Marine Accident Investigation Branch (MAIB) - Safety Digest

Contents Glossary of Terms and Abbreviations .........................................................................4 Introduction ....................................................................................................................5 Part 1 Merchant Vessels ................................................................................................6 Case 1 Grounding of a Cargo Vessel Blocks River .....................................................7 Narrative...................................................................................................................................7 The Lessons..............................................................................................................................8 Footnote....................................................................................................................................8 Case 2 Melting Moments!..............................................................................................9 Narrative...................................................................................................................................9 The Lessons..............................................................................................................................9 Case 3 Checklist Fallibility!.........................................................................................11 Narrative.................................................................................................................................11 The Lessons............................................................................................................................12 Case 4 A Small Slip, A Big Fall...................................................................................13 Narrative.................................................................................................................................13 The Lessons............................................................................................................................13 Footnote..................................................................................................................................13 Case 5 Man Overboard in Rough Weather the Nightmare Scenario .....................14 Narrative.................................................................................................................................14 The Lessons............................................................................................................................14 Footnote..................................................................................................................................15 Case 6 Collision in Thick Fog Container Feeder Vessel/Class V Passenger Vessel16 Narrative.................................................................................................................................16 The Lessons............................................................................................................................17 Footnote..................................................................................................................................17 Case 7 Near Miss in Dover Strait TSS .......................................................................18 Narrative.................................................................................................................................18 The Lessons............................................................................................................................18 Case 8 Hatch Cover Control .......................................................................................20

Narrative.................................................................................................................................20 The Lessons............................................................................................................................20 Case 9 Poor Contacts Generate Heat and Fire..........................................................22 Narrative.................................................................................................................................22 The Lessons............................................................................................................................22 Case 10 Creep!..............................................................................................................23 Narrative.................................................................................................................................23 The Lessons............................................................................................................................23 Case 11 Eighty Two People Fall Down Ladders or Stairways.................................24 Narrative.................................................................................................................................24 Part 2 Fishing Vessels ..................................................................................................25 Case 12 Collision in the Dover Strait..........................................................................26 Narrative.................................................................................................................................26 The Lessons............................................................................................................................27 Footnote..................................................................................................................................28 Case 13 EPIRB Saves Two Lives ................................................................................29 Narrative.................................................................................................................................29 The Lessons............................................................................................................................29 Footnote..................................................................................................................................30 Case 14 The Thinking Man!........................................................................................31 Narrative (1) ...........................................................................................................................31 Narrative (2) ...........................................................................................................................31 Narrative (3) ...........................................................................................................................31 The Lessons............................................................................................................................31 Case 15 I Will if you Wont! .........................................................................................33 Narrative.................................................................................................................................33 The Lessons............................................................................................................................33 Case 16 He Who Hesitates...........................................................................................35 Narrative.................................................................................................................................35 The Lessons............................................................................................................................35 Footnote..................................................................................................................................36 Case 17 Ideas for Tackling Flooding ..........................................................................37 Narrative.................................................................................................................................37

The Lessons............................................................................................................................37 Footnote..................................................................................................................................38 Case 18 Engine Room Flooding causes Another Fishing Vessel Loss .....................39 Narrative.................................................................................................................................39 The Lessons............................................................................................................................39 Footnote..................................................................................................................................40 Part 3 Leisure Craft .....................................................................................................41 Case 19 Be Prepared!...................................................................................................42 Narrative.................................................................................................................................42 The Lessons............................................................................................................................42 Case 20 The Cost of Cannon Firing ...........................................................................44 Narrative.................................................................................................................................44 The Lessons............................................................................................................................45 Footnote..................................................................................................................................45 A Pause for Thought Whither the weather ...............................................................46 Appendix A ...................................................................................................................50 Appendix B Reports issued in 2001 (unpriced) .........................................................51 Appendix C Reports issued in 2002 (unpriced).........................................................54

