Marine Accident Investigation Branch (MAIB) - Safety Digest

Contents Part 1 - Merchant Vessels..............................................................................................3 1. Passenger ship suffers damage in hurricane ...........................................................3 2. Over-reliance on integrated navigation system led to grounding of cruise vessel6 3. Vessel runs aground after auto-pilot failure............................................................8 4. Crankcase explosion in main engine ......................................................................11 5. Engine-room fire on dredger ..................................................................................12 6. Seamen injured during ro-ro cargo operations.....................................................13 7. Collision in fog in the Humber Estuary .................................................................14 8. Flash fire in a deep fatfryer.....................................................................................16 9. Two cargo vessels ground in remarkably similar circumstances ........................17 10. Failure to follow cleaning instructions .................................................................20 11. Escort tug prevents grounding..............................................................................21 12. Man overboard from pilot boat ............................................................................23 13. Standby safety vessel hits offshore oil installation ..............................................25 14. Notices to shipping notheeded...............................................................................27 15. Contact with moored vessel during berthing operations ...................................28 16. Grounding of a small passenger launch...............................................................30 17. Stranding of a sail training vessel .........................................................................32 Part 2 - Fishing vessels.................................................................................................34 18. Loss of a Fish Processing Factory Ship ................................................................34 19. Deckhand injured by parting rope .......................................................................36 20. Fishing vessel struck by unidentified coaster ......................................................37 21. lack of lookout leads to collision in fog.................................................................39 Part 3 - Leisure craft....................................................................................................41 22. Three rescued from sinking sailing yacht in Solent ............................................41 23.Yacht founders in needles channel in severe gale - three killed..........................44 24. Motor cruiser sinks with loss of life in the Thames Estuary ..............................46 Appendix A Investigations Commenced in the Period 01/04/97 - 31/12/97 ............48

Appendix B Inspector's Inquiries...............................................................................51 Appendix C Reports issued in 1997............................................................................52 Appendix D Stationery Office Stockists and Distributors Overseas .......................53

Part 1 - Merchant Vessels The accidents included in this section are representative of the many reported to the MAIB every day. Although no specific trends are discernible, we have grouped together some reports which highlight current concerns such as sleeping on watch and accidents to crew members working on the vehicle decks of Ro-Ro ferries. Because the lessons to be learned from marine accidents are international in nature, we have also included reports from two of our sister organisations, the National Transportation Safety Board in Washington, USA, and the Transportation Safety Board of Canada. The texts are a précis of the original drafts but MAIB comments have been added. It will be noted that vessels' names have been given. This is standard practice in both countries. A report from the Southampton Harbour Master of an "almost-accident" involving a VLCC has been included as it shows how disaster can be avoided with careful passage planning and appropriate precautionary measures. The MAIB often receives reports of incidents stemming from material failures from which many useful lessons are learned by the way the consequences are handled. We notice, however, that the cause of the original failure is either never properly investigated or is not reported. A main propulsion failure or a steering breakdown in the open sea is sometimes no more than an irritant. The same thing occurring in confined waters or when being set onto a lee shore in a gale is a potential disaster. The MAIB stresses the importance of always investigating the causes of such breakdowns and reporting the results. By doing so, design faults or other shortcomings can be identified and corrective action taken. We include one or two reports of incidents which stem from unresolved mechanical or electrical failures.

1. Passenger ship suffers damage in hurricane Narrative (Times are Ship's Time) A large passenger ship left a European port in September for an Atlantic crossing. During the passage it became clear that the intended track of the vessel and the predicted track of a hurricane were convergent. Weather forecasts predicted hurricane force winds out to 130 miles and storm force winds out to 275 miles from the storm centre in the south-east quadrant. The hurricane was travelling at about 30 - 35 knots to the north-east. See Figure1.

At 0800 on the third day of the passage, when the storm was about 1000 miles to the south-west, the Master decided to take action to avoid the storm centre. The vessel was making about 28knots on a west-south-westerly course. After discussing the situation with his senior bridge watch keeping officers the Master decided that the vessel's course should be altered 20° to port. The new course was intended to take her about 120 miles to the east and south of the predicted centre of the storm. Very strong winds were expected during the following night while the storm passed to the west and north of the vessel. Although an uncomfortable night was predicted, it was thought that the speed of this large well-found vessel would be affected for a short time only as the hurricane would pass at a relative speed of about 60 knots. Some delay in the vessel's schedule was anticipated but the proposed course of action was considered sufficient and that any interruption to the voyage would be minimised. At 0930 the passengers were informed, over the public address system, to expect heavy weather during the night and were advised not to go out on deck. At this time the vessel was moving easily in a slight to moderate sea and low swell. The wind was southerly Force 4 and the vessel was still making full service speed. By 2100 the barometric pressure was falling rapidly and the wind had backed from south to south- south east and increased to gale Force 8. At 2130 the Officer of the Watch reduced the vessel's speed to about 26 knots but maintained a course of231º. Two hours later the vessel's anemometer was carried away by the increasing force of the wind and one of the radar scanners stopped turning. At midnight the wind was recorded as hurricane force from the south-south east. The course being steered was still231º. The centre of the storm was now about 135 miles away to the north west of the vessel and, although a speed of 23 knots had been made good over the previous hour, the sea

