MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accidents No 1/2017

is an

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April 2017

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;

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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 2017

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. A Catastrophic Outcome 4

2. Fatal Short-Cut to Using the Gangway 6

3. Isolated Working Leads to Girting 8

4. No Pool Attendant, No Rescue 10

5. A Snake’s Wedding 11

6. Exploding Grinding Disc 13

7. Damaged Butterfly Lets in Water 14

8. Maintenance Blindness 16

9. Where’s He Going? 19

10. The Fatal Consequence of a Routine Task 21

11. The Engine That Ran Away 24

12. Blinded By Caustic Soda 26

13. When Steel Meets Granite 27

14. Uncontrolled Release Clouds Discharge Operations 30

PART 2 – FISHING VESSELS 32

15. Cold Water Can Kill in as Little as 2 Minutes 34

16. An Unheard Alarm Means No Alarm 36

17. Fishermen DON’T Have to Die 38

18. Let It Go And Come Back Later 40

19. Stay Dry, Stay Alive 42

20. Keep a Lookout 45

21. Entrapment in Winch Leads to Severed Fingers 47

22. One Hand For You, One For Your Chips 49

PART 3 – RECREATIONAL CRAFT 52

23. Never, Ever Assume 54

24. Alone, No Kill Cord, No Lifejacket, No Chance 57

25. Petrol Fumes Plus Bow Thruster Equals Explosion 58

APPENDICES 60

Investigations started in the period 1/09/16 to 28/02/17 60

Reports issued in 2016 61

Reports issued in 2017 62

Glossary of Terms and Abbreviations AB - Able seaman “Mayday” - The international distress signal (spoken) AIS - Automatic Identification System MCA - Maritime and Coastguard Agency C - Celsius MGN - Marine Guidance Note CCTV - Closed Circuit Television MOB - Man Overboard CO2 - Carbon Dioxide MSC - Maritime Safety Committee CPR - Cardio-Pulmonary Resuscitation OOW - Officer of the Watch DSC - Digital Selective Calling P&I - Protection and Indemnity ECDIS - Electronic Chart Display and Information System PFD - Personal Flotation Device EPIRB - Emergency Position Indicating Radio PLB - Personal Locator Beacon Beacon PPE - Personal Protective Equipment ESD - Emergency Shutdown rpm - revolutions per minute gt - gross tonnage SRV - Safety Relief Valve IMO - International Maritime Organization UHF - Ultra High Frequency kt - knot VHF - Very High Frequency LPG - Liquefied Petroleum Gas XTD - Cross Track Distance m - metre

Introduction As I write this introduction, one of the first of the winter storms to hit the UK in 2017 is driving the rain hard against the windows of my office in Southampton. Ashore, the ravages of the weather can be inconvenient, a distraction that mercifully rarely ends in disaster. However, at sea most mariners quickly learn that to ignore the vagaries of wind (and tide) is, at best, foolhardy. Case 1 of this edition of the Safety Digest provides a sobering example of the power that can be generated when gale force winds oppose strong tidal streams; a small laden cargo vessel was overwhelmed and capsized when the ship entered an extremely hazardous channel at the very worst time possible. Sadly, none of the ship’s crew survived. When compiling this edition, I was struck by a common theme that runs through many of the accidents – taking an unnecessary risk to save time or get a job done more quickly. This is something that we probably have all been guilty of doing at some point in our careers whether afloat or ashore. Again, Case 1 is a strong example of why it’s important to take the time to plan carefully any voyage and be ready to amend that plan should the circumstances change. However, Cases 10,12,13,15,16,17,19,20,22,23,24 and 25 also illustrate why it is so important to pause and ask yourself “what could go wrong?” and then ensure the appropriate barriers and controls are in place before commencing any task. 2016 was not a good year for our fishing industry. Too many fishermen died when they fell, or were taken overboard from their vessels. Full details will be contained in my Annual Report when published later in the year. However, these fishermen have mostly succumbed to the effects of cold water shock, which can be debilitating and cause drowning within minutes of entering the water (Case 15). I fully support the views expressed by Simon Potten in his excellent introduction to the Fishing Vessel section of this Safety Digest: boat skippers need to take more responsibility for the safety of their crew by ensuring onboard working practices reduce the risk of going overboard and insisting their crews wear PFDs when working on the open deck. I would also add that it is crucial that the skipper leads by example. With the approach of spring, many readers will be preparing to go back on the water in their small craft. Some of you may also be considering carrying spare petrol on the boat. Please don’t! or at least keep the quantities you need to carry to the absolute minimum and always stow it on the open deck in sealed containers that can be quickly jettisoned. Case 25 explains why this is so important. In closing, I take this opportunity to thank Guy Platten, Simon Potten and Steve Usher for their thoughtful introductions to this edition of the Safety Digest. Until next time, keep safe.

