MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accidents No 1/2012

is an

© Crown copyright 2012

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.

This publication can also be found on our website: www.maib.gov.uk Further copies of this report are available from: Marine Accident Investigation Branch Mountbatten House Grosvenor Square Southampton April 2012 SO15 2JU

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 2012

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. Heavy Weather – Serious Injuries 10

2. Poor Housekeeping = Own Goal 13

3. Ship Moovement Highlights Need for Lashing Securing Points to be ‘Beefed’ Up 15

4. Lift Shaft Working Can Kill 16

5. A Testing Time 19

6. Almost a Step Too Far 23

7. They Didn’t Bank on That Happening 25

8. Inexperience and a Lack of Communication – a Dangerous Mix 27

9. Watch Where You Are Going 29

10. No, Not That One 31

11. Watch ‘Sleeping’ Leads to Grounding 34

12. Who Started This? 35

13. Watch Your Step 36

14. It’s Such a Drag-ging Anchor 39

15. Navigating the Cut 42

16. Is the Forward Store a Dangerous Space? 44

PART 2 - FISHING VESSELS 46

17. Lookout! Where? 48

18. Scotch on the Rocks 50

19. Clocked by a Block 53

20. An Unwanted Christmas Present 55

21. Fire-Fighting Drills – a Sound Investment 56

22. Prompt Actions Avert a Tragedy 58

PART 3 - SMALL CRAFT 60

23. The Case of a Broken RIB 62

24. Be Prepared – Even on a Nice Day 65

25. Crash Gybe Results in a Broken Neck 67

26. Your Lifejacket – Are You Giving it Your Full Attention? 69

APPENDICES 73

Appendix A - Investigations started in the period 01/10/11 to 29/02/12 74

Appendix B - Reports issued in 2011 75

Appendix C - Reports issued in 2012 76

Appendix D - Safety Bulletins issued during the period 01/10/11 to 29/02/12 80

Glossary of Terms and Abbreviations

AB - Able seaman m - metre ARPA - Automatic Radar Plotting Aid mA - milliamps BA - Breathing Apparatus “Mayday” - The international distress signal (spoken) C - Celsius MGN - Marine Guidance Note CCTV - Closed Circuit Television MSN - Merchant Shipping Notice COLREGS - International Regulations for the Prevention of Collisions at Sea OOW - Officer of the Watch 1972 (as amended) PSV - Platform Supply Vessel COSWP - Code of Safe Working Practices RIB - Rigid Inflatable Boat for Merchant Seamen Ro-Ro - Roll on, Roll off CPA - Closest Point of Approach SOLAS - International Convention for the CPP - Controllable Pitch Propellers Safety of Life at Sea CPR - Cardio-Pulmonary Resuscitation TSS - Traffic Separation Scheme DPS - Dynamic Positioning System VHF - Very High Frequency DSC - Digital Selective Calling VTS - Vessel Traffic Services HAT - Harbour Acceptance Trial VTSO - Vessel Traffic Services Officer IMDG Code - International Maritime Dangerous XTE - Cross Track Error Goods Code, IMO IMO - International Maritime Organization

Introduction I would like to thank Nigel Adams, Rodney Smith and Dee Caffari for their excellent introductions to the individual sections of this Safety Digest. Both Nigel and Dee have made some very wise observations which I urge you to read, and need no amplification from me. However, Rodney’s contribution is perhaps the most thought provoking. It starkly reminds us of the horrors that the families of mariners who are lost must endure. I can only express my admiration for the courage it must have taken Rodney to write about the death of his brother Neil, who was the singlehanded skipper of the fishing vessel Breadwinner. I hope that, by reading this Digest, mariners from all sectors of our industry will take on board the lessons it contains and spare their families the trauma that always follows any accident to a loved one.

Emergency drills provide an opportunity for crews to test procedures and develop or fine tune plans that will help manage the consequences of marine accidents. Making the drills realistic can be a challenge but, by regularly practising responses to foreseeable emergencies, crews can en- sure that their reactions become instinctive – a common feature in a number of recent investiga- tions conducted by the MAIB has been muddled or confused responses to emergency situations that can be directly attributable to the absence of drills. If you have regularly practised how you might fight a fire in a confined space, wearing breathing apparatus, or considered carefully and then conducted drills in the recovery of an unconscious man from the water, you are more likely to succeed when you have to do so in earnest. Case 2 and Case 21 are examples of the success that can be achieved with a well drilled crew.

