Marine Accident Investigation Branch (MAIB) - Safety Digest - Fishing 2000

Contents Marine Accident Investigation Branch ........................................................................6 Glossary of Terms and Abbreviations..........................................................................7 Fishing 2000 Safety Digest Introduction .....................................................................8 Part 1 Bilge Alarms and Pumping ...............................................................................9 Case 1 Two Recent Flooding Cases -Vessels Saved by the Bilge Alarm ................10 Narrative I .............................................................................................................................. 10 Narrative II............................................................................................................................. 10 The Lessons ........................................................................................................................... 10 Case 2 Fishing Vessel Flooded during Bilge Pumping.............................................11 Narrative ................................................................................................................................ 11 The Lessons ........................................................................................................................... 11 Case 3 Defective Bilge Alarm delays Discovery of Flooding ...................................12 Narrative ................................................................................................................................ 12 The Lessons ........................................................................................................................... 12 Part 2 Flooding and Foundering................................................................................13 Case 4 Corroded Pipework causes Flooding of a Fishing Vessel ............................14 Narrative ................................................................................................................................ 14 The Lessons ........................................................................................................................... 14 Footnote ................................................................................................................................. 14 Case 5 Rapid Capsize following Flooding ..................................................................15 Narrative ................................................................................................................................ 15 The Lessons ........................................................................................................................... 15 Case 6 Three Recent Flooding Cases -Mechanical Failures....................................16 Narrative I .............................................................................................................................. 16 Narrative II............................................................................................................................. 16 Narrative III ........................................................................................................................... 16 The Lessons ........................................................................................................................... 16 Footnote ................................................................................................................................. 16 Case 7 Loss of Older Wooden Fishing Vessel ............................................................17

Narrative ................................................................................................................................ 17 The Lessons ........................................................................................................................... 17 Case 8 Valve Jams Open and Vessel Sinks ...............................................................18 Narrative ................................................................................................................................ 18 The Lessons ........................................................................................................................... 18 Part 3 Personal Injuries ..............................................................................................19 Case 9 Deckhands Injured While Shooting Pots .......................................................20 Narrative I .............................................................................................................................. 20 Narrative II............................................................................................................................. 20 The Lessons ........................................................................................................................... 20 Footnote ................................................................................................................................. 20 Case 10 Crew Member Crushed to Death on Beam Trawler .................................21 Narrative ................................................................................................................................ 21 The Lessons ........................................................................................................................... 21 Case 11 Cook Falls on Conveyor Belt -Fractures Ankle and Leg ..........................22 Narrative ................................................................................................................................ 22 The Lessons ........................................................................................................................... 22 Case 12 Fishermen Struck by Seas on Deck ..............................................................23 Narrative ................................................................................................................................ 23 The Lessons ........................................................................................................................... 23 Case 13 Deckhand Injured by Parting Rope ............................................................24 Narrative ................................................................................................................................ 24 The Lessons ........................................................................................................................... 24 Footnote ................................................................................................................................. 24 Part 4 Man Overboard ...............................................................................................25 Case 14 Crewman Lost Overboard -Fatal Accident ................................................26 Narrative ................................................................................................................................ 26 The Lessons ........................................................................................................................... 26 Footnote ................................................................................................................................. 27 Case 15 Lone Fisherman Lost Overboard ................................................................28 Narrative I .............................................................................................................................. 28 Narrative II............................................................................................................................. 28 The Lessons ........................................................................................................................... 28

Case 16 Crew Member Dragged Overboard and Loses his Life ............................29 Narrative ................................................................................................................................ 29 The Lessons ........................................................................................................................... 29 Part 5 Keeping a Good Lookout ................................................................................31 WATCHKEEPING................................................................................................................ 31 NAVIGATION ...................................................................................................................... 31 Case 17 Fishing Vessel Grounds due to Fatigue of Watchkeeper............................32 Narrative ................................................................................................................................ 32 The Lessons ........................................................................................................................... 32 Case 18 Fishing Vessel Runs Aground after Wheelhouse is Left Unattended ......34 Narrative ................................................................................................................................ 34 The Lessons ........................................................................................................................... 34 Case 19 Collision betweenTwo Fishing Vessels .........................................................35 Narrative ................................................................................................................................ 35 The Lessons ........................................................................................................................... 35 Case 20 Lack of Lookout Leads to Collision in Fog.................................................37 Narrative ................................................................................................................................ 37 The Lessons ........................................................................................................................... 37 Footnote ................................................................................................................................. 38 Part 6 Machinery Maintenance .................................................................................39 Case 21 Fishing Vessel Runs Aground after Main Engine Failure ........................40 Narrative ................................................................................................................................ 40 The Lessons ........................................................................................................................... 40 Footnote ................................................................................................................................. 40 Case 22 Dirty Fuel Disables a Fishing Vessel ...........................................................42 Narrative ................................................................................................................................ 42 The Lessons ........................................................................................................................... 42 Case 23 Steering Failure .............................................................................................43 Narrative ................................................................................................................................ 43 The Lessons ........................................................................................................................... 44 Footnote ................................................................................................................................. 44 Case 24 Lifesaving Appliance Shortages Cost Lives Again.....................................45 Narrative ................................................................................................................................ 45

