MARINE ACCIDENT INVESTIGATION BRANCH MAIB Marine Accident Investigation Branch Safety Digest Lessons from Marine Accident Reports 2/2012 is an

SAFETY DIGEST Lessons from Marine Accidents No 2/2012

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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 2012

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 2012 – Regulation 5:

“The sole objective of the investigation of a safety investigation into an accident under these Regulations shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of such 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. Fire and Explosion Detaches Poop Deck - an Amazing Escape 10

2. Fatal Towing Accident - Are You Properly Prepared? 13

3. Stop! 16

4. Just One Kick Should Do It 20

5. Another Mooring Fatality 21

6. Beach Party 24

7. The Importance of Good Bridge Watchkeeping 26

8. Familiarity Breeds a Dent 29

9. Vehicle Unloading - the Need for Close Control 33

10. It’s Good to Talk 35

11. The Silent Killer 37

12. Assumptions and Misplaced Confidence 40

13. A Risky Climb 43

14. Watchkeeping Standards 46

15. Fast Rescue Craft Recovery Drama 48

PART 2 - FISHING VESSELS 50

16. Self-Shooting Needs Self-Discipline 52

17. When Late Detection is Just Too Late 54

18. Mind Your Back 56

19. Keep it Simple, Keep it Safe 58

20. Rock Steady - an Abrupt End to a Good Day’s Fishing 60

21. Five Go Fishing 64

22. Who Will Help Me If Something Goes Wrong? 66

PART 3 - SMALL CRAFT 68

23. Are We There Yet? 70

24. Racing to Disaster 72

25. Boom Bang a …! 76

APPENDICES 97

Appendix A - Investigations started in the period 01/03/12 to 31/08/12 79

Appendix B - Reports issued in 2012 80

Appendix C - Safety flyers issued in 2012 81

Glossary of Terms and Abbreviations

AB - Able seaman m - metre AIS - Automatic Identification System “Mayday” - The international distress signal (spoken) ARPA - Automatic Radar Plotting Aid MCA - Maritime and Coastguard Agency C - Celsius MGN - Marine Guidance Note Cable - 0.1 nautical mile nm - Nautical Mile COLREGS - International Regulations for Preventing Collisions at Sea 1972 OOW - Officer of the Watch (as amended) PFD - Personal Flotation Device CPA - Closest Point of Approach PLB - Personal Locator Beacon CPP - Controllable Pitch Propeller PPE - Personal Protective Equipment DGPS - Differential Global Positioning System RHIB - Rigid Hulled Inflatable Boat DSC - Digital Selective Calling Ro-Ro - Roll on, Roll off ECDIS - Electronic Chart Display and SAR - Search and Rescue Information System SMS - Safety Management System EPIRB - Emergency Position Indicating VDR - Voyage Data Recorder Radio Beacon VHF - Very High Frequency FRC - Fast Rescue Craft VTS - Vessel Traffic Services GPS - Global Positioning System kt - knot

Introduction This edition of the Safety Digest contains the usual eclectic mix of accidents. However, Cases 7, 14, 17, 19 and 20 all highlight disturbingly common themes - very poor watchkeeping standards combined with a disregard for the requirements of the COLREGS. The obligation to keep an effective lookout at sea is fundamental to safe navigation as is the need to adhere to the rule of the road. Failure to comply with either should be unthinkable for any responsible mariner.

Equally unfathomable is the mindset of the crew involved in the accident described in Case 6 whose drunken antics led to a cargo vessel proceeding with an unmanned bridge, across busy shipping lanes, before grounding on a mercifully benign stretch of coast. Excessive alcohol consumption and navigation is a toxic mix which should not be tolerated. The vast majority of professional mariners would find the circumstances that led to the accident described in this case barely credible but, sadly, this is not the only accident of this type that has been reported to the MAIB. If such behaviour is to be eradicated, ship owners need to be more proactive in ensuring drug and alcohol policies are effective and properly policed.

