MARINE ACCIDENT INVESTIGATION BRANCH

Summary of Investigations No 2/94

Marine Accident Investigation Branch 5/7 Brunswick Place SOUTHAMPTON Hants SO15 2 A N

Telephone : 0703 395500

Accident Reporting Line 071 276 6004 (24 hours)

This summary contains facts which have been determined up to the time of issue. This information is published to inform the shipping industry and the public of the general circumstances of accidents and must necessarily be regarded as tentative and subject to alteration or correction if additional evidence becomes available.

Extracts can be published without specific permission providing that the source is duly acknowledged.

Crown copyright 1994

INTRODUCTION A reader of the Summary of Investigations, involved in safety management training, telephoned the office. He made the observation that on reading the Summaries, or at least some of them, he has the impression that we only look at the incidents in a superficial way. He considered that we tend to blame the person who had the accident and leave it at that without looking further down the causation tree to find out the root cause of the accident. This is an interesting observation and raises two points which need addressing.

The first point is that we are concerned if people think our investigations are superficial because this implies they are not thorough enough. This, I believe, is not so because we fully realise the importance of determining not only the immediate cause of an accident, but also the basic factors behind the immediate cause. As an example, the immediate cause of a collision in fog could be incorrect interpretation of the radar information, but this might have resulted from, for example, lack of training, distraction or fatigue. It would be wrong to think that every accident has both immediate and basic causes - sometimes things really are as simple as they seem - or that it is possible to uncover the basic ones. Sometimes they are so obscure they defy detection. However, the basic or root causes will always be in the mind of the Inspector when he carries out his investigation.

The second point raised by this observation is the matter of blame. The fundamental purpose of our investigations is to determine the circumstances and the causes of accidents with the aim of improving safety of life at sea and the avoidance of accidents in the future. This is set out in the Accident Investigation Regulations in Regulation 4 which goes on to say that it is not the purpose of our investigations to apportion liability, nor, except so far as is necessary to achieve the fundamental purpose, to apportion blame. In practice, in almost all cases it is impossible to determine the causes of an accident without considering the question of blame, and this of course brings us back to the matter of basic factors, because the fault behind the cause may very well lie with someone, or some organisation, somewhat removed in both distance and time from the accident.

It is disappointing if our summaries can give the impression that accidents are not fully investigated and that we are too willing to apportion blame. It must be remembered, though, that that is what they are - summaries of our investigations. When a report of an investigation is condensed to only a couple of pages, and in some cases less than that, it is not always possible to include all the findings of the Inspector, certain aspects may have to be sacrificed. What is important though is to include the safety lessons to be learnt and we hope that is what we are doing.

This introduction is not meant to discourage readers from giving us feedback, in fact just the opposite. It is only by receiving feedback that we can judge whether this publication is achieving its main objective of getting across the safety message to those on board the ships, those who manage and operate them from ashore and all who have an interest in safety at sea.

Chief Inspector of Marine Accidents August 1994

INDEX

Introduction Page No

Grounding of Oil Tanker after Windlass Failure 1

Panic Action leads to Loss of Ship 3

Fatal Accident whilst Opening Hatch Covers 5

Cargo Shift causes Vessel to be Beached 7

Over-pressurisation of Cargo Tank during Ballasting Operations of a VLCC 8

Stand-by Safety Vessel puts Offshore Installation at Risk 11

Two Fires involving Lubricating Oil Filter Installation 13

Inadvertent Release of CO, 15

Stand-by Safety Vessel collides with Tow and Sinks 17

Undue Reliance placed upon VTS Radio Communication 19

Passengers Injured in River Collision 21

Collision in Fog 23

Major Injury caused by Revolving Propeller Shaft 25

Collision between Gill Netter and Gas Carrier 26

Hazards of Fishing near Traffic Lanes 29

Man Swept Overboard by Large Wave 32

Small Fishing Vessel is pulled under by Winch 33

Injury caused by Incorrect Operation of Equipment on board a Fishing Vessel 34

Any Means of Access must be Safe 35

First Aid Saves Life of Fisherman 37

Appendix A - Investigations Commenced in the Period 01/04/94 - 31/07/94

Appendix B - MAIB Priced Publications available from HMSO

Appendix C - HMSO Stockists and Distributors Overseas

1. GROUNDING OF OIL TANKER AFTER WINDLASS FAILURE

Narrative

An oil tanker of 50,000gross registered tonnage arrived in ballast at her intended port of loading. The vessel was initially anchored approximately 2 miles from the coast within port limits. She was scheduled to load in 5 days time. During the following morning, the Master decided to shift the vessel to a position approximately 2.5 miles from the coast where she was re-anchored using the port anchor and 6 shackles of cable. The prevailing wind was offshore Force 2.

