MARINE ACCIDENT INVESTIGATION BRANCH MAIB Marine Accident Investigation Branch Safety Digest Lessons from Marine Accident Reports 1/2014 is an

SAFETY DIGEST Lessons from Marine Accidents No 1/2014

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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 2014

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 the investigation 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. Who’s in Control? 10

2. Post-refit - Falls From a Lifeboat. Have You Spotted the Risks? 13

3. Enclosed Lifeboat = Enclosed Space 17

4. Bridge Team Management is Not a Spectator Sport 20

5. Mooring Dangers - the Need to Always Keep Alert 23

6. Delivery Voyage Tragedy 26

7. Kill the Critters, Not the Crew 28

8. Taking a Turn for the Worse 31

9. On Deck in Heavy Weather - Why and Under What Conditions? 33

10. Bridge Team Communications - Or Lack Of 35

11. Failure to Recognise a Suspended Load Results in Death 38

12. Cracked Nipple Fire Risk 43

13. Pilot Ladders … Shouldn’t be a ‘Leap of Faith’ 44

14. Hot Work - the Need for Effective Controls 47

PART 2 - FISHING VESSELS 50

15. Drills - Your Emergency Investment 52

16. PLB ... Is Yours a Lifesaver? 56

17. Splashes to Ashes 58

18. Look After Your Pipework 61

19. Man Overboard Recovery Goes to Pot 63

PART 3 - SMALL CRAFT 66

20. Kill Cords and Lifejackets – Your Tools for Survival 68

21. Well Prepared, Well Equipped, Well Done 71

22. Almost a Deadman’s Handle 73

23. A Tragic End to the First Trip of the Season 76

24. Kill Cords Save Lives, When Used Properly 79

25. Hold on Tight, If You Can 83

APPENDICES 87

Appendix A - Investigations started in the period 01/09/13 to 28/02/14 87

Appendix B - Reports issued in 2013 88

Appendix C - Reports issued in 2014 90

Appendix D - Safety Bulletins issued during the period 01/09/13 to 28/02/14 91

Glossary of Terms and Abbreviations

AB - Able Seaman MCA - Maritime and Coastguard Agency BA - Breathing Apparatus MGN - Marine Guidance Note C - Celsius MRCC - Maritime Rescue Co-ordination Centre CO2 - Carbon Dioxide MSN - Merchant Shipping Notice COLREGS - International Regulations for the PLB - Personal Locator Beacon Prevention of Collisions at Sea 1972 PTW - Permit to Work (as amended) RIB - Rigid Inflatable Boat COSWP - Code of Safe Working Practices for Merchant Seamen RNLI - Royal National Lifeboat Institution

CPR - Cardio-Pulmonary Resuscitation Ropax - Roll on Roll off Passenger Ferry

DSC - Digital Selective Calling Ro-Ro - Roll on, Roll off SAR - Search and Rescue EPIRB - Emergency Position Indicating Radio Beacon SMS - Safety Management System

GRP - Glass Reinforced Plastic SOLAS - International Convention for the Safety of Life at Sea 1974, LSA - Life Saving Appliances as amended m - metre STO - Safety Training Officer “Mayday” - The international distress signal VHF - Very High Frequency (spoken) VTS - Vessel Traffic Services

Introduction As those of us in the UK shelter from the succession of winter storms that has left much of our country under water, we should spare a thought for our colleagues at sea for whom a winter storm is just one of many occupational hazards that have to be dealt with.

Mercifully, the extraordinarily extreme weather systems that have pummelled the UK this winter do not appear to have produced an upturn in related marine accidents. However, Case 9 provides a graphic illustration of the consequences of sending men on deck in heavy weather without a proper plan.

This edition of the Safety Digest also provides many other examples of the risks faced by mariners on a daily basis. Poor communication, failure to adhere to defined procedures, inadequate product knowledge, poor seamanship and cursory maintenance regimes have all been factors in accidents that could have been avoided.

Improved safety on ships is achievable if we not only routinely think about what might go wrong before conducting a voyage, an individual task or period of maintenance, but also take responsibility to check that the appropriate safety barriers and contingencies, designed to prevent the worst from happening, are in place throughout.

