MARINE ACCIDENT INVESTIGATION BRANCH MAIB Marine Accident Investigation Branch Safety Digest Lessons from Marine Accident Reports 2/2010 is an

SAFETY DIGEST Lessons from Marine Accidents No 2/2010

is an

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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 Mountbatten House, Grosvenor Square, Southampton SO15 2JU.

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 information which has 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.

If you do not currently subscribe to the Safety Digest but would like to receive an email alert about this, or other MAIB publications, please get in touch with us: • By email at maibpublications@dft.gsi.gov.uk; • By telephone on 023 8039 5500; or • By post at: Publications, MAIB, Mountbatten House, Grosvenor Square, Southampton, SO15 2JU

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 2010

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. It’s Behind You! 10

2. Bad Luck Comes in Threes – So Do Avoidable Accidents 14

3. Shocking Connections – That Could Have Been Terminal 18

4. When Starboard Was Not Right 20

5. I Didn’t Touch It 21

6. Freefall Workboat Injures Two 23

7. No Margin For Error 25

8. Testing of CO2 Fire Extinguishing Systems – A Close Shave 26

9. Are You Sitting Comfortably? 29

10. Pilotless Port Entry Ends in Heavy Contact With Quay 31

11. What a Drag 34

12. Too Busy to Look 37

13. Stand Clear Below 40

14. Watch Out 41

15. It Pays to Follow Procedures 44

16. Squally Weather Eases Tension 46

PART 2 - FISHING VESSELS 50

17. Drum Roll – But No Fanfare 52

18. Where is That Water Coming From? 54

19. Don’t Stop Trying 57

20. Steering Into Trouble 60

21. A Flukey Escape 62

PART 3 - SMALL CRAFT 64

22. Time and Tide Wait For No Man 66

23. Don’t Drink and Drive 68

24. Look Out! 69

25. She Was Never to be Named 71

APPENDICES 73

Appendix A - Preliminary examinations and investigations 73 started in the period 01/03/10 to 30/09/10

Appendix B - Reports issued in 2010 75

Glossary of Terms and Abbreviations

AB - Able seaman MBL - Minimum Breaking Load AIS - Automatic Identification System MCA - Maritime and Coastguard Agency ARPA - Automatic Radar Plotting Aid MGN - Marine Guidance Note ASD - Azimuth Stern Drive mt - metric tonne C - Celsius OCIMF - Oil Companies International Marine Cable - 0.1 nautical mile Forum

CCTV - Closed Circuit Television OOW - Officer of the Watch

cm - centimetre PTW - Permit to Work

CO2 - Carbon Dioxide RIB - Rigid Inflatable Boat

CPP - Controllable Pitch Propellers Ro-Ro - Roll on, Roll off

ECDIS - Electronic Chart Display and rpm - revolutions per minute Information System RYA - Royal Yachting Association ECS - Electronic Chart System SOLAS - International Convention for the EN - Equipment Number Safety of Life at Sea

ERRV - Emergency Response and Rescue SPM - Single Point Mooring Vessel TSS - Traffic Separation Scheme GPS - Global Positioning System UTC - Universal Co-ordinated Time GT - Gross tonnes VHF - Very High Frequency kg - kilogram VTS - Vessel Traffic Services m - metre “Mayday” - The international distress signal (spoken)

Introduction In this, my first introduction to the Safety Digest, I must pay tribute to my predecessor, Stephen Meyer, who retired in August. Stephen’s vision and commitment during the last 8 years has led to MAIB developing into one of the world’s most respected marine accident investigation organisations. The MAIB owes him a huge debt of gratitude and we will miss him.

Regular readers will be aware that this issue of the Safety Digest is published later than was originally intended. Concern over the actions of some elements of the press did raise questions about the continued viability of the Safety Digest in its current form. However, after careful consideration, I have decided that the Safety Digest is too important a safety tool for it not to be published. This decision was made easier by the many strong messages of support MAIB received and I would like to thank everyone who wrote to us. The Safety Digest is not, and never will be, an instrument of blame. Its sole purpose is to enlighten the marine community of what can, and does, go wrong and to provide guidance on how accidents can be avoided in the future.

