MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accidents No 2/2014

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This publication Further copies ofcan thisalso be found report on our website: are available from: www.maib.gov.uk Marine Accident Investigation Branch Mountbatten House Grosvenor Square Southampton October 2014 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 email address is maib@dft.gsi.gov.uk

Summaries (pre 1997), and Safety Digests are available online www.maib.gov.uk

© Crown copyright 2014

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. Ship That Went Bump in the Night 10

2. Lookout! Teamwork is Vital 13

3. Oil and Water Don’t Mix 15

4. ‘Weather’ or Not to Fit Storm Shutters – Don’t Let it Dampen Your Day 16

5. Look Out B(u)oy 18

6. No Time to Fall Asleep on the Job 20

7. Mustn’t Forget 23

8. ‘Fouled’ Lines of Communication - A Close Call 25

9. Manoeuvring on (or over) the Limit 27

10. Refrigerated Container Unit Fire - Are You Prepared? 30

11. Reversal of Fortune 31

12. FIRE - Oil and Water (Too Much of One, Too Little of the Other) 32

13. Snap - (keep) Back 34

14. Fire Danger - Don’t Fret, Take Action 36

15. Sit Down, Feet Up; There’s Nothing To Do (Apparently) 40

PART 2 - FISHING VESSELS 44

16. Rock Solid - The Perils of Distraction 46

17. Know Your Loading Limits 50

18. Tightening the Grip 52

19. Seeing is Believing 55

20. Engine Access Blocked, Vessel Lost 57

21. Surprised by the Unexpected, But Dressed to Survive 60

PART 3 - SMALL CRAFT 62

22. A Skipper’s Nightmare 64

23. Bang on Target 67

24. An Exhausting Time 71

25. Falling Into Difficulty 75

APPENDICES 77

Appendix A - Investigations started in the period 01/03/14 to 31/08/14 77

Appendix B - Reports issued in 2014 78

Appendix C - Safety Bulletins issued during the period 01/03/14 to 31/08/14 80

Glossary of Terms and Abbreviations

AB - Able Seaman MCR - Machinery Control Room AFFF - Aqueous Film Forming Foam MGN - Marine Guidance Note AIS - Automatic Identification System MGO - Marine Gas Oil ALB - All Weather Lifeboat mph - miles per hour ASD - Azimuth Stern Drive OOW - Officer of the Watch BA - Breathing Apparatus PFD - Personal Flotation Device BNWAS - Bridge Navigation Watch Alarm System PPE - Personal Protective Equipment C - Celsius RIB - Rigid Inflatable Boat CCTV - Closed Circuit Television RNLI - Royal National Lifeboat Institution CO - Carbon Monoxide Ro-Ro - Roll on, Roll off COLREGS - International Regulations for the RYA - Royal Yachting Association Prevention of Collisions at Sea SOLAS - International Convention for the 1972 (as amended) Safety of Life at Sea CPP - Controllable Pitch Propellers SOP - Standard Operating Procedure ECS - Electronic Chart System STCW Code - International Convention on FRC - Fast Rescue Craft Standards of Training, Certification GPS - Global Positioning System and Watchkeeping for Seafarers 1978, as amended GRP - Glass Reinforced Plastic (STCW Convention) ISM Code - International Safety Management Code UHF - Ultra High Frequency kts - knots UMS - Unmanned Machinery Space m - metre VHF - Very High Frequency “Mayday” - The international distress signal VTS - Vessel Traffic Services (spoken) MCA - Maritime and Coastguard Agency

Introduction On the 7th August, the MAIB commemorated its 25th anniversary. As I write this introduction, I cannot help but ponder the dreadful maritime disaster that provided the rationale for the establishment of this organisation.

On the 6th March 1987, the cross channel ferry Herald of Free Enterprise capsized soon after leaving the port of Zebrugge. 193 passengers and crew lost their lives. The immediate cause of the accident was that the bow doors of the vessel had been left open as it left the harbour, allowing sea water to enter the main vehicle deck in large quantities. The resulting free surface effect destroyed the vessel’s stability and the vessel capsized very quickly. The events leading to the capsize were a mix of complacency, poor shipboard procedures and inadequate leadership, both afloat and ashore. One could argue that the disaster proved to be a watershed for maritime safety, leading to not only the formation of the MAIB, but also greater emphasis on the direct responsibility shore managers have for safety, and which culminated in the industry’s adoption of the ISM Code in 1998.

