MAIB Safety Digest 1/1993

MARINE ACCIDENT

INVESTIGATION BRANCH

Summary of Investigations No 1/93

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 1993

INDEX Page No.

Introduction

1) Loss of Dangerous Goods from Ro-Ro Vessel

2) Flooding of Tanker’s Engine Room

3) Fire in Accommodation of Standby Vessel

4) Release of Bitumen into the Pumproom of a Tanker

5) Fire in Engine Room

6) Two Incidents of Heavy Weather Damage 8

7) Injury to Crewman whilst Recovering a Fast Rescue Craft 10

8) Flooding and Foundering of a Small Tanker 11

9) Fire in Incinerator Room 13

10) Improper Lookout and Failure to Offer Assistance 14

11) Unattended Winch Controls 16

12) Loss of a Fishing Vessel due to Flooding 18

13) Accident to Deckhand in Beam Trawler 19

14) Loss of Fishing Vessel due to Engine Room Fire 21

15) Flooding of a Fishing Vessel’s Engine Room 24

16) Fishing Vessel Collision caused by Poor Lookout 25

17) Sinking of Two Small Beam Trawlers with Loss of Life 27

Appendix A

Appendix B

INTRODUCTION

This edition of the Summary of Investigations marks the start of our fourth year in the publication of the series. Although statistics are not included, it is interesting to note that in the last three years we have published eight editions of the Summary containing a total of 136 summaries. Of this total about two thirds relate to merchant vessels, a third to fishing vessels and a couple to pleasure craft. The terms "merchant vessel", "fishing vessel'' and "pleasure craft'' are used in the broadest sense. However, these figures are a bit misleading because some summaries cover more than one incident (there are two such examples in this edition), and in some incidents where two vessels are involved one might be a merchant vessel and the other a fishing vessel. The incidents covered have been very varied and deal not only with the more frequent type of accidents such as collisions, floodings, fires and accidents to persons, but also the less common such as danger from mines and a battery explosion. What they all have in common though is a lesson to be learnt, and in many instances the type of vessel or the person involved is not too important because the message contained in the summary is applicable to everybody, no matter what type or size of vessel they are sailing on. We hope to be able to continue in the same way in all future editions.

It should be well known by now that the fundamental purpose of our investigations is to determine the circumstances and the causes of accidents 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. Even so, there is still a fear in the minds of some people, not least those who have been involved in an accident which is under investigation by the Branch, that the investigation will lead to prosecution and that the declaration they have given to the Inspectors will be used in evidence against them. This Introduction is a good medium to make the position clear on this very important and sensitive matter.

Firstly, the Branch has no powers to take disciplinary action or proceed with a prosecution. We can only make recommendations to that affect and it is up to the regulatory body to take action if they consider it appropriate. We would only recommend prosecution under the Merchant Shipping Acts if our investigation determined there had been a flagrant or conscious contravention of the regulations.

Turning now to the question of declarations. Declarations are not released to a third party without the consent of the witness himself, however as in most things, there are a number of exceptions to this rule. Declarations may be produced at a Formal Investigation or a Section 52 Inquiry; they may in principle (though it is not normal practice) be used in a prosecution except when the declarant is being prosecuted; they may on request be given in confidence as background information to other authorities, for example Police or Coroners, to assist their separate inquiries; and they will have to be produced in any legal proceedings relating to the accident if the Court so requires but no answers given in declarations shall be admissible in evidence against the person giving the answers or his spouse, except in the case of a prosecution for a false declaration. It is hoped this clarifies the matter and we can only stress that the purpose of the declaration is to assist the investigation in determining the circumstances and the causes of the accident.

To conclude this slightly longer than usual Introduction, we would like to thank those people who write to us expressing their appreciation for this publication. From these letters we know that a number of shipping companies use it as part of their safety awareness programmes and maritime colleges worldwide use them as case studies for the students. This is extremely gratifying and it gives us considerable pleasure to know that our efforts to produce a publication that is both interesting and useful to the maritime world are worthwhile. There have been one or two letters which have questioned the details of specific incidents, but whether it be praise or complaint we welcome all correspondence concerning this publication.

Chief Inspector of Marine Accidents April 1993.

1. LOSS OF DANGEROUS GOODS FROM RO-RO VESSEL

A freight ro-ro vessel, operating in European waters, had loaded approximately 50 freight vehicles. These units were evenly distributed, between the main vehicle deck and the weather deck, several being 20 foot tank containers carrying dangerous goods. The order of loading, although under the control of the Chief Officer, was largely dependent on the availability of freight at the loading berth which led to several of the tank containers being stowed forward and outboard on the weather deck.

