in Port Approach Channel ..........14 Narrative.................................................................................................................................14 The Lessons............................................................................................................................14 Case 6 Seaman Lost while Waiting for Pilot .............................................................16 Narrative.................................................................................................................................16 The Lessons............................................................................................................................16 Case 7 Whirling Crank Handle Hits Crewman ........................................................17 Narrative.................................................................................................................................17 The Lessons............................................................................................................................17 Case 8 Air Compressor Blows Up...............................................................................18 Narrative.................................................................................................................................18 The Lessons............................................................................................................................18 Case 9 Another Low-Pressure Fuel System Fire.......................................................19

Narrative.................................................................................................................................19 Case 10 Power Failure on New Ro-Ro due to Error during Construction.............20 Narrative.................................................................................................................................20 Case 11 Explosion in Gas Compressor.......................................................................21 Narrative.................................................................................................................................21 Case 12 Overheating of Propeller Oil Box Disables Tanker ....................................23 Narrative.................................................................................................................................23 Case 13 Supply Vessel Loses Position when Working Cargo ..................................24 Narrative.................................................................................................................................24 Case 14 Fuel Starvation causes Loss of Main and Auxiliary Power .......................25 Narrative.................................................................................................................................25 Case 15 Jetty Rammed by Bulker...............................................................................26 Narrative.................................................................................................................................26 Case 16 Lots of Smoke with No Fire ..........................................................................30 Narrative.................................................................................................................................30 Case 17 Large Container Vessel Grounds while under Pilotage .............................31 Narrative.................................................................................................................................31 Case 18 Small GRP Fishing Vessel Collides with Large Vehicle Carrier...............33 Narrative.................................................................................................................................33 Part 2 Fishing Vessels ..................................................................................................35 Case 19 Pair Trawling - Crewmen Injured in Two Similar Incidents....................36 CASE 1...................................................................................................................................36 Narrative.................................................................................................................................36 CASE 2...................................................................................................................................36 Narrative.................................................................................................................................36 The Lessons............................................................................................................................37 Case 20 Fishing Vessel Grounds after Skipper Falls Asleep....................................38 Narrative.................................................................................................................................38 The Lessons............................................................................................................................38 Case 21 Close Encounter in Fog .................................................................................39 Narrative.................................................................................................................................39 The Lessons............................................................................................................................39 Case 22 Beamer Capsizes ............................................................................................41

Narrative.................................................................................................................................41 The Lessons............................................................................................................................42 Case 23 Sidewinder Sinks in Heavy Seas Six Die ......................................................44 Narrative.................................................................................................................................44 The Lessons............................................................................................................................45 Case 24 Deckhand Struck by Port Fishing Gear.......................................................46 Narrative.................................................................................................................................46 The Lessons............................................................................................................................46 Case 25 Weathertight Closures Left Open. Vessel Sinks. Four Die. .......................47 Narrative.................................................................................................................................47 The Lessons............................................................................................................................48 Part 3 Leisure Craft .....................................................................................................49 Case 26 Man Overboard Fatality from Keelboat......................................................50 Narrative.................................................................................................................................50 The Lessons............................................................................................................................50 Case 27 Winter Fishing Trip Ends in Tragedy .........................................................51 Narrative.................................................................................................................................51 The Lessons............................................................................................................................52 Addendum Yacht Race Rescue Radio Communications.........................................54 Correction...............................................................................................................................54 Comment ................................................................................................................................54 Appendix A ...................................................................................................................55 Appendix B Inspectors Inquiries ................................................................................56 Appendix C Reports issued in 1999/2000 (Priced)....................................................57 Appendix D Reports issued in 1999/2000 (Unpriced) ...............................................58 Appendix E Stationery office stockists and distributors overseas...........................60