Glossary of Terms and Abbreviations AB - Able Seaman ARPA - Automatic Radar Plotting Aid CO2 - Carbon Dioxide CPA - Closest Point of Approach EPIRB - Emergency Position Indicating Radio Beacon FRC - Fast Rescue Craft GT - Gross tons IFOS - International Festival of the Sea IMO - International Maritime Organisation Mayday - The international distress signal (spoken) MCA - Maritime and Coastguard Agency OOW - Officer of the Watch Pan Pan - The international urgency signal (spoken) RIB - Rigid Inflatable Boat RNLI - Royal National Lifeboat Institution RYA - Royal Yachting Association SAR - Search and Rescue TSS - Traffic Separation Scheme UTC - Universal Co-ordinated Time VHF - Very High Frequency

Introduction Whenever one contemplates safety at sea, there is a tendency to think of it in terms of regulations, procedures, equipment and training. Important though these are there is, of course, far more to it than that. It not only embraces having to cope with an unforgiving environment but also living with management style and the attitude of colleagues. If the senior management ashore take a personal interest in safety, masters and chief engineers will do likewise. If they, in turn, set good examples, others will follow suit. We are all, ultimately, responsible for safety but perhaps the most far reaching aspect is imbuing the next generation with a culture of good seamanship and safety. It is not something we should impose, but convey through example. I learned much of my seafaring trade from hard won experience and am forever grateful to those many people who took the trouble to train me and show me how to do things properly. I am the first to admit I made many mistakes and frightened myself far too often in the process. I richly deserved some of the admonishments that came my way but, looking back on it all now, I realise that I learned most from those who were sympathetic to youth and who were prepared to say Well done, when I did something right. It is also true to say that the safest ships were the happiest ones where good humour and laughter prevailed. I, for one, noticed how constant criticism rapidly became counter-productive when trying to develop a safety culture. After a working life in the maritime sector it is now time for me to go ashore for the last time. The moment provides me with an opportunity to look back on a wide range of experiences, including five years as the Chief Inspector of Marine Accidents. Investigating accidents is a curious profession; one where you see the frailties of man all too often. But it has its rewards. By finding out what went wrong and, more importantly why, inspectors find themselves in the same category as the conscientious trainer by being well placed to pass on to others the lessons learned. I believe the accident investigation profession plays a modest part in creating safe, and happy, ships. It is almost impossible for me to judge whether the Safety Digests have done anything to improve safety, but it is very satisfying to discover how many read them. They are sent to people as far afield as Beijing, Murmansk, Cape Town and the Philippine Islands, and are known to reach mariners on board every type of vessel from cruise ships to harbour tugs. They are despatched to Fishermen's Missions and we know they are used as training aids in many nautical colleges and sailing schools. It gives us great pleasure to find articles and opinions reproduced in other publications, and many of you have been gracious enough to compliment us on our efforts. If, as a result, we have saved a life, or prevented a single accident, our efforts will have been worthwhile. On this, my final introduction to a Safety Digest, I pay tribute to my staff for all their hard work in preparing each edition for publication. I thank my inspectors for producing the articles and the administrative staff who support them. I am particularly grateful to my editor, Jan Hawes, who collates the material and does so much to ensure that the highest standards are always met. My final thought as I depart is that the safety culture, that the MAIB tries so hard to encourage, will become second nature to all those who are fortunate enough to be working afloat in what I believe to be one of the most rewarding and fulfilling of all professions, seafaring. It only remains for me to wish my successor, Stephen Meyer, well in this fascinating appointment, to bid our readers Bon Voyage, and to give that traditional last command, Finished with Engines. John Lang Chief Inspector of Marine Accidents