The UK, along with many other countries, is trying to cope with the consequences of one of the worst economic downturns in living memory. The MAIB is not immune from the general process of belt tightening that is percolating through government departments and one of my first tasks has been to use the recent publishing hiatus to re-assess the way in which we produce the Safety Digest. As a consequence, I have decided that the number of editions produced annually will be reduced from 3 to 2. I trust you will understand the reasons behind this decision.

This edition of the Safety Digest contains the usual unwelcome mix of accidents and incidents. Indeed, Stephen Meyer would have encountered many of the same safety issues when he wrote his own first introduction in 2002. Seafarers need to re-discover the habit of inwardly asking themselves “what could possibly go wrong?” before embarking on any task, no matter how routine or simple the task may appear. By continually posing this question and planning accordingly, many of the accidents that occur in our industry, such as the ones described in this Digest, can be avoided.

Keep safe.

Steve Clinch Chief Inspector of Marine Accidents November 2010

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Part 1 - Merchant Vessels I am very And this is where a recently published book grateful to by the MCA; “The Human Element; a guide to Stephen Meyer human behaviour in the shipping industry” in asking me to comes in. It is an excellent description of the contribute a sort of human fallibilities I’ve been talking foreword to the about - and written specifically in the context MAIB Safety of our industry. I would urge you to get hold Digest. In the of a copy and digest the lessons of how we Port of London humans can let ourselves down but also how Authority, we we can counteract these weaknesses. And place great then, just maybe, at 0300 whilst working on emphasis on a boring repetitive task and you are thinking reading each “Oh I don’t need to get out of the chair and safety digest and distilling those lessons check that – it will be fine”, the alarm bell in learned applicable to port operations and then your brain might go off and an accident will feeding them into our safety management be avoided. system. Quite a few of the PLA’s procedures have changed over the years as a result of Have a look at a copy and share it with the various safety digests. There’s a lot to be said people round you – I am sure you will find it for learning from other people’s experiences. useful.

Reading through the reports for this digest, We also, in my opinion, have some of the I was struck by how fallible we humans are! most committed and talented people in any Like many of you, I suspect, I have been industry, working in what can be a very hostile through that awful pit of the stomach feeling environment. Because of all these things, when I realised that something I had just done we owe it to ourselves, our colleagues and could have been done differently and the risk our families to “get home safely.” just taken, avoided.

But how do we counter our fallibilities? There are all sorts of well established processes such as adequate professional training and the practising of emergency procedures and drills. But underpinning these measures there needs to be an understanding of how human fallibility can undermine these measures. We all know that a nice routine repeat of something we’ve done a thousand times before can turn into a crisis because we were complacent and didn’t check the basics.

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David Snelson

David Snelson was appointed to the post of Chief Harbour Master of the Port of London Authority in December 2006 after a seagoing career in the Royal Navy.

As the PLA Chief Harbour Master he has responsibility for operational and navigational matters including pilotage, vessel traffic services, hydrography, harbour services and port security over an area from Teddington in west London to the Thames Estuary outer limits north of Margate. The port is the second largest in the UK, moving over 45m tons in 2009.

During his naval career he was an aircraft controller, bridge watch keeper and commanded 3 ships, including the aircraft carrier HMS ARK ROYAL.

Admiral Snelson is a Fellow and past Council member of the Nautical Institute, a member of the Honourable Company of Master Mariners and a Younger Brother of Trinity House. He was appointed a Companion of the Bath in 2003 and is a holder of the United States Legion of Merit. He retains an interest in defence matters as a specialist adviser to the House of Commons Defence Committee.

