MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accidents No 2/2016

is an

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October 2016

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: MAIB, 1st Floor, Spring Place, 105 Commercial Road, Southampton, SO15 1GH

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

Safety Digests are available online www.gov.uk/government/collections/maib-safety-digests

© Crown copyright 2016

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

INTRODUCTION 1

PART 1 – MERCHANT VESSELS 2

1. When Stability is Taken for Granted 4

2. A Clutch of Problems Leads to a Fire 5

3. ‘Normal’ But No Longer Safe 7

4. Hoping For The Best 9

5. Chain Reaction 11

6. Not The Way to Make a Splash 13

7. Lookout, By All Available Means 15

8. Uncontrolled Fire, Unexpected Fireball 18

9. Proper Prior Planning Prevents Groundings 21

10. A (not so) Funny Turn 23

11. There is No ‘I’ in Team, But There is in ‘Grounding’ 25

12. First-Hand Experience – Literally 28

13. Knot a Good Time for Teaching 30

14. Be Careful Where You Step 31

15. Assume at Your Peril 33

16. Total Constructive Loss was Totally Unnecessary 36

17. Don’t be a Fall Guy 39

PART 2 – FISHING VESSELS 40

18. Think What’s Different – Think What If ? 42

19. Catch Fish – Not Waves 45

20. A Nasty Bight 47

21. Who’s Catching Who? 49

22. Unplanned Winter Swims – Are You Prepared? 50

PART 2 – RECREATIONAL CRAFT 52

23. Ocean Passage – Ready or Not? 54

24. Tragic Speedboat Ride 55

25. A Case of Bad Gas 57

APPENDICES 59

Investigations started in the period 1/03/16 to 31/08/16 59

Reports issued in 2016 60

Safety Bulletins issued during the period 01/03/16 to 31/08/16 61

Glossary of Terms and Abbreviations AB - Able seaman kg - kilogram AIS - Automatic Identification System m - metre ARPA - Automatic Radar Plotting Aid “Mayday” - The international distress signal (spoken) BA - Breathing Apparatus MCA - Maritime and Coastguard Agency BNWAS - Bridge Navigational Watch Alarm System MGN - Marine Guidance Note C - Celsius nm - nautical mile CO2 - Carbon Dioxide OOW - Officer of the Watch COLREGS - International Regulations for the OS - Ordinary Seaman Prevention of Collisions at Sea, 1972 PBA - Personal Buoyancy Aid (as amended) PFD - Personal Flotation Device CPA - Closest Point of Approach PLB - Personal Locator Beacon DSC - Digital Selective Calling RA - Risk Assessment ECS - Electronic Chart System SAR - Search and Rescue EPIRB - Emergency Position Indicating Radio Beacon SOG - Speed Over The Ground FRC - Fast Rescue Craft SOLAS - International Convention for the Safety of Life at Sea GNSS - Global Navigation Satellite System VHF - Very High Frequency GRP - Glass Reinforced Plastic VTS - Vessel Traffic Services gt - gross tonnage VTSO - Vessel Traffic Services Officer

Introduction It is customary for identify a disconnect between the safety culture that the three sections shore-based managers believe (or perhaps hope) is in of the MAIB place within their fleet and what is really happening Safety Digest to on board. Cases 1, 11 and 16 are good examples be introduced by of this. A strong safety culture is not something respected members that will appear by magic, it takes hard work and of our industry. commitment – particularly from senior managers This edition is no ashore and afloat. Similarly, safety management exception and I systems need to evolve over time if they are to am very grateful remain credible. If the procedures on board your for the wise vessel are not working, don’t just use convenient comments provided work arounds to get tasks done – flag up the problem by John Rose, and make sure they are changed or amended in a Keith MacRae and Duncan Wells respectively in controlled way that ensures the system retains its their introductions to the merchant, fishing and credibility and continues to reflect the company’s recreational craft sections. However, I would like to best practice requirements. particularly thank Bari Khan, currently an MCA A depressing fact, taken from many investigations surveyor, for his contribution (see Case 12). Bari was that the MAIB has conducted into accidents which serving as an engineer on board a vessel when he was have resulted in the crew going into the sea, is that involved in an accident, which resulted in the tip of PFDs are not being routinely worn by fishermen one of his fingers being severed. His candid account when working on the open deck (see Cases 18 and about the circumstances that caused the accident is a 22). This is despite a concerted campaign by many graphic reminder that accidents can (and do) happen different stakeholders to encourage this. So here is to anyone if we allow our emotions to override our another fact: if you fall, or are taken overboard from training. your fishing vessel, based on the typical year round The procedures and safe working systems that temperatures in UK waters, MAIB statistics indicate lie at the core of all safety management systems you will most likely die from the effects of cold water are there for a reason – invariably mariners have shock within 15 minutes if you are not wearing a been hurt, ships and/or their cargoes have been PFD. Think about how your loss will affect your damaged or lost, or the environment harmed. MAIB family and loved ones. investigations into marine accidents consistently In closing, I make a plea to all fishermen reading identify cases where mariners chose to ignore the this Safety Digest: please, please, always ensure you instructions and guidance contained in companies’ wear a PFD when working on the open deck of your safety management systems. The root cause for this fishing vessel. is often complex, but MAIB investigators regularly Until next time, keep safe.

