MAIB Safety Digest 1/1992

MARINE ACCIDENT

INVESTIGATION BRANCH

Summary of Investigations No 1/92

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

Telephone : 0703 232424

Accident Reporting Line 071 276 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 1992

INDEX

Page No. Introduction

Seawater Cooling System Failure Resulting in Engine Room Flooding 1

Contact Between a Ro-Ro Ferry and Harbour Breakwater

Contact Damage to a Passenger Vessel

Engine Room Flooding;

Collision at the Junction of Two Channels

Cargo Shift Aboard a Ro-Ro Ferry

Collision at the Junction of Traffic Separation Schemes 10

Contact Between a Supply Vessel and an Offshore Installation 13

Two Similar Incidents Involving Fires 14

Collision Between a Safety Standby Vessel and a Floating Oil Production Installation 16

Accident During an Emergency Drill 17

Contact Damage to Offshore Supply Vessel 18

Accident Caused by the Inadvertent Disengagement of a Lifeboat Hook 20

Accident whilst Painting on Deck 22

Hand Trapped in Watertight Doorway 23

Sinking of a Fishing Vessel 24

Grounding of a Fishing, Vessel 25

The Grounding and Loss of a Fishing Vessel 27

Gas Explosion on a Fishing Vessel 28

Appendix A

Appendix B

In previous editions of the Summary of Investigations, the introduction has tended to include a message to the readers; a message which, if understood and taken to heart and most importantly put into practise, would help reduce the number of accidents. Subjects which have been covered hitherto include the use of commonsense, the advantages of good management, and that Merchant Shipping Notices (M Notices) are published to be read, not just to adorn the bookshelf in the company's offices or the chart room. The messages contained in the introductions are intended to supplement the main messages in the various summaries, which are of course those important lessons to be learnt.

In this edition there are ample lessons to be learnt concerning all aspects of safety, many of which will not be new to you. However, it is not intended to carry a further "lesson to be learnt" message in this introduction but to use the opportunity to clear up a question which is often asked: what are the different levels of investigation undertaken by MAIB?

Firstly there is the Inspector's Inquiry, which is undertaken in the most serious cases. These investigations are always led by a Senior Inspector, and result in a Chief Inspector's Report being submitted to the Secretary of State for Transport which is then published. An example is the collision between the dredger BOWBELLE and the passenger launch MARCHIONESS on the River Thames in August 1989.

The next level is an Inspector's Investigation; this involves the Inspector making field visits to the ship and possibly the owner and other interested parties during which either declarations or statements are taken. The outcome of these investigations may be the publication of a separate Report, an example being the loss of the fishing vessel PREMIER in December 1990, or possibly a summary report for inclusion in this publication.

The third level is an Administrative Inquiry which is used in the greater number of cases. This involves an exchange of correspondence between MAIB and the interested parties, possibly including the completion of a questionnaire, to establish details of the accident, but it does not involve the Inspector making field visits. However, one should not be misled by the title into thinking it does not involve the Inspectors. Although the administrative staff in MAIB handle the correspondence, an Inspector reviews all the correspondence and invariably poses the questions which need to be asked and determine further action as appropriate. A number of the summaries in this publication are the result of Administrative Inquiries.

It is hoped that this explanation has helped readers to understand the various levels of investigation.

An additional item in this edition may be found in Appendix B which lists MAIB publications obtainable from HMSO. It is only these Summary of Investigations which are free distributions; all other MAIB publications have to be purchased through HMSO or good booksellers. The list will be updated in future editions of the Summary of Investigations.

Chief Inspector of Marine Accidents April 1992

1. SEAWATER COOLING SYSTEM FAILURE RESULTING IN ENGINE ROOM FLOODING

A 4000 gross tonnage suction dredger, propelled by two 3722 kW engines each driving a controllable pitch propeller was in a position 11 miles east of Harwich with a crew of 14 on board, when it was discovered that she was taking water in the engine room.

The ship side valves were closed. This action stopped the ingress of sea water, though it also resulted in the propulsion and alternator systems being shut down. To reduce the vessel’s displacement the cargo of dredged aggregate was dumped.

Following a request by the Master the RNLI Harwich lifeboat arrived and provided a portable pump. With this and the vessel’s small portable submersible pump a start was made to reduce the flood water in the engine room. The alternator’s seawater cooling system suction pipe was disconnected and a temporary pipe was fitted so that the alternator could draw cooling water direct from the engine room bilge. This operated successfully and the level of sea water in the engine room was significantly lowered.

The cause of the leak was identified to be in the starboard main engine seawater cooling system. The leak was isolated, enabling the port engine to be restarted and then the vessel was able to make safe passage to port for repair.

