MAIB Safety Digest 1/2015

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accidents No 1/2015

is an

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This publication Further canthis copies of also be found report on our website: are available from: www.gov.uk/government/organisations/marine-accident-investigation-branch Marine Accident Investigation Branch Mountbatten House Grosvenor Square Southampton April 2015 SO15 2JU

MARINE ACCIDENT INVESTIGATION BRANCH

The Marine Accident Investigation Branch (MAIB) examines and investigates all types of marine accidents to or on board UK vessels worldwide, and other vessels in UK territorial waters.

Located in offices in Southampton, the MAIB is a separate, independent branch within the Department for Transport (DfT). The head of the MAIB, the Chief Inspector of Marine Accidents, reports directly to the Secretary of State for Transport.

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 information which has 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 receive an email alert about this, 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, Mountbatten House, Grosvenor Square, Southampton, SO15 2JU

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 email address is maib@dft.gsi.gov.uk

Safety Digests are available online www.gov.uk/government/collections/maib-safety-digests

© Crown copyright 2015

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 2012 – Regulation 5:

“The sole objective of the investigation of a safety investigation into an accident under these Regulations shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of such 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

INTRODUCTION 1

PART 1 - MERCHANT VESSELS 2

1. Where There’s Smoke ……… 4

2. Lucky it was Sand 8

3. Out of Sight, Out of Mind 9

4. Badly Timed Tackle Results in Another Lifeboat Accident 12

5. Gone With the Wind 14

6. 100 Tonne Flood 16

7. No Buoy – Oh No! 19

8. Over-Speed Damage 21

9. A Lifeboat Out of Control 23

10. Too Hot to Handle 26

11. The Correct Tool is Key to Safe Maintenance 28

PART 2 - FISHING VESSELS 30

12. A Lonely Death 32

13. It’s All in the Balance 34

14. Crunch – Where Did he Come From? 36

15. The Perfect Gift 39

16. Double on the Rocks 41

PART 3 - RECREATIONAL CRAFT 44

17. Are You Certain You’re Clipped On? 46

18. Mediterranean Mystery 48

19. Three Crew Down 50

20. Lack of Planning Ends Adventure 52

21. A Back-Breaking Experience 54

22. Slippery Slope to Danger 56

23. A Narrow (boat) Escape 58

24. A Fatal Blow 61

25. One Slip Away From Disaster 63

APPENDICES 64

Investigations started in the period 07/08/14 to 28/02/15 64

Reports issued in 2014 65

Reports issued in 2015 67

Glossary of Terms and Abbreviations AB - Able Seaman MCA - Maritime and Coastguard Agency AIS - Automatic Identification System MGN - Marine Guidance Note C - Celsius MOB - Man Overboard CCTV - Closed Circuit Television NIFPO - Northern Ireland Fish Producers’ Organisation CO2 - Carbon Dioxide OIC - Officer in Charge COLREGS - International Regulations for the Prevention of Collisions at Sea 1972 OOW - Officer of the Watch (as amended) “Pan Pan” - The international urgency signal CRT - Canal and River Trust (spoken) DSC - Digital Selective Calling PLB - Personal Locator Beacon ECDIS - Electronic Chart Display and RA - Risk Assessment Information System RIB - Rigid Inflatable Boat EPIRB - Emergency Position Indicating Radio RNLI - Royal National Lifeboat Institution Beacon Ro-Ro - Roll on, Roll off GPS - Global Positioning System RYA - Royal Yachting Association GRP - Glass Reinforced Plastic SAR - Search and Rescue LSA - Life Saving Appliances SOLAS - International Convention for the m - metre Safety of Life at Sea “Mayday” - The international distress signal VHF - Very High Frequency (spoken)

