MAIB Safety Digest 1/1995

Summary of Investigations No 1/95

April 1995

INDEX

Page No Introduction

1. Engine Room Fire whilst Alongside 1

2. Fundamental Errors cause Stranding of Small Cargo Vessel 3

3. Attempted Removal of Access Covers causes Injury to Crew Members 5

4. Chlorine Gas Escape from Swimming Pool of Passenger Vessel 6

5. Potential Danger of Water Based Mud 7

6. How to Plan and Conduct a Passage 8

7. New Seaman Injured during Cargo Operations 10

8. Injury due to Incorrect Wiring of Dough Roller Safety Guard 11

9. Occupants; of an Angling Vessel thrown into the Water without Life-jackets 12

10. Unsafe System of Work causes Serious Injury to Fisherman 14

11. Two Crew are Injured during Winch Operations 16

12. Flooding o f An Elderly Wooden Fishing Vessel 18

13. Unsafe Practice during Hauling 19

14. Fishing Vessel Backfloods through its Bilge Pumping System 21

15. Incorrect Operation of Bilge Pump leads to Loss of Fishing Vessel 22

16. Watertight Bulkhead Saves Fishing Vessel 23

17. Accident to Deckhand when Shooting Pots 24

18. Fatalities due to Cordage: not Fit for Use 25

19. Failure of Bilge Alarm leads to Loss of a Fishing Vessel 26

Appendix A - Investigations Commenced in the Period 01/12/94 - 3 1/03/95 Appendix B - MAIB Priced Publications available from HMSO Appendix C - HMSO Stockists and Distributors Overseas

INTRODUCTION

This edition of the Summary of Investigations marks the start of the sixth year of this publication. Including this latest edition we have now published 15 editions which contain over 260 case studies. Some readers might have copies of every edition, while others possibly will only have the later ones. However, looking back over the past editions one of the things which is immediately obvious is that little has changed over five years. A very large proportion of the accidents are still due to failures to observe the basic principles of seamanship, and in many cases a lack of commonsense. It would be wrong to think that all accidents could be prevented but a very great number would not have occurred if only people had given some thought to the job in hand and the likely consequences of what could go wrong. There is a lot of truth in the maxim "To fail to plan is to plan to fail".

All of us make mistakes some time or another and I regret to say we did so when publishing the last summary of investigations - No 3/94. Case study number 5 - "Obstruction at Tidal Berth Causes Pollution" - was included by mistake. The investigation into the accident in question has not been finalised and the “comments” are not strictly valid. When the investigation has been completed we will include a revised summary in a future edition of Summary of Investigations. We apologise for any problems this may have caused readers.

Chief Inspector of Marine Accidents

April 1995

1. ENGINE ROOM FIRE WHILST ALONGSIDE

This 6,009 gross registered tonnage refrigerated cargo vessel was undergoing various voyage and damage repairs whilst in drydock. Amongst those repairs was the requirement to remove a number of damaged shell bottom plates and floors underneath the engine room.

At approximately midnight, the night shift were removing a shell plate by burning along a shell seam from the underside of the vessel. This shell plate formed part of a double bottom tank, several plates of which had already been removed. As the burner was working on the seam, a loud bang was heard from within the tank right above where he was working. The chargehand, who was observing the burning operation from the dock bottom, immediately stopped the burning. Seeing flames within the vessel he tried to put out the fire with an extinguisher which was at hand. However thick black smoke rapidly built up and he decided to leave the dock bottom.

Having told one of his men to ring for the Fire Brigade, the chargehand together with another man, rushed on board, each carrying a fire extinguisher. On reaching the engine room the smoke was so thick that entry was impossible through the engine room door. The ship's staff managed to enter the engine room via the tunnel escape trunk and attacked the fire initially with fire extinguishers, then with a fire hose.

Once the fire was out and the engine room had been cleared of smoke, the seat of the fire was found to be centred around two access manholes to the tank being repaired. Two burnt out plastic containers plus rags were found in the area as well as a quantity of oil and water.

Observations

1. Prior to the start of the work on this double bottom tank, the tank had been gas freed and a "Safe for Hot Work" certificate issued. A fire watch was operative externally but did not extend to the engine room space immediately above the hot work site.

2. On investigation, the fire was found to have started forward of the aft engine room bulkhead in the immediate tank top area above the lub oil tank under repair. No damage was found to either the tank or the internal pipes and n o internal debris was found.

3. The two plastic containers with their tops cut off had most probably contained slops from the tank cleaning that had been carried out prior to the burning operation. Rags drenched in oil and water together with a variety of charred tins were found in the immediate vicinity of the tank access manhole.

4. Most probably the fire was ignited by sparks from the burning operation shooting through the manhole and dropping onto either oil soaked rags or the fluid in the open top containers.

Comment

1. It is important that a fire watch and fire patrols cover not only the immediate area where hot work is taking place, but also those areas adjacent.

