Marine Accident Investigation Branch (MAIB) - Safety Digest

Contents Glossary of Terms and Abbreviations .........................................................................3 Part 1 - Merchant Vessels..............................................................................................8 Case 1 Collision between Stand-by Vessel and Fishing Vessel ..................................9 Case 2 Autopilot Failure in Confined Waters ...........................................................11 Case 3 Man Overboard while Preparing Pilot Ladder ............................................12 Case 4 Steering Difficulties Lead to Collision With Yachts .....................................13 Case 5 High-Speed Ferry has Difficulties Entering Harbour in Strong Winds .....16 Case 6 Motorman Killed in Berthing Accident .........................................................18 Case 7 Don't Forget the Effects of Wind and Tide! ..................................................20 Case 8 Collision Between Two Cranes!......................................................................21 Case 9 Safety First........................................................................................................22 Case 10 Fuel Bacteria Results in Grounding.............................................................23 Case 11 Oil Versus Water! ..........................................................................................25 Case 12 Undetected LPG Leak, then Explosion! ......................................................27 Case 13 Inertia - a Property of Flywheels and Purifier Bowls.................................29 Case 14 A Simple Job, a Serious Scald.......................................................................30 Part 2 - Fishing Vessels ................................................................................................31 Case 15 Expect the Unexpected ..................................................................................32 Case 16 Fisherman Swept Overboard by the Wash From a High-Speed Ferry ....33 Case 17 Call the Coastguard when in Difficulties .....................................................34 Case 18 Liferaft - a Godsend, After Small Fishing Vessel Sinks .............................36 Case 19 Flooding and Foundering of a Small Fishing Vessel ..................................37 Case 20 Flooding and Foundering of a Steel Fishing Vessel ....................................38 Case 21 The Importance of Safety..............................................................................39 Part 3 - Leisure Craft...................................................................................................40 Case 22 Two Fail to Survive Dinghy Foundering .....................................................41 Case 23 Too Little, Too Late .......................................................................................43 Appendix A ...................................................................................................................45

Appendix B ...................................................................................................................48 Appendix C Reports issued in 1999 and 2000 (Unpriced)........................................52 Appendix D Stationery office stockists and distributors overseas ..........................55

Glossary of Terms and Abbreviations ARPA Automatic Radar Plotting Aid

CCTV Closed circuit television

CO2 CarbonDioxide

CPA Closest Point of Approach

EBM Electronic Bearing Marker

EPIRB

Emergency Position Indicating Radio Beacon

GRP Glass Reinforced Plastic

GT Gross Tonnage

kW kilowatt

LPG Liquefied Petroleum Gas

MAIB Marine Accident Investigation Branch

MCA Maritime and Coastguard Agency

PEC Pilotage Exemption Certificate

RNLI Royal National Lifeboat Institution

Ro-ro Roll-on, roll-off

SCBA Self-contained Breathing Apparatus

VHF Very High Frequency

VTS Vessel Traffic Services/System

While every accident at sea has its unique characteristics, certain features tend to repeat themselves again and again. My staff do their best to identify these and propose remedies to prevent others from making the same mistakes. There is rarely a single solution, but very often just identifying the problem can do much to draw awareness to certain factors and ensure greater care is taken in future. My attention has been drawn recently to the number of accidents that have occurred when a mariner, for whatever reason, suddenly departs from a previously formed plan and fails to assess the risks involved with the alternative course of action. The word 'risk' is often used in a maritime context. By its very nature seafaring is a risky business and we face potential dangers and pitfalls on a daily basis. Even putting to sea in the first instance has its attendant risks but, by identifying what they are in advance, making appropriate plans and taking suitable precautions to overcome them will do much to ensure a safe outcome. Yet we all face the unexpected from time to time: the fairway is blocked ahead of us, the gangway lighting fails an hour after sunset and the electrician has already gone ashore, or you are asked to carry an extra passenger in an already well-laden dinghy. Any group of mariners can have fun by posing likely, and perhaps less likely situations for colleagues, and asking what they would do if faced with an unexpected predicament. Most of us would like to think we had enough knowledge, common sense or experience to propose workable solutions, but the reality from a marine accident investigator's point of view is that too often the selected course of action is not thought through sufficiently, and an accident occurs. Given that an unexpected situation has suddenly developed, a decision often, but not always, has to be taken quickly to overcome it. On what basis do you judge the new course of action to be safe? There are no golden rules, but if with someone else it can pay handsome dividends to say what you are going to do out loud. Your colleague may well be in a position to assist in ensuring the alternative action is safe or, could draw your attention to some feature that you had overlooked which makes the plan unsafe. So when the master tells you that he proposes to cut inside the buoy marking the bend in the channel to give a wider berth to the inbound ferry, you can remind him it is low water springs and the draft on sailing matches the predicted depth of water where he intends going. He might give you a dirty look but he should have the grace to thank you as he selects Plan C.

