MAIB Safety Digest 1/2007

MARINE ACCIDENT SAFETY DIGEST Lessons from Marine

INVESTIGATION BRANCH Accident Reports 1/2007

MARINE ACCIDENT INVESTIGATION BRANCH

is an

INVESTOR IN PEOPLE

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 1/2007

MARINE ACCIDENT INVESTIGATION BRANCH

is an

INVESTOR IN PEOPLE

Department for Transport Great Minster House 76 Marsham Street London SW1P 4DR Telephone 020 7944 8300 Web site: www.dft.gov.uk

© Crown copyright 2007

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: Marine Accident Investigation Branch First Floor, Carlton House 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 2007

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 2007

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. What Lighthouse? 10 2. Lagging Fires – Hidden Danger 13 3. A Touch Astern 16 4. Watch That Grill 18 5. Grounds For Concern? 20 6. Differing Perspectives 23 7. When “One Hand For the Ship and One Hand For Yourself ” Wasn’t Enough 25 8. “Let Go the Tug!” Easy, Not So 28 9. But We’ve Always Done it that Way 30 10. Lookout – What Lookout? 32 11. From Small Beginnings … 34 12. Galvanic Action – the Hidden Danger 38 13. Master/Pilot Confusion Results in Grounding 40 14. Cable Laying Vessel Requires Better Lines of Communication 43

PART 2 – FISHING VESSELS 46 15. Smoking Kills! 48 16. Assumptions (Based on Scanty Information) Lead to Collision 50 17. Fire at Sea – Be Prepared, Be Trained – It Could Be You Next 53 18. “Invited Back On Board” 55

PART 3 – LEISURE CRAFT 58 19. Check Your Knots 60 20. The Sailing “Taster” that Left a Bitter Taste 61 21. The Tragic Consequences of Not Wearing a Lifejacket 65 22. To Sail or Not to Sail? 68 23. Cheap, Cheerful and Dangerous – Case 1 71 24. Cheap, Cheerful and Dangerous – Case 2 74 25. Steering Seizure 75

APPENDICES 77 Appendix A – Preliminary examinations and investigations started 77 in the period 01/11/06 to 28/02/07 Appendix B – Reports issued in 2006 78 Appendix C – Reports issued in 2007 80

Glossary of Terms and Abbreviations AB – Able Seaman ARPA – Automatic Radar Plotting Aid cm – centimetre CO2 – Carbon Dioxide CPA – Closest Point of Approach CPP – Controllable Pitch Propeller DPA – Designated Person Ashore DSC – Digital Selective Calling ECDIS – Electronic Chart Display and Information System EPIRB – Emergency Position Indicating Radio Beacon ETA – Estimated Time of Arrival FRC – Fast Rescue Craft GPS – Global Positioning System GRP – Glass Reinforced Plastic Hp – Horse power ISM – International Safety Management Code kW – kilowatt “Mayday” – The international distress signal (spoken) MOB – Man Overboard OOW – Officer of the Watch PEC – Pilotage Exemption Certificate PI – Parallel Index RNLI – Royal National Lifeboat Institution SAR – Search and Rescue SCBA – Self-Contained Breathing Apparatus UHF – Ultra High Frequency VHF – Very High Frequency XTE – Cross Track Error

Introduction I start this edition of the Safety Digest by returning to the subject of complacency. Nearly all of us who go to sea, be it professionally or for leisure, rapidly become inured to the hazards of what we are doing. The media is largely disinterested in accidents at sea, unless they result in oil spills or BMW motorbikes appearing on beaches. So there is little to remind us of the dangers.

Let me use some early statistics for 2006, emerging from analysis of our database:

Fishing still remains, by a very large margin, the most dangerous occupation in the UK. In 2006, 16 fishermen died in accidents, up from 9 in 2005. Although fishing vessel losses are slightly down, we have still lost a UK commercial fishing vessel on average every 13 days over the last 10 years.

In 2006, 117 merchant vessel accidents were reported to us. Happily, this number is down from the 188 reported to us in 2005. However, numbers of accidental deaths in merchant ships were slightly up.

Twenty four accidental deaths occurred in leisure craft (of all types), plus 4 in hired boats, which technically count as “other commercial” rather than leisure.

The message from these statistics is that none of us can afford to be complacent.