Part 1 Merchant Vessels Previous Safety Digests have drawn attention to the importance of maintaining a proper lookout. It is one of the most fundamental requirements of seafaring but, as we all know, it isn't the only one. It is essential that bridge watch keepers have a complete understanding of the Regulations for the Prevention of Collisions at Sea. Despite this statement of the obvious, it is all too evident that there are a number of people in charge of vessels who, for one reason or another, are either unfamiliar with the Rules, or do not know how to apply them. It is a frightening revelation. Every one of us relies on the man on watch doing the right thing, at the right time, to prevent a collision. There are those who maintain the Rules are flawed, lack clarity or do not cater for every situation. Such sentiments are not particularly helpful for the unfortunate watch keeper doing his best on a wild night in a traffic separation lane, with a flashing orange light on one bow, a survey vessel on the other, a fisherman dead-ahead, three ships astern overhauling him and a sandbank to starboard. He detects a vessel on his port bow showing a green light and on a steady bearing. As the range closes he finds it is doing nothing whatsoever to give way. He wonders if farming isn't an easier way of life, and mentally reminds himself that the Rules are the only ones there are, and that he is paid to interpret them correctly. The problem facing many a watchkeeper in a potential collision situation is assessing what the other ship is going to do. This is especially true when you are in the stand -on vessel and are beginning to wonder if the other vessel has seen you. A few moments later you start to ask yourself if he is going to give way. As the distance closes further, and still nothing happens, your pulse begins to beat a little more rapidly and you have that sinking feeling that he is going to do something indescribably stupid. It is at times like these that the watchkeepers in both vessels should remember Rule 2 of the Regulations. It reminds us of our responsibilities and the consequences of any neglect to comply with the Rules or of the neglect of any precaution which may be required by the ordinary practice of seamen Translated, the ordinary practice of seamen involves making an early assessment as to whether risk of collision exists. If it does, and you are required by the Rules to do something about it, it requires the appropriate action to be taken in good time and in such a way that your intentions are clear to the other vessel. Put another way, it means observing good sea manners. The MAIB finds that all too often collisions occur, or near misses arise, because the watchkeepers are not keeping a good lookout, make little or no assessment as to whether risk of collision exists and sometimes feel they are somehow exempt from doing anything about it. Many of those required by the Rules to take avoiding action compound the problem by doing so far too late. We also find that a number of watchkeepers fail to anticipate the limitations, or likely intentions, of other vessels underway in heavy traffic or in confined waters. They give no thought to the fact that the other vessel may well be constrained by her draft, or poised to alter course before crossing a traffic lane, or is having to take avoiding action herself for someone else. In sum, the watchkeeper in a modern merchant vessel has a formidable responsibility to ensure he is totally focussed on navigating his vessel safely and avoiding a collision. He cannot, must not, allow himself to be distracted by anything else. To avoid a collision he needs to be 100% sure he knows how to interpret the Rules. He will have heard others say the same thing to him before.

Case 1 Grounding of a Cargo Vessel Blocks River Narrative

The River Nene is a narrow, fast running, waterway draining into the Wash on the east coast of England. Port Sutton Bridge lies about 2½ miles from the mouth and is used by small cargo vessels carrying a range of goods. The river is insufficiently wide to turn vessels, and a swinging basin has been created to enable them to do so. The 24 year old general cargo vessel Lagik, carrying a cargo of 2250.40 metric tonnes of steel products for discharge at Port Sutton Bridge, was preparing to berth. She was under pilotage on the last of a spring flood tide, and was entering the swinging basin to turn so she would berth bows to sea. There then followed conflicting evidence as to who had the conduct of the navigation. However, control was lost and her bow grounded. The tide quickly caught her stern and she grounded aft within a few seconds. With the distance between the points of grounding both fore and aft equating the vessels length, she was effectively wedged in position. High water came and went. As the tide went out she found herself suspended between the two banks until such time that the combined effect of the steel cargo, and the falling tide, broke her back. She settled further into the river on each successive tide and was declared a constructive total loss. She was eventually cut up in situ after the owner effectively abandoned all rights to ownership. She blocked the River Nene and closed the port of Wisbech for 44 days. The cause of the grounding was found to be loss of control during the turning operation. The investigation identified a number of factors which contributed to the grounding and the eventual loss: • The master taking the helm from the pilot as the vessel was about to enter the swinging basin. • Differing perceptions as to who had conduct of the navigation after the master took the helm. • Inappropriate manoeuvring for the prevailing conditions. • The master either ignoring the pilots advice, or failing to exercise his right to intervene when he became concerned about the pilots intended manoeuvre. • No spring line being used. • No tug standing by ready for immediate use.

Contributory factors to the ultimate loss of the vessel were found to be: • The master not pumping out the ballast in the forepeak immediately after the vessel had grounded. • The master stopping the propeller immediately after the vessel had grounded. • The restricted width of the river and the effect of the flood tide. • No formal written risk assessment having been made by the competent harbour authority for the turning operation at Port Sutton Bridge.

