SAFETY DIGEST Lessons from Marine Accident Reports

Featuring introductions by Captain Hywel Pugh | Dmitrijs Skripacevs | Mark Todd

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 regarded as tentative and subject to alteration or correction if additional evidence becomes If you wish to report an accident or incident available. The articles do not assign fault or blame nor please call our 24-hour reporting line: do they determine liability. The lessons often extend +44 (0)23 8023 2527 beyond the events of the incidents themselves to ensure The telephone number for general use is: +44 (0)23 8039 5500 the maximum value can be achieved. The branch email address is: maib@dft.gov.uk Extracts can be published without specific permission providing the source is duly acknowledged. This publication and previous safety digests are available online: www.gov.uk/government/collections/maib-safety-digests The editor, Clare Hughes, welcomes any comments or suggestions regarding this issue. To see how the General Data Protection Regulation (GDPR) affects the If you do not currently subscribe to the safety digest way we use and store your data go to: or other MAIB publications and would like to find out www.gov.uk/government/organisations/marine-accident-investigation- more, please get in touch with us: branch/about/personal-information-charter

▶ By email to publications@maib.gov.uk; © Crown copyright 2024 ▶ By telephone on +44 (0)23 8039 5500; or 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 post to MAIB, First Floor, Spring Place, within an organisation. This is subject to it being reproduced accurately and not used in a misleading context. The material must be acknowledged as 105 Commercial Road, Southampton, SO15 1GH Crown copyright and the title of the publication specified.

GLOSSARY OF TERMS, ABBREVIATIONS AND ACRONYMNS

CHIEF INSPECTOR’S INTRODUCTION 1 INDEX

M MERCHANT VESSELS 2 THE SPOTLIGHT ON PILOT LADDERS CONTINUES... 4 1. It was all very fast 6

2. It's not you, it's them! 7

F 3. Can you handle the tension? 8 FISHING VESSELS 28 4. Guard that opening! 10 15. Untangled success 30 5. I wouldn't stop there if I were you 12 16. Schrödinger’s ships 31 6. Not once, not twice, but three times lucky 14 17. From fishing boat to mine sweeper 32 7. Tight squeeze 16 18. Alone and adrift 33 8. Hammer time 17 19. The time has come to talk of many things 34 9. Compressor compressions really hurt 18 20. Ready or not 36 10. A brief dip in the mud 20

11. Lest we forget 22

R 12. Cough, sputter, gunk 23

13. Bent arm hand-off 24 RECREATIONAL VESSELS 38 21. A turn to port too far 40 14. Two hook, or not two hook, that is the question 26 22. Just one more for the road 41

23. A hatch in time 42

INVESTIGATIONS 44

REPORTS 45

SAFETY BULLETINS 46

SAFETY FLYERS 58

GLOSSARY OF TERMS, CHIEF INSPECTOR’S INTRODUCTION ABBREVIATIONS AND ACRONYMNS Welcome to the first MAIB Safety Digest of 2024. The digest contains a wealth of experience as always, including some great success stories. When you have finished reading it, please pass it on so that others can benefit. ° degrees I would like to start by thanking the writers of the introductions to the merchant, AB able seaman commercial fishing and recreational sections of this edition. Captain Hywel AIS automatic identification system Pugh, relief skipper Dmitrijs Skripacevs and chair of the Association of Sail Training Organisations, Mark Todd, all bring their individual insights to C/E chief engineer improving safety, and their perspectives make compelling reading. CCTV closed-circuit television The merchant vessel section contains many cases involving injury to crew or COLREGs Convention on the International Regulations for Preventing Collisions at Sea, 1972 contractors working on board, and some themes stand out: the urge to press on and get the job finished, resulting in corners being cut; the supervisor who either could not see the activity CPA closest point of approach or had become directly involved instead of overseeing; and inexperienced crew being unfamiliar with the DfT Department for Transport task. Accidents can be avoided by ‘precautionary thought’ or, more simply, taking time to: review the task, ECDIS Electronic Chart Display and Information System what it involves and the risks; consider the team and whether they are properly trained and equipped; and, check that everyone understands their part in the plan. Lastly, the toolbox talk should be a two-way EOD Explosive Ordnance Disposal exchange that allows all to raise concerns before the work is started. kg kilogram I am extremely grateful to Dmitrijs Skripacevs for agreeing to share his experience of a man overboard kts knots recovery as the introduction to the commercial fishing section. The MAIB often reports on fatal man overboard accidents where one or more things have gone badly wrong. Most commonly, the crew LNG liquefied natural gas were not wearing a personal buoyancy aid when they fell in, and the vessel’s man overboard recovery m metre procedure failed to deliver. In UK waters, cold shock and cold incapacitation can quickly render a victim incapable of assisting with their own recovery, so a quick emergency response is essential. Dmitrijs’ story “Mayday” the international distress signal shows that it is possible to get it right, and to save a life. If you read nothing else, please take time to read “Mayday Relay” the international distress signal transmitted on behalf of another vessel in distress Dmitrijs’ introduction. MCA Maritime and Coastguard Agency Sail training is unsurpassed for developing young people’s self-confidence and teaching them the MGN Marine Guidance Note importance of teamwork. Mark Todd’s introduction to the recreational section is therefore both inspirational and humbling: inspirational because when looking after young lives safety is a priority and NAABSA not always afloat but safely aground at the forefront of everything the sail trainers do; and humbling because Mark shows that talking through OOW officer of the watch close calls with your team can be a better way of learning that benefits everyone.

