MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 2/2019

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October 2019

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:

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

© Crown copyright 2019

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. More Haste Less Speed 4

2. A Soft Landing 5

3. Wrong Place, Wrong Time 7

4. There’s None so Blind as Those Who Do Not Look 9

5. Working in Isolation 11

6. Astern Demanded, Ahead Delivered 12

7. Did Not Know We Had a Trap Door 13

8. Anything Can Happen in the Next Half Hour… 14

9. Give ‘em Enough Rope… 16

10. Delicate Balancing Act 18

11. Self-discharging CO2 20

12. Another Big Ship in a Tight Space 22

13. When the Forecast is Spot On 24

14. A Fall From Grace 26

PART 2 - FISHING VESSELS 28

15. Deathly Entanglement 30

16. All Caught Up 32

17. Swift Action Prevents Spread of Fire 34

18. A Winning Rollover 35

19. Doing it Right When it Goes Wrong 37

20. Lifejackets Save Lives 39

21. One in the Eye 41

PART 3 - RECREATIONAL CRAFT 42

22. Are You Safely Clipped On? 44

23. Splash ‘n’ Dash 46

24. An Unexpected Swim 48

25. The Tragic Cost of Entering a Flooding Vessel 50

APPENDICES 53

Investigations started in the period 1/03/19 to 31/08/19 53

Reports issued in 2019 54

Safety Bulletins issued during the period 1/03/19 to 31/08/19 55

Glossary of Terms and Abbreviations AB - Able Seaman HSE - Health and Safety Executive AC - Alternating current ILO - International Labour Organization AIS - Automatic Identification System hp - horsepower ARPA - Automatic Radar Plotting Aid kt - knot C - Celsius m - metre CCTV - Closed Circuit Television "Mayday" - The international distress signal (spoken) cm - centimetre MCA - Maritime and Coastguard Agency CO2 - Carbon Dioxide MOB - Man Overboard COLREGS - International Regulations for the Prevention of Collisions at Sea 1972 OOW - Officer of the Watch (as amended) PA - Public address CPR - Cardio-Pulmonary Resuscitation PPE - Personal Protective Equipment DC - Direct current RIB - Rigid Inflatable Boat DSC - Digital Selective Calling RNLI - Royal National Lifeboat Institution ECDIS - Electronic Chart Display and Ro-Ro - Roll on, Roll off Information System RYA - Royal Yachting Association ECR - Engine Control Room UHF - Ultra High Frequency ECS - Electronic Chart System V - Volt EPIRB - Emergency Position Indicating Radio Beacon VHF - Very High Frequency GPS - Global Positioning System

Introduction As always, I will start my opening comments by thanking Hans Hederström, David Dickens and Keith Colwell for the introductions they have written for the three main sections of this edition of the MAIB’s Safety Digest. We ask guest introduction writers to make insightful comments from their own perspective and to pass on pearls of wisdom. They have not let us down. Do please take time to read their words which are, as ever, very powerful. Throughout my seagoing career, and especially since joining the MAIB, it has been true to say that ‘every day has been a school day’. There is always something new to learn. I would therefore like to thank Hans for introducing me to his tactful but effective approach to raising concerns when things are not going according to plan. You will read more about his acronym PACE – Probe, Alert, Challenge, Emergency – over the page, but it seems to provide a simple method of escalating expressions of concern, and I will be adding it to my toolkit. Of course, it does require all members of the team to understand the plan beforehand – that shared mental model – so they can spot when things are starting to go awry, and this edition contains a number of examples where this has been the case. More than half the articles in this edition’s Fishing Section recount stories when the actions of the crew were significant, either in resolving the situation or reducing its consequences. One of my former captains once told me, “it’s not what happens, it’s how you deal with it that matters”. His point was that you cannot always prevent bad things happening, but dealing with them effectively can help prevent a drama from becoming a crisis. The fire-fighting tale (Case 17) and abandonment story (Case 19) provide good examples of when drills and training before the event significantly improved the crew’s ability to deal with an emergency. Is the message about wearing lifejackets when on deck getting through? I hope so. The deckhands in Cases 18 and 20 would probably have perished had they not been wearing lifejackets when they went overboard. While both these cases had a positive outcome, they also help make the point that surviving the initial immersion and remaining on the surface to be rescued is only the first part of the story. A man overboard is not safe until he or she is back on board. Hopefully, you already review and practise your manoverboard recovery procedures but, if you do not, now would be a good time to start. Some years ago, I was training to become a powerboat instructor. Our teacher told us that it was important to assess the abilities of the students right at the start of the course, and that a good way to do this was during the opening session to invite everyone to introduce themselves and say a bit about their boating experience. Those who were completely new to powerboating would probably say so, but others might claim extensive prior experience. The difficulty was knowing how much value to place on an individual’s self-account. The teacher suggested one simple method for assessing prior experience that was, simply, to quietly invite anyone who might perhaps be overselling themselves to coil up a discarded rope. His theory was that a good seaman would instinctively coil up and secure unused lines. In doing so, they would not just be tidying up. They would be checking the condition of the line as it passed through their hands, ensuring it was kink free, and that it was ready for immediate use when required. His ethos was that professionalism and safety go hand-in-hand. I think he was right.

