SAFETY Marine Accident DIGEST Lessons from Marine

Investigation branch Accident Reports 3/2009

is an MARINE ACCIDENT INVESTIGATION BRANCH

INVESTOR IN PEOPLE

SAFETY DIGEST Lessons from Marine Accident Reports No 3/2009

is an MARINE ACCIDENT INVESTIGATION BRANCH

INVESTOR IN PEOPLE

© Crown copyright 2009

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Further copies of this report are available from: Marine Accident Investigation Branch Mountbatten House Grosvenor Square Southampton SO15 2JU

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 2009

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 Mountbatten House, Grosvenor Square, Southampton, SO15 2JU.

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 information which has 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, Mountbatten House, Grosvenor Square, Southampton, SO15 2JU

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 2009

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. A Flood and Fire – a Testing Time 10 2. Of Course They Can See Us, Can’t They? 16 3. Complacency Leads to Blackout and Grounding 19 4. New Berth, Old Routine 22 5. It Takes Two to Tango 25 6. Timber Cargo Reminder 28 7. Hot Work – Some Risks Are Not Always Obvious 31 8. Thanks For The Advice! 34 9. An Unconventional Manoeuvre with a Surprise Ending 35 10. Failure of Provisions Crane 39 11. Select Your Experts Carefully 42 12. Lorry Cab Fire – Vigilance and Training Saves the Day 44 13. Bow Door Cautionary Tale 47 14. Passing Gas Causes Concern 51 15. Turn For The Worse 53 16. Too Much to Do 55

Part 2 – Fishing Vessels 56 17. What Did We Hit? 58 18. A Costly Snack 62 19. A Basic Mistake Costs a Deckhand His Life 63 20. Over and Out 65 21. Downflooding and Stability Reminder 67 22. What Price an Arm? 69

Part 3 – Small Craft 74 23. Teenage Tragedy 76 24. Waves Aren’t Always Fun 78 25. Injured, But Lucky to be Alive 81

APPENDICES 82 Appendix A – Preliminary examinations and investigations  82 started in the period 01/07/09 to 31/10/09 Appendix B – Reports issued in 2009 83

Glossary of Terms and Abbreviations AB – Able seaman m – metre ARPA – Automatic Radar Plotting Aid “Mayday” – The international distress signal C – Celsius (spoken) CCTV – closed circuit television MCA – Maritime and Coastguard Agency CO2 – carbon dioxide OOW – Officer of the Watch CPP – Controllable Pitch Propellers PTW – Permit to Work ECR – Engine Control Room RIB – Rigid Inflatable Boat EPIRB – Emergency Position Indicating RNLI – Royal National Lifeboat Institution Radio Beacon Ro-Ro – Roll on, Roll off GPS – Global Positioning System SMS – Safety Management System HRU – Hydrostatic Release Unit SWL – Safe Working Load IMO – International Maritime TSS – Traffic Separation Scheme Organization UV – ultraviolet kg – kilogram VHF – Very High Frequency LPG – Liquefied Petroleum Gas VTS – Vessel Traffic Services

Introduction It is only a year since I last wrote about the importance of risk assessments. However, in the past 12 months, so many deaths have been reported that could have been avoided by a simple consideration of the risks, that I feel compelled to return to the subject.

Just the phrase “risk assessment” is enough to cause most mariners’ eyes to glaze over. “More paperwork and bureaucracy” I hear you cry. But what I am after is the thought process, not the paperwork. Let me give you a couple of examples.

This morning I was briefed on the death of a fisherman. The owner and the skipper of the vessel had so nearly got it right, but for want of following things through, a man died last week. The fishing boat had one of the best risk assessments I have seen, and the fish deck had been specifically designed to eliminate major hazards. Unfortunately, in the months since the vessel had been built, the method of working had been modified, and the hazards associated with the new system had not been risk assessed. Additionally, neither the skipper nor the owner were monitoring how the crew were operating, and one of the crew had developed his own system of repairing fishing gear. These two minor changes to a well risk assessed system cost one man his life – what a price for 20 minutes or so, to risk assess those changes.