Case 15 highlights the importance of drills. Properly trained crew who have been regularly drilled in the responses needed to deal with foreseeable emergencies are far more likely to react instinctively (and correctly) to a developing situation. Too many ships and lives have been lost because the skills taught during basic training have not been applied when a “real” fire, flooding, collision or abandonment occur. The practical difficulties of recovering someone back on board even a small boat can only be appreciated, and mitigated if this scenario is regularly drilled. Imagine how you would feel if your mate were to go over the side and survive, only to lose his life to the effects of cold water because you had never practised how you would recover someone from the sea.

The small craft section of the Safety Digest contains articles, some previously published, that focus on the use of kill cords. This is in support of a campaign being led by the Royal Yachting Association and other industry stakeholders which promotes the use of this important safety tool. With the advent of spring and the prospect of better weather, many leisure boaters will be putting their craft back into the water. I therefore repeat the plea I made in the introduction to my last Safety Digest: if your boat is fitted with a kill cord, please ensure the device is always securely attached to the driver whenever the engine is switched on.

Until next time, keep safe

Steve Clinch Chief Inspector of Marine Accidents April 2014

MAIB Safety Digest 1/2014 7

Part 1 - Merchant Vessels For an organisation one set of risks with another. whose mission is “to enhance the For LR we have to maintain our knowledge safety of life, of existing ship design and construction property and the whilst keeping an eye on the future. Any new environment”, the technology needs to be understood, particularly work of Lloyd’s within a marine context, so that its application Register (LR) can be managed safely. For this reason we are makes it a natural strengthening our technical capability, and partner to the investing in resources to understand new MAIB. technologies, with the opening of our Global Technology Centre on the campus of the In the Marine Business we work with regulators University of Southampton this summer. in the form of port states, flag states, regional The access to university resource, and the agencies such as EMSA, and other stakeholders, opportunity to collaborate with research and to provide a global framework to provide risk industry partners at the Southampton Marine assurance. It is this network of national and and Maritime Institute (SMMI), will enhance international organisations that helps create our ability to meet the challenges that all kinds a safety regime for the global seaborne fleet of stakeholder pressure will continue to place of merchant cargo, passenger and even naval on the marine business. vessels. Over the next few years we can expect new Over the 254 years that the concept of Marine emission regulations, the ballast waste convention, Classification has existed, from Lloyd’s Register’s the recycling convention and other new pieces roots as an offshoot of Lloyd’s of London, the of legislation to add more complexity to industry. challenges continue to change and increase. LR is doing its utmost to ensure it can be in a position to give objective advice to designers, The safeguards in place have not always builders, owners and operators of ships on prevented marine accidents and incidents, how to comply safety with this new wave of but a continuous evolution of technical under- regulatory change. standing has allowed lessons to be learnt, and rules amended accordingly. Increasingly the risk We live in interesting times. has focussed on human rather than technical factors, and many see the advent of further on-board automation as a potential solution, as we have seen in the aviation and automotive fields. With the advent of new connectivity of communication systems, which will dramatically increase the coverage of the oceans, with large bandwidth, the opportunity for remote operation becomes more of a potential reality. Such a change will require its own regulation, and security, to ensure we don’t simply replace

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Tom Boardley

Tom Boardley is Marine Director of Lloyd’s Register, which provides ship classification services to a large global fleet. Founded in the City of London in 1760, Lloyd’s Register works closely with shipbuilders, shipowners and insurers to ensure ships are safe to operate throughout their life. It also provides technical advice to the marine industry on environmental and regulatory matters. Tom joined Lloyd’s Register in April 2009 and is responsible for worldwide operations as well as strategy and business development.

From July 2012 to July 2013, Tom also took on the Chairmanship of IACS, the International Association of Classification Societies.

Prior to joining Lloyd’s Register, Tom had held several senior management positions in the container shipping and ports industry. At the Japanese shipping giant NYK, he had managed the European operations for the container shipping division, including the co-ordination of related activities including inland logistics and supply chain management for major Japanese manufacturers. At P&O Ports, Tom had led business development and acquisitions activity, helping build a global network of container ports that was acquired by Dubai Ports World in 2006. He had also managed the Canadian business post-acquisition, based for a year in Vancouver B.C.

