Marine Accident Investigation Branch (MAIB) - Safety Digest Contents 1. MAIN ENGINE FAILURE AT SEA .......................................................................3 Narrative .........................................................................................................................3 Observations ...................................................................................................................3 Comment.........................................................................................................................3 2. COLLISION BETWEEN A LOADED TANKER AND A TRAWLER ..............4 Narrative .........................................................................................................................4 Observations ...................................................................................................................4 Comment.........................................................................................................................4 3. FATAL ACCIDENT ON BOARD A SUPPLY VESSEL.......................................6 Narrative .........................................................................................................................6 Observations ...................................................................................................................6 Comment.........................................................................................................................7 4. SHIFT OF CARGO CAUSES HEAVY LIST .........................................................8 Narrative .........................................................................................................................8 Observations ...................................................................................................................8 Comment.........................................................................................................................9 5. ENGINE-ROOM FIRE CAUSES FATALITY.....................................................10 Narrative .......................................................................................................................10 Observations .................................................................................................................10 Comment.......................................................................................................................11 6. LOSS OF PASSENGER OVERBOARD...............................................................12 Narrative .......................................................................................................................12 Observations .................................................................................................................13 7. DEATH OF WORKER IN SEWAGE SPACE .....................................................14 Narrative .......................................................................................................................14 Observations .................................................................................................................14 Comment.......................................................................................................................14 8. INJURY CAUSED BY A REVERSING TRAILER ON A RO-RO VEHICLE DECK 16 Narrative .......................................................................................................................16 Observations .................................................................................................................16 Comment.......................................................................................................................16 9. LIFEBOAT FIRE DURING TESTING ................................................................17 Narrative .......................................................................................................................17 Observations .................................................................................................................17 Comment.......................................................................................................................17

10. FALL FROM MAST .............................................................................................18 Narrative .......................................................................................................................18 Observations .................................................................................................................18 Comment.......................................................................................................................18 11. GENERATOR FIRE IN PORT............................................................................19 Narrative .......................................................................................................................19 Observations .................................................................................................................19 Comment.......................................................................................................................19 12. FLOODING AND FOUNDERING OF A 32 METRE FISHING VESSEL.....20 Narrative .......................................................................................................................20 Observations .................................................................................................................20 Comment.......................................................................................................................21 13. ENGINE FAILURE AND EVENTUAL LOSS OF VESSEL............................22 Narrative .......................................................................................................................22 Observations .................................................................................................................22 Comment.......................................................................................................................23 14. GROUNDING OF A 23 METRE FISHING VESSEL .......................................24 Narrative .......................................................................................................................24 Observations .................................................................................................................24 Comment.......................................................................................................................24 15. FATAL CRUSHING OF FISHERMAN IN POWER BLOCK.........................25 Narrative .......................................................................................................................25 Observations .................................................................................................................25 Comment.......................................................................................................................25 16. THREE CREW MEMBERS WASHED OVERBOARD BY UNEXPECTED WAVE 27 Narrative .......................................................................................................................27 Observations .................................................................................................................27 Comment.......................................................................................................................28 17. DECKHAND FALLS OVERBOARD FROM TRAWLER...............................29 Narrative .......................................................................................................................29 Observations .................................................................................................................29 Comment.......................................................................................................................29 18. SKIPPER LOSES LEG IN WINCH ACCIDENT..............................................30 Narrative .......................................................................................................................30 Observations .................................................................................................................30 Comment.......................................................................................................................30

1. MAIN ENGINE FAILURE AT SEA

A 1,908 gross registered tonnage Ro-Ro vehicle passenger ferry was on passage when the starboard main engine started to overheat. A rapidly increasing knock developed together with vapour emissions from the crankcase. The engine was stopped and with a cracked cylinder liner suspected, a decision made to proceed on passage on the port main engine only. The vessel arrived in port later that evening.