In reading through this edition, I am struck by a common thread in many of the cases in the merchant vessel and leisure sections: teamwork. Nearly all of the collisions and groundings in Part 1 would have been avoided if the bridge crew had been operating as a team. More training is being conducted on Bridge Team Management, but this training often fails to translate into actions at sea. A lookout is a vital member of the bridge team, and should not be ignored; equipment, alarms and other facilities must be utilised to support the watchkeepers; and integrating a pilot into the bridge team is a key element of safe operations in pilotage waters. In leisure sailing, briefing one’s crew on what the plan is; of what could go wrong; and what to do if something does go wrong, is fundamental to safe sailing. Although not applicable to the fishing vessel cases in this edition, the same points apply to the fishing sector.

It doesn’t take much to ruin one’s day at sea – equally, it doesn’t take much thought to stay safe.

Stephen Meyer Chief Inspector of Marine Accidents April 2007

MAIB Safety Digest 1/2007 7

Part 1 – Merchant Vessels A hand injured when Additionally, the repetitive nature of life at sea letting go a line; a can breed complacency and induce grounding because inadvertent risk taking. the depth of water was less than Although accidents are often put down to expected; a collision human error, that ‘error’ is sometimes caused while the ship’s by a well meaning failure to follow laid down bridge was procedures. The challenge for the maritime unmanned. The industry is to impress upon the seafarer the common theme importance of always being alert to what might running through go wrong when conducting shipboard tasks, to most of these case adhere to company procedures at all times, to studies is the failure to follow best practice or get proper rest, to ask for assistance when to apply established work procedures that needed and to avoid taking unnecessary risks. were designed to minimise risk and prevent Such apparently simple things are often the failure. While it is true that some procedures most difficult to achieve, but we must continue were not followed correctly, in many cases to work on this challenge by focussing on there was simply a lack of good seamanship. safety issues, developing strong safety cultures and encouraging, at all times, good The hand was injured because the rope was seamanship. not handled correctly: the grounding occurred because the depth of water had not been checked: and the collision took place because the watch officer left the bridge after first sending the look-out on an errand.

In other examples, we see that a grounding took place on a ship because the master was unsure how to change the steering from manual control to river pilot; that a fire occurred when oil leaked and soaked into lagging; and that a cooking grill was switched on and left unattended. There is the case of a boatswain lost overboard whilst working without assistance lowering a pilot ladder, and standing on it at the same time; and that of a crewmember washed off the deck of a pilot- cutter because he was not using a safety line.

Accident prevention does not have to require major changes in legislation or radical overhaul of training systems. In many cases, simple application of common sense and good seamanship is sufficient. For example, ships’ crews cut corners, or work long hours, in the belief that they are helping the owner; in fact, their actions have the opposite effect because they increase the likelihood of failure.

8 MAIB Safety Digest 1/2007

Eric Murdoch

Eric Murdoch was born in 1955. On leaving secondary school in 1973, he joined the P&O Steam Navigation Co as a deck cadet, rising to a second navigation officer before leaving the sea for further study. He obtained his Bachelor of Science in Marine Technology in June 1980 (UWIST) and his Master of Science in Ship Production in 1981 (Strathclyde). He subsequently worked as a design engineer with Cammell Laird Shipbuilders, Birkenhead, during a time when the shipyard was building destroyers, tankers, a semi- submersible drilling rig and a jack-up rig. He later worked for Lloyd’s Register of Shipping in Liverpool and London as a ship surveyor specialising in international conventions, becoming a Chartered Engineer in 1986. After leaving Lloyd’s Register of Shipping in 1987 and having a 2 year stint at Panama Bureau, he took employment with Charles Taylor & Co Ltd to head up and develop the Standard P & I Club’s safety and loss prevention programme. This involved ship condition surveying, material on loss/accident prevention and an extensive seminar programme. Mr. Murdoch is presently the director of risk management for the Standard P&I Club and director Marine Technical CTC Marine.

He is a member of the Institute of Marine Engineers, Royal Institute of Naval Architects, and the Society of Consulting Marine Engineers and Ship Surveyors. He has written a number of articles on accident prevention, collision avoidance, piping corrosion, container lashing and hatch cover maintenance, and co- authored the Master’s Guide series of publications. He is a member of the marine advisory Board of CHIRP – the UK Confidential Hazardous Incident Reporting Programme and has attended the IMO as an advisor.

