Marine Accident Investigation Branch (MAIB) - Safety Digest 2/2004

Contents Marine Accident Investigation Branch ........................................................................3 Glossary of Terms and Abbreviations..........................................................................4 Introduction ....................................................................................................................5 Part 1 - Merchant Vessels ..............................................................................................6 Case 1 Pleasure Cruiser Strikes Bridge................................................................................... 8 Case 2 Treacherous Waters! ................................................................................................. 10 Case 3 Lifeboat Winch Handle Injures Crewman................................................................. 12 Case 4 Constrained by her Draught?..................................................................................... 13 Case 5 Important Fire-Fighting Tool Overlooked ................................................................ 15 Case 6 Shift of Timber Deck Cargo...................................................................................... 17 Case 7 Damaged Lifeboat - Successful Test......................................................................... 19 Case 8 Galley Scald Injury.................................................................................................... 20 Case 9 If It Can Be Done Wrong, It Will Be!....................................................................... 21 Case 10 Failing to Plan can Mean Planning to Fail .............................................................. 25 Case 11 An Exploding Battery.............................................................................................. 26 Case 12 Too Hot for Comfort ............................................................................................... 27 Case 13 Be Careful How You Rig Your Tricing Pendants................................................... 30 Case 14 Vertical Chute Evacuation Drill Tragedy................................................................ 32 Part 2 - Fishing Vessels ................................................................................................35 Case 15 I See No Ships!........................................................................................................ 36 Case 16 Fishing Vessel Flooding and Foundering................................................................ 39 Case 17 Bilge Alarms, Bulkheads and Televisions .............................................................. 40 Case 18 Anchored Bulk Carrier Sinks Fishing Vessel 1....................................................... 42 Case 19 The Price of Coronation Street................................................................................ 45 Case 20 Seacocks - So Important.......................................................................................... 47 Case 21 One Skipper's Relief Causes Stress to Another....................................................... 49 Part 3 - Leisure Craft...................................................................................................50 Case 22 Winter Storm in Biscay Claims Life ....................................................................... 51 Case 23 An Inverted RIB ...................................................................................................... 53

Case 24 What Boat?............................................................................................................... 55 Appendix A ...................................................................................................................56 Appendix B - Reports issued in 2004 in the period 01/03/04 - 30/06/04 ..................58

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 can be obtained free of charge 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 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. The role of the MAIB is to contribute to safety at sea by determining the causes and circumstances of marine accidents, and working with others to reduce the likelihood of such causes and circumstances recurring in the future.

Glossary of Terms and Abbreviations

AB - Able Seaman CO2 - Carbon Dioxide DGPS - Differential Global Positioning System EPIRB - Emergency Position Indicating Radio Beacon GRP - Glass Reinforced Plastic GT - Gross tons IMO - International Maritime Organization "Mayday" - Spoken distress signal MCA - Maritime and Coastguard Agency MGN - Marine Guidance Notice OOW - Officer of the Watch PPE - Personal Protective Equipment RAF - Royal Air Force RIB - Rigid Inflatable Boat Ro-Ro - Roll on - roll off TEU - Twenty Foot Equivalent Unit UTC - Universal Co-ordinated Time VHF - Very High Frequency VTS - Vessel Traffic Services

Introduction Herewith our latest batch of accidents and incidents; when you read them, please think of how they may apply to you in your sphere of seagoing, be it professional or for pleasure, in coaster, fishing vessel, ferry, yacht, deep sea trade or whatever. The lessons are often applicable to all seafarers. And many of the accidents we investigate result from a lack of understanding or appreciation of other seafarers' difficulties: in reading this Safety Digest, try to understand the perspective of the other sea users - in that way the sea will become a safer place for all of us. A spate of accidents and near misses over the last few months (which will be reported in future Safety Digests) brings me back to the subject of lone watchkeepers. More and more vessels - be they merchant ships, fishing vessels or leisure craft - are depending on a single watchkeeper. Sadly, a single watchkeeper can make a mistake, can become incapacitated, can fall asleep, can become overloaded, can become distracted, all of which can - and do - lead to accidents. The MAIB is conducting a safety study into bridge watchkeeping, the results of which should be published at about the same time as this Digest. Read it on our website, or ring and get a free hardcopy; it will make salutary reading. In the meantime, remain alert for potential errors by other seafarers - it is the prudent mariner who takes early action, rather than staking his life on others getting it right. Stephen Meyer Chief Inspector of Marine Accidents August 2004

