MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 2/2018

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October 2018

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.gov.uk;

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If you wish to report an accident or incident please call our 24 hour reporting line 023 8023 2527

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The Branch fax number is 023 8023 2459 The email address is maib@dft.gov.uk

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

© Crown copyright 2018

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 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. Listen Carefully, I’ll Say This Only Once 4

2. No Alarm Bells 6

3. Brake Failure 8

4. Hot Water Pockets 10

5. Overflow in an Instant 12

6. What Was That? 14

7. From the Frying Pan Into the Fire 16

8. ‘Under’ Pressure 18

9. All the Right Notes – Just in the Wrong Order 20

10. Stuck in the Mud 22

11. Fast and Furious – a Descent into Danger 24

12. The Missing Link 26

13. Loose Lashings and Broken Bones 28

14. Gulp! Gulp! Who Removed the Plug? 30

15. Whoops, Wrong Way 31

PART 2 – FISHING VESSELS 34

16. One for the Road has a Fatal Consequence 36

17. Fothering… What’s That? 39

18. Too Cold to Swim 41

19. Lucky Escape After Capsize 43

20. Don’t Get in a Tangle 44

PART 3 – RECREATIONAL CRAFT 46

21. A Flip Too Far 48

22. The Cyclic Effect 50

23. Broken Gear, Broken Wrist 52

24. Carbon Monoxide – the Invisible Killer 54

APPENDICES 57

Investigations started in the period 1/03/18 to 31/08/18 57

Reports issued in 2018 58

Safety Bulletins issued during the period 1/03/18 to 31/08/18 59

Glossary of Terms and Abbreviations AB - Able Seaman LSMGO - Low Sulphur Marine Gas Oil ARPA - Automatic Radar Plotting Aid m - metre BNWAS - Bridge navigational watch alarm "Mayday" - The international distress signal system (spoken) C - Celsius MCA - Maritime and Coastguard Agency CCTV - Closed Circuit Television MES - Marine Evacuation System COSWP - Code of Safe Working Practices for nm - nautical mile Merchant Seamen OOW - Officer of the Watch CPR - Cardio-Pulmonary Resuscitation PFD - Personal Flotation Device ECDIS - Electronic Chart Display and RHIB - Rigid Hulled Inflatable Boat Information System RNLI - Royal National Lifeboat Institution ENC - Electronic Navigation Chart RYA - Royal Yachting Association ERV - Emergency Response Vehicle SOLAS - International Convention for the GRP - Glass Reinforced Plastic Safety of Life at Sea GPS - Global Positioning System VHF - Very High Frequency HSFO - High Sulphur Fuel Oil VTS - Vessel Traffic Services kts - knots VTSO - Vessel Traffic Services Officer LPG - Liquid Petroleum Gas

Introduction If you are reading this introduction it is likely that you are already one of the converted who ‘gets’ safety. However, as many of these articles show, not everyone does. So, when you have finished with this edition of the MAIB’s Safety Digest, could I ask you to pass it to someone you feel will genuinely benefit from reading these articles. If you are accessing this on-line, then send on the link: there is no limit to the number of people who can learn from the experiences of others. One team of people who definitely ‘get’ safety are this edition’s introduction writers. I am delighted that Sir Alan Massey, Sheryll Murray MP and Theo Stocker have agreed to write the introductions to the merchant, commercial fishing and recreational craft sections of this digest. All three have written from both their professional and own personal perspectives, and their words are very powerful. If you read nothing else in this issue, I would encourage you to read the section introductions. Anyone who knows me will already be aware that I like simplicity. There is seldom anything simple about a marine accident, but to my mind there are usually three recurring components: an underlying weakness or vulnerability in the system (which includes the people); a trigger event or additional stressor that exploits an existing weak spot to cause an accident; and the aftermath, or how it is dealt with. As I was reminded as I approached my first sea command, “it is not what happens that matters; it is how you deal with it”. Like so much in life, safety is about preparation, and doing things today instead of putting them off until tomorrow. Many of the underlying weaknesses that create the pre-conditions which allow an accident to happen involve matters that ought to have been addressed, but have been left unattended for one reason or another. Just this month another fishing vessel has been lost due to downflooding because leaking seals on a couple of through-deck hatches had not been replaced. However, what is striking about this edition is the number of cases where shortcuts and work-arounds have become part of normal business, with the result that essential safety barriers such as alarms and limits were not set, or were disabled or ignored. At the other end of the accident timeline is the aftermath: the crew’s ability to deal with an emergency situation. Anyone who has experienced a flood, fire, explosion, man overboard, or any other emergency will be determined not to let it happen to them again. They will make an effort to learn their ship’s systems and procedures, and how to locate and use the emergency equipment. They will also, often, be frustrated with those who see safety as an unnecessary and time consuming chore. It’s an old adage, but if you think safety is expensive, try having an accident! Be safe,

