Marine Accident Investigation Branch (MAIB) - Safety Digest Contents 1. ENGINE-ROOM FLOODING, ENGINE FAILURE AND EVENTUAL GROUNDING ..........................................................................................................................................3 Narrative .........................................................................................................................3 Observations ...................................................................................................................3 Comment.........................................................................................................................4 2. ENGINE-ROOM FIRE ALONGSIDE OIL BERTH.............................................5 Narrative .........................................................................................................................5 Observations ...................................................................................................................5 Comment.........................................................................................................................6 3. FLOODING THROUGH BILGE INJECTION SYSTEM....................................7 Narrative .........................................................................................................................7 Observations ...................................................................................................................7 Comment.........................................................................................................................7 4. TWO CASES OF INTERACTION..........................................................................8 Case 1 ..............................................................................................................................8 Narrative .........................................................................................................................8 Observations ...................................................................................................................8 Case 2 ..............................................................................................................................8 Narrative .........................................................................................................................8 Observations ...................................................................................................................8 Comment.........................................................................................................................9 Case 1 ..............................................................................................................................9 Case 2 ..............................................................................................................................9 5. REPORTED CARGO HOLD FIRE AT SEA .......................................................10 Narrative .......................................................................................................................10 Observations .................................................................................................................10 Comment.......................................................................................................................11 6. INHALATION OF HARMFUL FUMES ..............................................................12 Narrative .......................................................................................................................12 Observations .................................................................................................................12 Comment.......................................................................................................................12 7. DUST CLOUD EXPLOSION IN CARGO LOADING EQUIPMENT ..............13 Narrative .......................................................................................................................13 Observations .................................................................................................................13 Comment.......................................................................................................................14

8. SEAMAN INJURED WHILE OPENING HATCH COVERS............................15 Narrative .......................................................................................................................15 Observations .................................................................................................................15 Comment.......................................................................................................................15 9. MOORING BOAT CAPSIZES ..............................................................................16 Narrative .......................................................................................................................16 Observations .................................................................................................................16 Comment.......................................................................................................................16 10. PLEASURE YACHT COLLISION WITH FERRY CAUSED BY INTERACTION 17 Narrative .......................................................................................................................17 Observations .................................................................................................................17 Comment.......................................................................................................................18 11. FATALITY ON A TUG ........................................................................................19 Narrative .......................................................................................................................19 Observations .................................................................................................................19 Comment.......................................................................................................................19 12. FAILURE OF AIR INLET VALVE UNDER PRESSURE ...............................20 Narrative .......................................................................................................................20 Observations .................................................................................................................20 Comment.......................................................................................................................20 13. CREWMAN INJURED BY UNGUARDED MACHINERY.............................21 Narrative .......................................................................................................................21 Observations .................................................................................................................21 Comment.......................................................................................................................21 14. ENGINE FAILURE AND EVENTUAL LOSS OF VESSEL............................22 Narrative .......................................................................................................................22 Observations .................................................................................................................22 Comment.......................................................................................................................22 15. FISHERMAN LOST OVERBOARD...................................................................23 Narrative .......................................................................................................................23 Observations .................................................................................................................23 Comment.......................................................................................................................24 16. FATAL INJURIES CAUSED BY OUTBOARD ENGINE PROPELLER ......25 Narrative .......................................................................................................................25 Observations .................................................................................................................25 Comment.......................................................................................................................25 17. TWO PERSONS LOST OVERBOARD FROM SAILING YACHT ...............26 Narrative .......................................................................................................................26 Observations .................................................................................................................26

Comment.......................................................................................................................27

1. ENGINE-ROOM FLOODING, ENGINE FAILURE AND EVENTUAL GROUNDING

A 16,000 gross registered tonnage Bahamian bulk carrier had a mixed nationality crew of 25. The Master had been with the ship for over three years, the Chief Engineer for six months. Shortly after sailing, a quantity of water was found in the engine bilges which was more than the bilge tank could hold. It was decided to pump the excess into the after peak tank using the ballast line and the emergency direct bilge suction.

