MARINE ACCIDENT SAFETY DIGEST Lessons from Marine

INVESTIGATION BRANCH Accident Reports

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INVESTOR IN PEOPLE

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 2/2006

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INVESTOR IN PEOPLE

Department for Transport Great Minster House 76 Marsham Street London SW1P 4DR Telephone 020 7944 8300 Web site: www.dft.gov.uk

© Crown copyright 2006

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.

Further copies of this report are available from: Marine Accident Investigation Branch First Floor, Carlton House Southampton SO15 2DZ

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. July 2006

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 and incidents. 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 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 2006

MARINE ACCIDENT INVESTIGATION BRANCH

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.

Extract from The Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”

INDEX GLOSSARY OF TERMS AND ABBREVIATIONS 6

INTRODUCTION 7

PART 1 – MERCHANT VESSELS 8 1. Radar Lookout – So Important 10 2. Problems Compounded! 12 3. Engineer’s Nose Wins! 15 4. Fatal Accident While Recovering a Gangway 17 5. Family in Hit and Run Scare 19 6. A Grounding in the Basics 22 7. A Dare Too Far 23 8. Just Because it Isn’t Leaking, Doesn’t Mean it is Right 24 9. Language Difficulties 27 10. Transferring Equipment at Sea Causes Head Injury 29 11. Protect Yourself From the Sun 31 12. Mandatory Tests Are Not a Guarantee 32 13. Fatigue and Distraction Lead to Malacca Strait Collision 34 14. Tug in Trouble 38 15. Splash!! – Freefall Lifeboat has a Mind of its Own 42 16. Inadequate Protection 46

PART 2 – FISHING VESSELS 50 17. With the Best of Intentions … 52 18. A Continuous Navigational Watch Must Be Kept 54 19. Capsize – a Question of Stability 56 20. Collision and Sinking While Pair Trawling 60 21. Water in the Bilges – So What? 62 22. Rapid Capsize Causes Loss of Life 64

PART 3 – LEISURE CRAFT 66 23. Junior Powerboat Racing Accident Raises Safety Concerns 68 24. Almost a ‘Deadman’s’ Handle 72 25. When Danger Lurks Between the Sheets 75 26. Smoke Without Fire 77

APPENDICES Appendix A – Preliminary examinations and investigations started 78 in the period 01/03/06 – 30/06/06 Appendix B – Reports issued in 2006 79

Glossary of Terms and Abbreviations “Mayday” – The international distress signal (spoken) AB – Able Seaman AIS – Automatic Identification System ARPA – Automatic Radar Plotting Aid C – Celsius CO2 – Carbon Dioxide COLREGS – International Regulations for the Prevention of Collisions at Sea CPA – Closest Point of Approach DPA – Designated Person Ashore DSC – Digital Selective Calling EPIRB – Emergency Position Indicating Radio Beacon GMDSS – Global Maritime Distress and Safety System GPS – Global Positioning System Gt – gross tonnes HP – Horsepower Kg – kilogram m – metre MCA – Maritime and Coastguard Agency MRCC – Maritime Rescue Co-ordination Centre OOW – Officer of the Watch PPE – Personal Protective Equipment RIB – Rigid Inflatable Boat Ro-Ro – Roll-on, roll-off SAR – Search and Rescue SCBA – Self-Contained Breathing Apparatus SOLAS – International Convention for the Safety of Life at Sea STCW – International Convention on Standards of Training, Certification and Watchkeeping TCPA – Time to Closest Point of Approach VCU – Vessel Capacity Unit VHF – Very High Frequency VTIS – Vessel Traffic Information Services VTS – Vessel Traffic Services

Introduction Again, a mixed-bag of cases in this edition of the Safety Digest, reminding us all that danger lurks in many different places. People who remain alert and aware of the risks are the most likely to avoid trouble. Please use all these articles to think about the problems others have encountered, and how you can ensure that they don’t happen to you.

Case 4 is an account of the death of a motorman while working on deck. This is one of a number of accidents MAIB has investigated recently, where engine room or catering staff have been killed or injured while undertaking a seaman’s tasks. If you are using non-deck ratings to assist in mooring and other seamanship evolutions, think carefully about their lack of training and awareness. Extra briefing and supervision is essential to ensure the safety of all concerned.

