Marine Accident Investigation Branch (MAIB) - Safety Digest - Fishing 2001 Contents Introduction ....................................................................................................................4 Case 1. Fires Love Open Doors.....................................................................................8 Narrative...................................................................................................................................8 The Lessons..............................................................................................................................9 Case 2. Explosion aboard Fishing Vessel causes Injury ...........................................11 Narrative.................................................................................................................................11 The Lessons............................................................................................................................11 Case 3. Liferaft - a Godsend, after Small Fishing Vessel Sinks ...............................12 Narrative.................................................................................................................................12 The Lessons............................................................................................................................12 Case 4. Wear and Tear! ...............................................................................................14 Narrative 1..............................................................................................................................14 Narrative 2..............................................................................................................................14 Narrative 3..............................................................................................................................14 The Lessons............................................................................................................................14 Case 5. Fishing Vessel Grounds due to Over-Reliance on the use of Navigational Aids 16 Narrative.................................................................................................................................16 The Lessons............................................................................................................................16 Case 6. Fishing Vessel Grounds after Skipper Falls Asleep.....................................17 Narrative.................................................................................................................................17 The Lessons............................................................................................................................17 Case 7. Loss of Fisherman Results in Lifejacket Campaign ....................................18 Narrative.................................................................................................................................18 The Lessons............................................................................................................................18 Case 8. Deckhand Struck by Port Fishing Gear........................................................20 Narrative.................................................................................................................................20 The Lessons............................................................................................................................20 Case 9. Expect the Unexpected ...................................................................................22 Narrative.................................................................................................................................22 The Lessons............................................................................................................................22 Case 10. Beamer Capsizes ...........................................................................................23 Narrative.................................................................................................................................23 The Lessons............................................................................................................................25 Case 11. Know How Much Catch you can Load on your Vessel .............................27 Narrative.................................................................................................................................27 The Lessons............................................................................................................................27

Case 12. Fatal Crushing of Fisherman in Power Block............................................29 Narrative.................................................................................................................................29 The Lessons............................................................................................................................29 Case 13. Three People Washed Overboard ...............................................................31 Narrative.................................................................................................................................31 The Lessons............................................................................................................................31 Case 14. The Dangers of Standing on the Gunwale at Sea.......................................32 Narrative.................................................................................................................................32 The Lessons............................................................................................................................32 Case 15. Wheelhouse Exhaust Fires!..........................................................................34 Narrative 1..............................................................................................................................34 Narrative 2..............................................................................................................................34 The Lessons............................................................................................................................35 Case 16. Major Facial Injury While Shooting Nets ..................................................36 Narrative.................................................................................................................................36 The Lessons............................................................................................................................36 Case 17. Fishing Vessel Struck by Unidentified Coaster..........................................37 Narrative.................................................................................................................................37 The Lessons............................................................................................................................37 Case 18. Loss of Trawler Due to Engine Room Flooding.........................................39 Narrative.................................................................................................................................39 The Lessons............................................................................................................................40 Case 19. Fisherman Swept Overboard by the Wash from a High-Speed Ferry ....41 Narrative.................................................................................................................................41 The Lessons............................................................................................................................42 Case 20. Morse Cable Problems .................................................................................43 Narrative 1..............................................................................................................................43 The Lessons............................................................................................................................43 Narrative 2..............................................................................................................................43 The Lessons............................................................................................................................44 Case 21. Overloading, Disregard of Stability, and Flooding Results in Loss of Vessel and Skipper ..........................................................................................................................45 Narrative.................................................................................................................................45 The Lessons............................................................................................................................45 Case 22. Grounding and Loss of Fishing Vessel........................................................47 Narrative.................................................................................................................................47 The Lessons............................................................................................................................48 Statistics ........................................................................................................................50 Fishing Vessel Losses ............................................................................................................50 Deaths.....................................................................................................................................50 Major Accident Locations ...........................................................................................51

........................................................................................................................................52 Published Reports ........................................................................................................54 MAIB Published Reports Available free of charge from MAIB ...........................................54 SAFETY DIGEST .................................................................................................................55 GLOSSARY of terms and abbreviations /.................................................................56 Picture Credits........................................................................................................................56 MAIB Safety Digest/Report Request Form ...............................................................57 MAIB PUBLISHED REPORTS - free of charge ..................................................................57

Introduction Accidents hurt. They are an unwelcome component in the often tough business of fishing.

