MAIB Safety Digest 1/2005

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 1/2005

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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 2005

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

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. March 2005

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 2005

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

A PAUSE FOR THOUGHT WATCHKEEPING, FATIGUE AND HOW TO STAY ALERT! 9

PART 1 – MERCHANT VESSELS 14 1. Quick Response to Fire not Recorded on VDR 16 2. Hanging From The Yardarm 18 3. Fatal Accident to a Chief Officer of a Dry Cargo Ship 20 4. Don’t I know you? 22 5. A Mutually Exclusive Plan 25 6. Wash Out! 27 7. Don’t Drink and Drive 28 8. What You See is Not Always What You Get 30 9. Zzzzzz – Bump – Where am I? 33 10. Wrong Switch – Big Trouble 35 11. Parametric Rolling Causes Loss of Containers 36 12. Fingers and Rotating Vee Belts Don’t Mix 37 13. Poor Risk Assessment Causes Contact and Puts Passengers at Risk 40 14. Always Tie Up Your Vessel Securely 42 15. Being House-Proud Has Its Limits 43 16. Risk Assessment Could Have Prevented a Serious Accident 44

PART 2 – FISHING VESSELS 47 17. Man Overboard – Fatal Accident 48 18. Capsized – With Assistance 49 19. Quick, Sensible and Effective Action 52 20. Fisherman Uses Rule 17 to Good Effect 54 21. Liferafts Do Save Lives 55 22. A Fatal Decision 57

PART 3 – LEISURE CRAFT 59 23. Three Lives Lost Due to Overloading and Unseen Flooding 60 24. Dangers of Rotating Machinery 62 25. Narrow Escape from Overhead 11kV Lines 64

APPENDICES 66 Appendix A – Investigations started in the period 01/11/04 – 29/02/05 66 Preliminary examinations started in the period 01/11/04 – 29/02/05 66 Appendix B – Reports issued in 2004 67 Appendix C – Reports issued in 2005 68

Glossary of Terms and Abbreviations AB – Able Seaman AIS – Automatic Identification System ARPA – Automatic Radar Plotting Aid CO2 – Carbon Dioxide CPA – Closest Point of Approach EEBA – Emergency Escape Breathing Apparatus EPIRB – Emergency Position Indicating Radio Beacon GRP – Glass Reinforced Plastic MCA – Maritime and Coastguard Agency MHWS – Mean High Water Springs OOW – Officer of the Watch “Pan Pan” – The international urgency system Ro-ro – Roll on – roll off SFIA – Sea Fish Industry Authority TSS – Traffic Separation Scheme VDR – Voyage Data Recorder VHF – Very High Frequency VTS – Vessel Traffic Services

Introduction The work of the MAIB over the past 4 months Fishing vessel losses: In the 10 days prior to has once again been dominated by 2 types of writing this article, the MAIB has been finalising accidents: collisions and the fatal founderings of the reports into 3 founderings of under 15m under 15m fishing vessels (Code boats). fishing vessels, all of them fatal. Last night, we had yet another double fatality reported. Just Collisions: There is nothing new to learn from because there is no mandatory stability testing any of the collisions we have investigated, just requirement for Code boats, does not mean good the same old chestnuts! You will not have a stability is not vital to the survival of your boat. collision if you follow 3 basic principles: If you are not certain of the stability of your vessel, or if you are planning any structural 1. Lookout. Keep a good lookout, both visually alterations (extra deck house, net drums, and by radar. At night, in poor visibility, in A-frames etc) seek expert advice. heavy shipping or in navigationally constrained waters, you MUST have an Whilst we would ideally wish for our vessel not additional dedicated lookout in accordance to sink, it is essential to have appropriate with STCW. In virtually every collision we equipment in case the unthinkable happens. A investigate, the additional lookout has not well positioned liferaft, an EPIRB, and a good been on the bridge when he should have lifejacket ready-to-hand, could save your life one been. Not using a lookout, means not using day. It is a false economy not to be prepared for one of the most important safety nets the the worst. OOW has. Fatigue: Unusually, in this edition of the Safety 2. Electronic navigational equipment. All too Digest we have a piece of research, which affects often, OOWs just use radar target trails to the readers of all three sections of the Digest. It judge CPAs, sometimes with catastrophic has therefore been placed after this introduction. results. Facilities such as automatic plotting, Fatigue is not well considered at sea, and yet its electronic bearing lines, variable range effects are insidious. Please take the time to read markers and radar guard alarms, are normally this short article, and ponder on how safe you provided to assist the OOW. Using them to may be when you are tired. assist in maintaining a good situational awareness of other shipping is the professional Finally, the MAIB developed a new website at thing to do. the end of 2004. For those who have not visited it, it can be found at www.maib.gov.uk. We hope 3. Taking early action. If you are the give way you will find it faster and easier to use. vessel, the sooner you take action, the less dramatic the action has to be, and the sooner Safe sailing. the risk of collision is avoided. Leaving alterations until the last minute endangers your vessel and presents the other officer of the watch with a quandary. Similarly, if you are the stand-on vessel, do not assume “he will alter at the last minute”. Use the Stephen Meyer appropriate signals laid down in the ColRegs, Chief Inspector of Marine Accidents and, if necessary, initiate a manoeuvre under April 2005 Rule 17, as soon as it becomes apparent that the vessel required to keep out of the way is not taking appropriate action.