Steve Clinch Chief Inspector of Marine Accidents

October 2016

MAIB Safety Digest 2/2016 1

Part 1 – Merchant Vessels The MAIB After the grounding the Master did not use has once again the emergency checklist available to him pulled together and took the ship full of passengers to sea. A an excellent great deal of time and experience goes into summary of preparing emergency checklists. Their use incidents, some provides a ready-made strategy to ensure that of which it has mistakes and omissions in the heat of the investigated. It moment do not make a bad situation worse. is in a format that is both Navigation and collision avoidance aside, the easy to read and OOW also needs to be available to respond to identify the to emergencies such as fire, machinery lessons learned. This is a most commendable breakdown and man overboard. In one case effort by the MAIB, and I hope the readers reported in this edition, the OOW was not of this latest digest of reports will put the on the bridge for 20 minutes – the OOW is lessons learnt into good practice. required to maintain a continuous watch on the Bridge for good reasons! As usual we can see that there are a wide range of contributory factors that result in The Maritime and Coastguard Agency maritime accidents and incidents. However (MCA) has recently issued Marine Guidance the one contributory factor occurring Note MGN 520(M)1. It contains the “Deadly consistently throughout the reports is the Dozen” which describes the most common Human Element – people’s ability and people based factors in maritime safety, with capability to deal effectively and safely with suggested mitigating actions. Readers are the complexity, difficulty, pressures and recommended to read the MGN 520(M) in workload of their daily tasks, not only in conjunction with the findings included in this emergency situations, but also during routine digest. operations. CHIRP aims to seek out root causes for near Crewmembers and the ship’s superintendents misses, identify the lessons learned and to should ask themselves, “What is normal on consider how best this information can be board our ships?” In one case it was to sail used to prevent reoccurrence elsewhere in the on a routine basis with inadequate stability! maritime industry, whilst not apportioning In others there appeared to be no risk blame to any company or individual assessments undertaken and an absence of a whatsoever. Near miss reports that have been management of change process. received by CHIRP over the last 12 years were analysed using the “Deadly Dozen” Seafarers now undertake mandatory training human factors definitions and the top five in resource management, leadership and failings were identified. These accounted team working skills at an operational level, for 75% of the causal factors in maritime then leadership and managerial skills at incidents, namely failures in: situation management levels. So why do we still read awareness, alerting others, communication, about Masters demonstrating rule breaking complacency, and the safety culture behaviours and equally, not being challenged onboard. All of these items can be seen to by the Officers? The Master of a passenger have surfaced in the full incident reports ship that went aground had not amended investigated by the MAIB. People need to the passage plan when a new destination learn more from near misses and hazardous for anchoring was required – subsequently occurrence reporting. without a plan to work with, the Bridge Team was unable to adequately assist the Master. 1 MGN due to be published in November 2016. 2 MAIB Safety Digest 2/2016

Reading these reports from the comfort of Ask yourself what safety margins you are an armchair or as a dedicated professional working to and are these sufficient when at your place of work, some of the casual taking into account the exposure to potential factors in this digest of reports appear to be risks? Please remember the lessons learned unbelievable in this modern age of advanced here will not only apply to seafarers but also technology and training, but they did happen to people at all levels and positions within and unless the lessons learned are consistently the overall wider maritime system. Let us all applied, as advised in this and previous try harder to send all seafarers safely home to MAIB publications, we shall be reading their family and loved ones at the end of each similar reports in the future. and every trip.

