MARINE ACCIDENT SAFETY DIGEST Lessons from Marine

INVESTIGATION BRANCH Accident Reports

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INVESTOR IN PEOPLE

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 1/2008

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INVESTOR IN PEOPLE

Department for Transport Great Minster House 76 Marsham Street London SW1P 4DR Telephone 020 7944 8300 Web site: www.dft.gov.uk

© Crown copyright 2008

This publication, excluding any logos, may be reproduced free of charge in any format or medium for research, private study or for internal circulation within an organisation. This is subject to it being reproduced accurately and not used in a misleading context. The material must be acknowledged as Crown copyright and the title of the publication specified.

Further copies of this report are available from: Marine Accident Investigation Branch First Floor, Carlton House Southampton SO15 2DZ

Printed in Great Britain. Text printed on material containing 100% post-consumer waste. Cover printed on material containing 75% post-consumer waste and 25% ECF pulp. April 2008

MARINE ACCIDENT INVESTIGATION BRANCH

The Marine Accident Investigation Branch (MAIB) is an independent part of the Department for Transport, the Chief Inspector of Marine Accidents being responsible directly to the Secretary of State for Transport. 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 and incidents. 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 Editor, Jan Hawes, welcomes any comments or suggestions regarding this issue.

If you do not currently subscribe to the Safety Digest, but would like to be added to the distribution list for hard copies, and/or email alerts about it or other MAIB publications, please get in touch with us:

• By email at maibpublications@dft.gsi.gov.uk; • By telephone on 023 8039 5500; or • By post at: Publications, MAIB, Carlton House, Carlton Place, Southampton SO15 2DZ.

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.gov.uk

Summaries (pre 1997), and Safety Digests are available on the Internet: www.maib.gov.uk

Crown copyright 2008

MARINE ACCIDENT INVESTIGATION BRANCH

The role of the MAIB is to contribute to safety at sea by determining the causes and circumstances of marine accidents, and working with others to reduce the likelihood of such causes and circumstances recurring in the future.

Extract from The Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”

INDEX GLOSSARY OF TERMS AND ABBREVIATIONS

INTRODUCTION 7

PART 1 – MERCHANT VESSELS 8 1. Caution – Seabed Last Surveyed by Leadline in Mid 19th Century 10 2. One Fire is Unfortunate, Two Fires is … 12 3. Left a Bit More 15 4. Too Little, Too Late 17 5. Buoy oh Buoy – Planning the Voyage Would Probably Have Prevented This Grounding 19 6. He Was Not Supposed to be There, Guv! 20 7. Backspring Strikes Leading Hand in the Face 23 8. Mooring Failure – Walking a Tightrope 25 9. To Cross or Not to Cross? 28 10. Don’t Try This at Home 32 11. In Command, Inebriated, Incapacitated and in Jail 35 12. Port or Starboard? 37 13. That Was Close, Too Close 39 14. Buried Tow Line Nearly Buries Tug’s Engineer 40 15. Sliding Load 41

PART 2 – FISHING VESSELS 42 16. Brief Visit to Deck Costs Life 44 17. Look Out or Lose Out 46 18. Sea Survival Training – Payback Time 48 19. The Flames Were Supposed to Stay Inside the Heater 50 20. Eyes Available But Not Used 52 21. Unguarded Machinery is a Riddle 53

PART 3 – LEISURE CRAFT 56 22. Uncontrolled Gybe Leads to Avoidable Death in the Baltic 58 23. Blank Off Ventilation at Your Peril 60 24. Short Sailing Trip Ends in Tragedy 62 25. Crash Gybe Claims a Life 64

MAIB NOTICEBOARD 68

APPENDICES 70 Appendix A – Preliminary examinations and investigations started in the period 01/11/07 to 29/02/08 70 Appendix B – Reports issued in 2007 71 Appendix C – Reports issued in 2008 73

Glossary of Terms and Abbreviations AB - Able seaman ARPA - Automatic Radar Plotting Aid Cable - 0.1 nautical mile CATZOC - Category of Zone of Confidence CNIS - Channel Navigation Information Service CO2 - Carbon Dioxide CPA - Closest Point of Approach DSC - Digital Selective Calling EBL - Electronic Bearing Line ECDIS - Electronic Chart Display and Information System ECS - Electronic Chart Systems GPS - Global Positioning System GRP - Glass Reinforced Plastic GT - Gross tonnes HGV - Heavy goods vehicle HRU - Hydrostatic Release Unit kW - kilowatt LPG - Liquid Petroleum Gas m - metre “Mayday” - The international distress signal (spoken) MGN - Marine Guidance Note MOB - Man Overboard Nm - nautical miles OOW - Officer of the Watch PPE - Personal Protective Equipment RNLI - Royal National Lifeboat Institution Ro-Ro - Roll on, roll off RYA - Royal Yachting Association SOLAS - International Convention for Safety of Life at Sea STCW - International Convention on Standards of Training, Certification and Watchkeeping TSS - Traffic Separation Scheme UHF - Ultra High Frequency UTC - Universal Time Co-ordinated VHF - Very High Frequency VLCC - Very Large Crude Carrier

