SAFETY DIGEST Lessons from Marine Accident Reports

Featuring introductions by Simon Graves | Duncan Murt | Andy Murray

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 an 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 that has been determined up to the time of issue.

This information is published to inform the merchant and fishing industries, the recreational 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 If you wish to report an accident or incident available. The articles do not assign fault or blame nor please call our 24-hour reporting line: do they determine liability. The lessons often extend +44 (0)23 8023 2527 beyond the events of the incidents themselves to ensure The telephone number for general use is: +44 (0)23 8039 5500 the maximum value can be achieved. The branch email address is: maib@dft.gov.uk Extracts can be published without specific permission providing the source is duly acknowledged. This publication and previous safety digests are available online: www.gov.uk/government/collections/maib-safety-digests The editor, Clare Hughes, welcomes any comments or suggestions regarding this issue. To see how the General Data Protection Regulation (GDPR) affects the If you do not currently subscribe to the safety digest way we use and store your data go to: or other MAIB publications and would like to find out www.gov.uk/government/organisations/marine-accident-investigation- more, please get in touch with us: branch/about/personal-information-charter

▶ By email to publications@maib.gov.uk; © Crown copyright 2023 ▶ By telephone on +44 (0)23 8039 5500; or This publication, excluding any logos, may be reproduced free of charge in any format or medium for research, private study or for internal circulation ▶ By post to MAIB, First Floor, Spring Place, within an organisation. This is subject to it being reproduced accurately and not used in a misleading context. The material must be acknowledged as 105 Commercial Road, Southampton, SO15 1GH Crown copyright and the title of the publication specified.

GLOSSARY OF TERMS AND ABBREVIATIONS

CHIEF INSPECTOR’S INTRODUCTION 1 INDEX

M MERCHANT VESSELS 2 1. A stone's throw 4

2. You nearly had your chips! 6

3. Unforeseen fall 7

F 4. Flash, bang, wallop! 8 FISHING VESSELS 30 5. Let down by the ladder 10 17. Say hello, wave goodbye 32 6. Close encounters 12 18. From the ashes rise the roses of success 33 7. Cardinal sins 14 19. Cold water? Shock! 34 8. It dragged on and on 15 20. Always look on the bight side of life 36 9. The cost of administration 16 21. Hauled on board 38 10. A bit of a shambles 18 22. Digit-less door access 40 11. Getting in contact 20

12. Bump and grind 22

R 13. Cry wolf 24

14. See and be seen? 26 RECREATIONAL VESSELS 42 23. Brief encounter 44 15. Learning the ropes 27 24. Charging into danger 45 16. The gravity of the situation 28 25. Catastrophe 46

INVESTIGATIONS 48

REPORTS 49

SAFETY BULLETINS 50

SAFETY FLYERS 62

GLOSSARY OF TERMS AND CHIEF INSPECTOR’S INTRODUCTION ABBREVIATIONS Welcome to the second MAIB Safety Digest of 2023. I will start by thanking Simon Graves, Duncan Murt and Andy Murray for their respective introductions to the merchant, fishing and recreational sections of this edition; their expertise ° degrees is self-evident, and their industry insights to safety help bring contemporary 2/O second officer context to the cautionary tales in the following pages. I hope you will find time to read the whole edition – there is something here for every mariner – but please AB able seaman do read the section introductions. And, when you have finished, please pass the AIS automatic identification system digest on so others can benefit too.

BWTS ballast water treatment system In his introduction, Simon Graves makes the point that technical solutions to remove or control hazards are reaching their limits, and that the solutions C/E chief engineer often lie with the individuals carrying out the tasks. In my introduction to one of last year’s safety digests CCTV closed-circuit television I wrote about precautionary thought, and Andy Murray continues that theme with his APEM acronym (appraise, plan, execute and monitor). Good precautionary thought helps avoid that sinking feeling of, CPR cardiopulmonary resuscitation I wish I had…before we left; we have all been there. However, Duncan Murt’s article about his fall overboard DC direct current demonstrates how even the most safety conscious individual can allow themselves to drift into bad habits or unsafe practices when what they are doing becomes routine and they forget to be afraid. DfT Department for Transport ECDIS Electronic Chart Display and Information System The near miss incidents in case 1 and case 6 are good examples where nothing could go wrong, until it did. Simple miscommunications or misunderstandings turned routine passings into near collisions because GMDSS Global Marine Distress and Safety System the safety margins had reduced to the point they were almost nonexistent. Next time you are considering GPS global positioning system taking a risk in an approach or narrow channel, remember the container vessel Ever Given blocking the Suez Canal and think again. kts knots The fishing section of this edition contains four instances where a member of the crew was dragged Li-ion lithium-ion overboard (cases 17, 19 and 20) or nearly overboard (case 21). Some of these had good outcomes, others LOTO lock-out/tag-out did not, but all show that the hazard of being dragged overboard during fishing operations remains ever present. There can be little doubt that wearing a lifejacket significantly improves your chances of living to m metre tell the tale; again, read Duncan’s introduction. However, if you are operating single-handed, carrying a “Mayday” the international distress signal personal locator beacon so you can raise the alarm will help ensure that others come to your rescue. And, MRCC Maritime Rescue Coordination Centre to take this introduction back to where I started, a bit of precautionary thought and avoiding a drift into unsafe practices could help prevent the accident in the first place. OOW officer of the watch Be safe. PFD personal flotation device PLB personal locator beacon PPE personal protective equipment ro-ro roll-on/roll-off Andrew Moll OBE t tonnes Chief Inspector of Marine Accidents V volt VHF very high frequency VTS vessel traffic services

