Marine Accident Investigation Branch (MAIB) - Safety Digest

Contents MARINE ACCIDENT INVESTIGATION BRANCH...............................................4 Glossary of Terms and Abbreviations .........................................................................5 INTRODUCTION..........................................................................................................6 PART 1 - MERCHANT VESSELS ..............................................................................8 CASE 1 Bad Dream Becomes a Reality - Middle Watch Grounding .....................10 Narrative.................................................................................................................................10 The Lessons............................................................................................................................10 Footnote..................................................................................................................................11 CASE 2 Rudder Fatigue .............................................................................................12 Narrative.................................................................................................................................12 The Lessons............................................................................................................................12 CASE 3 Inadequately Secured Deck Cargo .............................................................14 Narrative.................................................................................................................................14 The Lessons............................................................................................................................14 CASE 4 Confined Space - Life or Death ? ................................................................16 Narrative.................................................................................................................................16 The Lessons............................................................................................................................16 Footnote..................................................................................................................................16 CASE 5 Near miss in Dover Straits ...........................................................................18 Narrative.................................................................................................................................18 The Lessons............................................................................................................................18 Footnote..................................................................................................................................18 CASE 6 Cold Comfort .................................................................................................20 Narrative.................................................................................................................................20 The Lessons............................................................................................................................20 Carbon Monoxide...................................................................................................................20 CASE 7 The Explosive Force of High Speed Rotation!............................................22 Narrative.................................................................................................................................22 The Lessons............................................................................................................................22

CASE 8 Collision Between a Cargo Ship and Moored Yacht..................................24 Narrative.................................................................................................................................24 The Lessons............................................................................................................................24 Footnote..................................................................................................................................25 CASE 9 Complacent Navigation Causes Ferry to Ground ......................................26 Narrative.................................................................................................................................26 The Lessons............................................................................................................................28 CASE 10 Main Engine Turbo Charger Air Filter Fire ............................................29 Narrative.................................................................................................................................29 The Lessons............................................................................................................................29 CASE 11 Poor Operational Design Contributes to Gas Carrier Grounding .........30 Narrative.................................................................................................................................30 The Lessons............................................................................................................................32 Footnote..................................................................................................................................32 CASE 12 Care and Attention ......................................................................................33 Narrative 1..............................................................................................................................33 Narrative 2..............................................................................................................................33 The Lessons............................................................................................................................33 CASE 13 An Extra Pair of Hands ..............................................................................35 Narrative.................................................................................................................................35 The Lessons............................................................................................................................35 Footnote..................................................................................................................................35 PART 2 - FISHING VESSELS ...................................................................................36 CASE 14 Another Lone Fisherman Tragically Lost Overboard.............................37 Narrative.................................................................................................................................37 The Lessons............................................................................................................................37 Footnote..................................................................................................................................37 CASE 15 Grounding in Restricted Visibility.............................................................38 Narrative.................................................................................................................................38 The Lessons............................................................................................................................38 Footnote..................................................................................................................................39 CASE 16 Vessel Sinks After Hitting Wreckage ........................................................40 Narrative.................................................................................................................................40

The Lessons............................................................................................................................40 CASE 17 Man Overboard During Hauling Operation.............................................42 Narrative.................................................................................................................................42 The Lessons............................................................................................................................42 Footnote..................................................................................................................................43 CASE 18 How to Handle a Flooding Incident...........................................................44 Narrative.................................................................................................................................44 The Lessons............................................................................................................................44 CASE 19 Fishing Vessel Grounds While Leaving Harbour.....................................45 Narrative.................................................................................................................................45 The Lessons............................................................................................................................45 CASE 20 Use the Correct Caulking Compound .......................................................46 Narrative.................................................................................................................................46 The Lessons............................................................................................................................46 PART 3 - LEISURE CRAFT ......................................................................................47 CASE 21 School Trip Tragedy....................................................................................49 Narrative.................................................................................................................................49 The Lessons............................................................................................................................49 Footnote..................................................................................................................................50 CASE 22 Two Drown in Speedboat Sinking .............................................................51 Narrative.................................................................................................................................51 The Lessons............................................................................................................................51 Footnote..................................................................................................................................52 A Pause for Thought ....................................................................................................53 Footnote..................................................................................................................................56 APPENDIX A Investigations started in the period 01/07/2001 - 31/10/2001..........57 APPENDIX B Report issued in 2000 (Priced)...........................................................58 APPENDIX C Reports issued in 2001 (Unpriced) ....................................................59 APPENDIX D Stationery office stockists and distributors overseas ......................62

MARINE ACCIDENT INVESTIGATION BRANCH The Marine Accident Investigation Branch (MAIB) is an independent part of the Department for Transport, Local Government 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 Transport, Local Government 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 that 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 for Transport, Local Government and the Regions, and can be obtained by applying to the MAIB. Other publications are available from The Stationery Office and the DTLR 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

