Marine Accident Investigation Branch (MAIB) - Safety Digest

Contents About The Marine Accident Investigation Branch.....................................................5 Glossary of Terms and Abbreviations .........................................................................6 Introduction ....................................................................................................................7 Part 1 Merchant Vessels ................................................................................................8 Case 1 Close Quarters Situation in Dover Straits TSS...............................................9 Narrative...................................................................................................................................9 The Lessons..............................................................................................................................9 Case 2 Another Leak + Heat = Fire............................................................................10 Narrative.................................................................................................................................10 The Lessons............................................................................................................................10 Case 3 Working in the Dark.......................................................................................11 Narrative.................................................................................................................................11 The Lessons............................................................................................................................11 Case 4 Mixing Oil and Water! ...................................................................................13 Narrative.................................................................................................................................13 The Lessons............................................................................................................................13 Case 5 Pilot Falls Overboard during Disembarkation ............................................14 Narrative.................................................................................................................................14 The Lessons............................................................................................................................14 Footnote..................................................................................................................................15 Case 6 Collision Between a Barge and a Fishing Vessel ..........................................16 Narrative.................................................................................................................................16 The Lessons............................................................................................................................16 Case 7 Grounding of Tug ...........................................................................................18 Narrative.................................................................................................................................18 The Lessons............................................................................................................................18 Case 8 Crewman Falls Overboard During Fast Rescue Craft Recovery...............20 Narrative.................................................................................................................................20 The Lessons............................................................................................................................20

Case 9 The Value of Sound! .......................................................................................22 Narrative.................................................................................................................................22 The Lessons............................................................................................................................22 Case 10 The Application of Logic to Crane Failure.................................................23 Narrative.................................................................................................................................23 The Lessons............................................................................................................................24 Case 11 Major Oil Spill in Sydney Harbour.............................................................25 Narrative.................................................................................................................................25 The Lessons............................................................................................................................25 Footnote..................................................................................................................................26 Case 12 A Fire Alongside Caused by Water! ...........................................................27 Narrative.................................................................................................................................27 The Lessons............................................................................................................................27 Case 13 Collision Between a Tanker and a Vessel Alongside .................................29 Narrative.................................................................................................................................29 The Lessons............................................................................................................................29 Part 2 Fishing Vessels ..................................................................................................31 Case 14 Wheelhouse Exhaust FIRES!.......................................................................32 Narrative.................................................................................................................................32 Narrative.................................................................................................................................32 The Lessons............................................................................................................................33 Case 15 ..........................................................................................................................34 Morse Cable Problems.................................................................................................34 Narrative 1..............................................................................................................................34 The Lessons............................................................................................................................34 Narrative 2..............................................................................................................................34 The Lessons............................................................................................................................35 Case 16 Wear & Tear! ................................................................................................36 Narrative 1..............................................................................................................................36 Narrative 2..............................................................................................................................36 Narrative 3..............................................................................................................................36 The Lessons............................................................................................................................37 Case 17 A Chain of Events .........................................................................................38

Narrative.................................................................................................................................38 The Lessons............................................................................................................................38 Narrative.................................................................................................................................39 The Lessons............................................................................................................................39 Case 19 Fishing Vessel Grounds due to Over-Reliance on the use of Navigational Aids 41 Narrative.................................................................................................................................41 The Lessons............................................................................................................................41 Case 20 Know How Much Catch You Can Load on Your Vessel ..........................42 Narrative.................................................................................................................................42 The Lessons............................................................................................................................42 Footnote..................................................................................................................................43 Part 3 Leisure Craft .....................................................................................................44 Rigid Inflatable Boats ............................................................................................................44 General Safety The Last Resort .............................................................................................44 Case 21 Three Tidal Near Misses ...............................................................................46 Narratives ...............................................................................................................................46 Case 1- Close encounter with an anchored cruise ship ..........................................................46 The Lessons............................................................................................................................46 Case 2 In and out of the buoys ...............................................................................................46 The Lessons............................................................................................................................47 Case 3 - A tight squeeze with several onlookers....................................................................47 The Lessons............................................................................................................................47 Case 22 Sightseeing on a Bend Invites Trouble........................................................49 Narrative.................................................................................................................................49 The Lessons............................................................................................................................49 Footnote..................................................................................................................................50 Case 23 Flooding Caused by Faulty Hull Fittings....................................................51 Narrative.................................................................................................................................51 The Lessons............................................................................................................................51 Footnote..................................................................................................................................52 End of Year Think Piece A collision at sea can spoil your entire day....................53 Appendix A ...................................................................................................................59 Appendix B Reports issued in 1999/2000 (Priced) ...................................................60