At one end of the spectrum they are inconvenient. Damage needs to be repaired or equipment has to be replaced. Additional costs are involved, and it might be necessary to spend extra time in harbour instead of being at sea fishing. Injuries cause pain to individuals, or constrain their ability to work in some way.

The more serious accidents can have a major effect on earning power, or leave people seriously injured and even unable to work. They not only hurt, but also can be very costly.

When a vessel sinks with loss of life, the effect on families, communities and the entire industry can be devastating.

Attitudes to safety and the prevention of accidents vary. Some people are confident in their ability to go about their business without worrying unduly; the accident will not happen to them. Others recognise that accidents are possible, but are prepared to take risks. And a growing number realise that nearly every accident is preventable, and are taking steps to do all they possibly can to prevent them happening in the first place.

It is probably fair to say, however, that most fishermen are at least aware that accidents can occur, but do not necessarily have safety foremost in their mind while carrying out the often repetitious process of catching and handling fish in a wet and constantly moving environment. It will come as no surprise to them that fishing is currently the most dangerous industrial occupation of any in the United Kingdom.

Preventing accidents is not the most exciting activity. To some it conjures up images of expensive equipment to satisfy some new regulation that has either no practical value whatsoever, or gets in the way of catching fish. To others who adopt the traditionally fatalistic approach it is irrelevant; if it is going to happen, it is going to happen. These stereotyped images of attitudes to safety are unhelpful, and belie the very great concern that many do have about the awful, and ongoing, record of fishing vessel accidents that occur every year without any real sign of improvement.

The MAIBs task is straightforward: to investigate a number of accidents to bring home the lessons to others so they can learn from them. It does not prosecute, apportion blame or point the accusing finger at anyone. It does not pretend to know everything about the industry, despite having a fishing vessel skipper on its staff, and a steady accumulation of experience in determining the causes of so many accidents. But the Branch does have a unique insight into how counter productive some attitudes to improving safety are, and shares with many fishermen the view that much can, and should, be done to improve things.

We often talk about the need for the industry to improve the safety culture. This attracts mixed responses, from unqualified agreement to total scorn. In the end it doesnt really matter what the MAIB says, thinks or does; it is how the fisherman himself reacts, or more importantly, what his family thinks. MAIB inspectors spend much of their time talking to the next of kin and families of accident victims, and see at first hand the distress, anguish, and misery that accidents cause. The sadness, uncertainty and loss created is incentive enough to try, and try again, to persuade those

who go fishing that even if they are relaxed about the risks involved, there are others at home who would be completely devastated if they were to find out that whatever caused the accident could have been very easily prevented had greater care been exercised.

This Safety Digest repeats a formula adopted a year ago, to bring together a number of lessons from past accident investigations so that others can benefit from them. They are designed to attract the interest of those who go fishing, to provoke discussion, to get people thinking about safety. If it manages to persuade people to check that the liferaft HRUs are correctly rigged, or to make sure the automatic bilge pump is working properly, in addition to learning from the many other lessons, then the exercise will have been worthwhile.

A safety culture is strangely elusive to many fishermen. The reasons are complex, not least of which is that it is one of the oldest occupations in existence, and life at sea is often dictated by the most powerful and unforgiving environment known to man, the weather.

Fishing is one of the harshest and most difficult of all industries. Politics, bureaucracy, diminishing stocks, quota reductions, unstable prices conservation measures, competition, escalating fuel costs, real money difficulties and the practical difficulties of catching fish all vie with each other to complicate the life of people who argue that all they seek is a fair return for their endeavours.