Observations

On inspection it was discovered that a 1.7 metre straight length of 100 millimetres (mm) bore copper seawater piping running from the seawater circulating pump discharge, under the main engines to the starboard main engine cooler had fractured. Further inspection found that there was heavy internal erosion in way of the fracture, the wall thickness had been reduced from an original 2.5mm to less than 0.5mm in places. The erosion was probably caused by the movement under operating conditions of the considerable amount of sand and marine growth (mussels) that were found in the seawater pipe work.

Comment

1. The action taken by the crew illustrates they understood the functions and detail layout of their ship. The temporary cooling water supply to the alternator proved to be effective and resulted in a recovery from the flooded condition, enabling the vessel to reach port under her own power.

2. Merchant Shipping Notice No M.1361 highlights the dangers of flooding and recommends general operational procedures to be followed to reduce the risk of flooding.

2. CONTACT BETWEEN RO-RO FERRY AND HARBOUR BREAKWATER

A ro-ro ferry was making an entry into port at the end of a scheduled run. As the vessel was about to enter the port the Master ordered a large course change to enter harbour. The helmsman had to use full rudder and the vessel responded correctly but when the wheel was eased back from the hard-over position the rudder immediately went hard over in the opposite direction and brought the vessel back onto the original course. It was then noted that the off-course alarm was sounding and realised that the vessel was still in automatic pilot. This was corrected but the vessel was so close to the breakwater that contact with it could not be avoided. There were no injuries to passengers or crew but the vessel suffered considerable damage and had to be withdrawn from service.

At the time of the incident it was a dark night, with calm sea and good visibility.

Observations

1. The bridge of the vessel was well manned by the Master, certificated officers, and two seamen.

2. The helmsman had been stationed at the wheel well before arriving off the harbour entrance. Because of the calm sea he was not required to make any major rudder movements and so did not realise that he. was not in control of steering.

3. The usual practice in this ship was for the helmsman to change to manual steering when he took over the wheel on the vessel approaching harbour. The Officer of the Watch assumed without checking that this had been done; but it had not, because the helmsman on this occasion was not familiar with the system.

4. The change-over selector between manual and automatic steering was not illuminated, and there was no other indication as to which mode the steering was in.

5. The automatic steering allowed for emergency override of the auto-pilot if the wheel was put in the hard-over position.

6. Though the off-course alarm sounded when the vessel was about off the original heading it was not identified immediately. It was at first thought to be a navigation light failure alarm and then an alarm from the fire detection system.

7. There was a check-list system in operation which was intended to ensure that all the bridge systems were ready before entering port.

8. The officer responsible for the check-list was distracted from this duty and did not complete it. This did not prevent the vessel from being allowed to proceed in to the harbour, because there was no requirement for a positive report that the checks had been made.

9. The check-list system was started so late that even if it had been completed the vessel would probably still have been too close to the harbour entrance to allow effective corrective action to be taken.

Comment

1. Statutory Instrument No 571, The Merchant Shipping (Automatic Pilot and Testing of Steering Gear) Regulations 1981 states that it is the Officer of the Watch who is responsible for ensuring the correct changeover from automatic to manual steering.

2. The same Statutory Instrument also emphasises the need to test that the manual steering is operating correctly. The use of automatic pilot is also covered in Merchant Shipping Notice No M.1471 issued December 1991. A point highlighted in the Notice is the need for personnel to be familiar with the change-over system.

3. There should be means to positively identify which mode of steering system is in use. This can be achieved by ensuring the switch or other form of indication is illuminated and readilly visible.

4. A check-list is of great use but only if it is completed and reported on in sufficient time to allow any problems to be rectified. Negative reporting is in most cases a dangerous practice - positive procedures should be adopted when reporting on safety related matters.

5. The various alarms used at a control station should be readily and singularly identifiable to ensure as far as is practicable that in an emergency situation there is no confusion as to which alarm is being activated.

6. Action has been taken by the owners to prevent a similar accident in the future.

3. CONTACT DAMAGE TO A PASSENGER VESSEL

A passenger vessel of 27,670 gross registered tonnage was being navigated to a riverside berth in thick fog. She had on board two pilots, one of whom had the con. The visibility was about 90 metres. The ship was stemming an ebb current of up to six knots and tugs were waiting up river, ready to assist the vessel into her berth.

The pilot who had the con was navigating by radar and he spoke to one of the waiting tugs by VHF radio. The pilot, who had seen the tug visually, asked if she was standing by off the corner of an angled jetty, which the passenger vessel would pass on her way to the berth. The tug replied in the affirmative. The pilot then asked the Skipper of the tug to remain in that position, his intention being to pass the tug and the jetty on the starboard hand (see sketch).

