Contents Marine Accident Investigation Branch ........................................................................3 Glossary of Terms and Abbreviations..........................................................................4 Introduction ....................................................................................................................5 Part 1 - Merchant Vessels ..............................................................................................6 Case 2: Communications...Communications ...Communications ..............................9 Case 3: A Nasty Surprise .............................................................................................10 Case 4: Cargo Shift in Heavy Weather ......................................................................12 Case 5: Modified Bilge Pipework Causes Flooding...................................................14 Case 6: Who is Lowering the Lifeboat? .....................................................................16 Case 7: Delayed Action - Real Time Collision ...........................................................18 Case 8: Hidden Corrosion Causes Ingress of Seawater............................................20 Case 9: Two Unplanned Trips.....................................................................................22 Case 10: Suspended Weight and Unsecured Cargo Lead to Severe List in Port ...23 Case 11: If in Doubt - Get Out! ...................................................................................24 Case 12: Painter Away!................................................................................................25 Case 13: Severe Weather and Defective Equipment = Fatality ...............................26 Case 14: Fatal Accident Involving Hatch Cover Operations ...................................28 Part 2 - Fishing Vessels ................................................................................................29 Case 15: NUC or Not?..................................................................................................30 Case 16: Near Miss Leads to Grounding ...................................................................31 Case 17: Loss of Fisherman Within Harbour Breakwater ......................................33 Case 18: Can You See/Hear Your Bilge Alarm?.......................................................35 Case 19: Bilge Alarm Success Stories .........................................................................37 Case 20: Back Rope Bights Back ................................................................................39 Part 3 - Leisure Craft...................................................................................................41 Case 21: Vessel Sinks Beneath Party of Divers .........................................................42 Case 22: I Have Divers Down - Get My Drift? ..........................................................44 Case 23: Mind That Propeller.....................................................................................46 MAIB Noticeboard .......................................................................................................48

Appendix A: Preliminary examinations.....................................................................49 Appendix B: Reports Issued In 2003 ..........................................................................50

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 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 Editor, Jan Hawes, welcomes any comments or suggestions regarding this issue. The Safety Digest and other MAIB publications 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 The role of the MAIB is to contribute to safety at sea by determining the causes and circumstances of marine accidents, and working with others to reduce the likelihood of such causes and circumstances recurring in the future. 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 CPA Closest Point of Approach DSMB Delayed Surface Marker Buoy EPIRB Emergency Position Indicating Radio Beacon FRB Fast Rescue Boat GRP Glass Reinforced Plastic GT Gross tons IMO International Maritime Organization MARPOL International Convention for the Prevention of Maritime Pollution "Mayday" Spoken distress signal OOW Officer of the Watch RIB Rigid Inflatable Boat VHF Very High Frequency VTS Vessel Traffic Services

Introduction One of the saddest parts of my job is to see the number of deaths and serious injuries that result, not from exceptional or freak occurrences, but from absolutely routine business. It is in such work that seafarers are least alert, and when tired or busy mariners fail to recognize the risks. I was thus fascinated to read an excellent publication from "Step Change in Safety", an umbrella safety organisation for the offshore industry. It attempts to draw out the lessons from deaths in the offshore sector; with permission, reproduce extracts from the report which are equally applicable to our industry: "There are several common threads running through these fatalities. The most common is that of mistaking 'routine' for 'safe'. We manage complex operations effectively but at times exercise inadequate control over risks arising from routine operations. Responsibility for this lies with personnel at all levels........ At times we also fail to plan, design and supervise such routine tasks adequately, to make them as tolerant to human error and variations in human behaviour as possible." Common threads identified include: 1. "Routine tasks are consistently underestimated in terms of the risk they pose. Re-examination of routine tasks is necessary across the industry to assess exposure. 2. Supervisors are not spending sufficient time at the work site. Supervisors need to spend more time supervising and setting expectations and need to have sufficient administrative support to ensure that they achieve this. 3. Workers are vulnerable because they do not perceive the risk - or deem it acceptable (i.e. part of the job). Peoples' risk perception needs to be constantly challenged particularly in the area of routine tasks. 4. The extent to which established procedures are ignored is significant. The reason behind this needs to be an ongoing and active discussion on all installations. 5. Procedural violations were often observed but tolerated thus... a. The obligation to intervene must be embedded, but... b. People don't like to get involved and need to practice, and in practicing... c. People need to learn to be sensitive in offering challenge (criticism) and generous in receiving it. 6. The credibility and use of risk assessment is not at the required level. The character of risk assessment must be changed - in particular the written form. The starting point must be the question - What is useable, meaningful and useful to the workforce? Risk assessment should be live, should stimulate thinking, be an integral part of planning and be useful and useable i.e. well laid out - rather than driven by regulatory concern." Let us use the lessons from another sector to make our own industry safer. Stephen Meyer Chief Inspector of Marine Accidents December 2003

