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 .................................................................................................7 Case 1 How not to dry your dirty laundry! ................................................................8 Narrative...................................................................................................................................8 The Lessons..............................................................................................................................8 Case 2 Ferry grounds because sole look out is distracted .........................................9 Narrative...................................................................................................................................9 The Lessons..............................................................................................................................9 Case 3 You can always slow down!............................................................................10 Narrative.................................................................................................................................10 The Lessons............................................................................................................................10 Case 4 Floating maintenance .....................................................................................12 Narrative.................................................................................................................................12 The Lessons............................................................................................................................12 Case 5 Chips And ???? ...............................................................................................13 Narrative 1..............................................................................................................................13 Narrative 2..............................................................................................................................13 Narrative 3..............................................................................................................................14 The Lessons............................................................................................................................14 Case 6 Near miss in the solent passenger vessel/container vessel ...........................16 Narrative.................................................................................................................................16 The Lessons............................................................................................................................17 Footnote: ................................................................................................................................18 Case 7 Heavy Weather Causes Deaths ......................................................................19 Narrative.................................................................................................................................19 The Lessons............................................................................................................................19 Case 8 Slow speed saves the day ................................................................................20

Narrative.................................................................................................................................20 The Lessons............................................................................................................................20 Case 9 Safe access routes matter! ..............................................................................21 Narrative.................................................................................................................................21 The Lessons............................................................................................................................22 Case 10 Narrow channels! ..........................................................................................24 Narrative.................................................................................................................................24 The Lessons............................................................................................................................25 Case 11 Boiler tube corrosion ....................................................................................26 Narrative.................................................................................................................................26 So, what is on-load corrosion? ...............................................................................................26 The Lessons............................................................................................................................27 Case 12 Collision between tug and tow .....................................................................29 Narrative.................................................................................................................................29 The Lessons............................................................................................................................30 Part 2 Fishing vessels ...................................................................................................31 Case 13 Fisherman saved by lifejacket .....................................................................32 Narrative.................................................................................................................................32 The Lessons............................................................................................................................32 Case 14 See no vessel, hear no vessel!........................................................................33 Narrative.................................................................................................................................33 The Lessons............................................................................................................................33 Case 15 Things that go bump in the night ................................................................35 Narrative.................................................................................................................................35 The Lessons............................................................................................................................35 Case 16 A wooden vessel flood sand then sinks........................................................37 Narrative.................................................................................................................................37 The Lessons............................................................................................................................37 Case 17 Look after your tonnage valves ...................................................................38 Narrative.................................................................................................................................38 The Lessons............................................................................................................................38 Case 18 Skippers last-Minute action saves Vessel....................................................39 Narrative.................................................................................................................................39

The Lessons............................................................................................................................39 Case 19 No redundancy!.............................................................................................40 Narrative.................................................................................................................................40 The Lessons............................................................................................................................40 Case 20 Collision between fishing vessel and a general cargo ship ........................41 Narrative.................................................................................................................................41 The Lessons............................................................................................................................41 Case 21 Fishing vessel capsizes with loss of life........................................................42 Narrative.................................................................................................................................42 The Lessons............................................................................................................................43 Part 3 Leisure craft ......................................................................................................45 Case 22 Tragic end to a twister..................................................................................46 Narrative.................................................................................................................................46 The Lessons............................................................................................................................47 Footnote..................................................................................................................................49 Case 23 Don't drink and drive ...................................................................................50 Narrative.................................................................................................................................50 The Lessons............................................................................................................................50 Case 24 Differing perspectives!..................................................................................51 Narrative.................................................................................................................................51 The Lessons............................................................................................................................51 MAIB Noticeboard.......................................................................................................53 Attention all wearers of inflatable lifejackets! .......................................................................53 Appendix a ....................................................................................................................54 Appendix b Reports issued in 2002 (unpriced) .........................................................55 Appendix c Stationery office stockists and distributors overseas...........................58

Marine Accident Investigation Branch The Marine Accident Investigation Branch (MAIB) is an independent part of the Department for Transport, the Chief Inspector of Marine Accidents being responsible directly to the Secretary of State for Transport. 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 o 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 and other MAIB publications are only available from the Department for Transport, and can be obtained by applying to the MAIB.

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.gov.uk Summaries (pre 1997), and Safety Digests are available on the Internet: www.maib.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 CPA Closest Point of Approach CPO Chief Petty Officer DGPS Differential Global Positioning System EPIRB Emergency Position Indicating Radio Beacon ETA Estimated Time of Arrival GT Gross tons ISO International Standards Organisation LPG Liquefied Petroleum Gas Mayday Spoken distress signal MCA Maritime and Coastguard Agency Mhz megahertz OOW Officer of the Watch ORC Offshore Racing Council RFA Royal Fleet Auxiliary RHIB Rigid Hulled Inflatable Boat RNLI Royal National Lifeboat Institution RORC Royal Ocean Racing Club Ro-Ro Roll-on, roll-off RYA Royal Yachting Association SCBA Self-contained Breathing Apparatus SOLAS Safety of Life at Sea TSS Traffic Separation Scheme VDR Voyage Data Recorder VHF Very High Frequency VTS Vessel Traffic Services