My second example is given in Case 25. Two leisure craft were involved in this case, with two separate risks that had not been considered. In the first, a man fell overboard when doing the simplest of routine daily tasks. Had the risk been thought about, there were several simple ways of reducing it. He was not wearing a lifejacket, and owed his life to the alertness of two men in another yacht, who heard his cries and went to rescue him. Unfortunately, despite there being two men on board, they were unable to get him out of the water. Recovering a person from the water to a yacht or even a small power boat is much more difficult than people imagine. Have you worked out how you would do it – and have you briefed your crew in case it is you in the water? A simple mental run through the risks involved in sailing, and a crew talk at the start of a day’s sailing, would dramatically reduce the likelihood of an accident.

In the aftermath of an accident, we are almost always told what steps people intend to take to stop such an accident happening again. Please read through the accounts of incidents in this Safety Digest, and take appropriate steps now, rather than waiting until you learn the hard way.

Stephen Meyer Chief Inspector of Marine Accidents December 2009

MAIB Safety Digest 3/2009 7

Part 1 – Merchant Vessels As another year • Lack of or insufficient risk assessment, draws to a close we including not looking for hidden dangers should be grateful or respecting the power and capacity for that the MAIB has change of the elements published the third of this year’s Safety • Poor inter-personal skills and Digests. Each issue communications and the reports they contain are a valuable • Insufficient manning for the ship’s operating contribution to improving safety at sea and in environment. port, so protecting lives, property and the marine environment. They provide the means Whether we are working at sea or ashore, to learn from others’ misfortune even if when there is much to learn from these reports and, reading about an incident you may think the if we are honest, it is likely that we can all recall participants brought that misfortune upon similar incidents in which we have been themselves. Such is the benefit of hindsight. involved but were fortunate that something It is a crucial foundation of the MAIB’s role or someone intervened at a crucial moment not to be part of the increasingly prevalent to avert an accident. Perhaps too, we can Blame Culture which has inevitably led to remember practices before the ISM Code the criminalisation of seafarers for genuine when reporting of near misses (or near hits accidents rather than intentional acts. No as some now prefer to call them) was not excuses should be made for those deliberately required by international regulations. I can breaking the law but we must all work together certainly remember some of my unsafe to ensure that the IMO’s Guidelines on the practices and as I read MAIB and MARS reports Fair Treatment of Seafarers involved in marine others come back to me, and they still have accidents are universally applied. Accidents the power to make me shudder and thank my should not be criminalised and international lucky stars that they did not lead to a casualty. maritime law should be respected. In this Safety Digest, it is encouraging to read Yet we should soberly reflect on the recurring in some cases that despite the initial problems themes in these incidents that the MAIB has that resulted in the incident being investigated, so carefully investigated, and, if I may be the ship’s crew reacted professionally in permitted to mention them, the reports in containing the situation and averting disaster. the Nautical Institute’s confidential Mariners’ There are, for example, four cases involving Alerting & Reporting Scheme (MARS). In this fire – probably the seaman’s greatest fear. issue of the Safety Digest, we have In each case, the crew’s training resulted in a depressingly familiar reports on: rapid and successful fire-fighting response in challenging circumstances. This underlines • Poor watchkeeping, usually combined with the value of professional training courses and distraction by other work frequent drills on board. It should go without saying that these drills need to be varied and • Poor seamanship, in which I would include effective rather than just going through the lack of knowledge of the ship’s systems and motions to tick the right boxes in the Safety operating capabilities Management System documentation. Each drill should also be preceded by a risk assessment, in itself a useful training exercise, and planning involving the key personnel. The aim of all these activities is that, when a real emergency

