MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accidents No 1/2016

is an

© Crown copyright 2016 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.gov.uk/government/organisations/marine-accident-investigation-branch

April 2016

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: MAIB, 1st Floor, Spring Place, 105 Commercial Road, Southampton, SO15 1GH

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 email address is maib@dft.gsi.gov.uk

Safety Digests are available online www.gov.uk/government/collections/maib-safety-digests

© Crown copyright 2016

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

INTRODUCTION 1

PART 1 - MERCHANT VESSELS 2

1. Turn on Time – Stay on Your Line! 4

2. Lifeboat Drills - Practise, Practise, Practise! 6

3. Distraction Leads to Contact With Towering Structure 8

4. No Excuses – Wear a Lifejacket 10

5. Propelled Onto the Berth 12

6. Overexcited Overboard 15

7. A Day at the Beach 17

8. Maintenance Induced Fire 19

9. Sluggish Pitch Control Causes Serious Accident 22

10. Officer Fatigue Causes 5 Months Off-Hire 24

11. Training and Risk Assessment Could be Lifesavers 26

12. Undetected Wear 28

13. Is it Your Turn or Mine? 30

14. Fail to Plan, Plan to Fail 33

15. There’s a Gash in Your Stern Sir 36

16. Preparation is Key 39

PART 2 - FISHING VESSELS 40

17. Making a Big Impression 42

18. Don’t Get Carried Away 44

19. How Very Quickly Life Changes 46

20. Lone Working 48

21. Lost in the Fog 50

22. Supper Would Have Been on Time if the Vessel Had Not Sunk 52

PART 3 - RECREATIONAL CRAFT 54

23. One Fine Day, One Not So Fine Swim 56

24. Kill Cord and Lifejackets Helped Save the Crew 58

25. A Swell Idea, But the Gain Wasn’t Worth the Risk 60

APPENDICES 63

Investigations started in the period 01/09/15 to 29/02/16 63

Reports issued in 2015 64

Reports issued in 2016 66

Safety Bulletins issued during the period 01/09/15 to 29/02/16 67

Glossary of Terms and Abbreviations 2/O - Second Officer MCA - Maritime and Coastguard Agency AIS - Automatic Identification System MGN - Marine Guidance Note BA - Breathing Apparatus OOW - Officer of the Watch BNWAS - Bridge Navigational Watch Alarm PA - Public Address System PFD - Personal Flotation Device C - Celsius PLB - Personal Locator Beacon CCTV - Closed Circuit Television RIB - Rigid Inflatable Boat COLREGS - International Regulations for the RNLI - Royal National Lifeboat Institution Prevention of Collisions at Sea 1972 (as amended) Ro-Ro - Roll on, Roll off CPP - Controllable Pitch Propeller SOLAS - International Convention for the Safety of Life at Sea CPR - Cardio-Pulmonary Resuscitation STCW - International Convention on ECR - Engine Control Room Standards of Training, Certification EPIRB - Emergency Position Indicating Radio and Watchkeeping for Seafarers 1978, Beacon as amended FPD - Fall Preventer Device VHF - Very High Frequency GPS - Global Positioning System VTS - Vessel Traffic Services IMO - International Maritime Organization LPG - Liquid Petroleum Gas m - metre “Mayday” - The international distress signal (spoken)