A little later an officer on the forecastle of the passenger vessel reported that a tower situated on the head of the jetty was fine on the starboard bow and that the vessel appeared to be setting towards it.

Despite rapid and full power manoeuvres the passenger vessel contacted the outer knuckle of the jetty, sustaining hull damage. Before the contact, the tug which the pilot had spoken to earlier was seen by the inner knuckle and going full astern to increase her distance from the approaching passenger vessel.

Observations

1. The pilot had thought that the tug, was off the outer knuckle when in fact it was off the inner knuckle. Consequently the course which the pilot then steered did not clear the north east corner of the jetty. The strong river current set the passenger vessel on to the outer knuckle. Fortunately the damage was above the waterline and there were no injuries.

2. The bridge manning of the passenger vessel included two experienced senior officers, a navigator and the two pilots.

Comment

1. This incident highlights the need for caution when using inter-ship communications in restricted visibility.

Merchant Shipping Notice No M.845 draws attention to the uncertainties that can arise over the identification of vessels and the interpretation of information received. It states that "An imprecise, or ambiguously expressed message can have serious consequences".

I

2. The ship’s bridge staff should maintain an accurate check of the vessel’s position and movement, whether or not the pilot has the con, and the

3. intentions of the pilot should be fully understood. This advice is given in Merchant Shipping Notice No M.854.

The jetty would have presented a clear return on the radar and ‘parallel i indexing’, as recommended in Merchant Shipping Notice No M.1158, could have avoided the accident.

4. ENGINE ROOM FLOODING

An oil rig standby vessel suffered from a flow of water into the engine room whilst on station. All attempts to pump out the bilges using the ship’s own bilge and ballast pumps, and portable pumps supplied by rescue services, failed to prevent the water rising over a period of three hours, causing power failure and complete flooding of the engine room.

Once the vessel had been towed to port, its ship’s side valve openings plugged, and the engine room pumped out, it was found that the direct emergency bilge suction valve on one of the main engine seawater cooling pump inlets was open. On inspection it was found that this valve was of the screw lift type and not of the required non-return type. It was judged that the flood water had entered through this valve. Further, all other bilge suctions in the engine room were found to be choked with debris.

None of the ship’s engineers, who had joined the vessel a few days before the incident, were sufficiently familiar with the bilge system to explain how, or why, the main seawater pump direct emergency bilge suction valve had been opened.

Observations

1. Clearly a valve lid of an incorrect type had been fitted to the emergency bilge suction valve.

2. No engineer on board thought of using the direct emergency bilge suction line to pump bilges; the very system through which water was entering the vessel.

3. The vessel remained afloat, and retained sufficient stability, to be towed to port in poor weather conditions - wind Force 5-6.

Comment

1. Having recently joined the vessel the engineering staff were not familiar with the layout and function of the emergency bilge system. It is vital that new staff quickly become familiar with safety systems and that details of any unusual characteristics of these systems are passed to relief staff.

2. Poor housekeeping allowed debris to choke the bilge pumping arrangements, the proper functioning of which would have at least reduced the rate of flooding and given the ship’s staff more time to identify the problem.

3. It is unfortunate that no attempt was’ made to use the main engine sea water pump direct emergency bilge suction, as these systems are provided for the very purpose of handling large quantities of engine room bilge water.

5. COLLISION AT THE JUNCTION OF TWO CHANNELS

A fishing vessel was proceeding outward bound along the channel from the port of Boston. Her passage involved her having to cross the entrance to the Welland Cut, which leads to the port of Fosdyke. A cargo vessel was approaching from ahead. This vessel was under pilotage, inward bound along the same channel for Fosdyke. The passage to Fosdyke therefore required the cargo vessel to cross the channel from the starboard side to the port side in order to enter the Welland Cut. The fishing vessel started to cross the entrance to the Welland Cut as the cargo vessel was swinging to port. The cargo vessel completed her turn and then collided with the fishing vessel. The latter vessel was pushed into the Welland Cut during which time the Skipper and crew member of the fishing vessel were able to climb aboard the cargo vessel. Fortunately there were no injuries, but the fishing vessel subsequently sank.

Observations

1. It was a dark night and the weather and tidal conditions were calm. The visibility was good.

2. The pilot aboard the cargo vessel had broadcast his intended passage to Fosdyke on VHF radio and then assumed that the Skipper of the fishing vessel would be aware of his intention to cross the channel. The pilot expected the fishing vessel to keep out of the way.

3. The Skipper of the fishing vessel was of the opinion that the cargo vessel was bound for the port of Boston and would therefore keep to the starboard side of the channel and pass port to port.

4. Another vessel was approaching the junction outward bound from Fosdyke and, in order to provide sufficient sea room for this vessel to safely exit the Welland Cut, the pilot of the cargo vessel