Whatever the ultimate benefits such dreadful accidents may have in shaping and improving international maritime legislation, I cannot avoid reflecting on the human cost. Even today, the surviving next of kin and loved ones of the 193 who lost their lives, and the others who were injured or mentally scarred during the accident are still trying to cope with the effects and consequences of that fateful day. I was particularly struck by a recent magazine article in which the daughter of one of the victims of the Herald of Free Enterprise disaster described how she was still grieving the loss of her father today.

One of the consequences of a significant anniversary is that you become quite reflective about past achievements. Here are a few facts and figures which will probably not feature in any pub quiz but are none the less quite fascinating: Since its formation in 1989, the MAIB has: • raised reports on over 40,000 marine accidents and incidents • conducted 1500 investigations • published nearly 500 investigation reports, and • made more than 3000 safety recommendations.

Looking ahead, an objective for this Branch should be to work even harder to influence and improve maritime safety such that seafarers, the travelling public and their friends and families no longer have to suffer the consequences of avoidable accidents and there is no longer a need for accident investigation organisations like the MAIB - sadly, intuition gained from more than 40 years in this industry tells me this is an unlikely goal and leads me to expect an invitation to commemorate the MAIB’s 50th anniversary, should I live that long.

I am indebted to John Garner, Robert Greenwood and Mark Ranson for their insightful introductions to the three sections of this edition of the Safety Digest. I hope you will find the following articles, and the safety lessons they contain useful and instructive.

Until next time, keep safe.

Steve Clinch Chief Inspector of Marine Accidents October 2014

MAIB Safety Digest 2/2014 7

Part 1 - Merchant Vessels P&O Ferries studies the requirement to maintain a proper Holdings Ltd look out by all means available in accordance has long been with COLREGS Rule 5 when a vessel is respected the underway, has not been fully discharged. The basic world over and has fundamental principle of maintaining a safe look a long tradition for out at all times cannot be under estimated. Even excellence dating with the support of Bridge Navigation Watch back to 1837. The Alarm Systems (BNWAS) (which although Company was fitted were found not to be switched on) in case founded by Brodie a watch keeper becomes incapacitated for any McGhie Willcox reason. Unfortunately, the signs of fatigue have and Arthur not been recognised in these cases and supporting Anderson, then known as “Peninsular Steam arrangements such as a seafarer posted as a look Navigation Company”, and was awarded the out during the hours of darkness or the use of Government contract to carry the mail from UK additional/alternative seamen have not been taken to Spain and Portugal. into account when clearly they could have been.

As a ferry company which proudly bears the Apart from the above technical requirements P&O name, the day to day business of P&O of operating ships I also notice trends of Ferries Holdings Ltd brings the Company into complacency and a lack of situational awareness contact with many government organisations. leading to a lack of Bridge/Marine Resource As such, it is recognised that the role of the Management in almost two thirds of the case MAIB, of improving safety at sea through the studies within this section. Being responsible promulgation of lessons learned from marine for a large ferry fleet ex UK Ports conducting accidents, is of the highest level of importance. Circa 56,000 voyages per annum these are areas that we particularly focus on within P&O P&O Ferries Holdings Ltd works with regulators Ferries Holdings Ltd. Plying the same route of four Flag States, various Port States, the for a number of years can lead to complacency, European Commission and the International something that all ferry operators need to guard Maritime Organization (IMO) to further against. In my own company we introduced enhance the Safety and Environmental Standards Maritime Resource Management (MRM) in which are already in place. However this MAIB November 2009 following research we conducted Safety Digest brings together a range of case with other transport industries such as the studies which is very rich in data and provides Aircraft industry. learning opportunities for us all. Through this Digest the MAIB portray the very ethos of the I met with the Chief Pilot of British Airways International Safety Management (ISM) code who conduct Crew Resource Management which is, to “seek best practice”, and provide an (CRM) training which is mandatory in the ethos of “continuous improvement” and as such I airline industry. Airline pilots are trained to recommend this Digest to you all. communicate effectively and accept feedback. Co-pilots are taught to speak out when they In reviewing the cases presented within this see their senior pilot and colleagues about to Part 1 - The Merchant Vessels section, I have make a mistake. This is known as “challenge and noticed a number of themes which I would response”. like to share with you. These include technical matters such that in almost a third of these case