About the Marine Accident Investigation Branch The Marine Accident Investigation Branch (MAIB) is an independent part of the Department of the Environment, Transport and the Regions and is completely separate from the Maritime and Coastguard Agency (MCA). The Chief Inspector of Marine Accidents is responsible to the Secretary of State for the Environment, Transport and the Regions. The offices of the Branch are located at Carlton House, Carlton Place, Southampton, SO15 2DZ. This Safety Digest draws the attention of the marine community to some of the lessons arising from investigations into recent accidents. It contains facts which have been determined up to the time of issue. This information is published to inform the shipping and fishing industries, the pleasure craft community and the public of the general circumstances of marine accidents and to draw out the lessons to be learned. The sole purpose of the Safety Digest is to prevent similar accidents happening again. The content must necessarily be regarded as tentative and subject to alteration or correction if additional evidence becomes available. The articles do not assign fault or blame nor do they determine liability. The lessons often extend beyond the events of the incidents themselves to ensure the maximum value can be achieved. Extracts can be published without specific permission providing the source is duly acknowledged. The Safety Digest is only available from the Department for Transport, and can be obtained by applying to the MAIB. The publications home page contains information on how and where you can obtain publications produced by the Department for Transport.

If you wish to report an accident or incident please call our 24 hour reporting line 023 8023 2527

The telephone number for general use is 023 8039 5500. The Branch fax number is 023 8023 2459. The e-mail address is maib@dft.gsi.gov.uk

Summaries (pre 1997), and Safety Digests are available on the Internet: http://www.maib.dft.gov.uk/ Extract from The Merchant Shipping (Accident Reporting and Investigation) Regulations 1999 The fundamental purpose of investigating an accident under these Regulations is to determine its circumstances and the causes with the aim of improving the safety of life at sea and the avoidance of accidents in the future. It is not the purpose to apportion liability, nor, except so far as is necessary to achieve the fundamental purpose, to apportion blame.

Glossary of Terms and Abbreviations ARPA Automatic Radar Plotting Aid

CO2 Carbon Dioxide

CPA Closest Point of Approach

DR Dead Reckoning

EPIRB Emergency Position Indicating Radio Beacon

GPS Global Positioning System

GRP Glass Reinforced Plastic

GT Gross Tonnage

kW kilowatt

m metre

MAIB Marine Accident Investigation Branch

MCA Maritime and Coastguard Agency

RIB Rigid Inflatable Boat

RNLI Royal National Lifeboat Institution

ROV Remotely Operated Vehicle

SWL Safe Working Load

UMS Unmanned Machinery Space

VHF Very High Frequency

VTS Vessel Traffic Services/System

Introduction The Safety Digest series is aimed primarily at the seafarer, regardless of status or discipline. We hope to reach senior and junior staff alike; for those working on deck or below, on the bridge, the machinery spaces, in the wheelhouse or the cockpit. There is material for everyone; accidents are as likely to occur in the galley as they are on the gangway. Accidents reported to us embrace vessels of every size and shape, from the largest cargo carrying merchant ship to the most modest dinghy. We can learn from them all. We are delighted to find that past editions are reaching a much larger audience than we had dared hope. They are routinely used as training aids by the nautical colleges, some fishermens organisations, a number of shipping companies, some authorities overseas, and by sailing schools. We have been pleased to see that many articles are reproduced in a range of other publications. They are also read by academics carrying out research, by designers seeking feedback after an accident, and by organisations carrying out formal safety assessments. If this increasing interest, in what is one of the only freely available publications of its kind in the world, results in preventing or reducing accidents, then we are making a modest contribution to improving safety at sea. But we are subjected to two repeated criticisms. The first is that we do not publish enough editions of the Safety Digest, and the second is that it reaches too few people. We are, for instance, very aware that very few fishermen have ever heard of it. To meet the first criticism we are looking at ways of ensuring that we meet our commitment to regularly produce an edition in late spring, another in early autumn, and the last one at the end of the year. We would like to publish more, but the hard-pressed editorial staff is already working flat out. We are also constantly seeking ways of increasing our circulation, but because it is a free publication and is funded out of my very limited budget, we need to target the distribution very carefully. All we ask is that those interested in receiving the Safety Digest contact the Branch and ask to be included in our distribution list. We will do the rest. If any reader knows of anyone, or organisation, who might benefit from receiving regular copies, we hope they can be persuaded to contact us.

