MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accidents No 1/2018

is an

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April 2018

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

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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 2018

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. Dented Fortunes 4

2. Too Fast to Make Fast 6

3. Grounding on the Green Bit 7

4. Are Your Fittings Leak Free? 9

5. Too Much Speed Proves Fatal 11

6. Eye For An Eye 13

7. It’s Just a Jump to the Left... 15

8. I’ve Got the Steering; or Have I? 17

9. Control is Everything 19

10. Hot Work Results in a Meltdown 21

11. Don’t Forget to Check That You Can ‘Let Go’ Before You Get Going 23

12. Nothing to See? 25

13. Anchor Watch Can Be a Drag 28

14. Poorly Maintained Pilot Ladder Results in Rapid Transfer 30

PART 2 – FISHING VESSELS 32

15. An Invisible Snagging Hazard 34

16. No Smoke Without Fire, No Escape Without Smoke Detection 36

17. Sudden Sinking 38

18. The Twisted Chain 39

19. Didn’t Get His Feet Wet 41

20. A Quick Exit 43

21. Lotto Crabs 44

22. Heath Robinson Would be Proud… 46

PART 3 – RECREATIONAL CRAFT 48

23. Too Fast, Too Close, Too Late 50

24. Carbon Monoxide Strikes Again 53

25. A Tough Decision 55

APPENDICES 57

Investigations started in the period 1/09/17 to 28/02/18 57

Reports issued in 2017 58

Safety Bulletins issued during the period 1/09/17 to 28/02/18 60

Glossary of Terms and Abbreviations AB - Able Seaman "Mayday" - The international distress signal (spoken) AIS - Automatic Identification System MGN - Marine Guidance Note ASD - Azimuth Stern Drive OOW - Officer of the Watch C - Celsius OS - Ordinary Seaman CCTV - Closed Circuit Television PFD - Personal Flotation Device COLREGs - International Regulations for the Prevention of Collisions at Sea 1972 PTW - Permit to Work (as amended) RHIB - Rigid-hulled Inflatable Boat CPR - Cardio-Pulmonary Resuscitation RNLI - Royal National Lifeboat Institution DSC - Digital Selective Calling ro-pax - Roll on/Roll off passenger ECR - Engine Control Room ro-ro - Roll on, Roll off EPIRB - Emergency Position Indicating Radio RYA - Royal Yachting Association Beacon SOLAS - International Convention for the FEW - Finished With Engines Safety of Life at Sea GPS - Global Positioning System SOP - Standard Operating Procedure IMO - International Maritime Organization UMS - unmanned machinery space kts - knots VHF - Very High Frequency m - metre

Introduction As I write this, much of the country is slowly recovering from the effects of one of the worst snowfalls in a generation. It could be said that the chaos caused by a weather system described by the media as “the Beast from the East” was exacerbated by a collective failure to prepare for the worst. Regular readers of the MAIB’s Safety Digest will be aware that failure by seafarers to prepare for the worst, or at least properly consider the potential risks before commencing a voyage, operation or task has been an enduring theme. I made a very similar observation when writing my first introduction to the Safety Digest in 2010 (and on several occasions after that!). Almost 8 years later, my final introduction provides the same message; most of the incidents described in the following pages could have been avoided had the protagonists taken the time, beforehand to simply ask themselves “what could go wrong?” and put in place appropriate control measures to prevent a bad outcome. This edition of the Safety Digest contains an eclectic mix of safety lessons. Every accident provides a learning opportunity which often transcends traditional operational barriers. The importance of maintaining a proper lookout (Case 1), conducting effective passage planning (Case 3) and applying sensible maintenance regimes (Cases 4, 11, 14) has relevance for all sectors of our industry, as do the benefits of being prepared and doing the right thing when there is an emergency (Cases 19, 20, 23, 25). I would therefore urge you to take the time to read all the articles in this Digest – it is better to learn from the experiences of other seafarers, no matter what their background, than experience similar trauma first hand. I am grateful to Grant Laversuch, Nigel Blazeby and Peter White for their sage and interesting introductions to the merchant vessel, fishing and recreational craft sections. I will be retiring from the MAIB in a few months and so I use this opportunity to also express my sincere gratitude to my staff, who have worked hard to produce successive editions of the Safety Digest on time and to a consistent standard during my time as Chief Inspector. Special thanks go to the MAIB’s Technical Editor, Jan Hawes, who has steadfastly supervised the production of every Safety Digest almost since its inception. In closing, I would also like to thank the readership of this Safety Digest for their continued support and for the very positive feedback you have given me over the years. Keep safe and best wishes for the future.

