MAIB Safety Digest 1/1991

MARINE ACCIDENT

INVESTIGATION BRANCH

Summary of Investigations No 1/91

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

Telephone : 0703 232424

Accident Reporting Line 07 1 276 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 1991

INDEX

Introduction Page No

1. Phosphine Gas Emissions from a Fumigated Grain Cargo. 1

2. Collision between Two General Cargo Vessels on a River Passage. 2

3. Collision between Two Tankers. 3

4. Battery Explosion. 6

5. Collision between a Dinghy and a Ferry. 7

6. Dangerous Occurrence with a Painting Stage. 8

7. Engine Room Fire Successfully Controlled. 9

8. Oil Overflow leading to Engine Room Fire. 10

9. Falling Load causes Injury. 11

10. Damage when Berthing a Tanker. 12

1I. Danger of Out of Date Pyrotechnics. 14

12. Loss of an Angling Party. 15

13. Collision between a General Cargo Vessel and a Fishing Vessel. 18

14. Engine Room Fire followed by Sinking. 20

15. Engine Room Fire. 21

16. Flooding and Sinking of a Fishing Vessel. 22

Appendix

INTRODUCTION

From the contents page of this latest edition of Summary of Investigations, it will be noted that it contains a number of the type of accidents we have come to expect, such as collisions, fires and floodings. It also contains some of those infrequent accidents, the type that thankfully do not happen very often; the emission of gas from a fumigated grain cargo, a battery explosion and an accident involving pyrotechnics. In all these cases information was available which if it had been followed would have prevented the accidents taking place. Even the simplest and most mundane tasks can present hazards unless they are carried out properly and with forethought. It is hoped that by including accidents of these types in the Summary they will become even more infrequent.

A year has passed since the first Summary of Investigations was published. In that year three editions were published which contained a total of 49 summaries. If one goes back through those editions it will soon be apparent that a number of the investigations for which we have published details concern accidents which have a common thread. This latest edition is no exception, it aIso includes investigations which have that same common thread: poor management.

One dictionary definition of management is “The act or manner of managing”, and to manage is “To control or handle something properly or successfully”. In many accidents control of the situation was lost or the situation was not handled properly.

It goes without saying that if those situations had been handled successfully there would not have been any accidents. It is left to the reader to decide for himself which accidents in this edition had a contributory cause of poor management.

Proper and effective management is the best way to prevent accidents. The responsibility for proper management lies with everybody concerned in shipping. At sea, it rests not only with Masters, Skippers and senior officers, but also with all seafarers in that every job needs to be “controlled and handled properly” by whoever is carrying it out. Ashore, it is the responsibil- ity of the various office organisations, pilots and shipping agents to name just a few. Publication of these summaries can also be viewed as proper management because in bringing out the lessons to be learnt from accidents and making them known to the shipping community we are handling the situation in a way which should prevent them recurring.

The Merchant Shipping Notice on Good Ship Management which was issued in 1986 has recently been revised and issued as Merchant Shipping Notice No M. 1424. This puts the whole subject in perspective and forms the basis of sound management in shipping. It should be read and taken to heart by those to whom it is addressed.

Chief Inspector of Marine Accidents February 1991

1. PHOSPHINE GAS EMISSIONS FROM A FUMIGATED GRAIN CARGO

A 1,935 gross registered tonnage general cargo vessel loaded a cargo of grain in bulk. On completion of loading and shortly before departure, aluminium phosphide tablets were added to the cargo. The intention was that emission from these tablets during the de-composition process would fumigate the cargo during the seven day voyage.

The vessel duly berthed at the discharge port and the hatches were opened. Tests were undertaken by a representative of the consignee for the presence of noxious gas in the cargo holds. The results of these tests were declared to be satisfactory and discharge of the cargo commenced.

During the discharge, shore employees who were working in the vicinity of the discharged grain suffered the effects of exposure to phosphine gas. Cargo operations were suspended and the open holds were left to ventilate. During this time more employees were taken ill with similar symptoms. All were taken to hospital for observation and treatment as necessary.

Observations

1. All the employees eventually recovered from the effects of the gas, but some had to be detained overnight before release from hospital.

2. Neither the vessel’s Master and Officers nor the fumigators at the loading port complied with the recommended procedures listed in the IMO publication “Recommendations on the Safe Use of Pesticides in Ships”.

3. The representative of the consignee was familiar with neither the correct method of determining gas concentration levels, nor with the recognised exposure limits for phosphine gas.

Comment

The fumigant tablets had not fully decomposed within the bulk grain and phosphine gas was still being generated at the time of discharge. If the fumigant tablets had been contained in, for example, retrievable ‘socks’, then all of the remaining powdery residue from the tablets could have been removed from the holds on arrival at the discharge port. Such a method would have ensured that no further phosphine gas would have been generated within the holds.