PFD personal flotation device Finally, in 2008 my eyes were opened to the risks of spinal injury when travelling in rigid inflatable boats (MAIB report 11/20091). Since then, the vulnerability of passengers seated on tubes either falling in or PLB personal locator beacon being injured in collisions has also come to the fore. This digest contains two cautionary tales: in article 21, RIB rigid inflatable boat about a trainee suffering a propeller strike after falling overboard; and in the reprinted MAIB Safety Bulletin 3/2023, which reports on a passenger suffering life-changing spinal injuries. If you are a rigid RNLI Royal National Lifeboat Institution inflatable boat operator, please ensure all on board have good seats with dedicated handholds, and that RYA Royal Yachting Association the speed of the craft is adjusted to suit the conditions. VHF very high frequency VTS vessel traffic services

Andrew Moll OBE Chief Inspector of Marine Accidents

1 https://www.gov.uk/maib-reports/heavy-landing-during-boat-trip-on-the-rigid-inflatable-boat-celtic-pioneer-in-the-bristol-channel-near-penath-wales- with-1-person-injured

MERCHANT VESSELS For the last 24 years, To bring a ship in and out of a port safely many an hour has takes a great team effort on behalf of all the and analysed data presented in this safety digest ladder for my disembarkation. One of the crew been taken up with stakeholders. I see my role as the pilot to bring has been used in a positive way to educate all was working outboard of the rails without any reading through a all the parties together and execute the plan involved in the future safe transfer of pilots to safety equipment, harness or buoyancy aid. I safety digest while that has been agreed and understood. A plan is and from ships. Legislators and stakeholders are brought this to the attention of the captain, who sitting in a ready very much a template based on good practice working on changes to the current rules, which stopped the work and instructed the supervisor room waiting to pilot and is never a completed document. It will will come into force in 2028. The updated UKMPA for the task to make sure all the crew had the my ship. Soaking up need monitoring and updating as the passage pilot ladder poster, which should be published appropriate safety equipment for the associated the words of wisdom progresses. The master/pilot exchange is later this year, will provide guidance to ships’ risk. The ensuing arrangement was compliant, from this publication essential in this process as is the tug master/pilot crews and pilots. and everyone involved stayed safe. was a must when I exchange, albeit one that needs more formality, For me, a successful act of pilotage has occurred was embarking on my pilotage career and today with agreed speed of the vessel being crucial One of the crew was working when a vessel arrives or departs in a timely is no different; every day is a learning day and to a safe connection of the towline, along with those who are more experienced can still learn aspects of what assistance the pilot requires for outboard of the rails without manner with no paperwork or incident. This is no mean feat and requires planning, monitoring, from other events. the planned manoeuvre. any safety equipment, harness or and safe execution. We have a duty as pilots to I hold a very privileged position in my day job as buoyancy aid maintain our current skills and continue our a pilot trainer for new pilots in my port and in We each have a duty to report the professional development; reading the safety A presentation on a Bridge Resource digest is a noteworthy means by which we can assisting qualified pilots with their progression unsafe arrangements we see on a Management course for pilots was delivered support the ongoing achievement of these goals. to first class status. One of the cornerstones of this peer-to-peer exchange is ‘lessons learned’ daily basis at a UKMPA conference several years ago and and the safety digest delivers this in abundance. two phrases, “Lead the Task” and “Don’t delegate All the scenarios we run in our simulator are Pilot safety and pilot boarding and your responsibility” have stayed with me as being based on lessons learned from actual incidents disembarkation is another passion of mine applicable to all involved in any shipboard task. or near misses. We also bring in other lessons and has been since before I became chair Only the other day, I was in transit to a pilot from further afield and our own experiences on of the UKMPA. Five years ago, the UKMPA station and observed the crew rigging a pilot the river. introduced the pilot transfer reporting app and this has been successful in several ways, including data collection; providing a A plan is very much a template unified method of reporting for pilots; and based on good practice and is never transmission of an unsafe transfer arrangement to the relevant bodies so that they can take the a completed document appropriate action.