Andrew Moll (Interim) Chief Inspector of Marine Accidents

October 2018

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Part 1 – Merchant Vessels ‘Nothing happens by Yet accidents still do happen, and we know that accident’. Franklin human behaviours are most frequently at the D Roosevelt may root of them. The MCA is proud to have been have been talking one of the four commissioning bodies for the about politics when recent book, ‘Being Human in Safety-Critical he said those words, Organisations’. We did so because we believe but the adage works there is much more to be learned and understood for seafaring too. in that behavioural dimension if our maritime As you read these sector is to succeed in reducing its rate of fifteen, concise case avoidable accidents; an outcome that we would studies of marine surely all love to see. ‘accidents’, you will quickly spot the Learning that flows from the experiences of chain of judgments, decisions and events that others is an invaluable gift. I believe we could led to the unhappy outcome in each instance. do more to embed the lessons of hindsight None of them deliberate, for sure, yet almost into effective training, education and guidance all of them clearly having some human factor – underpinned by proportionate regulation, in the causation. Which means – bluntly – that where necessary, in order to improve foresight, if people had acted differently, these incidents situational awareness and the confident practice would in all probability never have happened. of good seamanship. Hindsight allows us to draw such conclusions. But what we can now see as fundamental errors So in your reading of this excellent little were, at the time, normal operational decisions – Digest, and your thinking about what might of the kind that you and I make, every single day. have broken the chain leading to each of these fifteen incidents, I would ask you to keep three In the MCA, as the UK government’s maritime simple questions in mind: would different rules or authority, we are constantly challenged to procedural guidance have helped?; would you have regulate less and educate more; to make new acted any differently in the circumstances?; will rules only where the risks are greatest; and – your learning from what happened have any effect where we can – to encourage safer behaviours on your own future behaviours? Perhaps the most by guidance rather than legislation. I completely powerful contribution to safety that this Digest support that approach and, for the most part, could make would be a resounding answer of it works extremely well. Even if in some cases, ‘yes!’ to at least that last question. more regulation eventually proves to be the most effective answer.

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SIR ALAN MASSEY CHIEF EXECUTIVE, UK MARITIME & COASTGUARD AGENCY

Since 2010, Sir Alan has been Chief Executive of the UK Maritime & Coastguard Agency: the UK’s maritime regulator, administrator of the British merchant fleet and seafarers, and maritime emergency responder. This appointment followed a career in the Royal Navy during which he commanded numerous major warships, including in combat operations, and learned a great deal about how things can go wrong at sea. During his time with the MCA, Alan has taken Her Majesty’s Coastguard through a complete overhaul of concept, technology and manning; revitalised the UK Ship Register to make it more business like and competitive; consolidated and modernised all airborne search and rescue in the UK and its waters; and transformed the Agency’s vessel survey and inspection capability. The MCA’s vision is to be the best maritime safety organisation in the world; and these multiple change programmes have sought to bring that vision closer to reality. Sir Alan will step down from his position in October this year.