Introduction In the last few months of each year, the MAIB puts considerable effort into compiling its statistics for marine accidents/ incidents in the previous year. These will be published in detail in the MAIB’s Annual Report, due out in June. However, with the normal caveat that these numbers are still provisional, there are some sobering figures that should remind all of us of the need for vigilance at sea:

1. We are aware of 12 fatalities in merchant vessels over 100gt, the highest number since 1992. While 6 seafarers died in just 2 accidents (Viking Islay and Flying Phantom) the others died in 6 separate accidents.

2. We have recorded 55 deaths in the “leisure sector”. While this dataset has a very broad definition, covering everything from canoes and canal barges to ocean- capable yachts and commercially operated leisure craft, it is still a tragically high number of deaths.

3. Although fishing has had a relatively average year (10 deaths, after 2006’s high of 16), there is no room for complacency here either. In November the MCA published Dr Stephen Roberts’s study updating “mortality for workers in the UK merchant shipping and fishing sectors”, which shows that over the 10 years 1996-2005, fishing remained, by many orders of magnitude, the most dangerous industry in the UK.

Finally, I would like to thank the large number of readers who have responded to our recent readership survey. Details of the survey, and our responses are on our Noticeboard at page 68.

Stephen Meyer Chief Inspector of Marine Accidents April 2008

MAIB Safety Digest 1/2008 7

Part 1 – Merchant Vessels It is a great pleasure tried and tested methods of ensuring safe to be invited to write operations, but it is the implementation of this Introduction to these methods which seems to fail. the Merchant Vessels Section of the MAIB’s It should be noted that the articles chosen for Safety Digest 1/2008, this Digest are just a few of the reported and it has a certain accidents which have occurred during the resonance for me as I period, but each one is interesting and of am an avid reader of relevance because of the specific lessons the MAIB Accident which can be learned. Reports. In my opinion, the The international association of dry cargo ship publishing of these Reports is a vital service to owners, INTERCARGO, continues to promote the shipping industry and there are lessons to the goal of quality across the dry bulk sector be learned from each and every incident. and is placing a greater emphasis on the role of the human element through the recent It is said that ‘experience is the best teacher’ creation of a joint committee with but that ‘the wisest learn from the experience INTERTANKO to provide a focus for the of others’. That is what the MAIB reporting adoption of industry best practices. The scheme is all about – to make us all wiser. publication of the MAIB’s Safety Digest is a useful tool in our efforts to achieve this goal. Anyone who regularly reads the MAIB Accident Reports will know that the same type of As I have done in the past, I congratulate the accidents occur on a regular basis. The Reports MAIB for the standard of reporting that it cover merchant vessels of all sizes and types continues to produce and I hope that seafarers undertaking short sea as well as ocean in conjunction with their managers and passages. It is quite clear that many of the owning companies can be made more aware of accidents reported could equally apply to any the experience of others and thereby become vessel and that, therefore, lessons can be wiser and less liable to repeat the same learned irrespective of the trading pattern and mistakes, with the inevitable tragic vessel size and type. consequences.

I would very much like to see the development of the MAIB accident reporting model in a wider international context so that more can be learned from the incidents which occur constantly around the world, but I have no expectation that this will happen in the near future.

In this Digest, we have some important recurring themes which relate to groundings, collisions and mooring accidents. All of these could have been averted through proper implementation of team management and briefing/planning prior to the event. In most cases the adoption of an effective monitoring process would have prevented the accident from occurring. The industry has effective

8 MAIB Safety Digest 1/2008

Roger Holt

Roger Holt began his career in the maritime industry as a Deck Officer with P&O in 1964 and came ashore in 1971 having graduated with a BSc in Nautical Science from Southampton University.

He was retained by the commercial department of P&O Bulk Shipping, and in 1980 he joined Burbank Marine in London and operated as a dry cargo broker on the Baltic Exchange until 1985. He then joined Mundogas in London as Chartering Manager. Mundogas was sold to Enron in 1988 and he was employed by the new ship owner to run its commercial office in London.

He was appointed Managing Director of Universal Bulk Carriers in 1992 until 1995. During this period, he was also involved with developing Aurora Tankers as a J/V between IMC and OMI.

He was then appointed Managing Director of UB Shipping until 1997 when UB Liner Services was sold and the reefer operation repatriated to Norway. In 1998 he established Holt Maritime Ltd as an independent consultancy and project brokerage company.

