MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accidents No 2/2011

is an

© Crown copyright 2011

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.

This publication can also be found on our website: www.maib.gov.uk Further copies of this report are available from: Marine Accident Investigation Branch Mountbatten House Grosvenor Square Southampton October 2011 SO15 2JU

MARINE ACCIDENT INVESTIGATION BRANCH

The Marine Accident Investigation Branch (MAIB) examines and investigates all types of marine accidents to or on board UK vessels worldwide, and other vessels in UK territorial waters.

Located in offices in Southampton, the MAIB is a separate, independent branch within the Department for Transport (DfT). The head of the MAIB, the Chief Inspector of Marine Accidents, reports directly to the Secretary of State for Transport.

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 2011

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. No Brakes 10

2. More Thought Less Speed 13

3. Unguarded Machinery and Lone Work – a Fatal Combination 15

4. Lulled Into a False Sense of Security 17

5. How Not to Use ECDIS 19

6. Corrosion – a Penetrating Issue 20

7. Too Little Too Late 22

8. It Only Takes One Slip For a Fatal Fall 24

9. Too Much Up Top 27

10. What Were They Thinking? 29

11. Are They In Or Are They Out? 31

12. Testing Times 33

13. Assumptions and Interaction Strike Again 34

14. A Lack of Planning Gets the Master Carried Away 35

15. Mind the Gap! 37

16. A Lucky Escape 39

PART 2 - FISHING VESSELS 42

17. Running on Autopilot 44

18. Thinking Outside the Box 46

19. Snagging Leads to Capsize 49

20. Anchor of Hope 51

21. Even a Small Item Failure Can Kill 53

22. Fire Below! 55

PART 3 - SMALL CRAFT 58

23. Too Exhausted to Climb 60

24. Know Your Limitations 62

25. Thrill of a Lifetime – But One to Forget 63

APPENDICES 65

Appendix A - Investigations started in the period 01/03/11 to 31/08/11 65

Appendix B - Reports issued in 2011 66

Appendix C - Safety Bulletins issued during the period 01/03/2011 to 31/08/11 67

Glossary of Terms and Abbreviations

AB - Able seaman “Mayday” - The international distress signal (spoken) CCTV - Closed Circuit Television MCA - Maritime and Coastguard Agency cm - centimetre COLREGS - International Regulations for the MGN - Marine Guidance Note Prevention of Collisions at Sea 1972 MSN - Merchant Shipping Notice (as amended) OOW - Officer of the Watch CPO - Crude Palm Oil RHIB - Rigid Hull Inflatable Boat CPP - Controllable Pitch Propeller RNLI - Royal National Lifeboat Institution ECDIS - Electronic Chart Display Ro-Ro - Roll on, Roll off and Information System RYA - Royal Yachting Association EPIRB - Emergency Position Indicating Radio Beacon SMS - Safety Management System GNSS - Global Navigation Satellite System TSS - Traffic Separation Scheme GPS - Global Positioning System VDR - Voyage Data Recorder IMO - International Maritime Organization VHF - Very High Frequency kg - kilogramme VTS - Vessel Traffic Services m - metre

Introduction As I write this introduction, the first storm of the Autumn is breaking over Southampton. The resulting turbulence in the Solent and English Channel reminds me that, as a young and very green cadet, one of the first things I learned was to respect the sea and be ever wary of its potential for destruction. Case 4 provides a very good example of why I was taught this…..

Forty years ago, that same cadet probably did not have the wit or vision to even dream about the technology available to today’s mariners. There is now an increasing reliance on technology to provide the information and tools needed to safely operate and navigate vessels of increasing size, speed and complexity. However, a number of recent accidents, including those described in Cases 5 and 10, have indicated that there may be many masters and OOWs who do not really understand the capabilities and operational limitations of new aids to navigation such as ECDIS. With paper charts being steadily replaced by this equipment, it is vital that ships’ crews receive proper instruction in its use. Robin Middleton also makes a similar observation in his introduction to the Merchant Vessel section of this Digest. If you are required to use an ECDIS on your ship, do you know how to operate it effectively?

Previous introductions to Safety Digests have highlighted the scant attention some fishermen give to their own and their shipmates’ personal safety. Sadly, the consequences of entirely avoidable accidents continue to kill and injure too many UK fishermen. However, Case 22 demonstrates that, with proper training, fishermen can successfully manage a potentially very difficult situation and provides good evidence on the effectiveness of the mandatory training courses provided by Seafish. If you are a fishing vessel skipper, have you completed your mandatory training? Have you made sure your crew are similarly trained? – it could save your lives.

