MAIB Safety Digest 1/2003

Safety digest 1/2003

Contents MARINE ACCIDENT INVESTIGATION BRANCH...............................................4 Glossary of Terms and Abbreviations .........................................................................5 INTRODUCTION..........................................................................................................6 Part 1 Merchant Vessels ................................................................................................7 CASE 1 Hooked! ...........................................................................................................8 Narrative...................................................................................................................................8 The Lessons..............................................................................................................................8 CASE 2 A Grounding in Navigation .........................................................................10 Narrative.................................................................................................................................10 The Lessons............................................................................................................................10 CASE 3 High Speed or Not GIVE WAY! .................................................................12 Narrative.................................................................................................................................12 The Lessons............................................................................................................................12 CASE 4 Serious Injury to Passenger Returning to Vehicle ....................................13 Narrative.................................................................................................................................13 The Lessons............................................................................................................................13 CASE 5 Be Prepared for Steering Failure and Safe Navigation! ...........................14 Narrative.................................................................................................................................14 The Lessons............................................................................................................................14 CASE 6 Talk-Back System Failure ...........................................................................15 Narrative.................................................................................................................................15 The Lessons............................................................................................................................15 CASE 7 Fire Around Oil-Soaked Lagging ...............................................................16 Narrative.................................................................................................................................16 The Lessons............................................................................................................................16 CASE 8 Ferry Grounds After Cutting Corner.........................................................17 Narrative.................................................................................................................................17 The Lessons............................................................................................................................17 CASE 9 When is a Vessel Constrained by her Draught?........................................19 Narrative.................................................................................................................................19

The Lessons............................................................................................................................19 CASE 10 Grounding ...................................................................................................22 Narrative.................................................................................................................................22 The Lessons............................................................................................................................23 CASE 11 Stand-by Vessel in Collision with a Rig....................................................25 Narrative.................................................................................................................................25 The Lessons............................................................................................................................25 CASE 12 Coaster Encounter......................................................................................26 Narrative.................................................................................................................................26 The Lessons............................................................................................................................26 CASE 13 Sun-drenched Coaster?..............................................................................27 Narrative.................................................................................................................................27 The Lessons............................................................................................................................27 Part 2 Fishing Vessels ..................................................................................................28 CASE 14 Check Your Lifejacket ...............................................................................29 Narrative.................................................................................................................................29 The Lessons............................................................................................................................30 CASE 15 Incorrect Use of Trawl Blocks Leads to Fatal Accident .........................32 Narrative.................................................................................................................................32 The Lessons............................................................................................................................33 CASE 16 Skipper Killed by Lifting Gear Failure While Alongside.......................35 Narrative.................................................................................................................................35 The Lessons............................................................................................................................35 CASE 17 The Tragic Outcome of Overloading........................................................36 Narrative.................................................................................................................................36 The Lessons............................................................................................................................37 CASE 18 Cooks Crash Diet........................................................................................39 Narrative.................................................................................................................................39 The Lessons............................................................................................................................39 Part 3 Leisure Craft .....................................................................................................40 CASE 19 Open Sailing Boat Causes Ferry to Crash Stop.......................................41 Narrative.................................................................................................................................41 The Lessons............................................................................................................................41

CASE 20 Speedboats Create Havoc in Small Harbour ...........................................43 Narrative.................................................................................................................................43 The Lessons............................................................................................................................43 CASE 21 High Jinx, Low Common Sense ................................................................44 Narrative.................................................................................................................................44 The Lessons............................................................................................................................44 CASE 22 Yachtswoman Dragged Under Chain Ferry ............................................45 Narrative.................................................................................................................................45 The Lessons............................................................................................................................46 APPENDIX A ...............................................................................................................48 APPENDIX B Reports issued in 2002 .......................................................................49 APPENDIX C Reports issued in 2003.......................................................................53

