Marine Accident Investigation Branch (MAIB) - Safety Digest

Contents About The Marine Accident Investigation Branch.....................................................3 Glossary of Terms and Abbreviations .........................................................................4 Introduction ....................................................................................................................5 Part 1- Merchant Vessels...............................................................................................6 Case 1 Collision in Restricted Visibility......................................................................7 Case 2 Light Reading!..................................................................................................10 Case 3 You Cannot Breathe without Oxygen!...........................................................11 Case 4 Alive or Dead ....................................................................................................12 Case 5 A Let Down! .....................................................................................................13 Case 6 Grounding of Coastal Tanker.........................................................................15 Case 7 Collision with the Nab Towe ...........................................................................18 Case 8 Alter Course to Port or Stand-On? That is the Question.............................21 Case 9 Singing from Different Song Sheets? .............................................................23 Case 10 Undeclared Dangerous Goods; Problems....................................................24 Case 11 One Thing Leads to Another ........................................................................26 Case 12 No Breathing, Engine Dies ............................................................................27 Case 13 Vessel Grounds in Thames............................................................................28 Case 14 Container Ship Slices Tanker in Two. Five Killed .....................................30 Part 2 Fishing Vessels ..................................................................................................33 Case 15 Fires Love Open Doors!.................................................................................34 Case 16 Overloading, Disregard of Stability and Flooding, Results in Loss of Vessel and Skipper ..........................................................................................................................36 Case 17 Lone Skipper Trapped in Winch for Several Hours ..................................38 Case 18 Low Freeboard Causes Two Fatalities.........................................................40 Case 19 Saturated Buoyancy Causes Dory to Capsize .............................................41 Case 20 Loss of Fisherman Results in Lifejacket Campaign ...................................43 Case 21 Grounding and Loss of Fishing Vessel.........................................................44 Part 3 Leisure Craft .....................................................................................................46

Case 22 So Close to Home and Yet So Far ................................................................47 Case 23 Tynemouth Tragedy Two Killed ..................................................................52 Case 24 Overtaking in Harbour Entrance.................................................................58 Part 4 Looking after the Passengers...........................................................................60 Case 25 Liner Hits Iceberg Over 1500 Perish ...........................................................61 Case 26 Fire On Passenger Ship Five Crew Members Overcome by Smoke .........64 A Pause for Thought ....................................................................................................69 Appendix A ...................................................................................................................74 Appendix B Reports issued in 2000 (Priced) .............................................................76 Appendix C Reports issued in 2000/2001 (Unpriced) ...............................................77 Appendix D Stationery office stockists and distributors overseas ..........................80

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 of the Environment, Transport and the Regions, and can be obtained by applying to the MAIB. Other publications are available from The Stationery Office bookshops and the DETR Publications Sale Centre, Unit 21, Goldthorpe Industrial Estate, Goldthorpe, Rotherham, S63 9BL (Tel: 01709 891318)

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: 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

CAST - Coastguard Agreement for Salvage and Towage CPA - Closest Point of Approach