Introduction I must start my first introduction by paying tribute to my predecessor. John Lang drove the development of the Safety Digest into the form that now enjoys such acclaim. Distributed to more than 9000 addresses world-wide, and with many of the copies reportedly well thumbed by several readers, it gets its message to a wide cross section of mariners. It, therefore, saddens me on reading many of the cases in this edition, to recognise old lessons that have not been learned. Lifejackets. In four of these cases, lifejackets were key factors. In one case, an experienced fisherman is happily walking around today simply because he was wearing a lifejacket. In threeother cases six people, who were not wearing life jackets, drowned. At least two of them would have been alive today had they taken that simplest of precautions. With modern life jackets being light, comfortable and unobtrusive, there really is no excuse. (See important note on life jackets in MAIB Notice board.) A Good Visual Watch. Four of the cases, and one of the deaths, are directly attributable to people not looking where they were going. Surely, this must be the most basic of mariners instincts. Yet we have all seen it happen: officers of the watch distracted by other tasks, or over reliant on radar; fishermen lending their crew mates a hand, when they should have been in the wheelhouse; or leisure boat users enjoying their day out to the full, but at the expense of looking forward. Awareness of Others. The essence of good seamanship, particularly in congested waters, is awareness of what others are doing, and making clear to others what you are doing. Always try to think from the other persons perspective; you may be happy with what you are doing, but is it clear to the other party? To be safe from collision, both parties need to be quite clear what is happening. Awareness of the Sea and Machinery. Again, this should be second nature to us all; yet in two of these cases, three very experienced seafarers have died unnecessarily through lack of awareness and, perhaps, complacency. Just pause and think; are you assessing the risks before you start any task? If you think you know better, you could be a danger to yourself and others around you. Fatigue. Finally, that old chestnut, fatigue. Lifeat sea is knackering! We all know that. And it is not the macho thing to suggest that we cant' hack it. So we press on regardless. Sadly, the MAIB sees the results of fatigue on an almost daily basis. One of the cases in this issue is directly the result of a watchkeeper falling asleep, but how many poor decisions in other reported cases have also been influenced by fatigue? None of these lessons is new. The reason they need repeating is the innate belief of mariners that accidents happen to other people. Sadly that is a belief that an unacceptable number of seafarers take to their grave. If people acted on just these five basic principles, the sea would be a much safer place for us all. Stephen Meyer Chief Inspector of Marine Accidents December 2002

Part 1 merchant vessels Slowing down is always an option, and yet it is one rarely taken by give-way vessels. Why? Because it conflicts with the fundamental commercial nature of merchant shipping. Why slow down when you can alter course? Why alter course? Although an alternative and equally valid option is often available, there are times when it is not. Slowing down not only enables a collision to be avoided; importantly, it allows more time to assess a developing situation. Good communication, in whatever form, is a cost-effective defence against accidents. Whether between ships, shipmates, or the ship owner and his crew, effective planning, monitoring, and compliance with realistic and relevant standard operating procedures, can mean the difference between a controlled event and one that leads inevitably to disaster. And even when you've slowed down and communicated well, danger lurks! We are all vulnerable to lapses of attention, either due to a distraction or the fact that we've switched off at the end of a watch. Slowing down, good communication and the need for continued vigilance all feature in this issue of the Safety Digest. Be safe: slow down, speak up, and stay with it!

Case 1 How not to dry your dirty laundry! Narrative A 5,307gt aggregates dredger was alongside, undergoing repair and maintenance, part of which involved overhauling the main engines. A team of engineers from the engine manufacturers had been working on board during the day. On completing their days work the team left the vessel at 2200, leaving their working overalls in the engineers changing room. Early the following morning, while doing his rounds, the watchman became aware of the smell of smoke. On checking the area, he found that one of the manufacturers engineers had left his boiler suit draped over the heater in the changing room. This had slowly heated up and, since the boiler suit was stained with oil and other debris, it had started to smoulder. Fortunately, it was discovered before it had fully caught fire. The watchman seized the boiler suit quickly, and hurriedly threw it outside the accommodation and on to the deck. It burst into flames immediately. Following this incident, all contractors were instructed to leave no working clothes on board the vessel overnight, and to ensure that each night, before leaving the vessel, they emptied all rubbish bins they had used that day. The owners also decided to disconnect the heater concerned and to install a battery-operated smoke alarm in the changing room.

The Lessons 1. This is yet another example of the importance of conscientiously doing rounds. If the watchman had not discovered the situation when he did, and responded so rapidly, a very different outcome might have ensued. 2. Never ever leave an article of clothing or material over a heater to dry, despite the temptation to do so. Most of us would prefer to step into a nice, warm, dry boiler suit in the morning, as opposed to stepping into one that is horribly cold and damp. But consider the risks. The MAIB has received numerous reports in the past where fires have occurred because clothes have been draped over heaters to dry. In some cases this has resulted in a fire serious enough to cause the loss of the vessel itself. 3. Ensure that heaters are in good condition and that temperature cut-outs and alarms are in working order. If a proper drying room is available, then use it. 4. Wet clothing, and clothing which is impregnated with oils and left in a heap over a period of time, is liable to spontaneous combustion i.e. they can catch fire without any outside ignition source. Hang clothes up properly to dry or to air away from any direct heat source.

