MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 1/2021

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April 2021

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 an 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 Publications Team welcomes any comments or suggestions regarding this issue.

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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. Unsafe Access, Fatal Consequence 4

2. Hi-Fog Hero 6

3. Are you secured for the Weather, Even Alongside? 7

4. Pinned by the Digit 10

5. Swimmers can be ‘Ferry’ Hard to Spot 12

6. Failure in the Fall Zone 13

7. Bend in the River 15

8. A Breath of Fresh Air 16

9. What Bulk Carrier? 18

10. Fire After Engine Maintenance 20

11. Mind the Gap 22

12. Balancing Act 24

13. All Decked Up 25

14. Watch Your Step 27

15. Getting Your Wires Crossed 30

16. One-armed Paper Hanger… 31

PART 2 – FISHING VESSELS 34

17. Between a Rock and a Hard Plaice 36

18. A Flipping Fishing Trip 38

19. Getting Ahead of Yourself 40

20. A Fatal Fall 42

21. A Wee Hole 44

22. Are you Ready for Fog? 46

PART 3 – RECREATIONAL CRAFT 48

23. Hung Up On Me 50

24. Oh Buoy! 53

25. What Lies Beneath? 54

APPENDICES 56

Investigations started in the period 01/09/2020 to 28/02/2021 56

Reports issued in 2020 57

Reports issued in 2021 58

Glossary of Terms and Abbreviations 2/E - Second Engineer m - metre AB - Able seaman "Mayday" - The international distress signal (spoken) AFFF - Aqueous Fire-fighting Foam MGN - Marine Guidance Note AIS - Automatic Identification System OOW - Officer of the Watch C - Celsius “Pan Pan” - The international urgency signal C/E - Chief Engineer (spoken) COLREGS - International Regulations for the PLB - Personal Locator Beacon Prevention of Collisions at Sea 1972 (as amended) RIB - Rigid Inflatable Boat COSWP - Code of Safe Working Practices for ro-ro - roll on, roll off Merchant Seamen SOLAS - International Convention for the Safety EPIRB - Emergency Position Indicating Radio of Life at Sea Beacon VHF - Very High Frequency kt - knot VTS - Vessel Traffic Services

Introduction Welcome to the MAIB’s first Safety Digest of 2021. I would like to start by thanking Fran Collins, David Fuller and Roger Brydges for writing the introductions to the merchant, fishing and leisure sections of this Digest. Their perspectives on maritime safety make compelling reading. At the MAIB, we try to keep our safety messages fresh. However, the articles in the Safety Digests are drawn from the cases reported, and all too often this means seeing the same sorts of accidents time and time again. Consequently, this edition contains accidents we have seen many time before involving safe means of access, suspended loads, noxious atmosphere and man overboard recovery. As mariners we take pride in our ability to get the job done, but many of the accidents reported here could have been avoided had those involved taken a little more time to assess the risks before getting on with the job. The old sailor’s adage of ‘one hand for yourself and the other for the ship’ is still valid today: doing your job should not involve putting yourself in danger. I have made the point before that accidents often come in batches. However, after a prolonged period during which there were no fatal accidents in the UK’s commercial fishing sector, the spate of such accidents over the winter months is concerning. Small fishing vessels can be extremely vulnerable both to capsize and to being overwhelmed by heavy seas, and 5 of the 7 fishermen lost over the winter months were likely trapped when their vessels suddenly and without warning capsized. The MAIB’s reports into these recent accidents will follow, but I make no apology for again asking owners and skippers of small fishing boats to make a proper assessment of their vessel’s stability and of the loads it can safely carry. For Northern hemisphere leisure boaters, Spring has arrived, better weather is expected, and for many there is a feeling of hope that the worst of the COVID restrictions are perhaps behind us and we can get on with some serious boating. In the autumn 2020 issue of the Safety Digest, I made the point that there had been some terrible tragedies over the summer, and I encouraged all leisure boaters to take advantage of the winter months to refresh their knowledge, carry out the inevitable maintenance tasks, and to plan how best to start the 2021 boating season. With the freedom to resume boating still some weeks away, I make no apologies for repeating that advice. One of my favourite quotes is by the English businessman Sir John Harvey-Jones MBE, which is as follows: Planning is an unnatural process; it is much more fun to do something. The nicest thing about not planning is that failure comes as a complete surprise, rather than being preceded by a period of worry and depression. When restrictions are eased and the sun is shining the temptation to get afloat will be immense. Please make the most of these last few weeks of enforced inactivity to properly plan and prepare for this year’s boating. I am quite sure you will not regret it. Keep safe