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Listen Carefully, I’ll Say This Only Once Narrative A large bulk carrier was approaching a laden Reluctantly, the bulk carrier’s master altered oil tanker in a traffic lane of a traffic separation course to overtake the oil tanker on its port scheme. With a speed of 16kts, the bulk carrier side. Shortly afterwards, when the vessels were was the overtaking vessel, and as both vessels just 655m apart, the oil tanker’s master ordered were heading for a turn in the lane, the bulk an alteration to port to increase the sea room carrier’s master ordered the OOW to hail the between his and another vessel that he was other vessel to ascertain its intentions. overtaking. No check for sea room astern was made and the master was unaware that the Accordingly, the OOW, who was Chinese, overtaking bulk carrier was now on his own hailed the oil tanker. Although irritated by port quarter. the call the Indian master of the oil tanker responded. During the conversation the Indian The bulk carrier’s master was alarmed to see master agreed to allow the bulk carrier to the oil tanker alter to port across his bow at overtake on his starboard side. Unfortunately such close range. Unsure of what to do, and the Chinese OOW misunderstood, and thinking that he had been instructed to pass informed his own captain that the oil to port, the bulk carrier’s master made a series tanker would not allow a starboard pass. The of helm movements in a vain attempt to avoid master, who had not been listening to the a collision. However, due to the proximity of conversation, accepted the second officer’s the vessels (see figure) there was nothing that explanation. could be done to avoid the accident. Both vessels were severely damaged but there were no injuries and no pollution.

The Lessons

1. Communications should improve 2. Manoeuvring should only be carried out understanding; they should not muddy once you are fully aware of what is around the waters. In this case, the conversation you. Assumptions should not be made, was carried out in neither party’s native and checking sea room ahead and astern is language, and confusion arose when an not only good practice but it should also be assumed action was not verified. The use of common sense. standard marine communication protocol might have enabled the information to be 3. Good bridge team management is a vital passed in a clear manner. tool in any navigational situation. Ensure that every member of the team is aware of the plan, their role in it, and that they are empowered to monitor the actions of others in the team.

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Figure: Tracks of the vessels leading up to the collision

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No Alarm Bells Narrative A small bulk carrier grounded on a sandbank. About 2½ hours into the watch the vessel’s The vessel had been following a planned track speed suddenly and rapidly decreased. The in the ECDIS but the ECDIS alarms had OOW did not know why, and immediately been turned off. The ship remained aground for called the master and chief engineer. The 6 days and was refloated by salvors. OOW also ‘zoomed in’ on the ECDIS display. The chief mate and many of the crew were also The second officer had taken over the bridge woken by the change in the ship’s movement. watch from the master at midnight. The vessel When the master arrived on the bridge he was heading 146˚ in autopilot at 11kts, but immediately realised that the vessel was during the watch handover the master told aground, and put the engine telegraph to stop. the oncoming OOW to shorten the planned The grounding checklist was started and, as route by moving it further to the west. After soon as the master was sure there was no water the master retired to his cabin, the OOW ingress, he attempted to manoeuvre clear of amended the passage plan by ‘dragging and the shallows. But without success. The vessel dropping’ several waypoints on the ECDIS. remained aground until it was refloated by The route was checked visually but the results salvors 6 days later. of the automatic check route function were not inspected. The vessel’s heading was then Subsequent inspection of the ECDIS adjusted to follow the revised route. The OOW indicated that the system’s ‘safety frame’ or then settled into the watch accompanied by a ‘look ahead’ was inactive and that its audible lookout. Both were seated, with the OOW able alarm had been disabled. Consequently, no to monitor the ECDIS and the ARPA displays alarm was generated when the vessel passed (Figure 1). Traffic was light and the visibility over the safety contour (10m) (Figure 2). was good. It was not busy.

Echo sounder Data organiser ECDIS

ECDIS BNWAS Autopilot

Radar

VHF BNWAS reset

Figure 1: Bridge layout

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Figure 2: Reconstruction of ECDIS display (zoomed in and ‘all’)

The Lessons

1. In recent years, a number of groundings they are not already aware of. However, have resulted from revised passage plans in coastal and open waters, where focus not being checked thoroughly. Although on the effective monitoring of the ship’s changes to such plans are frequently position is generally reliant on the bridge made at short notice and less than ideal watchkeeper alone, the ECDIS alarms situations, the bypassing of the usual are potential lifesavers. Preventing checks and controls is fraught with danger. alarms from being an annoyance and a Shortcuts might be expedient, but