MAIB Safety Digest 1/1990

MARINE ACCIDENT

INVESTIGATION BRANCH

Summary of Investigations No 1/90

Marine Accident Investigation Branch 5/7 Brunswick Place SOUTHAMPTON Hants SO1 2AN

Telephone: 0703 232424

Accident Reporting Line: 01 276 6004 (24 hours)

This summary contains facts which have been determined up to the time of issue. This information is published to inform the shipping industry and the public of the general circumstances of accidents and must necessarily be regarded as tentative and subject to alteration or correction if additional evidence becomes available.

Extracts can be published without specific permission providing that the source is duly acknowledged.

Crown copyright 1990

INDEX

Introduction Page No.

1. Accident involving a Movable Car Deck

2. Watertight Door Accident

3. Fire: Bad Working Practices

4. Collision between a Chemical Tanker and a Ro-Ro Cargo Ship

5. Non-declared Chemical Aboard a Ro-Ro Passenger Ferry 7

6. Failure of Lifting Gear on a Container Vessel 8

7. Hazardous Incident: Near Collision 9

8. Scalding and Impact Injuries 11

9. Fire in a Cargo Tank 12

10. Variable Pitch Propeller Malfunction 13

11. Failure of a Pump Casing on a Sand Suction Dredger 14

12. Fire on a Passenger Ship 15

13. Loss of a Small Cargo Ship 16

14. Grounding of a Ro-Ro Passenger Ferry 17

15. Alertness and Good Shipboard Operations 20

16. Loss of a Fishing Vessel 21

17. Stranding of a Fishing Vessel 22

18. Loss of a Small Fishing Vessel 23

19. Flooding of Fishing Vessels 25

Appendix 27

INTRODUCTION

The Merchant Shipping (Accident Investigation) Regulations 1989 require the publication by the Secretary of State for Transport of the report of an Inspector’s Inquiry unless there is good reason for not so doing. There is also a requirement for the Chief Inspector of Marine Accidents to publish from time to time collective summaries of investigations.

A large number of marine accidents are investigated each year covering both ships and people. To publish a report of every accident which is investigated would be extremely time consuming and result in a continuous stream of publications which probably would only be read by a very small number of people. However, some accidents are serious enough to merit an Inspector’s Inquiry which will result in the publication of a separate report. For other accidents though, it will be of greater benefit to the shipping industry if a selection is made of those which have a useful lesson to be learnt and then publish them in a collective form from time to time. There may also be accidents which are important enough to merit separate publication but were not the subject of an Inspector’s Inquiry. However, it is felt the collective summaries will normally be the most useful way of making known to the shipping industry the lessons learnt from our investigations, and in so doing improve safety of life at sea. Publication will be quarterly, but this will be kept under review.

These summaries are not in any specified order, except that accidents related to fishing vessels are grouped together as these will be of significant interest to that industry. They have not necessarily occurred since MAIB came into operation in July 1989; accidents before that time have been included if there is a useful lesson to be learnt. Recommendations resulting from an investigation are reflected in the “Comment” section which forms a part of each summary.

Some of the summaries relate to non-UK registered vessels in which accidents have been investigated by MAIB. In those cases copies of the Inspectors’ reports are sent to the appropriate Administration for them to take any necessary action.

It will come as no surprise that a number of the accidents included in the summaries are the type which have happened in the past and will continue to happen. By including such examples it will bring home the fact that these accidents continue to occur, and it is only by learning from the mistakes of others that we can hope to reduce the numbers of those types of accident.

A summary of every accident which is investigated is not included in this publication for the reasons explained. To give a clearer picture of the work undertaken, a list of MAIB investigations is given in the Appendix to these summaries. The list includes all those investigations which have begun since MAIB became operational on 3.7.89 and up to 3 1.12.89. It gives the date on which the accident occurred, name and particulars of the vessel and the type of accident. It should be noted that summaries relate to accidents which occurred over a longer period than that covered by the list and also a number of the investigations listed are still not completed.

This publication is not just addressed to the policy and regulation makers, or ship owners, or associations, or ship masters, or crews; it is intended for the shipping industry at large. It is hoped that it will have as wide a circulation as possible and that those reading its contents will learn the lessons which are to be found in the summaries. It is only by looking at the operations for which they are responsible and applying those lessons will we achieve the goal of avoiding accidents in the future.

Chief Inspector of Marine Accidents January 1990

1. ACCIDENT INVOLVING A MOVABLE CAR DECK

In a ro-ro passenger/vehicle ferry, on arrival at Dover, instructions were given to car drivers and passengers to go to their vehicles to be ready to disembark. One family, consisting of husband and wife and two children, proceeded to the mezzanine deck, which was in the raised position. There was a gap of 165 mm width between the deck and the centre casing, and the couple’s three year old daughter fell through this gap to the deck below, a distance of 2.65 metres. Fortunately she was not seriously injured and, after examination in hospital, she was released later the same day.

