M A R I N E A C C I D E N T I N V E S T I G AT I O N B R A N C H

Safety Digest

i s h i n g F 2 0 1 4

Published May 2014

M A R I N E A C C I D E N T I N V E S T I G AT I O N B R A N C H The role of the MAIB is to contribute to safety at sea by determining the causes and circumstances of 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 2012 – Regulation 5: “The sole objective of the investigation of a safety investigation into an accident under these Regulations shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of such an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”

The Marine Accident Investigation Branch (MAIB) examines and investigates all types of marine accidents to or on board UK vessels worldwide, and other vessels in UK territorial waters. Located in offices in Southampton, the MAIB is a separate, independent branch within the Department for Transport (DfT). The head of the MAIB, the Chief Inspector of Marine Accidents, reports directly to the Secretary of State for Transport. This Safety Digest draws the attention of the fishing community to some of the lessons arising from investigations into accidents and incidents. This information is published to inform 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.

If you do not currently subscribe to the Safety Digest but would like to receive an email alert about this, or other MAIB publications, please get in touch with us: • Online at: www.maib.gov.uk/publications/email_alert_subscriptions.cfm • By email at: maibpublications@dft.gsi.gov.uk • By post at: MAIB Publications, 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

© Crown copyright 2014

Contents This publication, excluding any logos, may be reproduced free of charge in any format or medium Chief Inspector’s Foreword 4 for research, private study or for internal circulation Tragedy Close to Home 6 within an organisation. This is subject to it being Lookout! Where? 8 reproduced accurately and not used in a misleading context. The material must be acknowledged as Crown Fatal Chain of Events 10 copyright and the title of the publication specified. Carbon Monoxide Kills 12 Rock and Roll 14 This publication can also be found on our website: A Flukey Escape 16 www.maib.gov.uk Who Will Help Me If Something Goes Wrong? 18 Mind Your Back 20 Anchor of Hope 22 Balancing Act 24 Snagging Can Lead to Loss of Vessel and Lives 26 Clocked by a Block 28 Fire-Fighting Drills – a Sound Investment 30 Prompt Actions Avert a Tragedy 32 When Late Detection is Just Too Late 34 Ready? Aye, Ready 36 Drum Roll – But No Fanfare 38 I Thought You Said the Fore Peak Was Empty 40 Shooting Pots Ends Tragically 42 Siesta Disaster 44 Fishing Vessel Accident Statistics 46 MAIB Published Reports 47 MAIB online resources 51

Glossary AIS - Automatic Identification System CPR - Cardiopulmonary Resuscitation DSC - Digital Selective Calling EPRIB - Emergency Position Indication Radio Beacon kg - kilogram kt - knot LOLER - Lifting Operations and Lifting Equipment Regulations 1998 MCA - Maritime and Coastguard Agency MGN - Marine Guidance Note nm - nautical miles PFD - Personal Flotation Device PLB - Personal Locator Beacon PUWER - Provision and Use of Work Equipment Regulations 1998 VHF - Very High Frequency

Chief Inspector’s Foreword Fishing continues to be, by a large margin, the most dangerous profession in the UK

This edition of the MAIB’s Safety Digest is the third in a series which focuses exclusively on the safety lessons learned from accidents that have occurred in the fishing industry.

Please take the time to read the articles. Think about whether something similiar could happen on your boat. By thinking about these cases, especially the safety lessons identified in each article, you will be in a better position to learn from the mistakes of others and avoid unnecessary harm to you, your crew and your livelihoods.

Safe fishing.

Tragedy Close to Home Narrative An under 10m steel fishing vessel sank while heading back to its mooring in rough seas and poor weather conditions. The owner, who was the only person on board, tragically lost his life.

The owner had checked the weather before he departed, and the forecast indicated that the wind would decrease to Force 3 for a time before increasing to Force 5 to 6. As the local conditions at the time appeared to be corresponding with this lull, he decided to spend the morning operating close to shore before the weather picked up. However, by lunchtime the weather had seriously deteriorated, and the owner made a call ashore using his mobile phone to say that he was heading back in to his mooring as the weather was ‘horrendous’. Nothing else was heard from the vessel, and no distress signal was received. It was later established that she had disappeared off a local radar system a short while later. The radar also indicated that the vessel was making around 4 knots when she disappeared, with a local weather data confirming that there would have been winds gusting up to Force 8 on her port bow at the time of the loss.