8 MAIB Safety Digest 2/2014

The Maritime Resource Management (MRM) Maritime Resource Management is a training training we have introduced into our fleet is a programme that builds upon well-established further development of the original SAS bridge facts as well as the latest research within the resource management training first delivered in human factors area. An important purpose about 1993. MRM is the use and coordination of the course is to establish safe attitudes and of all skills, knowledge experience/expertise and provide a set of “tools” that the participants will resources available to the crew to accomplish be able to take with them to use in their working or achieve the established goals of safety and environment such as on board ship or in their efficiency. shore office. Another objective is to increase knowledge about human performance and − MRM aims to change attitudes and limitations with the purpose of creating a better behaviours - not technical skills, hence understanding of what can lead humans into a simulators are not utilised in this training. lack of situational awareness and complacency. In − MRM includes the understanding of the summary, MRM training further develops and importance of good management and improves the “Safety Culture” within a company. team work and the willingness to change behaviours. The value and benefits of Resource Management − Importantly, Engineers and shore training have been recognised by the 2012 based Fleet personnel are included amendments to the STCW Convention in with the Deck Officers and Captains Manila. These amendments give a five year on MRM training courses. period during which officers need to be trained in Human Element, Leadership and Management The use of common terminology is emphasised (HELM) techniques. At P&O Ferries Holdings and MRM training aims to improve coordination, Ltd we welcome this development having already communications and team work. commenced this journey through the introduction of MRM, which I recommend to you all.

John Garner P & O FERRIES HOLDINGS LTD

John Garner is Fleet Director of P&O Ferries Holdings Ltd which provides ferry services to Tourist and Business customers through the deployment of 20 Ro-Ro passenger and high speed craft from UK ports. John joined P&O Ferries in November 2004 and is responsible for all ferry operations, charter- ing and new building as well as being a member of the Divisional Board. John is well known at the Chamber of Shipping having initially been Chairman of the Passenger Issues Committee and in 2010 becoming the Chairman of the Safety and Environment Committee. John is also well known through Interferry being a member of the European Committee and current Chairman of the Steering Group.

Prior to joining P&O Ferries Holdings Ltd John held senior management positions both in the public and private sectors. Between 1999 and 2004, John served initially as Deputy Director of Operations and then as Director of Standards at the UK Maritime Coast Guard Agency and prior to that John was responsible for the Stena UK Fleet including the integration of Stena HSS vessels into the UK Opera- tions. For the first 23 years of John’s career he served at sea in all ranks from Cadet to Senior Master and accrued 10 years’ experience as Master of Ro-Ro Passenger Ships and High Speed Craft.

John is a Fellow of the Nautical Institute, a Fellow of the Institute of Marine Engineers, Scientists and Technology, and a Chartered Marine Technologist.

MAIB Safety Digest 2/2014 9

Ship That Went Bump in the Night Narrative The chief mate relieved the master at midnight. The master instructed him to contact the pilot Shortly after 0300 a dry cargo vessel ran 2 hours before the vessel was due to arrive aground on a rocky coastline at almost 12kts. at the pilot station, and to call all hands 30 All the off duty crew were awakened by the minutes before the pilot boarded. At that time, impact, but when the master arrived on the the vessel was due to arrive at the pilot station bridge he found the chief mate asleep on the in about 3 hours. The vessel was being steered bridge chair and the vessel still in gear and by autopilot and, although a bridge navigation driving ahead. watch alarm system (BNWAS) was fitted, it was not switched on. Additionally, neither radar Two days previously, the vessel had berthed guard zones nor echo sounder shallow water in the afternoon ready to discharge her cargo alarms were set. the following morning. The chief mate would normally have been asleep in the early evening The chief mate forgot to radio the pilot station prior to taking his 0000-0600 watch, but as instructed and, like the master, he sent his instead he went ashore during this time and lookout below at 0130 to rest. Soon after the went to bed when he would normally have been lookout went below, the chief mate fell asleep on watch. in the quiet, cosy bridge. Despite there being a significant impact when, at 0300, the vessel hit At 0700 the following morning the chief mate the coast, when roused by the master the chief and two ABs were on deck to oversee the cargo mate was disorientated and shocked to find the discharge. At 1500 the vessel