I

2. COLLISION BETWEEN TWO GENERAL CARGO VESSELS ON A RIVER PASSAGE

Two motor vessels each of about 500 gross registered tonnage were proceeding down river with qualified pilots aboard. It was a still night with visibility of between a half and one mile. The tide was high water slack.

The vessels were in a gradual overtaking situation, there being little difference between the two speeds. As they approached a bend in the river, the pilots spoke to each other on the VHF radio. The slower vessel then left the channel on the inside of the bend whilst the fastervessel remained in the channel. The recorded VHF conversations showed that there was confusion as to which vessel would be ahead once the bend was rounded. Once round the bend the vessels were only about a ship’s length apart, the slower vessel still ahead and to starboard of the faster vessel.

The pilot of the slower vessel, who had been steering, then handed over to the Mate. It would appear that the Mate misunderstood the course, which was not given to him as a course to steer but only as an order to steer “steady-so”. The slower vessel altered course to port, crossing ahead of the overtaking vessel. By this time a third vessel was overtaking the two ships, on their starboard sides.

The slower vessel could not therefore alter course to starboard because of this third vessel and the action of the vessel astern of her was not sufficient to avoid collision.

Observations

1. The transcripts of the VHF conversations showed them to be very informal and lacking in proper procedures.

2. Both pilots involved in the collision acted contrary to what was regarded as normal local practice, namely that the overtaking vessel would leave the channel and that they would not normally attempt to overtake on a bend.

Comment

1. VHF, if used correctly, can be an aid to navigation but care must be taken to ensure that the agreed action is clearly understood by all parties. Merchant Shipping Notice No M. 1026 advises on VHF communication procedure and Merchant Shipping Notice No M.845 refers to the use of VHF in collision avoidance.

2. Rule 13 of the Collision Regulations clearly states that the responsibility of an overtaking vessel is to keep out of the way of the overtaken vessel.

3. The helmsman should be given clear instructions by the pilot, which should be monitored by the Officer of the Watch to ensure that they are understood and that the correct course is being steered. Merchant Shipping Notice No M. 1 102 refers to this procedure.

3. COLLISION BETWEEN TWO TANKERS

A tanker of 26,974 gross registered tonnage (grt) was bound for the River Humber with a cargo of some 52,000 tonnes of crude oil. As her berth was not immediately available it was decided to anchor north of the Humber Light-Float; this is a common anchorage for vessels awaiting entry to the River. Among ships already there, was another tanker, of 28,709 grtladen with some 46,500 tonnes of fuel oil. The Master of the in-bound ship decided to anchor about a mile to the north of this vessel. (See Figure 1).

The ship was making her approach from the north. The tide was setting southerly, at 2-3 knots. It was early morning and still dark, the weather being clear with occasional drizzle and a westerly breeze, force 3-4. The Master was conning the vessel; the Chief Officer and the Officer of the Watch were also on the bridge. The vessel was in hand steering and two radars were in use. Speed was being controlled from the bridge, by adjusting the propeller pitch.

In order to stem the tide it was necessary to turn through about 180" before anchoring. The manoeuvre was commenced, by altering course to starboard, when the anchored vessel was some 14 cables distant. Once the anchored vessel was well on the port bow the helm was put hard aport, the object being to complete the swing ahead - therefore up-tide - of that vessel. Unfortunately, insufficient allowance had been made for the tide and the ship set down on to the vessel at anchor so that collision occurred.

The impact ruptured the in-bound vessel's slop tank, and the heat which was generated as a result set oil escaping from that tank on fire. The fire spread to both vessels; that on the ship at anchor was extinguished by her crew, but the fire on the other ship became extensive and was only put out with the aid of fire-fighting tugs from the Humber and two off-shore support vessels which were in the vicinity. Despite this, no serious personal injury resulted from the accident. There was some oil pollution but it was quickly dealt with.

Observations

1. The collision occurred about three hours before high water and at spring tide. It is clearly shown on the Admiralty Chart (in use on board the in-bound vessel) that at such a time a southerly set of some 2.3 knots is to be expected. Moreover, the tide on the day in question was one of the highest of the year, and evidence suggests that the actual rate was more than 2.5 knots. However, the Officer of the Watch estimated the rate at less than 1 knot. It appears clear that the vessel's progress as the anchorage was being approached was not accurately monitored, for if it had been, the true rate of tide would have been appreciated.

2. Although the Master had two well-qualified officers on the bridge with him, he made little use of the assistance which they could have provided.

3. A proper watch was being kept on board the anchored vessel, and danger was apprehended when the other ship was seen to be altering course across the bow. An attempt was made to call her by VHF radio, but without response. No whistle signal was sounded.

