MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accidents No 1/2010

is an

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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 Mountbatten House, Grosvenor Square, Southampton, SO15 2JU.

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 information which has 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, Mountbatten House, Grosvenor Square, Southampton, SO15 2JU

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 2010

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 6

INTRODUCTION 7

PART 1 - MERCHANT VESSELS 8

1. Cargo Vapours – the Unseen Danger 10

2. Dream Becomes a Nightmare 14

3. Keep a Proper Lookout or Look Out! 16

4. Hot Surface + Fuel = Fire 18

5. Surf ’s Up 20

6. “Let Go Forward, Let Go Aft” – Are You Sure You Are Ready? 22

7. Wrong Side of the Buoy 25

8. When Pre-Arrival Safety Checks = Danger 28

9. Modern Technology – Same Old Problem 30

10. A Fatal Attraction 33

11. Failed Seal Causes Engine Room Fire 35

12. Ghost in the Machine? 38

13. Machinery Commissioning – A Shocking Result! 41

14. Leaving Buoyed Channel Leads to Grounding 45

PART 2 - FISHING VESSELS 46

15. Tragedy Close to Home 48

16. Fatigue and Defects Lead to Grounding and Contact 50

17. Fatal Chain of Events 53

18. Snagging Can Lead to Loss of Vessel and Lives 55

19. A Hard Day’s Night 57

20. A Stark Reminder of the Dangers of Drinking 59

21. Tender by Name – Tender by Nature 61

PART 3 - SMALL CRAFT 62

22. Taking a Turn for the Worse 64

23. Beware of Tractor Rides While Riding in a RIB 66

24. Fatal Entrapment 67

25. Hands-Free Mode Required When Mooring 69

APPENDICES 70

Appendix A - Preliminary examinations and investigations 70 started in the period 01/11/09 to 28/02/10

Appendix B - Reports issued in 2009 71

Appendix C - Reports issued in 2010 72

Glossary of Terms and Abbreviations

AB - Able Seaman MGN - Marine Guidance Note ARPA - Automatic Radar Plotting Aid MIRG - Maritime Incident Response Group BA - Breathing Apparatus MSDS - Material Safety Data Sheet BT - Bow Thruster OOW - Officer of the Watch Cable - 0.1 nautical mile P&A - Procedures and Arrangements CO2 - Carbon Dioxide PEC - Pilotage Exemption Certificate CPP - Controllable Pitch Propellers RIB - Rigid Inflatable Boat CPR - Cardio Pulmonary Resuscitation Ro-Ro - Roll on, Roll off CST - Crude Sulphate Turpentine SMS - Safety Management System DSC - Digital Selective Calling SOSREP - Secretary of State Representative (for salvage) ECDIS - Electronic Chart Display and StS - Ship to Ship (transfer) Information System TSS - Traffic Separation Scheme ECR - Engine Control Room UPS - Uninterruptible Power Supply ECS - Electronic Chart System UV - ultraviolet EPIRB - Emergency Position Indicating Radio Beacon VHF - Very High Frequency H2S - Hydrogen Sulphide VTS - Vessel Traffic Services MCA - Maritime and Coastguard Agency

Introduction MAIB is currently investigating the death of a seafarer, during which we have discovered evidence of dereliction of one of the most fundamental duties of the mariner - the moral and legal obligation to go to the aid of those in peril on the sea. Even at the height of war, civilised combatants went to great lengths to save the lives of sailors from enemy vessels they had sunk. Yet here we are, in the 21st Century, finding ships failing to respond to Mayday messages.

In the case we are investigating, poor visual lookout meant that most of the major vessels within 10 miles of the sinking vessel reportedly failed to see a series of distress flares. This in itself is disappointing, but even more alarmingly, most of the same ships also failed to respond to the Mayday Relay, issued several times by the Coastguard. Some claimed not to have heard the VHF (poor standard of watchkeeping again); some claimed not to have received the DSC distress alerts (!); and some masters claimed not to understand that they have a legal (and moral) duty to react.