8 MAIB Safety Digest 3/2009

occurs, the crew will know exactly what to do other operations without it may well be the and how to do it in a calm and efficient difference between a successful voyage and manner despite the pressure that an disaster. However, it is also about not emergency is bound to cause. developing an over-reliance on technology so, if you are a navigator, enjoy looking out of the This is simply good seamanship (fortunately bridge window and using all your senses to Political Correctness has not forced us to assess the shipping and elements around you. change to seapersonship just yet). So what Similarly, in cargo operations read everything makes a good professional seaman? A key you can about the cargoes’ characteristics, use attribute, I think, is attention to detail and a all your senses to assess danger and stop willingness to check, check, check. Does this operations whenever necessary. support the proliferation of check lists in the industry today? Yes, but only if they are Above all, share your knowledge and relevant to the ship and specific operation as experience with others, on board, within well as being used to really assess the your fleet and through industry publications equipment, readiness, or conditions rather so that lessons are learned and best practice than mindlessly ticking the box. They should encouraged. By doing so, you will be be an aide mémoir to correct operations, not contributing to safer and more efficient merely a documentary defence after the event. shipping operations which will not only This eye for detail must be combined with protect the marine environment, and so professional knowledge through effective gain the approval of the public, but will be training and will, with sufficient sea time, lead an important part of reversing the to experience. Seamanship is also about criminalisation trend. making competent use of the technology at your disposal whilst developing and Safe sailing and enjoy being a professional maintaining your core skills as a seafarer. seafarer. This is essential for those times when the technology lets you down at crucial moments, and being able to carry out navigation and

Mr Philip Wake, MSc RD* FNI In May 2003, Philip Wake became the Chief Executive of The Nautical Institute – the international professional body for qualified seafarers – having served in the Secretariat since November 1999. Prior to that, he was Chairman of the voluntary London Branch in 1998/99 and was elected a Fellow in 1996. Previously, he served at sea from Cadet to Chief Officer with Ellerman City Liners before coming ashore to a container consortium where he established a new commercial department focusing on operational cost control. He became a Senior Consultant in shipping economics at Lloyd’s Maritime Information Services, and latterly was a Director of Clarkson Research Studies – a division of major shipbroker, Clarksons. He gained his Master’s Certificate of Competency (Foreign Going) in 1978 and was awarded an MSc in Shipping, Trade, and Finance from the City University Business School, London in 1988. He also served in the Royal Naval Reserve specialising in Mine Counter Measures and Naval Control of Shipping. He is a member of the Council of the RNLI (Royal National Lifeboat Institution); a Younger Brother of Trinity House, London; an active member of the Honourable Company of Master Mariners; and a Trustee of the CHIRP Charitable Trust (which runs a confidential hazardous incident reporting scheme for aviation and maritime.

MAIB Safety Digest 3/2009 9

A Flood and Fire – a Testing Time Narrative against the windlass brake tension, into the water. As the ship had pitched, the anchor had The master of a Panamax container ship impacted against the hull, causing numerous obtained a weather forecast before sailing just indentations and holes (Figure 2), and flooding after midnight. The forecasted winds of force to five adjacent compartments. 5 to 6 were set to worsen, but this did not concern him. After dropping off the pilot the After securing the anchor once again, the master instructed the bosun to fully secure passage was resumed to the next port, where the anchors. The chain lashing was fitted and repairs had been arranged by the shore the Senhouse slip tapered pin pushed in by management. Despite the crew’s damage hand, the guillotine blocks were lowered and control efforts, and continuous bilge pump it was said that the brake was fully tightened operation, the water level in the bow thruster (Figure 1). After the bosun reported the room eventually reached the outside sea level anchors secured, the master increased speed. because of undetected holes in the bilge area. No heavy weather checks were carried out. As the ship continued her passage, the weather moderated, and she arrived in port for Overnight the weather deteriorated and the repairs and cargo operations 3 days later. ship’s speed was reduced. At about 0800 the chief officer was sufficiently concerned about On arrival at the lay-by berth, a survey the conditions that he put the upper deck out identified the need for 23 insert plates. The of bounds so that heavy weather checks could port authority approved the hot work, which not be undertaken. However, he did warn the was conditional upon the contractor engineers and catering staff to check that their complying with the ship’s Safety Management departments were properly secured for rough System (SMS). However, the instruction was in weather. A rapid sequence of events was about a foreign language which the crew did not to take place. understand, and they did not query it.

By 1200 the wind had further increased to The ship duly moved to the container berth force 8 to 9, with rough seas. At about 1215 to discharge her cargo. As far as the crew alarms sounded in the Engine Control Room. were concerned the contractors were moving There was a smell of burning around the their repair equipment on board, which electrical supply breaker panels, and a number included 15 acetylene and 16 oxygen bottles