MAIB Safety Digest 1/2006

SAFETY MARINE ACCIDENT DIGEST Lessons from Marine

INVESTIGATION BRANCH Accident Reports

is an

INVESTOR IN PEOPLE

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 1/2006

is an

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 2006

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 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. April 2006

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 2006

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 2005 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”

INDEX GLOSSARY OF TERMS AND ABBREVIATIONS 6

INTRODUCTION 7

PART 1 – MERCHANT VESSELS 8 1. Insist On Cargo Trimming – It Can Save Lives 10 2. Grounding – on a Soft Bottom 12 3. Timber Deck Cargo Shift Leads to Dangerous List in Heavy Weather 14 4. Let’s Not Get Carried Away 17 5. Bring Back the Budgie 19 6. Wrong Place – Wrong Time 21 7. Lifting Equipment – Exceeding the Safe Working Load = Danger 23 8. Face The Danger 25 9. A Turn for the Worse 27 10. Fatigue Nearly Leads to Disaster 29 11. When Safety Maintenance = Hazardous Incident 31 12. From What Height Can a Lifeboat be Safely Released? 33

PART 2 – FISHING VESSELS 36 13. Poor Stability and Hull Defects Lead to Fatal Accident 38 14. The One That Got Away! 41 15. A Fire Detection System Can Help Save Your Vessel 43 16. Didn’t Feel a Thing 46

PART 3 – LEISURE CRAFT 48 17. Double Tragedy 50 18. A Tragic End to the First Trip of the Season 53 19. Alcohol Ends a Weekend Pleasure Trip 56 20. Ouch! One Very Badly Cracked RIB 59 21. A Lovely Day Ends in Tragedy 62 22. Fire: Put It Out and Keep It Out 64 23. Perilous Propellers 67

24. Rafted Canoe Exercise Ends in That Sinking Feeling 69 25. Grounding in Perfect Weather 72

APPENDICES 75 Appendix A – Preliminary examinations and investigations started in 75 the period 01/11/05 – 29/02/06 Appendix B – Reports issued in 2005 76 Appendix C – Reports issued in 2006 78

Glossary of Terms and Abbreviations AB – Able Seaman BA – Breathing Apparatus CO2 – Carbon Dioxide COLREGS – International Regulations for the Prevention of Collisions at Sea ETA – Estimated Time of Arrival GPS – Global Positioning System GRT – Gross Registered Tonnes HP – Horsepower IMO – International Maritime Organization "Mayday" – The international distress signal (spoken) MCA – Maritime and Coastguard Agency MGN – Marine Guidance Note OBO – Oil Bulk Ore OOW – Officer of the Watch RIB – Rigid Inflatable Boat RNLI – Royal National Lifeboat Institution RYA – Royal Yachting Association SWL – Safe Working Load VHF – Very High Frequency VTS – Vessel Traffic Services

Introduction The diverse and growing readership of the Safety Digest is indicative of the wide range of accidents and incidents we report. This edition has a particularly broad span of cases. Sadly, we have fewer than normal good news tales, and many more with tragic consequences, particularly in leisure craft. I deal with this more fully in my introduction to the leisure craft section.

I will not try to précis the lessons from the accidents in this edition or offer a homily on the wisdom of risk assessment or the danger of complacency. I will leave it to each case to make its own impact.

Nearly every accident is a tragedy – whether it be through death, injury, loss of career or some other effect. It is difficult for MAIB inspectors to deal with these tragedies on a daily basis, and to know that the accidents could all have been avoided . . .

Stephen Meyer Chief Inspector of Marine Accidents April 2006

MAIB Safety Digest 1/2006 7

Part 1 – Merchant Vessels Master. At the same time, the Master is not allowed to forget that he works for an owner that expects the ship to be profitable, so he is then tasked with balancing matters of safety against the requirements of making a successful commercial voyage.