CAPTAIN JOHN ROSE MNM, EXC, LLM, FNI DIRECTOR (MARITIME): CHIRP (CONFIDENTIAL HAZARDOUS INCIDENT REPORTING PROGRAMME)

John’s experience in the Shipping and Maritime industries spans over 45 years. His seagoing career was with Shell, he is qualified as an Extra Master Mariner and subsequently awarded the Royal Society of Arts Silver Medal for highest marks in the examinations. His decision to work ashore started as Harbour Master/Chief Executive to the Harbour Commissioners for Yarmouth Isle of Wight, then later returning to Shell Shipping where he reached the position of General Manager for global shipping. In the last three years as CHIRP’s Director, the maritime programme has expanded to include involvement with seafarers from 46 countries and a following of 200,000 readers of their publications. In 2015 John was awarded the Merchant Navy Medal for his work in the detection of hazardous incidents at sea. John is a Master of Laws (Southampton), Fellow of the Nautical Institute and a Younger Brother of Trinity House.

MAIB Safety Digest 2/2016 3

When Stability is Taken for Granted Narrative A 50,000gt vehicle carrier had completed The list caused cargo to shift, resulting in loading and was proceeding to sea. As the ship breaches to the ship’s hull and consequent turned to port to follow the navigable channel flooding. However, all crew were safely around a sandbank, it developed a significant evacuated and there was no resulting pollution. starboard list. The list increased to in excess of 40º, causing the ship to lose steerage and propulsion and to drift onto the sandbank.

The Lessons

1. The ship heeled heavily to starboard while 2. It would have been possible to increase turning as a result of having departed port stability by loading additional ballast low with inadequate stability. The following down in the ship, but the shortcoming in factors contributed to its lack of stability: stability had not been identified prior to the ship’s departure. • The ship’s normal operating cycle had been changed, but the cargo Assessing a ship has adequate stability loading plan had not been adjusted. for its intended voyage on completion of Consequently, the upper vehicle decks cargo operations and before it sails is a were full while the lower vehicle decks fundamental principle of seamanship that were lightly loaded. must not be neglected.

• The change in operating cycle meant 3. A loading computer is an effective and that the ship was low on bunker fuel oil, useful tool for calculating a ship’s stability. which was stored low down in the ship. However, its output can only be as accurate as the information entered into it. • The estimated weight of many items of loaded cargo used in stability The value of establishing before departure calculations was less than their actual that a ship has a suitable margin of stability weight. for the intended voyage had eroded over time such that unsafe practices relating to • No allowance was made for the vertical cargo loading and ballast monitoring had centre of gravity of the loaded cargo become the norm. being above deck level. What is the norm on your ship? • The distribution of ballast on board the ship was not accurately known and bore no resemblance to reality.

4 MAIB Safety Digest 2/2016

A Clutch of Problems Leads to a Fire Narrative A cargo ship was proceeding on passage in a The engine room fans were started, the controlled traffic lane when the duty engineer generators run up and electrical power noted that one of the main engine clutches restored. The starboard engine was then was overheating and generating copious started, and the vessel commenced weighing amounts of smoke. He contacted the bridge anchor. However, before the anchor had and requested an immediate shutdown of the been fully recovered, the chief engineer affected engine. The engine was shut down, reported electrical short-circuiting from the the fire alarm sounded and the ship’s crew clutch controls, and smoke emanating from mustered at their emergency stations. the cables. The engine room was again shut down and monitored until it had sufficiently As there was a significant amount of smoke cooled and was clear of smoke. A request for coming from the engine room, a fire-fighting assistance was made and the ship was later team wearing BA was organised to investigate. towed to a safe haven for repairs to be carried While the BA team was investigating, the out. master prepared to deploy the anchor. A technical inspection of the port engine The BA team reported back that the clutch clutch found that an oil seal on the hydraulic area was extremely hot, with electrical control clutch control unit had failed. This had allowed wires melting, producing sparks and thick hydraulic oil to pass into the clutch housing, smoke. Local cooling was attempted. However, resulting in excessive pressure