conditions had become every rough. In the circumstances the Master slowed the vessel to minimum steerage way while the storm passed. The course of 231ºwas maintained throughout. Over the next two hours, and as the wind veered to the south-west, the vessel encountered very large seas of 10 to 15metres in height, many of which broke over the fore deck. Wind speeds in excess of 100 knots were estimated. At 0210 a very large wave, assessed to be approaching 30 metres in height, was encountered. It broke heavily onto the fore deck setting down a large part of it by about 0.5 metre and causing other damage. The damage control routine was set in motion and temporary repairs were swiftly carried out. By now the storm was quickly tracking away from the vessel to the north-east and the conditions began to moderate. The vessel's course was altered towards her destination and the speed gradually increased. By 0900 she was able to make over 20 knots and, by about 1700, had returned to full service speed. The vessel arrived safely at her intended destination having been delayed by approximately 8 hours. From data collected from weather buoys in the vicinity of the vessel, the Canadian Forces Meteorological and Oceanographic Centre was subsequently able to confirm the wave height as nearly 30 metres. They were also able to provide a possible explanation for the phenomenon that some of the waves in the right or easterly semicircle of the storm were, apparently, travelling at nearly the same speed and in the same direction as the storm itself. Thus a situation had been created where those waves had virtually unlimited fetch.

The Lessons 1. The Mariner's Handbook contains sound advice for avoiding or otherwise coping with a tropical revolving storm. In the North Atlantic such storms are called hurricanes. Although originally written many years ago when ships were generally smaller and less powerful, the advice is just as relevant today and remains applicable to large well-found vessels. In accordance with that advice, early action to stay at least 250 miles from the centre of the storm would have been prudent. 2. In any case, by about midnight, when the situation had deteriorated to an extent that minor damage was being caused and hurricane force winds were being experienced, it would have been prudent to have steered a course away from the storm in accordance with the advice given in The Mariner's Handbook. 3. This accident was caused in part by overconfidence in the vessel's ability to withstand the conditions. In this case it was combined with an underestimation of the conditions that might be encountered and the desire to meet a scheduled arrival time or, at least, minimise delay. Good and prudent seamanship dictates that mariners should not underestimate the power and unpredictability of the sea. This is especially true if entering the "dangerous" semicircle of a tropical storm.

2. Over-reliance on integrated navigation system led to grounding of cruise vessel This summary is based on a report issued earlier in the year by the US National Transportation Safety Board. It is included here with their kind permission.

Narrative

On the evening of 10 June 1995, the Panamanian registered passenger vessel ROYAL MAJESTY grounded on Rose and Crown Shoal about 10 miles east of Nantucket Island, Massachusetts. The vessel, with 1,509 persons on board, was en route from St Georges, Bermuda, to Boston, Massachusetts. About an hour after leaving St Georges the Global Positioning System (GPS) antenna cable became partly disconnected causing the GPS to switch to dead reckoning mode. Nobody noticed. The auto- pilot continued to react to the information derived from the GPS. Thus the set of the vessel, caused by wind, current and sea conditions, was not detected and allowed for by the system. The fault with the GPS, and the fact that the vessel was not in the position indicated by the integrated bridge navigational system, remained unnoticed by the watch officers during the 34 hours prior to the grounding. Initial attempts to re-float the vessel were unsuccessful while deteriorating weather and sea conditions prevented the evacuation of passengers and crew. On 11 June, ROYAL MAJESTY was re-floated with the aid of five tugs. Initial damage surveys revealed deformation of the vessel's double bottom. However, no penetration or cracking of the hull was detected, and no fuel oil had been spilled. The US Coast Guard gave the vessel permission to proceed to Boston to disembark the passengers. She arrived there safely on 12 June. Although there were no injuries as a result of this accident, the costs of repairs to the vessel and lost revenue were estimated at about US $7 million.

The Lessons This was a well found vessel with fully qualified and experienced bridge watch keepers. Like most, if not all, passenger liners the ROYAL MAJESTY was equipped with modern navigational aids including GPS, which is capable of determining a vessel's position with great accuracy. 1. Despite their experience and qualifications the watch keepers remained unaware of the increasing deviation from the planned track in the 34 hour period after leaving Bermuda.

General causal factors in the grounding include: • over-reliance by watch keeping officers on the automated features of the integrated bridge system;

• inadequate training in the technical capabilities and limitations of the integrated bridge system;

• poor navigational watch keeping practices in general.