2. The cause of the fire was bad housekeeping on the part of the persons employed to carry out the tank cleaning. All waste material and fluids should have been removed from the area and all fluids placed in sealed containers on completion of the shift. These and other precautions are identified in Chapters 2 and 13 of the "Code of Safe Working Practices for Merchant Seamen". Similar guidance will be found in the HSE Approved Code of Practice relating to Safety in Docks and the Docks Regulations 1988.

2. FUNDAMENTAL ERRORS CAUSE STRANDING OF SMALL CARGO VESSEL

A general/bulk cargo ship of 794 gross registered tons left Whitstable shortly after midnight bound for Le Havre. She was in ballast with a maximum draught of 2.45 metres. Her speed in this condition was 8 knots. On clearing the harbour the Master took the first watch. After about two hours the Mate took over the watch, at which time the vessel was about to alter course off North Foreland Lighthouse. The new course to make good was 151 (T) which would take the ship between Gull and Goodwin buoys and clear 0.5 nm NE of the Goodwin Knoll Bank (see chart extract). The wind at the time of the alteration of course was NE'ly 5 and the spring tide was ebbing giving a predicted set of 035 (T) x 1.5 knots.

It was the Mate's intention to navigate by pilotage techniques, steering gyro courses between visual sightings and radar detections of the buoys en route. The radar was set on the 6 mile range. The vessel was also equipped with a Phillips AP Navigator which worked from the Decca system. Visibility from the wheelhouse was restricted due to spray and the vessel was rolling heavily.

The Mate allowed a total of -6 on the course of 151 (T) for the resultant effects of wind and tide. The course steered was not noted in the ship's deck log. The first buoy should have been sighted within 20 minutes after the alteration of course. However, the Mate did not see this buoy or any of the other buoys expected visually or on the radar, neither did he attempt to use any other method to establish the ship's position. The Mate allowed this situation to continue for an hour until eventually he felt the ship run aground.

The vessel had stranded on the Goodwin Sands and was "high and dry" by the following low tide. The vessel was eventually refloated on the next rising tide. There was n o damage: to the ship, no injury to personnel and no pollution resulted from the accident.

Observations

1. The Mate had a 1st Mate's (FG) Certificate, 20 years experience in the Limited European Trade and, in all likelihood, had been using visual estimated positions from buoys and lights as the main or sole basis for navigation for many of those years. He qualified in 1966 and had not undertaken any formal training or updating since that time.

2. The choice of course to pass within 0.5 mile to the North of the Goodwin Knoll Bank in strong NE'ly winds was imprudent especially when considering the restricted visibility from the wheelhouse under those conditions.

3. The Master left no written or verbal "night orders'' before he left the bridge. Although this may not have contributed directly to the incident it is considered indicative of the general relaxed approach to formal bridge and navigational procedures.

4. The Master decided that, due to a heavy workload on the previous day, no watch rating would be required on the bridge.

5. In the 24 hours prior to the stranding the Mate had been able to sleep for an aggregate of about 7 hours over three different periods.

Comment

1. This incident shows how important the fundamental rules for good navigational watchkeeping practice are and how, if good simple procedures are in place, potentially hazardous incidents can be avoided. For example:

- A second person on the bridge would have helped in sighting and identifying navigational marks. Schedule 1 of the Merchant Shipping (Certification and Watchkeeping) Regulations 1982 refers.

- Night Orders may have highlighted the particular dangers to be expected and thus ensured a greater degree of vigilance. (Merchant Shipping Notice No M. 1102).

- Positively fixing the ship's position by any means which were available and preferably by more than one of those means or, if for any reason this was not possible, estimated positions plotted on the chart, would have indicated the potential for grounding. (Merchant Shipping Notice No M.854 para 21 and Merchant Shipping Notice No M.1102 para 20).

- Calling the Master when a navigational mark is not seen by the expected time or when having difficulty in fixing the ship's position, is a prudent and sensible practice which should have been followed on this occasion. (Merchant Shipping Notice No M.1102 para 24).

- Passage planning with proper consideration of the forecasted wind and tidal streams would have highlighted the potential hazard that the choice of course provided. (Merchant Shipping Notice No M.854).

Ensuring that the officer of the watch was properly rested before corning on watch would have helped ensure fitness for duty. Schedule 1 of the Merchant Shipping (Certification and Watchkeeping) Regulations 1982 refers.

The provision of any one of these procedures would have greatly reduced the likelihood of stranding. The fact that none of these procedures were in place made the event almost inevitable.

2. In addition, in connection with the poor standard of navigational watchkeeping shown, Merchant Shipping Notice No M.1328 draws attention to the "Small Vessels' Navigation and Radar Training Courses" which are run by nautical colleges.

3. ATTEMPTED REMOVAL OF ACCESS COVERS CAUSES INJURY TO CREW MEMBERS

Two incidents occurred on separate vessels, which resulted in injury to crew members. They both involved the attempted removal of inspection or access covers to tanks.