Shortly after departure the vessel encountered very poor weather conditions which caused her to roll heavily. After one such roll a number of the tanks containing dangerous goods broke free and fell overboard.

Observations

1. The IMDG Code advises that where tanks containing marine pollutants have to be carried on a weather deck they should be stowed inboard or in sheltered areas of the deck.

2. All the units were secured using the sizes and numbers of lashings as recommended in the "Code of Practice, Roll-on/Roll-off Ships Stowing and Securing of Vehicles".

3. The units were all properly documented and declared.

Comment

Although the units were secured as recommended in the 'Ro-Ro Code', no consideration was given to factors such as free play in vehicles suspension, free surface of liquid in tank containers and distance from roll axis of ship. All these are mentioned in the Code which strongly suggests that extra lashings, jacking up of vehicle trailers and frequent inspections were necessary, especially under the weather conditions encountered.

2. FLOODING OF TANKER’S ENGINE ROOM

An oil tanker of 65,000 gross registered tonnage was regularly employed loading cargo at an offshore terminal. These operations required that the vessel maintained station relative to the terminal, with a Dynamic Positioning system controlling main engine and transverse thrusters. Because the sea water cooling system for the generators and main engine were becoming choked with eels, the duty engineer decided that the main sea water inlet filter required cleaning. This task involved closing the low sea water inlet valve and removing the top cover from the filter housing. This part of the operation was performed without mishap. However, in order to flush the remaining eels from the filter housing the engineer decided to crack open the low inlet valve for a few seconds. The open/close control for this pneumatically operated butterfly valve was thus put to the open position and then immediately to closed. Unfortunately the valve opened and remained open, defeating all attempts to close it using the normal controls. Water pressure prevented the refitting of the filter cover. Sea water entered the engine room, via the opened filter housing, rapidly flooded essential equipment and caused the engineers to abandon the lower levels of the engine room. As the vessel was lightly laden at the time, the flood water rose to a level only a few feet above the lower platform. There were no injuries, lives lost, pollution or any serious immediate danger to the vessel’s safety.

Observations

1. Complete trust was placed on the ability of the ship’s side valve to re-close after the attempted flushing operation. There must always exist the possibility that any ship’s side valve may not reseat properly after being opened, due to debris etc. Where a closed ship’s side valve is the only barrier between the sea and any opened up section of the sea water system, no attempt should be made to open this valve.

2. No proper attempt was made to employ the emergency bilge suction valve on one of the main sea water circulating pumps. This valve was opened but unfortunately, because the ship’s side valve supplying this pump was still full open, no water was drawn from the engine room.

Comment

The proper use of the emergency bilge suction would not have prevented the ingress of water, but the flooding would have been controlled giving ship’s staff time to properly assess the situation and possibly refit the filter cover. Valuable advice on the importance of ship’s staff understanding the methods of operating emergency bilge suctions is contained in Merchant Shipping Notice No M.788.

3. FIRE IN ACCOMMODATION OF STANDBY VESSEL

The owners of an offshore supply vessel had converted her for safety standby duties by adding suitable and approved survivor accommodation for 250 persons. This accommodation was constructed from six cargo containers, suitably insulated and fitted out, connected together and mounted on stilts on the working deck of the vessel. Internally this module was equipped with the necessary furnishings eg blankets, seats, beds and was heated by electric space heaters. Whilst the vessel was on station these heaters were kept switched on to prevent condensation and maintain the module ready for immediate use.

Some three weeks after arriving on station to take up standby duties, smoke was discovered issuing from an air vent on the module; this was little more than an hour after a routine inspection of its interior. After isolating the electrical supply to the module, initial attempts were made to fight the fire using hoses via the access doors and air vents. Large quantities of smoke and heat rendered these attempts unsuccessful. After closing all external doors and flaps on the unit the crew maintained boundary cooling of all outside surfaces of the module until, after being relieved, the vessel arrived in port some 24 hours later. On opening the module’s doors the shore Fire Brigade doused the remains of the fire. The interior of the module was very seriously damaged, although all external surfaces were unmarked.

Observations

The accommodation module was not equipped with a fire detection system; this was not a requirement at the time of the incident. The cause of the fire could not be established with certainty, but balance of opinion is that one of the electric space heaters had overheated and ignited adjacent bedding.

Comment

1. The action of the crew in ensuring that all doors and air vents to the module were closed and concentrating the fire-fighting effort on boundary cooling was correct. This action reduced the risk of injury to the fire-fighting team and probably prevented the fire spreading.

