Marine Accident Investigation Branch (MAIB) - Safety Digest

Contents Marine Accident Investigation Branch ........................................................................5 Extract from The Merchant Shipping (Accident Reporting and Investigation) Regulations 1999 5 Glossary of Terms and Abbreviations .........................................................................6 Introduction ....................................................................................................................8 Part 1 Merchant Vessels ................................................................................................9 CASE 1 Fly Spray Bomb!............................................................................................11 Narrative.................................................................................................................................11 The Lessons............................................................................................................................11 CASE 2 Screwing Up!..................................................................................................12 Narrative.................................................................................................................................12 The Lessons............................................................................................................................12 CASE 3 Collision with Vessel Alongside...................................................................13 Narrative.................................................................................................................................13 The Lessons............................................................................................................................13 Footnote..................................................................................................................................13 CASE 4 Which Way Was It Wound?.........................................................................14 Narrative.................................................................................................................................14 The Lessons............................................................................................................................15 CASE 5 Master Overcome by Fumes in Cargo Hold ...............................................16 Narrative.................................................................................................................................16 The Lessons............................................................................................................................16 CASE 6 Passenger Falls Down Open Hatch on Fast Ferry......................................18 Narrative.................................................................................................................................18 The Lessons............................................................................................................................18 CASE 7 Collision Between a Tank Barge and a Vessel Alongside ..........................19 Narrative.................................................................................................................................19 The Lessons............................................................................................................................19 Footnote..................................................................................................................................20 CASE 8 Something to Gripe About............................................................................21

Narrative.................................................................................................................................21 The Lessons............................................................................................................................21 CASE 9 Twenty Litres of Trouble! ............................................................................22 Narrative.................................................................................................................................22 The Lessons............................................................................................................................22 CASE 10 Fatal Accident to Third Officer While Closing Hatches..........................24 Narrative.................................................................................................................................24 The Lessons............................................................................................................................24 Footnote..................................................................................................................................25 CASE 11 Grounding of General Cargo Ship with Pilot on Board ..........................26 Narrative.................................................................................................................................26 The Lessons............................................................................................................................27 Footnote..................................................................................................................................27 CASE 12 Compression Couplings Can Spell Danger ...............................................28 Narrative.................................................................................................................................28 The Lessons............................................................................................................................28 CASE 13 According to the Book! ...............................................................................30 Narrative.................................................................................................................................30 The lessons .............................................................................................................................30 CASE 14 Near Miss in the Dover Strait.....................................................................32 Narrative.................................................................................................................................32 The Lessons............................................................................................................................32 Part 2 - Fishing Vessels ................................................................................................33 CASE 15 Near Misses Involving Fishing Vessels ......................................................35 Narrative 1..............................................................................................................................35 Narrative 2..............................................................................................................................35 The Lessons............................................................................................................................35 Footnote..................................................................................................................................36 CASE 16 Fatality on Board Fishing Vessel................................................................37 Narrative.................................................................................................................................37 The Lessons............................................................................................................................37 Footnote..................................................................................................................................38 CASE 17 For Appearance's Sake ...............................................................................39

Narrative.................................................................................................................................39 The Lessons............................................................................................................................39 Footnote..................................................................................................................................40 CASE 18 Take Your Lifejacket and Phone with you ...............................................41 Narrative.................................................................................................................................41 The Lessons............................................................................................................................41 CASE 19 Poor Watchkeeping on Fishing Vessel.......................................................43 Narrative.................................................................................................................................43 The Lessons............................................................................................................................43 CASE 20 Tiredness Can Kill......................................................................................45 Narrative.................................................................................................................................45 The Lessons............................................................................................................................45 Footnote..................................................................................................................................46 CASE 21 Grounding of a Fishing Vessel ...................................................................47 Narrative.................................................................................................................................47 The Lessons............................................................................................................................47 Footnote..................................................................................................................................48 Part 3 - Leisure Craft...................................................................................................49 CASE 22 Even Maxis Capsize.....................................................................................50 Narrative.................................................................................................................................50 The Lessons............................................................................................................................53 Readiness for sea....................................................................................................................54 Planning and execution of the passage...................................................................................55 Leadership style .....................................................................................................................55 Storm tactics...........................................................................................................................56 Abandoning ship ....................................................................................................................57 Rescue at sea ..........................................................................................................................57 Footnote..................................................................................................................................57 CASE 23 Kill-Cord Conduct.......................................................................................58 Narrative.................................................................................................................................58 The Lessons............................................................................................................................58 Footnote..................................................................................................................................59 Case 24 Vigilance, ARPA and Relative Speed...........................................................60