Observations 1. On arrival in port, after a suitable cooling down period, the crankcase doors on the port main engine were removed and a full examination undertaken. This showed that No 1 unit cylinder liner had a cracked lower edge, all piston rings solid in their grooves and the piston crowns heavily scored. The gudgeon pin was scored and the crosshead bearing distorted. When the lub oil pump was run to test the system, only a trickle of oil emerged from the bottom end bearing outlet suggesting a blockage. The bottom end bearing was removed and found satisfactory. 2. In order to find the blockage, the supply pipe from the oil manifold to the main bearing housing was then uncoupled. Again only a dribble of oil appeared indicating that the blockage still existed. On removing the supply pipe from the oil manifold, a twenty pence coin dropped out followed by the full flow of oil. Further examination of the crankshaft pin, journal and bearing shells showed that they were undamaged. 3. The liner was replaced with a new spare, a reconditioned piston assembly fitted and all ancillary fittings replaced. The lub oil was purified and the engine run on test for 30 minutes. The oil flow was confirmed and bearings checked for overheating. On satisfactory completion of engine tests, the vessel re-entered service some 20 hours after the problem was encountered.

Comment 1. The lub oil system draws from the wet sump through a coarse filter to the circulating pump, thence through a magnetic filter, fine filter and into the external distribution manifold. Oil then passes into the internal oil manifold from which each main bearing is fed. The twenty pence coin is capable of passing through the external distribution manifold, the internal oil manifold, and supply pipes to the main bearings, but would be too large to pass through the coarse or fine filters. It would seem likely therefore that the coin entered one of the lub oil manifolds during a recent partial main engine overhaul. 2. This potentially dangerous situation was averted due to the prompt and correct action taken by the Chief Engineer and his staff. It highlights the need for care and cleanliness when assembling machinery and machinery systems. The accidental inclusion of foreign bodies can lead to a dangerous situation developing, involving not only possible serious injuries to staff but also severe damage to the vessel.

2. COLLISION BETWEEN A LOADED TANKER AND A TRAWLER

This collision happened in the North Sea, 60 miles north-east of Fraserburgh. The trawler was towing her gear in a north-easterly direction at about 2 knots. It was night time and she was showing the appropriate navigation and trawling lights. Her working deck lights were off. The tanker, which was loaded with over 80,000 tonnes of crude oil, was being steered by autopilot on a heading of 285° at a speed of about 11 knots. There was a strong south-south-westerly wind but the visibility was good.

A deckhand was alone on watch in the wheelhouse of the trawler. He noticed the tanker on his starboard side when it was at a range of two miles. He could see the vessel's red sidelight and masthead lights and he judged that it was going to pass clear ahead. Subsequently when the tanker was about half a mile away he noticed her masthead lights almost in line and realised that the two vessels might collide. He tried calling the vessel on VHF channel 16. Receiving no response, he took avoiding action by turning to port away from the tanker but, being hampered by the trawl, this action was insufficient to avoid the contact that ensued. The tanker scraped passed the trawler's starboard quarter damaging both the trawler and her fishing gear.

The fishing vessel tried to call the tanker on VHF Channel 16 a number of times immediately after the accident but received no reply. She retrieved her damaged gear and, although taking water slowly, was able to return safely to port without assistance.

It was some hours later, after having been contacted by the Coastguard, that the Master of the tanker realised that his vessel had probably been involved in a collision.

Observations 1. At the time of the accident, about 1900 hrs, the Chief Officer was on watch on the bridge of the tanker, assisted by a seaman lookout. The Chief Officer visited the toilet at about 1900 hrs but stated that, except for that time, "a few minutes", he remained on the bridge. Neither he nor his lookout remembered anything untoward happening during the watch. 2. The radars on the tanker were not being used even though the vessel was passing through an area where fairly heavy fishing, commercial and oil related traffic could have been expected. 3. The seaman lookout on the tanker had already worked a full twelve hour day before going on watch at 1600 hrs. 4. The watchkeeper on the trawler did not detect the presence of the tanker until it was two miles away and then did not closely monitor the developing situation and did not call the Skipper until the collision was imminent. 5. The tanker was clearly the give-way vessel under the Collision Regulations.

