SAFETY Marine Accident DIGEST Lessons from Marine

Investigation branch Accident Reports 3/2008

is an MARINE ACCIDENT INVESTIGATION BRANCH

INVESTOR IN PEOPLE

SAFETY DIGEST Lessons from Marine Accident Reports No 3/2008

is an MARINE ACCIDENT INVESTIGATION BRANCH

INVESTOR IN PEOPLE

© Crown copyright 2008

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 2008

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.

If you do not currently subscribe to the Safety Digest, but would like to be added to the distribution list for hard copies, and/or email alerts about it or other MAIB publications, please get in touch with us: • By email at maibpublications@dft.gsi.gov.uk; • By telephone on 023 8039 5500; or • By post at: Publications, MAIB, Carlton House, Carlton Place, Southampton SO15 2DZ.

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 2008

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. Shipped Waves Kill Two Seamen and Seriously Injure Another 10 2. Fire Extinguishers – Are You Sure Yours Are Correctly Serviced? 12 3. Full Astern! Not 13 4. Failing to Plan… 16 5. An Unfortunate Chain of Events 18 6. Snagged Ropes Can Kill, Too 21 7. Know your GPS Track Plotter Limitations – Over-Reliance Causes Grounding 23 8. The Hardest Way to Learn 26 9. Steaming Towards Disaster 28 10. Caught in a Jam 31 11. Poor Protection – Rash Outcome! 33 12. Beware of Fumigated Cargoes 37 13. Ship or Tug’s Line? 39 14. Pilot Vessel – You’re Fired 41 15. Bollards! 44 16. In the Tank – Not Over the Side 46

Part 2 – Fishing Vessels 50 17. Double Tragedy 52 18. Water in Fuel – A Recipe for Expensive Problems 54 19. Between a Rock and a Hard Place 57 20. When Making a Cup of Tea Wrecks a Crabber 59 21. Wooden You know 61

Part 3 – Leisure Craft 64 22. They Normally Wore Lifejackets 66 23. Clipped On? 68 24. Tragic End to a Day’s Fishing 70 25. Myriad of Fire Risks Ends in the Inevitable 74

MAIB NOTICEBOARD 78

APPENDICES 80 Appendix A – Preliminary examinations and investigations started  80 in the period 01/07/08 to 31/10/08 Appendix B – Reports issued in 2008 81

Glossary of Terms and Abbreviations AB – Able seaman CoSWP – Code of Safe Working Practices CO2 – Carbon Dioxide DSC – Digital Selective Calling EEC – Electrical Engineering Cadet EEO – Electrical Engineering Officer EGE – Exhaust Gas Economiser EPIRB – Emergency Position Indicating Radio Beacon FRC – Fast Rescue Craft GPS – Global Positioning System GRP – Glass Reinforced Plastic GT – Gross tonnes HP – Horsepower HSE – Health and Safety Executive IMDG – International Maritime Dangerous Goods IMO – International Maritime Organization ISM – International Safety Management Code kHz – kilohertz m – metre “Mayday” – The international distress signal (spoken) MCA – Maritime and Coastguard Agency MFO – Medium Fuel Oil MGN – Marine Guidance Note mm – millimetre OOW – Officer of the Watch PPE – Personal Protective Equipment RAF – Royal Air Force RNLI – Royal National Lifeboat Institution rpm – revolutions per minute SAR – Search and Rescue VDR – Voyage Data Recorder VHF – Very High Frequency VTS – Vessel Traffic Services

Introduction Tragically, in this edition of the Safety Digest, many of the incidents have ended with one or more fatalities. In nearly every case, the death(s) resulted from risks being taken unnecessarily and without recognition.

“Risk Assessments” have, to a certain extent, become mired in bureaucracy; they have become paperwork exercises, rather than life-saving assessments. Everything we do at sea is hazardous in one way or another – a few moments thought, to identify the risks of what we are about to do, would prevent most accidents. But familiarity breeds contempt; by the time we have done something a few times, we have lost the sense of danger. We rationalise subconsciously that, because we have always “got away with it”, it must be safe. Have this thought in your mind when you read the articles in this digest, and I hope you will see what I mean. Alertness to the dangers would have prevented many of the accidents. Then consider whether you, or the people who work with you, have become complacent.