A couple of hours later the vessel was reported as overdue to the coastguard, which initiated an extensive search. Sadly, only minor items of debris from the vessel were found. The vessel was located on the seabed the following day and was consequently recovered, but with no trace of the owner.

Subsequent examination of the vessel found that the hull was intact, with both of the deck hatches in place and with no obvious source of initial downflooding that might have contributed to the loss. The wheelhouse door was, however, missing and the displacement of some of the wheelhouse windows from their frames, along with the movement of other items on board, suggested that the vessel had most likely been overcome by the seas, and had capsized suddenly.

“The owner, who was the only person on board, tragically lost

” his life.

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Remember 3 . Although there is no regulatory

The Lessons requirement for a vessel of this size to carry an EPIRB, liferaft or Digital Selective Calling (DSC) capable VHF radio, all are recommended. None were on board this vessel (there was a VHF, but not DSC), and 1 . Although the owner was expecting 2 . Various modifications had been it is not inconceivable that any or all of the weather to deteriorate, he was almost made to the vessel over the years, these items might have helped identify certainly not expecting it to be as bad as including the fitting of a substantial that she was in difficulty and, indeed it turned out. Had he anticipated such a gantry. Such changes would have perhaps have saved the owner’s life. deterioration in the weather, he would reduced the stability and freeboard, have headed back in earlier as Force 8 and possibly contributed to this loss. was in excess of his normal operational Although there are no statutory stability 4 . The skipper had previously been limit. Forecasts are just that, only a requirements for under 15m fishing in the habit of using a personal locator prediction of what is likely to happen; vessels, it is advisable to be aware of your beacon while he was operating single- they don’t always get it spot on. They also vessel’s stability, and to consider how handedly. He had, however, recently tend to differ depending on the data used this will be affected by any proposed stopped using this. Again, particularly and the calculation methods employed. It structural alterations. One way of when operating alone, the use of a does no harm to consult a second or third doing this is to consult a qualified naval locator beacon such as this might have forecast before deciding how long to put architect; another is to attend the well- ensured his survival. No one pretends to sea for. received Seafish Stability Awareness that equipment such as EPIRBs and course. liferafts are cheap, but what value do you place on your life?

Figure 1: The fishing vessel being recovered

Lookout! Where? Narrative Two wooden fishing vessels had spent the day trawling about 25 miles from their home port; the weather conditions and visibility had been good and the catch wasn’t too bad. Boat A was crewed by her skipper and two deckhands while Boat B, which was almost 15m long and fitted with a substantial accommodation housing and shelter, was being sailed single-handed by her skipper.

By 1750, Boat A had finished her last tow of the day and began to head back home. It was dark so the skipper had switched on her navigation lights along with the floodlights on the aft deck. The skipper saw one radar target on the starboard bow, which was also returning to harbour. Having set the autopilot and adjusted the throttle to give a speed of about 5 knots, the skipper left the wheelhouse and went to the fully enclosed shelter to help the deckhands sort the catch. He occasionally returned to the wheelhouse, but he did not see any other vessels. At about 1800, the skipper of Boat B also decided that he had done enough for the day, and stopped his vessel. He then started to bring his catch inboard and stow the gear. The vessel’s navigation lights and deck floodlights had already been turned on. At 1840, as the skipper recovered a stray line from the starboard quarter, he felt and heard a loud thud. He ran forward past the accommodation to investigate, and found Boat A embedded into his vessel’s port bow. He immediately looked ito the fish hold and saw that it was rapidly flooding.

The skipper went to the wheelhouse and informed the coastguard about the collision via VHF radio. He then shouted across to Boat A, and asked her skipper, who had also felt a thud and had run to his wheelhouse, to pick him up from the stern. By the time Boat B’s skipper had stepped across on to Boat A, his vessel had started to go down by the head and list to port. She foundered seconds later.

