MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 2/2003

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INVESTOR IN PEOPLE

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© Crown copyright 2003

This publication, excluding any logos, may be reproduced free of charge in any format or medium for research, private study or for internal circulation within an organisation. This is subject to it being reproduced accurately and not used in a misleading context. The material must be acknowledged as Crown copyright and the title of the publication specified.

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Printed in Great Britain. Text printed on material containing 100% post-consumer waste. Cover printed on material containing 75% post-consumer waste and 25% ECF pulp. August 2003

MARINE ACCIDENT INVESTIGATION BRANCH

The Marine Accident Investigation Branch (MAIB) is an independent part of the Department for Transport, the Chief Inspector of Marine Accidents being responsible directly to the Secretary of State for Transport. 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 Editor, Jan Hawes, welcomes any comments or suggestions regarding this issue.

The Safety Digest and other MAIB publications are only available from the Department for Transport, and can be obtained by applying to the MAIB.

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.gov.uk

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

Crown copyright 2003

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.

INDEX GLOSSARY OF TERMS AND ABBREVIATIONS 7

INTRODUCTION 8

PART 1: MERCHANT VESSELS 9 1. Poor Lookout Costs Lives 10 2. Pushing the Limits and Getting it Wrong! 13 3. High-Speed Collision in the Dover Strait – in Thick Fog 16 4. A Powerful Cocktail 19 5. Check Before you Change! 20 6. No Dedicated Lookout Means No Error Recovery! 21 7. Collision – Ro-Ro and Fishing Vessel 23 8. Loss of Control Results in Collision 25 9. Tie Them Down 27 10. Power-Operated Watertight Doors – a Human Error Nightmare? 28 11. Grounding Can Be a Drag 31 12. CO2 Does Have its Limitations 33 13. Deck Officer’s Leg Crushed by Gantry Crane 34 14. Master Overrules Pilot and Vessel Grounds 36 15. Support Your Local Pilot! 39 16. The End of a Drum 42 17. Good for Sightseers – Bad for Ship! 44

PART 2: FISHING VESSELS 47 18. Rude Awakening! 48 19. Steering Fault and Poor Lookout Cause Pair Trawlers to Collide 50 20. Quay Ladders Always Require Care 52 21. Heavy Weather Fishing – Fatal Accident! 54 22/23. Lookout! – Unfortunately Not 56 24. Perished in the Darkness 59

PART 3: LEISURE CRAFT 61 25. The Perception of Risk 62 26. Helmsman Dies After Recovery Attempts Fail 63

MAIB NOTICEBOARD 65

APPENDICES Appendix A – Preliminary examinations and investigations started in the period 67 01/03/2003 to 30/06/2003 Appendix B – Reports issued in 2003 68

Glossary of Terms and Abbreviations 3EO – Third Engineer Officer

AB – Able Seaman

ARPA – Automatic Radar Plotting Aid

CO2 – Carbon Dioxide

CPA – Closest Point of Approach

GPS – Global Positioning System

GRP – Glass Reinforced Plastic

ISM – International Safety Management Code

OOW – Officer of the Watch

PLB – Personal Locator Beacon

RIB – Rigid Inflatable Boat

RNLI – Royal National Lifeboat Institution

Ro-Ro – Roll-on, Roll-off

SCBA – Self-Contained Breathing Apparatus

STCW – Standards of Training, Certification and Watchkeeping for Seafarers

TSS – Traffic Separation Scheme

VHF – Very High Frequency

VTS – Vessel Traffic Services

MAIB Safety Digest 2/2003

INTRODUCTION In this edition of the Safety Digest, we cover a Our “Noticeboard” on page 65 gives details of wide range of accidents and incidents. However, the newly instituted Confidential Hazardous yet again, by far the largest number of accidents Incident Reporting Programme (CHIRP). Its was a direct result of errors made by a lone introduction in no way replaces the legal duty bridge/wheelhouse watchkeeper. Lone laid down in the Merchant Shipping (Accident watchkeepers in merchant ships get overloaded, Reporting and Investigation) Regulations 1999 particularly in shipping or coastal navigation for a master/skipper to report an accident to the situations. Additionally, the lone watchkeeper is MAIB. Nor does it reduce our interest in much more likely to fall asleep, often with receiving details of accidents involving leisure catastrophic results. It is quite apparent that the craft, or near misses/incidents of any form. requirements for a dedicated lookout, laid down Nevertheless, I highly commend the CHIRP in the STCW Code Section A-VIII Part 3-1, are initiative to all seafarers. I fully understand that being widely flouted. Not only is this leading to there will be occasions when someone reporting many serious accidents and unnecessary deaths, safety concerns will want to protect their but also officers of the watch are now being jailed identity. In this way, I believe that CHIRP will as a result of an insufficient lookout. Masters and fulfil an important safety role. officers of the watch should demand a dedicated lookout other than in the most benign daylight situations.