Finally, with warmer weather approaching, and the main season for sailing about to begin, could I urge all leisure sailors to take particular note of the contents of Case 26.

Until next time, keep safe.

Steve Clinch Chief Inspector of Marine Accidents April 2012

MAIB Safety Digest 2/2012 7

Part 1 - Merchant Vessels ‘Keep it Simple’

I always read the new expensive and complex equipment is excellent MAIB going to have a secondary safety system in the Safety Digest with form of a safety pin. Some ships will need great interest new lifeboats. and occasionally there is a case Shipowners lose again and manufacturers that brings back stand to make a lot of money. Benefits are at memories of a best marginal. Indeed, if the new hooks are similar situation going to have ‘secondary safety systems’ would that I have been in it not be easier just to fit these wherever (which fortunately possible on existing equipment? Too simple, did not end up I suspect. as an MAIB case). Lifeboat incidents I read with great interest the excellent MAIB are very much in safety flyers on the loss of life on the car carrier this category and send a shiver up my spine. Tombarra. This involved a davit launched rescue boat, however the same old story; There is a common perception that in the last switch failed, crew fell 29m and significantly twenty years lifeboats have killed or injured ‘serviced every year by manufacturers’. more seafarers than they have saved. Statistics Enough said on this! can neither confirm nor reject this perception; however, significantly in 2001 the MAIB after a As I was finishing this introduction, the ‘Costa detailed review concluded: Concordia’ incident occurred. The media was full of reports about crew struggling • Lifeboats and their launching systems have to lower lifeboats and I watched one video cost the lives of a significant number of where a boat did get stuck and it was clear seafarers. that the crewmembers involved had little or • Accident causes are considered to have no experience in the lowering operation. Most their roots in the complexity of systems of us won’t forget the picture of the ship the compounded by poor instructional and following morning with the davit launched training material. liferafts stuck half-way down the ship’s side. • There has been no balancing payoff in lives saved by these systems. Lifeboats in the ‘Costa Concordia’ clearly played a significant part in the rescue operation, Manufacturers blamed lack of maintenance or however the weather was favourable. It would crew error, rarely the equipment. The majority have been a completely different matter if this felt otherwise, with the MCA stating in had not been the case. early 2008 that ‘many existing on-load release hooks, whilst satisfying the current There will no doubt be the usual reactionary, regulations, may be inherently unsafe and rushed through legislation post ‘Costa Concordia’. therefore not fit for purpose’. One hundred years after the ‘Titanic’ this is a good opportunity for a thorough review. I So where are we now and what next? At don’t have the solutions, however in line with significant cost all lifeboats will be compliant the MAIB findings previously mentioned more towards the end of the decade (some 25 years sophisticated and complex equipment is not after on-load hooks being introduced). The the answer. Simple liferafts are the preference

8 MAIB Safety Digest 1/2012

of the majority of seafarers particularly if there We all make mistakes. Learning from other is any kind of sea running (why complicate people’s mistakes is an important part of loss with davits and release systems). If there is prevention and the effort made by the MAIB in one lesson that should be learnt from the last summarising the key points of the main reports twenty five years it is ‘Keep it Simple’. through this publication is to be commended.

Coming back to the Safety Digest, poor planning and lack of communication appear to be a regular feature and in one case this results in the unfortunate death of an engineering officer. Disturbing is the number of cases where Senior Officers are involved who should know better and lead by example. Post incident actions by well trained personnel also never fail to surprise and shipping needs to work harder at developing the checklist discipline achieved by the airline industry.

Nigel Adams

Nigel Adams started his career as a Deck Cadet with the P&O Group in 1974. As a group cadet he spent time on various ship types, however on obtaining his 2nd Mates Certificate, he joined the bulk division and spent all his time at sea on tankers, bulk carriers and LPG/LNG carriers. He obtained his Master’s Certificate 1985 and was promoted to Master in 1988. He came ashore in 1992 and worked as Marine Surveyor/consultant with Cargo Analytics Ltd in Glasgow. This involved safety inspections, cargo survey work, accident and incident investigation, port captaincy and usual wide range of work involved with this type of position.

