The Marine Accident Investigation Branch is an independent part of the Department for Transport, (DfT) and is completely separate from the Maritime and Coastguard Agency (MCA). The Chief Inspector of Marine Accidents is responsible 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. This information is published to inform the fishing industry 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 Safety Digest is only available from the Department for Transport, and can be obtained by applying to the MAIB. Other publications are available from the MAIB.

If you wish to report an accident 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.gsi.gov.uk

Safety Digests are available on the Internet: www.maib.gov.uk

Extract from

The Merchant Shipping (Accident Reporting and Investigation)

Regulations 1999 The fundamental purpose of investigating an accident under these regulations is to determine its circumstances and the cause with the aim of improving the safety of life at sea and the avoidance of accidents in the future. It is not the purpose to apportion liability, nor, except so far as is necessary to achieve the fundamental purpose, to apportion blame.

Chief Inspector’s Foreword 4

1 Check Your Lifejacket 6 2 Incorrect Use of Trawl Blocks Leads to Fatal Accident 8 3 Skipper Killed by Lifting Gear Failure While Alongside 10 4 The Tragic Outcome of Overloading 11 5 Cook’s Crash Diet 12 6 Rude Awakening! 13 7 Steering Fault and Poor Lookout Cause Pair Trawlers to Collide 14 8 Quay Ladders Always Require Care 16 9 Heavy Weather Fishing – Fatal Accident! 18 10 Lookout! – Unfortunately Not 20 11 Lookout! – Unfortunately Not 21 12 Perished in the Darkness 22 13 NUC or Not? 23 14 Near Miss Leads to Grounding 24 15 Loss of Fisherman Within Harbour Breakwater 25 16 Can You See/Hear Your Bilge Alarm? 26 17 Bilge Alarm Success Stories 28 18 Back Rope Bights Back 30 19 The Price of Coronation Street 32

Contents Fishing Vessel Accident Statistics 34 Major Accident Locations Chart 36 MAIB Published Reports 37 Glossary 38 MAIB Report Request Form 39

Chief Inspector’s In 2003, 11 UK fishermen died in accidents. This was a pointless waste of life. You all know, better than I do, that fishing is a hard life, but it does not need to be as dangerous as it is. Just reading the articles in this Safety Digest, and thinking about the issues in them, will make your boat a safer place for you and your crew.

GOOD NEWS Scattered among accounts of tragic losses and needless deaths are a number of good news stories, where forethought or quick thinking have saved vessels and lives. Please read them carefully so that you are prepared for a sudden emergency. Thinking yourself into the situations that the men in this edition encountered will help you become the good news stories next year, not the disasters.

FLOODING/FOUNDERING Foundering, through flooding, is probably the single greatest cause of fishing vessel losses at sea. Two very simple and cost free checks can dramatically reduce losses through flooding.

Foreword 1. Check your bilge alarms – Test your bilge overloading of fishing gear on deck, along with alarm every trip before sailing, and daily at the unwanted fastener/boulder which may occur sea. This should be simple to do, and take no at any time whilst fishing. more than a minute. A working bilge alarm will give you early warning of a problem and So what is stability in fishing vessels? Stability time to overcome it. In nearly every case of is the ability of your vessel to right itself to the loss through flooding, the bilge alarm was upright position after it has been forced over by found not to have been working. an external force. But if modifications are made to the vessel, these changes can severely 2. Turn off your seacocks in harbour – This will restrict the vessel’s ability to come to the upright not only stop your vessel sinking in harbour position, and can, in extreme cases, cause the through faulty pipework, but it will also ensure vessel to overturn. that the seacocks are working and easily accessible by you and your crew. Again, it is So what can we, as fishermen, do to ensure the too late when pipework has fractured at sea stability of our vessels? We need to ask advice to find that your seacock is seized. from a suitably qualified person before we make any modifications to our vessels, no matter how small that change may be. We need to be STABILITY aware of the capabilities of our vessels, and be Stability is the other big killer at sea. I can do no prepared for the unexpected. Remember, better than to quote George Geddes (who many stability cannot be measured, it needs to be of you will know as a skipper/owner from calculated. Peterhead and representative of the Scottish Fishermen’s Federation): Take care when fishing, return home safely."

