Marine Accident Investigation Branch (MAIB) - Safety Digest

Contents Marine Accident Investigation Branch ........................................................................3 Glossary of Terms and Abbreviations .........................................................................3 Introduction ....................................................................................................................4 Part 1 - Merchant Vessels..............................................................................................5 CASE 1 Fire in Rechargeable Torch........................................................................................6 CASE 2 Mix up Leads to Dover Strait Collision .....................................................................8 CASE 3 Involuntary Movement of Ro-Ro at Berth...............................................................12 CASE 4 Engine Room Fitter Scalded ...................................................................................13 CASE 5 Another Nocturnal Grounding .................................................................................14 CASE 6 Rag Trouble! ............................................................................................................ 16 CASE 7 Vessel Loses Electrical and Main Engine Power when Quick Closing Valve Trips18 CASE 8 Serious Injury occurred during Loading of Gas Bottle............................................20 3. Before every operation consider the potential for an accident and take appropriate precautions. 20 CASE 9 Collision in Harbour between Dredger and Yacht ...................................................21 CASE 10 Hazardous Incident in Traffic Separation Scheme.................................................22 CASE 11 Crew Members Injured whilst Backing Up to Rig.................................................24 CASE 12 Atmospheric Problems and a One Way Door!.......................................................25 CASE 13 Fire On Board Catamaran ......................................................................................26 CASE 14 Lifeboat Falls 25m into Sea - Two Killed..............................................................27 CASE 15 Loss of Power and Hand Steering v Narrative.......................................................28 Part 2 - Fishing Vessels ................................................................................................29 CASE 16 Purchaser Beware! .................................................................................................30 CASE 17 Loss of Another Fishing Vessel ............................................................................31 CASE 18 Collision between Coaster and Fishing Vessel .....................................................33 CASE 19 Hooked-back Engine Room Door causes Loss of Vessel ......................................35 CASE 20 Corroded Pipework causes Flooding of a Fishing Vessel......................................36 CASE 21 Entrapped Water causes a Small Fishing Vessel to Capsize.................................37 CASE 22 Loss of a Small Clam Dredger ..............................................................................39 CASE 23 Collision between a Scalloper and an Angling Boat.............................................41

CASE 24 Cook Falls on Conveyor Belt - Fractures Ankle and Leg......................................43 CASE 25 Loss of a Small Crabber........................................................................................44 CASE 26 Problems Opening the Engine Hatch on a Flooded Small Fishing Vessel ............45 Part 3 - Leisure Craft...................................................................................................46 CASE 28 Catamarans Capsize in Weymouth Bay - Everybody Saved ................................49 End of Century Think Piece........................................................................................52 The Run Down Nightmare .....................................................................................................52

Marine Accident Investigation Branch The Marine Accident Investigation Branch (MAIB) is an independent part of the Department of the Environment, Transport and the Regions and is completely separate from the Maritime and Coastguard Agency (MCA). The Chief Inspector of Marine Accidents is responsible to the Secretary of State for the Environment, Transport and the Regions. The offices of the Branch are located at Carlton House, Carlton Place, Southampton, SO15 2DZ. This Safety Digest draws the attention of the marine community to some of the lessons arising from investigations into recent accidents. It contains facts which have 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 publications home page contains information on how and where you can obtain publications produced by the Department for Transport.

Glossary of Terms and Abbreviations AB - Able Seaman ARPA - Automatic Radar Plotting Aid CPA - Closest Point of Approach EPIRB - Emergency Position Indicating Radio Beacon GPS - Global Positioning System GRP - Glass Reinforced Plastic IMO - International Maritime Organization MAIB - Marine Accident Investigation Branch MCA - Maritime & Coastguard Agency RNLI - Royal National Lifeboat Institution RYA - Royal Yachting Association SCBA - Self-contained Breathing Apparatus STCW - Standards of Training, Certification and Watchkeeping SOLAS - Safety of Life at Sea UTC - Universal Time Co-ordinated VHF - Very High Frequency