Steve Clinch Chief Inspector of Marine Accidents

April 2017

MAIB Safety Digest 1/2017 1

Part 1 – Merchant Vessels It is an honour be right that our industry has a fatal accident rate to be asked to 20 times that of the average British worker and write the forward five times that of construction. Here at the UK to this MAIB Chamber of Shipping in 2017 we are embarking Safety Digest. The on a new leadership role on safety, bringing Marine Accident together seafarers, managers and regulators to Investigation work together to enable a step change in safety Branch undertake performance. The MAIB will undoubtedly play a a vital role in central role in this and ultimately we want to be investigating and able to look the families in the eye and tell them reporting on the their father, mother, son or daughter works in the sadly far too many safest industry in the world. accidents and incidents which take place in our industry every So I would urge you to read each of the reports year. The inspectors do this in a way that seeks to carefully and ask yourself the question ‘how establish the facts and causes so lessons can be would I have reacted in this situation?’ At all learnt rather than apportion blame – imperative levels of the industry we need to change the way if we are to prevent further accidents. These we think, to change our safety culture so that we incidents can happen at any time and in any always ‘do the right thing’ because ‘it’s the right sector and tragically all too often result in serious thing to do’. injury or loss of life.

This digest provides a timely round up of the breadth of incidents from the capsize of a coastal cement carrier with the loss of all hands to an exploding grinding disc. It is written in a style that draws the reader in and makes individuals think very carefully about the sequence of events leading to the accident and how we can learn the lessons to ensure that they do not take place again. I have always been an avid reader both during my time at sea and now ashore and as always the common thread throughout the reports is all too often complacency, communication and perceived commercial pressures that cause individuals to act in a way that set off the series of events which ultimately ends in tragedy.

We must never forget that shipping is about seafarers who go about their work in often difficult and harsh conditions. The most important thing to their families is that they return home safely at the end of each trip. It can’t

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GUY PLATTEN CHIEF EXECUTIVE, UK CHAMBER OF SHIPPING

Guy Platten is a master mariner with a long background in the marine industry. He was appointed Chief Executive Officer of the UK Chamber of Shipping in January 2014. His role includes responsibility for the UK shipping industry’s relations with government and other relevant bodies (national and international) on all fiscal, economic, employment, safety and environment, security and other issues. Prior to this, he was Chief Executive of Caledonian Maritime Assets (CMAL) Ltd. Establishing CMAL and building it into a respected company delivering vital transport infrastructure. He oversaw construction and delivery of two innovative hybrid ferries along with a number of significant harbour developments. Before joining CMAL, Guy was Director of Marine Operations for the Northern Lighthouse Board and was responsible for the NLB fleet, Oban port facility, 24 hour monitor centre and providing navigational advice regarding the provision of Aids to Navigation around the coast of Scotland and the Isle of Man. His career at sea began in 1982 with the Royal Fleet Auxiliary Service. Joining the RNLI as an Inspector of Lifeboats, latterly as Inspector for Scotland. He served with the MOD as a Salvage Officer..