Comment

1. Marine Directorate of the Department of Transport have instructed Surveyors to examine similarly constructed vessels and ensure that gaps of this size are not present or, if they exist, that hinged plates or handrails and a kick-plate are provided to stop a child falling through.

2. The owners of the ferry took action to prevent a recurrence.

2. WATERTIGHT DOOR ACCIDENT

A watertight door which was under local control in the crew accommodation area of the ship was partly opened by a member of the crew. While stepping through he operated the closing lever, which resulted in him being jammed between the door and its frame. Injuries sustained included a badly injured leg, large loss of blood, and shock. Fortunately other members of the ship’s crew, together with two nurses and a doctor who were passengers, were at hand to administer first aid.

Observations

This accident occurred when using a watertight door which was designated for use only in emergencies. The injuries sustained would have been even worse had the door not been on local control at the time.

Comment

1. The door operating instructions, printed on the door, had not been followed.

2. The reason for not following the instructions was attributed to the effects of tiredness and the possible earlier consumption of alcohol while off-duty ashore.

3. Merchant Shipping Notices Nos M.1283, M.1326 and M.1344 emphasize the safety procedures to be followed in respect of watertight doors.

4. A practical demonstration of the crushing power of a watertight door when closing would be educational during on-board training.

5. The owners of the ship concerned agreed necessary amendments to their standing orders and training instructions in the use of watertight doors, particularly for new crew joining the ship.

3. FIRE: BAD WORKING PRACTICES

Whilst in port the engine room bilge contents of an oil rig stand-by vessel were being pumped ashore to a road tanker using a portable pump and 7.5cm diameter plastic flexihose.

The hose split, causing a mixture of oil and water to spray on to an AC switchboard, which caught fire. The fire was quickly brought under control by the Chief Engineer Officer, who extinguished the fire inside 10 minutes using portable C02 extinguishers.

The oil in the bilges was fuel oil, which had leaked from a fractured fuel oil filter. The filter was situated between the main engine and floor plates so that it would be difficult to detect a leak unless the pressure was sufficiently high to cause a substantial spray.

The leak was discovered only when it was noticed that the fuel consumption was greater than normal. The leakage occurred over a long period of time, and some of the oil had been removed from the bilges using the oily water separator.

Observations

The fire was caused by fuel oil bursting from a temporarily rigged plastic pipe onto a hot surface.

It is likely that the filter failed because of long-term fretting between the filter spring and the bottom of the filter casing. The filter casing was probably 19 years old - the same age as the vessel.

Comment

1. Merchant Shipping Notice No M. 1229 describes similar incidents, and ship’s personnel should be aware of the dangers of the use of plastic pipes for the transfer of oil. It is fortunate that a more serious fire did not occur.

2. The presence of oil in the bilges should have been recognised earlier and the reason established.

4. COLLISION BETWEEN A CHEMICAL TANKER AND A RO-RO CARGO SHIP

A collision occurred in the Humber Estuary between a 1599 gross registered tonnage (grt) chemical tanker loaded with Propylene Oxide, and a ro-ro cargo ship of 9386 grt. Both vessels had a pilot on board.

The collision occurred within one cable of a position 0.22 miles, 030 degrees (T) from No 10 Buoy. There was dense fog at the time, and the tide was flooding at rather more than 2 knots. A copy of the relevant chart is at Figure 1.

The ro-ro ship, having cleared Immingham Lock at 0600 hours, was outward bound; at 0616 hours she passed Immingham Oil Terminal and course was set at 1 15 degrees (T), engines to half ahead. Speed made good between 0616 hours and the collision was about 10.5 knots, despite the fog and the flood tide. A small tanker was ahead and at 0619 hours, in order to overtake, the ro-ro ship altered to 100 degrees (T), reverting to 115 degrees after a short period.

The chemical tanker, inward bound for Immingham, cleared the Bull Anchorage at 0525 hours, and proceeded up river with her engine at slow ahead. Passing South Shoal Buoy, fog was seen ahead. Between buoys 6B and 63 steering was changed to manual, the course being 300 degrees (T); speed made good was about 9.4 knots. The ro-ro ship was seen on the radar, and course was altered to starboard by either 10or 20 degrees, (there is a conflict of evidence as to which) to allow more room. At 0625 hours the chemical tanker’s pilot called the ro-ro ship by VHF and said he was “pulling her a little bit to the north”. He also increased speed to half ahead, as he considered a close quarters situation seemed to be developing. At about this time those on the bridge of the chemical tanker heard a whistle apparently from ahead, and the chemical tanker sounded her own whistle in response. One further whistle blast was heard by the chemical tanker, almost immediately after which the ro-ro ship was seen and the two ships collided. No 2 cargo tank in the chemical tanker was holed and the cargo took fire.

Emergency action was quickly taken by the ship’s crew, by other vessels in the vicinity and by Harbour Control, who initiated the Humber Emergency Plan (HESMEP). As a result, the fire was brought under control, and was extinguished within about two hours. There were no major casualties.