Part 1 - Merchant Vessels

I was delighted when asked to write an introduction to the Merchant Vessels section of the August report, since in the past, I, personally, have been critical of the naming of ships in the Safety Digest. I'm happy to say that all this is now in the past and, unless you are directly involved in a report, it's quite difficult to identify participants (even the livery is changed) - and that's the way it should be. I welcome the new style and would support you to be open in your reporting so we can all benefit from it. Stephen encouraged this in the previous edition's introduction (which I fully endorse) - if you're in any doubt, just give him a call. This edition of the Digest has the usual sprinkling of incidents: some could be amusing, some incredulous and some desperately sad. When reading the detail, I sometimes wonder how on earth the circumstances could arise. In my time at sea, I have experienced several narrow misses as a result of my own actions, and have witnessed many others. You learn from these, and do things to try and avoid a recurrence. I well understand how masters can end up being overcautious. I sailed a long time ago (and long before GPS etc.) with a master who insisted on courses being drawn to 5 miles beyond the range of a light: one's eyes would be straining trying to take a bearing of the loom! The poor man must have had a close shave to promote that. No matter how carefully you might have planned to do something, people make mistakes, and it is a dreadful shame these days that litigation is always just round the corner waiting for you. Read the Digest, circulate it, and try to be ahead of the game. It's not just a matter of risk assessment and paperwork, it's being advised, aware, alert and adopting a common sense attitude. We have a reputation in this industry for getting things done, and that's good, but please take a step back and think for just a moment. There are many areas that we have to trade where we are operating close to the bottom, together with large tidal ranges. Regular trades, such as ferries in large tidal range areas, are well versed with this, and keep a very close watch on the state of the bottom in their ports. However, even they - with published timetables etc - have to operate within very strict underkeel clearances in order to avoid trouble, and some ferry schedules have to reflect this. I spent a lot of my junior years around the Indian coast, and recall well the care that masters used to take when going out from Calcutta, making sure that the vessel was in good water to the south before turning east for Chalna or Chittagong. Perhaps the master in the "Treacherous Waters" report wished he had given just a bit more offing. Don't chance it; just think of the paperwork! Another incident in this Digest caught my eye, described in the article entitled "Important Fire- Fighting Tool Overlooked"; the equipment that apparently was not used was the water fog. As a result of amendments to SOLAS (Ch.II- 2/10.5.6), your vessel may already, or may soon, be fitted with water-based local fire extinguishing arrangements in Category A machinery spaces in addition to the existing arrangements. My company has had such systems fitted in selected vessels going back over 20 years, and we introduced water fog systems into high speed vessels about 9 years ago. As a result of our experience with the latter equipment, we have reviewed our initial response to engine room fires such that, at the first indication of a fire, bang on the water fog. By doing this, you do two things: you buy yourself safe thinking time, and the fog will be taking heat out of the area and/or converting

into steam. You may not want to shut off the engines in that space, and you might want to leave the ventilation exhausting heat and steam etc out. The message here is "have a look at your engine room fire response plan if this equipment is fitted"; the old methods might not be the best. I think more guidance is needed here from the experts. This incident also brings another point to mind. By far the most frequent cause of engine room fires is oil spraying onto hot surfaces. By now, your vessel should have had jacketed piping for high pressure oil fuel pipes and insulation of surfaces with temperatures above 220°C (SOLAS II-2/15.2.1.12). But these regulations only deal with fuels, lube oils are just as liable to leak and to ignite. For many years now my company has fitted simple screening around vulnerable areas so as to dump any spray or leak into the bilge, rather than onto a hot surface. It's easy, cheap and effective. In this edition, there are four lifesaving outfit incidents resulting in several serious injuries and one fatality. It is a sad fact that this equipment has either injured or killed more people than it has saved, and it needs careful maintenance and handling. In 2001, the MAIB produced an excellent Safety Study of lifeboat launching systems and accidents. If you haven't seen it yet, I recommend you do so. Just go to the MAIB website and you'll find it under publications. And it's free. As Malcolm Billings used to say in the BBC overseas Merchant Navy Programme: "Have a safe voyage." Garth Halanen Garth Halanen is the Stena Line Group Safety Advisor. The Group operates passenger and ro-ro ferries around the UK coast, Ireland, Holland, Denmark, Sweden, Norway, Germany and Poland. He first went to sea in 1960 with Ellerman Lines until obtaining masters in 1970. He then went into tankers and bulk carriers with Hudson Steamship Company, and joined Sea Containers in 1980. When that company bought Sealin in 1985, he transferred into the ferry section. Sealink was bought by Stena Line in 1990. Garth represents Stena on various trade panels such as the UK Chamber of Shipping and the British Ports Association, and works closely with other trade organisations and government departments.