The Lessons ........................................................................................................................... 45 Case 25 An Experienced Fisherman Drowns ...........................................................46 Narrative ................................................................................................................................ 46 The Lessons ........................................................................................................................... 46 Case 26 Stern Trawler Capsizes during Trawling Operation.................................48 Narrative ................................................................................................................................ 48 The Lessons ........................................................................................................................... 48 Case 27 Loss of Life Close Inshore ............................................................................49 Narrative ................................................................................................................................ 49 The Lessons ........................................................................................................................... 49 Case 28 The Loss of a Fishing Vessel and the Stowage of Liferafts .......................50 Narrative ................................................................................................................................ 50 The Lessons ........................................................................................................................... 50 Stowage and Float Free Arrangements for Inflatable Liferafts.............................................. 51 Summary ................................................................................................................................ 51 Appendix - Diagrams of commonly fitted HRU's .....................................................52 Case 29 Discharged EPIRB and VHF Batteries cause Problems ...........................56 Narrative ................................................................................................................................ 56 The Lessons ........................................................................................................................... 56 Part 8 Conversions ......................................................................................................57 Case 30 Capsize of Open Fishing Boat in Adverse Weather...................................58 Narrative ................................................................................................................................ 58 The Lessons ........................................................................................................................... 58 Case 31 Poor Design of Working Arrangements Led to Death of Skipper ............59 Narrative ................................................................................................................................ 59 The Lessons ........................................................................................................................... 59 Footnote ................................................................................................................................. 60 Case 32 Loss of a Small Clam Dredger ......................................................................61 Narrative ................................................................................................................................ 61 The Lessons ........................................................................................................................... 61 Footnotes................................................................................................................................ 62 Part 9 Stability .............................................................................................................63 Case 33 Fishing Vessel Capsizes in Harbour .............................................................64

Narrative ................................................................................................................................ 64 The Lessons ........................................................................................................................... 65 Case 34 Two Cockle Dredgers Capsize .....................................................................66 Case 1..................................................................................................................................... 66 Narrative ................................................................................................................................ 66 Case 2..................................................................................................................................... 66 Narrative ................................................................................................................................ 66 The Lessons ........................................................................................................................... 66 Case 35 Rapid Capsize and Sinking of a Fishing Vessel with Loss of Life ............67 Narrative ................................................................................................................................ 67 The Lessons ........................................................................................................................... 67 Part 10 Weathertight Doors and Hatches .................................................................68 Case 36 Net becomes Fast on Seabed causing Vessel to Ship Seas and Sink .........69 Narrative ................................................................................................................................ 69 The Lesson ............................................................................................................................. 69 Case 37 Another Vessel Sinks after Shipping Heavy Seas ......................................70 Narrative ................................................................................................................................ 70 The Lessons ........................................................................................................................... 71 Case 38 Loss of Stern Trawler due to Snagging and Downflooding ......................72 Narrative ................................................................................................................................ 72 The Lessons ........................................................................................................................... 72 Case 39 Weathertight Closures Left Open and Vessel Sinks, Leading to Loss of Four Crewmen .......................................................................................................................73 Narrative ................................................................................................................................ 73 The Lessons ........................................................................................................................... 74 A Safety Postscript .......................................................................................................75 MAIB safety digest/report request form ....................................................................76 MAIB published reports (unpriced)...........................................................................76 MAIB published reports (unpriced)...........................................................................76

Marine Accident Investigation Branch The Marine Accident Investigation Branch (MAIB) is an independent part of the Department of The Environment, Transport and the Regions and is completely separate from the Maritime and Coast guard Agency (MCA). The Chief Inspector of Marine Accidents is responsible to the Secretary of State for the Environment, Transport and the Regions. The offices of the Branch are located at Carlton House, Carlton Place, Southampton, SO15 2DZ. This Safety Digest draws the attention of the fishing 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 fishing industry, and the public of the general circumstances of fishing vessel accidents and to draw out the lessons to be learned. The sole purpose of this 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 publications home page contains information on how and where you can obtain publications produced by the Department for Transport. 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.gsi.gov.uk Summaries (pre 1997), and Safety Digests are available on the MAIB site.