Appendix C Reports issued in 2000 (Unpriced) ........................................................62 Appendix D Stationery office stockists and distributors overseas ..........................64

About The 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 Safety Digest is only available from the Department of the Environment, Transport and the Regions, and can be obtained by applying to the MAIB. Other publications are available from The Stationery Office bookshops and the DETR Publications Sale Centre, Unit 21, Goldthorpe Industrial Estate, Goldthorpe, Rotherham, S63 9BL (Tel: 01709 891318)

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 e-mail address is maib@dft.gsi.gov.uk

Summaries (pre 1997), and Safety Digests are available on the Internet: www.maib.detr.gov.uk Extract from The Merchant Shipping (Accident Reporting and Investigation) Regulations 1999 The fundamental purpose of investigating an accident under these Regulations is to determine its circumstances and the causes with the aim of improving the safety of life at sea and the avoidance of accidents in the future. It is not the purpose to apportion liability, nor, except so far as is necessary to achieve the fundamental purpose, to apportion blame.

Glossary of Terms and Abbreviations AB Able Seaman ARPA Automatic Radar Plotting Aid CO2 Carbon Dioxide CPA Closest Point of Approach DZR De-zincification resistant FRC Fast Rescue Craft GPS Global Positioning System GRP Glass Reinforced Plastic GT Gross Tonnes HRU Hydrostatic Release Unit IMDG International Maritime Dangerous Goods Code

m metre MCA Maritime and Coastguard Agency MGN Marine Guidance Notice MoD Ministry of Defence OOW Officer of the Watch RIB Rigid Inflatable Boat RNLI Royal National Lifeboat Institution Ro-ro Roll-on, roll-off RYA Royal Yachting Association TSS Traffic Separation Scheme VHF Very High Frequency VLCC Very Large Crude Carrier

VTS Vessel Traffic Services/System

Introduction The Safety Digest has a single aim, to prevent marine accidents by learning from other people's experiences. It is almost impossible to quantify the success of these Digests, but several people have been gracious enough to tell us that they find them useful. We have, furthermore, been particularly encouraged to receive requests for bulk orders so that copies can be distributed to every vessel in a particular company, or every fisherman in a local fisherman's association. There has been a steady trickle of requests for individual copies to be sent to leisure sailors, and we hope that they too find them helpful. I am also pleased to see that many articles are either duplicated or discussed in various magazines, trade journals, or club newssheets. I encourage this approach, and am always pleased when editors feel able to use our material for the purpose of improving safety at sea. I only ask that they acknowledge the source. By distributing the Safety Digest free of charge I hope to remove any restriction on those likely to benefit from them, and I continue to encourage people to contact the Branch for copies to be sent. We have also responded to numerous requests to have the Digests made available on the Internet. This has now been done. If we can save just one life, or prevent any of the accidents that seem to feature so regularly, we will feel we have made a modest contribution to improving safety at sea. But learning from the mistakes of others is not the only way to prevent accidents. Seafaring is by its very nature unusually demanding. It doesn't matter whether you are the mate of an Aframax tanker, a stewardess in a cruise ship, the second engineer in an anchor handling tug, the deckhand in a fishing vessel, the navigator of a BT Global Challenger, or the midshipman of the watch onboard a frigate, you share an unforgiving environment: the sea. The person who instinctively checks things in the normal course, who puts right the things that are wrong when first noticed, and who also keeps half an eye on his ship mate, is likely to be part of a safety conscious team, and doing much to prevent the accident happening in the first place. One of the most glaring common denominators in all the accidents investigated by the MAIB is that nearly every single one was preventable, and would never have occurred had someone done something different in the hours leading up to it. This edition of the Safety Digest contains a number of examples where human error played a part, not only in the initiating cause of what happened, but in the underlying reasons. The articles are produced to invite discussion, to underpin training, to lodge in the subconscious and, above all, to prevent accidents. John Lang Rear Admiral Chief Inspector of Marine Accidents