A large number of merchant vessel accidents we investigate could have been avoided if only people had fully utilised the tools they were given. In nearly all recent cases of collisions and groundings at night or in restricted visibility, the lookout had been stood down by the officer of the watch, in contravention of STCW and, frequently, company standing orders. In most collisions and groundings, electronic aids such as ARPA, CPA and TCPA alarms, waypoint alarms and depth alarms had not been used. It is complacent to believe that you don’t need such support; we all make mistakes sometimes, these safety barriers will prevent your simple error becoming a disaster.

In the leisure craft section, Case 25 reports two near-fatal accidents while gybing. MAIB has had seven similar accidents reported this year, one of them fatal. However experienced you are, be prepared for a gybe, and remember that sheets and blocks can be dangerous as well as the boom.

Finally, Case 24 is yet another cautionary tale on kill-cords. Although the photographs on page 73 are not for the faint-hearted, this young man was lucky. Use the kill-cord.

Stephen Meyer Chief Inspector of Marine Accidents July 2006

Postscript: 1. After reading Case 17 in Safety Digest 1/2006, the MCA asked us to remind all seafarers that their Maritime Rescue Coordination Centres are always happy to answer telephone requests for local weather forecasts. 2. Our apologies to Chris Venmore, who wrote the Fishing Vessel introduction in Safety Digest 1/2006, for failing to print his name. Thank you Chris.

MAIB Safety Digest 2/2006 7

Part 1 – Merchant Vessels is a coincidence that the issues we will be I am honoured and tackling reflect very closely those issues which delighted to have been are causing concern to the MAIB. The Institute invited to provide this will be seeking, in cooperation with other Introduction to the organisations, solutions to the following main MAIB Safety Digest. issues: As the immediate past • Competence and core skills President of the • Manning levels Nautical Institute, the • Stress and fatigue leading international • Leadership and management skills professional body for qualified mariners and • Codes of practices others in control of seagoing ships, I am privileged to visit many of our branches Readers who would like more detail about the around the world. In various contexts it is quite Nautical Institute and how our strategic plan amazing just how frequently the MAIB Safety aims to address these issues are invited to visit Digest reports are referred to during these our website at www.nautinst.org visits and during debate generally with our international membership. Without doubt the Changing my Nautical Institute hat now for my MAIB Safety Digest is regarded internationally ISM Consultants hat, I would invite readers to as one of the most authoritative reference try a little experiment when you read these sources for learning lessons from the mistakes accident and incident reports. of others with regard to marine accidents. My own belief is that accidents or incidents There would appear to be many synergies cannot be investigated or analysed in isolation between the goals of the MAIB and those of from the requirements of the ISM Code. the Nautical Institute – both organisations are Although the MAIB does not get involved in committed to reducing marine accidents and blame or litigation, other organisations do! generally making ships safer. While the Law is still in its infancy with regard to considering the implications of the ISM Code The incident reports in this issue of the Safety and, specifically, the relevance of the Safety Digest, along with their respective analyses, yet Management System (SMS), I am in little doubt again makes for disturbing reading. With the that the bench mark against which the various benefit of hindsight we can say, with a high legal tests will be measured will be the ISM degree of certainty, that every single one of Code. I believe the Courts, (Civil and Criminal), these incidents could and should have been Prosecutors, Arbitrators, Lawyers and Insurers prevented. The same old issues continue to will look at issues of causation in any particular raise their ugly heads – fatigue, insufficient incident and will then examine very closely the crew, inadequately trained crew, failure to SMS to identify points of contact. There will be follow correct procedures, failure to manage three main questions in mind: situations, failure to contingency plan for emergency situations and failure to maintain 1. How was the SMS set up and structured? – ship and equipment. Virtually all these failures i.e. the procedures, manuals, checklists etc stem from a lack of leadership and belief in will be examined – including procedures for safety management from the top of the training, familiarisation and recruitment etc.; company. 2. How well were these procedures At the Nautical Institute we have just launched implemented in practice? This will include our next five-year strategic plan – which has reviewing internal audits, reports of been produced after extensive consultation accidents, hazardous occurrences and non- with our membership to identify the key issues conformities, as well as minutes of safety which need to be addressed. I do not think it