2. The nature of the module’s construction allowed access to all external surfaces for the purposes of boundary cooling. Although it is recognised that such ease of access, and means of clearing surface water may not be available for many ship fires, this incident does reinforce the value of the boundary cooling technique in controlling the spread of a fire.

4. RELEASE OF BITUMEN INTO THE PUMPROOM OF A TANKER

During a routine discharge of bitumen from a tanker, it became apparent that the filter of the port cargo pump, which was the only one in use, had become choked. In order to clean the filter, the pump was stopped and shore personnel informed; the latter then closed their manifold valve.

The Mate remained on deck to complete setting the deck lines in order to drain them back to an empty cargo tank. Meanwhile, the Second Mate and the Bosun went down to the pump room to clean the filter, which required removal of the cover. However, after about five minutes, the shore personnel decided to blow the discharge line back into the vessel, without waiting for permission from the tanker. They opened their air valve, which caused a plug of bitumen to blow back down the line.

The Second Mate and the Bosun noticed the back flow and they quickly left the pump room but the Second Mate was sprayed with bitumen before he could reach the exit ladder.

Observations

1. Bitumen is required to be heated to a high temperature to keep it fluid. When cargo pumping stops it is necessary to drain the lines before it can cool.

2. There was a failure to ensure a safe working system, in that:

- liaison between ship and shore was inadequate, - there was no work planning or defined procedure for the cleaning of filters,

- there was no proper isolation of the cargo system, - there was no "permit-to-work'' system for this operation. Comment

Since this accident, the tanker has reviewed the onboard permit procedures, which have now become part of the safety induction process for all Officers and Petty Officers when they join the vessel. Also a formalised procedure for the safe isolation and overhaul of the filters has been established. This includes, as a minimum, two valve segregation from any cargo system, prior to commencement of any work.

Furthermore, a series of training sessions on permits, in addition to current training schedules, has been introduced for all Officers and Petty Officers in the company.

There are two publications which are relevant to this case:

1. The "International Safety Guide for Oil Tankers & Terminals" gives details of the precautions that should be taken for the clearing of pipe and hose procedures.

2. The "Code of Safe Working Practices For Merchant Seamen", chapter 7 gives details on permit-to-work systems.

5. FIRE IN ENGINE ROOM

A 471 gross registered tonnage submersible support vessel was at sea in rough weather under an unmanned machinery space condition when at 2340 hours, the engine room fire alarm sounded. An initial inspection showed heavy smoke in the vicinity of No 4 main engine; a closer inspection revealed that the spill line from the fuel injector on No 1 unit had fractured allowing fuel to leak onto the engine top. Movement of the vessel due to rough weather subsequently caused the oil to drop onto the exhaust trunking where ignition took place shortly afterwards.

The General Alarm was sounded, fire parties mustered and preparations made to tackle the fire using carbon dioxide and dry powder extinguishers. Because of the weather, two main engines were required for propulsion so, prior to No 4 being shut down, to enable the fire to be tackled, No 3 main engine was started, parallelled and placed on load. As a precautionary measure, a PAN message was broadcast at 0003 hours. Over the next 30 minutes, seven dry powder and five carbon dioxide extinguishers were used both to fight the fire and to cool the exhaust trunking. This trunking was covered by a protective shroud which made direct access to it difficult.

With the fire out and cooling in progress the PAN message was cancelled. It was then discovered that fuel was still being fed to the area from the broken spill pipe connection. This was brought about by the heavy rolling of the vessel causing fuel in the service tank to be forced back down the spill line. To prevent this, the spill pipe was broken further upstream and the fuel overflow diverted. Cooling of the trunking continued until the trunking thermometer recorded approximately 200°C. At this point a light water spray was played over the trunking to further reduce the temperature. A fire hose had been rigged as a backup system, but was kept in reserve due to the close proximity of electrical equipment and was only to be used as a last resort.

Subsequent investigation of the fuel system revealed that a non-return valve was fitted in the fuel supply but there was no isolating arrangement in the fuel spill line.

Observations

The well-considered actions of the crew in the circumstances illustrate the value of both crisis management and fire-fighting training. Had they taken precipitate action concentrated entirely on the fire, and failed to take account of navigational requirements, a situation might have been created whereby fire-fighting could have become considerably more dangerous and could have ended in the evacuation of the engine room.

Comment

1. Subsequent to this engine room fire, non-return valves were fitted in each spill line thus preventing fuel from "returning" back down the line.

2. Spill pipe connections are now checked for defects on a regular basis in line with the normal routine 1000 hour inspection procedures.

6. TWO INCIDENTS OF HEAVY WEATHER DAMAGE

These heavy weather damage incidents caused damage to bridge windows, a compass binnacle and the electrical equipment.

Case 1 A 55