Finally, the MAIB has published two Safety Bulletins since the last edition of Safety Digest. They both relate to important issues arising from a fatal accident involving the failure of a fast recue boat launching system. They are reproduced at Appendix C.

Until next time, keep safe.

Steve Clinch Chief Inspector of Marine Accidents October 2011

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Part 1 - Merchant Vessels “The sea is selective; slow in recognition of effort and aptitude, but fast in sinking the unfit”. Felix Riesenberg. From my point Yet the number of marine casualties at sea of view it is a continues to give cause for concern. The particular International Union of Marine Insurance has privilege to recently published a report which states that contribute this 2010 will join the worst five vessel loss years introduction to in the last seventeen years. the Merchant Vessels Section of Accidents will happen and this Merchant the MAIB’s Safety Shipping Section outlines the circumstances Digest. which led to sixteen incidents. With hindsight it is perhaps easy to say that many of these Accidents happen. incidents need never to have occurred. Reality During my tenure however is not so straightforward. as the United Kingdom When being taught to become a diver I was Secretary of State’s Representative for Salvage introduced to the concept of the “incident pit”. and Intervention (SOSREP) I was involved in The incident pit is a slang term used by divers. over seven hundred incidents and the wider It refers to a conceptual pit, the sides of which SOSREP support team in many more. Some slope gently at first then steeper and steeper of those involved preventative activity, where until recovery from the pit (or incident) is a ship appears to be in potentially dangerous impossible. “Falling into the pit” is never circumstances, many others involved casualty intentional and often commences with a series salvage and mitigating the impact of accidents of events, each of which alone would not be whilst acting always, “in the overriding interests serious. However the effect is to put you onto of the UK”. the downwards slope and additional events can serve to cause more problems which exacerbate The MAIB’s role is, of course, that of safety the situation, and steepen the slope until a at sea. Whilst I was involved with aspects of point of no return is reached. It is often the incidents as they occurred the MAIB had a fact that many, if not all, of the events may occur significantly wider brief. From the outset I frequently and, when encountered on their came into contact with the MAIB Investigation own, often pass unnoticed. An example of this process and came to know their Inspectorate is outlined in the report “Are They In or Are well, and I like to think there was mutual They Out?” In “The Lessons” section appears the respect between us. We would meet on phrase “The chain of events began when . . . . .”. occasions for discussion of aspects of incidents from which process I learned that they would Reading through the narratives and lessons listen to opinions and consider points made I find that across the board, failures in before coming to their conclusions. After all seamanship and watch-keeping were they too were involved in the aftermath of significant contributors to the incidents with incidents and, by publishing the results of inadequate or missing planning and written investigations, in contributing to the knowledge procedures and key persons being distracted of the maritime world and furthermore by as joint second. And, perhaps surprisingly, making recommendations will prevent many in these times, failures in risk assessment potential incidents in future. Prevention and contribute to at least four of the incidents. cure. Two of the incidents exemplify topical issues: weighing containers and over-reliance on electronic navigational systems. 8 MAIB Safety Digest 2/2011

The MAIB has already pointed out that there The report “How Not To Use ECDIS” and is a strong case for weighing unaccompanied “What Were They Thinking?” provide examples lorry trailers before they are loaded for export. of what can go wrong. In the Lessons is the Similarly there is growing pressure in some statement, “In forthcoming years ECDIS will quarters for the IMO to establish a legal replace paper charts as the primary means of requirement that all loaded containers are navigation”. The lesson goes on to point out weighed at the loading facility before being that proper training is essential if this equipment stowed aboard a vessel for export. Such legal is to be used effectively and safely. Even on my requirements are probably years away from own boat I always check the whole of the being imposed, but there can be little doubt electronic passage plan on the larger magnification that such a move would be in the interests of screens, where small hazards show up better, good practice. And not only “loaded” containers and keep a full paper plot during transit. should be weighed – the incident “Too Much Up Top” exemplifies the implications of Finally, in “The Lessons” elsewhere, appears the inadvertently stacking loaded containers following, “Simply checking that an individual which were supposedly empty. carries the required certification is not sufficient in an industry where the consequences of poor Over-reliance on systems such as GNSS and practices can be devastating”. It is a major lesson ECDIS can be dangerous. In respect of GNSS and a lesson, as are others in this publication, trials have already established that systems are I believe, espoused by Lord Cullen following vulnerable to interference from both natural the PIPER ALPHA disaster in July 1988. (e.g. solar flares) or accidental or deliberate activities by man (e.g. jamming – where there It is my pleasure to commend the reading are no restrictions on supply of necessary which follows and the lessons, as they are set equipment). Trials have indicated that where out, to you. I would be surprised if many GPS signals are jammed the receiving units people could honestly say they cannot associate don’t just stop and close down, but they can with some of the events presented. provide false data which can be dangerously misleading. What we have to do now is learn . . . . . .

