MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 2/2020

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October 2020

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 functionally, 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 publications@maib.gov.uk;

• By telephone on 023 8039 5500; or

• By post at: MAIB, First 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.gov.uk

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

© Crown copyright 2020

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. Foggy Manoeuvres 4

2. No Space to Play 6

3. Another Weighted Heaving Line 7

4. Knock-On Effect 8

5. ECDIS is not an Alarm Clock 10

6. Fender or Offender? 12

7. A Splash of Danger 14

8. An Arctic Chill 16

9. An Unwanted Hot Shower 18

10. Hot News – TV on Fire 19

11. Wet, But Safe 20

12. A Shocking Tale 22

13. Don’t be Backwards About Going Forwards 23

14. Too Close for Comfort 25

15. A Bumpy Turn 27

16. A Cracking Building Site 29

PART 2 - FISHING VESSELS 30

17. When Working Alone, Keep an Eye on Yourself 32

18. Wrong Spares, Expensive Breakdown 34

19. Pulled Overboard 35

20. Stability, Stability, Stability… 37

21. Get the Anchor Ready 39

22. Know Your Systems 41

PART 3 - RECREATIONAL CRAFT 44

23. Mind the Gear Lever 44

24. Back to Basics 46

25. Ring the Helicopter 48

APPENDICES 50

Investigations started in the period 01/03/2020 to 31/08/2020 50

Reports issued in 2020 51

Safety Bulletins issued during the period 01/03/2020 to 31/08/2020 52

Glossary of Terms and Abbreviations AB - Able Seaman "Mayday" - The international distress signal (spoken) AIS - Automatic Information System MCA - Maritime and Coastguard Agency ARPA - Automatic Radar Plotting Aid MGO - Marine Gas Oil BNWAS - Bridge Navigational Watch Alarm System OOW - Officer of the Watch C - Celsius PEC - Personal Exemption Certificate CO - Chief Officer PLB - Personal Locator Beacon ECDIS - Electronic Chart Display and PPE - Personal Protective Equipment Information System RIB - Rigid Inflatable Boat EPIRB - Emergency Position Indicating Radio Ro-Ro - Roll on, Roll off Beacon VHF - Very High Frequency HFO - Heavy Fuel Oil VTS - Vessel Traffic Service kg - kilogram kts - knots m - metre

Introduction Welcome to the MAIB’s second Safety Digest of 2020. This has been a challenging year for us all, and some sectors of the marine industry have been very hard hit by the fallout from the COVID-19 pandemic. It therefore pains me to say that overall this year there seems to be very little change in the overall rate at which accidents and incidents are occurring. The need to improve safety is therefore very much with us, and I hope the articles in this digest provide you with the inspiration to review at least some aspects of your operation to see how safety can be improved. We can all learn from others’ misfortunes. I would like to thank Mike Drake (Director Marine Operations, P&O Cruises, Australia) and Sean Friday (Inspector, MAIB) for the introductions they have written to the merchant vessel and fishing vessel sections of this edition. Their contributions speak for themselves, and I encourage you to read them. In preparing to write my introduction I was struck by Mike’s comment that we need to understand the mind-set of the people doing the job before we improve their performance, and Sean’s frustration that investigators so often see similar issues repeated time and time again in tragic accidents. Some years ago I was discussing a conflict with an army intelligence officer, who said to me, “they are losing, but they are not yet ready to stop fighting”. His words made me think about people’s resistance to or, conversely, willingness to change their approach. After a serious accident has occurred we often find that organisations can be conflicted about what to do next. On the one hand, they do not want a re-occurrence; on the other hand, they worry that change could be seen as an admission of guilt or liability. To this I would suggest two approaches. The first, is to learn from others’ misfortunes before you have an accident yourself (see above). The other, is to consider that what went before was not necessarily ‘wrong’, but it could be ‘more right’. Seeing change in this light can help make it a positive activity. This edition’s Recreational Craft section does not have its own introduction as, unfortunately, the contributor had to back out at the last minute. It therefore falls to me to make some observations in lieu of a dedicated section introduction. The articles for the Recreational Craft section were chosen some weeks ago, and it is a coincidence that in this issue they are all about high-speed craft accidents. Unfortunately, it is likely that the spring 2021 Safety Digest will be similar, due to the high incidence of fatal and serious injury accidents involving RIBs, personal water craft (jetskis) and other high speed craft that have occurred this summer. It would not be right to read too much into this spike. Marine accidents are like buses: you can wait a long time for one and then a number arrive together. However, it could also be that the COVID-19 lockdown earlier this year prevented many leisure boaters from starting the season slowly, cautiously going afloat in late spring to refresh old skills before the good weather arrives. Whatever the reason, I would encourage all leisure boaters to take advantage of the winter months to refresh their knowledge, carry out the inevitable maintenance tasks, and to plan how best to start next year’s boating seasons. To misquote Louis Pasteur, “Fortune favours the prepared mind”. Keep safe