Introduction No matter how much effort is put into preventing transport disasters, they still occur around the world with alarming frequency. In recent weeks we have witnessed the Paddington rail collision, a tourist bus crash in South Africa and the loss of an Egypt Air aircraft off Nantucket Island. On the marine side, the fire onboard the ferry Dashun, and her subsequent foundering in rough weather off the Chinese coast was the worst marine tragedy in China for many years; about 280 people lost their lives. A further 17 people also died when the fast ferry Sleipner went aground at high speed off the Norwegian coast at the end of November. One of the significant differences between marine disasters and those involving other transport modesis that few, very few, vessels are ever fitted with data recorders or 'black boxes'. Many argue activelyagainst their fitting on grounds of cost. Finding out the main and underlying causes of an accidentpresents the marine accident investigator with a formidable challenge. Notwithstanding thishandicap, the MAIB inspector endeavours to look beyond the obvious causes and identifies thelessons to be learned. These are published in the Safety Digest which is published three times eachyear. We have been delighted with the response to these Digests but discover that all too often our targetaudience, the seafarer and especially the fisherman, continues to be unaware that we provide this freeservice. It is my hope that everyone at sea has access to these Digests so that they too can learn fromthe experiences of others. A telephone call, e-mail, fax or letter to our Southampton offices willensure your name is added to our distribution list. The Digests can also be accessed by visiting ourwebsite. As in previous Digests, this edition provides ample food for thought. We are particularly gratifiedwhen people write to say that a particular article was the focus of discussion onboard ship. Discussingaccidents, and identifying oneself with what has gone wrong elsewhere, will very often make a majorcontribution to the development of a safety culture and lead to an overall improvement in safety. I amvery aware that some of the features we draw attention to are beyond the scope of the man at sea.Nonetheless by identifying the problems, much can be done to reduce the risks - by applying some ofthe lessons to be learned. One unexpected consequence to publishing these Digests has been the growing number of seafarerswho have taken to writing to the Branch to draw our attention to safety matters. We ensure that anysuch reports are treated in the strictest confidence as some of the points raised have been veryrevealing and highlight practices at sea that are condoned by people who should know better. Someof these observations form part of our thinking when drafting the lessons to be learned. I encouragepeople to be open with us. You may unwittingly be saving a life, or a major marine disaster. Pleasecontinue to write to us.

John Lang Chief Inspector of Marine Accidents December 1999

Part 1 - Merchant Vessels Seafaring is not without risks. As a vessel approaches her port of discharge at the end of an otherwiseuneventful voyage, she might be coping with bad weather, heavy traffic and a concentration of fishingvessels. The master is becoming anxious about the need to catch a tide, and the engineers are tacklingsome unexpected defect that has necessitated a reduction in speed. The vessel eventually reaches portand cargo work starts. An army of visitors jockey for position at the bottom of the gangway, and aweary master and equally tired mates, have to cope with the many demands placed on them. A tidelater, the ship sails. Fog descends and the radar reveals yet more fishermen. The master, his officersand crew are resigned to being tired and know they are at their most vulnerable, but it is the reality ofshipping today. The commercial pressures dictate little or no let-up in the pace. The man at sea will do his very best to avoid a mistake, but human failure in the guise of fatigue,interrupted sleep, lack of training, poor communication, failure to delegate, inadequate teamwork,social conditions onboard or poor ergonomics in the workplace, all feature as contributory causeswhen determining why so many accidents happen. The conscientious ship owner will have done his best to identify the risks, and taken measures toovercome them. And yet, when MAIB inspectors identify the primary and underlying causes ofaccidents, they often identify practices and procedures that have survived unchallenged for years yetcontribute directly or indirectly to whatever happened. Too often we see the lookout at night being stood down to rest or, worse still, never being used at all.We see junior officers sitting back and watching errors being made by their seniors, but, because theold man or the pilot is assumed to know what he is doing, they do nothing to query the action, orintervene. At times of high activity we have seen the master, as the senior officer and mostexperienced man present, taking charge of the detail of whatever needs to be done. He is usually theonly person not involved elsewhere and few people would question that this is his proper role. Wesee, nonetheless, masters in this position making avoidable mistakes or being responsible for errors ofjudgment. As many other mariners have discovered over the years, there is a very strong argument forthe master to delegate charge to a subordinate, and then stand back and absorb the wider picture.When things go wrong, as they surely will, he is very well placed to spot them immediately and ensurethe right action is taken. When he becomes too involved himself, his focus of concentration narrowsdangerously. This Safety Digest describes a variety of things that have gone wrong recently. The thinking mariner will reflect on what he or she would have done had he been present at the time.

Fire in Rechargeable Torch The 32,500gt container vessel Cap Blanco was in mid-Atlantic on passage from Europe when, at 1855, the automatic fire alarm system activated showing a fire in the accommodation on "C" deck. Immediate investigation found a fire in the cook's cabin. The ventilation to that area was stopped, with "C" deck, "D" deck above and "B" deck below electrically isolated. At 1903, a fire party comprising the chief officer, cadet, and AB, all wearing self-contained breathing apparatus (SCBA) because of the thick smoke, tackled the fire. It was extinguished within a minute using two portable extinguishers; one water and the other CO2 . Ventilation was then restarted to clear the area of smoke to allow the cause to be investigated. Decks "D" and "B" were checked for hot spots and a head count taken of the crew; they were all found safe. A fire check in the area continued by taking down deckhead panels and checking the electrical circuits for damage. The area was declared clear at 2052. A new fire detector head was fitted in the cabin and electrical power restored. Fire extinguishers and SCBA air bottles were refilled. The investigation found a rechargeable torch lying in a molten heap on the cook's cabin desk top with the remains of a stereo speaker fused to it. The wooden desk top was burnt under and around the torch and the bulkhead behind it was also damaged. The bulkhead electrical socket, into which a two pin charging lead for the torch was still inserted, was flame damaged as were adjacent book shelves and deckhead panelling. The supply cables to the socket had been burnt away. Despite heavy smoke damage to the cabin and bathroom, the fire had not penetrated into the void spaces above. The rechargeable torch had been bought in the UK from a reputable store just before departure. It was supplied with a charging transformer and a UK standard three-pin plug. (The ship's sockets were three-pin round. By using a multi voltage mains transformer adapter with a two-pin round on one end and four sockets on the other, the charging transformer had been connected to the ship's system.) Although the wiring was damaged, there was no evidence to indicate that the transformer adapter had caused the fire. Examination of the torch suggested that a short circuit in the torch's internal wiring was responsible. The torch was described as a "6 Function Rechargeable Lamp" and was fitted with a large 6V 4AH lead acid battery, rechargeable from either the mains or a 12V car lighter socket.