Introduction At first glance, this edition of the Safety Digest contains 25 diverse examples of accidents. However, on closer inspection you will see a number of familiar themes emerging from these unfortunate chronicles of mishap. The consequences of failing to properly plan a voyage on a large merchant ship are graphically described in Case 2 but Case 20 describes a similar outcome, this time on a leisure vessel. Preparing a passage plan is vital if voyages are to be conducted safely, irrespective of the size/ type of the vessel. However, once the plan is in place, don’t blindly follow the track line – look ahead and anticipate what is going to happen during your watch. Make sure that the plan is not placing the vessel in danger and keep a good look using all available means (don’t just rely on what your electronic navaids are telling you, look out of the window and make sure that what you can see makes sense!). Case 8 describes another type of planning failure; the failure to properly adhere to the planned maintenance schedules of machinery can have catastrophic consequences. Ships’ engine rooms are inherently dangerous places and it is important that engineering staff are properly trained and follow sound engineering procedures if avoidable accidents are to be prevented. Cases 10 and 11 are good examples of what can happen when tasks are not properly planned and /or short cuts are taken which fall outside customary good practice. Previous Safety Digests have regularly highlighted the importance of wearing lifejackets when working on the open decks of fishing vessels and leisure craft (Case 15 and 19). Fitting spray hoods to lifejackets and investing in Personal Locator Beacons (PLBs) and an EPIRB can also save lives. Fitting a liferaft, even though one may not be required by regulation, is also a smart move – should the worst happen, why get wet when you can remain relatively dry and warm until help arrives? (Case 13) Any accident can be life changing – not only for those directly involved but also for their colleagues and loved ones. Therefore, before commencing any potentially hazardous task, whether on deck, in the engine room, on a large ship or small, get into the habit of asking yourself “what’s the worst that could happen?” then check that the necessary barriers are in place to protect yourself, the ship and everyone on board. In closing, I would like to thank Commodore David Squire, Tony Delahunty and Paul Bishop for their insightful introductions to the relevant sections of this Safety Digest. Until next time, keep safe.

Steve Clinch Chief Inspector of Marine Accidents

April 2015

MAIB Safety Digest 1/2015 1

Part 1 - Merchant Vessels The selection of eventualities. Carrying out a risk assessment case studies in before undertaking an operation or task the Merchant should not be a ‘one person’ function; tool Vessel section box talks encourage collective thinking and of this MAIB should involve both experienced and lesser- Safety Digest experienced personnel, for it is sometimes indicates an the lesser experienced (and the most junior) all-too-familiar who will identify a hazard that has not been trend of previously thought of. accidents that should never Navigational planning is a form of risk have happened. assessment, because on each passage the Many have hazards will differ even if the ship is on a human or regular route. ECDIS makes the planning operator error as causal factors and all reflect process easier, but only if the operator of the a failure to properly comply with the Safety system is properly trained in its use and is Management System (SMS), in accordance fully aware of its capabilities. It is ultimately with the provisions of the ISM Code. the master’s responsibility to cross-check the plan before departure, but each OOW In our daily lives, we all take risks and we also has a responsibility to ‘look ahead’ when all make mistakes – it is human nature; in taking over the watch, to ensure that the some cases these mistakes can have disastrous planned route does not stand the ship into consequences, but in the vast majority we are any danger. But, most important is the need able to quickly rectify the situation without to maintain a proper visual and radar lookout causing any harm to ourselves or to other not just to monitor other vessels but also to people or property. In the maritime context, positively identify aids to navigation that are this is where accident investigations, such as positioned to direct the ship away from a those undertaken by the MAIB, are of great hazard. value. They do not seek to apportion blame or determine liability; they are conducted Procedures outline the steps to be followed solely with the objective of preventing marine to accomplish specific tasks. Operational, casualties and marine incidents in the future. maintenance and emergency procedures are crucial elements of the safety equation. They Safety recommendations from accident can be in a variety of forms, ranging from the investigation reports can trigger actions COLREGS – specifically Part B, the Steering ranging from the development of more and Sailing Rules – which set out the actions regulations, to increased training or simply to to be taken to prevent collisions at sea; to review a company’s/ship’s safety management procedures for the operation and maintenance systems. But, what is important is that we of machinery and systems and for the should learn from our mistakes, and from the maintenance and launching of lifeboats and mistakes of others. liferafts; or for the action to be taken in the event of a fire or man-overboard. Assessing the risks associated with carrying out an operation or task should not be Some procedures need to be committed to simply a tick-in-the-box exercise. Generic memory, especially the COLREGs, and those risk assessment templates and checklists are procedures related to emergency situations, all well and good, but they do not cover all but there is no reason why the latter should

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not be supported by an aide memoire, provided I commend the reading of this publication to all it does not become just another ‘tick list’. Others who are involved in the design, management and will have to be followed to the letter, especially operation of seagoing vessels. in the case of the operation and maintenance of complex systems.