Andrew Moll Chief Inspector of Marine Accidents

October 2020

MAIB Safety Digest 2/2020 1

Part 1 - Merchant Vessels The Maritime One of the curious aspects of accident analysis Industry is one of is that it is often not obvious how the human a number of safety behaviour at the centre of accidents is any critical sectors along different from that on days when no accident with others such as occurs. This means we must look more at what aviation, chemical, influences people to do the things they do at the nuclear and rail time they do. etc. Operating ships is a complex Improving/enhancing human performance and safety critical in everyday operations requires a greater process. Accidents understanding of the mind sets of people doing within safety critical their jobs & creating the right support structure sectors and the around them. Mind set analysis is a systematic science connected with underlying contributions process for drawing out and understanding the has evolved dramatically over the last 30 years. decisions taken at the time of an incident, what The whole idea of an “accident” is relatively alternatives were available and the learning modern; the most common viewpoint in recent implications for an organisation. Simply adding times is that of a failure of risk management. more rules and procedures is often of limited value; cause and effect chain of events evoke There has been a rapid growth in our knowledge interest but are not very useful in a complex of human behaviour. An appreciation and system. We need a different approach. understanding of human factors is now a primary tool; an effective understanding of human Concluding that staff are complacent is a poor behaviour in normal and safety critical contexts explanation for accidents and does not lead to is a key component of improving safety at sea. any useful way forward. Split second operational The underlying drivers of human behaviour have decisions evaluated, dissected and analysed evolved over millions of years, will not disappear retrospectively for long periods can sometimes and should be utilised as a tool to minimise result in conclusions and recommendations that future accidents. Humans are the source of contribute little to preventing a reoccurrence of a system safety as opposed to weak links or sources similar incident in future. of failure – but to assist with this we must move away from “cause and effect” towards “drivers A new approach to understanding how and and improvers” of performance and safety. why complex systems go wrong is “resilience Instead of a root cause we need to discover how engineering”. Resilience is the key to safe all aspects of the system and its dynamic parts operational performance at all levels- from front combined to produce a negative outcome, noting line operators to board level directors. Humans that the same system had managed to avoid this are crucial to safe performance in complex previously. systems. Our strengths are vulnerable and our weaknesses need to be supported. A great source We now understand much better how humans of information on organisational resilience is perceive and make sense of the World; how provided in the book “Being Human in safety we make decisions; what really motivates us critical organisations”. Witten specifically with at work; how we are affected by technological, the maritime industry in mind I commend this environmental and organisational factors; how publication to everyone with any operational we communicate and work co-operatively with connection or influence in the maritime domain. each other. Areas covered within the publication include

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how to practically deal with fatigue, stress, to solve the traffic problems? What was their motivation, social capital and boredom – all in understanding of the situation and their intended the context of preventing incidents. goal?