This takes us into the realms of risk management. Probably the best piece of ‘risk’ advice I ever received was given to me shortly after I obtained my Second Mates Certificate in 1961. My first trip as a Third Mate was on a very small ship called the Palaccio of the MacAndrew Line. Once or twice a week, we used to round Cape St Vincente. As we approached the Cape, the Captain would come on the bridge and take charge of the ship. He would alter the course so that we passed less than half a mile from the coast, so one could easily see people in the monastery I feel pleased to have been given the that was built on the edge of the high cliff. It opportunity to write an introduction to this was quite a fascinating manoeuvre, and it was edition of the “Safety Digest” as this, in effect, one that I visually enjoyed. serves as my personal endorsement of the valuable contribution to the seafaring However, there was some risk because community carried out by the MAIB. periodically we would meet another ship doing the same thing from the opposite direction, In my career at sea, spanning just over 47 and often we would not see it until we had years, I have seen the use of the word safety rounded the Cape. After enjoying this increase year by year, and now there is hardly a experience for several months, an older, more nautical publication that does not include the experienced Captain took over command, and word. In particular, there is the Code of Safe immediately introduced an order saying that all Working Practices for Merchant Seamen. coastal navigation courses had to be plotted 3 miles off the land in the daytime, and 5 miles off The Code of Safe Working Practices for at night. Needless to say, this rule made a 4 hour Merchant Seamen clearly states our spell on watch far less interesting. After a few responsibilities towards safety. Of particular weeks, curiosity and frustration got the better note is that the Code makes the Master of me, and I plucked up courage to question responsible to ensure that safety is enforced. the Captain about his rule. To question the The importance of the Master’s responsibility Master in those days was unheard of, so I was is highlighted by the fact that non compliance emotionally prepared to receive some harsh is a punishable offence. There are very few words in reply. Instead, the Captain quietly said professions that make their senior staff “son, you do not get any extra pay for taking accountable to such a severe degree. unnecessary risks”, and he turned away. To this Accordingly, it is of paramount importance that day, I have never forgotten those words. officers embrace the culture of safety very early in their career, and have a clear understanding On our Atlantic crossings, one of the most of the associated legal accountabilities of the frequently asked questions by passengers is

8 MAIB Safety Digest 1/2006

about the Titanic. Some Captains I know feel continue to occur, so it is important that we that it is taboo to discuss the subject, but I take advantage of the MAIB cases discussed in have always felt to the contrary. The sinking of this, and previous editions, of the “Safety the Titanic was a tragedy, but out of that Digest” to remind ourselves and our seafaring tragedy came some good. For instance, the colleagues of the dire consequences of putting International Ice Patrol was introduced, and safety on the back burner. new and improved safety regulations were put in place. However, we should not rely on accidents to improve safety, but instead should be pro-active and do everything we can to avoid them. Notwithstanding, accidents

Commodore Warwick

Commodore Warwick commenced his sea-going career at the age of 15 as a cadet at the pre-sea training ship HMS Conway in North Wales. After obtaining his Second Mate’s Certificate in 1961, he spent the next several years sailing with various companies to gain experience on different types of ships. In 1970, he joined the Cunard Line, where he served in many ships before taking his first command, Cunard Princess.

Commodore Warwick first took command of the Queen Elizabeth 2 in July 1990, and in June 1996 was appointed to the position of Marine Superintendent of the Cunard Line fleet. On 4 July 2002, at the keel laying of Queen Mary 2, he was appointed Master Designate, taking command of the new ship when she was handed over to Cunard on 22 December 2003.

In 2004, Commodore Warwick received the Shipmaster of the Year award from the Nautical Institute and Lloyds List, and was presented with the Silver Riband Award by the Ocean Liner Council of the South Street Seaport Museum for his lifetime achievement in the maritime industry. In 2005 he was made an Officer of the British Empire in the Queen’s Birthday Honours, received an honorary Doctor of Laws degree from the University of Liverpool, and was awarded the Merchant Navy Medal. He is an Honorary Fellow of the Institute of Transport Administration, a member of the Admiralty Circle of the Maritime Museum of the Atlantic, a Younger Brother of Trinity House, a member of the court of the Honourable Company of Master Mariners, a founder member and Fellow of the Nautical Institute, Governor of the Marine Society, he is Patron of the Cunard Steamship Society, President of the Queen Mary Association and Vice President of the Bristol Ship Society. The Commodore holds the rank of Honorary Captain in the British Royal Naval Reserve.