The Lessons Being responsible for a vessel that is impaled on opposite banks of a narrow river, with the prospect of a falling tide, is among the more alarming nightmares to confront a master or pilot. It shouldn't happen and if something does go wrong, actions have to be taken very quickly indeed. A lesson for any harbour authority is to contemplate such an eventuality, and take whatever steps are necessary to minimise the risks involved. In the event of the unthinkable happening, contingency plans should be in place to deal with it. 1. The pilot has local knowledge, skills and experience and is, normally, the most suitable person to have conduct of the navigation during a difficult manoeuvre such as turning a vessel in a strong tidal stream or current, although a master may well have better knowledge of his vessels manoeuvring characteristics. 2. Language skills, where different nationalities are carried, should always be sufficient to ensure safety is not compromised. 3. The competent harbour authority had not made a formal written risk assessment for the turning operation. This would be likely to identify control measures which could include, for example, the use of a spring and/or a tug standing by when a vessel is turning using her bow thruster. 4. Detailed advanced planning will allow all issues to be discussed and a plan to be agreed upon. 5. Well-rehearsed written procedures and contingency plans will save time and ensure nothing is missed in the event of an unexpected incident.

Footnote This incident was the subject of a full MAIB investigation. A comprehensive report, giving details of the causes, an analysis, and recommendations was published in December 2001.

Case 2 Melting Moments! Narrative

Hoxa Lass, a 20.42mpassenger vessel, provides a scheduled boat service between Houton and Flotta oil terminal in the Orkney Islands. She is licensed to carry 97passengers with a crew of 2. At 1815 one summer evening, Hoxa Lass left Houton for Flotta with 18 passengers and 2crew. At 1835, when she was about 2 miles north of Flotta, a passenger noticed fumes entering the aft passenger compartment from the starboard side bulkhead. The coxswain was notified immediately, and the starboard main engine stopped. After the crew carried out a brief investigation, the vessel continued on passage using the port engine. Once the vessel had arrived safely in port, the passengers disembarked and she was taken out of service for repair. The investigation found that a drive belt, on the starboard engine cooling water pump, had broken and fouled the other drive belts. This had caused the remaining drive belts to slip and eventually force the pump to stop. Once the cooling water stopped, the engine over heated rapidly, with the result that the exhaust trunking started to melt. This allowed exhaust gases to percolate through the bulkhead into the passenger areas. Temperature gauges were fitted on the engine and were found to be working correctly and accurately. High temperature alarms were also fitted, but failed to operate. Subsequently, the temperature senders on both port and starboard engines were renewed, relays re- calibrated, and the operational and maintenance procedures reviewed.

The Lessons 1. Instruments are there to be looked at much the same as those on the dashboard of a car. They need to be of such a type that they can be easily read, and placed in such a position that they can be scanned regularly without difficulty. 2. Temperature gauges need to be checked regularly, together with alarm sensors. The failure to either read, or alarm, accurately can lead to very expensive main engine repair costs. 3. Regular checks of belt drives and their correct tension is also important. If a belt is in poor condition, change it do not wait until it breaks. If you do, it will undoubtedly break just when you need engine power the most!

It is interesting to note that the exhaust trunking failed before the main engine showed any signs of seizure. It does raise the question as to what might have happened had passengers not raised the alarm at such an early stage.

Case 3 Checklist Fallibility! Narrative

The fast catamaran Rapide, which operates a regular ro-ro passenger service between Douglas, Isle of Man, and Liverpool, remained in Douglas overnight while the nightshift carried out normal maintenance duties. At 0600 on the morning of 31 March2001, pre-departure checks were carried out prior to loading. At 0700, with 445 people on board, the vessel sailed in moderate conditions with good visibility and a south-west force 6 to 7wind. At 0715, when about 7 miles south-south-east of Douglas, and travelling at 34 knots, the main engine alarm system showed abnormal exhaust temperatures. Main engine speed was reduced, followed shortly afterwards by the realisation that the fuel header tanks were