SAFETY DIGEST Lessons from Marine Accident Reports

SOG: 3.2 kn HDG: 320.0° COG: 303.8°

© Made Smart Group BV 2023 © i4 Insight 2023

Featuring introductions by Ashley Nicholson MBE | Hazel Bennett | Andrew Flanagan

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 that has been determined up to the time of issue.

This information is published to inform the merchant and fishing industries, the recreational 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 If you wish to report an accident or incident regarded as tentative and subject to alteration or please call our 24 hour reporting line: correction if additional evidence becomes available. +44 (0)23 8023 2527 The articles do not assign fault or blame nor do they determine liability. The lessons often extend beyond The telephone number for general use is: +44 (0)23 8039 5500 the events of the incidents themselves to ensure the maximum value can be achieved. The branch email address is: maib@dft.gov.uk This publication and previous Safety Digests are available online: Extracts can be published without specific permission www.gov.uk/government/collections/maib-safety-digests providing the source is duly acknowledged.

The editor, Clare Hughes, welcomes any comments or suggestions regarding this issue. To see how the General Data Protection Regulation (GDPR) affects the way we use and store your data go to: If you do not currently subscribe to the Safety Digest www.gov.uk/government/organisations/marine-accident-investigation- or other MAIB publications and would like to find out branch/about/personal-information-charter more, please get in touch with us: © Crown copyright 2023 ▶ By email to publications@maib.gov.uk; This publication, excluding any logos, may be reproduced free of charge in any format or medium for research, private study or for internal circulation ▶ By telephone on +44 (0)23 8039 5500; or within an organisation. This is subject to it being reproduced accurately and not used in a misleading context. The material must be acknowledged as ▶ By post to MAIB, First Floor, Spring Place, Crown copyright and the title of the publication specified. 105 Commercial Road, Southampton, SO15 1GH

GLOSSARY OF TERMS AND ABBREVIATIONS

CHIEF INSPECTOR’S INTRODUCTION 1 INDEX

M MERCHANT VESSELS 2 1. Too hot to handle 4

2. It has to go somewhere! 5

3. A nerve-racking accident 6

F 4. A dizzying loss of control 8 FISHING VESSELS 32 5. An unfortunate fitting start to a new vessel 10 17. Where did that come from? 34 6. Cylinder liners and metatarsals: a painful combination 12 18. Far too close for comfort 36 7. A sting in the tail 14 19. Mind the gap 37 8. Oops!... I did it again 16 20. Asleep at the wheel 38 9. Li-ion +H2O = explosion 18 21. Nail your maintenance 39 10. To me… to you. To me… to you! 19 22. The hole story 40 11. Bowling a leg break 20

12. Even screws need some tender loving care 22

R 13. Wind beneath my (bridge) wings 24

14. MOB recovery is time critical 26 RECREATIONAL VESSELS 42 23. Our revels are now ended 44 15. A head for heights 28 24. Biting the hand that feeds you 46 16. A cracking lesson 30 25. Giving up smoking is not easy 48

26. Burn voyage 50

INVESTIGATIONS 52

REPORTS 53

SAFETY FLYERS 54

GLOSSARY OF TERMS AND CHIEF INSPECTOR’S INTRODUCTION ABBREVIATIONS Welcome to MAIB’s first Safety Digest of 2023. In my opinion, this is the more important of the MAIB’s biannual Safety Digests because it is published as the northern hemisphere emerges from winter. This is not simply an observation AB able seaman that the leisure boating season is about to start, though the digest does give AIS automatic identification system us the opportunity to re-emphasise some good safety tips before going afloat. More to the point, anyone can be caught out as the air warms and layers of CCTV closed-circuit television clothing are shed. Strong sea breezes that develop as the sun heats the land can CO2 carbon dioxide add significant wind-chill that turns a pleasant day into a cold one, and anyone entering the water, deliberately or otherwise, will find the sea temperature is still COLREGs Convention on the International Regulations for Preventing Collisions at Sea, 1972 very cold. COSWP Code of Safe Working Practices for Merchant Seafarers As usual, I will start by thanking Ashley Nicholson MBE, Hazel Bennett and Andrew Flanagan for their DSC digital selective calling respective introductions to the merchant, fishing and recreational sections of this edition. Each is an expert in their own field, and their industry insights help bring contemporary context to the cautionary GMDSS Global Maritime Distress and Safety System tales and safety messages in the following pages. I hope you will find time to read the whole edition but IMO International Maritime Organization please do read the section introductions. kg kilogram This digest has a good balance of stories but perhaps with an increased number of incidents and accidents kts knots that were controlled early on by a well-trained crew and so did not escalate into a disaster or tragedy. I am in complete agreement with Ashley’s words, It is how you deal with an incident rather than what happens that Li-ion lithium-ion matters; look at cases 5, 12 and 16 for some examples of where good system knowledge and well-practised m metre safety drills helped save the day.