Part 1 Merchant Vessels This section of the Safety Digest has an essentially engineering flavour. Many accidents occur because of problems that originate in the machinery spaces. Very often a very small error in an operating procedure, or an unnoticed defect, can be the initiating cause of something much more serious such as a fire, flooding or even a collision if it affects propulsion or steering. While many are quick to categorise these events as technical, they are often preventable by people going about their normal business who not only notice that something isn't right, but do something about it. Conscientious watchkeeping is a process of constant vigilance. It involves using ones ears, eyes, nose and touch. All the senses play a vital part in spotting the potential problem but, to be really effective, they necessitate an in-depth awareness of the normal state. For several decades now main machinery has been controlled and monitored from control rooms divorced from the machinery. Very often they will be unmanned outside normal working hours. While recognising the obvious advantages of such an arrangement, it also means that today's engineers can lose the machinery monitoring skills that earlier generations developed by keeping watches in the spaces and absorbing the atmosphere. Today's engineers must try and achieve this by being even more conscious about the normal state. Turning to specifics, the most common cause of fire in a machinery space is oil impinging on to a hot surface. Any leaking oil be it fuel, lubricating, hydraulic or thermal heating is a potential fire hazard, and anyone working in the machinery spaces must be alerted to the potential dangers of such leaks, and told to look out for them. From time to time, an inexplicable set of circumstances will arise to challenge even the most experienced engineers. Apart from relying on their accumulated knowledge, they should not underestimate the importance of checking back through the historical records of the system concerned, examining the detailed drawings, and adopting a methodical approach to identifying the root cause of whatever the problem is. Finally, accident investigations often reveal practices that are either ad hoc, or undertaken without thought for the consequences. Such practices, which are rarely recorded or set out as standard operational procedures, are often passed on as 'the way we do it'. When things begin to go wrong, a frequently observed shortcoming has been the failure to think through what needs to be done to rectify a particular problem and resort, instead, to the poor practices of the past. They are then faced with a far greater predicament which, when combined with other factors, can often result in a serious accident. Education, training, and thinking through problems before they happen, remain key elements in sound engineering practice.

Case 1 Close Quarters Situation in Dover Straits TSS Narrative A container vessel and five other vessels were proceeding in the SW bound lane of the Dover Straits TSS. A passenger ferry was crossing from Calais to Dover. It was a situation that might occur several times every day. The OOW on the ferry was maintaining a normal lookout and was, initially, aware of five vessels on his starboard bow. But he had not yet plotted on his radar the container vessel, which was coning up astern of the others. Unaware of her presence he decided to pass ahead of the first vessel in the group, astern of the next two and ahead of the last two. While crossing ahead of the leading vessel, the OOW first began plotting the container vessel tracking down the northern edge of the SW bound lane. He decided to continue as planned. Once he was clear of the first five vessels he proposed altering course to port to pass ahead of the container vessel. The container vessel, which had a North Sea pilot on board, became concerned about the small CPA of the ferry and, when about 2.0 miles distant contacted her on VHF Channel 6. The ferry's OOW informed the container vessel that the projected CPA was 0.8 miles, and suggested the container vessel "helps" the situation by altering course to port. The container vessel altered course to port and the ferry crossed about 0.6 miles ahead.

The Lessons 1. The Dover Straits is one of the busiest waterways in the world, and transiting it requires concentration, anticipation and a high degree of "situational awareness" at all times. 2. Alteration of course to starboard and/or slowing down is preferable to crossing a vessel ahead. (Rule 15 COLREGS). Footnote This incident was reported as a hazardous incident. To encourage further such reports, the identities of the two vessels concerned are not revealed.