Comment

1. Both vessels were properly manned, with the Master on the Bridge accompanied by an experienced pilot who was conning.

2. As they approached each other, the vessels were closing, in dense fog, at a combined speed of some 20 knots. Neither was proceeding at a safe speed, as required by the Collision Regulations.

3. The chemical tanker was not on her own starboard side of the channel (the proper side under the Collision Regulations). The ro-ro ship was on her own starboard side, but not so far over as she would have been had she not just overtaken the small tanker; it would have been better not to overtake until clear of No 10 Buoy.

4. The chemical tanker was not regularly sounding the proper fog signals on her whistle.

5. When the chemical tanker appreciated that a close quarters situation was developing, and at about the same time heard the ro-ro ship’s whistle, she did not reduce speed to the minimum as required by the Collision Regulations, but instead INCREASED to half ahead. The ro-ro ship did not, it appears, recognise danger until, almost immediately before the collision occurred.

6. With a hazardous cargo of Propylene Oxide and No 2 cargo tank breached, the potential existed for this accident to have very grave consequences indeed. The Master and crew are to be commended for the prompt and efficient way in which they tackled the fire which broke out at once after collision, which did much to reduce the immediate danger; the emergency services are also to be much commended for their action, which brought the situation under control and eventually restored safety. The Emergency Plan HESMEP underwent a severe test and came through it well. However, it is noted that one of the two fire-fighting tugs stationed on the Humber was locked in at Immingham docks, and it was only fortuitous that the other was outside the locks and immediately able to assist. There is a strong case for one of these tugs to be stationed outside the docks, so as to be readily available at all times.

7. The Port Authority subsequently imposed restrictions on the movement of vessels with hazardous cargoes in restricted visibility.

5. NON-DECLARED CHEMICAL ABOARD A RO-RO PASSENGER FERRY

A ro-ro passenger ferry accepted for shipment an enclosed trailer, the contents of which were described in the accompanying shipping note as ‘‘groceries”. The road haulage company concerned had previously accepted the consignment from a shipper in good faith that the goods were as described. The consignment itself gave no visible indication that it contained anything hazardous. On arrival at its destination, after transportation by sea, the rear doors of the trailer were opened. A strong acidic odour was detected and it was subsequently found that a drum containing the chemical Formaldehyde had been stowed within the consignment and had leaked during transit.

Observation

Formaldehyde is a class 9 dangerous substance as defined in the International Maritime Dangerous Goods (IMDG) Code and it should be stowed “away from” foodstuffs.

Comment

1. Following this incident, the shipper and haulier were reminded of the IMDG code which clearly states the required procedures for proper documentation, packing, marking and labelling of dangerous goods requiring shipment. The Code also gives specific instructions regarding stowage and segregation of substances where applicable.

2. Revised procedures for the shipment of dangerous substances were formulated between the shipper and the haulier to ensure that the IMDG Code was followed.

6. FAILURE OF LIFTING GEAR ON A CONTAINER VESSEL

The starboard hatch lid of a large container vessel was lifted from its stowed position up to about 2 metres above the hatch using the back reach of a docks crane. The portable hatch lifting adaptors at the hatch failed and the 30 tonne hatch cover fell onto the deck. There were no reported injuries.

These hatch lifting adaptors were part of the ship’s lifting equipment. Known as pots, they were inserted and locked into hatch cover fixtures positioned at the four comers of the hatch. The spreaders of the crane were attached to the pots. Two of the pots failed: the first because of obvious structural weakness due to inadequate weld penetration. The other pot failed because of subsequent overload after failure of the first.

Comment

At the time of the incident there was no evidence on board to show that these pots had been suitably tested by a competent authority, as is now required by the Merchant Shipping (Hatches and Lifting Plant) Regulations 1988. Following this incident, new pots with the relevant test certificates were placed on board.

7. HAZARDOUS INCIDENT: NEAR COLLISION

A car/passenger ferry and a ro-ro cargo ship nearly collided when both vessels were making their approach to Cherbourg Eastern harbour entrance. The sea state was slight; it was daylight with clear visibility and a westerly tidal stream was being encountered by both ships. A copy of the relevant chart is at Figure 2.

The two vessels were heading from separate directions towards the same harbour entrance, and as a consequence they were on converging courses. They were both travelling at full or nearly full speed, the car ferry being the faster of the two and therefore the overtaking vessel. Although initially the car ferry was one to two points abaft the ro-ro vessel’s starboard beam, the latter made a navigational alteration of course to port which increased the relative bearing of the former further abaft her starboard beam. However the car ferry maintained her course and relative greater speed until she was very close to the ro-ro vessel’s starboard quarter. The car ferry then altered course to starboard and proceeded to pass down the ro-ro vessel’s starboard side, on a parallel course, at a distance of approximately 18 metres. Because the two vessels were slightly to the right of the leads into the entrance, the car ferry realised that she was being forced towards the starboard arm of the breakwaters. At a position where the ro-ro ship’s bow was in line with the mid-length of the car ferry, the latter altered course to port. This alteration of