The Lessons 1. Any item of electrical equipment that is non standard to a vessel has the potential to cause damage however reputable its manufacturer or where it was purchased. No such equipment should ever be connected to the vessel's electrical supply until it has been checked by an electrical officer. Instructions to this effect should be stated in ship's standing orders and drawn to the attention of the newly joined crew. 2. This incident demonstrates the effectiveness of a swift response to a fire alarm in the accommodation spaces. The ventilation was stopped, electrical supplies isolated, it was tackled promptly by the crew who knew what to do, were properly dressed and carried the correct equipment. Regular training minimises the risk to personnel as well as limiting damage to the vessel.

3. The crew fully appreciated the potential danger from smouldering fires in void spaces above deckhead panels and from water cascading onto electrical installations on the deck below. Their actions showed the value of thinking through the situation once the fire was out, and what might have been affected by heat transfer and/or the firefighting efforts.

Mix up Leads to Dover Strait Collision

With one possible exception, activity in the Dover Strait during the closing hours of 5 May 1998 was normal. It was a dark clear night, the wind was west-south-west force 5 to 6 and traffic was moving easily both ways in the traffic separation scheme. As so often happens a "rogue" ship was heading north-east on the northern edge of the south-west bound lane. It was not identified. The only additional, but by no means unusual, activity that night was a cross channel survey by the 1,774gt survey vessel STM Atria. She was traversing the channel between a position off St Margaret's Bay and the Belgian coast. She was showing the lights of a vessel restricted in her ability to manoeuvre, red white and red all round lights, and also displaying an orange flashing light. Regular traffic information about her activities was broadcast by the CNIS every hour. She was making good between 4 and 5 knots. Several miles to the north-east the 347gt St Vincent and the Grenadines registered tug Towing Wizard was approaching the Strait in the south-west bound lane having sailed earlier from Tilbury. Without a tow she was on the first night of a passage to the Black Sea but was expecting to divert to a south coast port en route to repair a defect to her autopilot. She was making good about 6 to 7 knots. One officer was on watch and a rating was on the wheel. With a crew of six, there was no lookout. The radar was not ARPA fitted. A few miles astern of her, the 13,633gt Greek registered cargo vessel Anangel Honour was also heading towards the Dover Strait. She too had come from the Thames Estuary and was bound for the Le Havre pilot. Making between 9 and 10 knots she had four people on her bridge, the master (who had the con), the second officer, a helmsman and a lookout. She was overtaking Towing Wizard and those on the bridge could see her overtaking light. She was also held on the radar. On board Towing Wizard the master had handed over the watch to the mate at midnight (2300 UTC). He initially forgot to inform him about the survey ship activity but returned to the bridge to do so. The mate had, in the meantime, heard STM Atria over the VHF radio. He identified the survey vessel when she was still some miles ahead and he also saw the lights of the rogue vessel approaching from beyond STM Atria. He had not detected the overtaking Anangel Honour and was unaware of her presence. He monitored the unidentified rogue vessel as she altered course to starboard to pass ahead of the survey vessel. STM Atria had, by now, started to head south-east away from the Kent coast. The rogue's course alteration placed her in the separation lane going "the wrong way". Nevertheless she passed clear of both the survey vessel and the tug. Meanwhile the mate on board Towing Wizard had become concerned he was on a collision course with STM Atria and prepared to alter course to starboard to pass clear astern of her. On Towing Wizard's starboard quarter Anangel Honour continued to overtake. She had misidentified the survey vessel as a fishing vessel and had also seen the rogue ship approaching. She altered course 20° to port to bring her further inside the traffic lane which effectively allowed the rogue to pass clear to starboard. This course alteration to port brought her closer to the tug, whose stern light was clearly visible on the port bow. The master was unaware of any survey activity despite radio broadcasts to that effect. His second officer who was conducting the navigation could only speak a little English and would probably not have understood the broadcast had he heard it. The master became concerned at the developing close quarters situation between himself and the "fishing vessel".

Meanwhile the officer of the watch on board STM Atria (the chief officer), was becoming equally concerned by the two vessels approaching on his port bow. Of the two he was more anxious about the most easterly one (Anangel Honour) and called on his VHF "Ship on my port side ... eh ... Ship on my port side, approximate distance 1 m north-east of me, your approximate position is 51° 06.2'N 001° 30.7'E. This is the STM Atria". Towing Wizard, still unaware of the presence of Anangel Honour overtaking on his starboard quarter assumed the call was for him, and acknowledged it by saying he would keep clear by passing under the