Marine Accident Investigation Branch (MAIB) - Safety Digest

Contents MARINE ACCIDENT INVESTIGATION BRANCH...............................................3 GLOSSARY OF TERMS AND ABBREVIATIONS..................................................4 INTRODUCTION..........................................................................................................8 PART 1 - MERCHANT VESSEL ................................................................................9 CASE 1 Lights Out!!....................................................................................................10 CASE 2 Grounding of a Container Feeder................................................................12 CASE 3 Ferry Grounds due to Shortfall in Bridge Team Management ................14 CASE 4 One Bad Practice Leads to Another ............................................................17 CASE 5 "Blinded" by the Sun!...................................................................................19 CASE 6 A Crossing Situation is a Crossing Situation - TSS or not! .......................20 CASE 7 Overheated Diesel..........................................................................................22 CASE 8 A New Meaning to Smoking in the Toilets..................................................25 CASE 9 Steering Gear Failure....................................................................................26 CASE 10 Automatic Chaos .........................................................................................27 CASE 11 Control Failure on Small Ro-Ro Ferry .....................................................29 CASE 12 Who Should Check the Lashings? .............................................................32 CASE 13 Costly Transfers! .........................................................................................33 PART 2 - FISHING VESSELS ...................................................................................35 CASE 14 Fatal Accident while Shooting Pots............................................................36 CASE 15 Upside Down Louvres .................................................................................38 CASE 16 Attention to Safety Saves Lives ..................................................................40 CASE 17 Engine Room Flooding Leads to Loss of Vessel .......................................42 CASE 18 Defective Bilge Alarms Lead to the Loss of two Large Vessels...............44 CASE 19 The Invisible Killer......................................................................................46 CASE 20 Heavy Weather Damage in Sea Areas Rockall and Hebrides.................47 CASE 21 Corrosion Causes a Serious Flooding Incident.........................................49 CASE 22 Container Ship and Fishing Vessel Meet in Fog! .....................................51 PART 3 - LEISURE CRAFT ......................................................................................53

CASE 23 Vessel Drying Out Falls Over, Away From Quay ....................................54 CASE 24 Capsize of a RIB ..........................................................................................55 A PAUSE FOR THOUGHT When the draught of your vessel exceeds the depth of water.......... ....................................................................................................................58 APPENDIX A ...............................................................................................................63 APPENDIX B Report issued in 2000 (Priced)..........................................................68 APPENDIX C Reports issued in 2001 (Unpriced) ....................................................69 APPENDIX D Stationery office stockists and distributors overseas ......................72

MARINE ACCIDENT INVESTIGATION BRANCH The Marine Accident Investigation Branch (MAIB) is an independent part of the Department for Transport, Local Government 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 Transport, Local Government 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 that 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 Safety Digest is only available from the Department for Transport, Local Government and the Regions, and can be obtained by applying to the MAIB. Other publications are available from The Stationery Office and the DTLR Publications Sale Centre, Unit 21, Goldthorpe Industrial Estate, Goldthorpe, Rotherham, S63 9BL (Tel: 01709 891318)

If you wish to report an accident or incident please call our 24 hour reporting line 023 8023 2527

The telephone number for general use is 023 8039 5500. The Branch fax number is 023 8023 2459. The e-mail address is maib@dft.gsi.gov.uk

Summaries (pre 1997), and Safety Digests are available on the Internet: www.maib.dtlr.gov.uk

Extract from The Merchant Shipping (Accident Reporting and Investigation) Regulations 1999 The fundamental purpose of investigating an accident under these Regulations is to determine its circumstances and the causes with the aim of improving the safety of life at sea and the avoidance of accidents in the future. It is not the purpose to apportion liability, nor, except so far as is necessary to achieve the fundamental purpose, to apportion blame.