Stephen Meyer Chief Inspector of Marine Accidents August 2003

Part 1 – Merchant Vessels Single bridge watchkeeping Pilots Once again, the single factor causing the largest How do you get on with the pilot? We have number of accidents in this edition of the Safety found that most of you get on with each other Digest is the lack of a dedicated lookout. If you very well. But often, some of you are confused are complemented by a lookout, use him. about who is responsible for what. Consequently, communication on the bridge breaks down and navigation of the vessel becomes unsafe. The Time pressure master is charged with the responsibility for the safety of the vessel; the pilot with the Do you have the confidence to resist time responsibility to assist in the navigation of the pressures to leave port with an unsafe ship? Do vessel in confined waters. A number of Safety you question operational safety without rebuff or Digest articles in this section highlight this intimidation? Do you feel that management confusion. shares your responsibilities to ensure safety and health at sea? Design If the answer is “no” to any of these, you are entitled to question the effectiveness of your The principle of ergonomic design is to ensure a safety management system! Effective good “fit” between people and the things they implementation of the ISM Code will empower use. It is about design, which accounts for human you to operate safely. abilities, attributes and limitations. Too often, for example, we learn of controls of winches and Time pressure is the enforcer of short-cuts. cranes, so positioned, that people become Masters leave port with deck cargo improperly crushed, unseen by the operator. Alarms are not secured and hatches left open. Irresponsible? Of heard or seen by the victim. If you suspect that course. But management is responsible to ensure poor layout is handicapping your endeavour to that clear policies are in place and guidance is act safely, report your concern. A good safety available. Such policies and guidance can management structure will address this concern empower masters and crew members to resist promptly and effectively. time pressures and ensure a safe ship.

MAIB Safety Digest 2/2003

CASE 1 Poor Lookout Costs Lives

Chemical tanker Photograph courtesy of Fotoflite

Narrative lookout at the critical time. Although the tanker, as the overtaking vessel, had the principal The master of a small cargo vessel lost his life responsibility to alter course to avoid the when his vessel collided with a 4,600gt chemical collision, had either watchkeeper been keeping tanker. The accident happened in the south-west an effective lookout the collision might have lane of the Dover Strait TSS during fine weather been avoided. and good visibility. Both bridges were being manned by certificated and experienced officers. In the preceding 13 months, three other very similar collisions occurred in the same area. The tanker had been overhauling the cargo However, this one was made particularly notable vessel at a relative speed of about 6 knots. The because the cargo vessel was holed below the tanker was fitted with a modern integrated waterline and quickly listed to starboard and bridge, including two radars, an electronic chart sank. system and an autopilot with track control system. The two vessels had been on coincident The tanker’s crew mounted a fast and credit- tracks for over an hour before the collision. worthy rescue effort but, as stated above, despite their valiant endeavours, tragically the cargo The collision occurred because the watchkeepers vessel’s master drowned. The other collisions on both vessels were distracted from keeping a could also just as easily have ended in tragedy.

Part 1 – Merchant Vessels Extract from CNIS plot showing tracks of all the vessels in the Varne Bank area between 1200 and 1800 on the day of the accident

MAIB Safety Digest 2/2003

Cargo vessel

Investigations have shown that the vast majority 3. Watchkeepers must not become distracted. of vessels choose to transit the Strait towards the They should look out of the window, as northern edge of the south-west lane. This causes well as at navigational instruments, and bunching and an increased chance of close should keep focussed on their key quarters situations and collisions (see plot). responsibility – to maintain a proper However, the fundamental cause of this, and lookout. nearly all collisions, is poor standards of lookout. 4. Risk of collision is heightened when large numbers of vessels choose the same or The Lessons similar tracks. When transiting the Dover Strait, or elsewhere in high-density traffic, 1. Poor lookout can cost lives and careers choose a track clear of the busiest routes, (the tanker’s watchkeeper was convicted of and stay clear of trouble. manslaughter and was imprisoned for 12 months).

2. Poor lookout is inexcusable. It is fundamental to good watchkeeping practice and is essential for the avoidance of collisions.

Part 1 – Merchant Vessels

CASE 2 Pushing the Limits and Getting it Wrong!

Narrative Owing to the lateness of sailing from the berth, the pilot found it necessary to proceed downriver A 2,500gt general cargo vessel was preparing to at full speed so as to meet the required deadlines sail from a river berth. The pilot was ordered for for adequate underkeel clearances in accordance 2100, with a latest departure time of 2147. with his passage plan.