During the following night, the wind veered and increased to Force 8. The port anchor cable was slackened to 8 shackles and, later, the starboard anchor and 4 shackles of cable were let go in order to take some weight off the port anchor cable. By morning, the wind was gusting to Force 10 which caused the vessel to roll and pitch heavily. The port anchor cable was slackened to 11 shackles in order to reduce the chance of dragging. The Master then decided to weigh both anchors and proceed to sea. The starboard anchor was hove up and secured. The vessel then commenced weighing the port anchor. The main engine was on Dead Slow Ahead. With 6 shackles of cable still in the water, the port windlass hydraulic motor exploded. The brake was then applied to the port anchor cable and the starboard anchor and 4 shackles of cable were let go.

With the brake hard on, the port anchor cable pulled out until the bitter end bracket in the chain locker broke and the port anchor and 14 shackles of cable were lost overboard. The starboard anchor cable was then slackened to 10 shackles. The vessel was now approximately 2 miles from the coast.

During the day, the ship's engineers effected a repair to by-pass the damaged port windlass hydraulic motor in order that the starboard motor could be used. Despite use of the main engine, the vessel dragged her anchor a distance of 0.7 mile. On completion of the repair, the Master decided to weigh the starboard anchor and proceed to sea. However, heaving was stopped when a severe leakage from the starboard windlass hydraulic motor was discovered. The starboard anchor cable was then slackened back to 10 shackles.

The starboard windlass hydraulic motor casing was found to be cracked. The weather improved over the next few days during which time the windlass hydraulic motors were removed in preparation for fitting replacements.

The wind then veered and strengthened to Force 8 - 9, gusting Force 11,which caused the vessel to drag her anchor again. Although the main engine was on Full Ahead, the vessel continued to move astern towards a lee shore. The Master called the Port Authority by radio and requested tug assistance. Although 2 tugs were instructed to assist, they were forced to return to port by the severe weather conditions.

An attempt was made to pull out the starboard anchor cable and to break the securing bracket in the chain locker by running the main engine Full Astern. The attempt was unsuccessful and the vessel eventually grounded on the lee shore.

Observations

1. The anchorage is a recognised waiting area. However, its use is not recommended during periods of onshore winds.

2. The weather conditions encountered by the vessel had been forecast.

3. Two RNLI lifeboats attended the scene. One of the lifeboats capsized twice in succession from which she quickly recovered. However, one of her crew members was swept overboard but he was subsequently recovered from the water by helicopter.

4. Nine non-essential crew members were evacuated from the vessel by rescue helicopter.

5. No attempt had been made to withdraw the starboard anchor cable retaining pin from the bitter end in the chain locker.

Comment

1. On the morning following her arrival, it would have been prudent for the vessel to have proceeded to sea until the forecast adverse weather conditions had passed rather than to have re-anchored.

2. The use of increased main engine speed to reduce strain on the anchor cables might have prevented damage to the port windlass hydraulic motor and the subsequent loss of the port anchor and cable.

3. The Master’s intention of slipping the starboard anchor cable and proceeding to sea if the prevailing weather conditions deteriorated was reasonable although it would have been prudent to have withdrawn the pin from the bitter end in-advance.

4. In view of the wind forecasts and the fact that the vessel had already dragged her anchor, it would have been wise to have slipped the starboard anchor and to have proceeded to sea well in advance of the vessel dragging her anchor again. The delay in attempting to do so allowed insufficient time for assistance to be rendered when the situation became critical.

5. The RNLI lifeboat crews demonstrated their bravery in standing by the vessel in the prevailing weather conditions. However, after the vessel grounded and became unapproachable from the sea, they were being exposed to danger for no purpose.

2. PANIC ACTION LEADS TO LOSS OF SHIP

Narrative

A 95 metre 1,739 gross registered tonnage cargo ship anchored off a small Scottish east coast harbour. The chosen anchorage was 3.5 cables east of the north breakwater of the harbour and the port anchor was used, with 5 shackles of cable in 23 metres of water. The weather conditions were moderate and the vessel, which was in ballast, was expected to remain at anchor for 3 days.

During the following day the weather conditions deteriorated and by evening it was blowing a Force 8 south-easterly gale, with heavy rain and poor visibility. The vessel was pitching, occasionally heavily, and shipping frequent water across the deck. The engines had been put on stand-by.

Later in the evening it was noticed that the position of the vessel had moved half a cable downwind, but the Master thought that this was due to the anchor cable having become taut. About an hour later it was concluded that the anchor was indeed dragging and the anchor party was sent forward to weigh it so that the vessel could ride out the weather further to seaward.

The vessel was by this time rapidly closing the shore and ahead power was used on the engine to take some of the weight off the cable. After 1.5 shackles had been heaved in, the stress in the cable proved to be too much for the windlass. The Third Officer, who was in charge forward, looked over the side and saw that the cable was leading directly aft.

