Marine Accident Investigation Branch (MAIB) - Safety Digest

Contents Marine Accident Investigation Branch ........................................................................5 Introduction ....................................................................................................................6 Part 1 Merchant Vessels ................................................................................................7 Case 1 Grounding of Large Container Vessel ............................................................8 Narrative...................................................................................................................................8 The Lessons..............................................................................................................................8 Footnote....................................................................................................................................9 Case 2 Crankcase Explosion caused by Fitting of Wrong Type of Damper Securing Bolt 10 Narrative.................................................................................................................................10 The Lessons............................................................................................................................10 Case 3 Lifeboat Accident While Undergoing Inspection causes Injury.................11 Narrative.................................................................................................................................11 Case 4 Fire in Engine Room of Container Ship .......................................................12 Narrative.................................................................................................................................12 The Lessons............................................................................................................................12 Case 5 Procedural Failure leads to Near Disaster ...................................................13 Narrative.................................................................................................................................13 Case 6 Failure of Pilot Ladder while Boarding........................................................15 Narrative.................................................................................................................................15 The Lessons............................................................................................................................15 Footnote..................................................................................................................................15 Case 7 Cargo Vessel Runs Aground shortly after Leaving Port ............................16 Narrative.................................................................................................................................16 The Lessons............................................................................................................................16 Case 8 Cleaner Stops Ship!.........................................................................................18 Narrative.................................................................................................................................18 The Lesson .............................................................................................................................18 Footnote..................................................................................................................................18 Case 9 Crewman Falls into Dock while Attempting to Board ................................19

Narrative.................................................................................................................................19 The Lessons............................................................................................................................19 Footnote..................................................................................................................................20 Case 10 Bulk Carrier runs Aground after Master Falls Asleep on Watch.............21 Narrative.................................................................................................................................21 The Lessons............................................................................................................................21 Footnote..................................................................................................................................22 Case 11 Failure of Battery Charging Arrangements causes Loss of Steering........23 Narrative.................................................................................................................................23 The Lessons............................................................................................................................23 Case 12 Deflagration in Sewage Tank System..........................................................24 Narrative.................................................................................................................................24 The Lessons............................................................................................................................25 Footnote..................................................................................................................................25 Case13 Collapse of Cargo Stack causes Death of Stevedore ....................................26 Narrative.................................................................................................................................26 The Lessons............................................................................................................................27 Footnote..................................................................................................................................27 Case 14 Loss of Steering Control on Safety Standby Vessel ...................................28 Narrative.................................................................................................................................28 The Lessons............................................................................................................................28 Case 15 A Collision and Near Miss in the North Sea. Dredgers Involved ..............29 Narrative I ..............................................................................................................................29 Narrative II .............................................................................................................................29 The Lessons............................................................................................................................29 Case 16 Lack of a Safe Access Results in Fatality.....................................................31 Narrative.................................................................................................................................31 The Lessons............................................................................................................................31 Footnote..................................................................................................................................32 Part 2 Fishing Vessels ..................................................................................................33 Case 17 Crewman Lost Overboard Fatal Accident .................................................34 Narrative.................................................................................................................................34 The Lessons............................................................................................................................36

Case 18 Explosion aboard Fishing Vessel causes Injury .........................................38 Narrative.................................................................................................................................38 The Lessons............................................................................................................................38 Case 19 Valve Jams Open and Vessel Sinks .............................................................39 Narrative.................................................................................................................................39 The Lessons............................................................................................................................39 Case 20 Mistaken Identity ..........................................................................................40 Narrative.................................................................................................................................40 The Lessons............................................................................................................................41 Case 21 Two Recent Flooding Cases Vessels Saved by the Bilge Alarm ...............42 Narrative I ..............................................................................................................................42 Narrative II .............................................................................................................................42 The Lessons............................................................................................................................42 Case 22 Fishing Vessel Runs aground after Main Engine Failure .........................44 Narrative.................................................................................................................................44 The Lessons............................................................................................................................44 Footnote..................................................................................................................................45 Case 23 Deckhands Injured whilst Shooting Pots....................................................46 Narrative I ..............................................................................................................................46 Narrative II .............................................................................................................................46 The Lessons............................................................................................................................46 Footnote..................................................................................................................................47 Case 24 Steering Failure.............................................................................................48 Narrative.................................................................................................................................48 The Lessons............................................................................................................................49 Footnote..................................................................................................................................49 Case 25 Fishing Vessel Flooded during Bilge Pumping...........................................50 Narrative.................................................................................................................................50 The Lessons............................................................................................................................50 Part 3 Leisure Craft .....................................................................................................51 Case 26 Yacht Knocked Down in Bay of Biscay. One Man Lost............................52 Narrative.................................................................................................................................52 Lessons Learned.....................................................................................................................53