SOLAS is quite clear on the subject:

“Regulation 33 - Distress Situations: Obligations and Procedures

The master of a ship at sea which is in a position to be able to provide assistance, on receiving information from any source that persons are in distress at sea, is bound to proceed with all speed to their assistance, if possible informing them or the search and rescue service that the ship is doing so. This obligation to provide assistance applies regardless of the nationality or status of such persons or the circumstances in which they are found. If the ship receiving the distress alert is unable or, in the special circumstances of the case, considers it unreasonable or unnecessary to proceed to their assistance, the master must enter in the log-book the reason for failing to proceed to the assistance of the persons in distress, taking into account the recommendation of the Organization to inform the appropriate search and rescue service accordingly.”

I approached the senior management of each of the ships involved. I am pleased to report that all reacted with horror that their vessels had not responded, and took urgent action to instruct all their ships to respond properly to such situations in the future.

I would urge all companies and mariners to remember that this requirement is not optional. It is also not up to coastal stations to call ships with a request to assist; in such circumstances it is the duty of every “master of a ship at sea which is in a position to be able to provide assistance” to at least call the search and rescue service and then respond to their instructions.

Stephen Meyer Chief Inspector of Marine Accidents April 2010

MAIB Safety Digest 1/2010 7

Part 1 - Merchant Vessels When I was nature of the shipping community, with many asked to write the owners under many different national regimes. introduction to However, I am firmly of the view that if we this edition of the all, as individuals, commit to learning and “Safety Digest,” following safe practices, we can make a I was very happy difference. In this respect, two areas we need to volunteer. The to guard against are complacency; and the very reason for this is nature of the “can do” attitude of a seafarer. that prevention of incidents in the With regard to complacency, I came across fleet I manage is the following statement recently: “If eternal something my vigilance is the price of liberty, then chronic team and I think unease is the price of safety.” What I believe about every day. Any organisation or report this means is that when operating in a which helps in this endeavour is worthy of hazardous environment it is essential each support. individual is constantly thinking of what can go wrong and acting accordingly. One could think Before beginning to write, I had the opportunity of it as an ongoing mental risk assessment. to review a number of the articles describing a I recognise that maintaining such a mental wide range of incidents, and was immediately state for lengthy periods of time is challenging. struck by how many were almost identical to However, I believe we need to look at this as accidents I have read about previously, or the price of safety. indeed experienced in some way through my career. Two that particularly resonated with me As to the seafarer’s “can do” attitude, I see were: “Cargo Vapours - The Unseen Danger;” this as a much larger challenge. Seafarers have and “Machinery Commissioning - A Shocking a reputation as proud individualists with a Result.” Luckily, there were no fatalities in long history of simply getting the job done no either instance, but there so easily could have matter what the circumstances. There is a very been. large degree of truth in this and it is something we should be proud of. When I read of such events, it is very disturbing on a number of counts. Not only are real However, it’s also true to say that shipping, people suffering real injuries, or in the worst because of its incident rates, has always case even death, but also our industry seems ranked as a hazardous profession. From both unwilling to really learn the lessons of the past. a humane and societal perspective, this is not something we can and should accept. While there are no excuses for this perceived We need to overcome the scepticism around inability to learn, there is little doubt that such following “Risk Assessment” and “Permit to a quest is not assisted by the fragmented Work” procedures, and move away from the

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tick box mentality. These are tools to prevent We also, in my opinion, have some of the injury to you and your fellow seafarer. These most committed and talented people in any safety measures are not simply processes industry, working in what can be a very hostile that need to be carried out. They need to be environment. Because of all these things, we interwoven into the management of the task owe it to ourselves, our colleagues and our and adjusted if circumstances change. families to “get home safely.”

Finally, let me finish on a positive note. Without shipping, trade would not exist and without trade, the world as we know it would not exist. Because we are largely unseen then we rarely get the recognition we deserve, but nevertheless, it is something we can all be proud of.

