MARINE ACCIDENT INVESTIGATION BRANCH MAIB Marine Accident Investigation Branch Safety Digest Lessons from Marine Accident Reports 1/2013 is an

SAFETY DIGEST Lessons from Marine Accidents No 1/2013

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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 2013

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 2012 – Regulation 5:

“The sole objective of a safety investigation into an accident under these Regulations shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of such 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. Passenger Ferry Leaves Berth - With Shore Embarkation Structure 10

2. You Delegate the Job, Captain - Not the Responsibility 13

3. Good Bridge Team Management Prevents a Collision; Bad Bridge 16 Team Management Almost Leads to One

4. One Risk Too Many 19

5. Pilot Boat Fire - Disaster Prevented by Swift Actions 21

6. Can You Hear Running Water? 25

7. A Heavy Burden to Bear 27

8. Calculate Tug Power Required - Before You Need It 30

9. Fatal Bight 34

10. Just Because He’s the Master Doesn’t Mean He Can’t Be Wrong 36

11. Near-Fatal Gas Release 39

12. Uncontrollable Pitch Propeller 42

13. So Safe Yet So Dangerous 44

14. Lifeboat Drills – When Remote Control = Loss of Control 46

15. RIB and Spinal Injuries 51

PART 2 - FISHING VESSELS 54

16. Fatal Flip-Flop Fall 56

17. Wake up to the Reality of Falling Asleep! 59

18. Carbon Monoxide Kills 61

19. Ground(ing) Hog Day! 63

20. Alarmed When the Alarms Didn’t! 65

21. Siesta Disaster 68

22. Own a Leaking Boat? 70

PART 3 - SMALL CRAFT 72

23. At Night, at Speed and Without Lights – What Do You Think Happened Next? 74

24. Saved By His PLB 77

25. Know Your Operating Limits 79

APPENDICES 81

Appendix A - Investigations started in the period 01/09/12 to 28/02/13 81

Appendix B - Reports issued in 2012 82

Appendix C - Reports issued in 2013 84

Glossary of Terms and Abbreviations

AB - Able Seaman MCA - Maritime and Coastguard Agency AIS - Automatic Identification Syste MGN - Marine Guidance Note BNWAS - Bridge Navigational Watch Alarm MHz - megahertz System OOW - Officer of the atch bp - Bollard Pull OS - Ordinary Seaman C - Celsius OSB - Orientated Strand Board CO2 - Carbon Dioxide PLB - Personal Locator Beacon COLREGS - International Regulations for the RIB - Rigid Inflatable Boa Prevention of Collisions at Sea 1972 (as amended) RNLI - Royal National Lifeboat Institution CPA - Closest Point of Approach Ro-Ro - Roll on, Roll off CPP - Controllable Pitch Propellers rpm - revolutions per minute CPR - Cardio-Pulmonary Resuscitation SAR - Search and Rescue DSC - Digital Selective Calling SOLAS - International Convention for the Safety of Life at Sea EPIRB - Emergency Position Indicating Radio Beacon TSS - Traffic Separation Schem GPS - Global Positioning System VDR - Voyage Data Recorder gt - gross tons VHF - Very High Frequency IMO - International Maritime Organization VTS - Vessel Traffic Service ISM - International Safety Management WBV - Whole Body Vibration (Code) XTE - Cross Track Error kg - kilogram m - metre

Introduction Case 3 of this Safety Digest reminds me of a recent visit I made to Dover, where I was able to spend a day on board a large cross channel ferry. During my visit I was impressed by not only the professionalism of the ship’s staff, both on the bridge and in the engine room, but also how the company’s procedures were being carried out in a natural but completely comprehensive fashion. I was left in no doubt that a robust, effective safety culture had been completely imbedded into the psyche of everyone on board. There was a real sense of shared purpose between shore and sea staff.

