MAIB Safety Digest 1/2004

MARINE ACCIDENT SAFETY DIGEST Lessons from Marine

INVESTIGATION BRANCH Accident Reports

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INVESTOR IN PEOPLE

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 1/2004

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INVESTOR IN PEOPLE

Department for Transport Eland House Bressenden Place London SW1E 5DU Telephone 020 7944 3000 Web site: www.dft.gov.uk

© Crown copyright 2004

This publication, excluding any logos, may be reproduced free of charge in any format or medium for research, private study or for internal circulation within an organisation. This is subject to it being reproduced accurately and not used in a misleading context. The material must be acknowledged as Crown copyright and the title of the publication specified.

Further copies of this report are available from: MAIB 1st Floor Carlton House Carlton Place Southampton SO15 2DZ

Some of the photographs supplied courtesy of FotoFlite.

Printed in Great Britain. Text printed on material containing 100% post-consumer waste. Cover printed on material containing 75% post-consumer waste and 25% ECF pulp. February 2004

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 and incidents. 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 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

Crown copyright 2004

MARINE ACCIDENT INVESTIGATION BRANCH

The role of the MAIB is to contribute to safety at sea by determining the causes and circumstances of marine accidents, and working with others to reduce the likelihood of such causes and circumstances recurring in the future.

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.

INDEX GLOSSARY OF TERMS AND ABBREVIATIONS 6

INTRODUCTION 7

PART 1 – MERCHANT VESSELS 8 1. Hands-on Training – yes – but Don’t Lose Control! 10 2. ‘Spontaneous’ Lowering of a Lifeboat 12 3. Low Pressure – Not Low Risk 13 4. A Stopper That Didn’t Stop 14 5. Late Changeover Leads to Grounding 15 6. If There is no Risk Assessment, Do Your Own 17 7. Out of Control 18 8. Unplanned Trip up the River 19 9. Tug Trauma 21 10. Ouch! 24 11. Quick Response to Vehicle Fire on Ro-Ro Ferry 26 12. What a Foul Up! 27 13. Who Put That There? 29 14. It Has Been Drained, But is it Dry? 31 15. Beware of Berths that Dry Out 33 16. Stay A Leading Light – Use Them! 35

PART 2 – FISHING VESSELS 37 17. Modifications Result in Loss of Stability, Vessel and a Life 38 18. Overloaded, Overdue, Over….. 40 19. Too Much On Top 42 20. Quick Action Saves Fishing Boat and Crew 44 21. Winch Problem Leads to Capsize 45 22. ‘Dodgy’ Alarm, So No Warning 47 23. A Fatal Override 48

PART 3 – LEISURE CRAFT 49 24. Catamaran Capsize in Solent 50 25. Out of Sight, Out of Mind 52 26. Early Warning Headaches 54 27. Lookout! What Lookout? 55

MAIB NOTICEBOARD 56

APPENDICES Appendix A – Preliminary examinations and investigations started in the 57 period 01/11/2003 to 29/02/2004 Appendix B – Reports issued in 2003 58 Appendix C – Reports issued in 2004 60

Glossary of Terms and Abbreviations AB – Able Seaman CO2 – Carbon Dioxide CPP – Controllable Pitch Propeller

EPIRB – Emergency Position Indicating Radio Beacon

GT – Gross tons

“Mayday” – Spoken distress signal

Ro-Ro – Roll on – roll off

RYA – Royal Yachting Association

VHF – Very High Frequency

VLCC – Very Large Crude Carrier

Introduction Welcome to the first Safety Digest of 2004. For those who go to sea for pleasure, there is no Regular readers will notice a couple of changes in legal requirement to report accidents. However, style; not only have we introduced colour, to try we would encourage you to report to make the articles more readable, but we have accidents/incidents anyway. We have recently also, for the first time, asked non-MAIB people tracked down an unidentified ship that collided to write the introductions to the three sections. with a yacht and, in Case 27 of this edition, we As part of our move to persuade the maritime describe how we followed up a near-miss incident community to become more involved in our in the English Channel, reported to us by a work, you will find introductions written by well- yachtsman. If you don’t report things, we do not known and respected members of the know the scale of the problem, and we cannot commercial, fishing and leisure industries. try to improve matters. Do your bit for safety – report accidents/incidents. Although the style might have changed, the substance remains the same. Here are 27 Finally, I would like to draw readers’ attention to accidents or incidents, all very different, reported the MAIB Noticeboard on page 56. This in (I hope) a straightforward manner, so that we replicates an important Safety Bulletin published can all learn the lessons from the misfortunes of as a result of an accident that occurred on 30 others. Please take the time to consider them all. January 2004, which had the potential to be lethal. Although it happened on board a fishing For anyone operating a vessel commercially – vessel, all mariners should take heed. merchant ship, fishing boat or leisure craft – there is a legal duty to report accidents. If you are in doubt about the requirements, give us a ring, or report it anyway – we would far rather have over-reporting than under-reporting. If you believe accidents are being suppressed, rather Stephen Meyer than reported, tell us (we have a legal duty to Chief Inspector of Marine Accidents protect our sources), or report it to the April 2004 confidential reporting system – CHIRP.