DGPS - Differential Global Positioning System

DR - Dead Reckoning

ETA - Estimated Time of Arrival

ETV - Emergency Towing Vessel

GPS - Global Positioning System

GRP - Glass Reinforced Plastic

GT - Gross Tonnes

IMDG - International Maritime Dangerous Goods Code

m - metre

"Mayday" - Spoken distress signal MCA - Maritime and Coastguard Agency

MES - Marine Evacuation System

MGN - Marine Guidance Notice

OOW - Officer of the Watch

PLB - Personal locator beacon

RNLI - Royal National Lifeboat Institution

Ro-Ro - Roll-on, roll-off

RYA - Royal Yachting Association

SCBA - Self contained breathing apparatus

TSS - Traffic Separation Scheme

VHF - Very High Frequency

VLCC - Very Large Crude Carrier

VTS - Vessel Traffic Services/System

Introduction We are grateful to the number of our readers from around the world who have contacted us to express appreciation for the way we publish the lessons to be learned from marine accidents. The comments have tended to focus on two themes: approval of the no blame culture coupled with what some kindly refer to as the common sense approach, and the value that many readers appear to attach to learning how other types of vessel might be operated. Merchant ship watchkeepers have found it useful to be reminded about how engrossed their opposite numbers in fishing vessels can become in the fishing and are not as alert to other shipping as they might be. There is a contact on the radar and the ARPA predicts a CPA that involves no risk of collision. The OOW turns his attention elsewhere and fails to spot the subsequent change in CPA when the contact, almost certainly a fishing vessel, has turned through180°and is now on a collision course. This is not as uncommon a problem as some might think. In the same vein the fisherman might also be reminded that to suddenly alter course to avoid a bottom obstruction, or for any other reason, and steer into the path of approaching traffic might not be spotted by the other ship until it is too late. Some merchant ship officers of the watch will assume the fishing vessel is going to maintain the original course and speed and stop paying attention. It shouldn't happen, but it does. Some leisure craft users, meanwhile, have told us how much they welcome the chance to learn something about how merchant vessels are run and discover something about their limitations. If this is translated into an action whereby a yacht skipper goes out of his way to avoid embarrassing a merchant ship in confined waters then the Safety Digest has served its purpose. We are very conscious that nearly all the lessons we publish are directed at seamen, engineers or fishermen. We have not forgotten that there are others employed at sea, the hotel and entertainment staffs in passenger vessels. With them in mind we have compiled a special Section 4 in this edition to remind them of the sort of problems they may confront in the immediate aftermath of a major accident. None of the points raised are new, but an analysis of past accidents reveals they are often forgotten. We would like to think this section will act as a catalyst for discussion about the difficulties likely to be encountered when the unexpected occurs in any vessel carrying passengers. Readers will wish to know that most Safety Digests are now available on our web site; www.maib.dft.gov.uk John Lang Chief Inspector of Marine Accidents

Part 1- Merchant Vessels Few mariners can be unaware of that well-known litany, "About 80% of all accidents at sea are caused by some form of human error." We probably acknowledge there is some truth in it but feel it doesn't apply to us. Even if it did, there is virtually nothing we can do about it. We have, for example, heard about such things as 'fatigue', but what can you expect in a ship where we know there are too few people to fulfil every expectation without getting tired or, to put it more delicately, 'knackered?' We have no say in the manning levels, and if we complain we are likely to get the sack. Although fatigue is one of the most obvious examples of the human factor, there are many others. Taken at random they include ergonomics, welfare, diet, training, communications, morale, stress, cognition, human information processing and health. Ignore any of these and human error follows. Some ship owners and managers go to great lengths to ensure safety and prevent human error by trying to recruit and train high calibre people. But many, too many, don't and overall the MAIB detects a widespread lack of understanding of what is meant by the human factor. It is so easy to blame someone for making a mistake, or failing to act correctly in a specific situation, but so often this 'blame' culture totally fails to understand why the mistake was made in the first place. The temptation to recommend some new regulation, or a technological solution, to prevent a repetition is irresistible to those who must be seen 'to do something.' It also means that whatever the underlying cause, it remains in place, and is likely to feature as a significant underlying cause in some future accident. While many of the solutions lie in the hands of the owners and managers, the seafarer can do much to improve safety if he or she, too, develops a greater understanding and awareness of how humans behave and perform in a marine environment. There is very little literature on the subject in a form digestible to the average mariner, and the MAIB attempts to meet the need by publishing lessons learned in the Safety Digests. We attempt to highlight some examples of how the human factor has played a part in the causes of past accidents. Once you understand why mistakes are made, you are much less likely to make them yourself. As we have said on many previous occasions, an accident only occurs when a number of totally unrelated events come together to create the circumstances that lead to something going badly wrong. If one begins to understand the effects of fatigue, how humans relate to each other, the effects of over-the-counter medication, or the limits of absorbing information, then measures can be put in place to live with them. Man has great ability to sense information by sight, hearing, smell and touch. But he has only one single decision-making channel. Over and over again we see that same person being swamped with information only to be severely criticised, or even arrested, for getting it wrong. Human factors matter. Learn from the experiences of others before it is too late.