Specific factors include: • the routing of the GPS antenna cable, which made it vulnerable to damage;

• the fact that the echo sounder alarm had been set to zero depth;

• deficient monitoring of the status of the GPS;

• no cross-checking of the GPS derived positions by watch keepers;

• sole reliance on the position-fix alarm for warning of deviation from the vessel's intended track;

• the configuration of the integrated bridge system which neither recognised nor allowed for the fact that the GPS had switched to dead reckoning mode. Its design did not adequately incorporate human factors engineering;

• the remoteness of the GPS receiver, and the short duration of the aural alarm which sounds when switched to the dead reckoning mode, contributed to the failure of the watch keepers to notice the change.

Acknowledgement to US National Transportation Safety Board 2. MAIB Comment. Modern navigation aids can fail; sometimes without being noticed by the operator. A fundamental rule of safe navigation is to always check the primary method of navigation by an independent source. Radio aids, astro-navigation, visual fixing and use of the echo sounder are all available to the conscientious navigator. Special care is needed when making a landfall.

3. Vessel runs aground after auto-pilot failure Narrative A general cargo vessel of 1,960 GT loaded with potash was approaching Great Yarmouth from the south-east via Holm Channel (see chart extract). The Master had the con and was the only person on the bridge. The vessel was being steered by auto-pilot. The wind was westerly Force 2 with good visibility and there was a southerly tidal stream of about one knot. The time was about 0530 and it was dark.

Reproduced from Admiralty Chart 1536 by permission of the Controller of HMSO and the Hydro- graphic Office. After leaving Cort on buoy to port, the speed of the vessel was reduced to Half Ahead. The auto- pilot was set to steer a course of 300º but due to the effect of the tidal stream the vessel made good a course of 297º. In order to leave NE Holmbuoy to port, the auto-pilot setting was altered to 330º and the vessel initially made good a course of 325º. However, the Master then observed Holm Sand buoy on the starboard bow and altered the auto-pilot setting to starboard in order to counter what he considered to be the increased effect of the southerly set. Shortly afterwards the Master realised that both the auto-pilot and gyro compass had failed and attempted to prevent the vessel from running aground on Holm Sand by changing over to hand steering and applying full starboard helm. His action was too late to prevent the vessel from grounding. The vessel remained aground for a day but was not seriously damaged. Like many small vessels operating in United Kingdom coastal waters, bridge watch keeping was shared between Master and Mate.

The Lessons 1. The good seaman knows that when navigating in shoal waters, and especially in a narrow channel, a vessel should be in manual steering with a dedicated helmsman. This Master did not comply and found himself unable to take sufficiently early corrective action when something went wrong. The steering failed, the Master was slow to notice it and the vessel grounded. This accident highlights the real risks arising from one man bridge operation in confined waters. The lesson is to

always have two men on the bridge in such circumstances, one with the con with the other on the helm. 2 Whenever helm is applied, whether in the open sea or in confined waters, an immediate check should always be made to ensure that the rudder has functioned as ordered. This will ensure that early corrective action can be taken if the wrong helm has been applied. 3. The cause of the electrical failure which led to the failure of both auto-pilot and gyro compass was never discovered, but four fuses were reported to have failed. Whatever the reason, it happened at an awkward moment and could happen again. 4. By not having a dedicated lookout on the bridge with him at night, the Master was also in clear breach of the STCW Regulations. The Regulations state, quite clearly, that the only time a look-out can be dispensed with is during daylight in certain circumstances. (See also Report No 9)

4. Crankcase explosion in main engine Narrative The engineers on board a 6,737 GT cross Channel Ro-Ro ferry had been monitoring a steady increase in crankcase pressure on one engine over many days. Although the engine was inspected, no problem was identified and it continued to be run. Shortly after departing Dieppe for an overnight cross-channel passage to Newhaven, Full Away was given at 0107 and the engines brought to full power by 0125. Six minutes later the engine- room fire alarm sounded and an inspection revealed the engine-room to be full of smoke. Both main engines were stopped and the engine-room was battened down. An inspection carried out by a breathing apparatus team revealed no fire but found the crankcase explosion doors on the port main engine had operated. The vessel continued to Newhaven using only the starboard main engine. On arrival an inspection revealed that No 18piston of the port main engine had partially seized in the liner. Shortly before the fire alarm sounded the crankcase pressure on the port main engine had been observed as high,90 mm of water, compared to its normal value of 60 mm. No clear cause for the failure was established but the most likely initiating cause was a broken piston ring.

The Lesson Some operators of medium speed marine engines have employed vapour detectors in each bay of engine crankcases to locate the units on which blow-by is occurring. A more sensitive method of detecting blow-by, other than a simple water gauge, may be of value for these engines.

5. Engine-room fire on dredger Narrative A dredger of 3,500 GT was on passage in the English Channel when the engine-room fire alarm sounded shortly before midnight. The duty Second Engineer made his way to the engine-room, operating in the unmanned mode, and was met by a haze of diesel oil vapour on the port side of the main engine and the adjacent generator. After informing the Officer of the Watch (OOW) of the situation and his intentions, the Second Engineer switched over generators and stopped the main engine. An inspection revealed that the fuel inlet pipe to one of the main engine's high pressure fuel pumps had fractured allowing oil to spray over the engine, the adjacent walkway and the generator. Because of the absence of a hot surface to