I am indebted to Roger Barker, Albert Sutherland MBE and Richard Falk for their contributions. Well known and respected in their sectors of the maritime industry, they have freely provided their time and sagacity to introduce the relevant sections of this report. All three have impressive CVs which I won’t labour here (a summary of each is appended to their respective contributions). I simply urge you to carefully read their introductions and take on board the messages these contain. Albert’s account of the circumstances of a narrow escape he experienced when he first started his fishing career in his father’s yawl, fifty years ago is particularly sobering - Albert was lucky that he was recovered from the water relatively unharmed. Sadly, Cases 16 and 22 demonstrate that this type of accident still happens today but often with less happy outcomes.

Until next time, keep safe.

Steve Clinch Chief Inspector of Marine Accidents October 2012

MAIB Safety Digest 02/2012 7

Part 1 - Merchant Vessels Avoid over familiarity and complacency It is interesting generic and type specific courses, but we must to me, but remain cautious to avoid complacency and unfortunately not over familiarisation, to the extent that we surprising, that in forget the importance of our core skills. almost all of the reports in this As with the “old” Decca fix, the underlying section of the data is still the same - digital soundings, for digest there is an example, displayed on the digital chart, are still element within dependent on the source information, but how the cause of many of our colleagues consult the source data familiarity and diagram before making a change of route? complacency. Bridge resourcing is tight, as is overall vessel In assessing manning, and we know that where there is a modern vessel corner to be smoothed there will be those who operation and Bridge team practices I believe take advantage without considering the risk. the dangers of both must be carefully considered. Passage planning comes to mind. Early It is right and proper that we take account and electronic planning looked really good: make appropriate use of modern technology • Quick and easy plotting of the passage available to us but do we fully assess the benefits • Automatic checking of clearance depth and possible dangers, and do some of the • Shortest route developments lead directly to complacency? • Easy storage for subsequent voyages • Multiple bridge displays, and much more, Use and reliance on Electronic positioning systems is an example. But: I clearly remember when we moved from • The first time the Master and Bridge team the trusted “Decca” ruler, and the hyperbolic assess the chart may be when the vessel patterns on the nautical chart, to using the arrives at that location, and this only a “up-to-date” digital read out of Latitude and snapshot that is available on the screen in use. Longitude. There were those who mistakenly • Are the latest navigation warnings plotted thought how accurate our 3 decimal place as required? position had now become - NO, still the same • Have the vessel parameters changed? underlying data just plotted differently, in fact Draught / trim / manoeuvring characteristics less accurate plotting if the local errors were etc ignored. • Familiarity of the bridge team with the area / route may be different to when the original Things have moved along apace and the voyage was planned. widespread use of the electronic nautical chart, ECDIS, ECS and wholly automated I return to the highlighting of over familiarisation bridge systems are possibly increasing risks and complacency - all of the problems that in vessel operation, and complacency. I have mentioned with the use of technology can be accommodated for provided we take The move towards mandatory carriage of that important step back and assess where ECDIS is in many ways a good thing together an error or problem may lie. with the requirements for training both with

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I found the description of the two mooring Complacency, familiarisation, and perhaps over accidents to be particularly thought provoking. confidence, spreads to the Master, Chief and I doubt that I will be alone in considering how others in charge aboard the vessel. I believe, close I have been to similar situations in the however, that those “in charge” ashore must past. also consider their requirements. The pressure on a Master to submit a routine departure Unfortunately in both cases visibility for report, for example, may well take him away personnel was a contributory factor. I am sure from his control of the vessel earlier than he that once again familiarisation and complacency perhaps should. may be a significant factor in many mooring accidents or near misses. We must all remain careful that proportionate emphasis is placed on all tasks to ensure the Vessels and crews on “Short Sea” schedules, requirement for a safe operation is maintained. where mooring stations are a daily event, may A departure report to the charterers sent half be particularly exposed to these dangers. The an hour late, is a far better outcome than a nature of these “very” routine operations is grounding, or worse. such that the frequency of the event by no means reduces the possible risks of an accident. The very clear narrative and concise advice given by the MAIB in the lessons from each Day in, day out, the operation will go without a of the accidents are excellent and should hitch, and a significant danger is that as a result encourage us to examine our own operations of this familiarisation with the task, the number closely, ensuring our seafarers remain safe, of personnel will be cut. I totally agree with the and shores remain free from environmental requirement for a “toolbox talk” and this must damage. include a realistic assessment of the number of personnel required for the operation to be completed safely?

