MARINE ACCIDENT INVESTIGATION BRANCH MAIB Marine Accident Investigation Branch Safety Digest Lessons from Marine Accident Reports 2/2013 is an

SAFETY DIGEST Lessons from Marine Accidents No 2/2013

is an

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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 2013

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. Alcohol-assisted Collision 10

2. No Air, No Clutch, No CPP, No Brakes 13

3. To Turn or Not to Turn? 15

4. Ready or Not - I’m Crossing 18

5. Mist-er Oil Filter 20

6. Port Helm, Starboard Turn 23

7. Honestly Chief, It Just Fell Off 25

8. Don’t Spoil the Party 28

9. Ramming Home the Point - Distraction Causes Accidents 30

10. Know Your Limits 35

11. The Cost of Poor Planning 37

12. Ragtime Blues 39

13. Air Cooled, You Say? 42

14. It’s Good to Talk … 45

15. Blown Out of Proportion 48

PART 2 - FISHING VESSELS 52

16. Too Good a Catch 54

17. Where’s That Light? 56

18. Lifejackets do Work 58

19. Keep Your Feet on the Deck 59

20. Too Hot to Handle 62

21. Ready? Aye, Ready 65

22. Liferafts Save Lives 66

PART 3 - SMALL CRAFT 68

23. Double Trouble 70

24. High Adrenalin Sport Needs Careful Thought 72

25. Sliding Canopy Injures Boat Hirer 74

APPENDICES 77

Appendix A - Investigations started in the period 01/03/13 to 31/08/13 77

Appendix B - Reports issued in 2013 78

Appendix C - Safety Bulletins issued during the period 01/03/13 to 31/08/13 79

Glossary of Terms and Abbreviations

AIS - Automatic Identification System kg - kilogram C - Celsius m - metre CO2 - Carbon Dioxide “Mayday” - The international distress signal COLREGS - International Regulations for the (spoken) Prevention of Collisions at Sea 1972 MCA - Maritime and Coastguard Agency (as amended) MGN - Marine Guidance Note COSWP - Code of Safe Working Practices for Merchant Seamen MOB - Man Overboard CPP - Controllable Pitch Propeller OMD - Oil Mist Detector DSC - Digital Selective Calling OOW - Officer of the Watch ECR - Engine Control Room PFD - Personal Flotation Device EPIRB - Emergency Position Indicating Radio Beacon RIB - Rigid Inflatable Boat

FRC - Fast Rescue Craft Ro-Ro - Roll on, Roll off

GM - Metacentric Height SAR - Search and Rescue

TSS - Traffic Separation Scheme GZ - The righting lever that acts on a vessel to restore equilibrium when VHF - Very High Frequency inclined by an external force VTS - Vessel Traffic Services HSC - High Speed Catamaran

Introduction In reviewing the merchant vessel section of this edition of the Safety Digest I was struck by the number of cases where communications (or rather the lack of effective communication between departments and individuals) have been causal. We have perhaps become used to reading about cases where the inability of the deck department to share information has led to accidents (Cases 14 and 15). However, engine room staff can also sometimes be guilty of not appreciating the wider consequences of a developing problem. Cases 2 and 3 provide examples of what can happen when there is a failure to communicate, either between the engine room and the bridge, or within the engine room team itself.

Proper planning is integral to effective communication when executing a voyage or conducting other potentially hazardous operations. When developing a plan, the prudent mariner should always be alert to the possibility that changes to the prevailing circumstances may require it to be kept under review and/or contingencies developed. By asking yourself “what if?” and “what are the risks?” at every stage you are more likely to be able to anticipate, and prevent potential threats to the safety of everyone concerned. For example, tidal conditions may alter (Case 11) or be unexpectedly strong (Case 6); the traffic situation when approaching an alteration of course might require the plan to be adjusted (Case 4). Ultimately, blind adherence to a plan that is flawed or inflexible can be as dangerous as having no plan at all (Cases 10 and 13).