MERCHANT VESSELS No one could ever Why? and the How?, which have a tendency to say that a maritime be the more difficult questions an investigator Many of the cases you are about to read have It has often been said that the best accident to career lacks variety. has to answer to determine why an accident reached the limit of a practicable technical learn from is one that someone else has had When my mother has happened. solution to completely remove the hazard – a and, writing as someone who works for an put me on a train at mooring rope still has to be placed over a bollard organisation with the sole purpose of removing the tender age of 16 We read in the media about the rapid and I think chips will always form part of the the need for its own existence, I fully agree with years old to embark technological advancement underway in the menu on most ships. The solutions therefore lie the sentiment. I urge the readership of this safety on mine (something industry as it looks for greener solutions. The with the people: to look at how they do things; digest to take the lessons from this crop of cases, she has never quite speed and variety of the technical solutions being why they do things; why they do not do things; those from the past and, sadly, the ones still to forgiven herself for), implemented for the decarbonisation of shipping how they interact with the things around them; come and think about how to apply them on a I never thought I is producing new, and sometimes unidentified, and how they communicate. The latter comes personal level to use the hard-won hindsight for would end up here. I will forever be a seafarer risks that our seafarers will be exposed to. to the fore when reading the two near misses your own benefit. first and foremost, but experience in ship Increasingly, risk mitigation needs to focus on between passenger ships. human rather than technical factors: many see I briefly served on the Herald of Free Enterprise management and regulation provides different perspectives of safety when looking into the the development of on board automation as a ...the best accident to during the early stages of my career so maybe I potential solution, but the interface between can say that I have come full circle. The terrible accidents I now investigate. the systems and the people will need careful learn from is one that losses on board this cross-channel ferry in Attitude to safety is often in the eye of the assessment from design through regulation to someone else had 1987 resulted in fundamental change to the beholder. As a seafarer, you are very much operation to ensure that the management of one industry and the establishment of the MAIB. engaged in the here and now; the doing of the risk does not introduce another. None of the articles in this section resulted in a Hopefully, the safety lessons among these task. Every inspector in the branch has at one fatality, but each of them had the capability to pages will contribute to the achievement of time or another looked at the circumstances of The recurrence of similar cause one. We should never forget the effect that something similar. an accident through gritted teeth, knowing they a serious injury has on a person, sometimes for were lucky to get away with doing something incidents continues the rest of their lives. very similar. Equally, there is not one inspector in again and again the branch who views risk in the same way they did before they joined. There is an expectation that accidents involving new technology will eventually begin to cross Risk mitigation needs to our desks. For the moment, the cases in the pages that follow mirror those from the past. focus on human rather We see how times, people and equipment may than technical factors change but many of the themes of the accidents call to mind those of years ago: navigational As a regulator you are primarily concerned collisions and near misses, falls from height, pilot SIMON GRAVES CEng CMarEng BEng(Hons) PGCert MIMarEST | MAIB Inspector of with compliance. During MCA surveys I often ladders and mooring and lifting accidents all Marine Accidents recounted the anecdote that, after years of feature in this edition, as they have done almost Simon joined the MAIB as an inspector in 2021, transferring from an assistant director role at the training and study, I spent a large proportion of continuously over the years. I have certainly seen Maritime and Coastguard Agency (MCA) where he was responsible for technical services (operations). my time measuring things with a tape measure, attitudes to safety evolve during my time in the Simon holds an honours degree in engineering from Newcastle University, which he studied for after watching doors open and close and counting industry, and we observe increased maturity in qualifying as a chief engineer. lifejackets. Regulation drives safety and is vital the systems and working practices intended to After a long career at sea serving on a wide variety of ships, ultimately as chief engineer on cruise ships, for the industry – Titanic would certainly have prevent marine accidents from happening, but Simon joined the MCA as a surveyor. He moved with his family to New Zealand for a position in ship carried more lifeboats had the regulations the recurrence of similar incidents continues management before joining Maritime New Zealand, dealing with the operational port and flag state required them – but safety is multifaceted and again and again. aspects of the organisation. Simon returned to the UK, and the MCA, in 2010, where he progressed to a while regulation tends to define the What?, it principal surveyor role before promotion to assistant director. is the human elements that tend to define the With the arrival of COVID-19 Simon was faced with managing risk while developing and implementing a regulatory framework to keep UK ships trading under the most trying circumstances. He was also part of the multiagency team that developed the roadmap for returning the cruise industry to service after the dark days of the pandemic.