Case 27 Four Die in Narrow Boat Accident .............................................................56 Narrative.................................................................................................................................56 The Lessons............................................................................................................................56 Appendix A ...................................................................................................................59 Appendix B Inspectors Inquiries ................................................................................61 Appendix C Reports issued in 1999...........................................................................62 Appendix D Stationery office stockists and distributors overseas .........................63

Marine Accident Investigation Branch The Marine Accident Investigation Branch (MAIB) is an independent part of the Department of the Environment, Transport and the Regions and is completely separate from the Maritime and Coastguard Agency (MCA). The Chief Inspector of Marine Accidents is responsible to the Secretary of State for the Environment, Transport and the Regions. The offices of the Branch are located at Carlton House, Carlton Place, Southampton, SO15 2DZ. This Safety Digest draws the attention of the marine community to some of the lessons arising from investigations into recent accidents. It contains facts which have been determined up to the time of issue. This information is published to inform the shipping and fishing industries, the pleasure 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 available. The articles do not assign fault or blame nor do they determine liability. The lessons often extend beyond the events of the incidents themselves to ensure the maximum value can be achieved. Extracts can be published without specific permission providing the source is duly acknowledged. The publications home page contains information on how and where you can obtain publications produced by the Department for Transport.

Introduction As the Chief Inspector of Marine Accidents I am charged with investigating as many accidents as I can to determine their causes with the specific aim of preventing them happening again. Part of this process involves promulgating the lessons learned and making whatever recommendations are considered appropriate. It also involves trying to identify anything that appears to feature repeatedly as a cause. The most obvious is the human factor and my inspectors are focusing more and more attention on this aspect to try and understand why errors are made. This edition of the Safety Digest contains several accounts of incidents where this is done so we can draw attention to the human issues involved. The challenge we face is describing such incidents without appearing to apportion blame. People are understandably very sensitive to implied criticism and we are careful to draw out the lessons in such a way that we depersonalise them as far as we are able without detracting from some of the very important lessons to be learned. Feedback on past editions suggests we have got the formula about right and most people understand why we often extend the lessons beyond those that naturally fall out from the incident described. Learning from the experiences of others is an essential feature of seafaring and the MAIB will continue in its efforts to present a cross section of incidents so that as many people as possible can benefit from the results of our investigations. One benefit of reading a number of reports in quick succession is that your eye catches sight of a word or phrase that keeps on repeating itself. While reviewing some accident reports recently I was struck by the number of times the word assume featured. It soon became apparent that in many instances a contributory factor to whatever the eventual incident was involved someone assuming something was going to happen, or had been done. The officer of the watch of the stand on vessel assumed the give way vessel would do just that, or an engineer officer assumed his colleague had checked something. Very often it seems that the assumption is far from justified. Readers with long memories can relate this observation to past incidents such as the capsizing of the Herald of Free Enterprise when an assumption was made that the bow doors were shut. As people absorb the lessons from this edition it might be instructive to count the number of times the word assume features. While this might have some academic appeal, the mariner should develop an element of caution when assumptions start to be made at sea. It doesnt matter if you are on the bridge, in the wheelhouse or cockpit, in the engine room, galley, storeroom or on deck but, the moment you assume something has been done and you are not absolutely sure, allow the mental alarm bells to start ringing. Many accidents in the past have started with similar assumptions being made. The sensible mariner will back his instinct and make a double check that all is well. Your increased alertness may well prevent an accident.