Of course, cynics will point out that it is a lot easier to imbed a safety culture into a business, such as a ferry operation, where managers and seafarers are able to meet and discuss issues much more regularly than, say a bulk carrier on world-wide trading. However my experience over the years, whether at sea, in shore management or through establishing the causes of accidents, is that managers tend to get the crews they deserve. Unfortunately, an STCW qualification does not guarantee that a seafarer will always be competent. The MAIB is currently investigating three serious accidents involving collisions where qualified, seasoned senior officers have ignored the most basic of watchkeeping principles. Complacency, often exacerbated by fatigue will usually lead to accidents but a culture of short-cuts (see Case 13) is difficult to avoid unless managers demonstrate their commitment to best practice by engaging with their sea staff at every level. In particular, masters and chief engineers must feel they are part of the wider management team, rather than simply the hired help if robust, effective safety cultures are to flourish in all sectors of our industry.

The ImarEST is an organisation which has been at the forefront of efforts to raise professional standards within our industry and I am grateful to Malcolm Vincent, the Institute’s current President, for his introduction to the Merchant Vessel section of this Safety Digest. Malcolm’s comments about the importance of the regular practice of drills are too often demonstrated when the absence of such training leads to vessels being lost and seafarers unnecessarily becoming injured or worse.

Liz Forsyth, who has graciously given her time to introduce the Fishing Vessel section, is someone who regularly risks her life to rescue seafarers in distress. Liz provides an alternative perspective for fishermen on the reasons why survival and location aids are so important to the successful outcome of SAR operations. In support of the points that Liz makes in her introduction, Case 16 provides yet another example of why it is so important that fishermen should routinely wear lifejackets on the open deck and, ideally, should also carry PLBs to maximize the chances of survival if they fall or are taken over the side.

In his introduction to the Small Craft section, Howard Pridding explains the nature of the important work that the British Marine Federation has been involved with over the last 100 years. The Federation has a proud history of working with national and international bodies to ensure that the codes and standards are fit for purpose. Howard makes the point that, although the pages of this Safety Digest are testament to the fact that accidents do happen, generally the leisure and small commercial boat industries have good safety records. However, you should always think about how you might react to an emergency. For example, if you are the owner of a small boat (or fishing vessel) please consider stowing in a handy place on your vessel a go bag containing flares, a torch, sharp knife and other useful items that you might need in case you are unlucky enough to need to abandon - the kit supplied with many small liferafts can be quite limited.

Until next time, keep safe.

Steve Clinch Chief Inspector of Marine Accidents April 2013

MAIB Safety Digest 01/2013 7

Part 1 - Merchant Vessels Improving professionalism by working together The safety cases The research team at Warsash has developed within this section a novel approach to the evaluation of shore- of the Safety training which they hope will provide evidence Digest reflect the of the effectiveness of the training, and enable reality of life at sea students to assess for themselves their own in merchant ships strengths and weaknesses and where they and highlight the need to improve. This approach is based importance of the on the application of reflective practice, regular practice of a methodology being used to evaluate the drills as the best effectiveness of such training and at the same means of being time promoting reflection on practice by prepared to cope the students concerned. Their view is that with emergency reflection on professional practice during situations. They a training course, and afterwards in the include bridge operational environment, adds value to the team management, fire drills, and coping with student’s learning experience and benefits failure modes of critical equipment. their professional development.

The training experts at Warsash Maritime For simulator training to be effective therefore, Academy, who have studied the Crew Resource the lessons learnt need to be taken to sea. Management (CRM) of team training in So, for example, do employers encourage simulators, tell us that productive learning is continuous learning through personal about influencing attitude, behaviour and development plans, appraisal and 360 degree cognitive change. The maritime training feedback; and do seafarers themselves take community often finds that the application the time to reflect on their practice and take of Simulator-based learning is limited to a responsibility for seeking out opportunities retro-active ‘dose’ of remedial training after for learning? an incident has happened. A collision or a grounding is likely to result in bridge teams One of the key roles of the Professional being prescribed a course of ‘treatment’ in Engineering Institutions, such as IMarEST, passage planning; or an engine room fire is to provide opportunities for structured or catastrophic failure is likely to result in Continuing Professional Development (CPD) engineering officers being prescribed a course such as lectures, conferences, journals, online of treatment in engine room management. discussion forums and branch networking. They also provide online tools to plan and An Engine Room Simulator, like any other tool, record development plans. However taking is only as good as the operator. Simulation time to think about what one did right and scenarios which are well thought out and why, and indeed what went wrong and managed can provide excellent opportunities why is where the learning and professional to practise both normal and abnormal development is effective. Effective CPD operations, although nothing can fully involves critical self-reflection and analysis substitute real experience picked up on the and working out “what did I learn and how I job in the real world, through well-constructed would do it differently next time”? This applies training and backed by structured Continuing to all individuals whether part of the bridge Professional Development or CPD. or engine room teams.