Introduction A recent article in a UK newspaper reported on the comments made by a Coroner during the inquest of a 7 year old child who had drowned in a hotel swimming pool while on holiday overseas. The Coroner had said that she would write to travel agents asking them to review the provision of lifeguards (there had been none at the pool where the child died.) Case 11 describes an accident in which a passenger drowned in the pool of a cruise vessel. In that accident, there was also no lifeguard poolside – in fact no attempt had been made by the ship’s operator to assess the risk to its passengers when using the pool. The MAIB has recently investigated a number of similar accidents which have occurred on cruise vessels. In every case, the ships’ operators have rejected suggestions that lifeguards be stationed poolside citing that the provision of additional warning signage about the potential risks of drowning is a proportionate response. The mix of holiday makers, swimming pools, food and alcohol provides an obvious pre-cursor for an accident, while the logistics and cost of providing a lifeguard to sit poolside on a cruise liner seem trivial compared to the benefits of preventing someone from drowning. However, in the interest of preventing the further loss of life, I sincerely hope the operators’ assessment proves to be the correct one. Regular readers of the MAIB Safety Digest will be aware that I often write about the poor risk awareness demonstrated by the crews of vessels which feature in MAIB investigations. I make no apology for repeating myself. A cautionary approach should be second nature to every mariner about to start a task or embark on a course of action on the bridge, in the engine room or on deck. It doesn’t matter whether you are sailing on a large commercial vessel, fishing boat or small leisure craft; taking the time to ask oneself “what can go wrong?” and then making sure bad things can’t happen before committing yourself to, for example a change of course or, an entry into a confined space is clearly a sensible thing to do. Sadly, MAIB Safety Digests contain many examples where this simple lesson has been forgotten or ignored - this edition is no exception. Case 14 details how a failure to properly understand the risks of opening a main sea water line, or take appropriate measures to ensure the planned task was executed safely almost resulted in the loss of a ship. Think before you act; plan the task in hand and ensure you monitor the plan carefully. Above all, ensure that everyone involved in the task understands the plan and his/her role. Toolbox talks (see Case 16) can be a particularly useful way of ensuring a common understanding of how even the most basic tasks are to be carried out. If you don’t already conduct toolbox talks on your vessel, give it a go! You will be surprised at how effective these are at improving risk awareness and encouraging better, safer ways of working. In closing, I would like to thank Ian McNaught, Frankie Horne and Andy Proudfoot for their informative introductions to the relevant sections of this Safety Digest. Until next time, keep safe.

Steve Clinch Chief Inspector of Marine Accidents

April 2016

MAIB Safety Digest 1/2016 1

Part 1 - Merchant Vessels The modern are reflected in this digest. There is clearly ship has something going wrong, whether it is the become a very standard and style of training which forms technology the attitudes of modern officers who are on driven the bridge, the equipment being put aboard environment ships, the style of management from ashore and that change or the interface between them all perhaps. has happened The technology is here to stay and we must throughout embrace the benefits, but we must also ensure my forty years we train our officers accordingly. at sea, and continues today. For us at Trinity House, one of the more I can remember obvious results of this is that more of our at the beginning of my career when Blue Star physical aids to navigation are being damaged Line ripped all their radars off their bridges by collision from vessels. Using AIS data, it is to avoid radar assisted collisions, and early quite clear that ships are being taken closer to ships I sailed on where the radar was only danger and that passage plans are perhaps not to be used in an emergency. Things have as cautious as they once were. Over reliance certainly changed since then. on technology seems to allow the navigator to take a few more risks than perhaps is We now live in a world of ECDIS and prudent, and looking at the screens from cockpit style bridges, but even so, I recently his chair, watching the ARPA and ECDIS read a report from IALA stating that the presentations, with all the information number of groundings and collisions remains provided on CPA, TCPA, vectors, AIS unacceptably high, imposing significant cost messages, the NAVTEX churning out on the maritime community, the environment warnings, GMDSS doing its thing and the and the general economy. VHF chattering away, there is a lot going on to distract the OOW. I also recently read a letter from a Master of a large LNG carrier, who was especially One of the benefits of all these electronics is interested in the design of modern bridges. that now, of course, we know exactly when He had observed how the OOW now sits and who hit our navigation buoy or indeed in his chair surrounded by a plethora of one of our lightvessels. And I suppose, in navigation equipment, but also when the the long run, it is better to hit the Aid to ship is UMS, he/she is expected to monitor Navigation rather than run aground, although the machinery spaces as well as handle please don’t feel encouraged to do this. My communications. He also hopefully has a advice is that all the electronics are aids to lookout at night. The Master pointed out that navigation, but so too is the bridge window. when he is sitting at his console the OOW Please look out of it, get out of your chair is virtually precluded from looking out of the regularly and check the view out of the window by being so focussed on his internal window. Doing so will give you the best view screens and, as ever, he was concerned about of the situation around you and that feeling technology driving down the size of the crew. of spacial and situational awareness that will help you make the best decisions to ensure a Both these points, a distracted OOW, safe passage, backed up by the information on reduced crew leading to fatigue, and indeed screen. problems with technology on the bridge

2 MAIB Safety Digest 1/2016

The clear narrative and concise advice given by the MAIB in the lessons learned from each incident in this digest are excellent and should encourage all of us to examine our own operations closely to ensure that our seafarers remain safe and that our shores remain free from environmental damage.