"Stability is difficult for most of us to understand, I echo George’s sentiment: but in some of the cases you are about to read, what becomes clear is that stability has been Take care when fishing, return home safely. greatly affected by modifications. These changes sometimes occur over a period of time whereby the vessel has been constructed for one particular fishing pattern, and has changed to another. Other effects on stability can be the

Check Narrative Soon after the winch stopped, the vessel A steel fishing vessel was started to list heavily to trawling off the Western port, prompting the six- Isles in force 6 wind, man crew to muster on rough seas, and darkness the starboard side of the when her port net became wheelhouse. The three snagged on a seabed deckhands who had been obstruction. Attempts working on deck were, in were made to free it but, accordance with company in the process, the winch policy, already wearing stopped. Less than five inflatable lifejackets. Both minutes later, the vessel the skipper and the capsized and sank. engineer donned theirs This article focuses while the mate, who had on the lifejackets being been working in the worn by her crew – wheelhouse with the inflatable working skipper, realised his was lifejackets, which met EN stowed below. He had 396 criteria. insufficient time to collect

The Lessons The owner’s policy regarding the wearing of lifejackets on deck is commendable; indeed, it might well have saved one fisherman’s life in this case. Mariners must remember, however, that when worn constantly, lifejackets are subjected to heavy use. Day in, day out, the fabric of a lifejacket rubs against the gas cylinder and this can, eventually, cause the cylinder to unscrew from the release unit if it has not been fully tightened.

your lifejacket it, so was forced to and, while attempting to immediate concerns about promulgate the advice abandon ship without one. board the upturned raft, the effectiveness of at listed below. Readers of Such was the speed of one of the men least one type of lifejacket the Safety Digest were events. disappeared. After being used at sea, so tests also alerted to the safety Before abandoning boarding it, they tried to were carried out without issues highlighted by this the sinking vessel, the five locate their colleague, but delay. article, in the Noticeboard crew wearing lifejackets without success. The The tests revealed that of Safety Digest 3 of tried to inflate them missing man was one of the lifejackets which had 2002. manually by pulling the those whose lifejacket had failed to inflate, had release toggles, rather failed to inflate. He was probably done so because than waiting for automatic never seen again. the gas cylinders had inflation on taking to the While on the upturned become detached from the water. Only one of the five raft, one man successfully Hammar release units. lifejackets inflated. inflated his lifejacket by So that the lessons Three of the crew blowing into the oral tube. learned from this accident managed to board the The liferaft was eventually could be brought to the starboard liferaft, but it righted, the five survivors attention of as many flipped over when the boarded it and all were seafarers as possible, the vessel capsized. They all later rescued, unhurt. MAIB issued a Safety ended up in the water The accident raised Bulletin immediately, to

1 Fishermen and mariners who routinely wear inflatable lifejackets should ensure that the gas cylinders are firmly tightened into the release units. 2 Set aside a few minutes to read MGN 155(F), published by the MCA. It is available free of charge and contains useful guidance on inflatable Owners of lifejackets fitted with Hammar release units lifejackets and other buoyancy equipment for fishermen are particularly urged to make this check, and should at work. IT MAY SAVE YOUR LIFE. also carry out the safety checks listed in the booklet issued with every lifejacket:

◆ Check that the single point indicator is green. 3 The notice placed by Hammar, in various marine publications, to advise users of the problems highlighted by this case, is reproduced opposite. It contains ◆ Check that the expiry date has not been reached. important advice, please read it. ◆ Check that the red handle is attached.

◆ Check that the gas cylinder is firmly tightened by

holding it through the jacket fabric.

Any deficiencies should be dealt with as soon as practicable and before the vessel next goes to sea.

Incorrect use of blocks leads t Narrative The snatch blocks being used on the aft gantry to While fishing off the east lead the trawl wires over coast of England, a crew the stern, were being member from a 15.8m used in the open stern trawler was killed condition. Because of the after being crushed by a general condition of the trawl wire. The following is blocks, and the lack of an account of how snatch any locking pins, they blocks, if operated were unable to be used in incorrectly, can lead to the correct manner tragedy. anyway. Two members of When the trawl doors the four-man crew were were heaved clear of the aft at their stations while water, the winchman the gear was being stopped the winch and the hauled. A third was deckhands began operating the winch and “dogging-up” the doors. the skipper was in the The crew member on the wheelhouse. starboard side began

The Lessons 1 Snatch blocks must always be operated in the correct manner, with the cheek plate closed. Although at times it may be convenient and time saving to operate them in the open position, this accident proves the consequences of doing so can sometimes be fatal.

2 A rigorous routine of regularly inspecting and maintaining all lifting equipment on board will, in the long run, pay dividends.