Andrew Moll Chief Inspector of Marine Accidents

April 2021

MAIB Safety Digest 1/2021 1

Part 1 – Merchant Vessels I firmly believe I feel proud to be part of an industry that places that safety at work great value on ‘safety culture’. But as capable as must be considered we are within the maritime world, we are often a basic human guilty of failing to identify what truly drives and right. Ensuring motivates those at the highest risk of accident or that both we and injury. our colleagues go home safely at As seafarers, we take great pride in ‘keeping the end of each the railroad running’. We are rightly proud of contract or shift our abilities in being efficient and economical, is an individual, to make do and make good (I’m sure many civic and moral recall the ‘used-but-good spares’), and to deliver responsibility, and it to schedule. But this is often at higher than applies to each and every one of us – on land and acceptable cost and risk and may have long at sea. Yet despite great improvements in systems lasting and tragic impacts. Culturally, these and advancement for safety culture, accidents behaviours are self-perpetuating, and without continue to occur with the same themes. When intervention the tolerance of risk becomes ever reading anonymised reports devoid of names higher. The challenge for us, both ashore and and faces, it is all too easy to forget the human afloat, is to ensure that we collectively understand cost that results from accidents. Imagine if every the boundary between ‘enough’ and ‘too much’. report also included a “Where are they now?” section, complete with details about how the This boundary can only be defined through accident affected their physical health, mental collaboration between ship and shore with health, relationships, career, financial situation each acknowledging the contribution of the and prospects, or worse, the impact on family, other. Many shore-based managers have spent friends and children left behind. The next time considerable time at sea, but it is often easy to you come to the end of an incident report, I ask forget the specific challenges faced by those to remember that it’s not really the end. Pause on the front line when creating policies and and spare a thought for the rest of the story. defining procedures. This is particularly so when Make it a habit to take just one minute to think working with a diverse and geographically about what might have happened next. When remote workforce, who may not be aware of reviewing accidents, it’s as important to focus management constraints. on the human impact as it is on the human element. As vessel operators we must ensure that we’re always working to the perspective of an As vessel owners, managers, designers and end-user who is potentially in a different time operators, it is imperative that we more fully zone, managing conflicting demands, living and challenge the root causes behind accidents, working on an unstable platform and missing incidents and near misses. Focussing on the their home. Working together to a shared mental human elements that result in unsafe actions model means we are ALL more likely to go has historically been an easy excuse. But now, home safely. with the help of new and improved technology and deeper understanding, we must ensure that It would be remiss of me not to mention the we proactively “design out” the root flaws in our Coronavirus pandemic. Aside from the very infrastructure and systems so that we eradicate obvious risks to our colleagues that result directly the causes that lead to unsafe behaviours. from the virus, we must remember the indirect effects on safety more broadly. Operating within

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the spectrum of the pandemic has resulted in For the time being, it appears as though our many reactive changes, and changes to changes battle against the virus isn’t going away anytime that by necessity have been made at lightning soon. Our efforts in this space must work speed and within a short space of time. Crises in alongside our continuous safety programs, not the maritime theatre are usually short-lived and replace them. At no time is it ever acceptable operational in nature, whereas this pandemic has to say, “we stopped focusing on elements of our affected virtually every aspect of what we do and safety program, because Covid took priority.” how we do it for some considerable time. There That’s not good enough. We need to accept is a great risk that focus is taken away from the that the pandemic has added to our scope and priorities that keep us safe and it is imperative changed the look of the playing field. that we do not compromise our core efforts.