John Lang Chief Inspector of Marine Accidents April 2000

Part 1 Merchant Vessels Those of us who drive cars on motorways will be familiar with the road sign that says TIREDNESS KILLS, TAKE A BREAK. Whenever we drive when tired, or indeed do anything when sleepy, we are well aware of it. If it is late at night, or we have been behind the wheel for hours, we become very conscious we are not as alert as we should be. We wind down the window, or turn up the radio in an attempt to stay awake. We know we should pull into the next service station and take the break so wisely recommended. And to be fair to ourselves, we usually do. Can we say the same about seafaring, particularly if we are watchkeepers? The answer is no. Seafaring is, by definition, a strenuous job that makes huge demands on peoples stamina. It always will. Yet we keep on demanding more of those at sea. In the relentless pursuit of efficiency, or cost cutting, manning levels drop; the paper mountain grows as weary masters spend hours trying to keep up with the requirements of numerous regulations, and there are no longer enough people to maintain an efficient lookout. All these factors contribute to fatigue. And fatigue leads to mistakes. If you mention the word fatigue to the ancient mariner he will guffaw, tap his pipe, and launch into happy recollections about how he used to be on his feet for days on end, beating down the Irish Sea or crossing the North Atlantic in mid-winter in an 8 knot convoy. Yes, of course he was tired, and proud of what he achieved. Nobody cared about fatigue. There was a job to do and it was done. But at what cost? The reality of today is that a mistake at sea can lead to massive environmental damage, huge insurance claims, serious loss of life, expensive litigation and ruined careers. It is the shipmaster, the engineer, the watchkeeper or the able seaman, who invariably take the blame. And yet they often feel very isolated. They rightly ask if anyone is listening. They will argue they are having to work longer hours than in practically any other industry, yet find themselves the victims of a system that fails to provide the necessary personnel to alleviate the problem. If they complain, they could be jeopardising their future. We have heard of instances where drawing attention to overwork and fatigue is a sure ticket to dismissal. So what can be done? Two things. Try and understand what is meant by fatigue. Note the examples in our many Safety Digests and talk about them among yourselves. Be honest and see what can be done to alleviate the problem onboard. The options may well be very limited, in which case try the alternative; write to us. We will treat any information sent to us in the strictest confidence. Many people have already contacted the Branch with some startling revelations about safety at sea, and their stories often underpin many of the published lessons to be learned. Given more information, we can make changes. Without it, our ability to improve things, or expose the reasons behind the worst examples of fatigue is, sadly, all too limited.

Lift Failure due to Poor Loading An aircraft lift on board RFA Argus was loaded beyond its safe working load of 18.4 tonnes. There were no injuries to any personnel, or material damage to the ship or its equipment. During a planned stay in port, 500 compressed oxygen cylinders were required to be landed. These were normally stowed on a lower deck and needed to be transferred to the weather deck before being taken ashore. Before the vessels arrival in port, the planned operation was discussed between various officers and senior ratings, one of whom was to supervise final discharge of the cylinders from the ship. Once in port, a senior rating gave instructions to three juniors to transfer a number of cylinders to the weather deck. He then left them alone to load the cylinders onto the platform of an aircraft lift. The cylinders weighed 19.95 tonnes, which was greater than they had been instructed to load. In addition to this excess weight they added a fork lift truck weighing 5.5 tonnes. The lift was then raised. When it reached the weather deck, the lift was unable to stow at the correct level. When investigated it was discovered that the load of both CO2 bottles and the fork lift truck was greater than its safe working load (SWL) and this had prevented the locking cleats at the flight deck (weather deck) engaging. The lift was taken out of service for testing and inspection.

The Lessons 1. The three junior ratings were allowed to work unsupervised with large weights of potentially hazardous compressed gas cylinders. They also operated a large piece of lifting equipment unsupervised. Although senior staff had discussed details of the work at a planning meeting, none of them were present to supervise the task to ensure that the procedures agreed and discussed were followed. The failure was due to not recognising that the total weight of bottles would exceed the SWL. 2. Lifting gear is always marked with its safe working load. Items to be lifted are not always so marked with their weight, and this is often the case with ships stores. If no weighing facilities are readily available, it is essential that whoever is in charge of the task has sufficient experience of the loads, lifting equipment and the overall operation to avoid overloading the lifting gear.