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 ARC Atlantic Rally for Cruises ARPA Automatic Radar Plotting Aid DGPS Differential Global Positioning System EPIRB Emergency Position Indicating Radio Beacon GMDSS Global Maritime Distress and Safety System GPS Global Positioning System GRP Glass Reinforced Plastic GT Gross tonnes HAZ Heat Affected Zone HSE Health and Safety Executive LPG Liquefied Petroleum Gas OOW Officer of the Watch RYA Royal Yachting Association SAR Search and Rescue SCBA Self-contained Breathing Apparatus TSS Traffic Separation Scheme UMS Unmanned Machinery Space VHF Very High Frequency VLCC Very Large Crude Carrier

INTRODUCTION On October 15, 1913, a poem titled "Our Fathers" by a Captain R A Hopwood, Royal Navy, appeared in The Naval and Military Record. It was written during the naval manoeuvres that year and was dedicated to the memory of the nameless killed and wounded at sea. It appeared a few months before World War I broke out. One verse in the poem stands out, and is as relevant today as it was then. In an age of swift invention it is frequently believed That the pressure of a button is as good as work achieved: But the optimist inventor should remember, if he can, Though the instrument be perfect, there are limits to the man. Nothing much has changed. We live in an age of rapidly advancing technology. It dominates much of our lives and has made a major contribution to economic success, the business of shipping and other forms of seafaring, and safety at sea. It has enabled substantial savings to be made in operating costs. It is now possible to communicate instantly around the world, for much of the drudgery of working at sea to be removed, and for complex calculations to be made in a microsecond. But for all its undoubted advantages, there are three factors that are as relevant today as they have always been: The sea is still as unforgiving of mistakes as ever. • Even the most sophisticated 'machine' (and I include computers) can either malfunction or be incorrectly operated.

• And there are limits to the man.

Man still has to make the decisions. Man still has the pair of eyes to actually see what is happening, rather than having implicit faith in what the computer tells him. Man still has the ears and sense of smell to alert him to something that isn't right. Man still has the extraordinary ability to make mistakes, and to prevent them. The good seafarer possesses an instinctive feel for what is going to happen next, and will constantly be making what modern terminology describes as risk assessments. But if the man is badly treated, ignored, taken for granted, overworked, or is made to live in fear of his job, he cannot possibly give of his best. Man is the single greatest asset the shipowner has. He is worth looking after, and money spent training him will pay handsome dividends. For the man at sea, however, learning about how people react in certain situations, understanding how the mind functions and realising just how important adequate rest is, will make the vessel you are serving in a more effective and, ultimately, a happier place to both live and work if the right kind of leadership is provided. This edition of the Safety Digest contains a number of references to the human factor, and readers are invited to focus their attention on these to see what can be learned. A deep understanding of this issue is one of the last great challenges of the sea. And it faces us all. Bon Voyage.

J. S. Lang Chief Inspector of Marine Accidents

PART 1 - MERCHANT VESSELS A feature of life at sea today is modern technology such as electronic charts, unmanned machinery spaces and satellite communications. Whether we like it or not the oil lamp, topgallants, oilskins, morning stars, Morse code, and the steam reciprocating engine are distant memories to most of us. The ancient mariner might find certain features of today's equipment a little perplexing but, with his grasp of basic skills, he will usually be in a position to cope with the challenges presented by the sea. On the other hand the younger seafarer may well have a better understanding of the technology involved and might be something of a prodigy on the keyboard, but could be floored if the system fails. The reality is that all of us at sea, both young and old, on deck or in the engine room, hotel staff or franchise holder, have to live with technology. It features in every shape and form from computer- controlled equipment to navigation aids, from alarm monitoring to system diagnostics, and from cargo handling to the exchange of data. It goes without saying that the value of such systems is degraded if we, the operators, do not know how to use them properly. There are three issues to consider: an ability to operate the system or equipment correctly, an understanding of any limitations, and an awareness of the 'distraction' factor. Knowing how to use technology is a basic requirement, but many of us are not as good as we should be. Analysis of accident investigations frequently reveals, for instance, shortcomings with the human/technology interface. Most of us know the basics but are thrown if we push the wrong button, or the system defaults in some way. We sometimes come across seafarers who are provided with perfectly reliable equipment but are not using it correctly because they don't know how to, and are too embarrassed to say so. Training is the key to overcoming such shortcomings, but it must embrace both normal and abnormal situations. One example of operator error we see over and over again is the failure to change from auto steering to hand, or vice versa, and especially when tension on the bridge is high. Practice makes perfect. Some systems give a sense of security that isn't always justified. Navigation aids fall into this category, and there are numerous examples of watchkeepers who assume GPS is infallible and don't bother to cross-check the ship's position by independent means. Going aground is not popular. Or there is the person who worships at the shrine of the ARPA and fails to look out of the window. Over reliance on automation is often found to be a crucial factor in accident causes. Looking at limitations from a different direction, we must not forget the poor operator who sometimes has to absorb an excessive amount of information. Anyone working alone soon becomes swamped, and there is an expectation that people will react correctly and instantly to an alarm in a crisis situation. This rarely happens. Research shows it usually takes at least 30 seconds for an operator to react correctly. Finally the 'distraction' factor. Some people become so absorbed by the system that they forget to get on with the job in hand. It is a curious characteristic of the human that when the telephone rings, he or she feels compelled to answer it. GMDSS can be a major distraction. If you feel tempted to respond to them at precisely the same moment you find yourself on a collision course

with another vessel, there should be no prizes for guessing which requirement takes priority. Too many watchkeepers think it's the telephone!