I put a “stop press” notice in my introduction to the last Safety Digest, on an enclosed space fatality. This fatality is currently under investigation by the MAIB; MAIB has also recently published reports into a triple fatality on board Viking Islay and a double fatality in Sava Lake. There continues to be serious concern by accident investigators around the world that there remains an unacceptably high death rate due to enclosed space entry. On the noticeboard at the back of this digest, there is a copy of the Safety Bulletin MAIB issued on the subject.

Finally, in Sections 2 and 3, fishing and leisure, we find yet again that the biggest killer is the lack of a lifejacket. Unless you are wearing your lifejacket, properly fitted and secured, it will not help you in an accident. Accidents normally happen without warning at sea, so there is rarely time to “put them on when they are needed”. Do not make the assumption that you don’t need one because you are a strong swimmer – look at the tragic consequences of Case 22. The tide is slowly starting to turn and more people are routinely wearing lifejackets – please join the club.

Stephen Meyer Chief Inspector of Marine Accidents December 2008

MAIB Safety Digest 3/2008 7

Part 1 – Merchant Vessels The “Human related to safety issues. The ISM code, which in Element” is a rather essence is a fairly simple framework developed cold term that is to ensure the safe operation of ships, has been sometimes used to allowed to expand exponentially as a result of refer to “they that go the desire to produce a foolproof safety code, down to the sea in and to quote Douglas Adams “A common ships”. I became mistake that people make when trying to aware of the specific design something completely foolproof is to terminology of the underestimate the ingenuity of complete “Human Element” a fools”. Not that I would suggest we are few years ago when I complete fools, far from it, but I’m sure every attended an MCA hosted seminar on the very person who has ever written a policy or a subject. The seed was sown, and since then I procedure has experienced the same have tried to gain benefit from the learning disappointment of discovering that when his opportunities that incidents have presented to perfect policy is implemented the “Human me, with particular regard to the “Human Element” manages to find the one loophole Element”. Logically, if we can identify the which renders the policy or procedure causal factors of an incident it allows us to ineffective. develop safeguards to ensure, or at least minimise, the likelihood of a repetition of the We are all human and therefore we all make incident. There is no doubt in my mind, that mistakes, but the only real mistake we can the most common causal factor within most make is the one from which we learn nothing. incidents is the “Human Element”. It must be considered best practice to learn from our own mistakes, but to my mind it is I am sure that all masters will agree that even infinitely preferable to learn from someone well found vessels backed by a robust Safety else’s mistakes. To enhance our ability to learn Management System, manned by a trained and from each other we must communicate professional crew are frequently presented efficiently and effectively across the whole with learning opportunities. However, and spectrum of our industry, this is a fundamental despite all the advice available to us in our requirement and is of paramount importance Company Regulations, Safety Policies and to ensure the safety of all seafarers and the safe Procedures, Safe Working Practices, Risk operation of our ships. The MAIB safety digest Assessments, Safe Systems of Work and the is at the forefront of this communication mountains of information available externally network and is well supported by marine from professional bodies, we still suffer guidance notes, safety bulletins & of course incidents, accidents and near misses which, CHIRP reports. The prudent mariner will take after investigation, are generally found to be note of the advice and guidance from all attributable to the “Human Element”. sectors of our industry, as often the only thing that separates or defines incidents into a The Industry should recognise that the particular sector is the matter of scale. ‘Human Element’ extends beyond the crew to include shore administration, designers and management, who are just as liable to experience the effects of the “Human Element”. For example I would suggest that the effectiveness of the ISM code is being diluted due to the inclusion of too many operational elements which can be loosely

8 MAIB Safety Digest 3/2008

Captain Alastair McFadyen Captain McFadyen commenced his sea-going career with Wm Thomson of Leith, working on Ben Line steamers as cadet and second officer between 1972 and 1979. He then took a year’s sabbatical ‘working’ on sailing vessels in the Caribbean. In 1980 he joined Canadian Pacific, serving as second officer and chief officer. Between 1986 and 1992 he worked as executive officer for a prestigious government organisation in the Sultanate of Oman. Captain McFadyen joined P&O European Ferries in 1992 serving as second officer and chief officer before being appointed to the position of master and then senior master. In 2008 Captain McFadyen was delighted to receive the award of Lloyds List Ship Master of the Year. He is married with three children and lives in Sutton Coldfield. His hobbies include walking the dog and playing golf (though not necessarily in that order).