8 MAIB Safety Digest 2/2006

• To what extent was the accident a result of a committee meetings, Masters’ reviews, failure of a typical SMS? Company reviews and other relevant contemporary evidence such as details of • What failures of a SMS can you identify? any risk assessment undertaken, STCW hours of work/hour of rest records, passage • What procedures should have been in place plans, checklists, maintenance records – or in the SMS which might have helped prevent whatever other records may be of relevance. the particular incident from happening? 3. To what extent did a failure of the SMS • What could be done by way of corrective contribute to the accident/incident under action to tighten up the SMS to ensure that consideration? This will become evident the chances of the incident being repeated when reviewing the evidence collected from are reduced to a minimum? the investigation of the incident with the requirements of the SMS. I would encourage all readers, including the MAIB Inspectors, to consider utilising this When you read the reports try and keep in simple methodology in their analysis of mind an idea of the contents of the ISM Code incidents which will help to bring the ISM and consider, for each incident the following Code, and the SMS, alive and more relevant in questions: the way we look at and manage safety on board our ships. Although, of course, a preferred • Do you think the incident was a result of a option would be to prevent the accidents and non-compliance with some specific section incidents occurring in the first place! of the ISM Code?

• Which specific section(s) of the Code did you identify?

Dr. Phil Anderson BA (Hons.), D.Prof., MEWI, AMAE, FNI Dr. Anderson is the immediate Past President of the Nautical Institute and regarded internationally as a leading authority on the ISM Code. Dr. Anderson commenced a seagoing career in 1969 as cadet with the Bibby Line of Liverpool. He remained with the Bibby Line throughout his seagoing career, serving on board general cargo vessels, bulk carriers, OBOs, liquid gas carriers and container vessels. He came ashore in 1980, after obtaining a Class 1 Master Mariners’ Certificate, taking up a career as P&I Claims Executive with Sunderland P&I Association. In 1987, he transferred to North of England P&I Association, in a similar capacity and was appointed to a unique new position in the P&I Industry in 1991 as Liaison and Training Executive responsible for all education, training and loss prevention initiatives. From 1998 he was Manager in charge of Risk Management and Loss Prevention and was appointed Director of North Insurance Management Ltd. He was awarded the degree of Doctor of Professional Studies from the National Centre for Work Based Learning Partnerships at Middlesex University in 2003 – in respect of a major research project into the implementation of the ISM Code – ‘Managing safety on board ships’. In January 2005 he established ConsultISM Ltd., a specialist consultancy company providing advice to the shipping and marine industries, and as court expert witness, in the ISM Code – details can be found on the company website www.consultism.co.uk . He is Member of the Expert Witness Institute and Practicing Associate of the Academy of Experts. In addition, he undertakes some academic work teaching in a number of universities. He has also written a number of technical and legal text books including: ‘ISM Code – A practical Guide to the Legal and Insurance Implications’; ‘A seafarers guide to ISM’ and ‘What have the World Cup and ISM got in common’ –; Lead Author – ‘Cracking the Code’; and his latest work, ‘The Mariners Role in Collecting Evidence – in Light of ISM’.

MAIB Safety Digest 2/2006 9

Radar Lookout – So Important

Figure 1

these “insurance” lines had dropped down the Narrative chain and had become wrapped around the swivel, jamming it. The line had been cut and A 192m length bulk carrier was outbound at left, and in the months preceding the accident, night on a UK river when she collided with five the barges had rotated around the mooring at unlit barges. The vessel was holed in her fore each change of the tide, progressively twisting peak and had to be repaired before she could the chain until a shackle failed. continue her voyage (Figure 1). The barges were damaged to varying degrees and four of The bridge on the bulk carrier was well them sank. manned and the visibility was good. The pilot had the con and was navigating by eye, and the Four of the barges were filled with containers master and helmsman were looking ahead. of rubbish and were moored on one side of The second mate was using radar for the river in preparation for being taken to a navigation, but was not using it for lookout. jetty at high tide for discharge. The barges As the ship approached the barges, the master containing rubbish (Figure 2) were tied up to a saw a shadow about 100m ahead of the bow collar barge with breast lines. The mooring and, shortly after, the second mate confirmed between the collar barge and the anchor was a that it had a radar echo. However, an chain, which incorporated a swivel. Additional immediate turn to port did not prevent the lines were generally attached between the collision. rubbish barges and the chain, for extra security (Figure 3). On a previous occasion, one of

10 MAIB Safety Digest 2/2006

Figure 2

Figure 3

2. This accident has clearly demonstrated The Lessons the importance of a properly functioning swivel in a river mooring system. 1. Although unusual, dangerous unlit Moorings should be frequently checked, objects can be encountered on a river at and mooring practices that could lead to night, rendering a visual lookout alone a swivel becoming jammed should be insufficient. This bridge team was avoided. keeping an excellent visual lookout, but it should have made use of all available means, including radar.

MAIB Safety Digest 2/2006 11