Progressive shipping companies, organisations Case 5 – why did many of the bridge practices & on-board management that reward those (ECDIS planning & alarm, BNWAS switched who report problems and seek to implement fair off , AB leaving the bridge etc.) make sense at minded accountability, and are clear about the the time to the officer of the watch? distinction between accountability and blame, will be better placed to avoid major incidents. Answering this question and then identifying In establishing an effective safety culture, it is what to change next time will go a long way small, steady changes that will end up creating a to preventing re-occurrence. However, those huge difference. Experience shows that there is necessary changes may extend beyond that a cumulative effect; a good idea from the crew, if particular ship itself. acted upon, encourages others to offer up their own. Seniors and crew should bounce ideas off A Shipping Company & the on-board teams each other. Leadership, both ship and ashore answering these and similar questions will be is most important to drive improvements and able to determine why a course of action made reduce crew injuries, and major accidents. This sense to those on-board at the time- and what is an important part of resilience engineering influencing factors might be changed to help which requires feedback and true attention. minimise the chance of reoccurrence in future. Training, fatigue, rosters, procedures, equipment In reading some of the cases a couple of and/or ergonomics, manning levels, ship questions spring to mind, which are: schedules, how large is the gap between “work as imagined” and “work as done” and what can be Case 1 – why did it make sense to use AIS rather done to narrow the gap. than ARPA? What was the captain and officer of the watch’s frame of mind? To what extent did they believe they had the knowledge and skills

MIKE DRAKE, DIRECTOR MARINE OPERATIONS & DESIGNATED PERSON ASHORE P&O CRUISES, AUSTRALIA Mike is Head of Marine Operations & Designated Person Ashore (DPA) for P&O Cruises, Australia (part of Carnival Corporation & PLC) based in Sydney. He is a Master Mariner with 35 years’ experience and a fellow of the Nautical Institute. As Director Marine Operations he is responsible for providing leadership, strategic planning and direction in the field of Marine Operations & acting as the Company “Designated Person Ashore” as per the International Safety Management Code ; the person based ashore whose influence and responsibilities should significantly affect the development and implementation of a safety culture within the company. The role requires strong engagement with all regulatory bodies concerned with safety; AMSA, UK Marine & Coastguard Agency ( Flag State) , Hydrographic Services, ATSB, MAIB, Great Barrier Reef Marine Park Authority and various state regulators , Port Authorities, Harbour Masters and Pilots etc. In addition to developments within Carnival Corporation Mike has been very involved in navigational developments within the Oceania Region; in particular the challenges of navigational infrastructure in SW Pacific & SE Asia. P&O Cruises, Australia have a commitment to continuous improvement in the maritime domain. In addition to using the World Class Carnival Corporation training centre, C Smart, recent company initiatives include a Safety Culture project, Port Pilotage Navigational project, “Near miss” programme, & formal navigation and engine room assessment programmes.

MAIB Safety Digest 2/2020 3

Foggy Manoeuvres Narrative Due to severely restricted visibility in thick On the bridge of the gas carrier, the master fog and darkness, berthing and unberthing was conning and was aware of the container of vessels had been suspended at a large vessel ahead from radar and AIS data. As the commercial port that was located near a busy range reduced, the master made an alteration traffic separation scheme. of course to starboard to avoid the container vessel. Realising that this alteration of course An inbound container vessel had been had not delivered the anticipated separation, instructed by the port authority to wait the gas carrier’s master applied full starboard outside the port until conditions improved rudder; however, this was insufficient to avoid (Figure 1). At the same time, a gas carrier collision. Figure 2 shows the damage to the was proceeding at about 13kts towards a boat container vessel’s port quarter. transfer rendezvous position near the port’s entrance. In the same vicinity, there were eight other vessels heading west towards the traffic separation scheme (Figure 1).

The eastbound tanker

The inbound gas carrier

The drifting container vessel, waiting for a pilot

1nm

Figure 1: Extract of the container vessel’s radar picture 4 minutes prior to collision

4 MAIB Safety Digest 2/2020

Figure 2: Detail of damage to the container vessel’s port quarter The Lessons

1. Collision avoidance decisions must be of neither vessel’s bridge team following made using the most accurate information these Regulations. When the shipping available. The gas carrier’s master’s situation starts to deteriorate and risk of understanding of the situation was collision exists, bridge watchkeepers must primarily based on the container vessel’s take all necessary measures to ensure safe AIS data, which suggested that it was passing. ‘underway using engine’ and heading south-west. This perception resulted 3. Reducing speed is a very effective method in the gas carrier’s master’s decision to of allowing more time to assess a situation, alter course to starboard to avoid the especially in restricted visibility. In this container vessel by passing its stern, even case, the gas carrier was pressing ahead though it was not visible. However, the towards its rendezvous position at its AIS