Graham Westgarth

Graham Westgarth joined Teekay in February 1999, and as President of Teekay Marine Services is responsible for the day-to-day operations of the Teekay fleet that is in excess of 165 vessels, and close to 5,000 multi-disciplined sea and shore staff. Graham’s mandate includes newbuildings, conversions, repair and maintenance, manning and training, procurement, marine, and last but by no means least, health, safety, environment, and quality. He has over 38 years of industry experience, 17 of which were at sea, including 5 years command experience. Prior to joining Teekay, Graham spent 12 years with the Maersk Company heading up its UK flag fleet. During this period, he established and was the general manager of AP Moller’s FPSO operations in the UK sector of the North Sea. In 2006, Graham relocated to Norway for 8 months following the acquisition of Petrojarl ASA, and as interim CEO successfully led the company and integrated it into Teekay. In August 2007, he resumed his position in Vancouver. Graham has held a number of Board positions over the years, has completed the Columbia Business School Senior Executive Development Program, and is currently Chairman of INTERTANKO.

MAIB Safety Digest 1/2010 9

Cargo Vapours - the Unseen Danger Narrative generic MSDS from the internet, which also did not mention H2S. As a result, the surveyor Most of the officers and crew of a chemical equipped himself with the incorrect respirator tanker had served with the company for a filter to protect against H2S vapours. number of years and had a wide range of chemical cargo experience. It therefore came A pre-arrival conference was held in as a bit of a surprise that when they were preparation for the StS transfer, but once instructed to load a cargo of 2000 tonnes of again it was in general terms only, and did not MARPOL category “X”, Crude Sulphate highlight the need for any special precautions. Turpentine (CST), for a Ship to Ship (StS) The original location for the StS transfer was transfer at a cargo terminal, nobody on board changed, and it was a week later that it took had any previous experience of it, nor of its place, but the pre-arrival conference was not associated hazards. reconvened.

The ship’s Safety Management System, Terminal staff carried out cargo and safety Procedures and Arrangements (P&A) manual, checks with the chief officers of both ships. cargo checklists and ship’s orders, provided Emergency procedures were covered in detail, detailed instructions of cargo briefing but no checks were made to identify the cargo requirements, loading and discharging dangers listed in the MSDS because everyone programmes and precautions. Supported by thought they had the correct data. The cargo this detailed guidance, there was no reason for surveyor carried out his checks while wearing anything to go wrong – that is, providing the his respirator. The accompanying AB, who instructions were followed! opened the tank Butterworth hatches, was not protected and did not query why the surveyor Prior to loading the cargo, the chief officer was wearing a respirator and yet he was not. conducted the required pre-arrival conference, but he did not have the cargo Material Safety While the StS transfer was completed without Data Sheet (MSDS) at the time, so the safety mishap, there was a very strong, pungent, briefing did not properly cover the cargo “rotten egg” smell throughout, which drifted hazards. Unbeknown to him, the cargo across the site as the atmosphere from the contained hydrogen sulphide (H2S), receiving ship’s tanks was displaced. However, organo-sulphides and mercaptans. Later, the no one investigated this properly and no shipper handed him a cargo-specific MSDS, reference was made to the MSDS to check but the hazards were not briefed to the crew. the cargo hazards. In the meantime, the ship manager obtained his own MSDS which was not cargo-specific, Following the StS transfer, a mandatory and which did not mention H2S. MARPOL pre-wash was carried out. The P&A manual stated that the normal method of The MSDS obtained by the ship manager was washing was to use the fixed systems, but passed, in good faith, to the discharging port as most of these were defective, the agent, who in turn passed it to the receiving portable washers were used. These were StS ship and to the terminal staff. It was not passed through the open Butterworth hatches. passed to the cargo surveyor who obtained a As the washers agitated the tank’s atmosphere

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Figure 1: Butterworth hatch

the pungent, heavier than air cargo vapours Meanwhile the chief officer attempted to were driven through the open hatch and rescue the AB, but without testing the accumulated in the vicinity of the hatch. atmosphere and without wearing breathing apparatus (BA). The inevitable happened. As the pre-wash completed, one of the duty As he approached the AB he lost his motor ABs went down to the hatch (Figure 1) to functions, could not speak, and slipped in remove the portable washer. As he descended and out of consciousness. Another AB the ladder he lost the pungent smell, began to attempted a further rescue from the walkway shake uncontrollably, and collapsed across the above the Butterworth hatch. He took large open hatch. Very soon afterwards another crew gulps of air before descending to the member saw the casualty and alerted the chief casualties. He was badly affected by the cargo officer. The chief officer