Simultaneously, the remote hydraulically operated sea and tank valves and the manual direct bilge suction valve were opened. During this operation the bilge water level rose covering the main engine crankcase shaft seal and a fall in oil pressure indicated that water was entering the crankcase. The main engine was stopped. Preparations were made to transfer bilge water to the aft peak tank through hoses connected to the bilge and fire pump discharge. During these preparations the main engine was restarted. About one hour later, the main engine was stopped again so that the contaminated lub oil could be transferred into the dirty oil sump storage tank.

Once this transfer was complete, a new lub oil charge was run down from the storage tanks but as it was cold this took some time during which the vessel drifted, eventually anchoring only 1.5 miles off the coast. Five minutes after anchoring, the Chief Engineer informed the Master that the engine was ready. The Master started weighing anchor only to be told that the engine would not start due to thick, unheated fuel oil in the system. The vessel dragged anchor and drifted closer towards the shore before re-anchoring.

Six hours after first anchoring, the main engine was started but whilst weighing the anchor the vessel grounded.

The vessel managed to manoeuvre further out to sea where she re-anchored to assess the situation. The rudder was inoperative, the bow was damaged and two ballast tanks were holed.

Observations 1. The Master was experienced and qualified and was familiar with the handling characteristics of the vessel and deck machinery. Although only 12 miles off a lee shore when the initial breakdown occurred, he did not advise the Coastguard. Having eventually anchored 1.5 miles offshore and with little sea room to manoeuvre, he should not have started weighing anchor until the main engine had been started. 2. It was fortunate that serious damage was not caused to the main engine bearings by running the engine with low oil pressure and water contaminated lub oil. 3. The Chief Engineer knew that the cold fuel oil would delay the main engine starting and should have reported that fact to the Master. 4. The use of emergency bilge suctions to pass bilge water through ballast lines is an extreme measure but provided the non-return valve fitted is operational, the bilges should have been drained quite quickly. A delay in starting the pump with the sea valve open and a defective non-return valve on the bilge suction, could be expected to cause rapid back flooding. Bilge high-level alarms had sounded while the vessel was in port but no-one investigated the situation.

5. Apart from technical considerations, a communication problem existed between the Chief Engineer and the Chief Officer because neither could speak each other's language and both had only a limited knowledge of English. 6. Although not suffering a language problem, the Master and Chief Engineer did not communicate properly and failed to explain the actions they were taking and their likely outcomes.

Comment 1. It was fortunate that the vessel was only slightly damaged with no loss of life or injury to the crew. The circumstances of the incident had all the ingredients of a major disaster and it was fortuitous that the weather did not deteriorate. Considerable quantities of fuel and lubricating oil were on board and there was a risk of serious pollution. 2. Vessels operating with a multi-national crew need to pay close attention to communication and clarity of instructions. Whilst reasonable competence in the English language is acceptable for every day work, unusual requests between different nationalities require extra care and confirmation prior to implementation. 3. Given the vessel's position off a lee shore, the Master should have advised the Coastguard of the situation and of his intentions. 4. Emergency direct bilge suctions should be checked at regular intervals for ease of operation and the effectiveness of the non-return valve. They are fitted for emergency use only, and for that reason their condition should never be in doubt.

2. ENGINE-ROOM FIRE ALONGSIDE OIL BERTH

An oil tanker of 2,979 deadweight tonnes was using a cargo pump to discharge ballast to shore facilities. The pump was driven by an auxiliary engine located in the engine-room. A connecting rod punctured the engine entablature which caused a fire to start. As soon as the engine-room smoke detection alarm was activated the general alarm was sounded and the port emergency plan was initiated. The fire was eventually extinguished by the shore fire brigade using high expansion foam. There were no resultant injuries to personnel.

Observations 1. The connecting rod of the auxiliary engine probably became detached due to a fractured rocker arm, preventing the opening of the exhaust valve, and subsequent overloading on the respective piston. 2. The cause of the fire is deduced to have been an ignition of crankcase oil vapour by the hot white metal of the bottom end bearing. 3. Operation of the remote pull-wire arrangement failed to initiate the gang release of the fixed CO2 fire extinguishing system. A local attempt to release it was aborted when the CO2 bottle room had to be evacuated due to leakage from a joint on the pressure alarm sensor fitted to the gas manifold. 4. The minimal forward draught of the vessel prohibited an intake of water from the sea to the emergency fire pump. An alternative intake from the forepeak was unavailable because the tank was empty. 5. The auxiliary engine could not be stopped because the bridge remote stop arrangement, although installed, was not connected. The fuel tank quick-closing valves were shut but, because the fuel in the common fuel line to the multi-engine installation was of sufficient capacity, the auxiliary engine continued to run for a prolonged period. 6. The engine-room ventilation trunking had years of accumulated oil internally and thick coats of paint externally which contributed to the intensity of the fire. The engine-room had been in a dirty condition. 7. A crew member had to be rescued from his cabin after failing to respond to the sound of the general alarm. A number of false alarms had occurred in the past and he assumed that this was another one.

