MAIB Safety Digest 1/2009

SAFETY Marine Accident DIGEST Lessons from Marine

Investigation branch Accident Reports 1/2009

is an MARINE ACCIDENT INVESTIGATION BRANCH

INVESTOR IN PEOPLE

SAFETY DIGEST Lessons from Marine Accident Reports No 1/2009

is an MARINE ACCIDENT INVESTIGATION BRANCH

INVESTOR IN PEOPLE

© Crown copyright 2009

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 2009

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.

If you do not currently subscribe to the Safety Digest, but would like to be added to the distribution list for hard copies, and/or email alerts about it or other MAIB publications, please get in touch with us: • By email at maibpublications@dft.gsi.gov.uk; • By telephone on 023 8039 5500; or • By post at: Publications, MAIB, Carlton House, Carlton Place, Southampton SO15 2DZ.

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 2009

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. Iron in the Fire 10 2. Chute for Safety 12 3. A Close Quarters Situation 14 4. Not Too Much Astern 16 5. Poor Planning = Poor Performance 18 6. CO Poisoning – It’s a Gas! 20 7. Non-Routine Manœuvre Leads to Contact 22 8. Dangerous Cargo – it Did What it Said on the Tin 25 9. Stopped in Time – Just 29 10. New Beginning, Old Problem 31 11. Early Preparation Can Save a Lot of Trouble Later On 34 12. Oh Dear – It’s Happened Again 37 13. Close to the Edge 40

Part 2 – Fishing Vessels 44 14. Watch Where You’re Going 46 15. Lucky to Survive 48 16. Foundering – Always Check Why Bilge Alarms Sound 50 17. The Blind Leading the Blind 53 18. No Safety Training, Faulty Fire Detectors and Emergency Equipment – 56 A Sorry Tale of Woe

Part 3 – Small Craft 62 19. A Not So Lucky Escape 64 20. Hold On Tight, If You Can 66 21. Can’t See Him? Then Alter Course 70 22. “It Can Happen to the Best of Us” 72 23. Excess of Alcohol Contributes to Four Accidents 74 24. The Importance of Electrical Isolations 76 25. Two Wrongs Don’t Make a Right of Way 79

APPENDICES 81 Appendix A – Preliminary examinations and investigations started 81 in the period 01/11/08 to 28/02/09 Appendix B – Reports issued in 2008 82 Appendix C – Reports issued in 2009 84

Glossary of Terms and Abbreviations AB – Able seaman AIS – Automatic Identification System ARPA – Automatic Radar Plotting Aid C – Celsius Cable – 0.1 nautical mile EmS – Emergency Schedule EPIRB – Emergency Position Indicating Radio Beacon GPS – Global Positioning System GRP – Glass Reinforced Plastic HP – Horsepower HSE – Health and Safety Executive ICS – International Chamber of Shipping IMDG – International Maritime Dangerous Goods Code IMO – International Maritime Organization ISM – International Safety Management Code kg – kilogram m – metre mm – millimetre “Mayday” – The international distress signal (spoken) MCA – Maritime and Coastguard Agency MES – Marine Evacuation System MGN – Marine Guidance Note MSN – Merchant Shipping Notice OOW – Officer of the Watch “Pan Pan” – The International Urgency Signal (spoken) PEC – Pilotage Exemption Certificate PLC – Programmable Logic Controller RIB – Rigid Inflatable Boat RNLI – Royal National Lifeboat Institution Ro-Ro – Roll on, Roll off rpm – Revolutions per minute RYA – Royal Yachting Association SMS – Safety Management System SOPEP – Shipboard Oil Pollution Emergency Program TSS – Traffic Separation Scheme VHF – Very High Frequency

Introduction I was disappointed recently to learn that some of our readers still misunderstand what our Safety Digest tries to achieve, and how it fits in with the rest of our work. An experienced seafarer, who professed to be an avid reader of the Safety Digest, complained to me that the lessons identified were normally “pointing the finger” at the mariner rather than looking at the broader aspects of the incident.

When the MAIB investigates an accident or incident, our primary “output” is recommendations to try to prevent such accidents recurring. We work hard with the industry to try to identify the most appropriate recommendations, and we make them to the apposite body. It is very rare that such recommendations are made to individual seafarers; nearly all are focused at systems, companies, trade bodies and regulators. Nevertheless, there are always lessons for the seafarer to learn, and indeed we believe that just reading about accidents – and so thinking about accidents – helps to make us all more safety conscious. Thus, the Safety Digest is primarily aimed at getting the lessons from accidents and incidents out to the seafarer, and we have other ways of promulgating the important safety messages to the rest of the industry. I hope this helps clarify the focus of the lessons that appear in these pages.