The pilot arrived on board at 2110. As he did so, As the vessel approached a turn in the river, he noticed that the vessel’s cargo hatches were about an hour after departure and, by then, on a still open, and she had not yet refloated on the strong ebb tide, the pilot ordered an alteration of flood tide. Before the vessel could sail, it was also course to negotiate the turn. Part way through necessary to carry out a draught survey. the turn, he realised that not only had he started the turn too late, but also the tide was setting As soon as the vessel refloated, at 2130, the him on to the far bank of the river. He had no draught surveyor began his work, finishing 15 reserve engine power at his disposal to recover minutes later. On the master’s insistence, the the situation. Shortly after, the vessel grounded. pilot agreed to sail at 2150, even though the cargo hatches were still open. This contravened As the tide continued to ebb, the vessel the local navigation bylaws. The master assured eventually settled on the bottom with a 20° list. the pilot the hatches would be closed Later, as the tide flooded, water entered an open immediately after letting go. They were not. emergency escape hatch to the engine room.

MAIB Safety Digest 2/2003

Vessel following the grounding

Part 1 – Merchant Vessels

Fortunately, the vessel floated to an even keel 2. The master had assured the pilot that the before floodwater was able to reach the open hatches would be closed immediately after cargo hatches. letting go. They were not. This left his vessel dangerously exposed to floodwater Eventually, the vessel was towed to safety. Apart entering. Never, ever sail with open from superficial flood damage to her engine hatches. room, she was virtually unscathed. It is very fortunate indeed that floodwater didn’t reach the open cargo hatches. Had it The Lessons done so, a very different outcome would have ensued. 1. Even though the departure deadline had passed, the pilot still elected to sail. The 3. You might think, at the time, that you are passage plan deadlines were introduced by doing someone a favour by exceeding a the competent harbour authority, and deadline or by contravening a bylaw. But, served a purpose. They should not have as demonstrated here, this has a nasty been exceeded. Had the pilot not found it habit of backfiring on you! necessary to proceed at full speed downriver, when making the turn, he would have had reserve engine power at his disposal. This might have prevented the vessel grounding.

MAIB Safety Digest 2/2003

CASE 3 High-Speed Collision in the Dover Strait – in Thick Fog Narrative When the distance between both vessels reduced to 6–7 cables, with no noticeable improvement A high-speed craft was crossing the channel in in the CPA, in an attempt to avoid a collision, the area of the Dover Strait when she was the ferry master ordered a further alteration of involved in a collision with a cross-channel course by 20° to starboard. freight ferry. The visibility was between 50 and 150 metres maximum. The high-speed craft was On board the high-speed craft, when the range carrying 148 passengers and crew, and the freight reduced to 4–5 cables, the echo of the ferry ferry was carrying 102. Fortunately, there were no began to arc through 360° on the radar screen. injuries as a result of the collision. When this happened, the master, believing the danger to be on his starboard side, altered course The high-speed craft, travelling at a speed of 29 hard to port. Shortly after, the high-speed craft knots, first detected the freight ferry travelling at collided with the ferry’s port side at a point a speed of 20 knots, as the latter departed Dover. slightly aft of amidships. Her prow made contact Neither vessel had contemplated reducing speed first, followed by her starboard wave piercer. to make allowances for the restricted visibility. Fortunately, as both vessels were turning away from each other, the collision was more of a When the ferry had settled on course, after ‘glancing blow’ than ‘square on’ contact. leaving harbour, the bridge team on the high- speed craft determined from the two on board The high-speed craft suffered substantial damage, ARPAs: her range 2 miles, CPA 3 cables to but managed to limp back to Dover under her starboard and they assumed, incorrectly, a own power. The ferry suffered only minor reciprocal green-green passing situation. Course damage and continued on passage. and speed were maintained. Shortly after, the ferry detected the high-speed craft. Her bridge team also determined a CPA of 3 cables. Course was altered 7–10° to starboard.

Part 1 – Merchant Vessels

MAIB Safety Digest 2/2003

The Lessons 3. The freight ferry should also have acted in accordance with Rule 19 of the Collision 1. Both vessels should have been travelling at Regulations. An alteration of course by a safe speed in accordance with Rule 6 of only 7 to 10° was as good as standing on. the Collision Regulations. It is appreciated Again, this was probably done because of that the criteria for constituting a safe the “unwritten rule”. The master expected speed, especially on board high-speed craft, the high-speed craft to keep clear. Only are open for debate. However, the prudent when he realised this was not the case, did approach in a congested area such as the he decide to take avoiding action. Dover Strait would be to adjust speed to Unfortunately, the alteration of course to reflect the shipping situation, the visibility starboard by 20° was far too late, and was and the stopping distance of the vessel. insufficient to avoid the collision. With a developing close quarters situation, it is evident that both vessels should have 4. The bridge team on board the high-speed radically reduced speed. craft should have anticipated side-lobing on the radar displays, especially when in such 2. The incorrect assumption of the high- close proximity to other vessels. It is a speed