Case 1 Pleasure Cruiser Strikes Bridge

Figure 1 Vessel pinned to bridge (note: flow of river water by bow)

Narrative One serious injury and 34 minor injuries were reported among 139 people who were dramatically evacuated from a river cruiser after she struck repair scaffolding under the centre arch of a main road bridge in a major city. The vessel suffered mainly superficial damage, but lay stricken for several days, attracting a great deal of attention from passers-by. The accident occurred during darkness in winter, when the vessel was cruising upriver in strong currents and high levels of water. As she passed through the centre arch of the bridge, her starboard quarter struck scaffolding. The strong current pushed her on to the upriver side of the bridge's buttress, where she was pinned. She was further damaged when a scaffolding pole pierced one of the windows and side plating on the lower deck. With the assistance of the emergency services, the passengers evacuated the vessel, some by climbing scaffolding, others using a hydraulic platform. It is miraculous that only one person was seriously hurt. The accident happened because control of the vessel was lost in the fast and confused flow of water through the centre arch of the bridge; navigation under the bridge was already difficult, due to the repair scaffolding.

Figure 2 'Flotsam' on southern buttress

The Lessons 1. This accident could so easily have become a major tragedy. All parties involved in carrying large numbers of passengers on UK waters must continually review their safety procedures and, if necessary, improve them. Safety is everyone's responsibility. 2. The city council had identified the hazards which were to be expected while the scaffolding was present, and had suggested possible control measures. However, it had assumed that the work would be completed before the winter. Therefore, by the winter, the control measures were inappropriate for the conditions. Risk assessments should be constantly reviewed to ensure that any changes - expected or unexpected - are taken into account. 3. A build-up of flotsam on the scaffolding had tended to divert the flow of water through the arch, so that on two previous occasions the vessel had been set close to the scaffolding. However, this did not deter the skipper from sailing through the arch on the evening of the accident. After the accident, the owner declared that the vessel should not sail under the bridge while the works were in progress, but this decision should have been taken as part of a risk assessment before the accident happened. 4. Poor communication was at least a contributory factor in this accident. Despite being a principal river user, the owner did not receive restriction notices. Furthermore, the local council and local navigation authority were not aware that the cruiser sailed in the winter. It is essential that any information affecting the safe navigation of inland waterways is brought to the attention of all users.

Case 2 Treacherous Waters! Narrative An 80 metre commercial vessel, with a draught of 4.6 metres, was required to undertake a passage in a region where sandbanks were common. Her third mate laid a course on the relevant paper chart. It passed over the narrowest part of a sandbank where the least chart depth was between 8 and 9 metres. Notes on the chart warned of 'Changing Depths' in the area, and made reference to a 'Caution' highlighting the possibility that sandbanks in the area continually changed. The Admiralty Pilot book contained a similar warning, but also mentioned that buoyed channels should be used. The third mate was unaware of these cautions. The master was mindful of the general features and characteristics of the local sandbanks, but felt happy with the chosen course, largely because charted depths, and the state of the tide, suggested he would have at least a 10 metre depth of water. He approved the course, and the third mate transferred it onto the chartplotter. The vessel began the passage on autopilot, to the north of her intended track and with the master on the bridge. There was a strong tidal stream running to the south, and this was expected to compensate for the difference in starting position. As she passed over the bank, at about 9 knots, where the chart gave depths of 8 to 9 metres, the echo sounder gave a minimum depth of 10 metres, as the master had anticipated. Once the echo sounder began to give readings of 20 metres or more, the master assumed he was in clear water, and increased speed. He then handed over to the third mate and left the bridge. A very few minutes later, the vessel stopped; a slight shudder was felt. The engine controls were pulled back to stop, and the master quickly returned to the bridge. The echo sounder showed no water under the keel, indicating the vessel had grounded. The vessel's emergency plan for grounding incidents was activated. All crew were mustered and, after a headcount and a check for injuries, the vessel was examined for damage. All tanks were sounded and other internal spaces sighted. Lead line soundings were made all around the vessel. An effort to refloat her, using her own engines and bow thrust unit, was unsuccessful. There were no injuries to the crew, or damage to vessel that was immediately apparent. However, the lead line soundings showed very limited water depth around much of the vessel; in some areas it was less than 3 metres. A position obtained by DGPS gave her position as being on a 20 metre contour on the chart (see figure). With the assistance of both a rising tide, and a tug, the vessel was refloated