“Mayday” the international distress signal Case 12 interested me because it involves the failure of a component that was not the subject of routine maintenance or periodic replacement. Safety critical systems are full of such components; in this case it is a MCA Maritime and Coastguard Agency fuel actuator valve, but it could be a limit switch (see case 6), a pressure relief valve or any number of other MOB man overboard items. Ships can be in service for 25 to 30 years and while many components are inspected, maintained and routinely replaced, others soldier on until they fail. When you have done all the easy jobs, start thinking MSC Maritime Safety Committee about the onboard systems you take for granted, and what might happen if they were to fail suddenly. If MSN Merchant Shipping Notice you do find out the hard way, please let us know and we will include your story in these digests so others nm nautical mile can learn from your experience.

OOW officer of the watch Finally, the Reul A Chuain safety flyer, reproduced at the back of this digest, helps me make the point that it is too late to start thinking about man overboard procedures when you have someone in the water. One PMS planned maintenance system of MAIB’s key safety messages for 2023 is not just to think about how you would recover an unconscious PPE personal protective equipment man overboard, but to actually practice it as realistically as possible. Put simply, if your risk assessment identifies a risk of falling or being knocked overboard, especially if one of the mitigations is wearing a RIB rigid inflatable boat personal flotation device, then should that occur the next task will be man overboard recovery. RNLI Royal National Lifeboat Institution Putting a lifejacket on is easy; recovering a man overboard is not – please practice it. ro-ro roll-on/roll-off I hope you enjoy reading this edition and, when you have finished, please pass the digest on so others can RYA Royal Yachting Association benefit too. SAR search and rescue Be safe. UKHMA UK Harbour Masters’ Association VHF very high frequency VSP Voith Schneider Propeller VTS vessel traffic services Andrew Moll OBE Chief Inspector of Marine Accidents

MERCHANT VESSELS From my very overreliance on electronic safety systems and, early years in the all too often, the failure to use our basic skills them effectively can help prevent a mistake from the tools they require to identify and manage maritime industry culminate in the creation of an act or omission becoming a crisis. The firefighting responses the risks that arise and continually improve their I was told to ensure that creates an unsafe condition. in case 5 and case 12 provide good examples procedures in the process. I read the latest of when drills and training before the event significantly improved the crew’s ability to deal The MAIB reports provide a vital element in MAIB publications when they landed. We must treat with an emergency and minimised the severity of highlighting lessons, good and bad, from accidents and incidents across the industry. As a new and the source not the the outcomes. However, similar to having a robust safe inexperienced team member this symptom A well-trained and competent individual will operating system in place and failing to follow provide greater value to the overall safety and it, improvements to safety will only come if its proved worthwhile It is important when we investigate incidents performance than that of an automated system recommendations and advice result in review advice and I found it both interesting and that we ascertain the root cause so as to ensure and it is important that we do not become and reflection and, where appropriate, changes thought-provoking. I have ensured that the we can truly address the issue rather than overreliant on the mechanics. In a world of to practice, equipment or process, that reduce teams I have worked with over the years have implement another procedure to mask one ever‑evolving technological developments, the risk of similar incidents in the future. Too done and continue to do the same; continuous that is failing. We must treat the source not increased use of artificial intelligence, often the MAIB’s conclusions are that incidents improvement through collaboration is key the symptom. autonomous vessels and alternative fuels we could have been avoided and yet the same or to growing as individuals and together as an must never underestimate the value of human similar tragedies continue to appear on the pages industry. For this reason I was truly honoured The root cause analysis technique developed involvement in the decision-making process. It is of its reports and digests. While improvements to to be asked to write the introduction for the by Sakichi Toyoda1 of asking Why? five times to important that we see people less as a source of safety management are important, the need to Merchant Vessels section of this Safety Digest. determine the true origin of an incident should error and more as the creators of safety. learn from mistakes and experience will endure; I joined the port industry nearly 15 years ago, assist in making certain that we do not fail to that being said, we must base our growth and identify the reason the individual may have development of good safety practice on good having spent a very short period of time at sea. I relied heavily on the procedures and processes to chosen to override the system or not follow the It is how you deal with solid foundations and not the shoogly pegs. help me through my cadetship, and my transition procedure. Where human error is attributed as an incident rather the cause, we do not stop there but continue to into a shore-based role in vessel traffic services. Over the years my career has been entirely ask Why? to safeguard the removal of systemic or than what happens focused on the maintenance of navigational underlying issues and allow meaningful learning and improvements. In reality there will always be gaps in any system safety within ports and harbours, and in doing so because creators cannot foresee all situations. It the creation and implementation of appropriate I have spent many hours liaising with captains, is therefore important that our people, our crew processes and procedures to facilitate the safe tug masters, pilots and operators undertaking and our teams are trained and supported with movement of the large variations of traffic we see detailed incident investigations and, whether in our UK waters. This remains my key priority in it be poorly-managed isolation processes my roles as both president of the UKHMA and causing a mechanical or electrical fault during marine director at the Port of Tyne. manoeuvres, as in case 2, or the more complex Ports, harbours and ships across the UK and the waters of commercial pressures overriding ASHLEY NICHOLSON MBE | Marine Director, Port of Tyne and President of the UK wider world are run and operated by people who safety decisions, it is apparent that not all Harbour Masters’ Association all wish to stay safe in their workplace. Few, if any, procedures are regularly followed. With this in Ashley joined the Port of Tyne in 2021 as its marine director and a member of the executive team. incident investigations find that the root cause mind we must ensure that our port personnel, She is responsible for the port’s marine operations, including pilotage and conservancy, and leads on was a wilful act. We therefore ask ourselves this: pilots, tug boat crews and ships’ crews alike the decarbonisation of its vessels and responding to global trends as deep-sea shipping switches to Why do our procedures continue to fail and why do we are appropriately trained in responding to sustainable fuels. Ashley joined the Port of Tyne following over a decade at Forth Ports, where she held continue to fail to follow procedures? emergency situations. a variety of roles from VTS operator through to senior harbour master.