For the first 24 years of Tom’s career, he was with the container shipping division of P&O, originally trading as OCL and subsequently as P&O Nedlloyd. He held various management roles in the UK, Taiwan, Korea and Japan before being appointed as Director for Australia and New Zealand, based in Sydney, in 1996.

Tom is an engineering graduate of Oxford University and is also a fellow of the Royal Institute of Naval Architects.

MAIB Safety Digest 1/2014 9

Who’s in Control? Narrative In manual control, engine orders were passed from the bridge to the engine room via the The crew of a general cargo vessel joined engine telegraph. The orders were acknowledged 2 days prior to its scheduled sailing from a by the ship’s electrician using the telegraph discharge port. During the handover, the repeater in the engine room. He then indicated relieving crew were told that the main engine’s the intended direction of movement by pointing automatic bridge control system was unreliable either forward or aft. The chief engineer and that it was safer to operate the engine and operated the gearbox and clutch solenoid gearbox manually from inside the engine room, controls (Figure 1) and the second engineer particularly when manoeuvring in confined adjusted the engine governor (Figure 2) waters. However, the ship’s managers had to control the engine’s speed. A shaft speed not been informed about the situation. and direction indicator was not fitted in the engine room.

Clutch in/out ahead/astern

Figure 1: Gearbox solenoid controls

10 MAIB Safety Digest 1/2014

Main engine governor

Governor manual speed control

Figure 2: Main engine governor

Prior to sailing, the main engine’s operation After the mooring ropes were let go, the was tested ahead and astern. The chief officer vessel was gently set off her berth by the light then met the harbour pilot when he arrived wind. Once sufficiently clear, the master set on the bridge. The pilot was informed that the bridge telegraph to ‘dead slow astern’ to the vessel was operating correctly; no defects manoeuvre the vessel towards the centre of were reported. When the master arrived on the the dock basin. All was going well and, when bridge he advised the pilot that he preferred the vessel approached the intended turning not to make fast the tug that had been ordered position, the master moved the telegraph because he wanted to gain an understanding lever to ‘stop’. However, this did not check the of the vessel’s manoeuvring characteristics. vessel’s speed astern.

MAIB Safety Digest 1/2014 11

The cargo ship started to close a dredger Less than a minute later, the stern of the general that was working on the opposite side of the cargo vessel struck the dredger’s starboard dock basin, so the pilot told the master to go side and pushed the dredger into the side of ‘ahead’. Accordingly, the master moved the another vessel which was discharging her cargo telegraph lever to ‘slow ahead’ and, soon alongside. The cargo vessel’s engine continued after, to ‘full ahead’, but the vessel continued to operate astern until ‘stop’ was ordered on to move astern. This caused concern to the the engine telegraph when prompted by the dredger’s master, who called the cargo ship pilot. The vessel was then manoeuvred back via VHF radio. In reply, the pilot confirmed that alongside. All three vessels involved in the the outbound vessel was going ‘ahead’. collision were damaged.

The Lessons 3. Reporting defects to ship managers and authorities such as classification societies 1. Propulsion systems do not have to be and ports is critical to vessel safety. If a controlled automatically from the bridge, defect is not reported, it is likely not to get but the use of the alternative methods of fixed and could easily stand a vessel into control must be carefully considered. danger. In particular, pilots must be made Factors such as engine room ergonomics, aware of all defects affecting a vessel’s safe the provision of shaft speed and direction navigation in order to allow appropriate indication, means of communication, precautions to be taken. crew familiarity and the potential for human error must all be taken into 4. An enclosed dock, with limited manoeuvring account. Although secondary methods of space and other vessels in close proximity, control should be available, some are is not the ideal place to get to grips with a suitable for use only in an emergency. vessel’s handling characteristics.

2. When manoeuvring, it is important that all orders are acknowledged and are followed. To do this, the ordered action must be closely monitored and its completion must be reported. In this case, scrutiny of the bridge shaft indicator would have quickly shown that the shaft was still rotating astern, even after the order for ‘ahead’ had been passed and acknowledged. Mistakes happen but, if quickly spotted, accidents can be prevented.

12 MAIB Safety Digest 1/2014

Post-refit - Falls From a Lifeboat. Have You Spotted the Risks? Narrative Officer (STO) to carry out ship-familiarisation and general emergency training based on the The completion date for an extended refit of duties detailed on the muster list.