Andrew Moll Chief Inspector of Marine Accidents

October 2019

MAIB Safety Digest 2/2019 1

Part 1 - Merchant Vessels Intervention - an Important Tool for Safety What Captain Larjo had put in place was an It was a cold early version of BRM with the aim to avoid January evening in that error by one person escalating into negative 1983 in Stockholm consequences. He had realized that all actions in when I for the first time critical operations must be cross checked time was welcomed and for that reason the operators must have a on the bridge of a shared mental model based on an agreed passage Silja Line ferry by plan. the master, Captain After my meeting with Captain Larjo I Kari Larjo. This presented my passage plan on every pilotage I ferry was trading was assigned to until I resigned as a senior pilot the challenging in 2000. archipelago between Reading the cases 1, 2, and 12, it appears to me Stockholm and that there are at least two things missing for Turku 364 days and nights per year sometimes a different outcome. First of all, nobody knew in dense fog, thick ice and strong winds. When I when to intervene/challenge as the ship started introduced myself as Gothenburg pilot, Captain to run into an undesired state. Secondly, this Larjo, in his typical short cut Finnish manner lack of intervention was probably due to the said “A pilot without a passage plan is not a absence of a detailed passage plan with clear pilot.” The passage plan was for this legendary margins for when to intervene. To make it clear Captain one of the corner stones for successful when to intervene the passage plan should be navigation in the archipelago providing all team planned with a track surrounded by a corridor members on the bridge with a reference tool. or navigable area to be used under normal Another corner stone for this captain was conditions. Outside the planned navigable area the bridge design and layout of controls and there should be a margin of reserve to the NO instruments, which he had arranged similar to an GO area. This margin of reserve should be fully airline cockpit with two navigators sitting side navigable waters, which provides flexibility to be by side in front. They operated their own set of used in abnormal situations. The speed should radars and between them there was a centerpiece be planned in a range of values for each leg or containing all control functions. The navigator section, e.g. 4 – 6 kn, making it easy for anybody on the left side, the company line pilot, normally to raise their voice if the speed is outside the had the con and the other navigator, the officer stated range. When the passage plan is discussed of the watch, was tasked with supporting and during the team briefing and the master - pilot cross checking the person conning. The Captain exchange the set values should be highlighted in himself had his own radar just behind those order to clarify the importance to intervene in two navigators in order to get a good overview case of a deviation. of the operation. On this bridge the traditional Traditionally ship handling has been and, by hierarchical way of working had been replaced some people, still are considered as a one-person by a coordinated team approach. “Ideally”, operation. However, accident and incident Captain Larjo said, “for optimum safety those reports often show that incidents are the result two navigators should have the same level of of one person’s unsafe control actions not being competence.” cross checked resulting in a negative outcome. It “So how can you get two navigators with the is therefore essential to realise that BRM should same level of competence?” I asked. be practised at all times the ship is underway, “One of the most important tasks for a Captain from berth to berth. It is the responsibility of the is to train and coach the officers, if possible, Captain to establish coordinated teamwork based all the way up to my own level” the Captain on an agreed plan and effective communication replied. “We don’t expect to get experienced and during all critical operations to mitigate risks. well-trained officers directly from the nautical Effective communication by the person conning colleges, the college is just the starting point of a the vessel is to verbalise his/her intentions, the lifelong maritime learning.” reason for this and the expected outcome, we

