MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accidents No 1/2011

is an

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MARINE ACCIDENT INVESTIGATION BRANCH

The Marine Accident Investigation Branch (MAIB) examines and investigates all types of marine accidents to or on board UK vessels worldwide, and other vessels in UK territorial waters.

Located in offices in Southampton, the MAIB is a separate, independent branch within the Department for Transport (DfT). The head of the MAIB, the Chief Inspector of Marine Accidents, reports directly to the Secretary of State for Transport.

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 receive an email alert about this, 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 2011

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. Close Encounters of the ‘Aframax’ Kind 10

2. Different Interpretations 12

3. Snagged & Dragged 14

4. Generators Don’t Just Make Electricity 16

5. STS Run-In, No Margin for Error 18

6. Lack of Communication, and Distraction Lead to Benzene Spill 21

7. ECDIS Assisted Grounding? 22

8. Last Out Turns the Lights Off! 23

9. Davit Control Adjustments – Proceed With Caution 26

10. Early Release Led to Early Demolition 28

11. ‘Improvement’ Causes Unforeseen Consequences 30

12. Last Act of Defiance 33

13. Fire Below – The Need for Effective Engineering Oversight 35

14. Poor Cargo Configuration Results in Hull Failure and Pollution 39

15. Know Your Systems Back to Black 41

16. When I’m Cleaning Windows 42

PART 2 - FISHING VESSELS 44

17. Balancing Act 46

18. Shooting Pots Ends Tragically 48

19. It’s Foggy – No Stand-On Vessels Allowed 50

20. Never Give Up 52

21. I Thought You Said the Fore Peak Was Empty 54

22. Rock and Roll 56

SMALL CRAFT 58

23. A “Plan” That Went Wrong 60

24. No Margin for Error Leads to Catastrophic Grounding 61

25. Don’t Forget When You Have Pulled the Plug 62

APPENDICES 65

Appendix A - Preliminary examinations, field deployments and investigations started in the period 01/10/10 to 28/02/11

Appendix B - Reports issued in 2010 67

Appendix C - Reports issued in 2011 68

Appendix D – Safety Bulletins issued during the period 01/10/10 to 28/02/11 68

Glossary of Terms and Abbreviations

AB - Able seaman MCA - Maritime and Coastguard Agency ARPA - Automatic Radar Plotting Aid MCR - Machinery Control Room ASD - Azimuth Stern Drive MGN - Marine Guidance Note C - Celsius MIRG - Marine Incident Response Group cm - centimetre OOW - Officer of the Watch CO2 - Carbon Dioxide “Pan Pan” - The international urgency signal COLREGS - International Regulations for the (spoken) Prevention of Collisions at Sea 1972 PTW - Permit to Work (as amended) RNLI - Royal National Lifeboat Institution CPA - Closest Point of Approach Ro-Ro - Roll on, Roll off DSC - Digital Selective Calling RYA - Royal Yachting Association ECDIS - Electronic Chart Display and SMS - Safety Management System Information System STS - ship-to-ship (transfer) ECR - Engine Control Room TSS - Traffic Separation Scheme ERRV - Emergency Response and VHF - Very High Frequency Rescue Vessel VTS - Vessel Traffic Services FRS - Fire and Rescue Service kN - kilonewton m - metre “Mayday” - The international distress signal (spoken)

Introduction I’ve recently returned from the annual meeting of the Marine Accident Investigators’ International Forum (MAIIF). 29 organisations were represented and it’s perhaps not surprising that our wide ranging discussions covered a number of the issues captured in this edition of the Safety Digest. This included: poor application / knowledge of the COLREGS (Cases 2, 19); over reliance on ECDIS combined with a widespread lack of understanding about the limitations of this aid to navigation (Case 7); inadequate passage planning (Cases 23, 24); and the perennial reluctance of fishermen to wear lifejackets when working on deck (Cases 17, 18, 20).

The Forum’s discussions about the use of lifejackets when working on the decks of fishing vessels struck a particular chord with me as the MAIB is currently investigating 3 separate accidents involving fishermen who tragically have lost their lives after falling, or being taken over the side. Arguably, the lives of all 3 could have been saved if they had been wearing a lifejacket. My heart goes out to the families of those concerned and I make no apology for repeating a plea to skippers of fishing boats and other small craft that has been made in this Digest before – please make sure that everyone working on the deck of your boat wears a lifejacket. If you do this, then wearing them will become as routine as using a seatbelt in cars has become, and lives will be saved.