Some fishing vessels are well run, with conscientious and successful skippers. They rarely have accidents. Others are less fortunate, and those operating them may argue that to stay in business they have to push their luck with the weather, or say they cannot afford to carry out essential maintenance. Others will cut corners to catch more fish in the easiest possible way, and ignore accepted safe practices to achieve this. They also wish to carry out their business with as little interference as possible from others who, they will argue, know little about what it means to be out there in all weathers, carrying out an extremely repetitive job with precious few rewards.

Many will argue that more money is the answer, and pin their hopes on this being provided. Others believe the solution lies in more effective enforcement of the rules. Better training would undoubtedly reap benefits. Any of these solutions would make a contribution to reducing the number of accidents, but the danger is that while everyone argues about the merits of one solution over another, and accusations fly in every direction as people take sides, the tragic reality is that the accidents continue. The year 2000 was one of the worst years for the number of fatal accidents. The MAIB does not pretend to have all the solutions, but strongly believes there is a need to improve the safety culture. Much of the stimulus for this approach comes from the industry itself, from the individual fishermen who write to us in confidence, and the growing body of people within a handful of fishing communities who are working so hard to change attitudes.

A safety culture involves everyone. Officials, the fishing press, local communities, owners, skippers, mates, the crews and, most especially, the families. It is the families who suffer most when things go wrong and, when all is said and done, they are the ones who have to pick up the pieces when everyone else has gone back to work.

A safety culture requires a basic understanding of what is meant by preventing accidents. It not only means having properly designed and built vessels, but ones that are operated safely within the designed limits. A soundly-built vessel should be able to withstand all that the sea can throw at it. But as a study of some of the articles in this, and other Safety Digests will show, there are too many fishermen who still do not realise how easy it is to make a vessel unstable. There is too much evidence to show that some do not understand that by adding permanent top weight without

professional advice, or who leave weather tight hatches and doors open at sea, are running real risks of capsizing and sinking rapidly. Others appear to have no concept of the very real dangers that exist by having just a few inches of water sloshing around in the fish hold: free surface effect can cause a very serious accident. And any of these situations can be aggravated if those who go to sea do so in the knowledge that the automatic bilge alarm doesnt work.

It can be very easy to blame the MAIB for these shortcomings, to claim that its team of inspectors does not understand the business of fishing, or that the examples given are not representative of what really happens. But whatever people might say, the MAIB sees an abundance of evidence to show that all these things are happening. We dont have a magic wand to cure all that is wrong, but we can hope that by hearing about what happens whenever there is an accident, others will learn from it, and take whatever measures are necessary to stop it happening again.

A safety culture involves having an instinctive feel about what to do if, despite all the precautions, things go wrong. It is well known that when trouble strikes, there is rarely time to take stock of what needs to be done. In times of crisis, or in an emergency, people will often revert to their original training. When no such training has been undertaken, or if no previous thought had been given to how a particular situation might be handled, the average person will revert to instinct or self-preservation. If for instance flooding occurs, will those on board know how to deal with it using the available resources? If fire breaks will they know how to prevent it spreading further and fight it?

A safety culture means knowing what to do when faced with the ultimate consequence of an accident, survival. It means knowing how to ensure a liferaft is capable of being used. It means wearing a lifejacket whenever working in an exposed position or working alone. It means having an EPIRB that is properly registered and capable of floating free. It means having immersion suits on board, and knowing how to put them on.

It means thinking safety today, tomorrow and the day after.

Safety can be improved by a number of means. Fishermen are confronted by them daily: new regulations, calls for more safety equipment, better training and by formal safety assessments. Each has a part to play. But the cheapest, the most effective, and ultimately the most successful, is a change in attitude to safety and the adoption of a positive safety culture. Many fishermen tell us they do this already. The evidence shows that many do not.

This Safety Digest does nothing more than draw fishermens attention to what has gone wrong at sea with the hope that it gets them thinking, talking and, ultimately, doing something to reduce the number of accidents and improve safety.

John Lang Chief Inspector of Marine Accidents

Case 1. Fires Love Open Doors Narrative

Be Ready, a 24m fishing vessel operating out of Scalloway, Shetland, left port on Monday 17 January 2000 with a crew of four for the fishing grounds 60 miles west of Shetlands. She returned briefly on Thursday, to embark a new set of trawl boards and an additional deckhand, before returning to the same area and re-start trawling.