8 MAIB Safety Digest 01/2013

It is incumbent on leaders at all levels in the maritime community to promote an active dialogue to achieve safer professional practice and to develop a holistic approach to the management of ships’ officers’ learning. The MAIB Safety Digest provides an excellent, valuable and vital part in telling us where things still go wrong and pointing to the challenges for the whole maritime community to improve. By working together, at sea and ashore our maritime professionalism can rise to this challenge.

President of the Institute of Marine Engineering Science and Technology (IMarEST)

Malcolm Vincent 110th President of IMarEST

Following Alternative Training Cadetship and seagoing appointments with Shaw Savill and Cunard, Malcolm Vincent joined P&O Technical Services Division. He undertook various engineering and business development appointments leading to Managing Director of Three Quays Marine Services Ltd undertaking new ship design and construction activities in China, Japan, South Korea, India, Europe and UK. He was appointed director of a ship repair company, and subsequently director of a business services consultancy, which led to appointments with BT Global Services where he was responsible for commercial development and negotiation of major service contracts.

Malcolm Vincent was awarded an IMarEST scholarship to study at Surrey University and has a Masters Degree in Automation & Systems Engineering from City University. As a Trustee of the RNLI, Council Member and Chairman of the Technical Committee he is responsible for the design, build and maintenance of all weather and inshore lifeboats and lifeboat stations. He is also a Liveryman and Member of the Court of Assistants of the Worshipful Company of Engineers. Currently a Trustee and Chairman of the IMarEST Retirement Benefit Scheme he recently chaired the Institute’s Building Working Group.

About IMarEST Established in London in 1889, The Institute of Marine Engineering, Science & Technology (IMarEST) is the leading international membership body and learned society for marine professionals, with over 15,000 members worldwide. The Institute has a strong international presence with an extensive marine network of 50 international branches, affiliations with major marine societies around the world, representation on the key marine technical committees and non-governmental status at the International Maritime Organization (IMO). It is the only membership body that can award Chartered Marine Scientist and Technologist, Chartered, Incorporated and Engineering Technician status to their professional engineering counterparts.

MAIB Safety Digest 01/2013 9

Passenger Ferry Leaves Berth - With Shore Embarkation Structure Narrative knowing full well that the starboard engine shaft was turning at the normal sea speed of Shortly after leaving dry dock, the crew of a 150rpm. The master was standing at the port ro-pax ferry discovered that the forward bow wing and could see two tachometers indicating thruster was not functional due to a wrongly that the starboard engine was running. The assembled circuit breaker. The master decided chief officer, who was at the central console, that, given the prevailing and forecast weather could also see two tachometers with the conditions, he could manage with one bow same indication. However, as this routine thruster for a few days. The workshop staff was repeated twice daily for every day of the who carried out the circuit breaker overhaul in year except Christmas and New Year’s day, he dry dock were asked to attend the next day. moved the pitch control of both engines to full ahead. Technicians came on board within 24 hours, repaired the fault and asked the ship’s The mooring ropes, held with winches in engineers to test it. To power up the breaker, the auto-tension mode, payed out as forward the engineers started the starboard main thrust was applied and the vessel surged propulsion engine which drove the shaft ahead along the quay, causing serious damage generator dedicated to the forward bow to the passenger access structure. The foot- thruster. passenger walkway detached at both ends and collapsed onto the quay. The gangway fell As there was no clutch between the engine and from the vessel’s side shell door and was left propeller, the CPP was maintained at neutral hanging on a single rope. Fortunately, there pitch. The vessel was at its usual berth and were no passengers in the walkway or on the passenger embarkation and vehicle loading gangway as these collapsed. Eight passengers carried on throughout. The bow thruster were trapped in a compartment between was successfully tested, and as the vessel was the walkway and the gangway and were due to depart in a short while the engineers subsequently rescued by the fire service. decided not to stop the engine.

Shortly afterwards, the chief officer came up on the bridge to test the controls before departure. The usual practice was to test the steering and alter the pitch