MARINE ACCIDENT INVESTIGATION BRANCH The Marine Accident Investigation Branch (MAIB) is an independent part of the Department for Transport, the Chief Inspector of Marine Accidents being responsible directly to the Secretary of State for Transport. The offices of the Branch are located at Carlton House, Carlton Place, Southampton, SO15 2DZ. This Safety Digest draws the attention of the marine community to some of the lessons arising from investigations into recent accidents. It contains facts which have been determined up to the time of issue. This information is published to inform the shipping and fishing industries, the pleasure craft community and the public of the general circumstances of marine accidents and to draw out the lessons to be learned. The sole purpose of the Safety Digest is to prevent similar accidents happening again. The content must necessarily be regarded as tentative and subject to alteration or correction if additional evidence becomes available. The articles do not assign fault or blame nor do they determine liability. The lessons often extend beyond the events of the incidents themselves to ensure the maximum value can be achieved. Extracts can be published without specific permission providing the source is duly acknowledged. The Editor, Jan Hawes, welcomes any comments or suggestions regarding this issue. The Safety Digest and other MAIB publications are only available from the Department for Transport, and can be obtained by applying to the MAIB.

If you wish to report an accident or incident please call our 24 hour reporting line 023 8023 2527

The telephone number for general use is 023 8039 5500. The Branch fax number is 023 8023 2459. The e-mail address is maib@dft.gov.uk

Summaries (pre 1997), and Safety Digests are available on the Internet: www.maib.gov.uk Extract from The Merchant Shipping (Accident Reporting and Investigation) Regulations 1999 The fundamental purpose of investigating an accident under these Regulations is to determine its circumstances and the causes 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.

Glossary of Terms and Abbreviations ARPA Automatic Radar Plotting Aid CPA Closest Point of Approach CPR Cardio Pulmonary Resuscitation GT Gross tons MCA Maritime and Coastguard Agency MGN Marine Guidance Notice OOW Officer of the Watch PA Public Address (system) RNLI Royal National Lifeboat Institution Ro-Ro Roll-on, roll-off UHF Ultra High Frequency VHF Very High Frequency

INTRODUCTION Since taking up the post of Chief Inspector of Marine Accidents last August, I have repeatedly been asked the question: what exactly does the MAIB do? Therefore, I am taking this opportunity to remind people of who we are, what we are trying to do, and how we do it. Our role is very simple: to identify the underlying causes of marine accidents so that we can prevent them happening again. Our job is not to point the finger of blame at the normally conscientious skipper who, in an attempt to meet heavy quotas, took a few short-cuts. Nor is it to help prosecute the shattered watchkeeper whose vessel grounded after he fell asleep. Instead, by identifying the underlying problems that led to the accident, we can make recommendations to reduce the risk of such problems recurring. Simply, we seek to answer four basic questions: • What happened? • How did it happen? • Why did it happen? • What can be done to prevent it happening again? As Chief Inspector of Marine Accidents, I report directly to the Secretary of State for Transport. I have four teams of accident investigators, all professionally qualified and experienced in the nautical (including fishing), engineering, or naval architecture disciplines of the marine industry, and a small administrative staff. You will find them all approachable, and any information given to them is treated in the strictest confidence. We are empowered to conduct examinations and investigations into accidents to, or on board, UK merchant ships, fishing vessels and pleasure craft anywhere in the world, and to similar foreign vessels within UK waters. UK waters are, broadly speaking, out to 12 miles from the UK coast including canals, lakes, rivers and estuaries. The master or skipper of any commercially operated vessel within this definition is required to notify the MAIB of any accident to, or on board his/her vessel. This includes vessels in commercial use for sport or pleasure. Skippers of private pleasure vessels do not have to report accidents to us, but we would encourage them do so. Obviously we cannot fully investigate more than a tiny fraction of the 1500 or so accidents that are reported to us each year. We conduct an administrative enquiry (by mail and or telephone only) on many accidents and incidents, we conduct a preliminary examination on a smaller number, and conduct a full investigation, leading to a full accident report, on only the most crucial accidents. Our criteria for deciding which of these is appropriate to each accident is simply the lessons likely to emerge for future safety. In summary, our focus is your safety. Lets work together to make the sea a safer place. Stephen Meyer Chief Inspector of Marine Accidents April 2003