John Lang Chief Inspector of Marine Accidents August 2000

Part 1 - Merchant Vessels One dictionary defines seamanship as 'skill in seafaring'. According to the textbooks its elements include the need to keep water out of a vessel, keeping from hitting anything and the work of the seaman onboard ship. It is an ancient skill, part science, part art and part instinct borne out of long experience. Many of our forefathers were experts. They had a natural affinity with the sea in all its forms and could handle ships and the gear on board with great skill no matter what the conditions. MAIB inspectors see a wide range of accident reports. Most come to us direct, others originate from a wide range of sources from around the world. We keep a permanent weather eye open for common causes, or for incidents where the same factors repeat themselves again and again. There are many such examples and a selection has featured in past editions of the Safety Digest. Important lessons can, and should, be drawn from them. It would seem that in the prelude to many accidents the practice of good seamanship is waning. We hear about gangways that are incorrectly rigged and lead to people being injured or even killed. We learn of instances of badly secured cargo that leads to delays and damage. We know of cases where those on board a vessel have failed to investigate the source of an unidentified leak, or the officer of the watch who, on being confronted with a complex rule of the road situation at night, resorts to hoisting the not under command lights. We have seen reports of people falling over the side because of an incorrectly rigged stage, and ships grounding because nobody had remembered to switch on, and look at, the echo sounder. And many others. There are any number of underlying causes for poor seamanship and they include inadequate training, poor supervision, inexperience and, increasingly, too few people onboard to carry out the tasks required of them. One of the most common reasons for things going wrong is when people on board decide, often on the spur of the moment, to take a shortcut to tackle a particular problem. Although there might be a sensible, or seamanlike, way of tackling it, or clearly laid down procedures to follow, they decide to do it 'their way' and then find they are confronted with a situation they cannot handle. Good seamanship is safe seamanship, and if anyone ever contemplates taking the shortcut to solving a problem there is every prospect that something unsafe is about to happen. In nearly every instance the subsequent accident could have been avoided had the instigator stopped to think what he was about to do (or not do). It only needs someone to say 'Stop, this isn't sensible' and take stock of the situation to avoid an accident. Much falls on the shoulders of the person in charge to ensure the seamanlike action is taken but, equally, there are instances when a subordinate might see something going badly wrong but, because of his status, feels he can't intervene. But he should; good seamanship is just as much about effective teamwork as individual skills. Bon Voyage!

Collision between Stand-by Vessel and Fishing Vessel The 782gt stand-by vessel Toisa Puffin was on passage from Bessamar gasfield to Aberdeen Bay to await orders. She had also been told to remain within mobile telephone range. After making landfall off Flambourgh Head, Toisa Puffin paralleled the coast and headed north- west. It was daylight and the weather conditions were good. In a position11miles south-east of the Tyne she was steering 335°at a speed of 9 knots. The mate, who was alone on watch, detected a target on his ARPA fitted radar. Because he judged there was no risk of collision, he did not plot it. He estimated the target was bearing north easterly at a range of approximately 4 miles. The North Shields fishing vessel Luc was trawling and displaying the correct shape to indicate she was doing so. She was steering 315° and making good a speed of 2.5 knots. As the distance between the vessels closed, Toisa Puffin's mate eventually decided to plot the target on the ARPA and noted the bearing as 034°, distance 2.6 miles, CPA 1.2 miles and TCPA18 minutes. He altered course by15°to starboard, and prepared to plot his position on the chart and to transfer it onto the next chart. By now Toisa Puffin and Luc were closing. When the distance between them had reduced to less than1mile and no avoiding action had been taken by Toisa Puffin, Luc's skipper became concerned. He called Toisa Puffin on VHF channel16 but received no reply. This was not an entirely new situation to him, having had previous experience of close encounters with this type of vessel before. Some deliberately come close to observe fishing operations. He assumed Toisa Puffin was following this precedent on this occasion and decided to maintain his course and speed. The range continued to close. When the skipper realised that Toisa Puffin was getting far too close for comfort, he called once again on VHF, and slowed down. The distance between the vessels was less than 200m, and in a last attempt to avoid a collision the skipper de-clutched the propeller in the hope that the weight of the fishing gear would pull his vessel astern. He then sounded the whistle to attract attention. The mate on Toisa Puffin looked up from the chart table and realised a collision was imminent. He hurried forward to the helm control and altered course hard to port. An alteration to starboard was impossible, it was where Luc was. As Toisa Puffin came hard to port, her starboard quarter collided with Luc's port bow, before she eventually passed ahead. Fortunately, only minor damage was sustained. After details were exchanged between the vessels, contact made with Tynemouth Coastguard and damage assessments carried out, Toisa Puffin continued on passage towards Aberdeen, and Luc returned to her home port of North Shields.