Roger Barker

Roger joined the Merchant Navy at 16 as a Deck Cadet with P&O. Early years were spent with the P&O Company. On gaining his 2nd Mates certificate he transferred to the United Baltic Corporation, part of the Andrew Weir Group, sailing mostly on the short sea Baltic service but closely involved with new building programmes. Navigation in ice was a skill that he developed and particularly enjoyed. Roger continued to sail in the Andrew Weir/UBC fleet gaining a Master Mariners Certificate and HND in Nautical Science and served as Master aboard four of the company’s vessels, latterly the RoRos Baltic Eagle and Baltic Eider. He came ashore to take on the role of Marine Superintendent and was closely involved with bringing into service six strategic RoRo vessels. This enabled him to develop his close interest in integrated bridge systems and electronic charting. After 28 years with Andrew Weir he left in July 2005 to join Trinity House as Navigation (Examiner) Manager. He took over as Director of Navigation in May 2009 at which time he also became an Elder Brother of the Corporation and trustee of the two Trinity House Charities, the TH Corporate Charity and the TH Maritime Charity. He is a Member of the Nautical Institute. Married to Sue, with 2 grown up children, he lives in Rowlands Castle.

MAIB Safety Digest 02/2012 9

Fire and Explosion Detaches Poop Deck - an Amazing Escape Narrative and through a doorway which had been left open. As the fire moved into the steering gear A self-discharging bulk carrier was alongside a compartment, there was a severe localised quarry loading a cargo of granite stones. At the detonation as a stowage of “ship’s-use” same time, hotwork repairs were being carried chemicals, including oxidisers, interacted out on the carcass of the cargo discharge with each other. chute. Both the repairs and cargo operations were proceeding well when a fire was It is likely that this caused the poop deck to discovered on the vertical cargo discharging lift, allowing air to mix with the compartment’s conveyor belt. hydrocarbon-rich atmosphere, created by the release of oils stowed there and from Although the crew tackled the fire from within the various hydraulic systems. The resultant the hold conveyor tunnels, it quickly spread explosion tore off the entire poop deck, fully through the conveyor tower and into the exposing the steering gear compartment accommodation area (Figure 1). The engine (Figure 2), and landing it on the funnel deck room was also fully involved as the heat (Figure 3). Fortunately, there were only minor transferred through the adjacent bulkhead smoke inhalation injuries.

Figure 1: Fireball erupting from the vertical conveyor belt tower

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Figure 2: Exposed steering gear

Figure 3: Poop deck relocated on the compartment funnel deck

MAIB Safety Digest 02/2012 11

The fire was most likely to have been caused and none was mandatory. In addition, the by hotwork repair debris falling from the cargo drill schedule did not specify that fire drills hopper at the top of the tower into the side were to be carried out in the cargo handling curtain of the conveyor belt. The hotwork area despite the high fire risk relating to the repair had been authorised by the ship’s conveyor belts and potential difficulties in manager, but other hotwork relating to the fighting a fire in the area. regular repair to the high tensile steel hull, carried out at the same time, had not. There It is not unusual for ship’s-use chemicals were violations of the company’s hotwork to be stowed in steering gear compartments. procedures, including not keeping a constant In this case, alkalis, acids and oxidisers were fire watch, no dedicated fire watchman in close proximity to each other and to a being nominated and work being routinely wide variety of oils. There was also evidence undertaken in unauthorised areas. of other corrosive and flammable chemicals stowed in machinery spaces, passageways and The crew made a good effort in tackling workshops, increasing the risk of fire spread. the fire but their work was hampered by containment difficulties. The cargo handling To further complicate the matter radioactive space was very large and not designed with any isotopes were fitted to the cargo hopper method of division. The door into the engine for monitoring cargo “back-ups”. Despite room workshop was hinged and required not being used for 10 years and being in an bolting to be securely shut; it was poorly extremely poor condition, they were still designed for fire containment purposes. active. Risk assessments did not recognise the Other doors and vents were left open, making risk of exposure to radiation by gamma rays, the fire-fighting effort very difficult. This was and the SMS did not provide any guidance on especially so as there was no fixed fire-fighting inspections or safety precautions to be taken. system fitted in the cargo-handling space,

The Lessons likely. Crew