New regulations relating to health and safety aspects of lifting operations and lifting equipment are to be introduced shortly. These regulations will place an obligation on an employer to ensure that the work equipment, including lifting gear, is safe for workers to use. It seems likely that there will be a requirement for lifting equipment on fishing vessels to be inspected and,

trawl to fatal accident passing the dog chain between the trawl door and the securing brackets, but the trawl wire suddenly came free from the snatch block and caught him across the right-hand side of his body, crushing him against the aft gunwale. The wire was under huge tension, since it supported both the weight of the trawl door and the weight of the trawl itself. The skipper hastily attempted to release the crew member by reversing

2 the winch, but the crew member was dragged over the side of the vessel. After being immersed momentarily, the crew member reappeared on the sea surface approximately 3 to 4 metres from the vessel. One of the deckhands quickly threw him a lifebuoy, but he was unable to grasp it. He soon lost consciousness and was seen floating on the surface face-down. The skipper eventually managed to manoeuvre his vessel alongside the casualty and, with the aid of the other two crewmen, passed a rope around his body. This enabled them to haul the crew member back on board where, despite several attempts, he couldn’t be revived.

where considered appropriate, tested. All other equipment, including hauling gear, will be required to be inspected. 4 And finally, recovering a man overboard is not easy. The person is likely to be very cold, completely exhausted, and his waterlogged clothing will be weighing him down, making recovery that much more

3 In this case, the skipper acted quickly in attempting to release the crew member. Unfortunately, his efforts were in vain. difficult.

If faced with a similar situation to this skipper, would you know what to do? Just in case the answer is no, carry out In light of this accident, and as a result of suggestions by regular manoverboard drills. In other words, be prepared. both the industry and the MAIB, a review of the current Your life, and the lives of your crew may just depend on Sea Fish risk assessment document, being used by many it. fishermen, is to take place. All fishermen are encouraged to actively take part in the risk assessment process on board their particular vessel. Unless you understand what it’s all about, and its purpose, it will be of little value. It is hoped that simplifying the document, and making it more user-friendly, will encourage its use.

Skipper killed by

lifting gear failure while alongside Narrative causing the derrick and its load to crash down on to crown of the eye. During the manufacturing had been an attempt to weld repair the inner A 24.44m Jersey the fish quay where the process, a hole was drilled bearing surface of the eye registered beam trawler skipper was standing. He into the crown (to allow of the block. The quality was lying alongside, was killed and two female machine finishing) and of this repair was poor, repairing her nets in bystanders were injured, subsequently filled with with porosity and Plymouth and about to one seriously. weld. This weld seal was entrapped weld defects discharge her catch. The A detailed exam- compromised and being evident. starboard derrick had ination of the block found corrosion penetrated, Other blocks were been topped with a net that it failed because of beginning the process of discovered with similar hoisted for repair. progressive cracking progressive cracking. defects. The eye of the emanating from an Further examination topping lift block failed, inherent defect at the also revealed that there

The Lessons 1 Skippers and owners are recommended to check all lifting equipment for evidence of welding and, if any is found, arrange to have it replaced. 3 Marine engineers should not make weld repairs or any significant heating to lifting equipment. Such work should only be carried out by the equipment manufacturers, when it would be in accordance to their

2 Owners/operators of vessels should institute a system of maintenance for lifting equipment on their vessels. This system should include both in-service specifications and subject to specialist thorough examination.

checks and regular thorough examinations by a competent person (eg insurance engineer, specialist lifting equipment company etc). If such checks, or thorough examinations, reveal that an item of lifting gear has gone beyond laid down discard criteria (eg in terms of wear, corrosion, broken wires, evident deformation or cracking), the only safe option is to scrap that item and provide a new one to the correct capacity.

The tragic outcome Narrative of overloading

A small fishing vessel was before any corrective action rescue fishing vessel bung were used to seal trawling for mussels in could be carried out, they revived the unconscious the inboard end of the what was described as were scrambling for their man, before continuing to overboard discharge pipe. ideal weather for mussel lives. The vessel capsized search for the missing The bilge alarm had not fishing, with light winds and and rolled completely crewman. Once additional been tested on the day of a calm sea. A substantial upside down, throwing the help had arrived, the the accident, and was not catch of mussels had been men into the water. rescue fishing vessel heard at any time during caught the previous day One of the crew headed for a nearby pier to it. The vessel had also and had been left stacked remained conscious land the casualties at an been modified significantly on deck overnight. throughout the ordeal and, awaiting ambulance. in the past, with no Late morning, the last once he had surfaced and Divers later recovered estimate of the likely catch of the day was tipped kicked off his boots, looked the third crewman from effects this would have on on to the mussel bench and quickly for his two the seabed. He was stability or load-carrying processing began. Two colleagues. He saw a rushed to hospital, but capacity. Three lifejackets crewmen were next to the lifebuoy and swam to it. never regained were found tightly packed bench cleaning and raking Shortly after,