Steve Clinch MNM Chief Inspector of Marine Accidents

April 2018

MAIB Safety Digest 1/2018 1

Part 1 – Merchant Vessels Here at P&O colleagues. It could be said that he had become Ferries we have complacent. As I said before, complacency is been running a something common to all human beings, but in a course based on high risk industry like shipping the consequences the human element are so often tragic. for a number of years. Shortly after The best example that I have seen of how the start of each complacency creeps up on us in our seafaring course, once we career, is demonstrated as follows: In the five have looked at the years that I have been in this position at P&O first case study, I have interviewed 43 deck officers for the invariably after command interview before they take command a few minutes for the first time. While many of these new the C word appears; complacency. It is an easy captains have since been involved in incidents, way to explain a multitude of errors away, but none of those incidents were construed to have if we really understood what complacency was, been caused by complacency. However during it wouldn't exist. Complacency isn't unique to that same time, we have had some incidents that seafarers; it is a weakness of human beings. We were complacency driven and without exception are all vulnerable to complacency in our daily these have involved very experienced masters. I lives. There are many definitions of complacency, know with the passage of time those 43 younger however for me it is when we feel comfortable Captains will be at risk of moving into the with something and start to let our guard down. complacency trap.

On the next page are details of a fatal accident How do we, as seafarers, guard against falling that are similar to one we suffered on one of into this complacency trap? For me it is about our vessels last year. The seafarer involved was never fully feeling comfortable in anything we highly experienced, well-qualified and had do. The day we feel fully comfortable in anything worked on board this vessel for five years. He was we undertake, is the day that we are in for a nasty professional, well trained and certainly knew the surprise. risks involved in working on a vehicle deck. He did the same work every day, worked with the We are all human and we all make mistakes, same people every day, and no doubt started to seafarers and management alike. We all need to feel comfortable in the job he did. On this day he acknowledge this, recognise our mistakes, share made one mistake and put himself into a place and support each other, challenge ourselves and of danger. The consequences were tragic and the challenge others. impacts were huge to him, his family and his

GRANT LAVERSUCH P&O FERRIES Grant Laversuch is the Head of Safety Management and Designated Person Ashore at P&O Ferries. Grant started his career as a deck Cadet with Ocean Fleets before moving onto Shell Tankers UK and then Cunard. After fifteen years at sea, the last five years on the QE2, Grant moved ashore. The first two years ashore was in Cunard’s New York office working on cruise planning. This was followed by three years of cruise ship planning on a self employed basis. Grant then moved to Saga Cruises and spent 13 years as the Operations Director there. The last five years has been at P&O Ferries. Grant sits on the Standard Club’s Loss committee, is a member of the Nautical Institute and the Honourable Company of Master Mariners. 2 MAIB Safety Digest 1/2018

Ro-Pax - Vehicle Deck Fatality An experienced AB was acting as a banksman for the loading of an unaccompanied piece of freight that was being loaded by a tug-master. The crew member became trapped between the rear of the trailer and a vent housing. He was fatally injured. The vessel completes a 24 hour rotation between two ports, six days a week. The deck crew were employed to load and lash vehicles. Five crew were involved in this operation on the upper vehicle deck and were loading two pieces of unaccompanied freight being reversed in by a shore tug-master. Normally crew members guiding reversing freight into position stand in a position of safety while they are directing the tug driver. Once the trailer is in the correct position a whistle is then blown by the banksman to indicate that the tug should stop. The tug driver reversed the trailer, jack-knifing to the left and right to achieve a straight trajectory and line the trailer up with the freight already parked. He was expecting to hear a whistle signal from the banksman when the trailer reached the correct position. Meanwhile, the crew member acting as the banksman had moved from a position of safety and was crushed between the rear of the trailer and a vent housing. The whistle signal instructing the tug driver to stop was not given.

