MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 1/2019

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April 2019

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.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.gov.uk

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

© Crown copyright 2019

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

INTRODUCTION 1

PART 1 - MERCHANT VESSELS 2

1. When Your Watch is Dragging... 4

2. Re-boot the Engine with the off-on Switch 6

3. Lead Not Fair for Fairlead 8

4. Who Pulled the Plug Out? 11

5. Naked and Hot: Keep Hands Away 13

6. Mixing Doesn’t Always Match 14

7. What’s That Noise? 16

8. Autonomous Mode Not Yet Engaged 18

9. A Matter of Thrust… 20

10. Location, Location, Location 22

11. Loss of Fingers 24

12. Keep the Fire in the Furnace 26

13. Anchors Aweigh, and so is the Tow 28

14. Don’t Drive When Tired 30

15. You Were Only Supposed to Blow the Doors Off 32

PART 2 - FISHING VESSELS 34

16. Get Home Safely 36

17. That Sinking Feeling 37

18. Bigger Fish Could End Up Fried 38

19. Going, Going, Gone 39

20. No Alarm, No Alert, No Chance 41

21. That Sinking Feeling… 42

PART 3 - RECREATIONAL CRAFT 44

22. Weekend Bash 46

23. A Wave of Pain 48

24. Turning into Sand 50

25. A Tragic Slip 52

APPENDICES 54

Investigations started in the period 1/09/18 to 28/02/19 54

Reports issued in 2018 55

Reports issued in 2019 56

Safety Bulletins issued during the period 1/09/18 to 28/02/19 57

Glossary of Terms and Abbreviations AHTS - Anchor Handling Tug Supply kts - knots AIS - Automatic Identification System m - metre C - Celsius “Mayday” - The international distress signal (spoken) CCTV - Closed Circuit Television MBL - Minimum Breaking Load CFPP - Cold Filter Plugging Point MCA - Maritime and Coastguard Agency CO2 - Carbon Dioxide MGN - Marine Guidance Note COSWP - Code of Safe Working Practices for Merchant Seamen MGO - Marine Gas Oil CPR - Cardio-Pulmonary Resuscitation MOB - Man overboard DSC - Digital Selective Calling OOW - Officer of the Watch ECDIS - Electronic Chart Display and “Pan Pan” - The international urgency signal Information System (spoken) ECS - Electronic Chart System RHIB - Rigid-Hulled Inflatable Boat EPIRB - Emergency Position Indicating Radio RNLI - Royal National Lifeboat Institution Beacon SOLAS - International Convention for GPS - Global Positioning System the Safety of Life at Sea 1974, as amended GRP - Glass Reinforced Plastic SWL - Safe Working Load gt - Gross tonnage t - tonne HMPE - High Modulus Polyethylene VHF - Very High Frequency IBA - Incinerator Bottom Ash VTS - Vessel Traffic Services ILO - International Labour Organization IMSBC - International Maritime Solid Bulk Cargoes

Introduction At the start of this introduction, I’d like to thank this edition’s introduction writers. I am delighted that Captain Nick Nash, Andrew Locker and Steve Gravells have agreed to write the introductions to the merchant, commercial fishing and recreational craft sections of this digest. All three have written from both their professional and own personal perspectives, and their words are very powerful. If you read nothing else in this issue, I would encourage you to read the section introductions. When I took command of HMS YORK, the squadron navigator gave me some advice that has stayed with me throughout my seagoing career. Very simply, it was to check the emergency steering thoroughly before letting go to leave port, or before entering pilotage waters on the way in. Doing this ensured that: everyone was closed-up in their correct position, the communications worked; the rudder angle indicator and gyro repeater in the steering gear compartment were reading correctly and, importantly, the secondary and local steering systems actually functioned. The first time we did this it was a right pain. By the time we were doing it for the third or fourth time everyone’s confidence in and knowledge of the system had increased immeasurably. When one day the primary steering system did fail as we made our way into harbour, we took it in our stride and berthed as if nothing had occurred. I’m putting this story in my introduction because this issue of the digest has many examples of accidents that could have been avoided altogether, or at least somewhat mitigated, had the individuals involved spent a bit more time getting to know the reversionary operating modes of their safety critical systems. When things are going wrong, the human endocrine system has a tendency to flood the body with adrenaline. This hormone dates from the time of our earliest ancestors. It is useful if you need to run away from a sabre-tooth tiger, but damn all help if you are trying to read some small print instructions by torchlight when the alarms are sounding all around you. So, please take the time to thoroughly learn your systems before the fur starts flying, and make a point of testing them before you need them. The second theme I would like to highlight from this issue is that of providing a safe means of access to your vessel. As I write, the MAIB has started two investigations into fatal accidents (see Appendix A). One accident occurred as a crewman was attempting to leave his vessel; the second as a crewman was trying to board. Both accidents happened when the vessels were moving or about to move. It is likely that both individuals were trying to be helpful and to get things done quickly, but there were better ways of getting the lines ashore or letting go, and the shortcuts cost them their lives. The investigation reports will be published later in the year, but in the meantime may I ask you to review your procedures for passing and letting go mooring lines to ensure you are not putting anyone at risk. As always, when you have finished reading this edition of the MAIB’s Safety Digest, please pass it to someone you feel will genuinely benefit from reading these articles. If you are reading this on-line, then send on the link: there is no limit to the number of people who can learn from the experiences of others. Be safe.