John Lang Chief Inspector of Marine Accidents October 1999

Part 1 Merchant Vessels As this edition of the Safety Digest was being prepared for publication, two large merchant ships, the Bahamas registered cruise ship Norwegian Dream and the Panamanian container vessel Ever Decent, collided in good visibility in the northern approaches to the Dover Strait. The accident is being investigated by the two flag states involved and it would be entirely wrong to speculate on what the inquiries will reveal. There are, however, three certainties about the accident; it should never have happened in the first place, it did, and every mariner wants to know what went wrong. Had the owners, masters and the officers of the watches been asked a few hours before the event whether two well found vessels, equipped with the latest technology and manned by competent crews could collide, they would probably have thought it inconceivable that either of their vessels could be involved. And yet they were. We will have to wait and find out what the investigators discover but shipowners throughout the world will, once again, be reviewing their procedures and asking themselves the same question. Could such a thing happen to one of my ships? The uncomfortable reality is that it could. No matter how good the regulations, preparations, the training, the technology, formal safety assessments and precautions, collisions still occur. As with all collisions the same questions will be asked. Who was to blame, why were the Regulations for the Prevention of Collision at Sea seemingly ignored, are the regulations adequate, was human error involved, was there a technical failure, should there be more control for busy shipping lanes? It is not up to the marine accident investigator to apportion blame, but he will wish to find out what happened and why. If human error was involved, a key feature of the investigation will be to establish why. In the meantime shipowners, masters and officers of the watch will be reflecting whether there is anything more they can do to minimise the risk of collision. The Dover Strait and its approaches are, we are reminded on a daily basis, one of the busiest waterways in the world. The northern approaches are especially complex with major terminals to both east and west. Crossing, joining or leaving, the main north/south transit lanes demands immense concentration, technical competence and a thorough understanding of the regulations. It is not a dangerous area but it can be busy, especially if visibility is poor, and fishermen and yachts are present. We do not yet know how many people were on the bridges of both Norwegian Dream and Ever Decent, but of all the waterways in the world where pilotage is not compulsory, the area that embraces the Dover Strait, the Thames estuary and the approaches to the ports of Belgium and the Netherlands is one of the busiest for an officer of the watch. Not only does he have to be sure of his position; shoals and sandbanks abound, but the volume of shipping can be high. Any decision to prevent collision must be made on reliable information, in good time and after a full assessment has been made. It is, very probably, one of those few occasions when safe navigation is better conducted by two people rather than one. The permutations are wide. It could be master and mate, pilot and mate or two certificated officers of the watch. At the time of writing nobody knows the causes of the Norwegian Dream/Ever Decent collision but can any ship owner or manager put hand on heart and say, with total conviction, that such an accident could never possibly happen in his ship? If the answer is 'no' then, peeling the outcome of the investigation, an appraisal has to be made about how best to minimise the risk of collision in these waters.

Case 1 Grounding of Large Container Vessel Narrative The 65,475 gt container vessel NOL Cyprine with an overall length of 274m and a draught of 11m was inbound for the port of Felixstowe. The vessel was well found and all systems were in good working order. There was a north-westerly wind of 12 knots. It was daylight, the visibility was good and the spring tide was running at half-ebb in a north-easterly direction across the approach channel. The pilot boarded the vessel four miles north-east of the Sunk light float. Once on board he discussed and agreed the inward passage plan with the master. However, neither the pilot nor the ports VTS informed the master that Nos 3 and 4 main channel buoys were off station by 50m to the north and south respectively to facilitate on-going dredging operations. This made the channel appear wider by 100m. The pilot had been informed by VTS that two vessels were outward bound and he also knew that another large container vessel was in the process of sailing. In view of this the pilot decided to proceed slowly along the channel until the outbound container vessel had rounded Landguard Point. Speed was reduced from half to slow ahead as NOL Cyprine approached the first of the two outward bound vessels that was on a reciprocal course and in the middle of the channel. Both vessels were approaching the point where the buoys had been repositioned. There was no communication between them and neither the pilot nor the VTS contacted the outward bound vessel to draw attention to the fact that by keeping to the centre of the channel, she was making NOL Cyprine stay well to starboard. Although the radar echo of NOL Cyprine was, by now, overlapping the northern edge of the channel, VTS did not advise the pilot that he was very close to the edge. NOL Cyprine was still proceeding very slowly and the pilot assumed he was safe. After passing the outward bound vessel to port and No 3 buoy to starboard, NOL Cyprines bow began swinging to starboard. Full port helm and bow thrust were applied and the main engine speed was increased but the swing to starboard continued. Moments later NOL Cyprine grounded on the north side of the channel. Initial attempts to refloat her on a rapidly falling tide were unsuccessful but, with the assistance of four tugs she was successfully refloated on the next high tide. The vessel was undamaged and there was no pollution.