Glossary of Terms and Abbreviations CPR Cardio pulmonary resuscitation EPIRB Emergency position indicating radio beacon GPS Global positioning system grp glass reinforced plastic HRU Hydrostatic release unit kg kilogram LSA Lifesaving appliance m metre MAIB Marine Accident Investigation Branch MCA Maritime and Coastguard Agency MGN Marine Guidance Note Mhz megahertz MRCC Marine Rescue Co-ordination Centre MRSC Maritime Rescue Sub-Centre Pan Pan The international urgency signal (spoken) RAF Royal Air force RNLI Royal National Lifeboat Institution SAR Search and rescue VDU Video display unit VHF Very high frequency

Fishing 2000 Safety Digest Introduction Any accident at sea is unwelcome. At best there might be light damage or a minor injury. At worst a vessel is lost and people are killed. But no matter what the outcome, there will be implications for those most closely involved. These are likely to be additional costs, loss of earnings, pain, grief and suffering by an unknown number of people. In the worst cases, entire communities may be affected. Families may have to suffer hardship for years, and the memories will linger for a very long time. One question will dominate peoples thinking, why? Although many of the lessons arising from past fishing vessel accidents are now incorporated in better designed vessels and the equipment carried, the sea is as unforgiving as it ever was. If a mistake is made, or the vessel is not as sound as it might be, or basic safety precautions are not taken, the sea will find the weakness and strike with devastating effect. It is all too easy to be fatalistic about such matters and accept them as the inevitable consequence of a traditional, and tough way of life, but the families who are left to mourn see things very differently. It is they who have to suffer the after math, and who push hard to make sure that whatever went wrong will never happen again. They are not alone. The Marine Accident Investigation Branch (MAIB) is committed to the same objective. Its inspectors investigate a number of the fishing vessel accidents reported each year. In1999 the Branch received 372 reports of fishing vessel accidents. The prime purpose of carrying out an investigation is not to apportion blame, or make ridiculous recommendations for fishermen to spend small fortunes in improving safety, but to find out exactly what happened so that the necessary steps can be taken to stop it happening again. We do this in two ways. Firstly, based on whatever we find, we make recommendations to whoever is best placed to implement measures to prevent a recurrence. Secondly we publish the lessons to be learned through the Safety Digest, issued three times each year. This special edition of the Safety Digest, produced especially for Fishing 2000, is an amalgam of MAIB lessons learned during the past five years. Most have already featured in past editions, but are repeated here as it has become very evident that few fishermen have seen a copy or are even aware of its existence. There is an application form at the end of this booklet if you would like to be placed on our mailing list to receive the Safety Digest. It is FREE of charge. The same application form can be used to receive any of our unpriced fishing vessel reports. These too are FREE of charge and are available on request. We are also using the opportunity to comment on some of the more common safety problems we see on a regular basis. One of the primary aims of pulling together these observations is to encourage discussion about matters to do with safety, and to instil a safety culture in the industry. Our overriding objective is to reduce the number of accidents at sea. John Lang Chief Inspector of Marine Accidents March 2000

Part 1 Bilge Alarms and Pumping We often find when investigating flooding incidents, that a major short coming in too many vessels is the state of, or lack of, bilge alarms in the engine room. We hear, over and over again, that the crew are seemingly unaware that the engine room is flooding until it is too late. Had the alarm sounded when flooding was first detected, adequate action could have been taken to save vessel and lives. We often find the alarm had been landed for repair and not been replaced, or was known to be defective and due to be looked at next time in harbour, or even assumed to be correct, but never tested. We even hear of some that have been muted because the noise was irritating. In each case the epitaph is the same. If only.................. Bilge alarms matter. Test them daily, and make sure they work. In some cases the bilge alarm works as designed, but the flooded area cannot be pumped because the strum box or valve is clogged with debris such as and fish parts. Check and clear strums and valves frequently - your life could depend on it.

Two Recent Flooding Cases -Vessels Saved by the Bilge Alarm Narrative I This 19m long wooden fishing vessel Helenus touched bottom. A short time later the bilge alarm in the fish hold went off prompting the crew to inspect the hold. It was flooding. The rate of water ingress was greater than the bilge pumps could handle, so the coastguard were contacted for assistance and the vessel headed for the nearest port. Watertight bulkheads either side of the fish hold restricted the extent of flooding and the vessel made port safely. She was met by a fire brigade tender and pumped dry. The cause of the flooding was damaged planking from the earlier contact with the sea bed.