The importance of planning and anticipation is again highlighted in the fishing vessel section (Cases 17 and 21) while Cases 18, 19 and 20 identify the need for fishermen to conduct realistic safety drills on board their vessels. Other perennial issues, such as inadequate testing of alarms, the need to wear personal flotation devices when working on deck, and the challenges faced by fishermen when trying to recover colleagues who have fallen overboard, all feature in this section.

In the small craft section, I make no apology for the graphic photo of an injury sustained by a member of the public (Case 25). It serves as a reminder that hire companies need to ensure that their customers are provided with thorough briefings (including demonstrations of the operation of any bespoke or unusual equipment) before handing over their craft to someone who may have little or no experience of boating.

The potential consequence of not using a kill cord is demonstrated in Case 23. Sadly, the recent tragic accident that befell a young family while manoeuvring a RHIB at speed in the Camel Estuary provided a more harrowing example of why kill cords must be used when fitted. This accident prompted the publication of MAIB Safety Bulletin 1/2013 which is included at Appendix C. Since the accident, a lot of work has been done by organisations such as the RYA and the RNLI to promote the use of kill cords. If your boat is fitted with this device please, please make sure the cord is always securely attached to the driver whenever the engine is switched on.

Until next time, keep safe

Steve Clinch Chief Inspector of Marine Accidents October 2013

MAIB Safety Digest 2/2013 7

Part 1 - Merchant Vessels The famous historian Livy once wrote

“To err is human indeed it is the cause of most of our misery. Invariably though it is to the Gods that we look for remedy”

How true, although It can sometimes be made much worse as insurers in because persistent rule violators often assume, today’s world we somewhat misguidedly, that nobody else will might refine it a violate the rules, at least not at the same time! bit to read (The boy racer in his sports car overtaking on a bend never considers there may be another “Human Error is boy racer doing a similar thing on the other the cause of most side of the bend!) of our misery. Invariably though Violating safe working procedures is not just it is to the P&I a question of recklessness or carelessness Clubs that we by those at the coal face. Factors leading to look for reimbursement” deliberate non compliance extend well beyond the psychology of the individual in This is why we must applaud and support direct contact with working hazards. They efforts like this of the MAIB to highlight and include organisational issues (latent failures) raise awareness of current issues in our industry. such as: We can’t manage what we can’t measure, so it is imperative that hard facts such as these are • The nature of the workplace recorded and made available for industry to act • The quality of tools and equipment on so as to help prevent future accidents and • Whether or not supervisors or managers reduce claims. turn a “blind eye” in order to get the job done In the following incidents it can be seen that whilst humans “err” they also “violate”, • The quality of the rules, regulations we as insurers see this, on a daily basis in the and procedures claims we handle. The important distinction • The organisation’s overall safety culture between the two being that each have different or lack of it. mental origins, occur at different levels of the organisation, require different counter Violations are usually deliberate, but can also measures and have different consequences. be unintended or even unknowing. They can Everyone in an organisation, from members of also be mistaken in that deliberate violations the Board to those at the coal face, bears some may bring about consequences other than responsibility for the commission of violations. those intended, as at Chernobyl. In that case, It therefore follows that ALL employees have a out of seven unsafe acts leading up to the part to play in minimising their occurrence, explosion six were a combination of a rule not just those on the vessel. violation and an error. Here was a sad and remarkable case in which a group of well Assuming that a safe operating procedure is motivated and exceedingly expert operators well founded, any deviation will bring a violator destroyed an elderly but relatively well defended into an area of increased risk and danger. The reactor without the assistance of any technical violation itself may not be damaging but the failures. act of violating takes the violator into regions in which subsequent errors are much more likely to have bad outcomes. 8 MAIB Safety Digest 2/2013

As insurers we frequently see incidents caused Were human errors/violations the cause of by what we call “Routine violations” often any of the following incidents? Few of us in the defined by the phrase - “we do it like this all marine industry are experts on human nature, the time and nobody notices” “Optimising least of all us as insurers. I wonder if we put violations” corner cutting, i.e. following ourselves in some of the following situations the path of least resistance. “Situational and ask ourselves honestly what would we violations” standard problems that are not have done, would we have violated. I wonder, covered in the procedures i.e. “we can’t do perhaps Mark Twain was right, none of us is this any other way”. “Exceptional violations” perfect !!!! unforeseen and undefined situations i.e. a crew man entering an enclosed space to help rescue “Man is a creature made at the end of the a collapsed colleague, gut impulse frequently week when God was tired” stronger than dictates of training and common sense. Mark Twain