The Lessons

1. This is another example of two ships managing to collide in good weather with someone on watch in both. Most people would think it could not possibly happen, but it can. Keeping a good lookout remains the most fundamental responsibility of anyone entrusted with keeping a bridge watch. The Mark One eyeball is still the most efficient, and ultimately, the most reliable tool available to a watchkeeper. It must be used. It not only readily sees other vessels, but can identify them and make an assessment of their course and, sometimes, speed. It can also instantly spot any changes to their heading. All it requires is a commitment to look. 2. Toisa Puffin's mate apparently failed to 'see' Luc until her range was about 4 miles. He did not, apparently, take a bearing but made a mental assessment that there was no risk of collision. At that stage, his judgment was correct. But lesson No.1 is take a bearing of any contact that might develop into a close quarters situation; Lesson No.2, start plotting it; Lesson No.3, keep watching it. Fishing vessels are quite capable of being unpredictable. 3. Navigating is important, but when obviously clear of danger in the open sea, it should never be allowed to preclude the keeping of a good lookout and the avoidance of collision. 4. ARPA is a first class aid when properly used, and is in many situations, the best tool for assessing whether risk of collision exists. But it does rely on the human factor. Every time you change course or speed in your own ship, previous predictions on the CPA of a radar target will change. And of course the reverse applies. When the other ship alters course or speed so will the CPA. The solution is to keep watching the other vessel until it has passed and clear. 5. Maintaining a proper lookout at the same time as doing something else on the bridge is one of the oldest predicaments facing the officer of the watch. Of course one has to take a fix and plot the position, write up the log book, monitor instruments, answer the telephone (the mobile is here to stay in coastal waters, and incoming SATCOM calls are no respecters of shipping density worries). There is also the myriad of other tasks that can preoccupy us when on watch. But no task should ever be so consuming that it prevents keeping a good lookout. If you can't cope, seek assistance. And you must have a dedicated lookout at night in addition to the officer of the watch. 6. The skipper of Luc did what so many of us have either done, or are tempted to do in similar situations, call the 'other' vessel on VHF radio. It seems so easy, just call the other vessel, have a friendly chat and all will be well. It can work, yes, but time and time and time again, it doesn't. Valuable seconds were wasted trying to elicit a response in this instance. 7. The appropriate sound signals are designed to alert other vessels when there is a failure "to understand the intentions or actions of the other ..." It is very probable that had the correct sound signals been made at an early stage (on a whistle that was of course working) it would have alerted Toisa Puffin's mate in sufficient time for him to take avoiding action. 8. An alarming feature of this incident was the apparent assumption by the skipper of Luc that many vessels, especially stand-by vessels, deliberately close fishing vessels to "have a look". If true, or if any officer of the watch feels tempted to repeat this practice, the lesson is short, sharp and very much to the point; don't. 9. One final thought: the thinking reader will note the number of times the word "assume" appears in this narrative. Whenever a mariner "assumes" anything at sea, part of his mind should be switched to caution.

Autopilot Failure in Confined Waters The1,023gt oil tanker Banwell was in ballast and departing King's Lynn under pilotage. The rudder indicator linkage had failed on the inbound passage, and a temporary repair had been effected while the vessel was in port. However, as a precautionary measure against further problems with the rudder indicator, the master decided to use the autopilot wandering lead for the outbound passage. During the passage, the autopilot failed and applied full port helm. The master immediately stopped the engine, changed to hand steering, turned the wheel hard to starboard, and then increased speed to full ahead. However, by the time full starboard helm had been achieved, the vessel had already swung out of the channel. She subsequently ran aground. Fortunately, she grounded on soft mud, and there was no damage or pollution.

The Lessons 1. The vessel departed King's Lynn using the autopilot wandering lead rather than hand steering for the sole reason that no reliable means was available to monitor the rudder angle. Hence, undue reliance was placed on the autopilot in an area restricted to the extent that effective action could not be taken to prevent the vessel grounding when the autopilot failed. 2. The autopilot should never be used in confined waters. 3. A reliable means of monitoring the rudder angle should always be available. Where this cannot be achieved remotely, the rudder angle should be monitored locally, and effectively communicated to the bridge. 4. The steering gear, autopilot, and associated systems should be regularly serviced. Any deficiencies should be properly rectified as soon as practicable. The implications of any deficiency that cannot be properly rectified immediately should be carefully assessed before deciding whether or not it is safe to proceed to sea.

Man Overboard while Preparing Pilot Ladder Mineral Century, an 81,589gt bulk carrier, was departing in ballast from Port Talbot. It was a dark night with good visibility and the sea temperature was14°c. A number of crew members were instructed to prepare the starboard combination ladder for disembarking the pilot. The relative wind on the starboard side was force 5 to 6, but the prevailing conditions did not cause any significant movement to the vessel. The operation initially required the rigging of an accommodation ladder, the upper end of which was permanently attached to the main deck. The ladder was 22m long, and its lower end was suspended by wires connected to a winch. A railing with collapsible stanchions was located on each side of the ladder and ran the full length. Each railing consisted of two sections. The standard procedure was for the upper section to be rigged first, and then for the lower section to be rigged and connected to the upper section with a pin. However, it had become customary for both sections to be permanently connected, and for the full length of the railing to be rigged in one go. Three crew members were required to stand equally spaced on the ladder and simultaneously pull up the stanchions with the attached railing. Each crew member wore a lifejacket, but no safety line. As the three crew