He was appointed Secretary-General of INTERCARGO in June 1999.

MAIB Safety Digest 1/2008 9

Caution – Seabed Last Surveyed by Leadline in Mid 19th Century

Figure 1: Jack-up barge in position Figure 2: The tug used to escort the jack-up barge

Narrative The tug skipper discussed the situation with the tow master, and they agreed to change A jack-up barge, towed by a 32m tug and their route to a channel used less frequently by escorted by a second tug, was being moved as deep draught vessels, but one the skipper had part of a project to install a coastal renewable used many times before. This route also had a energy installation. The visibility was good, minimum expected depth of water in excess of with light, variable winds; perfect for 20m. As the tug and tow altered course to run transferring the barge. Although it was the day with the ebb tide, their speed increased to before spring tides, the barge had been around 9 knots. transferred the previous day, within the same area, without concern. The tug skipper used Following the decision to change the route, paper charts for planning and navigation the tow master and tug skipper agreed to together with a chart plotter for monitoring lower the barge legs further, to 13m, to reduce the passage. the expected rolling when they crossed the tidal flow later, and to have the legs at the The least expected depth for the passage was correct depth for positioning the barge on the greater than 20m. Once clear of the port seabed. approaches, the barge master and tug skipper agreed to lower the barge legs to a depth of Shortly after altering course, and half an hour 9m to improve the barge’s stability for the after low water, the barge grounded on the anticipated swell. forward two, of her four, legs. The force of the grounding caused some of the barge The tow’s progress through the water was personnel to fall; however, no one was injured. slightly reduced as the barge trimmed forward now that the legs had been extended. As the The charted depth at the position of the tug and tow approached the halfway point in grounding was shown to be greater than 20m, the voyage the following spring ebb tide, with the closest sounding on the chart flowing at about 6 knots, set the tug and barge showing a depth of 26m. closer to the coast than expected.

10 MAIB Safety Digest 1/2008

The tug skipper reacted quickly to the possibly due to the turbulence caused by the grounding by simultaneously applying astern fast flowing tidal streams in the area. propulsion and paying out the towing cable. The escort tug promptly connected a tow to Following the grounding, the national the stern of the barge to relieve the strain on hydrographic office initiated NAVTEX warnings the barge legs, and held her in position to wait of the danger. A week after the grounding, the for the rising tide and a reduction in the tidal local pilot boat carried out a survey of the area, flow. which confirmed the presence of an uncharted bank with a minimum depth of less than 8m The jack-up barge refloated 40 minutes after covering an area of approximately 2.5 x 2.5 the grounding and was returned to harbour. cables. The published chart correction revised All four legs were found to be damaged, with the charted depth of the bank to be 7.1m. the damage to the barge costing an estimated £1m to repair. The delay in returning the barge The source diagram for the chart showed the to her destination also resulted in extensive area to have been surveyed by leadline delays to the project when the seabed frame, between 1839 and 1848. The original survey constructed during the previous installation record showed that the survey of the stage, collapsed in the strong tides. grounding area was carried out in 1844, and the findings were correctly transferred to the The tug’s echo sounder was running chart. The 7.1m bank had been missed due to throughout the voyage, although the depth the sampling nature of the leadline surveys. trace prior to the grounding was illegible;

The Lessons instead of the traditional Source Data diagram shown on paper charts. 1. Ever larger and deeper draught vessels, However, CATZOC might be an including passenger ships, are navigating ECDIS menu option which is not more frequently in remote and immediately available to the navigator infrequently visited areas of the world. and so easily forgotten during passage This grounding should alert masters and planning. A full description of marine managers to the risks of routing CATZOC is provided in the Mariners their vessels in these areas. Handbook – NP100.

2. The tug skipper and the tow master had • Electronic chart systems (ECS) and not appreciated the implications of the chart plotters might not display source data on the chart they were using. CATZOC or survey source data at all, 19th Century source data implies therefore their reliability should be leadline surveys which, by their nature, carefully considered by the prudent are not as comprehensive as modern navigator. If appropriate, reference surveys. Prudent mariners must check should be made to updated paper the source data of their charts to assess charts. the risk to their passage plan. 4. Depths that are significantly less than 3. When using electronic charts, source charted may exist wherever your voyage data can be hard to find or, once found, takes you, and the possibility of their interpret: existence should not be ignored. Echo sounders should be used in poorly • ECDIS equipment uses Category of surveyed regions, even when shallows Zone of Confidence (CATZOC) are not expected.

MAIB Safety Digest 1/2008 11

One Fire is Unfortunate, Two Fires is…

Figure 1: Fire Service attending to the fire (image captured from CCTV)

Narrative of the funnel. The engine room was evacuated, closed down and the CO2 flooding system was A 2500gt general dry cargo ship had arrived at operated