MAIB Safety Digest 1/2007 9

What Lighthouse? Narrative vessel late afternoon, and a short time later the vessel sailed. The master held a PEC, so no A 90m cargo vessel was operating a regular pilot was required to manoeuvre the ship off route along the UK coast, transporting the berth or clear the harbour. Once clear of containers. The deck officers on board the port, but still in pilotage waters, the master comprised a master and mate working a 6 left the mate on watch and went below to have hours on, 6 hours off watch routine. a shower and eat his dinner.

The vessel arrived in port and moored The master returned to the bridge 20 minutes alongside one evening, after two very tiring later and the mate went below to his cabin. days for the master. He had only managed 4-5 The lookout reported to the bridge at 2000. hours sleep during the previous 2 days as he The sea was calm, there was only a light breeze had been on the bridge for extended periods and visibility was very good. Other vessel traffic while in pilotage waters. However, he was able was light. At 2130 the master sent the lookout to get 6 hours sleep overnight in port. Next to conduct safety rounds, which took no morning, he carried out ship’s business during longer than 20 minutes. his morning duty period. The mate supervised the loading and unloading of the ship’s cargo Sometime later, the ship passed an island, at throughout the day. which a course alteration of 12° to starboard was required according to the passage plan. After lunch, the master went ashore to have a The master altered course by only 3° as this drink with a fellow crew member and also to appeared adequate to ensure the lighthouse do some shopping. He then returned to the on the next headland was on the port bow.

Bottom damage as a result of the grounding

10 MAIB Safety Digest 1/2007

On passing the island, the radar range was When the mate returned to the bridge a short reduced from the 12nm to 6nm. After the turn, time later, the vessel was afloat. There was the vessel slowly diverged from her planned some confusion and heated discussion on the track and, eventually, the GPS alarm sounded bridge and, eventually, the mate took the con as she strayed outside of the 2 cable cross and set a course clear of the coast and back track error (XTE) margin. This alarm was towards the vessel’s intended track. No acknowledged, but the course was not damage was found and the engine appeared to corrected and the passage continued. No fixes be running smoothly. As a result, the master were marked on the chart, and even the decided not to report the incident to the normal recording of GPS positions in the log authorities or the ship’s management was not carried out. company, and the ship continued on its passage. The master left the bridge, leaving the At about 2325, the master again sent the mate to complete his midnight to 0600 watch. lookout on safety rounds and told him not to return to the bridge but to shake his relief Throughout the night, checks were made for after he had finished. Very soon after the flooding or signs of damage. The mate, having lookout left, the master fell asleep, even considered the situation further, decided at though there was a functioning watch alarm 0200 to report the incident to the DPA on the bridge which needed resetting every 12 (Designated Person Ashore) by sending an minutes. The act of cancelling the alarm was anonymous text message on his personal mobile insufficient to rouse the master into effectively phone. However, the DPA did not find the text monitoring the ship’s position. message until 0800. When the master returned to the bridge at 0600, the chief engineer The vessel vibrated as it ran aground, and the reported having discovered flooding in three master awoke suddenly. He immediately set tanks, and at that point the decision was made to the pitch on the CPP to zero. The master report the incident. Eventually, at 0900, the could see the lighthouse, now on his master made contact with the ship managers, starboard bow, very close by. His first reaction although several unsuccessful attempts had was to refloat the ship, so he put some astern been made from shore to contact the ship. pitch on the CPP. The general alarm was not sounded. The company emergency response team convened, and plans were made to divert the As soon as they felt the vibration, the chief ship to allow the damage to be assessed. At engineer and oiler went to the engine room, 1125 the ship was redirected to port and HM where they started the auxiliary generators coastguard was informed. The ship arrived in and decoupled the shaft generator. They then port safely for cargo discharge and dry checked for any signs of damage. The mate docking, 24 hours after the grounding. went to the bridge shortly after the grounding, not really knowing what had There was significant damage to the vessel, happened. There, he plotted the vessel’s with three long grooves in the double bottom, position on the chart before checking the several small splits in the shell plating and hold and hull for damage. damage to three of the propeller blade tips.

MAIB Safety Digest 1/2007 11

The Lessons 4. Following the grounding, chaos reigned: the master lost control,