Robin Middleton CBE

Robin Middleton became the Secretary of State’s Representative for Maritime Salvage and Intervention in October 1999. As the SOSREP he officiated in more than 700 maritime and offshore incidents and emergencies, five of which involved activation of the UK’s National Contingency Plan.

Mr Middleton’s background includes qualifications and work in law enforcement, commercial diving, multi-disciplinary organisational management and peacetime emergency response.

He has served the Royal National Lifeboat Institute as a lifeboat crew member and has received the Institute’s Silver Medal for Bravery. He still serves the RNLI as a member of Council and is a patron of the Maritime Volunteer Service.

In recognition of his achievements he has received the Lloyds List Lifetime Achievement Award, been awarded the first Honorary Life Membership of the International Salvage Union, made a life member of the Tug and Salvage Association, a life Member of UKSPILL, elected to Honorary Membership of the International Tug and Salvage Union. He was nominated as Personality of the Year by the British Tug-owners Association in 2007.

Robin Middleton retired from the post of SOSREP at the end of 2007 and now lives in retirement in the Isle of Man.

MAIB Safety Digest 2/2011 9

No Brakes Narrative visor was penetrated by the linkspan arm (Figure 1) and the forefoot and forepeak buckled As a ro-ro passenger ferry approached a link- on impact with the concrete ramp (Figure 2). span, she did not slow down as expected. The Control of the starboard CPP system was lost master further reduced the pitch on the two because a linkage had failed, leaving the pitch controllable pitch propellers (CPP) from the stuck on full ahead (Figure 3). An identical control panel on the port bridge wing, but failure had occurred on the starboard CPP soon noticed that the pitch indicator for the system several months earlier when the system starboard propeller was still at full ahead. was being tested alongside. On that occasion, the broken linkage was replaced but the The master ordered the chief officer to take cause of its failure was not investigated. The control of the propulsion in the wheelhouse replacement linkage was taken from onboard and to put the pitch on both propellers to full spares but was longer than the original astern. This was done quickly, but the vessel’s component and had to be adjusted after fitting. speed remained at about 10 knots and the Unfortunately, the adjustment of the linkage vessel’s bow sheered towards an adjacent pier. caused it to come into contact with other As the bow glanced off the pier, the starboard components when the engine was overloaded, anchor was let go and the starboard engine which ultimately led to its eventual failure was stopped. Seconds later, the ferry hit the during the ferry’s passage. linkspan and was severely damaged. The bow

Figure 1: Penetration in bow visor

10 MAIB Safety Digest 2/2011

Figure 2: Buckling of the stern and forepeak

Figure 3: Failed linkage from CPP

MAIB Safety Digest 2/2011 11

The Lessons 3. When a CPP system fails, the default position for the pitch varies between full 1. Mechanical and electrical failures are not ahead and full astern. In this case, the pitch always readily apparent. Therefore, the failed to full ahead. Consequently, although testing of propulsion and steering controls full astern was ordered, this only increased prior to port entry and after changing the power ahead on the starboard propeller. control positions is crucial. 4. Ships’ engineers often pride themselves 2. Machinery breakdowns have a knack of on fixing machinery when it goes wrong. occurring when least expected. When they However, a role that is equally important, happen close to dangers, accidents can is finding out why the machinery or frequently only be prevented by rapid equipment failed in the first place. This diagnoses and response. In this respect, goes a long way in preventing a similar breakdown drills not only improve system breakdown occurring in the future. knowledge among bridge teams, but they If required, technical advice can be sought also help to prepare for the unexpected. from shore superintendents, manufacturers and class.

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