Comment The management company has been advised to:

1. Clean the engine-room and engine-room ventilation trunking; 2. Ensure that auxiliary engines can be shut down by the intended remote means; 3. Pressure-test the CO2 manifold and fittings to the working pressure; 4. Conduct periodic checks to ensure the security of the CO2 pressure alarm sensor; 5. Confirm the effectiveness of the remote control wire for the CO2 release; 6. Maintain a log of fire alarm initiations in order to ascertain the frequency of false alarms; 7. Give an assurance that the emergency fire pump will always be available to maintain pressure on the fire main; 8. Issue standing orders for crew members to respond promptly to any emergency alarm.

3. FLOODING THROUGH BILGE INJECTION SYSTEM

Prior to sailing from a port the bilge high-level alarm sounded on a general cargo vessel of 1,041 gross registered tons.

Shortly after departure whilst two general service pumps were being used to supply the fire and deckwash line, it was noticed that the bilge water in the engine-room was rising. Eventually the level was such that bilge water was thrown by the engine flywheel towards electrical equipment essential for the operation of the main engine. To reduce the amount of spray, engine speed was reduced. This caused the stand-by lub oil pump to switch in automatically and to short circuit, resulting in a temporary loss of electrical power to the vessel.

The main engine was stopped and the vessel rolled heavily in the prevailing weather conditions. All sea water suction valves were shut and the accumulated bilge water was then pumped overboard. The main engine was subsequently restarted and the vessel proceeded to a safe anchorage.

Observations 1. The Chief Engineer reported that it was normal practice to connect the port and starboard general service pumps in series to boost the discharge pressure to the fire and deckwash line. 2. Both pumps' bilge injection non-return valves were found to be held in a partially opened position by an accumulation of swarf and rags.

Comment 1. The bilge high-level alarm had sounded while the vessel was still alongside. Measures should have been taken to discharge the bilge water ashore prior to departure. 2. Flooding of the engine-room was due to seawater being pumped back through the partially opened non-return bilge valves by the two series- connected general service pumps. 3. Bilge injection lines are not fitted with strainers. It is, therefore, most important that engine-room bilges are kept free from accumulations of debris so that the pumping system can be used effectively at all times. 4. Merchant Shipping Notice No M.788 provides advice on bilge pumping and injection systems.

4. TWO CASES OF INTERACTION These cases both involved the effects of interaction, but in quite different circumstances.

Case 1

Narrative A loaded bulk carrier of 7,482 gross registered tonnage was overtaking a general cargo vessel of 524 gross registered tonnage in a narrow channel. Both vessels were under pilotage. It was agreed between the vessels on VHF radio that the general cargo vessel would leave the channel to enable the bulk carrier to overtake on the port side and at a safe distance.

The bulk carrier had reached a point abeam of the other vessel as they approached the next starboard hand beacon, which indicated the lateral extent of the channel. The general cargo vessel then altered course to port so as to pass inside the beacon. The bulk carrier increased speed to emergency full ahead in an attempt to avoid a close quarters situation. However, the vessels converged and the effects of interaction caused the smaller vessel to sheer to port and collide with the bulk carrier. There were no injuries and damage was minor.

Observations 1. The pilot on board the bulk carrier called the general cargo vessel on VHF radio after the latter vessel had altered course to port but received no response. 2. The draught of the general cargo vessel was only three metres and the vessel could have remained outside the channel and passed safely outside the beacon.

Case 2 Narrative A 12 metre workboat was requested to assist in the berthing of a coaster. As the coaster approached her intended berth, the workboat proceeded alongside and then moved forward towards the bow of the coaster to take a tow rope.