MAIB Safety Digest 1/2004 7

Part 1 – Merchant Vessels They tell us of something lacking. A lack of planning, risk assessment, maintenance, training, competence, pre-work briefings (called “tool box talks” in the offshore industry), challenge, management of change, accountability, equipment, and so on and so on. Quite a list! Quite an indictment!

And why do these accidents always seem to happen without warning? Well isn’t that what an accident does? But, hold on! Are they without warning? Are not the warning signs there? They just have to be looked for, hunted down, I like a good read, and I always look forward to observed, identified and dealt with. Then we will the thump of the MAIB Safety Digest landing on see them for what they are, these same themes. the doormat. And it is a good read. Draw the curtains, make up the fire and settle into a If one were to choose just a few themes to favourite armchair. Here are exciting tales of concentrate on, which should they be? If I were adventure on the high seas, groundings, fire on to choose they would be: board, storm at sea and others. When you read it from cover to cover you get a whiff of Joseph • Planning – no work should be considered Conrad in these tales. without a plan. For the complicated and unusual tasks a proper one must be made in But these tales are not fiction. These are not the advance, but for routine work it can be as outpourings of the fevered imagination of the simple as “tool box talks” with all those to be Chief Inspector, Stephen Meyer, and his crew. involved just before the work starts. What is No imagination could have invented better the job, what resources are needed, what stories than these. This is cold, stark, mean procedures exist, who will do what, etc? reality that is laid out before us. Lurking in these pages are not the heroes and villains of fiction. • Risk assessment – a meaningful and thorough These are real, honest, decent people. Real risk assessment is essential to highlight the people who are getting hurt. Real people who are hazards and risks and the actions to take to getting killed. They could be our colleagues; for lessen them. It will also show up the strengths some they are. When this sailor returns home, and weaknesses in training, equipment etc. adoring mothers, wives and children will not see The risk assessment should be a living a happy smiling face. Perhaps they may never see document, visited frequently and always his face again. More than one life can be aligned with the plan. wrecked in these adventures. • Management of change – widely used in the So these pages are not for entertainment; they oil and gas industry, this allows you to deal are for learning. And just like those collected with unplanned events or changes, which stories of fiction there are recurring themes, occur during the work. Being alert to changes themes we have seen before on these pages and in weather, timing, berthing, equipment, etc. elsewhere. But unlike Conrad, these are not of and revisiting the plan and risk assessment murder, greed, desire or revenge; these are much when they occur. more mundane and straightforward. These are themes of inadequacy. They are about not coming up to scratch, not cutting the mustard.

8 MAIB Safety Digest 1/2004

• Challenge – all those carrying out work must And let’s keep this admirable Safety Digest off the continually question the work in hand and if bookshelf and well thumbed in the mess-rooms they are unhappy, even that slight unease in and canteens of our workplaces. Do you have the gut, then they should stop the job and enough copies and do you send them out to all challenge the process. your ships? Discuss the stories on board and in the office. Take a copy to the next safety So let’s keep Joseph Conrad firmly on the meeting. bookshelf and make sure all the characters of OUR stories come home safe and sound. Let’s Ask another simple question. Can this happen to make sure they come home to their families us? When reading these accounts we can all without harm. Stop and take time to think how recognise the familiar themes. Take action before we can achieve this because, make no mistake, it an event happens and you or your colleagues can be achieved. Ask some simple questions such become the main character in the next story the as: Chief Inspector will write for the entertainment of others. “How can I perform this task without injury to myself?” Safe sailing.

“How can I perform this task without injury to others?”

David Blencowe David Blencowe is Area General Manager of Maersk Supply Service in the UK, based in Aberdeen. He is a master mariner who has served in passenger ships, cross channel ferries and as master of offshore vessels. He has a deep interest in safety of ships’ crews and is a member of the steering group on the offshore industry’s Marine Safety Forum.