GLOSSARY OF TERMS AND ABBREVIATIONS AB Able Seaman

CCTV Closed Circuit Television

CPA Closest Point of Approach

DGPS Differential Global Positioning System

ECDIS Electronic Chart Display and Information System

ECR Engine Control Room

EPIRB Emergency Position Indicating Radio Beacon

GPS Global Positioning System

IMDG International Maritime Dangerous Goods Code

MCA Maritime and Coastguard Agency

MGN Marine Guidance Notice

PEC Pilotage Exemption Certificate

RIB Rigid Inflatable Boat

Ro-Ro Roll-on, roll-off

SCBA Self-contained Breathing Apparatus

SFIA Sea Fish Industry Authority

TSS Traffic Separation Scheme

UTC Universal Time Co-ordinated

VHF Very High Frequency

INTRODUCTION A feature of accident investigation is the number of times a particular word will appear in conversation or writing. I have in the past drawn attention to the number of times the word assume has featured in reports. Somebody in a stand-on vessel will assume the other ship was going to give way, or assume a gangway was properly secured, or the breathing apparatus was properly recharged after the last exercise. In each case such assumptions were unduly optimistic; the give way vessel failed to do so, the gangway collapsed while someone was crossing it and the BA set was empty when it was needed to fight a real fire. The lessons are obvious. Dont assume. Good seamanship is all about anticipating the worst and doing something about it. It involves checking, double-checking and spotting the problem before it occurs. Accident prevention is infinitely better than sorting out the mess afterwards. The word if is another word to appear regularly. People involved in accidents will often reflect on what has happened by saying If only If only I had checked the valve was shut If only I had not been distracted by. If only I kept an eye on If only, if only, if only. It is perhaps the sentiment most frequently expressed by people who have been involved in an accident. Interestingly, very few ever seem to say, If only I had followed the regulations. There isnt a seafarer afloat that doesnt complain about the number of regulations, rules, procedures and bylaws that have to be adhered to. They do, of course, play an important part in ensuring safety at sea, but even rigid adherence doesnt necessarily prevent the accident. Safety at sea is a product of training, professionalism, experience and an instinctive feel for when something isnt right. Safety breaks down when people dont know what to do, take a short-cut, are badly distracted, are too tired or are trying to do too much at once. It also breaks down when the seafarer forgets how accidents are caused. Accidents rarely occur because of a single event; they are invariably the product of several things coming together in a certain sequence. In short, a chain of events, often unconnected, causes an accident and all that is needed to prevent it is for the sequence to be broken. Very often it need be no more than a simple check or a routine action. It could be the process of thinking through the implications of a certain course of action, or comparing one source of information against another. It can be broken by being honest with yourself: by calling for help when you dont know how to do something or cant do it by yourself. Above all, common sense prevents accidents. It is far better to prevent the accident than to be in the position of saying If only .. after the event. Accidents can be expensive, time consuming, commercially damaging, very painful and sometimes tragic. Dont let them happen. John Lang Chief Inspector of Marine Accidents August 2001

PART 1 - MERCHANT VESSEL Earlier this year the MAIB published Safety Study 1/2001, more usually referred to by its title Review of Lifeboat and Launching Systems Accidents. It makes sober reading. The study was carried out following receipt of a number of reports from UK-registered vessels revealing that people were being injured or killed while using lifeboats during training exercises or when testing them. This prompted the MAIB to carry out an in-depth analysis to identify the reasons why. A root cause in many of the accidents was an over complicated design of launch system and its component parts. It also found that personnel handling lifeboats faced many risks. The seafarer has no control over the design of the lifeboat launching system on board his ship, but he can reduce the risk of an accident by conscientious equipment maintenance, operation and training. The review identified that training, repair and maintenance procedures fell short of what was necessary. As a seafarer you have an interest in the lifeboats on board your own vessel. You may not necessarily be involved in their maintenance, but you could be involved in using one. How well prepared are you? Are you aware of any shortfall in your knowledge and if so, what do you intend doing about it? How familiar are you with your lifeboats and launch systems? Try a self test. Have you ever sat in a lifeboat while it was being lowered? And if so, did you know what to do with your hands? At face value these are two very simple questions. If the answer to the first question is no, and you dont know the answer to the second, you may well be one of the many people at sea who could do with some refresher training. You might have been told what to do but, unless you have actually tried it yourself, the chances are that you will have forgotten some crucial feature of the drill or may be unfamiliar with the equipment fitted. Dont be shy in admitting it. It is far better to find out now and do something about it, than be caught out when it really matters. Try a different approach. Do you have confidence in the lifeboat system in your ship? You may well have heard ominous reports about people being injured or even killed when using them, or you may have looked at your lifeboat and seen the bilge keel grab rails corroding away. You could, as a result, be mildly apprehensive about getting into one. It is however, essential, that you have that confidence which only comes with familiarity in how to use them correctly and the knowledge they are correctly maintained and looked after. If push comes to shove (metaphorically speaking of course) and you have to use the lifeboats, you will be banking on three things: it will function as designed, it wont kill anyone in the process, and you wont let anyone down by not knowing what to do. If the ship is sinking beneath you, or the heat from the fire is getting a trifle warm, it is probable you will be preoccupied with the problem of the moment. It is not the time to take a crash course in lifesaving equipment, to understand how to deploy it or how to use the lifeboats. If you have that uncomfortable feeling you need further training, do something about it. Now.