Part 1 Merchant Vessels In the last issue of the Safety Digest we highlighted the need to be safe: • Slow down • Speak up • Stay alert. We are all vulnerable to lapses of attention. But those moments of inattention can cost lives, cause costly and extensive damage to vessels, and they will often create huge embarrassment for all concerned. The conscientious seafarer will do everything possible to prevent them. The dangers inherent when that old enemy fatigue sets in are all too obvious. Even the most experienced seafarer will begin to make mistakes; his/her judgment will be affected, decisionmaking skills will be impaired and the ability to stay alert will be lost. Tiredness at sea can be brought on by many factors: long hours, a shortfall in the number of crew required to safely man a vessel, work pressure, or several days at sea working a gruelling schedule. The seafarer working a night watch, feeling completely drained, will find the monitoring of complicated modern navigation, or machinery controls, that much more difficult. He/she will also be less able to keep a good lookout for other vessels. If you find yourself in the position of having to work when tiredness has long since set in, ask another officer to check that all course and engine changes are as planned. This person must be alert, well rested, and prepared to voice their concerns if they see something that doesnt look quite right. We are well aware of vessels trading around the UK coast with just two watchkeepers and a commercial workload which involves little, if any, break in the watchkeeping routine. Cumulative fatigue can build up and if control measures, such as watch alarms and a lookout, are not in place or fail, then the result can be a missed alteration at a waypoint, or the failure to take avoiding action in the event of a situation involving risk of collision. The MAIB has made recommendations following fatigue-related accidents on several occasions in the past. These recommendations have addressed both manning as well as control measures. We are also aware of other underlying issues involved with fatigue, such as management, environment and teamwork, relating to quality of sleep as well as sleep deprivation. Finally, never allow other duties, or fatigue, to jeopardize the maintenance and inspection of safety equipment. We all know that when this equipment is needed it must be fully operational. Peoples lives will be depending on it. And it may be your own!

CASE 1 Hooked! Narrative A 22,986gt ro-ro passenger vessel was berthed stern to the jetty for loading/unloading, and starboard side alongside dolphins. As part of the vessels normal routine of testing of lifeboats, it was decided that No 1 lifeboat on the starboard side should be deployed, as it was well clear of the dolphins. With the ships officers and crew in attendance, the lifeboat was prepared for lowering. As the davits moved outboard, both forward and aft auto release trip mechanisms operated, but only the forward gripe dropped free. With the aft gripe still hooked on, further lowering of the davits caused the lifeboat to twist on the davits. The davit brake was applied, and the aft gripe released by hand, causing the lifeboat to swing violently on the falls. The test was abandoned, and the lifeboat winched back into the stowed position so that the cause of the hang up could be investigated. On examining the aft auto release trip mechanism, it was found that the hook, on which the gripe wire link was secured, had developed a very well defined groove where the link normally lay. The depth and contours of the groove were sufficient to hold this link in place, even when the operating arm had tripped. The wear on the hook had obviously taken some time to develop, and had probably been caused by a combination of corrosion, slight movements of the lifeboat in the davits, and vibration. The company repaired the hook and fitted a new heel pad to ensure that the gripe wire link was correctly placed when the lifeboat was in the stowed position.

The Lessons 1. Any mechanism that uses a release mechanism requiring a sliding action between solid materials, should be examined at regular intervals. Wear is a natural phenomenon, and with the addition of corrosion, surface irregularities soon develop. 2. Lifeboats are an essential part of the vessel, and every effort should be made to maintain them to a high state of readiness. By their very nature, they are placed in a relatively exposed position, and for that reason are susceptible to corrosion and varying weather-imposed loadings. If you find noticeable wear developing, report it to a senior officer. It may not be significant or dangerous at that moment, but by reporting your concerns, action can be taken to prevent it developing further. 3. These events happened during routine testing, and a problem was found when nobody was at risk. This illustrates clearly the importance of testing.