Narrative.................................................................................................................................60 Incident 1:...............................................................................................................................60 The Lessons............................................................................................................................60 A Pause for Thought Keeping a Good Lookout - Again ..........................................62 MAIB NOTICEBOARD..............................................................................................66 APOLOGIES..........................................................................................................................66 READERSHIP .......................................................................................................................66 BOOK REVIEW.................................................................................................................... 66 APPENDIX A ...............................................................................................................67 Appendix B Reports issued in 2001 (unpriced) .........................................................68 Appendix C Reports issued in 2002 (unpriced).........................................................71 APPENDIX D Stationery office stockists and distributors overseas ......................72

Marine Accident Investigation Branch The Marine Accident Investigation Branch (MAIB) is an independent part of the Department for Transport, Local Government 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 Transport, Local Government 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 that 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, Local Government and the Regions, and can be obtained by applying to the MAIB. Other publications are available from The Stationery Office and the DTLR 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 AB Able Seaman

ARPA Automatic Radar Plotting Aid

DNV Det Norske Veritas

DR Dead Reckoning

EPIRB Emergency Position Indicating Radio Beacon

ETA Estimated Time of Arrival

FRC Fast Rescue Craft

GT Gross tons

IMDG International Maritime Dangerous Goods Code

IMO International Maritime Organisation

ISM International Safety Management

kW Kilowatt

MCA Maritime and Coastguard Agency

MCB Main Circuit Breaker

OOW Officer of the Watch

"Pan Pan" The international urgency signal (spoken)

RIB Rigid Inflatable Boat

Ro-Ro Roll-on, roll-off

RYA Royal Yachting Association

TSS Traffic Separation Scheme

UMS Unmanned Machinery Space

UTC Universal Co-ordinated Time

VHF Very High Frequency

VTS Vessel Traffic Services

Introduction One of the first things a new marine accident investigator learns is that an accident is never the result of a single cause. It happens because a number of things have gone wrong, and the various measures put in place to prevent it failed for some reason. This knowledge prompts the investigator to look beyond the obvious explanations, and to investigate a wide range of factors which could well have been contributory, or underlying reasons, why the incident occurred. Furnished with the same basic awareness, every one of us at sea, regardless of rank or status, should be in no doubt that everything we do plays a part in preventing accidents. By keeping our eyes open, and having all our senses tuned to identifying that little something which isn't right, we are part way to preventing an accident. The other part is doing something about it. We either take the appropriate action ourselves or draw it to the attention of someone else who has the ability to deal with it. Such actions interrupt the causal chain of an accident. To many of us this ability to spot the 'something' that isn't right is almost a sixth sense. It comes from sound training and from experience acquired over the years. Very often it is acquired from having got it wrong in the past. We all make mistakes; the important thing is to learn from them. The opposite, sadly, is also true. We can all too easily find ourselves in the causal chain of an accident because we have either failed to spot a problem, or turned a blind eye to something that wasn't right, or were insufficiently competent to handle a situation. Every one of us is guilty of cutting corners. Most times we get away with it but, sooner or later, we will get caught out. Few of us can resist that siren voice that tells us we can turn a blind eye to something because 'it has always been done that way,' or because someone else is bound to deal with it later. The embarrassment is that something overlooked or ignored today could well come back to haunt you. An accident chain can be very long and the links can appear very minor indeed. Even things as small as failing to eat a proper diet, or being late on watch, or saying you know how to do something when you haven't a clue, can be the cause of something going badly wrong. The wrong diet can lead to degraded performance. Being late on watch can lead to a very grumpy off-going watchman and a botched handover, and we all know how difficult it is to admit to not knowing how to do something when the person giving the order is being particularly anchor faced. Being safe at sea means being aware of everything around you. If you detect something isn't right, do something about it. If you don't, the omission could well be that crucial link in the causal chain leading to an accident. The MAIB's investigations unearth the causes and contributory factors of accidents in detail. They are well worth reading, are free of charge and are now also available on the Internet at www.maib.dtlr.gov.uk. J. S. Lang Chief Inspector of Marine Accidents