Captain Ian McNaught MNM Ian was born in Sunderland. Having spent some time at sea with his father, who was a marine engineer, he decided to join the Merchant Navy and, after attending Fleetwood Nautical College for pre sea training in 1971, went to sea as a Deck Cadet with BP Tanker Company. This was followed by time as 3rd Officer with Bibby Line with service on general cargo ships and LPG tankers. He then moved on to Hullgates Shipping with service as Chief Mate on product and LPG tankers. In 1987 Ian joined Cunard Line and after service on board QE2, Cunard Princess and Sea Goddess II, he finally gained command of Sea Goddess I, then command of QE2 until she was retired and thereafter Queen Victoria. His final commands at sea were Seabourn Oddyssey and Seabourn Pride. Having come ashore in 2011, after 40 years at sea, Ian is now Deputy Master of Trinity House in London which is the General Lighthouse Authority for England, Wales, the Channel Islands and Gibraltar and is also the UK’s largest endowed maritime charity. Ian is also now a trustee for RNLI, the Marine Society and Sea Cadets and is a Board Member at the Standard P&I Club. Ian is married to Sue and their son, Steven, is the Navigating Officer on board P&O Cruises Britannia.

MAIB Safety Digest 1/2016 3

Turn on Time – Stay on Your Line! Narrative A tanker in ballast was on coastal passage plotted on the radar (also Figure 1). When but navigating near well charted and buoyed this alarm sounded the OOW realised that sandbanks; visibility was good in daylight, he had missed the turn to the new course, so traffic was light but there was a strong applied port helm and steadied on a westerly northerly tidal stream. The master had directed heading with the intention of regaining the the OOW to fix at 5-minute intervals when planned track. The OOW did not fix the ship’s passing in close proximity to the sandbanks. position until 12 minutes after the turn was The OOW, who was also the navigator, was complete; this showed that the vessel was still alone on the bridge and correcting charts that significantly to starboard of the planned track had been delivered to the vessel just before so the OOW made a correction of a further 3º sailing and were required later in the passage. to port. When on a northerly heading (Figure 1), the radar alarm sounded on the bridge as the vessel Fifteen minutes later, the OOW correctly crossed the safety corridor, 5 cables south of recorded a fix in the bridge logbook but the new north-westerly heading. The OOW incorrectly plotted it 1 mile south of the was not expecting the alarm and was unaware vessel’s actual position. This error led him of the approaching turn; nevertheless, he to assess that the vessel was regaining track; plotted a fix then returned to working on the however, a few minutes later, the strong chart corrections. northerly tidal stream caused the vessel to ground on a sandbank. Eleven minutes after the first radar alarm, it sounded again, this time to indicate that the vessel was exiting the 5 cable safety corridor

4 MAIB Safety Digest 1/2016

The Lessons

1. The first duty of the OOW is the safety passing the sandbanks was not effective of the ship. It is understandable that the mitigation of the navigational risk that OOW, as the ship’s navigator, had a strong had been identified. It would have been desire to correct the newly delivered charts more appropriate for the lookout to close as soon as possible. However, this proved a up and for the vessel’s master to have been very significant distraction and the OOW on the bridge to monitor the navigation. lost situational awareness at a crucial point in the passage leading to the grounding. 3. When the OOW took over the watch, Without realising the immediate danger he did not calculate the anticipated tidal ahead, he also did not call for help. stream, so was unaware of its effect. This proved critical as the heading adjustments 2. Bridge management is about teamwork; made were insufficient to counter the there were sufficient qualified bridge tide’s effect. Other measures could have watchkeepers on board for the master to been taken to closely monitor the track have temporarily relieved the OOW so he of the vessel, such as radar parallel index could finish the corrections and complete lines and close observation of the available the passage plan. The master’s direction visual clues such as the buoys. to use a 5-minute fixing interval when

Figure 1: Analysis of perceived route

MAIB Safety Digest 1/2016 5

Lifeboat Drills - Practise, Practise, Practise! Narrative A Port State Control inspection on a The aft gripe wire had been secured and the refrigerated cargo vessel in a UK port found forward gripe wire was still being connected deficiencies in the