MAIB Safety Digest 2/2010 9

It’s Behind You! Narrative The following morning, the riggers attended a “tool box” talk given by their supervisor. A specialist offshore wind farm construction They were reminded of the need to wear their vessel carried a large alignment tool which safety harnesses when working at height. On was used to align the intermediate section of completion, all those involved in removing the wind turbine tower to the bottom section the tool’s stowage signed the Tool Box Talk of the tower that was driven into the seabed Register to confirm that they had understood (Figure 1). the supervisor’s requirements.

The tool was carried on board the vessel in The shift supervisor then instructed two of a dedicated stowage (Figure 2). The stowage the riggers to go onto the stowage working had a working platform from which the riggers platform to remove any loose items before it could access the top of the alignment tool to was craned ashore. A number of items were connect the slinging arrangements when it was lowered to the deck using the ship’s 40 tonne to be deployed. The platform perimeter was crane. The two riggers, who were not wearing fitted with guardrails. The grating deck had two safety harnesses, then removed the plywood openings, the smaller of which accommodated sheet covering the smaller of the two holes in the alignment tool’s guide rails. The larger of the deck grating. The plywood was lowered to the two openings was fitted with a removable the deck. The two riggers then turned their grating to allow for another specialist tool to attention to removing the grating covering the be stowed. When the tool was in the stowed larger of the two holes. As one of the riggers position the small opening was effectively filled used his radio to discuss the options with the with the tool’s steel guide rails, so there was crane driver, he stepped back from the plat- insufficient space for anyone to fall through it. form guardrails and put his left foot through The risk was also minimised because there was the smaller hole which was previously covered no need to access the platform until the tool by the plywood. He lost his balance, struck was in place and the small opening filled with the opening with his left hand and fell nearly 7 the guide rails. metres to the main deck below (Figure 3).

The riggers were very familiar with deploying On hearing the thud, the supervisor looked and re-stowing the tool as it had been used for around and saw the - still conscious - casualty approximately 80 wind farm installations. lying on his back. He immediately instructed the casualty not to move and contacted the On completion of the construction contract ship’s medic. An ambulance was also called, it was intended to offload both the tool and and this arrived a few minutes later. The its stowage. The tool was removed to the casualty was transported to hospital, where quayside, which left the small opening on the he was diagnosed as having two broken ribs, a working platform open. Because there were punctured lung and minor cracks in two of his no guardrails around the hole, the riggers vertebrae. Fortunately his injuries were not covered it with a large section of thick life-threatening. plywood, and before completing their shift they secured plywood to the platform grating to prevent anyone falling through the opening.

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Figure 1: Wind turbine tower alignment tool

MAIB Safety Digest 2/2010 11

Figure 2: Alignment tool secured in its stowage

Figure 3: The deck grating from where the crewman fell to the main deck

12 MAIB Safety Digest 2/2010

The Lessons

The casualty was extremely lucky not to suffer 2. It is all too easy to become distracted more severe or even fatal injuries. Neither of when working aloft, so personnel should the riggers wore a safety harness despite the wear a safety harness or other arresting requirement being covered during the “tool device; in some cases a safety net may also box” talk. They rather naively felt safe because be appropriate. Chapter 15 of the Maritime of the guardrails fitted to the perimeter of the and Coastguard Agency’s (MCA) working platform. However, a momentary publication – Code of Safe Working lapse in concentration caused the casualty to Practices for Merchant Seamen provides fall through the unguarded opening. Had he more detailed guidance. worn a safety harness, his fall would have been arrested and he would have escaped injury. 3. Where possible, access hatches in working decks should be designed to be closed off The following lessons can be drawn from this using hinged covers where practicable. accident: Where this is not possible because of operational reasons, consideration should 1. “Tool box” talks are an excellent way of be given to fitting removable guardrails. advising the crew and contractors, when Had they been fitted after the alignment appropriate, to the work procedure, tool had been removed, this accident would associated dangers and precautions. not have occurred. However, it is no good signing off that the instructions are understood if the safety precautions are not implemented and enforced. In this case, the use of safety harnesses was covered, but they were not used, and the supervisor did not check to ensure that they were.

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Bad Luck Comes in Threes - So Do Avoidable Accidents Narrative Case 2: