MAIB Safety Digest 1/1994

MARINE ACCIDENT INVESTIGATION BRANCH

Summary of Investigations No 1/94

Marine Accident Investigation Branch 5/7 Brunswick Place SOUTHAMPTON Hants SO15 2AN

Telephone : 0703 395500

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 1994

INDEX

Page No Introduction

Burn Injury during Loading of Incinerator 1

Cargo Shift causes Vessel to List 3

Fall Overboard of Pilot in Disembarking 4

Main Engine Failure whilst Leaving Harbour 6

Heavy Weather Damage to Wheelhouse Windows 8

Scalding due to Uncontrolled Release of Steam 11

Fatal Accident during an Unberthing Operation 12

Collision caused by Fatigue 14

Explosion in Engine Room at Sea 16

Battery Box Explosion causes Injury 18

Collision between two Fishing Vessels in Fog 19

Loss of Trawler through Flooding 20

Bilge Alarm and Watertight Bulkheads Save Flooding Fishing Vessel 21

Lack of Maintenance resulting in Flooding of a Fishing Vessel 22

Fishing Vessel Floods while Crew Sleeps 23

Flooding as a Result of Squeezing Damage 24

Crabber Sinks and Two Lives are Lost 26

Capsize of Small Fishing Vessel with Loss of Life 28

Collision between Two Fishing Vessels and their Subsequent Loss 30

Appendix A - Investigations Commenced in the Period 01/12/93 - 31/03/94

Appendix B - MAIB Priced Publications available from HMSO

Appendix C - HMSO Stockists and Distributors Overseas

INTRODUCTION Deciding on a theme for the introduction to any edition of the Summary of Investigations can come about in a number of ways. Sometimes it requires a lot of brain-storming while on other occasions a germ of an idea has been slowly developing, possibly since the time the previous edition was published. Occasionally the idea for a theme is generated from a passing remark. The theme for the introduction of this edition came about in exactly that way, though to be more precise this arose from remarks made by different persons in totally different surroundings.

The first remark was when one of the Inspectors in the Branch was playing in a golf competition. One of his playing partners, who was a complete stranger to him, happened to be a marine engineer. When he realised the type of work the Inspector carried out he told him that the company he worked for provided copies of the Summary of Investigations to their ships. Thankfully, his comments about the Summaries were complimentary though he did have one "complaint": he would like to see more engineering related summaries.

The second remark was made a few weeks later when, during a presentation about the work of MAIB followed by a question/answer session, a recently retired Chief Engineer was surprised to learn that hazardous incidents (near misses) of an engineering nature were of interest to the Branch and that we have always recommended the voluntary reporting of such incidents.

From these two remarks it seemed appropriate that the theme for this edition should be engineering related, particularly because it includes three engine room incidents and at least three others with an engineering connotation.

Good engineering practices are just as important as good seamanship, for the safe and efficient operation of vessels. It is particularly important that corners are not cut to save time and that all the right safety precautions are taken, whether they concern the operation of equipment or the maintenance of that equipment. It is sad to say that many accidents are the result of not having taken time to consider properly the hazards associated with the job which is to be carried out. Some classic examples are the likelihood of residual pressure in a pipeline which requires to be opened up; proper isolation (electrically or from other power sources) before starting work on a piece of equipment; ensuring that lifting tackle is of the correct safe working load; selection of the correct tools for the job; working knowledge of the piece of equipment; and so on. This might all seem obvious to any self-respecting engineer; but unfortunately the obvious is all too often neglected.

Turning now to the reporting of hazardous incidents of an engineering nature. A hazardous incident is defined as "any incident or event, not being an accident, by which the safety of a ship or any person on board is imperilled, or as a result of which serious damage to any ship or structure or damage to the environment might be caused". Obviously there are many engineering incidents that occur on board which have potential to be accidents and a lot of lessons can be learnt from those incidents. However, it is important that the details are not kept quiet for this clearly prevents others from becoming aware of the potential for an accident which is present in their

own operations. In Merchant Shipping Notice No M.1383 Owners and Masters are strongly urged to report such incidents voluntarily, and though the wording is perhaps not very clear it includes engineering related hazardous incidents. Perhaps also the retired Chief Engineer was not aware of this advice because M Notices, unless they are clearly addressed to the Engineering Officers on board, tend to be considered the responsibility of the Master and are not always brought to the attention of all those concerned on board. Please remember that if the information and advice contained in M Notices is to be put to the best use, the Notices need to be given as wide a circulation on board as possible and need to be discussed, not just kept in a file.

Chief Inspector of Marine Accidents April 1994

1. BURN INJURY DURING LOADING OF INCINERATOR

Garbage was being incinerated in a 9,158 gross registered tonnage offshore support vessel. Four bags of garbage had been partially incinerated. A motorman was in the process of loading additional bags into the furnace of the incinerator using a long- handled broom. A blow-back occurred which caused burns to his face and particles to enter his eyes.

0b serva ti ons

1. The incinerator incorporates a double door loading chamber. The chamber inlet door is manually operated. The chamber outlet is closed by a counter-balanced steel flap which is pivoted at the top. The flap opens to allow the free passage of garbage and automatically closes after the garbage has passed. The furnace inlet door is pneumatically operated by manual push-buttons.

2. In order to load solid garbage into the incinerator, the following procedure is required to be followed:

2.1 press the door "OPEN" push-button. (This initially causes the auxiliary burner and forced draught fan to automatically stop and then the furnace door to open);

2.2 ensure the rotary arm is rotating and that the loading ram is pulled back to the outer end of the loading chamber;

2.3 open the loading chamber inlet door;

2.4 load one full bag of garbage into the chamber;

2.5 close and latch the chamber inlet door;

2.6 push the loading ram firmly towards the incinerator to the full extent of travel;

2.7 return the loading ram to its original position;

2.8 repeat the loading operation up to a maximum of three bags;

2.9 press the door "CLOSE" push-button, (this initially causes the furnace door to close and then the forced draught fan and burner to start).

3. The management company has reported the following:

3.1 a full face visor was available at the incinerator but was not used;

aerosol cans have been known to explode in the incinerators in the past. The company has now stopped providing aerosols for sale from ship’s bonds;

an Internal Safety Notice has since been issued incorporating the following instructions:

appropriate safety equipment, including face visor, must be used when operating incinerators. A sign to this effect shall be displayed at the incinerator position;

incinerators shall only be used strictly in accordance with manufacturer’s instructions. Chief Engineer is to ensure that personnel using the incinerator are instructed in its safe use. An instructional sign is to be displayed at the incinerator showing the correct mode of operation;

all vessels should address the subject of the safe disposal of pressurised aerosols, this includes those vessels without rubbish incinerators.

1. The incinerator was fitted with an interlock such that, with the furnace inlet door open, at least one of the loading chamber doors should have been shut. The deliberate action of the motorman caused the interlock to be overridden. Such action was contrary to the manufacturer’s loading instructions.

2. The injury sustained by the motorman was a direct result of him being exposed to the furnace without any form of facial protection.

3. It is considered that the action since taken by the management company will contribute to preventing a recurrence of the incident.

2. CARGO SHIFT CAUSES VESSEL TO LIST

A 299 gross registered tonnage general cargo vessel was loaded with a cargo of 467 tonnes of anchor chain. As the tank top was constructed in steel, wooden dunnage was arranged to prevent the first layer of chain moving. Bundles of chain were loaded into the hold by crane, but no further securing was carried out. The Master and Mate were satisfied with the stow. She departed in fine conditions with wind Force 2 - 3. The forecast was Force 8 southerly, so some double bottom tanks were ballasted. Over the second and third days of the voyage the winds increased to Force 7 - 8, with a long swell. At 0500 hours on the fourth day the cargo shifted and the vessel listed heavily to port after being hit by two huge waves on the starboard quarter. It was estimated that the angle of list was 25 to 30 The crew prepared the liferafts and put on their survival suits. No 1 ballast tank starboard side was filled and VHF contact was made with the Coastguard. There was an increase in wind which produced a further cargo shift and the list increased to 40 . Water was over the deck but not up to the hatches. At 0620 hours the rescue helicopter arrived and by 0640 all the crew had been airlifted from the starboard bridge wing. The machinery remained operational during the incident.

The crew were safely landed ashore and the vessel was later towed into sheltered water. The cargo was re-stowed and the vessel continued her voyage.

Observations

1. It was the first time the Master and Mate had taken a cargo of this type.

2. The severe weather conditions caused the unsecured bundles of anchor chain to shift.

Comment

1. This incident put the persons on board at risk. Had the Master and Mate followed the guidance set out in the IMO "Code of Safe Working Practice for Cargo Stowage and Securing" Annex 8 - Safe stowage and securing of anchor chains - this incident would not have occurred.

2. The aim of the code is to provide an international standard for the safe stowage and securing of cargoes. It gives advice on ways of securing and stowing cargoes and gives specific guidance on cargoes which are known to create difficulties or hazards. It also gives advice on action to be taken in heavy seas and to remedy cargo shift.

3. FALL OVERBOARD OF PILOT IN DISEMBARKING

A cargo vessel was outward bound from a United Kingdom port under pilotage, and the pilot was to disembark into a launch in relatively open estuarial waters. It was night-time, with good visibility; the wind was south by east Force 4 (broad on the cargo ship’s starboard bow) with a wave height of 1 - 1.5 metres. The ship’s freeboard was about 4.5 metres.