MAIB Safety Digest 1/2005 7

A Pause for Thought Watchkeeping, Fatigue and How to Stay Alert! The investigation files on 66 collisions, groundings, contacts and near collisions were reopened recently for a safety study into watchkeeping practices. The evidence was thoroughly reanalysed, focussing on the makeup and performance of the bridge watchkeeping teams. In addition, the MAIB’s database was used to extract broader information from over 1,600 relevant accidents which had been reported to the Branch during a 10-year period. This data was used to look at trends and anomalies. The safety study, which was published in 2004, concluded that, among other things, watchkeeper fatigue was a major factor in many of the accidents and particularly in groundings. This accords with the general experience that MAIB inspectors have gained from meeting crews after accidents, and will be no surprise to officers involved in the short sea trade in particular.

A number of the accidents in the study were caused as a direct result of a lone watchkeeper falling asleep, but fatigue was a factor in many more of them. Long before a watchkeeper has reached the stage where he cannot keep his eyes open, fatigue is affecting his performance. It can cause the following:

• Inability to concentrate, including being less vigilant than usual

• Diminished decision-making ability including: – Misjudging distance, speed, time etc – Overlooking information required for complex decisions – Failing to anticipate danger

• Poor memory, including forgetting to complete a task or part of a task • Slow response, including responding slowly to normal, abnormal or emergency situations

• Reduced competence in interpersonal dealings

• Attitude change, including: – Being too willing to take risks – Displaying a “don’t care” attitude – Disregarding warning signs

The data used in the safety study, especially that associated with grounding accidents, indicated a strong link between fatigue and watchkeeping arrangements.

MAIB Safety Digest 1/2005 9

The above figure, which uses data from all groundings in UK waters that were reported to MAIB over a 10-year period, and which involved a merchant vessel of over 500gt, shows that groundings are much more likely to occur at night. It can also be seen that they are much more likely to happen towards the end of a watch. The most common times being 0400 to 0500, 1700 to 1900 and at about 2300. This clearly indicates that fatigue is likely to be a factor.

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There were 23 groundings considered in detail in the study. The above diagram shows the watchkeeping arrangements in each of those groundings. The link between 6-on 6-off watchkeeping, and groundings that occur at night, can be clearly deduced.

Since concluding the study the MAIB, along with QinetiQ Centre for Human Sciences has been looking more closely at the effects on watchkeepers of 6-on 6-off watchkeeping routines. As part of this study, typical marine work/rest routines were fed into a previously developed programme designed to test whether air crews are fit to fly. The parameters used for air crews were adjusted to account for some of the differences in the conditions of work and rest for marine officers. The effect of these adjustments was to make them considerably more lenient for the marine application. The parameters were then adjusted even further, by a factor of 25%, to allow for the fact that marine crews may become hardened to a punishing routine in time.