Direction of travel of the trailer

Position where crew member directing the trailer Approximate position where the crew member was would normally stand in a protected position trapped between the trailer and the vent housing

The Lessons Although derived from the company’s internal investigation, the following lessons are also relevant for the crews of many vessels engaged in ro-ro operations. • A safe system of work is required to ensure no crew member moves into a dangerous zone behind moving freight. • Whistle signals should only be used to stop a vehicle. Whistle means STOP. • Crew members and tug drivers need to work as a team. Watch my Back – always look after your team mates. • Training should involve both ship and shore teams working together. • If the tug driver loses sight of the banksman he must stop. • If the banksman loses sight of the tug driver he must blow his whistle.

MAIB Safety Digest 1/2018 3

Dented Fortunes Narrative In daylight and good visibility, a laden general flooded wheelhouse through a window, and the cargo vessel commenced its passage to deliver crewman was washed overboard but managed bulk cargo and containerised goods to a group to hold onto the bulwark top edge then of islands; the ship did the same round-trip climb back on board when the rush of water every week. Once clear of the harbour, the subsided. master and lookout left the bridge and the chief officer was left alone on watch. Having The bunker barge suffered a large indentation set course on the autohelm, the chief officer below the waterline where it was struck by the did some paperwork at the chart table and cargo ship’s bulbous bow (see figure). There then sat down in the bridge chair. was also significant flooding of the vessel, the main engine seized and there was some A small bunker barge with a cargo of diesel pollution from leaking fuel cargo. fuel was on coastal passage ahead of the cargo ship. The vessels were on a steady bearing for The master pumped seawater into an empty about 25 minutes before colliding. The bunker ballast tank to correct the post-collision list. barge quickly listed over 90º and both the This reduced the stability of the barge to a master and crewman on board were extremely dangerous level, but it was later towed back to lucky to survive. The master escaped from the the safety of a nearby harbour without further incident.

Figure: Indentation in the bunker barge’s hull caused by the cargo ship’s bulbous bow

4 MAIB Safety Digest 1/2018

The Lessons

1. Keeping a good lookout is perhaps 3. Lone watchkeeping is acceptable during the most fundamental watchkeeping daylight, in good weather conditions and requirement on any vessel; it is an low traffic levels where the OOW can essential task enshrined in Rule 5 of the focus on navigational safety. However, the COLREGs. In this case, both ships’ decision to reduce to a lone watchkeeper watchkeepers were alone and not keeping needs to be taken with care, and all the a proper lookout so neither was aware of associated risks properly assessed. the risk of collision before the accident. 4. Understanding stability is critical for 2. On board the cargo vessel, the chief officer maintaining the safety of your vessel, missed opportunities to detect the bunker especially if it is damaged. In this case, the barge by visual, radar and AIS means; this master of the bunker barge pumped water happened because the repetitive nature of into the vessel without understanding the the vessel’s tasking made him complacent effect on the damaged stability. This made and he allowed himself to be distracted by the stability situation worse, not better, paperwork. On board the bunker barge, and could have resulted in the loss of the the master was on watch and was aware of vessel and, potentially, the lives of him and a larger vessel approaching, but he did not his crewman. monitor its relative movement, assuming that it would keep clear.

MAIB Safety Digest 1/2018 5

Too Fast to Make Fast Narrative Two tugs were tasked to assist a car carrier The car carrier was travelling at a speed of that was arriving in port. The car carrier’s pilot 6.5 knots (kts) through the water. Tug A ordered one tug (Tug A) to make fast on the approached the ship bow-to-bow, and a centreline forward, and the other (Tug B) to heaving line was passed from the ship to the make fast aft. The weather was good, the sea tug. The tug's skipper then increased speed was calm and there was a light breeze. An ebb astern to clear the ship’s bow. In doing so, tide was