The weight in the cable increased further and it started to slip over the jaws of the gypsy. The Master thought that the anchor had become foul. The shore was very close and he put the engine to full ahead, to try to part the cable. A short while later the vessel landed heavily on an outcrop of rocks just to the north of the harbour.

Observations

1. The duty harbour controller had seen that the vessel was dragging and made unsuccessful attempts to contact her by VHF.

2. Fortunately the crew of 22 were lifted off the vessel safely by rescue helicopters. Although there was some pollution, it was broken up and dispersed by the adverse weather; the remaining bunker and other oil was later pumped ashore by salvors. The vessel was high and dry at low water and it was not possible to salvage her. The wreck was eventually c u t u p and removed.

Comment

1. Dragging on to a lee shore is one of the most common marine accidents. In this, as in most other such cases, obvious warning signs were not heeded and by the time action was taken it was too late to avert the stranding. A VHF radio watch was not kept; if it had been, the early warning from the harbour controller that the ship was dragging her anchor would have been received.

2. However, the circumstances of this stranding were rather unusual. In the haste to heave in the cable, too much engine power was used and the vessel overrode the anchor. The Master was evidently unaware of this. In the desperate attempt to part the cable, the vessel turned right round on the anchor and drove in a north-westerly direction towards the shore, assisted by the wind and seas and dredging the anchor astern of her. The anchor then snagged on outlying rocks and the vessel turned again to port and grounded broadside to the shore, heading south.

3. The Third Officer should have frequently looked over the side as the cable was being weighed, so that the bridge could be kept informed as to how it was leading and how much weight was on it. The Master should have made sure that he was given this information.

Guidance on keeping an anchor watch is published in Merchant Shipping Notice No M. 1102.

3. FATAL ACCIDENT WHILST OPENING HATCH COVERS

Narrative

A 1975 built, 499 gross registered tonnage single hold mini bulk cargo carrier, had completed her discharge and the holds were cleaned and washed. The vessel was trimmed by the stern and the hatch covers were closed for the night but rigged for opening in the morning. The ship was fitted with MacGregor single pull hatch covers, one section opening forward and the other aft. Each section comprised 7 separate panels linked together with side chains and running on eccentric wheels. On opening, each section is pulled to the end of the hatch coaming, mounts the stowage rails, and rotates about a central wheel into the vertical stowage position.

At about 0530 hours the following day, the Chief Officer and 2 crewmen prepared to open the hatch covers ready for loading. One crewman went forward to operate the forecastle winch whilst the Chief Officer remained on the port side aft to watch the aft hatch opening. The preventer rope stopping the hatch rolling aft was slackened off, the winch operated and the aft hatch covers started to move. After moving aft a few feet they jammed, No 7 cover failing to rotate into the vertical position. The winch was stopped and the deckhand joined the Chief Officer on the main deck. The cause of the jamming was a projecting wedge preventing the first or No 7 cover rotating into the vertical position. The Chief Officer, despite cautionary advice from the deckhand, climbed on top of the hatch cover and knocked the wedge clear. This immediately released No 7 cover causing it to swing into the vertical position and pull No 6 cover aft.

With the preventer rope not having been re-secured, the aft hatch covers continued to roll aft under the influence of the vessel’s trim and the momentum of the tilting covers. The Chief Officer was thrown between covers Nos 6 and 7 and crushed, with fatal consequences, by the remaining covers swinging into the stowed position.

Observations

The Chief Officer was new to the vessel and although it is understood that he had had previous experience with mechanical hatch covers, he had not sailed with this particular type. Despite this earlier experience and advice from the crew member as to the correct way of releasing the jammed cover, he embarked on a dangerous course of action before considering all aspects of the problem.

Comment

1. The function of a preventer or check wire is to prevent the hatch covers moving inadvertently and to act as a brake and control the speed of movement when they are moving under their own momentum. It should have been standard practice for the preventer wire to be made secure before any attempt was made to free the jam. This is particularly important when the winch is stopped, and the winch operator leaves the controls. With a vessel trimmed by the stem, any freeing of the obstruction immediately allows the hatch covers to roll aft and go into the stowed position. Once moving they are virtually impossible to stop.

2. This totally avoidable fatal accident can only re-emphasise the need for ALL sea-going staff to "think safety" and to be continually aware of the potential dangers that can exist in typical ''every day" type of operations. Chapter 18 of "The Code of Safe Working Practices for Merchant Seamen 1991"specifically mentions the need to secure the check wire to prevent premature rolling when the tracking is not horizontal and also warns that no-one should climb on to any hatch cover unless it is properly secured.

4. CARGO SHIFT CAUSES VESSEL TO BE BEACHED

Narrative

A 8,940 gross registered tonnage cargo ship had loaded a part-cargo, mainly of steel, in a European port and was bound for a UK port to complete loading. Whilst lying- off in heavy weather awaiting clearance to enter,