There has been a small change to the format of the Safety Digest. At Appendix D you will find details of any Safety Bulletins the MAIB has produced since the last edition.

In closing, I would like to take the opportunity to thank Don Cockrill, John Goodlad and Sarah Treseder for the time they have given to produce the introductions to the three industry sections of this report. MAIB is extremely lucky to be able to record the thoughts and experience of people such as Don, John and Sarah for the benefit of its Safety Digest readership.

Until next time, keep safe.

Steve Clinch Chief Inspector of Marine Accidents April 2011

MAIB Safety Digest 1/2011 7

Part 1 - Merchant Vessels This section of Examples are insufficient or incorrect use Safety Digest once of tools and equipment, excessive speed, again provides insufficient personnel delegated. Such inferred a unique and pressures are not limited to those on board, invaluable source shore managers are equally susceptible. of information Sometimes, we take routine tasks for granted. for mariners of Most of us have experienced finishing a task all disciplines only to realise that we have no recollection of to learn and actually doing it. The problem is of course that benefit from because we may not have full concentration on the unfortunate the task in hand, we overlook the simplest of experiences of unexpected and undesirable occurrences and others. may make mistakes which can lead to a serious accident. Fatigue too can play a major part in It is worth reflecting on why it is, that this, not only by causing lack of concentration despite comprehensive regulation, numerous but simply a sort of numbing of the mind to operational codes of practice and ever the matter in hand and increasing vulnerability evolving training, qualification and certification to distractions. In even the apparently simplest schemes, so many accidents (or rather, failures of tasks, there is a need for variety and frequent of risk management) still occur in commercial breaks to ensure continuity of concentration. shipping. Sometimes it can be a result of equipment failure through poor design, Being aware of our own fallibility adds a system fatigue or old age. However, in reading significant enhancement to any training regime through the following reports it is clear that as or the compliance with an operational code of ever, there are many cases where the accident practice. There are numerous published works is attributable to some sort of “operational on the subject, but one I can recommend that error” arising from the fallibilities we all suffer is easy to read, amusing and very relevant is - the “human factor” elements. Such failings, the memorably titled The Invisible Gorilla. illustrated in the reports, include a common human desire, particularly strong in seafarers, In reading the reports that follow, consider if to get the job done as a first priority. This is you would have intentionally and knowingly often with complete disregard to personal risk, taken the same risks and/or made the same perhaps due (especially in the current economic “mistakes”, probably not; neither in nearly climate) to minimal profit margins and so any all the cases most probably did the people delay is financially damaging. Alternatively, involved. Remember that even in keeping perhaps the programmed maintenance regime a lookout, you may not see the obvious. is dispensed with to save expenditure on Safe sailing! parts and labour. Managerial pressures, often (though not always) unintended are frequently inferred by those tasked with achieving a goal as requiring corner cutting to achieve the quickest and most economical solution.

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Captain Don Cockrill FNI

My seafaring adventures started in 1973 with Canadian Pacific (CP Ships) where I progressed from cadet to master specialising in petro-chemicals. I joined the Port of London Authority as a pilot in 1991 following a short period in the NW European Chemical tanker coastal trade with Stolt Nielsen. In recent years I have been significantly involved in the various aspects of pilot training and its associated professional skill standards with particular emphasis on simulation as well as conventional processes. I have been involved in one way or another with the work of the United Kingdom Maritime Pilots’ Association almost continually over the last 20 years and took over the Chairmanship in late 2010.