MAIB Safety Digest 3/2008 9

Shipped Waves Kill Two Seamen and Seriously Injure Another Narrative the first seaman turned towards the anchor cable, a large wave was shipped over the bow. A Panamax crude oil tanker carried out a ship-to- The ship pitched into the following trough and ship transfer while at anchor in a deepwater bay, then a second, larger wave was shipped on and loaded a full cargo of crude oil. After the board. The two seamen on the winch platform loading operations were completed, she were swept aft, towards and under the flying weighed anchor and proceeded seawards, her bridge. The other seaman was swept aft and escort tug letting go and her two pilots came into contact with a protection plate for disembarking near the entrance to the the forward liferaft. The bosun had managed deepwater bay. She then followed a designated to cling onto the store room door when the deepwater route in the relative lee of the land. first wave was shipped, and then onto the The wind was near gale force, with waves of about ladder rungs of the foremast as the second 4 to 5m high. The ship’s freeboard was about wave swept over the foredeck. He remained 6.6m and spray was being shipped on board. uninjured.

After weighing anchor, the bosun and a All three injured men were taken to the seaman had secured the port anchor and had accommodation. The ship reported the begun stowing three loose mooring lines down accident to the coastguard and requested into the forward store room. During the medical assistance. Later, the coastguard transit, two other seamen, who were stowing arranged a radio telephone link between the loose mooring lines away aft, were sent to ship’s master and a doctor at a hospital. Such assist forward. was the severity of the injured men that a local doctor was transferred by helicopter to the On clearing the confined waters of the ship. Once on board, the doctor determined deepwater route, the bosun instructed one that two of the seamen had died from their seaman to place a securing wire through the injuries and that the other should be taken to starboard anchor cable, while the other two, hospital. The helicopter airlifted the doctor on the starboard winch platform, were lashing and the injured seaman from the ship, which canvas covers around the mooring wires. As then returned to the deepwater bay.

10 MAIB Safety Digest 3/2008

Position of crew at the starboard winch platform

The Lessons 3. The master’s decision to leave the shelter of the deepwater bay before the 1. The two large waves that were shipped foredecks were secured for sea should over the bow could not have been have prompted an effective plan of considered abnormal and should have action. The plan could have concentrated been expected in the prevailing weather the crew forward earlier, leaving the conditions. It is dangerous to assume stowing of the after ropes until the fore that it is safe to work on deck in part of the vessel had been secured. marginal conditions, even in the largest ships. 4. The plan should also have prompted the need for precautionary measures, such as 2. It would have been more wise for the considering the option of turning the master to have delayed the sailing so that ship away from the weather, when safe the ship could be secured for sea in the and practicable to do so, to secure the sheltered waters of the deepwater bay. anchor.

MAIB Safety Digest 3/2008 11

Fire Extinguishers – Are You Sure Yours Are Correctly Serviced? Narrative exercise a practical demonstration was given on the correct use of the foam extinguisher. A large container ship was undergoing a The chief officer was dismayed by the “watery” routine dry docking in a Far Eastern shipyard. nature of the foam and its inability to provide Progress was good and on schedule. an effective foam blanket. Suspecting that it was an isolated case, he discharged a second As part of the contract, all the ship’s fire extinguisher, but with the same results. extinguishers were removed ashore for servicing by a certified contractor, and To compare the foam quality, the chief officer temporary extinguishers provided. In total, arranged for the two expended extinguishers 59 × 9-litre foam extinguishers were serviced, to be recharged using onboard spares. These which included renewal of the foam charge. produced the expected, thick foam blanket, The extinguishers were each provided with a which quickly smothered the fire. servicing certificate as they were replaced on board. The contractor quickly responded to the chief officer’s concerns and recharged all the foam An emergency exercise was carried out while extinguishers to the correct standard within 6 the vessel was still in dry dock. As part of the hours of the incident.

The Lessons It is reasonable to expect that a certified fire extinguisher servicing contractor should be It is unclear whether the contractor used the fully aware of the extinguishing materials wrong foam compound or if the specification. Nevertheless, the following concentration was incorrect. Fortunately, the lessons can be drawn from this hazardous defective extinguishers were not used in a incident: real incident. Had they been, it appears that the foam would have been incapable of 1. Where possible, check that the providing the necessary blanket to extinguish extinguisher