No 1 lifeboat, starboard side

Worn hook on aft gripes

CASE 2 A Grounding in Navigation Narrative A small commercial vessel was on a river passage with ten foreign student passengers embarked for 'team-building' training. The master was an experienced mariner, but had not been to sea for about 2.5 years, and had previously visited the vessel on only one occasion. The students, who had no prior experience at sea, split into three watches and, during the passage down the river and under the supervision of the master, were tasked to keep the vessel within the navigable channel. At 0600, about 3 hours after sailing, the master was feeling tired, so sat on a bench at the rear of the wheelhouse to eat a bacon sandwich. Fifteen minutes later, up to six Dutch students were in the wheelhouse during the watch changeover. The oncoming watch quickly became concerned that the vessel was on the south side of the river in a green-shaded area of the electronic chart, but decided that the position displayed was incorrect. As the master could not understand Dutch, and was unfamiliar with the electronic charts in use, he was unaware of the students of concerns. The vessel had left the navigable channel and was heading towards the morning sun and into shallow waters. Although the master by that time had moved to the starboard side of the wheelhouse to discuss the passage plan with a student, and could see ahead, he was not aware of the vessel's position. About 10 minutes later, however, he noticed that she was starting to feel the ground, and instructed the student helmsman to steer for the middle of the river. The vessel grounded moments later.

The Lessons 1. Even for the most experienced mariners, returning to sea after a lengthy absence brings problems, including dealing with new technology and adapting to a different work pattern. Few individuals can pick up from where they left off, and will need time to familiarise themselves with new equipment, and settle into a watchkeeping regime. 2. When working alongside during the day, with everybody feeling fresh and alert, it is all too easy to forget the demands that will be made on individuals at sea overnight, after the ship has sailed. There's always a lot to do and many people to see, and inevitably time marches on without some crew being adequately rested. Fatigue affects us all, however, and staying up all day unavoidably results in tiredness at some stage during the night. Falling asleep is only one effect of fatigue; others, including a reduction in alertness, can be just as dramatic when watchkeeping. When preparing for a night sailing, always make sure that everyone has sufficient opportunity to rest during the day. 3. Supervising others can be tedious, particularly when trainees are doing well and appear to be coping admirably with minimum direction. Trainees, however, are unlikely to have the experience to spot the danger signals when things start to go wrong, and if those overseeing them do not keep a close eye on the situation, disaster can strike. Supervisors must, therefore, continually cross-check the work of the trainees, regardless of their apparent competency, and be ready to intervene should the need arise. 4. Over the years, the use of echo sounders has undoubtedly reduced as the accuracy of other navigational aids has increased. They remain, however, the only aid able to provide the exact

depth of water under the keel, rather than what there should be. Take nothing for granted the nearest danger might be lurking just below! 5. Too many people in the wheelhouse or bridge can be extremely disruptive, particularly when different languages are spoken. Keep the number of people and amount of noise in these spaces to a minimum, and make sure that everyone remains aware of what is going on. 6. When heading into the sun, it can be extremely difficult to see navigational marks (or to be aware of their absence). Having sunglasses available in the wheelhouse or on the bridge is a wise precaution. 7. Everyone should be encouraged to voice their concerns if they see something that doesnt look quite right or is potentially dangerous.

CASE 3 High Speed or Not GIVE WAY! Narrative A high-speed ferry was proceeding in open water on a course of 290° at 27 knots. A tanker was steaming 020° at 12 knots. It was daylight, the visibility was good and the sea was slight. The ferry detected the tanker by radar at 14 miles range, and her ARPA indicated that a close quarters situation was developing. The tanker monitored the ferrys approach from 8 miles range and her ARPA indicated that she would pass close ahead of the ferry. Although concerned, and recognising that his was the give-way vessel, the tankers OOW maintained course and speed, relying on his interpretation from the radar that the tanker would pass ahead. The ferry, on the other hand, reduced speed to increase her CPA. The tanker eventually passed ahead of the ferry at a range of 4 cables.

The Lessons 1. Although anxious about the developing situation, the tankers OOW maintained course and speed. The Collision Regulations make it clear that if there is any doubt, a risk of collision shall be deemed to exist. The tanker was the giveway vessel in a simple crossing situation, and should have taken early and substantial avoiding action to give the ferry a wide berth. 2. Although high-speed craft are generally more manoeuvrable than traditional vessels, the Collision Regulations make it clear that they carry no special privileges or obligations with respect to collision avoidance, and do not relieve a give-way vessel of her obligation of acting early to ensure her intentions are clear. 3. The ferrys actions prevented what would otherwise have been an unnecessarily close encounter.

CASE 4 Serious Injury to Passenger Returning to Vehicle Narrative A female coach passenger was seriously injured on one of the car decks of a ro-ro passenger ferry discharging passengers and vehicles. All the coaches were parked on the starboard side of vehicle deck