MAIB Safety Digest 1/2006 9

Insist On Cargo Trimming – It Can Save Lives

Photographs courtesy of Smit

Narrative capsized so quickly remained unclear. A technical working group was therefore Tragedy ensued after a recently-built, 161m commissioned to assess the vessel’s stability state-of the-art bulk carrier carrying 23,243 and to help prevent a recurrence of the tonnes of gravel and stone, hit rocks which accident. ripped a hole in her side. Within seconds, the vessel heeled over and capsized. Many of her The working group discovered that, when the 30 crew members were trapped inside, and a cargo was loaded into the vessel’s single hold, valiant rescue attempt, involving cutting a hole the cargo was not trimmed (there was not a through the vessel’s hull, was hampered by flat cargo surface) in accordance with current freezing temperatures, darkness and the regulations. Without trimming, the sides of the vessel’s slippery hull. Eighteen seafarers lost piles of cargo took up an angle of repose of their lives. between 32° and 38°.

A court case, aimed at establishing the cause of The working group identified the very serious the accident, reviewed the reliability of sea effects resulting from the consequent shift of charts mapping the seabed where the vessel is cargo, and produced the following lessons to believed to have run aground. However, the help prevent a similar accident in the future. reason why this modern, state-of-the-art vessel

10 MAIB Safety Digest 1/2006

The Lessons 3. Many types of cargo will shift: in another accident, untrimmed bulk 1. Had the cargo been trimmed during cement, loaded into a large open hold, loading, the vessel could have sustained resulted in the loss of a vessel, together angles of heel of over 30° during her with all her crew. The vessel had not voyage, before the cargo would have grounded, nor had she collided with begun to shift. This would possibly have another vessel, but she was operating in given the crew more time to abandon heavy seas. It is therefore essential that ship safely. bulk cargoes are loaded and trimmed in accordance with the requirements of the 2. It was calculated that, after the IMO BC Code1. grounding, the ingress of seawater into the vessel through the hole in her side, would have eventually led to her capsizing. However, the time taken to capsize was considerably reduced due to the shift of cargo as the vessel heeled over.

1 IMO 260 C ( c ) Code of Safe Practice for Solid Bulk Cargoes

MAIB Safety Digest 1/2006 11

Grounding – on a Soft Bottom

Introduction resultant difference was that, on previous occasions the tidal stream had been setting to A vessel was making an approach to a pilot the south-west, whereas on this occasion it station for the purpose of embarking a pilot to was setting north-easterly. proceed upriver and berth. While embarking the pilot, the vessel ran aground. Luckily, the The distance from the anchorage to the pilot seabed was soft mud and no environmental or embarkation point was just over 10 miles. With physical damage resulted. the anchor aweigh at 1235, and a maximum speed of 14 knots, allowing time for acceleration and deceleration the vessel was Narrative never going to achieve the programmed ETA for the pilot of 1315. The prevailing force 6 westerly The vessel, a 23,000 tonne double hull wind, and the north-east tidal stream, were chemical/oil tanker, was carrying 16,300 tonnes both unfavourable. Pressing on at full speed, of lower sulphur fuel oil. The vessel arrived at the vessel’s progress was being monitored by the estuary early and proceeded to anchor in a the local vessel traffic services (VTS). There designated deep-water anchorage. The master were no other vessels in the vicinity. The entry was informed by his agent that the pilot was course had been planned as 262 and the initial booked for 1315 the following day; the master request from VTS was for the pilot ladder to be made arrangements accordingly. The time of rigged on the starboard side. The prevailing 1315 allowed a 30 minute delay factor, after wind was virtually right ahead, and the which berthing would have to be postponed. designated pilot embarkation point provided sufficient sea room to port and starboard for a Although the master was familiar with the vessel to alter course and provide an adequate estuary, it had been nearly 10 months since his lee. In this case, however, the combination of last visit. Previously, the vessel had always ship speed and tidal stream meant that the entered close to high water; this time entry vessel overshot the designated boarding point, took place 1 hour before low water. The key and entered the channel close to a shoal area.

12 MAIB Safety Digest 1/2006

With the vessel now 20 minutes behind the vessel’s position, and when asked by the schedule, the pilot boat became aware of the pilot to turn to starboard he did so without high speed on approach, and called the vessel fully appreciating the very close proximity of to slow down and swing to starboard to the shoal patch. As soon as the pilot had provide a lee for boarding. Communication boarded, the master swung the vessel back to between the pilot launch coxswain and the port, but by the time the helm had been put vessel became confused, and this led to over, and the vessel started to swing back, it further delays. Throughout this