Andrew Moll Chief Inspector of Marine Accidents

April 2019

MAIB Safety Digest 1/2019 1

Part 1 - Merchant Vessels Can the log speed readout be confused with the echo sounder readout particularly by a stressed navigator or pilot? Have the team considered using a “Head Up” display in pilotage waters? Finally, has your team been Trained on the bridge equipment? Have they been fully briefed on your steering switchover and control switchouts to the bridge wings? Is everyone fully updated on the ship’s present version of ECDIS and Track (auto) pilot systems and most importantly their display settings and limitations? DECIDE! On a port approach or departure this “BET” This is where all your training, bridge team must be in the background as you make that resources, experience and local knowledge critical decision that must take precedence over (including the pilot’s) lead to the ultimate all other decisions a captain will make that decision – ‘to go or not to go’. day, overriding e-mails, conference calls, cargo/ However before we get to that place, you as passenger issues and scheduling. master should have done an “invisible check/ One major self-help tool seafarers out at sea can confirmation” that your ship’s ‘BET’ is in place easily use to check that their own ship’s “BET” and robust enough for you to enter or leave the is robust enough are the MAIB reports, certain port confidently and safely. Whether you do this reports selected from its cousin the AAIB and at the start of each voyage or at the beginning of The MAIB Safety Digest. The ‘Digest’ stands your contract, ‘BET’ should always be at the back out with its sometimes ‘tongue in cheek’ easy of your mind. to remember incident titles while giving a ‘BET’ in this case doesn’t refer to the lottery, but: clean summary of the pertinent facts, a sensible narrative and conclusions without apportioning B - Bridge Team Management (inc communications) blame. This is something we, as sailors, E - Ergonomics (bridge equipment & controls layout appreciate. T - Training We can learn from others’ misfortunes and errors, Is your Bridge Team Management robust we don’t need to blame them. enough? Have all the deck officers been fully One from The AAIB stands out: 30 years ago trained in its practical use? Do you use BRM a Boeing 737 crashed on to the embankment consistently? Are you leading from behind of the M1 motorway, near Kegworth, with a well-briefed plan and good bridge Leicestershire, England, while attempting to team cohesiveness (consider closed loop make an emergency landing at East Midlands communications) taking into account your team’s Airport on 8 January 1989. Of the 126 people previously noted ‘BRM procedural drifts’? aboard, 47 died and 74 sustained serious injuries. Are the bridge Ergonomics good and equipment, The AAIB report’s recommendations included, displays and controls well laid out? If not are among others, better CRM, improved cockpit you, your team and the pilot (and your company) engine instrument ergonomics and crew training fully aware of any controls or switches that can – a full ‘BET’ failure. be operated in error? For example, this could A few pertinent ‘BET’ lapses can be found in the include the critical steering or engine telegraph following MAIB investigation reports: systems, particularly when switching control stations – i.e. to the bridge wings. BRM: - Heavy contact made by container vessel ‘CMA CGM Centaurus’ with quay and shore cranes at Jebel Ali, United Arab Emirates May