Select the thumbnail to view the accompanying chart (134KB)

The Lessons 1. Always bear in mind the likely effects of the tidal stream when navigating in narrow channels or close to the shore, especially when it is a cross tide. Its effect is aggravated when proceeding at slow speed.

2. Mariners will need no reminding of the interaction effects between vessels passing each other in a narrow channel. The effect is exaggerated if one vessel is propelling at a speed slower than the other. The slower vessel may well find her handling characteristics are affected when she clears the pressure area that forms between them as they pass. 3. In the interests of safety, bridge teams must be made aware if any navigational buoy or mark is out of position or is not displaying the charted characteristic. In this case, neither the pilot nor the VTS advised the master that Nos 3 and 4 buoys were out of position. Without this information the bridge team was unable to provide adequate navigational support to either the master or pilot. 4. VTS operators should be aware of the greater risks faced by vessels when navigating in the vicinity of an area where navigation marks have been repositioned. Greater attention should be paid to their movements and if any vessel navigates in a manner to cause concern, a VTS operator can do no wrong by alerting the pilot or master to the matter. The pilot concerned may well have cause to be grateful, especially if he is on a deep draught vessel.

Footnote This accident was investigated by the Harwich Haven Authority who concluded that errors of judgment were made by steering the vessel so close to the northern edge of the deep water channel without making sufficient allowance for the north setting tide.

Case 2 Crankcase Explosion caused by Fitting of Wrong Type of Damper Securing Bolt Narrative The 8,007 gt passenger ro-ro vessel European Trader was on passage in the Irish Sea, both main engines were operating at service speed with electrical power being supplied by shaft generators. At 0055 the port main engine crankcase oil mist alarm sounded, followed shortly afterwards by an explosion and a fire. With the port main engine damaged and stopped, and the starboard main engine shut down so the fire could be tackled, the vessel experienced a blackout until the emergency generator cut in. The fire, which had burnt electric cabling and a plastic container next to the crankcase doors, was extinguished by the crew using portable extinguishers. The coastguard was informed and a Pan Pan message was relayed to all ships. The fire was declared out at 0126 and steps were taken to see what services could be made available. Full electrical power was restored at 0300, which together with full use of starboard main engine, enabled the vessel to resume passage to port under her own power. A subsequent investigation into the cause of the explosion found that a nut securing the viscous damper at the forward end of the engine crankshaft had become loose and had rubbed against the inside of the crankcase housing. This caused a hot spot which had caused the oil film in the area to evaporate and create an oil mist. The hot spot eventually provided the ignition source for the explosion. Simultaneously with the explosion, the loose bolt nut had jammed causing the damper assembly to twist and the remaining three bolt heads to shear. The damper had come off and smashed the crankcase casing releasing a fireball into the engine room which then set fire to combustibles in the immediate area. The primary cause of the incident was excessive clearance on the securing bolts these should have been fitted bolts. Ordinary bolts or those with excessive clearance, can lead to fretting and the eventual fracture of the castellated nut securing split pin.

The Lessons 1. At regular intervals and at all crankcase inspections, always check that all bolts are tight and that any nuts fitted or designed for securing devices have the device correctly fitted in place. 2. At every overhaul, carefully examine all bolts removed for signs of wear or fretting. Each bolt should be marked to ensure it is refitted in original position. 3. From section 9.5.1 of the Code of Safe Working Practices: All personnel should be made fully aware of the precautions necessary to prevent fire in machinery spaces in particular the maintenance of clean conditions, the prevention of oil leakage and the removal of all combustible materials from vulnerable positions.

Case 3 Lifeboat Accident While Undergoing Inspection causes Injury