Comment 1. A proper lookout was not being maintained on either vessel and, in the case of the tanker, it is questionable whether there was anyone on the bridge and alert during the period 1830 to 1930 hrs. 2. The radars on the tanker should have been on and used to supplement the visual lookout. 3. The watchkeeper on the trawler should have detected the tanker earlier and monitored the situation efficiently. Had he done so he would have realised at a much earlier stage that the tanker was not taking action to keep clear and that risk of collision existed. At that time he should have called the Skipper and taken action himself to avoid the collision. Rule 17(a)(ii)

of the Collision Regulations allows for this. As it was he left it too late to call the Skipper and too late to avoid the contact. 4. Under Rule 8 of the Collision Regulations the give-way vessel must take early and positive action to avoid a close quarters situation. It is especially important to positively resolve the situation at an early stage if the other vessel is hampered in her ability to take last minute avoiding action herself.

3. FATAL ACCIDENT ON BOARD A SUPPLY VESSEL

A supply vessel was required to load cargo from an offshore platform in Liverpool Bay. The cargo included a bridge walkway with the following dimensions:

Length:15.15 metres Breadth: 1.85 metres Height: 2.90 metres

The walkway weighed six tonnes.

Cargo from another platform had already been stowed on the aft deck of the vessel and it was intended by the Master that the walkway should be loaded upright, longitudinally and immediately inboard of, and adjacent to, the cargo stowed on the port side of the deck. During the loading operation, the Chief Officer manoeuvred the vessel from the port aft conning position on the bridge. The Master was also on the bridge and was checking to make sure that the vessel remained sufficiently clear of the platform during the loading operation.

The walkway was loaded using one of the platform cranes and was guided into the required position by two crewmen on deck. The weather conditions were calm and both the Master and the Chief Officer considered that it was unnecessary to secure the deck cargo for the short passage to Liverpool.

As the vessel proceeded up the River Mersey, the two crewmen were engaged in preparing the aft deck for a towing operation, which was required to be undertaken immediately after discharge of the deck cargo. While approaching Langton Lock, the walkway fell onto its side and trapped the two crewmen underneath it.

The emergency services attended the vessel in the lock. One of the crewman died as a result of the accident and the other was seriously injured.

Observations 1. When upright, the walkway was supported at two points on its underside; a fixed locating pin situated at its forward end, and a locating pad, with freedom to swivel about an athwartship axis, situated at its aft end. The locating pin and pad projected vertically below the underside of the walkway at distances of approximately 0.4 metre and 0.6 metre respectively. 2. The Master was aware of the locating pad at the aft end of the walkway but neither he nor the Chief Officer had noticed the locating pin at the forward end during the loading operation and their restricted view from the bridge had prevented them from noticing that the forward end of the walkway had not landed fully onto the deck. 3. The two crewmen were experienced in offshore cargo operations and it was normal for them to secure deck cargo only if they deemed it necessary to do so, without having to await instructions from either the Master or the Chief Officer. Although they were aware that the forward end of the walkway had not landed fully onto the deck, they decided that it was unnecessary to secure the walkway in the prevailing calm weather conditions. 4. Both the Master and the Chief Officer were satisfied with the stowage of the walkway and did not consider that any securing arrangements were necessary in view of the gangway's

apparent stability, its location immediately adjacent to other cargo on its port side, the prevailing calm weather conditions and the fact that the vessel had a slight list to port.

Comment 1. The walkway probably fell onto its side due to the motion of the vessel. The main contributory factors were: o the inherently inferior stability of the walkway when in its upright condition and supported only by the locating pin and pad; and o the absence of any action taken to secure the walkway in its stowed position. 2. The walkway was an unusual item of cargo for the vessel to carry. When loaded in its upright condition, the height of the walkway in relation to its breadth should have given some cause for concern. However, there was a failure on board to appreciate the danger of allowing the walkway to remain in its upright condition without being secured. 3. Although the Master and the Chief Officer regarded the two deckhands as being competent with regard to cargo stowage and securing, it would have been prudent for one of them to have personally inspected the aft deck after loading in order to check that the walkway was stowed safely, particularly as there was no intention to secure it in the prevailing circumstances. Such action would have accorded with the advice provided in the IMO Code of Safe Practice for Cargo Stowage and Securing. 4. It is clear that the accident would have been avoided had the walkway been adequately secured in its stowed position, in accordance with the Owner's written Standard Procedures and with the United Kingdom Offshore Operators Association (UKOOA) Code of Practice entitled "The Safe Management and Operations of Offshore Support Vessels". 5. The nature of supply vessel cargo loading operations at offshore platforms generally prohibits prior inspection of the cargo by the crew. Therefore, it is important that the Master is advised of the details of any unusual items of cargo to be loaded and that, where possible, efforts are made prior to loading to reduce any foreseeable difficulties that might arise in stowing and securing those items on board the vessel. Appropriate advice in this regard is provided in the UKOOA Code of Practice.