A stone's throw passenger ferry | near miss

A passenger ferry completed loading and was Unaware of any conflicting traffic, the outbound preparing for departure. Harbour control gave ferry cleared the berth and started making way; Last starboard lateral buoy before entering the port, which approval for the ferry to depart and advised however, as it approached the breakwater the was designated as the holding area for the inbound ferry there was no traffic to affect the outward inbound ferry was spotted and the risk of collision passage. With all departure checks completed, immediately identified. The outbound ferry’s the master instructed the crew to let go of the master urgently attempted to agree a suitable mooring lines. passing arrangement with the inbound ferry’s master over very high frequency (VHF) radio, but At the same time, an inbound ferry was in the the situation remained unclear. Inbound ferry channel destined for the berth being vacated. Harbour control directed the inbound ferry to The outbound ferry’s master put the helm hard Outbound ferry wait in the vicinity of the last starboard lateral to starboard and applied full bow thruster power buoy, east of the breakwater (Figure 1). The to starboard. The outbound ferry’s bow swung inbound ferry’s bridge team misinterpreted the clear, but the stern was swinging to port towards message and continued their approach, thinking the inbound ferry so the master stopped the they had just been asked to slow down. The ferry bow thruster and applied port rudder to avoid passed the lateral mark and turned towards the collision. The ferries passed one another at about harbour entrance. 50m (Figure 2).

Figure 1: Chart reproduction, showing the tracks of the ferries and the position of the lateral buoy

The Lessons

1. Communicate → Navigational and safety communications from ship-to-ship and ship-to-shore must be precise and clear to avoid confusion and error; the use of standard marine communication phrases can avoid ambiguity. In circumstances such as this, where there was a lack of clarity among both the ferries and harbour control, closed-loop communications can ensure that messages are received and, more importantly, understood. Having a receiver repeat back the relayed information allows the sender to confirm the understanding of the message and, if necessary, relay it again. In this case, it might have prompted the port controller to reassess the intentions of the inbound ferry.

2. Equipment → The use of VHF radio for collision avoidance can be unhelpful and may even prove dangerous. In this instance, the radio communication delayed the manoeuvre and led to confusion between Figure 2: The close-quarters situation the bridge teams. Although it is useful in limited circumstances, VHF is not a collision-avoidance tool and must only be considered a navigation aid when it is appropriate to do so.

3. Monitor → Maintaining a safe watch starts before the lines are let go. Monitoring the automatic 4. Action → The inbound ferry did not communicate to harbour control that they needed to maintain identification system (AIS) and listening to VHF messages can provide an early indication of potentially headway for steerage and the strong breeze would have made waiting or loitering at the lateral buoy conflicting traffic. It was established after the incident that both ferries were transmitting on AIS and it difficult. Maintaining a higher speed to reduce drift is sometimes necessary; however, actions contrary to would therefore have been straightforward for the outbound ferry’s bridge team to plot the inbound ferry harbour control’s instructions should be communicated immediately to assess the impact on other traffic before getting underway. and maintain a shared mental model.

You nearly had your chips! Unforeseen fall naval auxiliary vessel | fire bulk carrier | accident to person

The crew on board a tanker had a lucky escape A bulk carrier was alongside in port late one after switching on the galley equipment afternoon. The cargo discharge had been electrical isolators to start preparing for lunch. completed and the second officer (2/O) and able The supply breaker to the deep fat fryers seaman (AB) were standing on the midship (see figure) tripped while the equipment was port side catwalk, preparing for the loading heating up and the engineers were called to Upper rail of the next cargo by lowering the upper rails reset it. around the hold hatches (Figure 1). Once the Two of the deep fat fryers had no oil in them and rail was released, the rail would hang vertically their heating elements quickly overheated when downwards and allow the cargo to be loaded the power supply was restored after the breaker without interference from the rail. was reset. The ship’s alarm and monitoring The 2/O was leaning towards the unsecured system detected the excessive temperatures rail when it suddenly started to fall outboard. and the thermal protection tripped the deep The 2/O, who was not wearing a safety harness