Narrative II In a severe gale, the bilge alarm went off on the30m long steel beam trawler Noordpool. It was found that the engine room was flooding from the fractured casing of the main engine driven cooling pump. An auxiliary driven bilge pump was started. Since the vessel was close to a leeshore it was imperative that the main engine was kept running, but to limit the rate of flooding, it was slowed down. When the flooding reached the main engine flywheel, water began spraying around the compartment. The engine was shut down, and the valve to the sea water inlet closed to stop the flooding. This provided the engineers with an opportunity to investigate why the bilge pumping was so ineffective. By now the vessel had begun to drift onto the lee shore. The coastguard was alerted, and an RNLI lifeboat and rescue helicopter were launched to assist. The engineers discovered that the bilge pump was sucking in air from the fish hold, which was known to be dry. Although the bilge line valve to the fish hold had been isolated so that the engine room bilges could be pumped, debris inside the valve body prevented it from being fully closed. Once it had been cleaned, the bilge pumping system was returned to full working order. This, together with a salvage pump from the lifeboat, managed to lower the water level in the engine room so that the main engine could be restarted. Noordpool was escorted safely to the nearest port by the lifeboat.

The Lessons 1. Both cases illustrate the benefits of bilge alarms, functioning bilge pump systems, and watertight bulkheads to limit the severity of a flooding incident. 2. The second incident shows the importance of maintaining a vessels bilges free of rubbish so it cannot be drawn in to the bilge system. 3. Valves on a bilge system must be regularly checked for correct operation.

Fishing Vessel Flooded during Bilge Pumping Narrative When hauling the prawn trawl on board his 6mlong steel fishing vessel Val G, the skipper sensed she was down by the head. He was working in rough seas some 8 miles south of Ayr. The crew lifted the deck hatch to check the condition of the fish room and discovered it was flooded to a depth of about 1.6m.Watertight bulkheads either side of the fishroom prevented the spread of the flooding. The coastguard was alerted, and the Girvan and Troon RNLI lifeboats were launched to assist, as was a rescue helicopter. The vessel was towed into Troon and pumped dry. The source of the flooding was the vessels bilge pumping system which had been recently renewed. The skipper had set the valves with the intention of pumping out from the fishroom, but in fact they had been inadvertently set to pump sea water in. A bilge alarm was fitted to the fish room and was in good working order. Unfortunately it had been switched off.

The Lessons 1. Do not switch off bilge alarms when going to sea. A basic pre-sea check is to ensure they are switched on and functioning correctly. A non-operational bilge alarm, or one that is not switched on, could mean the difference between a successful fishing trip and a disaster. At worst it could result in the loss of a boat and a means of earning money. 2. In small vessels, it is essential that all crew members should know how to operate the bilge pumping system. 3. This accident has once more demonstrated the value of watertight bulkheads in preventing the spread of flooding.

Defective Bilge Alarm delays Discovery of Flooding Narrative Due to poor weather, the 20.8m long wooden prawn dredger Valiant, was berthed unattended alongside a quay at Mallaig for two weeks during February. The vessel was hard up against the quay with up to ten other vessels moored alongside her. Following an improvement in the weather, she sailed at 0500, with a crew of four on board. Three were newcomers on board, and only the skipper had any knowledge of its main and auxiliary machinery. At about 0900 the fishing gear was shot and towing commenced. This continued until 1200, when the skipper found flooding in the engine room during a routine inspection. After starting the main bilge pump, the skipper returned up top to supervise the hauling of the gear. Having completed hauling, he returned to the engine room at 1230 to find the water level slightly higher. Another fishing vessel was contacted by VHF radio and replied that she was about an hours steaming away, but would assist. By now, flooding was found to have spread to the cabin and fish hold. As a precaution, one liferaft was unlashed from its cradle by the crew but not launched or inflated. In spite of using the bilge pump driven by the auxiliary engine in addition to the main pump, the water level in the engine room continued to rise. Valiant was taken in tow by the second fishing vessel once she had arrived on scene and two crewmen were also transferred. The coastguard was contacted, and in response to this call, an RNLI lifeboat was requested to launch and provide a portable pump. Towing Valiant proved very difficult, and the water level in her engine room continued to rise. The skipper and remaining crewman on board, decided to evacuate to the second vessel to await the arrival of the lifeboat. However, 15 minutes later, and before the lifeboat arrived, the vessel rolled to port, capsized, moved quickly astern and sank. The unlashed liferaft floated free, but the second liferaft and EPIRB did not.

The Lessons 1. The cause of the flooding was not identified by the