Part 1 - Merchant Vessels A safety officer, MAIB investigator, or anyone else involved with safety investigation, is not satisfied in finding out just "whodunnit". Accident investigation is about understanding why accidents happen, and realising the underlying problems that have to be addressed for future safety. Even the most safety conscious of us will, occasionally, initiate unsafe acts such as those reported in this Safety Digest. Most of us do not commit these acts on purpose! The engineer did not mean to flood the engine room; the bridge watchkeeper did not intend a close quarter situation; the master did not want the ship to take a 25° list. Complacency is a word often discussed at the MAIB. People do things without appreciating the dangers. Routine, but unsafe, practices that have continued for months, if not years, are assumed to be safe simply because they have been undertaken without incident. A mooring winch, reported in this issue, was unfit for use, yet the crew had continued to use it in this condition until it killed a shipmate. Nobody: crew, classification society surveyor, manager, questioned its fitness for purpose until the accident. It is likely that readers will know what solutions are needed to prevent another dreadful accident such as this. But what is also important is the need for forethought and an awareness of what can be done to avoid hazards. We should ask ourselves if instructions and warning signs are understandable and easy to follow. An awareness of what might occur is often forgotten through habit and expectation. Forgotten knowledge, are you ready for an update?

Case 1: 2a and not 2b - That is the answer! Narrative An oil tanker was on passage in good visibility in the south-west lane of the Dover Traffic Separation Scheme. A ferry had departed Dover on an easterly course with the intention of crossing the south-west lane at right angles to the general direction of traffic flow. At about 2050, the ferry altered course to approximately 120°. At this time, the tanker was at about 5 miles range, and the alteration resulted in a predicted clearance of about 0.25 mile ahead of the tanker at a predicted time of about 2100. The tanker's OOW misinterpreted the predicted clearance, and was satisfied that a risk of collision did not exist. The ferry's OOW, however, interpreted that a risk of collision did exist and, at about 3 miles range, gave a series of flashes to prompt the tanker to take avoiding action. He then attempted to contact the tanker by VHF radio and gave another series of flashes before deciding to take avoiding action himself by altering course to port. The tanker's OOW maintained course and speed, and the ferry passed down the tanker's starboard side at a range of about 0.25 mile.

Extract from CNIS Plot showing the respective tracks of the tanker and the ferry

The Lessons The Collision Regulations make it clear that if there is any doubt as to whether a risk of collision exists, it shall be deemed to exist. In this case, however, the tanker's OOW had misinterpreted the predicted clearance and, consequently, was confident that a risk of collision did not exist. It is for this reason that the Collision Regulations provide stand-on vessels with an option to avoid collision by their action alone as soon as it becomes apparent that the give-way vessel is not taking appropriate action in compliance with the Rules. The ferry's OOW indicated his doubt by giving a series of flashes. This was recognised by the tanker's OOW; however he chose to maintain course and speed as he had originally intended. In doing so, he unnecessarily placed a burden of responsibility on the ferry's OOW to consider what best action to take. Rule 2(a) requires an OOW to be alert to special circumstances and to take precautions in accordance with the ordinary practice of seamen. In this case, it would have been seaman-like to have

heeded the ferry's doubt, assumed a risk of collision to exist, and altered course to starboard around the ferry's stern. By maintaining course and speed, the OOW merely prolonged a period of uncertainty and thereby reduced the safety margins available to both vessels in which to prevent a collision. 1. The ferry's OOW had an option of waiting for a suitable gap in the traffic before altering course to cross the traffic lane. He should have recognised that, by altering course at that time, at the edge of the traffic lane, he would create a risk of collision with the tanker, and that time would be limited for the tanker's OOW to assess the situation and take sufficiently early and substantial action. Such forethought derives from good seamanship, a quality required by Rule 2(a). 2. If circumstances permit, Rule 17(c) requires a power-driven vessel which opts to take action in a crossing situation, not to alter course to port for a vessel on her own port side. However, the ferry's OOW considered that an alteration of course to port could be executed safely in view of the vessel's high manoeuvrability and speed.

In requiring an OOW to be alert to special circumstances, including the limitations of the vessels involved, Rule 2(b) permits an OOW to depart from the Rules when necessary to avoid immediate danger. In this case, the ferry's OOW had alternative options, such as reducing speed or altering course to starboard to parallel the tanker's heading. An alteration of course to port was unnecessary in the circumstances and, therefore, contrary to Rule 2(b) as well as Rule 17(c).