The Timing of Trips! P&OSL Provence entered Dover harbour at 2047 with all five generators on load, and both bow thrusters running. When power was applied to the bow thrusters, the overload alarms on the generators sounded, followed immediately by a complete blackout. The emergency generator came on load, the starboard anchor was let go, and tug assistance was requested. Subsequent checks found only two of the five generators still running. Their breakers were closed and one main engine re-started, with control passed to the bridge. The other three generators were then started, but only two of the circuit breakers would stay closed. Despite this, the remaining three main engines were progressively started and control passed to the bridge. When attempts were made to re-start a bow thruster, excessive starting currents developed, and the attempt was abandoned. While weighing anchor, the bridge staff reported that they had no control over the propeller pitch of the starboard shaft. To correct this, both main engines driving the starboard shaft had to be stopped. Once the pitch control system had been re-set, both main engines were successfully re-started, and control was transferred to the bridge. No further trouble was experienced and the vessel was alongside by 2132. The initial investigation found that the aft bow thrust drive shaft had seized although the electric drive motor was satisfactory. The failed breaker was found to have tripped out on over-current and had not been re-set. A divers inspection found 15 turns of polyprop mooring rope round the aft bow thrust, preventing rotation. There were also 3 turns around the forward bow thrust. A detailed inspection of the generator and bow thrust breakers preferential trips and relays, listed the sequence of events as: • a mooring rope caught round the aft bow thrust causing the electrical overload;

• the overload on the bow thrust starter panels were thermal trip relays only, and not instantaneous;

• the over-current trip on one generator operated with overload still present;

• the remaining four generators tripped on low voltage due to bow thrust overload, causing the blackout;

• the main engines stopped when the auxiliary machinery cut out.

To prevent a recurrence, the following was carried out: • both bow thrust starter panels were fitted with high current instantaneous trips set at 2000 amps in series with the thermal overloads.

The Lessons 1. When machinery is not following commands, use the EMERGENCY stop. 2. Large electric motors MUST be fitted with INSTANTANEOUS overload trips.

3. In this particular case, the incident was caused by a length of mooring rope floating in the harbour, which had been left by another vessel being caught up in the bow thrust. However, it should also be borne in mind that when letting go mooring lines, make sure the shore riggers keep them in hand while the slack is taken in. There are any number of potential hazards for loose mooring lines these days; propellers, voith-schneider blades on tugs, and bow thrusters.

Engineer Superintendents Nightmare! The Veesea Eagle, a 622gt standby vessel, was on station in the North Sea. Early one morning, the superintendent received a call saying that No 1 generator had failed due to an exhaust pipe failure. Shortly afterwards, he received a further report saying that because of a damaged piston, No 2 generator had also failed. Back on board, the harbour generator was started to enable repairs to No 2 generator to be undertaken. While the company arranged for a replacement standby vessel, the chief engineer started to replace the damaged piston. Meanwhile, the harbour generator also failed. Although the main engine was still functioning, and steering was available by using the independently driven Azimuth Thruster, the company decided to tow the vessel back to port for repairs. The subsequent investigation revealed that: 1. No 1 generator Had been running successfully following a complete overhaul, including a new crankshaft, earlier in the year. After the vessel re-entered service, the chief engineer adjusted the fuel timing to improve performance. When he left, the relieving chief engineer also adjusted the fuel timing, but had not been told about the last adjustment. The result of the latter was massive after burning damage to a piston head, cylinder head, and exhaust trunking. 2. No 2 generator Had also been running successfully, when a piston failed for no apparent reason. 3. Harbour generator Failed because of a lack of lubricating oil and it wasnt monitored.

The Lessons 1. All repairs, adjustments or maintenance carried out on any machinery MUST either be recorded in a work book, or in whatever maintenance recording system is installed on the vessel. 2. If adjustments are to be made to the engine timing, consult the manufacturers handbook for advice. After adjustments have been made, always check exhaust temperatures, take indicator cards or peak pressure readings, and monitor