The reality when reading cases like those It is how you deal with an incident rather than Ashley is the first female president of the United Kingdom Harbour Masters’ Association (UKHMA), featured in this issue is that it is not always the what happens that matters; you cannot always which represents over 500 UK harbour masters and marine professionals and acts as an industry expert individual act that causes the incident but more prevent bad things happening, but handling consultee to UK government and regulatory agencies on UK maritime policy regarding safe marine so a series of other influencing factors. An operations. She is also an industry advocate for encouraging more women into the maritime workforce 1 https://www.mindtools.com/a3mi00v/5-whys and was recognised for this in Her Majesty The Queen’s New Year Honours List 2021.

Too hot to handle It has to go somewhere! passenger vessel | accident to person oil tanker | risk assessment

The propulsion engine of a small coastal The engineer sought assistance on board and An oil tanker was anchored off the south coast passenger vessel began to overheat while on was placed in a shower to cool the extensive of the UK when an auxiliary room fire alarm passage to its next port. One of the vessel’s burns to his back while the emergency services activated. The ship’s firefighting team went to engineers stopped the engine and cleaned the were called. He was evacuated ashore by a Royal the engine room to investigate and discovered sea water strainer, which had become clogged National Lifeboat Institution (RNLI) lifeboat, from smoke emanating from an overheating sea with debris and was restricting the flow of which he was transported to a local hospital and water pump (see figure); they stopped the cooling water to the engine. The engineer treated for superficial burns. pump, allowed it to cool down and found that also noticed that the engine’s cooling system there was little damage. expansion cap (Figure 1) looked loose; he It was later found that the securing lugs for the protected his hand with a rag and attempted to engine cooling system expansion cap were bent The pump supplied cooling water to several items tighten the cap, which suddenly blew off. The (Figure 2), which had possibly prevented the cap of machinery. Three days before the incident, engineer responded by instinctively turning his from sealing correctly. one of the ship’s engineers had closed the valves back to the unit but was sprayed with scalding to one piece of the machinery in preparation for hot water from the engine’s pressurised planned maintenance but did not know that all of cooling system. the other pieces of equipment were also isolated.

The cooling water had nowhere to go when the valves were closed and there was no flow through the cooling pump, which caused its mechanical seal to gradually overheat and generate smoke.

Figure: The sea water pump

Figure 1: Expansion cap in the fully closed position Figure 2: The bent securing lug

The Lessons 1. Observe → Always allow an engine to cool down before attempting to conduct maintenance on a pressurised cooling system. The Lessons 2. Risk → Ensure you refer to the risk assessments. These exist to alert operators to potential hazards and the mitigation measures that should be implemented before the task is undertaken. The risk assessment method 1. Communicate → Maintenance should be effectively planned and communicated. It is vital to consider the statement is a clear explanation of how you are going to manage the identified risks. effects of isolation on running equipment that may not be directly related to the job in hand. The use of isolation logs and lock-out/tag-out notices can help engineers monitor the status of their systems and prevent mishaps. 3. Procedure → The company issued a safety flash that highlighted the dangers identified in this case. Familiarise yourself with manufacturers’ manuals and ensure that you know how to complete a task correctly 2. Aware → All of the human