4. SHIFT OF CARGO CAUSES HEAVY LIST

The 1400 gross registered tonnage general cargo vessel left port on a winter evening at 1725 hrs, having loaded a cargo of 1500 tonnes of loose steel plates in freezing conditions. The weather was moderate with east-south-easterly winds force 4 - 5 and a heavy swell. The vessel's course put the swell on the beam and she rolled heavily.

At 1958 hrs the vessel took up a list to starboard of about 10°. The vessel was brought around into the swell and the crew were mustered. The holds were inspected and it was found that the plate cargo had shifted, though there was no visible damage to the hull side or any indication of water ingress. The Coastguard were informed and the vessel was turned back towards her port of departure. The local RNLI lifeboat was launched to escort her in. Weather conditions had deteriorated to winds south-easterly 7 - 8 by the time she reached a safe anchorage.

Shift of Inadequately Secured Cargo

Cargo Securely Lashed in Place

Observations 1. The steel plate was distributed equally between the two holds and secured with timber wedges/shores. 2. Friction would have been effectively reduced between the steel plates and the dunnage because it is likely that both would have been covered by ice to some extent, given the freezing conditions in which the cargo was loaded. 3. The original loading plan required that the steel plate cargo would be overlaid by steel pilings but this did not occur.

4. Vessels which are carrying steel cargoes can be very stiff and roll violently in a seaway and consequently any weaknesses in securing the stow will be quickly revealed. The fact that the steel pilings were not carried would exacerbate this tendency.

Comment 1. Movement of the cargo could have been avoided if it had been securely lashed in place with wire ropes set taut. This was indeed done before the vessel resumed her voyage with the overload of steel pilings.

5. ENGINE-ROOM FIRE CAUSES FATALITY

A UK coastal vessel, of 833 gross registered tonnage, built in the late 1960s, was at a loading berth taking on a cargo of waste material. The vessel's Chief Engineer and one other person were working on the main engine. This work required that the engine's fuel pumps were purged of air. This operation resulted in a small quantity of fuel, which was gas oil, being spilt onto the engine-room floor plates just beneath the main access ladder from the lower part of the engine-room. Apart from this fixed ladder the only other route to or from the lower floor plates was by way of a wire rope emergency escape ladder at the aft end of the main engine.

The work had reached a stage where the main engine needed to be rotated slightly. To do this both men went to the aft end of the engine in order to bar the engine over by hand. While they performed this task they heard a noise similar to that caused by tools being dropped onto a steel deck and thus placed no significance on this sound. However, once they had completed the engine turning these men looked towards the forward end of the engine and saw smoke and flames coming from the lower end of the access ladder.

An immediate attempt was made to extinguish the fire with a dry powder extinguisher. This extinguisher failed to function. The smoke levels in the engine-room prevented any further local attempts to fight the fire and both men decided to evacuate the engine-room. The Chief Engineer evacuated the space by way of the wire rope emergency escape ladder, the other man used the main access ladder thus stepping through the fire.

The Chief Engineer reached the open deck safely but only after experiencing some difficulty opening the escape hatch at the top of the emergency escape ladder. The other man reached the open deck with his boiler suit in flames. Once these flames were extinguished, and medical help requested from ashore, the engine-room was completely closed down and the CO2 flooding system activated.

After allowing several hours for cooling and ventilation, subsequent inspection of the engine concluded that a wandering lead lamp, which had been in use, had fallen into the spilt oil beneath the main access ladder causing ignition. The sound of this lamp falling had been heard by the men but had been ignored. The man whose boiler suit had ignited suffered serious burns and died the following day.