Case 2 Ferry grounds because sole look out is distracted Narrative An inter-island ferry left port with 4 passengers and 4 crew on board. There was a slight swell, a north-north-easterly wind of force 3 to 4 and good visibility. Once clear of some rocks, the auto - pilot was engaged and the mate went be low for a cup of tea, leaving just the master on the bridge. The master was occupied at the chart table facing aft, writing up a manifest for the agent. He periodically checked the vessel's progress visually. The chart plotter was switched on, but was set to a small scale, which was of little use in coastal waters. The master was untrained in its use. A passage plan was not being used. There was no admiralty chart out, and no chart on board had course lines or positions on it. The master saw rocks on his port bow and, once satisfied the vessel would pass clear of them, returned to his paperwork. A few minutes later, he looked ahead and saw the rocks again. This time, they were dead a head and at close range. He put the engines full astern, but could not prevent the vessel grounding at almost her full speed of 10 knots. Although there were no injuries or pollution, the vessel suffered substantial damage to her port bow.

The Lessons 1. The International Regulations for Preventing Collision at Sea require all vessels to maintain a proper lookout at all times. This is the basic rule of bridge watch keeping. The busy watchkeeper will, inevitably, have a multitude of tasks to preoccupy him, but these should never, ever, prevent him from keeping a good look out. This watchkeeper allowed himself to become distracted with very costly and embarrassing consequences. 2. The passage was not planned or monitored. It is not known how the rocks came to be right ahead of the vessel after they were initially seen on the port bow. Had a simple passage plan been prepared in advance, and been adequately monitored, it would have been sufficient to keep the vessel on the intended track, and enabled any deviations to be corrected as they occurred. 3. The intended passing distance of the rocks was said to be about 1.5 cables. As the rocks mentioned in this article are in open waters, it would have been wise, and in the interests of good seamanship, to pass at a greater distance than this. 4. It was the owners policy to have two people on the bridge when the vessel was underway. The additional person in this case was enjoying a cup of tea down below, leaving just one watchkeeper, who was preoccupied with other duties. Had two people been on the bridge, this unfortunate accident might have been averted. 5. All watchkeepers should be trained and familiar with the operation of all navigational aids carried on board.

Case 3 You can always slow down! Narrative A bulk carrier and a cargo vessel were proceeding on similar courses in the south-west lane of the Dover Traffic Separation Scheme (TSS). It was daylight, and the visibility was good. Having previously overtaken and crossed to the bulk carriers starboard side, the cargo vessel had then reduced speed and was now being slowly overtaken on her port side by the bulk carrier ata range of about 0.5 mile. As the vessels approached Dover, both observed a ferry leaving the harbour with the intention of crossing the TSS. The bulk carriers bridge team assessed that the outbound ferry was on a collision course, and that an inbound ferry, bearing approximately 60° to port at a range of about 4.5 miles, would pass astern with a CPA of about 0.2 mile. The bulk carrier altered course to starboard to increase the outbound ferry's CPA. However, this action resulted in a close quarters situation developing with the cargo vessel and, at a range of about 0.1 mile, the bulk carrier altered course to port, having assessed that the outbound ferry would now pass clear ahead. By this time, the cargo vessel had already taken avoiding action by altering her own course to starboard.

The Lessons 1. The bulk carriers bridge team correctly identified that a risk of collision existed with the outbound ferry and, in accordance with Rule 15 of the Collision Regulations, took action to keep out of the way. The master was faced with four single-action options: • an alteration of course to port; • an increase of speed; • an alteration of course to starboard; or • a reduction of speed. An alteration of course to port had the potential to result in a close quarters situation with the inbound ferry, contrary to Rule 8(c). An increase of speed would have caused the bulk carrier to cross ahead of the outbound ferry, contrary to Rule 15.The masters decision to alter course to star board would have been an appropriate action, had it not been for the presence of the cargo vessel. Although he considered his action to be safe, the alteration reduced what was already a relatively close passing distance, to one which left very little margin for error, again contrary to Rule8(c). The most appropriate action would have been to reduce speed in accordance with Rule 8(e). This would have avoided a collision with the outbound ferry, avoided a close quarters situation with the cargo vessel, and provided the inbound ferry with sufficient time to reassess the situation and take appropriate action. A reduction of speed is seldom the option taken by give-way vessels, since it conflicts with the commercial nature of shipping, and there is often a valid alternative action available. This is

particularly so in open water collision avoidance situations. However, in coastal waters, and typically in traffic separation schemes, the restricted nature of the available sea room, and the high density of traffic, necessarily reduce the margins of safety. In these situations, it becomes particularly important to consider all the options available. If in doubt, err on the side of safety slow down.

Case 4 Floating maintenance Narrative Just before midday, an engine alarm sounded on the bridge of a 2,968gt ro-ro passenger ferry making her scheduled crossing. This was followed almost immediately by the main engines shutting down, owing to the engine over heating. The