CASE 1 Bad Dream Becomes a Reality - Middle Watch Grounding Narrative While on passage from the Turkish port of Izmir, to Goia Tauro in Italy, the 7,720gt Cayman Islands-registered container ship Captain Spyros became stranded on Psara Island in the Aegean Sea in the early hours of 1 October 2000. Built in 1977, all her certificates were in date, she had three qualified deck officers in addition to the master, and was equipped with a full range of navigational equipment, including two radars and a GPS. She was employed on a weekly round voyage between Izmir, Goia Tauro and Piraeus. She had sailed from Izmir at 2145 on 30 September on what was a routine and familiar passage. Visibility was good and it was a clear dark night. The second officer relieved the third officer at midnight and the ship's position, derived from the GPS, was being plotted on the chart from time to time. The charts in use had the courses to steer marked in black ink and could not be erased. An AB shared the bridge watch. Course was altered at 0025, and again at 0047, with the ship's position being plotted on the chart each time she settled on to a new course. At 0243 she altered course again, to 237° and, once again, the position was plotted. About 45 minutes later there was a violent shuddering motion as Captain Spyros grounded at full speed on the steep, rocky east coast of Psara Island. The entire ship's company was woken. The time was 0325. The vessel was eventually refloated with the assistance of tugs, and was towed to Piraeus.

The Lessons 1. Even a well-equipped vessel with fully qualified officers who are familiar with a particular passage, can run aground on a well charted island. In this instance there were no problems in establishing the ship's position, and it was a clear night with good visibility. Why then did it happen? 2. This ship was on a regular route, and the courses had been indelibly marked on the chart. So, too, had the courses to steer. The numerals 237 were clearly evident, as was the reciprocal 157 for the return voyage. After the grounding it was found that the automatic steering had been set to 257°. Although the investigators could not prove the point beyond doubt, there was at least the possibility that the officer of the watch had inadvertently set the wrong course, having mixed up 237 with 157 in his mind, and arrived at 257°. It could explain the discrepancy. 3. Much more to the point is why, if as seems likely, this happened and why did nobody notice? 4. The most common mistakes at sea are made by people who are tired, when they carry out very repetitive tasks, and are working between the hours of 0100 and 0600. The ingredients for error on 1 October were all in place.

5. Because of the schedule being kept, with a constant round of relatively short passages, periods at anchor, berthing and cargo work, deck officers and ratings onboard Captain Spyros were working very long hours and getting little sleep. In the day immediately preceding the grounding both the second officer, and the AB sharing his watch, had worked in excess of 15 hours. There is no record of how much sleep they had managed to achieve, but both had been up for much of the previous night. Their time off duty before coming on watch at midnight had been less than an hour. 6. Very, very few mariners will ever confess to being tired; it is part of the culture. Expressions such as fatigue or sleep deprivation don't feature in the daily vocabulary. Unfortunately the human body, and more particularly the brain, doesn't pay attention to what the mariner thinks; it needs sleep and adequate rest. Unless it gets them, individual alertness deteriorates, and mistakes will be made. Once this is recognised, however, and measures are put in place to offset the risk of error, the chances of something going badly wrong are much reduced. 7. The conscientious navigator makes two basic checks when the time comes to alter course. He checks that the course drawn on the chart actually matches the numerals written alongside it, and double-checks to see it is safe by looking along the bearing of the new course to be steered. 8. A fix, from whatever the source, merely tells you where you were at a particular moment. To verify its accuracy, use some other means to confirm it. Fixes using visual means are still among the best means of all. GPS is extraordinarily accurate, but students of marine casualties will have noted the number of times a misplotted or misread position has led to a grounding. Never rely on a GPS position alone. You may get away with it 999 times out of a 1000, but the 1000th time will catch you out, probably in the middle watch. No doubt you will have assumed that the neat position drawn on the chart was correct. If an error creeps in, no matter how derived, and you don't notice it, the consequences could be very expensive indeed and lead to your becoming acquainted with all sorts of people you never knew existed. 9. Once a position has been plotted, the projected track and dead reckoning must be calculated. Any unexplained variation from the anticipated track will be the trigger to establish the reasons. 10. Plot fixes at regular intervals: the closer to land or other hazards, the more frequent they should be. All will be important, but none more so than those following a course alteration. If the wrong course has been set, it will start to show up when the plotted positions start to diverge from the planned track. 11. The oft-repeated phrase "keeping a good lookout" is not confined to the avoidance of collision. It also means you are responsible for preventing your vessel from hitting charted hazards. If navigating in the vicinity of islands, it pays to be particularly vigilant when looking ahead. A good pair of eyes, and frequent looks at the radar, will ensure you are not running into danger.

Footnote This article has been prepared from a report produced by the Cayman Islands Shipping Registry, whose assistance and co-operation is gratefully acknowledged.

CASE 2 Rudder Fatigue Narrative Arco Avon, a