MARINE ACCIDENT SAFETY DIGEST Lessons from Marine

INVESTIGATION BRANCH Accident Reports

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INVESTOR IN PEOPLE

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 3/2007

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INVESTOR IN PEOPLE

Department for Transport Great Minster House 76 Marsham Street London SW1P 4DR Telephone 020 7944 8300 Web site: www.dft.gov.uk

© Crown copyright 2007

This publication, excluding any logos, may be reproduced free of charge in any format or medium for research, private study or for internal circulation within an organisation. This is subject to it being reproduced accurately and not used in a misleading context. The material must be acknowledged as Crown copyright and the title of the publication specified.

Further copies of this report are available from: Marine Accident Investigation Branch First Floor, Carlton House Southampton SO15 2DZ

Printed in Great Britain. Text printed on material containing 100% post-consumer waste. Cover printed on material containing 75% post-consumer waste and 25% ECF pulp. December 2007

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 and incidents. 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

Summaries (pre 1997), and Safety Digests are available on the Internet: www.maib.gov.uk

Crown copyright 2007

MARINE ACCIDENT INVESTIGATION BRANCH

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 2005 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”

INDEX GLOSSARY OF TERMS AND ABBREVIATIONS 6

INTRODUCTION 7

PART 1: MERCHANT VESSELS 8 1. No Easy Withdrawals From This Bank 10 2. Odd Ship, Odd Handling 13 3. A Bridge Too Far 15 4. Rain, But No Rainbow 17 5. A Tale of Two Lookouts 18 6. Don’t Take Chances in Heavy Seas 20 7. Bridge Team’s Multiple Failures Lead to Grounding 22 8. Same Old Story … 24 9. Never Mind the Waypoint – Mind the Ship 26 10. Contain Containers 28 11. Hatch Hazards 30 12. Blocked Sea Suction Prevents Engine Room Flood 32 13. I See No Ships 34 14. Unsecured Electrical Fan Causes Cabin Fire 36 15. Pretty But Dangerous 38 16. Hurry Aground 39

PART 2: FISHING VESSELS 42 17. Too Much Up Top! 44 18. Not Dressed for the Job 46 19. Shrimp Boiler Lights up the Engine Room 48 20. Spot the Difference 51 21. Trim For Safety, Not For Catching Fish 52 22. Two Sides of the Same Coin 55

PART 3: LEISURE CRAFT 58 23. Relaxing Canal Trip Ends in Tragedy 60 24. Lookout – Above and Below the Water 62 25. How Safe is Your Safety Boat? 64

APPENDICES 66 Appendix A – Preliminary examinations and investigations started in the period 01/07/07 to 31/10/07 66 Appendix B – Reports issued in 2007 67

Glossary of Terms and Abbreviations AB – Able Seaman ARPA – Automatic Radar Plotting Aid Cable – 0.1 nautical mile CO2 – Carbon Dioxide CPA – Closest Point of Approach CPR – Cardiopulmonary Resuscitation DSC – Digital Selective Calling EPIRB – Emergency Position Indicating Radio Beacon FRC – Fast Rescue Craft GMDSS – Global Maritime Distress and Safety System GPS – Global Positioning System GRP – Glass Reinforced Plastic ISAF – International Sailing Federation ISM – International Safety Management Code kW – kilowatt m – metre MGN – Marine Guidance Note MOB – Man Overboard OOW – Officer of the Watch OSR – Offshore Special Regulations PEC – Pilotage Exemption Certificate RIB – Rigid Inflatable Boat RNLI – Royal National Lifeboat Institution RORC – Royal Ocean Sailing Club RYA – Royal Yachting Association SAR – Search and Rescue SFIA – Sea Fish Industry Authority SOLAS – International Convention for Safety of Life at Sea STCW – International Convention on Standards of Training, Certification and Watchkeeping TSS – Traffic Separation Scheme VHF – Very High Frequency VTS – Vessel Traffic Service

Introduction

I have just returned from the annual meeting of the Marine Accident Investigators’ International Forum (MAIIF). Attended this year by the senior investigators of 25 countries, it rapidly became apparent that we all had the same overriding safety concerns. Three of these - fatigue, complacency and poor Bridge teamwork - are amply illustrated in the Merchant Vessel section of this edition of the Safety Digest. Please read these cases and then consider, if accident investigators from around the world all see these same issues time and again in accidents, how confident are you that you/your ship/your company are getting them right?