2 MAIB Safety Digest 2/2019

can call it “thinking aloud.” This is one way to the final step and declare emergency. If you of creating and maintaining team situational are the captain, you can just say “I take over!” if awareness. you are an officer when a pilot is conning you can If for some reason the person conning, be it an say “I’m calling the captain.” officer, captain or pilot, seems to lose situational The purpose of BRM is to avoid incidents and awareness, the ship is about to deviate from accidents by a variation in performance of one agreed values, it is time for the team to intervene. person and the above tools are in my experience Clear and unambiguous margins for the planned some of the most helpful ones to meet the navigation area and for the speed range makes objectives of BRM. it so much easier to intervene. Intervention My first meeting with Captain Larjo was can start with a probing question like: “What’s followed by many more, he became my role your intention?” If there is no reaction from model. I also had the privilege to work with him the person conning it is time to alert by stating: in 1991 – 1993, as we were both members of the “The speed is now 9 knots, our planned speed development group converting the Scandinavian is 6 – 8 knots!” This would normally trigger Airlines CRM course into a maritime version, some reaction, if not, it is time to challenge: “I which is still used under different names such as suggest to slow down to bring the speed within BRM, MRM and MCRM. the agreed range!” It is important to note that probing, alerting and challenging is based on the In 1995 Captain Larjo was awarded the Gold outcome, not what the person conning should do. medal by the Royal Institute of Navigation Bridge team members should refrain from giving for his work related to the development of the direct advice or orders as this will mean a ‘de NACOS Integrated Navigation Systems. facto’ but not formal taking over of the conn. If I was very sad to learn that Captain Kari Larjo those three steps do not bring about the desired died at home in Turku in August 2018. result or an adequate explanation it is time to go

HANS HEDERSTRÖM, FNI Captain Hans Hederström holds a Master Mariners (class 1) licence, a Marine Engineers Certificate from the Maritime College in Gothenburg, Sweden. He has also studied Human Factors and Adult teaching at the Vast college in Sweden. Captain Hederström has sailed in all ranks up to and including Master. In 1978 he continued his career by becoming a Harbour Pilot in the Port of Gothenburg, Sweden. In 2001 Captain Hederström became the Director of Star Cruises Ship Simulator Centre, in Port Klang, Malaysia. In 2005 he moved back to Sweden, where he led the specification and establishment of a new Full Mission simulator at Chalmers University of Technology, Gothenburg, Sweden. In 2008 Captain Hederström moved to the Netherlands with the task to build and establish the CSMART simulator training facility. He retired as managing director at CSMART in December 2018 and is now working part time as an independent consultant to the maritime industry.

MAIB Safety Digest 2/2019 3

More Haste Less Speed Narrative A fully laden 363m container ship was arriving made a series of engine and helm orders in an in port. When the pilot arrived on the bridge attempt to avoid making contact with another he requested full ahead. The master pilot large container ship that was berthed nearby. exchange was brief and there was no agreed However, the inbound container vessel was plan for the inbound passage. The berthing not under full control and made heavy contact manoeuvre involved turning into a basin and with the quay at a speed of over 5kts. then swinging the vessel off the berth, but this was not discussed by the pilot; additionally, The