In one case a Chief Officer slackened an ullage port dog during the loading of a small tanker whilst venting of the P/V valves could clearly be heard. The pressure within the tank caused the ullage lid to blow open and eject the flame gauze into the Chief Officer's face.

The second case involved the removal of the securing nuts of an access cover to a bulk carrier's ballast suction well which had been isolated for several months. Internal pressure had accumulated in this well, probably due to the leaking of compressed air from the remote contents gauging system. The crewmen removed all the securing nuts on the cover and then, in order to free the cover from its joint, struck it with a hammer. The cover freed suddenly and was projected upwards by the air pressure within the well, breaking the hammer which struck and injured the crewman's ribs.

Observations

These two cases provide a clear demonstration of the large quantities of energy which may be present in gases at even modest pressure; energy which may suddenly be released once the gases are free to escape to atmosphere.

Comment

Guidance on the testing of enclosed spaces and systems for pressure, before securing bolts of covers or joints are fully removed, is contained in the "Code of Safe Working Practices for Merchant Seamen".

4. CHLORINE GAS ESCAPE FROM SWIMMING POOL OF PASSENGER VESSEL

The swimming pool area of a passenger vessel was reopened to passengers after being closed overnight. ‘The normal backflushing procedures were followed during which a quantity of chlorine gas escaped into the pool area affecting the pool attendant and some passengers. Immediate medical attention was available and all affected persons quickly recovered.

Observations

1. For the purpose of maintaining hygienic conditions the water in the swimming pool was regularly dosed with sodium hypochlorite; this was the source of the chlorine gas.

2. The management and crewing of the vessel had changed shortly before this incident suggesting that the crew were unfamiliar with the idiosyncrasies of the pool’s pumping, filtration and chemical dosing systems.

Comment

1. The vessel’s managers have taken steps to ensure that passengers are prevented from entering the pool area when pumping or chemical dosing operations are likely to cause a release of chlorine.

2. Modifications were made to the chemical dosing system to ensure thorough mixing, so preventing the accumulation of pockets of chemicals.

3. Also, tests for chlorine content of the water are to be performed on a routine basis with clear reporting procedures of the results. During these tests the system will be shut down and the area cleared of personnel.

5. POTENTIAL, DANGER OF WATER BASED MUD

An offshore supply vessel backloaded a cargo of water based mud from a mobile drilling rig. The cargo was loaded into tanks and circulated during the return passage to port. When alongside, the tank hatches were opened and discharge of the mud commenced.

After approximately one hour, a representative of the consignee boarded the vessel and noted the Mate leaning over the hatch coaming of a tank that was being drained. He advised the Mate: not to do so because the cargo was contaminated and was liable to give off hydrogen sulphide gas at a concentration level of 5 ppm.

Observations

1. The cargo was not manifested and the vessel had received no documentation stating that the water based mud was contaminated.

2. It was normal practice to have the tank hatches open during discharge in order to be able to readily monitor the quantity of cargo remaining in the tanks.

Comment

1. Although water based mud is not classed as a hazardous cargo, it can sometimes be contaminated with hydrogen sulphide gas.

2. The short and long term exposure concentration limits for hydrogen sulphide gas are 15 ppm and 10 ppm respectively.

3. Although the concentration of gas was apparently below the above limits, the vessel should have been provided with formal written documentation specifying that the mud was contaminated and would give off hydrogen sulphide gas at a concentration of 5 ppm. A safety data sheet for the gas should have also been supplied.

4. Unless there is a clear justification for not doing so, all bulk liquid cargoes should be loaded, carried and discharged under closed conditions.

6. HOW NOT TO PLAN AND CONDUCT A PASSAGE

A 2,333 gross registered tonnage stern trawler/fish factory vessel was awaiting orders and anchored to seaward of the island of Bressay, Shetland at position A. Her Master received orders to move his vessel to another position, B, about three miles to the north-west in the northern approaches to Lerwick Harbour (see chart extract). It was a fine day with a slight sea and good visibility.

It was the Master's intention to take his vessel past the northern tip of Bressay, steer a westerly course for about two miles and then turn to the north towards position B, leaving The Brethren rocks to starboard. He proposed to do this by visual pilotage. The Second and Third Officers were with the Master on the bridge, the Second Officer monitoring the radar and the Third Officer on the wheel.

On passing Score Head, the Master saw an island on the port bow and conned the vessel to pass it to port at a distance of about half a mile. A little later, the Second Officer fixed the position from the radar and marked it on the chart.

As the vessel approached Green Holm, the Master asked the Second Officer how far they would pass from "the island". On being told “two or three cables", he ordered an alteration of course to starboard to increase the passing distance. Shortly afterwards the echo sounder showed rapidly decreasing depths and a further turn to starboard was made. The vessel then grounded heavily on Nive Baa rocks.

Observations

1. The Master had taken Green Holm to be Holm of Beosetter. The Second Officer assumed, from the position he plotted, that the Master intended to pass between Green Holm and Nive Baa. So far as he was concerned, the vessel was very close to what he took to be the intended track. For this reason, the Second