The other key concern we all shared was the apparent growth in the number of accidents involving entry into enclosed/confined spaces. Although there are no examples in this Safety Digest, MAIB is currently dealing with three such cases, two of them fatal, and many other countries at MAIIF reported similar. Please look again at your systems and re-brief your crews on the importance of correct ventilation and entry procedures. This is a critical area, where complacency cannot be allowed to grow.

The Fishing Vessel and Leisure Craft sections again provide a cross section of accidents, many tragic. Better awareness of risk would stop most accidents - before a trip, or before a specific evolution, just think through with your crew: “What are the dangers?”; “What do we need to do to avoid each one happening?”; “What should we do to minimize the effect if it were to happen?”; and “how would we deal with it if it does happen?” Such a quick and simple discussion could save lives.

Think safety and stay safe.

Stephen Meyer Chief Inspector of Marine Accidents December 2007

MAIB Safety Digest 3/2007 7

Part 1 – Merchant Vessels Who can afford to continuous improvement. I have no doubt that ignore free advice the most influential factor upon the safety when it is readily management system for which I am available? This MAIB responsible, is our standard agenda item “Safe Safety Digest is Learning Events”. This ensures that fleet commended as a management meetings thoroughly consider all wonderful source of lessons to learn from any unplanned event in such advice. From order to improve procedures and guard cradle to grave we against risk. humans learn by experience. It was Safe learning events are not limited to own Oscar Wilde who company incidents but can usefully be wrote (in Lady extended to include those published by CHIRP Windermere’s Fan) “Experience is the name (The independent marine Confidential everyone gives to their mistakes”. How much Hazardous Incident Reporting Programme), better to learn from the experience of others MARS (The Nautical Institute’s Marine and avoid the stress of making the mistakes Accident Reporting Scheme) and of course the yourself! MAIB Safety Digest.

We work in a heavily regulated industry for I am convinced that the MAIB makes a major which most regulation can be traced back to contribution to safety at sea through its one of a number of major shipping casualties investigation of accidents and identification of that occurred during the twentieth century. lessons to be learned. The lessons identified in One such regulation gave us the ISM Code, an MAIB Safety Digests and Investigation Reports excellent framework for robust safety should be the staple diet of a healthy safety management which requires that each management system. company’s objectives include the continuous improvement of safety management skills. The Human behaviour is fundamental to the Code also requires procedures to ensure that effectiveness of even the healthiest safety accidents and hazardous situations are management system. Any procedure is only as reported, investigated and analysed with the good as the behaviour of those tempted to objective of improving safety. How many of the violate it. Unchecked, humans easily succumb major shipping casualties referred to could to complacency. We should rise above this have been prevented by an earlier focus on weakness and extract the learning points from continuous improvement through learning all unplanned events, whether in our from mistakes? experience or the experience of others. In this context we should also ensure and encourage Our industry has been poor at learning from a level of reporting that enhances its mistakes, but as a result of the ISM Code organisational learning and fosters continuous and a more enlightened attitude by improvement in safety management. management, a change has taken place in recent years to correct this weakness; there is The case studies included in this section of the a gradual move towards a culture where when digest clearly reflect the significant risks to safe things go wrong we now look for lessons to ship operation, although it might be argued learn rather than people to blame. that the number of ‘fire’ incidents reported is disproportionately light. The majority of It is only by identifying the lessons to learn studies relate to collision or grounding which from incidents that we will encourage resulted from weak bridge team management

8 MAIB Safety Digest 3/2007

and inadequate briefing. It is notable that one How professional is your behaviour? How third of these navigational incidents occurred strong is your Human Element? If you learn with a pilot advising on the conduct of the from every available opportunity and do not ship. It is essential that the pilot effectively allow complacency to get the better of you, interfaces with the bridge team who, if you will strengthen the influence of the human adequately briefed, can properly monitor element upon the safety management system compliance with the intended voyage plan. that your company operates. In that way we can all contribute to making our industry safer. Nearly all the case studies were the result of Let us start now by putting into practice the complacency in decision making or in the co- lessons identified in the following pages. ordination of actions. Complacency is the temptress that lures seafarers into violation of Safe sailing and best practice – always. safe procedures, the modern equivalent of the sea nymph “Siren”, and can only be resisted by highly professional individual behaviour at all times.

Captain Simon Richardson

Captain Richardson is Head of Safety Management for P&O Ferries. He has 30 years experience in the ferry industry, 9 years of which was spent in command. Since coming ashore into fleet management 10 years ago he has held the positions of P&O Group Marine Audit Manager, Fleet Manager for P&O Stena Line and moved into his current role upon the restructuring of P&O Ferries to include all the company’s ferry operations.