FRAN COLLINS MNM CHIEF EXECUTIVE OFFICER, RED FUNNEL Fran Collins has been CEO of Red Funnel Group since in June 2018, having spent over 20 years in the merchant navy. With a 160-year history of serving the Solent, Red Funnel now operates a fleet of 7 ferries between Southampton and the Isle of Wight. Fran’s early career was as a Dual Cadet with Shell Tankers, from which she qualified with both Deck and Engineer licences and served on various vessel types, particularly oil & gas carriers and sub-sea cable laying and repair ships. In 2002 she joined Condor Ferries as Chief Officer, and subsequently became Condor’s first female Master. In 2008 Fran transferred into shore-based business management, and developed her career through several executive roles, the delivery of which included operational management, customer services and strategic projects such as vessel acquisition and disposal, transactions and refinancing, and long-term business planning. Notwithstanding her current corporate focus, Fran retains a long-standing passion for improving safety in the maritime industry, particularly from the perspective of cultural strategy and human behaviours. Fran also chairs the Cruise & Port Group for Business South and sits on the Boards of the Merchant Navy Training Board and the IoW Chamber of Commerce. She is a member of the DfT’s Clean Maritime Council and was recently sworn in as a Younger Brother of Trinity House.

MAIB Safety Digest 1/2021 3

Unsafe Access, Fatal Consequence Narrative A tug was employed for emergency standby As the tug had been moved ahead from its duties at an oil terminal in the north original position, the quay’s steps were no of England on a January evening. The longer aligned with the tug’s access gate, which environmental conditions were severe with was now aligned with one of the large, flat very rough seas, a 2.5m swell and strong gale topped protective fenders on the quay. Seeing force winds. The sea temperature was 4ºC. this, the chief engineer decided to step onto Due to the extreme weather, the port control the fender to board his vessel. Unfortunately, office ordered the tug to abandon the standby in doing so he lost his footing and fell into the duties to meet and assist a passenger ferry in water through the gap between the fender and its berthing. the quay. The master immediately informed the port authorities. The master requested the chief engineer to let go the mooring lines from the quay. The The chief engineer was wearing a lifejacket chief engineer left the tug through its forward with the crotch strap fastened, and this auto- bulwark access gate (Figure 1) and stepped inflated immediately as he entered the water. on to the quay’s steps. Two crew members on The crew quickly attempted to throw him a deck helped to retrieve the lines as the chief lifebuoy with a lanyard and, after a few failed engineer let them go. When he was ready attempts, they threw it within his reach and to let go the forward line, which was on the he was able to put an arm through it. The crew towing winch, the master moved the tug then hauled him towards the mid-ships access forward to slacken the line. Having let go the door. However, having been immersed in the final line, the chief engineer approached the very cold water for some minutes, the chief vessel to re-board. engineer was too weakened to climb back on board using the recessed ladder in the hull.

Bulwark access gate Bulwark rescue gate

Recessed rescue ladder

Figure 1: Tug and its access doors

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The crew then attempted to use the vessel’s the chief engineer. Unfortunately, the chief manoverboard recovery device (Figure 2). engineer did not survive the ordeal. The However, they were not familiar with its postmortem examination revealed that he had operation and, having successfully looped it suffered a cardiac arrest shortly after falling around the chief engineer did not tighten the into the water. strop around him. Shortly afterwards, the chief engineer appeared to lose consciousness and It was subsequently found that it had become slipped out of the recovery device. a standard practice to use the quay’s fenders to step on and off tugs, and that the terminal had A rescue boat arrived within 22 minutes of facilitated this by painting them with non-slip the accident, and one of the rescue crew made paint. a tethered entry into the water to recover

Aluminium frame

Clips securing rescue-sling

Figure 2: Man overboard rescue device with detachable strop

The Lessons

1. Access to and from an un-moored vessel 3. Recovering an unconscious casualty back is a very dangerous activity, and should be on board a vessel is an extremely difficult avoided. When berthing or unberthing, task without someone entering the water shore-based linesmen should be employed. to assist. All crew