2 MAIB Safety Digest 1/2019

2017. Excessive speed was one of the main The Jebel Ali incident was one I remember that causes coupled with poor BRM, pilot/master we particularly discussed at our onboard team interchange and lack of a well thought out meeting as it well highlighted a couple of points plan. Pilot/Bridge Team communications were within the BRM/communication envelope. also a major cause along with the Port/Pilot 1. Master/Pilot Exchange - following this Management. report and others in the same vein - we now Ergonomics: - Collision between the pure car try to send our Pilot card and approach/ carrier ‘City of Rotterdam’ and the ro-ro freight docking plan to the port/pilots 48 hours ferry ‘Primula Seaways’ on the River Humber in in advance. Hopefully this will allow both December 2015. The report noted that the car parties to be on the same game plan at the carrier was of an unconventional design and the start of the exchange. pilot’s disorientation was due to ‘relative motion 2. Speed – The speed of the ‘CGM Centaurus’ illusion’, which caused the pilot to think that the was, in hindsight, too fast to achieve the vessel was travelling in the direction in which he required ROT into the Terminal 1 basin. We was looking. reassessed our own speeds of approach and Training: - The grounding of ‘Pride of harbour ‘turn ins’ and double-checked that Canterbury’ on The Downs – off Deal, Kent, we could achieve the required ROT with an January 2008. One of the recommendations was adequate safety margin. where an electronic chart system is fitted as an We can always learn from others’ mistakes, aid to navigation, proper generic and/or type and reading MAIB reports and the non- specific training in its use should be provided confrontational “Digest” give our onboard to all navigating officers to ensure a thorough meetings some foundations to reassess our understanding of its display and functionality. own ‘BET’ while we’re out at sea and away These are just 3 reports and although each had from our own Marine Operations & training numerous recommendations, I have picked the establishments. ones that stood out for me and fit clearly into my The old adage “Make sure your “BET” is in place “BET” acronym, which we use when discussing before the game starts” is very true! And always The Digest at our monthly on board “Nautical remember... Meetings”. I try to involve the team in using the “BET” idea to identify the recommendation “Doubt is the beacon of the wise” which stands out the most and then ensure William Shakespeare 1564-1616 we try to identify our own “Procedural Errors” within that recommendation.

CAPTAIN NICK NASH, MNM, CMMAR, FRIN, FNI. SHIPMASTER & PRESIDENT THE NAUTICAL INSTITUTE Nick Nash was born in Penzance, Cornwall, where he still lives. He ran away to sea in 1977 as a deck cadet with Port Line/Cunard cargo serving on general cargo, banana boats, oil tankers and container ships. Nine years later he joined the Royal Fleet Auxiliary as a 3rd officer serving on fleet oil tankers and landing ships in support of the Royal Navy. He passed for Master in 1988, and joined P&O/Princess Cruises in 1989 as 3rd officer. He was promoted to staff captain in 1997 and captain in 2002. He is currently senior master of the ‘Royal Princess’, a 144,000 GRT cruise liner. Nick is a part time consultant at Carnival’s Arison Maritime Center – CSMART - simulator training facility in Amsterdam, where he has also helped teach BRM and ship handling - of which he has recently written a book – ‘Shiphandling Passenger Ships - without Tugs’. He is the president of The Nautical Institute and was recently awarded the Merchant Navy Medal for meritorious service. Nick is an advanced driver, holds a PSV (bus) licence and enjoys navigating the canals of England and France in a narrow boat with his wife Sue, and a Border terrier.

MAIB Safety Digest 1/2019 3

When Your Watch is Dragging... Narrative Strong winds and tidal streams were forecast 30 minutes. During one of the checks, the when the master of a small general cargo vessel second officer noticed that the vessel had was forced to change his plans and anchor moved significantly closer to one of the other overnight in an estuary to await a bunker anchored vessels. As predicted, the easterly barge. The vessel had not been able to take wind was now force 9 and the rate of the bunkers when alongside, and had insufficient north-westerly flooding tidal stream had fuel to reach its next port. increased to over 2.5kts. The cargo vessel had been dragging its anchor for about 10 minutes After sailing with a river pilot on board, the at a speed of up to 1.4kts, and the second vessel proceeded to an anchorage as advised officer immediately alerted the master and by the VTS. It was then anchored 40 minutes called the engineer to start the main engine. before low water in a depth of 12m using 5 shackles of cable. Several other vessels were By the time the cargo vessel’s engineer had also at anchor close-by. Shortly afterwards, the dressed and started