The following figures, which, bearing in mind their provenance must be treated with caution, indicate the apparent levels of fatigue of the 12 to 6 watchkeeper on a fictional vessel. The times used are based on an idealised routine which is compliant with STCW. The vessel has only two officers, who each work 6-on 6-off. She arrives in a port at about 0600 every fourth day and sails again at about 1800. The chief officer has some extra duties on arrival in port while the master is dealing with port entry and other paperwork, otherwise the 6-on 6-off routine is maintained. The work periods are shown coloured, with green indicting ‘well rested and alert’ and red, at the other end of the scale, indicating ‘dangerously fatigued’. The grey areas indicate the periods when the chief officer was off duty and asleep.

Chief Officer (before day 10 he was well rested)

MAIB Safety Digest 1/2005 11

It can be seen that the chief officer appears to begin to get dangerously tired after about 3 weeks of this routine. However, no allowance is made for the quality of rest which is assumed to be good. To test the effectiveness of days off in port, a rest day was introduced into the programme at every second port call. It was found that these rest days did not make an appreciable difference to the levels of fatigue indicated.

The above diagram is based on an idealised routine, which most officers will recognise as being unworkable in practice. Real ships do not operate on such orderly schedules: emergency drills have to be conducted, rough weather disturbs sleep, breakdowns and rain prolong cargo work, long pilotages require both officers to be on duty and many other occurrences interrupt the schedules. As a comparison, a month of real data gained from the chief officer of a small, about 2,000gt general cargo vessel was fed into the programme with the following result:

It can be seen that, despite the chief officer getting several nights in port, the programme indicates that dangerous levels of fatigue are likely to exist after 2 or 3 weeks in the routine. The most dangerous times appear to occur towards the end of the midnight to 0600 watch, which ties in closely with the results shown in figures 1 and 2.

The diagrams serve to reinforce the MAIB’s long-held belief that fatigue, brought on by minimal manning and arduous watchkeeping and operational routines, is endemic at sea, especially in the short sea trade.

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The Lessons • Always post a designated lookout as a second watchkeeper at night in 1. Minimum safe manning levels need to be accordance with STCW. If used increased so that each seagoing vessel of properly, he will not only help to keep over 500gt has at least a master and two an efficient lookout but will also help bridge watchkeeping officers. to keep the officer alert.

2. Watchkeepers should: 3. On minimally manned vessels, the workload should be shared equitably • Be aware of fatigue, how it affects between the officers, even if this means performance and how best to guard the master turning-to on deck. against its incipient build up. 4. Masters and owners should ensure that a • Make the best of off duty periods for vessel does not leave harbour unless all resting, should not drink alcohol and the watchkeepers, including the master try to eat good nutritious food where appropriate, are well rested. regularly.

MAIB Safety Digest 1/2005 13

Part 1 – Merchant Vessels As a people-orientated organisation, NUMAST is primarily concerned with the importance of the human element in shipping safety. It’s now well known that around 80% of accidents at sea (and more than 90% in cases of collisions and groundings) involve so-called ‘human factors’. But less widely acknowledged is the way that technical issues continue to overshadow people- based issues when the industry and the regulators respond to accidents and seek to improve maritime safety.

Once again, this latest issue of the MAIB Safety Digest serves to demonstrate the pressing need for ‘human issues’ to be treated with the priority It’s no surprise that safety is one of the key they deserve. campaign issues for NUMAST. The sea is a dangerous place, ships are inherently hazardous In an industry where fierce cost-cutting pressures workplaces and seafaring is by far the most risky often seem to dominate decision-making, the occupation – with death and injury rates many report on the prompt response of officers to a fire times greater than shore-based employment. onboard a ferry in a UK port should remind us all how investment in skills, professionalism and Tracing NUMAST’s history back to its experience can lead to long-term savings rather predecessor organisations in the middle of the than the short-term approach so often pursued by 19th century shows that one of the most pressing companies. reasons for the foundation of seafarer unions was safety. Similarly, the report on the ‘near-miss’ between two gas tankers in the Channel – both using AIS Looking back through the safety of our industry and ARPA – highlights the truism that all the over the past 150 years, one could well be technology in the world will not provide a forgiven for asking: does anything ever change? substitute for high standards of seamanship. Well over a century ago, our archives show our forerunners voicing concerns over such issues as Indeed, as other reports demonstrate, if people mixed-nationality crewing, working hours and are not properly factored into the design of ships