One small change we have introduced in this edition, is to re-categorize one of the three sections of the Safety Digest. The replacement of the “Leisure Craft” section by “Small Craft” allows all appropriate incidents and accidents to be brigaded together without the pedants pointing out that, if commercially operated, they cannot be classed as leisure! However, I would still urge readers to look at every case – the more we understand about the problems that other seafarers face, the more we can operate safely together in our common environment.

Stephen Meyer Chief Inspector of Marine Accidents April 2009

MAIB Safety Digest 1/2009 7

Part 1 – Merchant Vessels On reviewing the development of systems; or even worse, that incidents detailed in ‘it is not worth the effort’ because nothing will this safety digest my be done anyway! first reaction was concerning the wide I also question whether in respect of range of difficult management systems there may be an element circumstances faced of ‘paper armour’: crew members are by seafarers as they delegating their safety to the ‘system’ (risk go about their daily assessment, tool box talks etc.), in the belief that duties. It is compliance with the system negates all risks and testament to their therefore absolves them of the need to consider professionalism that accidents and incidents their own safety and that of their colleagues. are, thankfully, comparatively few in number. We are all aware of the wonderful science of Complacency, or as coined in this report ‘task hindsight, and for those of us who now ‘pilot’ familiarity’, is one of the greatest threats to the a desk it is always an easy option to blame mariner. Much of what we do is repetitive: the crew! planning, navigation, watch keeping, maintenance and cargo operations. A seafarer is, and always has been, a ‘Jack’ of all Complacency is not easy to detect, particularly trades and is expected to face challenging where it develops over time. When tasks situations and take the correct decisions – become routine they become dangerous. often under the constraints of adverse conditions and time pressure. Accidents can happen to the best of us; in fact they often do happen to the best of us because It is not surprising to see the same lessons our perceived ability caused us to develop being learned time and again: resource feelings of invulnerability. It is said that ‘the management, complacency and lack of capability to know and follow authoritative training. guidance is the mark of a professional’. Because we become an ‘expert’ at one thing it The importance of bridge team training is does not mean that we should become stressed over and over again, yet frequently we complacent about others; professionalism is read of the Master, isolated in command, being about being balanced. overtaken by events with his support team oblivious to developments. Is this a cultural Perhaps once we recognise that a problem issue generated by dictatorial Masters exists, we will be better placed to solve it. In confident in their own invulnerability, timid the oil and gas industry, ashore and afloat, junior officers blissful in their ignorance, or people were familiar with HSE guidance and in complacency resulting from familiarity, general made efforts to put in place systems boredom and routine? that were designed to manage risk and prevent accidents. By contrast, the marine world still I cannot doubt that there may be poor tends to be characterised by ‘macho’ can-do management systems and that active seafarers attitudes, and the belief that accidents are are probably better able to write and review inevitable and simply part of getting the job systems than their office based counterparts. done; act now – risk assess later. But shore management have failed in their responsibilities if their Masters and crews feel We must all show and encourage respect for they cannot, and should not, influence the every position onboard, and recognise that

8 MAIB Safety Digest 1/2009

everyone onboard is a professional. If any Finally, as we all know, there can also be a individual believes that their role is not valued tendency to know and love the rogues; ‘he’s the then there will be more of a tendency to slip best ship handler in the company and always into ‘rogue’ behaviour. does it that way’…, yes he’s ‘Teflon coated’ … alright until it all goes horribly wrong. Let’s not underestimate the issue, maintaining vigilance in an atmosphere that nurtures ‘Experience is the best teacher’, but ‘the wisest complacency is an awesome challenge. learn from the experience of others’. Management at all levels (onboard and ashore) must support a culture of compliance. Ignoring or missing a non-compliant act or circumstance is as good as endorsing it.

Alastair Evitt Alastair is a Master Mariner and has spent over 33 years in the marine industry. He spent 15 years at sea before coming ashore to work in Ship Management in 1990. Of his 18 years in Ship Management, 5 were spent in Cyprus as Operations/Division Manager and 8 in Singapore as General Manager/Managing Director for a large third party ship manager. Alastair has sat as a committee member on both the Cyprus Shipping Council and the Singapore Shipping Association and was honoured to be appointed as a Councillor to the Singapore Shipping Association in 2003. In 2004 Alastair returned to the UK to take up his present position as Managing Director of Liverpool based Meridian Marine Management.