He is a Fellow of the Nautical Institute, a member of the Marine Advisory Board for CHIRP and a Younger Brother of Trinity House. His preferred leisure activities include walking and narrowboat holidays.

MAIB Safety Digest 3/2007 9

No Easy Withdrawals From This Bank Narrative At about 1600, course was adjusted to follow the second set of leading lights astern, the At 1544, an 1857gt general cargo ship slipped base course of which was 091°, to clear the from her berth. Before departing, the pilot and channel. The pilot then advised the master master had agreed that the pilot would that he was disembarking into the pilot cutter, disembark before the ship reached the port and that the master should put the engine to limits because of the potential difficulty in full ahead, and aim for the red buoy marking getting off in the swell which could be seen the south side of the entrance to the channel towards the open sea. They did not discuss the as soon as he was clear. ship’s engine power, which the master considered was 1000kW, but which was actually Escorted by the chief officer, the pilot 600kW. By 1551, the ship had turned off her disembarked at about 1602. The ship was berth and was heading toward the departure fewer than 5 cables from the end of the channel. The channel was 50m wide, just over channel and about 7 cables from the pilot’s 1 mile long, and its centre marked by two sets usual disembarkation position. The master of leading lights. It was semi-darkness, raining, then increased to full ahead, but the ship and the wind was a force 5 to 6 from the started to be set to the north. This was seen south. The master was on the helm and was by the pilot following in the cutter astern, steering courses as advised by the pilot, who and he immediately repeated his previous monitored the ship’s position using leading advice to the master via VHF radio. To assess lights astern. Speed was increased to 6 knots. the ship’s position, the master used the

Figure 1: Damage to the vessel’s steering gear

10 MAIB Safety Digest 3/2007

16:28:29

16:11:20

16:00:11 16:00:54 16:02:16 16:03:22

16:06:13

15:59:10

Figure 2

lateral buoys ahead, supported by single chief engineer reported to the master that the radar range and bearing fixes provided by the steering gear was badly damaged (Figure 1). chief officer on his return to the bridge, and The ship was now on a south easterly heading, was not immediately aware of the degree of and as she continued to be set to the north by the set being experienced. When he did the wind and the swell, her forward part made realise the ship was to the north of the contact with a green lateral buoy marking the channel, the master was reluctant to alter too north side of the channel. Both anchors were far to starboard because of the narrowness of then let go and the ship came to rest at about the channel and the dangers on its southern 1628. side. The ship’s ground track from leaving her berth At about 1605, the ship started to pitch heavily until 1630 is at Figure 2. She remained and slowed quickly as she started to take the aground for 6 days, and was only refloated ground on a sandbank. Her main engine was after her bunkers and some of her cargo were kept at full ahead, but was stopped when the removed.

MAIB Safety Digest 3/2007 11

The Lessons In the first instance, such information needs to be accurate, and where marginal 1. The need for compulsory pilotage is conditions make the manoeuvrability of a based on a risk assessment undertaken by vessel a major consideration, it should be the relevant port authority. It is therefore discussed between the master and the likely to be appropriate for such a pilot before sailing. requirement to apply in highly adverse conditions, particularly those which 3. Where there is little margin for error in a make boarding or landing a pilot too narrow channel, the use of leading marks dangerous. These conditions inevitably or lights in transit frequently provides make the safe passage through restricted the quickest and most accurate means of waters more difficult than usual, and the keeping a ship safe. However, the use of premature departure of a pilot can place these aids at night and when they are the master in an extremely difficult astern is not always easy. Unfortunately, situation, and one which he might lack although the use of buoys is much easier, sufficient experience and local knowledge it is far less reliable, and fixes based on to successfully resolve. Therefore, where single radar ranges and bearings are circumstances dictate that a pilot is nowhere near as accurate. unable to disembark or embark as intended, the postponement of a sailing 4. Bridge organisation is an extremely or arrival must be seriously considered by important aspect of navigation through both the port authority and the master restricted waters, and adjustments to concerned. As a minimum, the port normal practice are occasionally required authority should satisfy itself that the to meet the demands of differing ship and crew are prepared and capable of situations. In this case, the master was safely navigating within the port limits alone on the bridge during the without the benefit of a pilot. disembarkation of the pilot, and had to focus much of his attention on the helm. 2. Without basic manoeuvring information, The use of a helmsman would have such as the power output of a ship’s allowed the master to move around the engine,