Following the collision, the skipper of Boat B improved the visibility from his wheelhouse by modifying the wheelhouse deckhead (Figure 2). “Illuminating a boat like a Christmas tree and then assuming that everyone else will keep well away might seem like a sound plan, but it doesn’t work when other skippers in the area have the same idea.” digest ty Safe ish ed l pub st Fir 12

Remember 3 . Poor visibility from the wheelhouse has been a contributory factor in several

The Lessons previous accidents involving fishing vessels. In this case, Boat A had a shelter which, with equipment fitted to the deck, might have obscured her skipper’s view of Boat B during his occasional checks. Is 1 . Illuminating a boat like a some time on the night, but keeping a the visibility from your wheelhouse good Christmas tree and then assuming proper lookout can save a lot more time enough? that everyone else will keep well away and money in the long run. might seem like a sound plan, but it doesn’t work when other skippers in the 2 . Working single-handed is hard area have the same idea. Although the work at the best of times, but it is also chances of two fishing boats being in dangerous when the visibility from the same spot at the same time might the working decks is obscured by seem low, they increase considerably at accommodation housings and shelters, the end of a day’s fishing when everyone and the skipper is focused on his work on is heading home but not looking where deck. When working single-handed, the they are going. Sorting the fish before ability to keep a proper lookout is just as getting alongside might save important as being able to manage the gear. Figure 2: View of the modified wheelhouse

Fatal Chain of Events Narrative A crew member was lost overboard from a twin rig trawler during shooting operations, in darkness and moderate to rough sea conditions. Unfortunately, despite the best efforts of his crew mates, including one who jumped into the sea to assist, he could not be rescued.

The vessel had shot her gear and the crew were attaching the three towing chains to the trawl wires. After attaching the port and starboard towing chains, two crewmen were in the process of attaching the centre chain. Once attached, the load on the trawl wires was transferred onto the chains. During this time, one crewman became caught between the chains and the vessel’s bulwark rail, and was carried overboard as the load came onto the chains.

The man overboard managed to grab hold of the trawl wire, which was quickly hauled up in an attempt to recover him. However, unfortunately he was unable Recognising the boat’s lack of manoeuvrability with the trawl gear deployed, the skipper immediately ordered the wires to be cut using a petrol-powered angle grinder. The boat was quickly turned around and the crew located their colleague in the darkness by listening for his calls for help. Life-rings were thrown to him, but he was unable to hold on, and once again he drifted away from the boat. The skipper again manoeuvred the boat alongside and life-rings were thrown to the man overboard. Seeing that the casualty was unable to help himself, probably due to cold and water ingestion, the vessel’s skipper jumped into the sea, without protective clothing, in an attempt to help his colleague. Unfortunately he was unsuccessful and the skipper, too, began to succumb to the effects of the cold water.

Luckily, but with difficulty, the remaining crew were able to recover their skipper from the water. However, despite a concentrated search and rescue operation, the casualty was not recovered even though he was wearing a flotation jacket. to hold on long enough to be pulled on board and was swept away from the boat and into the darkness. The trawler’s skipper was airlifted to hospital suffering from hypothermia after an estimated 10 to 15 minutes in the sea. “Seeing that the casualty was unable to help himself, probably due to cold and water ingestion, the vessel’s skipper jumped into the sea, without protective clothing, in an attempt to

” help his colleague.

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Remember 4 . The skipper’s valiant attempt to

The Lessons rescue his crewmate almost cost him his own life. Wherever possible, thermal protective clothing and a lifejacket should be donned before entering the sea, and a lifeline attached for recovery. 1 . The two crewmen attaching the 3 . The casualty was wearing a 50 towing chains secured the port and Newton flotation jacket. Although starboard sides before attaching the these do provide a degree of thermal 5 . This skipper’s quick action in centre chain. This placed them in an area protection, they are classified for ordering the wires to be cut maximised of danger because a winch brake band “swimmers in sheltered waters use the chances of gaining manoeuvrability could have rendered while they were and where help is close at hand”; they of the vessel. Angle grinders, such as the attaching the centre chain. Attaching the are not lifejackets, and will not keep one used in this instance, are now readily centre chain first would have allowed the the wearer’s face and mouth clear of available. These enable the gear to be port and starboard sides to be secured the sea if they become unconscious. cut away if necessary and do not need to from a position of relative safety - while An inflatable lifejacket, on the other be plugged in to a boat’s electric supply. standing on the fore side of the chains. hand, gives no thermal protection. If Survival times of a man overboard can not too cumbersome, both a lifejacket be counted in minutes and seconds, so 2 . Transferring tension from the and thermal protection should be worn no time should be wasted hauling gear winch onto the towing chains should when on exposed open decks; this will which could be jettisoned and recovered be monitored continually and in direct maximise the chances of recovery in the later. communication with the winch operator. event of going overboard. Thereafter, slack wire from the winch should be pulled off only when the load has been fully transferred, and again carried out in a position of safety so that if a chain or connecting piece renders, the risk to crew members is minimised. Figure 3: Demonstration of where the