MAIB Safety Digest 1/2011 9

Close Encounters of the ‘Aframax’ Kind Narrative

Two Aframax size oil tankers were underway at lost its engine, but he did not use ship names a speed of 2.5 knots having just completed a and the bridge team on the other vessel did ship-to-ship (STS) transfer of diesel oil 10 miles not hear his call. No emergency signal was from shore. As the last lines were slipped, the sounded on the ship’s whistle. quarters of the two vessels closed. To check this movement, the overseeing superintendent As the manoeuvring vessel’s bow swung very on board the designated manoeuvring vessel slowly to port towards the other vessel, the ordered dead slow ahead and for 10° of port superintendent ordered ‘slow astern’. This helm to be applied. However, the vessel’s slow time, the engine started and the superintendent speed, direct drive engine did not start. immediately ordered full astern followed Observing this, her OOW immediately informed by a series of engine and helm orders the master and telephoned the chief engineer given in rapid succession. Seconds later, in the MCR. The superintendent was told about the manoeuvring vessel’s port anchor struck a minute later, by which time he had ordered the starboard lifeboat on the other vessel (see slow ahead and had increased the amount of figure). The manoeuvring vessel’s engine failed port helm. The superintendent immediately to start because a dirty air start pilot valve had broadcast on VHF radio that the vessel had not allowed starting air to pass into the cylinder.

Figure 1: Damage caused to the lifeboat

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The Lessons

1. When manoeuvring in close proximity 3. This was the superintendent’s eighth to another vessel or navigational hazard the consecutive STS operation, and the possibility of something going wrong must cumulative effect of long working hours be carefully considered. In such situations, over a 3-week period possibly adversely bridge and MCR teams need to be trained affected his alertness. Proper monitoring and ready to respond quickly and effectively of rest hours helps to prevent the onset of to engine and steering failures. fatigue, but masters should also keep an eye out for the signs of fatigue among their 2. Good internal and external communications crew and any person key to ship safety, are vital when operating close to another such as STS superintendents and harbour vessel. Dedicated communications operators, pilots. the correct use of radio procedures and a common language are all essential to ensure this is achieved.

MAIB Safety Digest 1/2011 11

Different Interpretations Narrative

A passenger ferry, on a southerly heading in After the ferry had crossed ahead of the cargo daylight and good visibility, was crossing a TSS. ship, the yacht altered course to starboard. The OOW was accompanied on the bridge by a The cadet reported this to the OOW, who then cadet and a lookout. A cargo ship was transiting altered the ferry’s course to starboard to the westbound traffic lane of the TSS. The increase the yacht’s passing distance to port. OOW had acquired her radar echo by ARPA, which predicted that the passenger ferry would cross ahead of the cargo ship at a range of 1 mile.

The lookout reported two yachts ahead: one fine to starboard and one fine to port; both were on westerly courses. The OOW acquired the radar echo of the yacht to port by ARPA, which predicted a CPA of 0.3 mile to starboard. He decided to maintain course and speed with the intention of crossing ahead of the cargo ship and then altering course to port to increase the CPA with the yacht.

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The Lessons

1. The ferry company’s instructions required 3. In interpreting a risk of collision with the its masters in normal circumstances to ferry, the yachtsman initially maintained accept a CPA of no less than 1 mile when course and speed in accordance with Rule passing ahead of another vessel. If the 17(a)(i). Unaware of the ferry’s intentions, OOW intended a closer CPA, he/she was he then took avoiding action himself, in required to seek approval from the master. accordance with Rule 17(a)(ii) when it In this case, the OOW was content to became apparent that the ferry was not accept a bow crossing distance of 1 mile taking appropriate action. with the cargo ship and a considerably reduced CPA with the yacht, without Unlike a crossing situation involving feeling the need to refer to the master. two power-driven vessels, the ferry was at liberty to alter course to port in The OOW had become over-confident complying with the COLREGs. This in his ability, to the extent that he was severely restricted the options open to prepared to stretch the parameters the yachtsman to take last-minute within which the master had permitted avoiding action. Whatever action he him to operate autonomously. A lack of took would have put the yacht at risk sufficient oversight and enforcement by if the ferry’s OOW had subsequently the master had contributed to this decided to alter course to port. complacency. Implementing company instructions, 4. The circumstances required the ferry’s motivating the crew in following them, OOW to think “outside the box” and to and verifying their compliance are view the developing situation from the fundamental elements of a master’s yachtsman’s perspective. Consequently, he responsibility. should have aborted his plan to cross ahead of the cargo ship. Such action would have 2. Assuming a risk of collision existed been in accordance with Rule 2(a), which with the yacht, the ferry’s OOW correctly requires an OOW to take any precaution interpreted that his was