Part 1 Merchant Vessels Keeping an anchor watch is among the most straightforward of all tasks falling to the mariner. Get it right and you might, just might, receive a grunt of approval from the old man. Get it wrong and you land up impaled on the rocks or find yourself high and dry on some beach, the ship's name is likely to be spread-eagled across the front pages of the papers. In such situations the owners tend, with a degree of justification, to be a trifle upset. If the grounding leads to pollution, you will have quite a bit of explaining to do to people who will be disinclined to put you on their Christmas card list. 'Getting it wrong' is not recommended, but a month rarely passes without some ship somewhere in the world suffering the ignominy of dragging her anchor and landing up on a lee shore. The ability to anchor safely is one of the most ancient skills known to the seafarer. In his 'Mirror of the Sea', Joseph Conrad reflected that 'An anchor is forged and fashioned for faithfulness; give it a ground that it can bite and it will hold till the cable parts.' True enough, but several steps are necessary before this state can be reached. In selecting a good anchorage and the length of cable to put out, the mariner will assess the degree of shelter afforded, the depth of water, the nature of the holding ground, the length of stay, the strength of the tide or current, the proximity of potential hazards and the predicted weather. In many instances, but not always, the exercise is straightforward. In deciding how much cable to put out, many of us adopt ready rules of thumb such as four or five times the depth of water. Others will turn to the relevant page of their salt stained seamanship manuals to be reminded that for mild steel cable the number of shackles to put out is one and a half times the square root of the depth of the water in metres. Knowledge of the handling characteristics of the vessel concerned, and the amount of cable available, will influence the decision. Having anchored and safely brought up, the aim is to stay there until you are ready to weigh. The problem is that certain things, particularly the onset of bad weather, can make life uncomfortable. The start point is to know exactly where the anchor itself is so you can calculate the swinging circle. Providing you remain within it you are likely to be safe but, as soon as you start to move outside that circle, you must act. Dragging can be a curious sensation. Many who have had the experience will recall the incredulity with which they watched other vessels in the same anchorage all seem to get underway in unison. Those same watchkeepers have invariably taken a moment or two to realise that they were the ones who were moving. Whether at anchor alone or in company, the watchkeeper must always be alert to the possibility of dragging. Once it starts, a ship can move with astonishing speed, and many mariners have been severely shaken by it. Two knots is not unknown. Preventing a grounding is better than trying to sort the mess out afterwards. If the sheltered anchorage becomes an exposed one, with a rising sea state and an onshore wind, you should consider your options. Should you let out more cable, let go the second anchor, start the engines or even weigh and go somewhere else including the open sea? Knowing whether you are dragging is crucial. Regular fixing by whatever means are available, and the use of clearing bearings or shore transits, will give an indication. Don't ignore the value of having someone on the fo'c'sle feeling the cable. And once you even suspect you are no longer securely at anchor, don't delay by double-checking everything. Do something about it.

If the lee shore beckons, the one thing you haven't got is the luxury of time.

CASE 1 Fly Spray Bomb! Narrative The 1005gt Colonel Templer was on passage in Scottish waters. The evening meal had just been finished and the cook was clearing up in the galley. On starting the food macerator, an explosion blew open the under sink cupboard doors and started a fire. The fire was limited to a box containing Brillo pads, and was quickly extinguished. Luckily the cook escaped without injury although, understandably, he was suffering from shock. Later investigation revealed an aerosol can of flying insect killer lying in the under sink cupboard among some cleaning products. It had obviously been there for some time, since the container had corroded to create a small pinhole, through which the contents had escaped. The propellant used in most aerosols is gas butane. It is also used for cigarette lighters and camping stoves. Any flammable gas is an explosion risk, but when mixed with air in a confined space it is, effectively, a bomb. The small electrical sparks created when the macerator was started were sufficient to ignite the explosive gas mixture.