MAIB Safety Digest 1/2004 9

Hands-on Training – yes – but Don’t Lose Control!

Narrative helm. He moved the pitch controls of both propellers to 40% and then, on the master’s A ferry was leaving port in daylight. The bridge instruction, to 60% ahead. The vessel started was manned, as normal, by the master, the chief swinging, but her rate of turn was slower than officer and a helmsman. However, instead of the expected. The chief officer then applied full bow master handling the controls, the chief officer, as thrust to port and, on the master’s suggestion, part of his training, was manoeuvring the vessel applied astern pitch to the port propeller. under the guidance of the master. The chief officer had only recently joined the vessel, As the vessel was completing the turn, the chief having served a number of years as a pilot in a officer applied 60% ahead pitch to both different geographical location. propellers with the helm amidships. At this point, the master walked to the starboard bridge The ferry, which was fitted with a Becker rudder, wing and noted that the vessel was moving was required to conduct a port turn to exit the towards the breakwater on that side, due, partly, harbour between two breakwaters. After to the tidal flow. He then ordered hard to manoeuvring from her berth, she proceeded at starboard helm and bow thrust to starboard in an slow speed so as to keep sufficiently clear astern attempt to prevent contact with the breakwater of another departing ferry. knuckle. Although the ferry started swinging to starboard, the manoeuvre failed to prevent her After the other ferry had cleared the harbour, the starboard side from striking the knuckle. The chief officer, from his position at the port bridge master then took control and manoeuvred the wing control position, ordered about 40° port vessel back alongside.

10 MAIB Safety Digest 1/2004

The Lessons Although the manoeuvre was inappropriate, the master failed to 1. The manoeuvre did not proceed as intervene in sufficient time to prevent expected. A successful outcome depends the accident. This was due to his on adequate planning, execution and misplaced confidence in the chief monitoring, and an ability to recover a officer’s ability, and the fact that his situation should things go wrong. In this position on the bridge caused him to case, the chief officer was following a adopt an abnormal overall perspective. manoeuvring plan which, although In other words, he was not in an normally achievable, was inappropriate appropriate position or mind-set to given the circumstances on the day. monitor the chief officer’s actions effectively. The ferry’s exit from the harbour was delayed, resulting in her creeping ahead Hands-on experience is an essential to a position from which she was unable element of training, but the risks should to complete her normal turn safely, given be carefully evaluated, and the level of the prevailing cross-tidal flow. This was supervision should be sufficient to because of her slow speed and close ensure that the master is able to restore proximity to the breakwater at the start control immediately should things go of the turn. wrong.

2. The chief officer had received no 3. The effect of a Becker rudder can be specific guidance as to how to significantly different to that of a manoeuvre the vessel out of the harbour. conventional rudder. Notably, the He had observed previous departing application of large angles of helm can manoeuvres and did not feel it necessary reduce a vessel’s forward motion. This, to receive a specific briefing on this together with the tidal flow, contributed occasion. Equally, the master considered to the slower than expected rate of turn it unnecessary to brief the chief officer on this occasion. It is essential that since he was aware that he had handled operators are made fully aware of this the vessel before and was an experienced effect before being required to pilot, albeit in a different geographical manoeuvre a vessel in confined waters, location. particularly if they are unfamiliar with high lift rudder systems.

MAIB Safety Digest 1/2004 11

‘Spontaneous’ Lowering of a Lifeboat The unusual direction of load on the aft suspension hook damaged the boat’s stern, but there were no injuries.

A later examination showed that the remote release wire of the winch had not been set up correctly, and had prevented its brake from being fully applied. Reports from the crew also indicated that there had been earlier incidents where lifeboat winch brakes had not been applied properly because of problems with remote release wires. Narrative During a stay in port, a cruise vessel lowered The Lessons several of her lifeboats to the water for crew training and engine testing. On completion, the 1. It would have been sensible for the boats were hoisted to their stowed position and senior officer to ask what the ratings their gripes secured. were doing to the lifeboat before he diverted them to another task. He would Shortly afterwards, two seamen noticed that one then have been aware that there was a of the boats was not in its properly stowed problem with this lifeboat. position, and released its gripes to re-position it. However, before they were able to complete this 2. The vessel’s safety management system task, a senior officer instructed them to carry out failed to take account of earlier reports another job. of similar