At about 0215 on Saturday morning, the vessel was slowly trawling in a southerly direction, when the mate, who was on watch, discovered a fire in the galley. The skipper and crew were called and gathered in the wheelhouse, passing the galley on their way. With the galley door secured in the open position, all saw the fire but nobody attempted to shut the door. A short abortive attempt was made to fight the fire but, by this time, the accommodation itself was starting to burn. The skipper called the coastguard on the VHF to tell them of the fire, but lost direct contact. He attempted to stop the main engine, but the controls failed to respond. Kirkwall lifeboat was launched and a rescue helicopter was airborne at 0219. Using a "Mayday" relay, local contact was made with fishing vessels in the area and contact re-established with the casualty.

Be Readys crew, having realised that the fire was beyond their control, launched both liferafts. With the vessel still going ahead slowly, both liferafts became entangled with the trawl wires aft, and were lost. Lifejackets had to be retrieved from the accommodation using the emergency escape hatch. The crew of five then moved forward and waited for the rescue vessels, maintaining contact via a hand-held VHF set. Weather conditions were force 8, rough seas with wintry showers.

The fishing vessel Mizpah was first on scene, followed by the helicopter. The helicopter tried twice to get a Hi-line aboard, but conditions were too bad. Mizpah then made two close passes, bow to bow, managing on the second attempt to pass a line connected to a liferaft to the casualty. Once the liferaft was alongside the bow, the crew entered the liferaft using a rope ladder over the starboard side. With all five aboard, they moved away from the burning vessel and were then lifted into the helicopter and taken to Lerwick hospital for a check up. Apart from minor burns and bruises, there were no injuries.

The galley fire is thought to have started due to a combination of a hot heating element on the cooker and items of clothing/drying cloths above or close to the hot plate. Once alight, and fanned by a strong draught from an open window on the starboard side shelter deck, and an open door on the port side, the fire rapidly gained strength and entered the accommodation.

After the fire had burnt itself out, Be Ready was towed to Lerwick for repair and/or re-sale.

The Lessons

1. When nobody is in the galley ALWAYS close and KEEP CLOSED the galley door. If a fire breaks out, this not only contains the fire within a protected space, but it also gives the crew valuable time to organise what course of action should be taken. Never tie or secure a fire door in the permanently open position. By doing so, you encourage the fire to spread, and then it can become too dangerous to risk closing the door.

2. Always turn off all hotplate elements and cookers after use. Never leave them on in an unattended galley. Leaving them on may save a few minutes in getting up to working temperature but it can also be the cause of a fire, or a bad burn as a result from a moments inattention by a fellow crew member.

3. Never leave drying cloths or clothes over, or close to, hotplate elements which are switched on.

4. In all cases of fire close all sources of ventilation to slow its progress SHUT all doors and windows to the space.

5. Once a fire such as this is found, the main engine throttles should be pulled back immediately to reduce the wind effect from forward ship movement on the fire.

6. The installation of a smoke or heat detector in the galley area would have detected this fire before it became well established, and allowed it to be tackled using the vessels fire extinguishers.

Case 2. Explosion aboard Fishing Vessel causes Injury Narrative

An explosion occurred in the 24m long stern trawler Egalite during repair work to insulation in the fish room. One of the crew suffered burns to his face and right hand.

The repair work involved applying expanding foam from an aerosol can. The crew had not appreciated that the gases from an aerosol can be inflammable and will slowly build up in a confined space. It then only needs a spark to ignite it and cause an explosion. This occurred when a cigarette lighter fell from someones pocket as the owner bent down to pick up a can. Without warning the gases ignited and the explosion occurred.

The Lessons

1. Ensure good ventilation of spaces where spray application maintenance work is being carried out.

2. In circumstances where danger of explosion might occur, all potential sources of ignition should be removed. Any aerosol can which contains a flammable warning on the label (a black flame on a yellow/orange