The Lessons 1. A safe and healthy ship can only be maintained through good housekeeping, and this is the responsibility of everyone on board. Only keep a minimum of cleaning products in use at any one time. Ensure, through reference to product data sheets and manufactures' instructions, that items can be stored together in the space intended. Under sink cupboards are likely to be wet, and this will lead to corrosion of metal containers. 2. Aerosols present a number of serious risks, and as a result must be treated with thought and respect. Flammable gases are now used as the propellant in most aerosols. This makes every aerosol a potential explosion risk, even when empty. They must be stored in cool, dry, well ventilated areas away from possible heat sources. Any damaged or corroded aerosols must be disposed of safely and in accordance with the manufacturer's instructions. Consideration must also be given to the dangers presented by aerosols in the event of a fire on board. 3. A regular inspection by ship's staff of all spaces, including storage areas and cupboards, will highlight lapses in housekeeping, and allow them to be put right.

CASE 2 Screwing Up! Narrative Pride of Bilbao, a 37,583gt ro-ro passenger vessel, was moored alongside in Southampton Docks while undergoing a minor refit. Part of this work involved the fitting of new wire falls to No 15 lifeboat davits. Once the work had been completed, arrangements were made to test the davit system with the lifeboat being lowered under 110% load conditions with an MCA surveyor in attendance. With the lifeboat correctly loaded, the second officer released the brake and started lowering the boat. When the davit arms had reached their lowest point on the trackway, the brake was re- applied. Almost immediately, the bottle screw securing the new wire on the aft davit parted, allowing the wire and the threaded part of the screw to run free. The wire ran through the sheaves until it jammed, causing a severe shock load to the davit arm. This loading caused the davit arm to pull free of its trackway and drop on to the boat. With the full weight of the lifeboat now transferred to the forward davit it, too, failed and the lifeboat fell into the water. The subsequent examination of both parts of the bottle screw found that the threaded sections were largely undamaged. Only one or two threads at the ends were affected. The cause of the bottle screw failure was either that it had not been refitted correctly after the new wire had been installed, or that while reeving the new wire, the bottle screw had rotated in its housing. To prevent a recurrence, existing bottle screws have been "locked" with seizing wire until new bottle screws, fitted with locknuts and anti-twist turnbuckles, are received.

The Lessons 1. On completion of ANY work involving lifting equipment and wires, ALWAYS check and re-check all securing points. 2. Always ensure that any thread-locking devices WORK, and that they are USED. 3. If the work involves any SAFETY OR LIFESAVING EQUIPMENT always check not only the item itself, but also the system. Your life may depend on it.

CASE 3 Collision with Vessel Alongside Narrative Xuchanghai was inbound for the Immingham bulk terminal, laden with 27,672 tonnes of Ilmenite and a pilot embarked. Aberdeen, a North Sea shuttle tanker, was alongside the Immingham oil terminal and was preparing to sail, having discharged her cargo. Xuchanghai had a tug connected forward as she lined up to turn off Immingham dock. A second tug was securing a line aft. The pilot reduced Xuchanghai's speed as she approached the eastern end of the oil terminal, to make the swing off the dock easier, and was making 3 knots through the water. She had a brisk wind on her port quarter and a 4-knot flood under her. Xuchanghai lost steerage and began to point at Aberdeen lying alongside. The pilot took corrective action using helm, engine and the bow tug, but the actions failed to prevent Xuchanghai colliding with Aberdeen. The aft tug managed to secure her tow line only moments before the collision. Aberdeen sustained a 20m gash in her No 2 ballast tank, a wing tank on her starboard side. Xuchanghai suffered indentations and buckling