CASE 1 Lights Out!! Narrative Pride of Dover was on the 1945 passage from Calais to Dover when, at 2027, the fire alarm sounded. It indicated a fire in the machinery spaces. The second engineer, on watch in the engine control room (ECR), saw the picture on the CCTV monitor covering the upper auxiliary engine room, turn grey to the extent it obscured any detail. On opening the ECR door to that space he was confronted by a blast of heat and zero visibility. The Hi-Fog fire-extinguishing system was operated above Nos 2 and 3 generators, while the fuel shut-off system was operated for Nos 2, 3, and 4 generators. No 1 generator was already isolated and under repair. The engineers alarm was sounded, the bridge informed and damage control groups assembled. At 2030 the vessel blacked out, causing the automatic emergency battery power system to activate. The emergency generator started automatically, but the breaker failed to engage with the emergency switchboard. By 2036 visibility in the auxiliary machinery space had improved to such an extent that the chief engineer was able to advise the bridge that no fire could be seen from the ECR door. A control team wearing self-contained breathing apparatus (SCBA) sets entered the auxiliary engine room to open the fuel shut-off line to No 4 generator. While there they found, and isolated, a broken high temperature cooling water outlet bellows on No 3 generator. The fire detection system was operating because steam was escaping from the broken bellows. There was no fire. At 2040, No 4 generator was started to enable power to be restored, including that supplying the emergency switchboard. Because so much cooling water had been lost through the broken bellows, it took 30 minutes for the system to be refilled and the main engines restarted. The vessel was then able to resume her passage to Dover where she arrived at 2149. Once alongside, tests were carried out on the switchboard automation. No abnormalities were found and all the auto systems worked as intended. The bellow failure followed other incidents over the years. In 1996, the quality and type were changed from a nylon-reinforced material to Purbunan material with wire reinforcing. Following a further failure in 1998, it was decided to upgrade it to an EPDM material with wire reinforcing. This new type of bellows is suitable for continuous use in a cooling water system at 100°C at a pressure of 4.5 bar with a suggested life of 5 years. At the time of the incident, these were being fitted according to the planned maintenance schedule. An in-depth investigation failed to find a satisfactory explanation as to why the emergency generator breaker did not engage but, as a precaution to prevent it happening again, the generator card in the control system was changed and all relays and auxiliary contacts renewed. The breaker itself was also overhauled. Since then, the system has worked well and the emergency generator has always come on-line on demand.

THE LESSONS

1. During the emergency, an electrical officer was sent to the emergency generator room to place the generator on the switchboard. At the same time, attempts were being made to restore main power in the engine control room. Senior staff then realised that the two actions could lead to simultaneous engagement with resultant damage to the switchboard. Their concern was that manual engagement would override the electrical interlock. In the event, this didnt happen. 2. The need to consider abnormal operating procedures to meet a particular situation will arise from time to time. Unless those responsible for authorising them are fully conversant with the system, the chances of aggravating the situation further will be reduced if a check is made of both electrical circuitry and the system before any action is initiated. Better a short delay and get it right, than a rapid response and get it wrong. 3. A key feature of any emergency response team is that its members are familiar with the spaces they are about to enter. The emergency may not necessarily be the standard fire so often practised in drills. Choosing the most suitable people to lead SCBA teams deserves careful thought. Use qualified engineers to lead the engine room team. 4. Engineers reading this narrative will ponder the 30-minute delay in restoring main engine power while the cooling water was restored. In the event, the vessel was in safe water throughout. Next time a lee shore could be featuring as an unwelcome distraction to the old man on the bridge. 5. This particular company now requires a strategic reserve of six tonnes of fresh water to be held in the cooling water drain tank. FOOTNOTE This incident had a satisfactory ending. The ships staff were familiar with the routines for emergencies, and practised them regularly. It paid off. But this incident demonstrated something else. It revealed how different the real thing can be to the training drill. It also demonstrated how important it is to take training seriously and to examine current safety procedures regularly. Emergencies have a nasty habit of highlighting holes or concerns in what were thought to be safe procedures. The better trained people are, the more likely they are to cope with the unexpected.

CASE 2 Grounding of a Container Feeder Narrative The 2,481gt container feeder vessel Coastal Bay sailed from Dublin on the evening of 20 July 2000 for passage to Liverpool via The Skerries TSS. The weather was fine, the sea calm, and traffic density light. Shortly before 2300, the chief officer relieved the master on the bridge. He felt fine and alert. He was alone on the bridge, the bridge watch alarm was switched off, the ship was in autopilot, and navigation was being monitored on a DGPS plotter. About 30 minutes later the chief officer fell asleep. A planned course alteration due at 2350, taking the vessel into the north-east bound lane of the TSS, was missed, and the vessel ran aground in Church Bay, Anglesey at 0020. She was later refloated. Damage to the hull was minimal. (Had she gone aground a few yards to either the left or right, it would have been far more serious.)

THE LESSONS 1. Vessels engaged in the short-sea trade invariably run to tight schedules. Passages can be rough. Port calls are frequent, cargo work has to be supervised, ships business attended to, and the never-ending army of port officials and surveyors have to be accommodated. The master has no say in the number of watchkeepers he has and with, so often, only two on board, the opportunities to take adequate rest are limited. It is no surprise, therefore, that many of those entrusted with the safe navigation become tired and run the risk of falling asleep, albeit briefly, while on watch. Fortunately, this does not always result in a fate similar to Coastal Bays. Most bridge watchkeepers recognise the risk and take precautions to either reduce their chances of