We have seen technology play an increasingly The MAIB is a recipient of the data and uses it CAPTAIN HYWEL PUGH | Haven pilot and chair of the UK Maritime Pilots’ Association important part in our job over the last 10 years, to compile reports and feedback on the current Hywel started his seagoing career in 1978 as a deck cadet with a British shipping company, which sadly with carry-on Portable Pilot Units of various state of pilot boarding arrangements via its disappeared in the mid-1980s. He worked on a variety of ships once qualified, including coasters/cable-laying complexity and accuracy taken on board to assist publications. Gathering, analysing and sharing and offshore supply/anchor-handling vessels. In 1989, Hywel joined a company that owned and operated an the pilot. This has enhanced our toolkit during this data enables us to educate seafarers on offshore semisubmersible floatel operating in the North Sea and, latterly, the Mexican sector of the Gulf of the act of pilotage – I remember carrying my compliant arrangements for safe embarkation Mexico. During his last few years with the company Hywel served jointly as the vessel’s captain and offshore charts with me when I first started, now it is all on and disembarkation of the pilot. We each have a installation manager. my iPad. Technology is also creeping into passage duty to report the unsafe arrangements we see Hywel came ashore in 1999 and started training as a pilot with the Port of London Authority, qualifying planning, with some ports now using electronic on a daily basis and, in turn, educate the industry. in early 2000 and progressing to become an unrestricted pilot. He currently pilots ultra-large container master/pilot exchange and passage planning The master has overall responsibility but is never ships and Aframax tankers. Hywel also works in the simulator training team and is a member of the ports tools; however, we must not forget to look out of at the point of access and therefore unaware of training panel. the window. what has been rigged for the pilot. The checked Hywel joined the UK Maritime Pilots’ Association (UKHMPA) executive committee in 2014 and became UKHMPA chair 3 years ago. He also sits on the Confidential Human Factors Incident Reporting Programme (CHIRP) Maritime Advisory Board.

Stanchion hinges The spotlight on pilot ladders continues... prevent a secure grip

Throughout 2023, we continued our project to throughout the UK and relies on UK pilots and gather data on noncompliant, inadequate, or harbour authorities to report incidents regularly otherwise unsafe pilot ladders rigged on board and accurately, with supporting photographs Figure 2: vessels calling into UK ports. where possible. A pilot ladder reported in 2023, showing the shackles Last year, we received a total of 314 reports of Following our attendance at the Marine Accident against the step pilot ladder incidents. In 2022, we canvassed Investigators’ International Forum held in London the 105 UK Competent Harbour Authorities and in October 2023, the Chief Inspector of Marine found that there had been over 400 pilot ladder Accidents wrote to the Maritime and Coastguard incidents across the UK1, of which only 205 were Agency (MCA) requesting that further guidance reported directly to the MAIB. The 53% increase was issued to its approved training providers in incidents reported directly to the MAIB in 2023 to improve seafarer training on the correct is an encouraging development, particularly rigging of pilot ladders. The letter also suggested Figure 3: when compared to the 302 incidents recorded for that the MCA highlight the noncompliant Cracked, warped rubber and potentially dangerous methods used at steps and worn side ropes. 2023 by the UK Maritime Pilots Association2. The ladder also appears to sea. The MCA accepted the chief inspector’s have been painted To continue to identify trends in pilot ladder proposal, demonstrating the power of data in Figure 4: An access gate without suitable issues the MAIB needs the data received to be making practical improvements for the safety of stanchions for the pilot to gain a secure grip suitably representative of pilots’ experiences maritime professionals. Incidents How did 2023 measure up? There were seven accidents to pilots while embarking Approximately 50% of all pilot ladder incidents reported to us in 2023 involved the same three or disembarking vessels, of which three involved the 1. Inspect → Examine the ladder at regular ladder shifting. One such incident, detailed in MAIB intervals and before each use to identify deficiencies as those reported during 2022 (Figure 1), the leading deficiency once again being pilot Safety Digest 2/20233, involved the pilot falling into the damaged or degraded parts and replace it ladders secured using shackles over the side ropes (Figure 2). Also known as ‘choke shackles’, this water when the inadequately secured ladder payed as necessary. Make sure there are sufficient arrangement brings the entire weight of the ladder onto one step, which is not designed to take a weight spares of a suitable quality on board. out as they stepped on to it. The other two incidents that should be borne by the side ropes. As in 2022, the next most common deficiencies were the ladder being in poor condition or having no or incorrect stanchions (Figures 3 and 4). involved the ladder shifting as the pilot applied their 2. Check → Secure the ladder to strong points weight to it, reportedly due to the ladder catching on using manila rope tails tied in a rolling hitch parts of the vessel’s structure. While neither of these around both side ropes. Do not use shackles two incidents resulted in the pilot entering the water, to secure the side ropes. Figure 1 one of them resulted in a minor injury when the pilot’s 3. Check → Make sure the stanchions at the finger was trapped between the ladder and the vessel. top of the climb allow the pilot to gain a firm grip during the transition between deck These accidents highlight the importance of and ladder. Comparison of pilot ladder supervision and testing the ladder before every use. deficiencies between 2022 and 2023* In some instances, such as during inclement weather, 4. Confirm → Test the ladder to be certain it