MAIB Safety Digest 1/2009 9

Iron in the Fire Narrative At about 0235, the duty AB detected a small fire in the open hold. He alerted the crew, who A general cargo vessel was scheduled to load attempted to extinguish the fire. However, this ferrous cuttings which included cast iron was unsuccessful. At 0308 the local fire and filings. The cargo was designated as UN 2793 – rescue service attended the vessel and began Ferrous Metal Borings, Shavings, Turnings or to douse the cargo with water (Figure 1). The Cuttings, and was delivered directly from the ship’s master and harbour authorities advised engineering works to the dockside. On against using large amounts of water because delivery, it was noticed that the cargo also of potential stability concerns. At about 0330 contained cutting oil and other combustible the fire was declared to be under control, and materials including plastic bottles and rags. three out of the five fire tenders providing assistance were released. The waste disposal contractor carried out the temperature checks as required in the Code of At 0530 the cargo loading crane driver arrived, Safe Practice for Solid Bulk Cargo 2004, and and an hour later he started to remove the although it was confirmed that the temperature smoking cargo to the dockside, where it was was below the maximum 55°C required, this cooled down once more. The temperature of was not formally recorded. At 2200 cargo the hold cargo was constantly monitored; it loading was suspended until the following reached a maximum of 93°C (Figure 2). The morning but, despite it starting to rain, none of cargo and hold water removal, and cargo the hatch covers were put in place. re-load took a further 60 hours.

Figure 1

10 MAIB Safety Digest 1/2009

Figure 2

The Lessons To prevent the risk of self-ignition, the following precautions should be taken as laid The cargo was liable to self-heat and ignite out in the Code of Safe Practice for Solid spontaneously because it contained fine Bulk Cargo 2004: shavings contaminated with cutting oil, cast iron borings and organic flammable 1. The temperature of UN 2793 cargoes materials. should be recorded by the waste management contractor. Prior to loading, The self-ignition risk was increased because the temperature taken from between the simple precaution of closing the hold 200-350mm into the pile should not hatches had not been taken. The Code of exceed 55°C. Safe Practice for Solid Bulk Cargo 2004 specifically highlights that cargo loading 2. If the cargo temperature exceeds 90°C should not be undertaken in wet conditions, during loading, operations should be and that hatch covers should be closed when stopped until the temperature has fallen the hold is not being worked. below 85°C.

The master relied on the waste management 3. A vessel should not depart unless the contractor to ensure that the cargo was safe temperature is below 65°C and has to load. In this case, the temperature was shown a steady downward trend for at reported to be compliant with the least 8 hours. regulations, but it was not recorded. In addition, no attempt was made to remove the 4. Cargo loading should be suspended organic matter, which significantly increased during wet conditions, and the hold the risk of self-ignition. hatches should be closed when the holds are not being worked.

MAIB Safety Digest 1/2009 11

Chute for Safety Narrative doors opened further than on the previous test and the carriage was able to move to its A ro-ro passenger ferry was conducting a required position. The rafts and chutes routine deployment of one of its Marine deployed, but during the process of heaving in Evacuation Systems (MES) as part of a planned the bowsing wires to secure the rafts inspection. The ferry was alongside and alongside, the wires were snagged by heavy arrangements had been made for 50 crew corrosion in the guiding channels, and they members to use the system and then to be parted under tension. The evacuation exercise recovered from the liferafts. The equipment was cancelled and an investigation began. had been installed between decks and was mounted on a carriage that slid out from the Inspection of the outer door mechanisms of ship’s side. Liferafts, connected to the ship by both MESs found that the outer door hinges vertical chutes, were then tipped into the were extremely stiff to move and could not be water. opened as intended. The hinges were mounted on the outside of the ship and, Representatives from the equipment although designed for use in a marine manufacturer were in attendance. They made environment, had deteriorated significantly. In their own checks of the system and confirmed the first instance, the carriage had then caught that it was configured correctly. The crew on the door structure, causing it to ride up as activated the evacuation system, and soon it moved outboard. Manufacturing errors in afterwards heard loud noises coming from the the shoot bolt prevented it from engaging operating system.