Had the tanker's OOW altered course to starboard, albeit belatedly, in response to the ferry's signal, uncertainty would have prevailed and a collision might then have resulted despite the ferry's high manoeuvrability and speed.

Case 2: Communications...Communications ...Communications Narrative In preparation for going to sea, a hydraulically powered deck crane on a 70m vessel was being stowed. During this operation, the piston rod of the jib control cylinder failed. This allowed the cylinder to fall and the jib to swing out from the crane body. There was no load on the crane at the time, and there were no injuries. The crane was disabled and securely lashed to allow the vessel to go to sea. The piston rod failed at the site of an earlier repair. This was a temporary welded repair, performed to allow the crane to be safely stowed while a new replacement piston rod was found. The material of the rod was unsuitable as a permanent welded repair, in a safety critical, load-bearing component. However, the crew had assumed the repair to be permanent and, quite naturally, were very concerned by this failure.

The Lessons 1. Ship's staff, who operated the crane when the piston rod failed, were unaware of the purpose of the temporary repair. Clear communication with the 'repairers' should have established the nature of the 'repair'. 2. Had the repair been a permanent one, the crane should have been examined and load tested according to regulation. Until such examination and tests were completed, the crane should have been clearly identified as being out of service and disabled.

3. Owing to crew changes, ship's staff were unaware of the purpose of the temporary repair to the piston rod. Communication at crew changes is vital on matters associated with safety critical systems such as lifting gear.

Case 3: A Nasty Surprise Narrative A steel workboat, capable of carrying 98 passengers, and operated in sheltered waters, had just been boarded and prepared for departure. Before she cleared the berth it was noticed that she was down by the head. The passengers were safely disembarked. It was found that a void space forward was flooded. The vessel was taken to a nearby slipway and hauled from the water. A hole, about 4cm diameter, was found in the hull plating about 50cm below the normal waterline (see figure). This was the cause of the flooding. Further areas of unexpectedly heavy pitting were found in other parts of the hull. The vessel had been surveyed about 10 months previously, when the hull's anodes were found in good condition. Many years of operating history in the same area caused the owners to believe they would comfortably last until the next planned survey. Further investigation established that the vessel had recently changed her duties. From being in use every day, she had been relegated to a standby role and, consequently, was used only once a week. She thus spent most of her time at a lay-up berth alongside a pier constructed of steel. The owners concluded that stray electrical currents between the steel pier and the vessel's hull in the lay-up berth had contributed to accelerated wastage of the anodes. In turn, corrosion rates of the hull then became significant and resulted in the perforation and flooding.

Close up of pitted area on the hull of the vessel

The Lessons 1. Accelerated wastage of anodes can be caused by changes in operating conditions. Rapid hull corrosion can follow. 2. Damaging stray electric currents can also be the result of electric welding on board without proper earthing. Other electrical equipment, such as battery chargers supplied by shore power, can cause them too.

Case 4: Cargo Shift in Heavy Weather

Cargo vessel at sea

Narrative A ship carrying just over 10,000m3 of timber packages, of which about one third was stowed on deck, encountered a severe gale and high seas while on passage in the English Channel. Proceeding directly into the wind and sea caused her to pound, which made it unsafe for her crew to check and tighten the wire lashings securing the deck cargo. Although speed was reduced from about 12 knots to 8 knots through the water, large amounts of water were shipped on to the deck cargo. About 2 hours after darkness had fallen, loud bangs were heard from the cargo deck as two of the wooden uprights used to help secure the stow were broken. The master realised the deck cargo had started to shift and altered course to port to close the French coast; the nearest place of safety. Speed was also increased to 12 knots. On the new course, the sea was now about 35° on the starboard bow, and the ship started to roll more heavily. About 20 minutes later, she rolled heavily to port. This caused the deck cargo to shift about 0.5m across the deck and to break all of the remaining uprights on the port side. The ship immediately listed to between 10° and 15° to port. Speed was reduced to 8 knots, and course was altered very slowly to put the sea on the port side to try and shift the cargo back to starboard. As the ship's motion was more comfortable on this heading, speed was again increased to 12 knots to close the English coast. Two tanks on the starboard side were then ballasted but, although this reduced the ship's roll, her list continued to increase. Several hours later, the ship experienced a total electrical failure, and the main engine stopped. Soon after, an attempt was made to jettison some of the deck cargo but, although the crew managed to cut the after-most wire lashing, the cargo did not move. As the next lashing wire could only