Case 2 Another Leak + Heat = Fire Narrative The Luxembourg registered high-speed craft Diamant suffered an engine room fire while on passage from Ostend to Dover during August1998. The fire was quickly extinguished using the drencher system. Securing bolts on a main engine high- pressure fuel pump were found to have fractured. This allowed the pump to move, disturbing pipework, and resulting in fuel impinging on a hot surface, most probably an indicator cock. The engine was a Ruston RK27 Mk2. Because this problem had been experienced on previous occasions, the vessel's engineers had been monitoring the pumps regularly. One precautionary step already taken had been the fitting of uprated pump-securing bolts just three months before this latest incident. The engine's manufacturer carried out further investigations and concluded that correct tightening procedures were an important element in the satisfactory performance of these bolts. Access using normal spanners and torque wrenches had been a problem, so to overcome these difficulties they designed a tool to ensure that specified torque could more easily be applied to all securing bolts. The manufacturers also issued a service bulletin setting out tightening torque and procedures. The bulletin also stressed the importance of using new nuts and flat washers whenever a pump was refitted.

The Lessons 1. The value of water spraying fire-extinguishing systems was shown in this incident. The fire was quickly extinguished without the need to close down the engine room. 2. This case is one of a long line of engine room fires on all types of vessels, caused by leaking fuel. Eternal vigilance is necessary to prevent their occurrence or to reduce their consequences. 3. When applying torque, follow the manufacturer's instructions very carefully. If you find you can't because of access or some other difficulty, record it and tell someone. This can be an important ingredient to identifying and overcoming a problem.

Case 3 Working in the Dark Narrative The dredger, City of Westminster, was on the Thames on passage from Charlton to North Sea dredging grounds when she suffered a total electrical failure. As a result, she lost steering control and collided with an inbound vessel, Dart 2, causing some damage but no injuries. Shortly before the collision, the watchkeeping engineer had begun to change over main generators. A main engine drove each of the two main generators, but electrically they could not be run in parallel. To perform the changeover, it was necessary to unload the outgoing machine on to the independently-driven auxiliary generator, then transfer the load on to the incoming main generator before shutting down the auxiliary generator. It was normal practice to carry out this procedure before arrival at the dredging area in open water. The engineer was relatively new to the vessel. Although there were written procedures requiring him to wait until reaching open water before making the changeover, he assumed the vessel was clear of confined water. The engineer decided to finish the task early in his watch. He had reached the stage where the auxiliary alternator was taking the load when its breaker tripped. All electrical power was lost. Propulsive power was maintained but not the control of steering and propeller pitch. The vessel veered to port. Thinking there was a problem with the auxiliary generator, the engineer began to check it. Meanwhile the Chief Engineer had arrived in the engine room and attempted to close the auxiliary generator's breaker. Because he did not operate the synchronising override, he was unsuccessful. After operating the override, his second attempt was successful. At this stage the collision occurred. Each vessel was able to make its own way to a berth for inspection and repair.

The Lessons 1. Crew recollections suggest that the auxiliary generator's breaker may have opened involuntarily on an earlier occasion, but the incident was neither reported nor recorded. This reduced the chances of identifying whether this latest incident was the failure of the breaker or human error. No matter how trivial an incident might be, record it. Such information can become a useful diagnostic tool when trying to identify the origins of a new problem. 2. Losing essential power supplies in a restricted navigation channel is highly undesirable, and is guaranteed to upset those on the bridge. Taking any action that might initiate such a failure should be avoided unless absolutely necessary. 3. This vessel had a written procedure of not changing generators in confined waters. However, there was no associated guidance on what should be considered as confined waters, and the engineer made his own erroneous assessment. Clearly, engineers should never attempt to navigate!

4. There was a slight delay in restoring electrical power, even though three generators were running, and the breaker on any of them could have been closed. In situations such as this where power has to be restored with the minimum of delay, procedures must be drawn up to achieve this. Watchkeeping engineers must, furthermore, be able to carry them out without hesitation. They can only do so if they practice them. The owners have introduced drills with this objective.

Case 4 Mixing Oil and Water! Narrative The 1,646gt