As the eye of the tow rope was being taken on board the workboat, her heading was altered to starboard in order to increase the distance between the vessels. However, the port quarter of the workboat struck the stem of the coaster; the workboat then swung rapidly to port and across the stem of the coaster. The workboat was pushed over to about 55° before righting herself. There were no injuries, although one of the two crewmen was thrown into the water and the workboat was partially flooded.

Observations 1. The coaster was proceeding at about 4 knots. 2. The effect of interaction pushed the stern of the workboat away from the ship's bow, causing it to swing to port and across the stem of the coaster.

Comment Merchant Shipping Notice No M.930 is entitled "Interaction Between Ships". The Notice provides advice on the causes of hydrodynamic interaction and the measures that can be taken to reduce its effects significantly.

Case 1 Overtaking manoeuvres in a narrow channel should be carried out at slow speed and, having agreed to an overtaking manoeuvre, the vessel being overtaken should be prepared to take further action, particularly if the overtaking vessel is larger and less able to manoeuvre.

Case 2 Berthing manoeuvres with workboats in close attendance should be undertaken at very slow speed for two reasons:

1. When a workboat moves forward towards the bow of the larger vessel, there is an initial tendency for her own bow to be deflected away. As she moves further forward, there is then a tendency for her stern to be deflected and for her to develop a sheer towards the bow of the other vessel. 2. The flow of water around the bow of the larger vessel causes a consequent decrease in the stability of an attending workboat and there is an increase in the likelihood of capsize if the vessels should make physical contact.

5. REPORTED CARGO HOLD FIRE AT SEA

A 1978 built, Panamian registered general cargo vessel of 11,084 gross registered tonnage, had loaded a cargo of baled plastic waste plus a deck cargo of 17 containers on the Continent for the Far East. When close to a UK port, a crew member reported smoke from the ventilator of No 5 hold 'tweendeck starboard. A brief inspection was carried out by the Master who confirmed that fumes were coming from the ventilator and closed the fire flap. The booby hatch for No 5 hold was opened and thin smoke or fumes could be seen. The hatch was re-secured and all drain lines from the hatch sealed with tape. The smoke detecting system for the hold was then switched on but it did not register any alarm. The fire alarm was sounded and the crew went to their fire stations. Preparations were made to use the CO2 flooding system whilst fire hoses were rigged and boundary cooling of the hatch and adjacent deck started.

The shore authorities were advised and all hold ventilation shut down. The fire brigade boarded with the pilot and carried out an assessment of the situation whilst the vessel proceeded to her anchorage. A two man fire team equipped with self contained breathing apparatus entered the hold but were unable to progress very far due to the dense cargo stowage. After further consultation, 13 bottles of CO2 were discharged into No 5 hold forward, port and starboard upper 'tweendeck and the lower 'tweendeck and a decision made to leave it overnight.

Approximately 16 hours later, the fire brigade re-boarded the vessel and carried out an inspection, a further nine bottles of CO2 having been discharged into the hold during the night to maintain the cover. With no apparent sign of smoke, the hatch covers were lifted in sequence until all hatch covers were open. Thermal image cameras failed to find any evidence of a hot spot and with no further sign of smoke or fire, entry was made into the lower hold but no evidence of combustion was found. The hatches were left open overnight with a fire watch and a further entry made the following morning after a number of bales had been removed to give better access. Again no evidence of any fire was found.

Observations 1. The vessel has four holds forward of the bridge and accommodation, and one hold aft, (No 5) - the latter was originally used for refrigerated cargo. No 5 hold has upper and lower 'tweendecks above deep tanks. It is further divided into a forward and aft section with the forward upper 'tweendeck section also divided into port and starboard compartments. There are three hatch openings, one each for the port and starboard upper forward sections and one for the aft section. The hatch covers for these aft hatch openings are insulated hinged steel covers which are operated by the aft derricks. 2. The combined smoke detecting and CO2 fire extinguishing system, originally fitted when the vessel was built, was tested weekly and had previously been in use during the preceding loaded voyage. The system uses a standard dual pipeline arrangement whereby the same pipes used by the smoke detection unit are also used, via a three-way valve, to discharge CO2. Normally the system would be turned on just prior to departure, but on this occasion it had been overlooked. Although turned on for a brief period when the "smoke" was first sighted, no alarm condition occurred. Once the three-way valves had been turned onto the CO2 discharge position in anticipation of a rapid discharge,