4. Fire-fighting on the in-bound tanker was gravely hampered because the foam generator was disabled in the collision, and the emergency switchboard was put out of action by the fire.

5. Fire-fighting tugs were quickly on the scene. This was a matter of good fortune, for the tugs might have been working anywhere on the River at the time, including within the enclosed dock system. There was a very good response from other vessels in the area, some 16 ships taking some part in the emergency operation.

Comment

1, This collision would not have taken place if the in-bound vessel’s approach to the anchorage had been properly planned and carefully monitored.

2. The collision might have been avoided if the bridge team had been better organised so that full use was made of the Chief Officer and the Officer of the Watch.

3. The fire might have been extinguished more quickly if the ship’s own fire-fighting capability had not been largely destroyed. It is disturbing that all the ship’s emergency services were knocked out by a fire which initially was confined to a relatively small area.

4. It is probable that by the time the anchored vessel recognised danger, the in-bound ship was committed and collision could not have been avoided. Nonetheless, it would have been sensible to have sounded the whistle as well as making a VHF call, especially as the identity of the other ship was not known. The whistle, at close range, remains an excellent alerting device.

5. The response of the local emergency services and of other ships was most commendable. The point made at observation 5 above about the fire-fighting tugs has been considered locally: the Humber is an extremely busy waterway and arrangements to ensure that the fire-fighting tugs are so stationed and employed that at least one is readily available in the Estuary at all times have now been put into effect.

4. BATTERY EXPLOSION

A Fifth Engineer Officer, having been asked to change the emergency generator batteries switched off the charging circuit and proceeded to disconnect the battery leads. Whilst he was undoing the last bolt, the spanner slipped and made direct contact between two adjacent terminals. The subsequent short circuit ignited gases which were present in the space. This caused an explosion with the result that sulphuric acid splashed on to the Engineer’s face and chest.

Comment

1. The shipping company concerned had issued safety bulletins on the need for care when working with batteries, and drawing particular attention to the need for proper supervision and safety procedures including reference to the “Code of Safe Working Practices for Merchant Seamen”.

2. In the Code, Chapter 24 paragraph I. 1 refers to the dangerous nature of the gases generated by batteries and the need for adequate ventilation, while paragraph 1.7 refers particularly to the dangers of a short circuit producing a spark leading to an explosion.

5. COLLISION BETWEEN A DINGHY AND A FERRY

A smallpassenger/ro-ro ferry was berthed in a river, heading inwards, the jetty being at an angle to the shore. A dinghy with two persons aboard was secured with a single rope alongside another vessel berthed immediately upstream of the ferry and parallel to the shore.

It was a fine day with a light breeze and good visibility. The tide was ebbing and approaching maximum strength.

The Master of the ferry had visually checked both upstream and downstream from his position on the bridge before commencing the departure manoeuvre. The ferry was turned as it moved astern. At the same time the rope securing the dinghy was inadvertently let go by those on board.

The dinghy was carried downstream by the current and forced under the starboard bow of the ferry, causing the dinghy to capsize, and throwing the occupants into the water, one of whom suffered a heart attack and died.

Observations

1. The dinghy was initially secured in a position which was visually obscured from the bridge of the ferry when berthed.

2. The Master of the ferry was unaware of the exact extent to which his visually obscured sectors had been checked by other members of the crew prior to departure.

3. A crew member stationed aft visually checked the area which he thought would be obscured from the bridge. This in fact did not include the area in which the dinghy was initially positioned.

4. The river in the immediate vicinity of the starboard side of the ferry, towards which the dinghy was carried, was not visually monitored by any members of the crew during the departure manoeuvre prior to the accident.

5. The persons aboard the dinghy were unable to control the progress of the dinghy once it was adrift and so could not prevent it from colliding with the ferry, because there was a strong ebb current and they had lost an oar.

Comment

1. All of the sectors visually obscured from the bridge in the immediate vicinity of the ferry should have been properly checked and positively reported upon by members of the crew.

2. There were several small craft near the ferry at the time and measures should have been taken to ensure that a proper lookout, appropriate to the prevailing circumstances, was maintained aboard the ferry during the departure manoeuvre after it had been positively verified that it was safe for the manoeuvre to commence.

3. The dinghy should have been sufficiently equipped with an adequate means of control in the prevailing tidal conditions.

6. DANGEROUS OCCURRENCE WITH A PAINTING STAGE

A painting stage was suspended against the bridge front of a 10,000 gross registered tonnage cargo ship. The second of its two gantlines was being made fast at the upper end and a seaman was standing on the stage waiting for this to be done. Without warning, the gantline began to strand. The seaman, who had been holding the gantline for