He then joined Acomarit as Marine Superintendent in 1994 with special responsibilities for the oil spill compliance programme and contingency planning. In 1996 his responsibilities increased to take on the safety and risk role for all of the Acomarit Group fleet and as a member of the company contingency team he was heavily involved in the ‘Sea Empress’ response in Milford Haven in 1996. This incident led to the introduction of the SOSREP. V.Ships took over Acomarit in 2001 and after a spell in the integration team Nigel was appointed Risk, Safety and Quality Director for V.Ships Ship Management Division.

In 2007, he was appointed Group Risk Director, however in 2008 for health reasons this post had to be relinquished.

Nigel is still working full time in V.Ships mainly focussing on projects and new regulation compliance. In his time ashore he was involved with the following committees and working group: Intertanko Safety, Technical and Environmental Committee; Informal Tanker Safety Officers Forum; Intertanko Lifeboat Working Group; Founding Maritime Board Member of Confidential Hazardous Incident Reporting Programme (CHIRP); Chairman of Intertanko Pilot Working Group.

MAIB Safety Digest 1/2012 9

Heavy Weather – Serious Injuries Narrative show was cancelled and the main swimming pool was emptied, but service in the bars and A large cruise ship fitted with gyro-fin stabilisers in the restaurants continued as usual. was on an ocean passage in heavy weather. The weather forecast indicated that the centre of The ship rolled very heavily several times, heeling the depression and the ship’s intended course the ship to more than 30º. This roll caused were converging, so the officers and crew had passengers and crew, along with unsecured - been ordered to secure the ship for heavy and some previously secured - equipment to weather. The passengers had been told of the be projected across the ship several times weather forecast and to exercise care while (Figure 1). Numerous passengers and crew moving around on board the ship. were injured, several seriously. The passenger public areas, including rooms designated as The master realised he would be unable to passenger muster stations, crew working areas monitor the sea conditions during the dark, and the galleys were strewn with furnishings, overcast night. As sunset approached he advised fittings and broken glass and crockery (Figure the passengers and crew of his intentions to 2). heave-to; he then turned the ship into the wind and sea and reduced speed, predicting The master instructed the passengers to return that the depression would pass ahead of his to their cabins as the crew dealt with the injured, intended track. The ship was occasionally rolling accounted for all the passengers, and started heavily and pitching moderately. The cabaret to clear up.

31°

Figure 1: Ship heeled during heavy weather

10 MAIB Safety Digest 1/2012

Figure 2: Crew mess room following the accident

Figure 3: Passenger muster station following the accident

MAIB Safety Digest 1/2012 11

The Lessons 4. Unsecured furniture, equipment and objects were free to move and hinder the 1. When the ship was hove-to at slow speed usability of the passenger spaces. the stabilisers became ineffective and acted only as a bilge keel. However, their presence Ships can roll heavily for numerous reasons gave the ship’s officers a false sense of such as heavy weather, inadvertent use of security that any rolling would be reduced. the helm or deliberate avoiding action. Ships’ fittings and equipment should Active stabilisers should be evaluated at therefore be sufficiently secured to prevent various speeds and weather conditions so serious injury to passengers and crew. A that their likely performance during heavy thorough study of the securing arrangements weather can be factored in to any mitigating on board, both permanent and temporary, action taken by masters and/or officers. along with the potential consequences of free to move objects, will confirm whether 2. The master and watch officers were unable the ship is sufficiently secured. to monitor the sea conditions due to the darkness and the heavy cloud cover. 5. Some of the muster stations (Figure 3) were made unusable following the accident; Night vision glasses may offer a way to had the situation deteriorated the master observe the sea conditions on overcast or would have been unable to send the moonless nights. passengers to their designated areas.

3. As the severity of the rolling was not Although not an IMO requirement, specific anticipated, the passengers continued to move consideration should be given to ensure the freely around the ship, served by the crew. viability of passenger muster stations following the effects of a large angle of heel. During particularly bad weather, consideration should be given to limiting the services available to passengers for their safety and the safety of the crew. This may include emptying all pools and spa baths, restricting bar service, closing shops and limiting the menu options offered.

12 MAIB Safety Digest 1/2012

Poor Housekeeping = Own Goal Narrative the engineers isolated electrical power to the forward part of the ship. The master of a feeder container vessel was on the bridge, together with a pilot, for a lengthy Ten minutes after the fire alarm had sounded, and busy river transit. It was a warm,