MAIB Safety Digest 1/2017 3

A Catastrophic Outcome Narrative A small, laden cement carrier capsized while of the crew survived. The alarm was not raised on passage through a coastal channel that until about 25 hours later when the upturned was notorious for its powerful tidal races and hull was spotted by a passing ferry (Figure 2). associated extreme sea conditions. The accident had gone unnoticed because: the capsize was so rapid that there was insufficient As the vessel approached the channel, the time for the crew to call a “Mayday”, the weather deteriorated and gale force winds EPIRB almost certainly became trapped and were opposing the strong tidal stream; this did not float free, and the AIS transmissions was creating treacherous conditions that were ceasing was not observed ashore. dangerous for small vessels. On entering the channel, it is evident from AIS evidence The hazards presented by the tidal races were that the bridge team slowed the vessel down, well publicised and the channel was impassable almost certainly to reduce the risk of pounding to small vessels during certain tidal conditions. or ploughing as they headed into the dreadful The ship and its master had passed through the sea conditions (Figure 1). Due to the direction channel many times before and the master had of the tidal stream, it is also evident that previously taken action, normally by altering course alterations were required to maintain course, to avoid entering the channel at the a safe navigational track over the ground. dangerous times. About 3 months prior to the However, these course changes had the effect accident, the master had altered course across of placing the large sea increasingly on the the sea in the approaches to the channel in vessel’s beam. order to avoid the extreme tidal races; however, this caused the vessel’s cement cargo to shift When close to the area of worst sea conditions, and resulted in a dangerous stability situation. the vessel capsized and remained afloat upside down for a considerable period of time; none

Direction of wind and very heavy seas

Direction of tidal stream

Figure 1: Vessel's track showing headings through the water (vessel shown 10 times actual size)

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Figure 2

The Lessons

1. Passage planning is critical for every this situation can be made worse by poor voyage; it needs to take into account all weather and constant ship movement, potential hazards and should include abort disrupting crew rest. plans where necessary. In this case the ship entered the extremely hazardous channel 3. Safety at sea must always be a priority at the very worst time of maximum ahead of commercial pressures. The crew opposing wind and current, creating had experienced some difficulties loading the fatal sea conditions. Options were the vessel and this had caused a delay in available to seek shelter or avoid the area. departure. The delay in sailing might have However, the decision to press ahead with created additional pressure on the crew to the voyage resulted from poor passage press ahead with the voyage in an attempt planning, a likely under-estimation of to regain the lost time. the environmental conditions, over- confidence in the vessel’s sea-keeping 4. It is important to understand your capability and an unwillingness to alter vessel’s stability condition and, for bulk across the sea after the recent experience of carriers, the cargo bulk density value is a dangerous cargo shift. critical. The vessel’s stability condition was not accurately determined after the 2. Other factors were likely to have played accident; however, it was established a part in the decision making on board. that the assumed bulk density value for The master and chief officer were in a 6-on the cargo was greater than reality, which / 6-off routine at sea and both also had could potentially have generated a false duties to fulfil in harbour. Such a routine impression of stability. This created a can be exhausting in the short sea-trading situation where the vessel was potentially routes that the vessel was undertaking; more vulnerable to capsize than the stability calculations would have indicated.

MAIB Safety Digest 1/2017 5

Fatal Short-Cut to Using the Gangway Narrative A small passenger vessel was alongside a berth shore worker alone in the main deck saloon. it used regularly on its scheduled service to A few minutes later they heard a cry from the an off-lying island. The crew were waiting side of the vessel and looked down to see that for the arrival of provisions and additional the shore worker was trapped on the belting, crew members before departure when a shore between the vessel’s side and a quayside fender worker, whose job was to handle the vessel’s (Figure 2). He had apparently decided to leave mooring lines from the quay, boarded via the the vessel through the shell door and walk vessel’s gangway for a cup of coffee with the along the belting to an area where he would crew. have been able to step across onto the quay.

The vessel was fitted with a shell door on each The crew went to the man’s assistance but were side of the main deck and an external belting unable to recover him back onto the vessel that ran most of the length of the hull (Figure and they had to lower him into the water. One 1). When there were no passengers on board, of the crew jumped into the water to keep the shell doors would normally be left open the man afloat and conscious until a lifeboat in port to improve lower deck ventilation. arrived. The lifeboat was quickly on scene