Case 1 Collision in Restricted Visibility Narrative Wintertide and MSC Sabrina were transiting the south-south-west traffic lane of the Off Vlieland TSS in poor visibility, which was assessed at about five cables. MSC Sabrina was making good 17.5 knots and overtaking Wintertide on her starboard quarter. She was predicting a CPA of eight cables. Although Wintertide was making sound fog signals, neither OOW had taken any specific precautions on encountering restricted visibility; the masters had not been informed, nor bridge manning increased, in accordance with company orders. With the vessels about 1.5 miles apart, the Netherlands-registered fishing vessel Concordia, was crossing the traffic lane from the south-east and passed close astern of the lead vessel Wintertide. Soon afterwards the fishing vessel collided with MSC Sabrina. Although the visibility had reduced further to less than two cables, the merchant ship kept going and maintained her original speed. Wintertide's OOW was aware that MSC Sabrina was overtaking, but did not estimate when or where the CPA would be. Neither was he aware that she had been involved in a collision. As MSC Sabrina closed to one mile on his starboard quarter the OOW, prompted by a GPS waypoint alarm, altered course 25° to starboard to follow the ship's planned track. In doing so he put the two vessels on converging courses. After the alteration, Wintertide's OOW estimated from his radar that the overtaking vessel would pass astern on the port quarter, and it wasn't until MSC Sabrina was sighted very close on the starboard side that he realised what was happening. At this point he applied 20° of port helm and put the propeller pitch to Dead Slow Ahead. Meanwhile, MSC Sabrina's OOW, who had been distracted by the collision with Concordia, did not notice Wintertide's alteration of course. This was only evident after the master arrived on the bridge following the incident with the fishing vessel and saw a radar contact 3-4 cables forward of the port beam on a converging course. The master immediately ordered the OOW to put the helm to starboard. Despite the actions taken by both vessels to avoid a collision, MSC Sabrina's port quarter struck Wintertide's starboard bow.

The Lessons 1. Any OOW, who happens to be on watch when visibility reduces, has an awesome responsibility. The owners expect him to do the right thing, the master trusts him to comply with the regulations and his standing orders, and other vessels expect him to be keeping a proper lookout and taking whatever actions are necessary to comply with the COLREGs. 2. The master's recurring nightmare is to be called too late when things begin to get out of hand. A responsible master will stress over and over again that he would rather be called unnecessarily if the OOW is in any doubt, than be called too late or not at all. Yet officers of the watch are seemingly reluctant to call the master on the assumption (often erroneous) that they think they can handle the situation themselves. By not informing the masters of the reduced visibility on this occasion, both OOWs denied themselves the benefit of added knowledge, watchkeeping experience, and judgment. The really good OOW is the one the master can rely on to call him.

3. A key feature of navigating a vessel through a TSS is to anticipate two separate events: the likely consequence of one's own movements on other vessels after any planned course alteration, and to think through what the other vessel may do when it too reaches a probable wheel over position. The one thing to be avoided at all costs is to ignore the inevitability that things will change once you, or the other vessel, alters course. And pay particular attention to the vessel coming up astern. Human nature, and bitter experience, shows over and over again that OOWs often overlook what is happening behind them. A bump up the backside is unlikely to endear an OOW to either the master or his employer, no matter what the Rules might say. 4. Before altering course, an OOW must check that both the new course and the appropriate quarter is clear before putting the wheel over. The practice applies in good visibility as well as in poor. An alteration of course into the path of an overtaking vessel so close astern in poor visibility is a guaranteed recipe for cardiac arrest. In the interests of healthy seamen, don't do it. 5. Tracks on a chart and planned passage speeds are not set in stone; ships may well have to deviate from them when the circumstances dictate. While a GPS waypoint alarm provides an invaluable reminder that a course alteration is due, the actual decision to do so depends on the OOW first checking it is safe. If there is something that prevents a safe alteration, such as an overtaking vessel close on the engaged quarter, a delay may be appropriate providing there is sufficient sea room. When checking to see that navigable water is available, OOWs should not rely exclusively on GPS and waypoint navigation. Those old friends the DR and the EP, still give a very good indication of where your vessel is likely to be in the minutes ahead. 6. To be an accurate aid to collision avoidance, radar must be closely monitored at all times on a range scale appropriate to the conditions and circumstances. Operators must also be aware of the capabilities and limitations of the radar in use. In a close quarters situation it is entirely appropriate to reduce the range scale of the radar in use. And the echo of a ship coming up astern may, for instance, lie within a blind arc created by a funnel. Or you are so focussed on looking at one echo that you ignore the new one that has just appeared at short range. In short, remember radar is a wonderful aid, but it doesn't produce all the answers- especially at close range when you don't hold the other vessels visual. A second, or even a third pair of hands on the bridge to help out is often a very sensible, even essential, ingredient to safe navigation in such circumstances. 7. Despite modern aids to prevent collision, the most common ingredient to accidents occurring in reduced visibility is excessive speed. It is so much better to slow down and be late, than to maintain full speed and perhaps arrive with a hole in the side; or even not make it at all. Engineers will often remind their bridge watchkeeping colleagues about how difficult it is to slow down at short notice. But given plenty of warning, and an early decision to put the engines on stand by if poor visibility is forecast when approaching congested waters, even the most hard-bitten among them will agree with the decision. 8. Sound signals in restricted visibility are made for a single purpose; for others to hear them. Masters should take whatever steps are necessary to ensure they comply with the requirement to (a) make