The pilot ladder was rigged on the starboard side, and as the launch approached the pilot climbed part way down. As the launch came alongside it was lifted by a wave and came up under the ladder causing the pilot to fall on to the launch’s deck, and before he could gain a secure hold he fell again, into the sea between launch and ship.

When he surfaced he was astern of the launch. A lifebuoy was thrown from the ship but out of reach of the pilot; however the launch kept him in sightwith the aid of the searchlight, turned and picked him up using the recovery platform fitted aft. He was in the water for less than five minutes, and suffered no serious injury; but as a result of hypothermia and sea water ingestion he was kept in hospital for some days.

Observations

1. At the time of disembarking the ship was steaming at some 6 - 7 knots and had not yet reached the recognised pilot station. The ladder was rigged on the weather side and no attempt was made to make a lee for the pilot launch. There was no communication between the ship and the launch as to the disembarkation arrangements.

2. The pilot climbed part way down the ladder before the launch was alongside.

3. The local pilotage authority had issued pilots with high visibility jackets with self-inflating buoyancy, reflective tapes and lights. The pilot involved in the accident was however wearing a black anorak with neither reflective tapes nor light, and no life-jacket or buoyancy aid.

4. The man-overboard recovery platform fitted to the launch proved its value, though some difficulty was experienced in its operation.

Comment

1. The pilot was fortunate to be recovered quickly; the incident occurred in January when the sea water temperature was low and this, combined with the failure to wear the proper safety jacket, might very easily have led to a fatal outcome.

2. ''The Boarding and Landing of Pilots by Pilot Boat Code of Practice", produced by British Ports Federation in conjunction with Pilots and Harbour Authorities, includes the following:

"VHF radio contact should be established between the pilot boat and vessel ... the pilot boat coxswain should liaise with the vessel in order to make the best lee for safe transfer ...”

"All pilots ... should wear appropriate protective clothing and buoyancy equipment ...”

"Before stepping on to the ladder the pilot should check that the pilot boat is laying alongside and has not fouled the pilot ladder ...”

"Retrieval drill for pilot boat crews ... should be carried out on a regular basis ... pilots should all be familiar with the recovery equipment of their pilot boats ...”

3. The Code of Practice has now been supplied to all pilots and launch crews in the district where this accident occurred. It contains in plain terms much advice in addition to that quoted, and adherence to it will do much to reduce the risk of accidents to pilots during transfer.

4. MAIN ENGINE FAILURE WHILST LEAVING HARBOUR

A 475 gross registered tonnage general cargo vessel engaged in a regular coasting trade was fitted with a marine diesel driving through a fixed ratio gearbox and clutch to single shaft and a fixed pitch propeller. The main engine was air started manually in the engine room with control then being passed to the bridge, the engine room being unmanned whilst at sea. The normal engine safety devices were fitted including a mechanical overspeed trip.

The vessel left her berth at 0630 hours and proceeded down river on the ebb tide towards the river mouth, passing the breakwater at about 0730 hours. The bad weather which had prevented an earlier departure was moderating at this time and was forecast as decreasing to northerly Force 4 - 5.

On leaving the shelter of the breakwater, the vessel experienced rough water together with a moderate to heavy swell causing the vessel to pitch a number of times. Noting that the main engine was slowing down, the Master sent a crew member below to find the cause of the trouble. By this time the main engine had stopped. Despite various attempts by the crew, they were unable to re-start the main engine with the result that the harbour authorities were informed and a tug requested. The vessel drifted towards the south-west under the influence of the weather, striking the ground hard before eventually grounding on a sandy beach. Shortly after the vessel grounded, the port anchor was dropped to try and prevent the vessel being driven further ashore. With no further action possible and with a lifeboat and helicopter in attendance, the Master ordered the evacuation of the vessel at 0755 hours.

Continued bad weather delayed the salvage although easy access to the vessel was possible at low tide. The sand was banked up to prevent further movement ashore whilst both anchors were laid out to seaward. Eventually a trench was dug to seawards from the vessel, the ballast was pumped out, and on a high tide, the vessel refloated. After testing of the main engine and steering gear the vessel proceeded into dry dock where some plate damage to the bottom was found although the hull remained intact and watertight. No damage was found to either the steering gear or the main engine.

Observations

1. The main engine was a standard marine diesel fitted with various safety devices including an overspeed trip. The function of this trip is to safeguard the engine in the event that the load is suddenly removed from the engine whilst under way, such as when the propeller comes clear of the water or the shaft fractures. Any sudden reduction of load whilst the fuel pumps are operating at a high level causes the engine to race and overspeed. On this engine an overspeed of 20% could be accepted by the safety mechanism before the trip operates.

2. On this occasion whilst negotiating the harbour entrance, the vessel pitched severely causing the propeller to either come clear of the water or sufficiently close to the surface to reduce significantly the load