Karl Lumbers

Karl Lumbers is the Risk Management Director for Thomas Miller P&I Ltd, managers of the UK P&I Club, one of the world’s largest liability insurers, insuring over 200 million tonnes of owned and chartered blue water shipping. Karl is a Master Mariner having served at sea with P&O until the early 80’s when he came ashore to join London based marine consultants Cleghorn Wilton & Associates. In 1985 after running their Dubai office, he returned to London to join Thomas Miller P&I Ltd managers of the UK P&I Club where he is now a member of their Global Management Team responsible for monitoring the quality of the ships in the Club, analysis of the claims they produce and the surveyors/consultants used in investigating those claims. He is also responsible for the risk management work carried out by the Club in trying to assist Members in reducing their claims.

Karl is a Fellow and past Council Member of the Nautical Institute, a member of the IACS Advisory Committee, Lloyds Register General and Classing committees, American Bureau of Shipping and Korean Register of Shipping European committees and a member of the Honourable Company of Shipwrights.

MAIB Safety Digest 2/2013 9

Alcohol-assisted Collision Narrative The cargo vessel’s master was alone on the bridge as the vessel approached the fairway A small outbound general cargo vessel and a buoy. On the ferry, the master had temporarily large inbound ferry collided near the fairway left the bridge, leaving the chief officer (who buoy that marked the seaward limit of a port. was also a pilotage exemption certificate holder Fortunately, there were no resulting injuries or for the port) with the con. The third officer pollution and both vessels managed to proceed and a helmsman were also in attendance. into port under their own power. However, the cargo vessel’s bow was extensively damaged As the ferry approached the fairway buoy, the (Figure 1) and the collision caused a large chief officer was content to close the cargo gash in the ferry’s port side (Figure 2). vessel because, in his experience, vessels departing the port routinely altered course It was shortly after sunset, the weather was to starboard after passing the fairway buoy. fine and the visibility was good. Each vessel had operational radar, each had contacted the The cargo vessel left the fairway buoy to port. port’s VTS at the required reporting points, However, instead of then altering course to and there was no other traffic in the vicinity. starboard, her master chose to alter course to port, which put the cargo vessel on a collision course with the ferry.

Figure 1: Damage sustained to the general cargo vessel

10 MAIB Safety Digest 2/2013

Bow section from general cargo vessel

Figure 2: Damage sustained to the ferry

The VTS operator had called the cargo vessel Once the vessels were alongside, local on VHF radio and had questioned the master’s police officers boarded each of them and intentions. On receiving confirmation from the breathalysed the deck officers. The cargo master that he was altering course to port, the vessel’s master was found to be more than VTS operator then called the ferry, informing three times over the legal limit for alcohol. the chief officer that the ferry was standing into He was later convicted for breaching the danger with the cargo vessel, and requesting Railways and Transport Safety Act 2003 and him to contact the cargo vessel directly. sentenced to 1 year’s imprisonment.

The chief officer followed the VTS operator’s advice and tried to make contact with the cargo vessel. Meanwhile, the third officer, who had seen the cargo vessel altering course to port, informed the chief officer of the fact and repeatedly advised him of the danger of collision. The chief officer then ordered hard to starboard and called the master back to the bridge. However, this action was too late to prevent the vessels colliding.

MAIB Safety Digest 2/2013 11

The Lessons indicates that he did not appreciate the time available in which he had to act before 1. Don’t drink and drive! It is totally collision became inevitable. How well do unacceptable to be in charge of a navigational you know your own vessel’s manoeuvring watch while intoxicated. In this case, the characteristics? Would you know when cargo vessel’s master received a prison to act? sentence for his reckless behaviour. A further contributing factor is likely to 2. The ferry’s chief officer assumed that the have been the chief officer’s distraction in cargo vessel would alter