Commodore David Squire, CBE, MNM, FNI, FCMI Commodore David Squire retired from the Royal Fleet Auxiliary Service (RFA) in March 1999 after a career spanning over 35 years which included a wide range of appointments at sea and ashore, culminating in a 5 year appointment as Commodore and Chief Executive of the RFA.

He is editor of Alert! the Nautical Institute’s award-winning International Maritime Human Element Bulletin, which is sponsored by the Lloyd’s Register Foundation.

He is a well-known authority on human element and safety of navigation issues, and has written and lectured widely on these subjects. He was a consultant editor to the Lloyd’s Register publication The Human Element- an introduction and was a consultant to Lloyd’s Register in the formulation of their Human Element Gap Analysis project.

He is Chairman of the Merchant Navy Training Board, the UK shipping industry’s central body for promoting and developing seafarer education, training and skills.

He is a member of the Council and Deputy Chairman of the Operations Advisory Committee of the RNLI; an Elder Brother of the Corporation of Trinity House; editor of the Journal of the Honourable Company of Master Mariners; and a Maritime Training Ambassador for the UKSA.

MAIB Safety Digest 1/2015 3

Where There’s Smoke ……… Narrative It was just another routine day. The cargo decks. At 0225, the chief officer reported that had been discharged from the ro-ro ferry the vents were closed. However, thick smoke and loading was going according to plan. continued to pour from many of the louvres As usual, the crew complained about the because they had not been correctly closed general condition of some of the vehicles as against their locking cams (Figure 1). a number of them had to be pushed or towed into position because of mechanical problems. In the meantime, the master alerted the However, that was the nature of the second- shore authorities to the situation as the chief hand and scrap vehicle export market. engineer reported that he was ready to inject the required 19.8 tonnes (t) of CO2 into the A total of 170 units was loaded and lashed main deck from the 21.3t capacity storage down, which included 10 vehicles accompanied tank. However, it was a further 5 minutes by their drivers. Despite the crew’s concerns before the chief officer was able to account for there were no risk assessments available or one of the crew, who had not reported at the material checks made to confirm the suitability muster station. of the vehicles for carriage. Loading was completed at 2100 and, at 2110, the ferry At 0230, the CO2 system was operated for departed. As the second officer took the watch, 15 minutes in accordance with the system he settled down for what he thought would be instructions. At the same time, the chief officer another routine and uneventful passage – but opened fire hydrants on the upper deck to not on this occasion! boundary cool the area above the fire. At 0245, the chief engineer reported to the master that At 0215 the fire detection system sounded, the CO2 tank contents gauge was showing indicating a fire on the starboard side of the 12t, suggesting that insufficient gas had been main deck. The on-watch rating was sent to injected. The system was operated for a further investigate the cause as the second officer 15 minutes, but the contents gauge still requested the master to come to the bridge. indicated 10t of gas remaining. Unsure of the He also looked at the main deck CCTV true situation, the master instructed that the monitor, but saw nothing untoward. In the CO2 system be manually operated instead of meantime, the rating opened the main deck using the automatic timing arrangement. The door. He did not detect anything unusual from chief officer had by now set up the drencher his position, and was reluctant to proceed any system to replace the hydrants for boundary further because of the tightly packed cargo. As cooling purposes. the rating returned to the bridge, the master looked at the CCTV monitor and noticed As the ferry made its way towards the agreed heavy smoke and then flames rapidly develop port of refuge, the 10 vehicle drivers, who on the starboard side of the main deck, before had been drinking heavily, started to become the camera lens became obscured. disruptive and distracted the chief officer from his primary incident management role. Muster stations were announced and the It was agreed to relocate them inside the nominated ventilation team immediately superstructure where they could be readily started to shut the 36 main deck ventilation evacuated if necessary. In the meantime, the jalousies positioned on the upper and weather deck temperature above the fire was being

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constantly monitored. As the temperature dampened the scene down and declared the had not increased and no other fire/smoke fire to be extinguished at 1325. detectors had alarmed, it was determined that the fire was under control. The vessel suffered distorted deck plates and longitudinals, and damage to minor electrical The ferry berthed alongside at 0640 where it circuits. A truck carrying a van was completely was met by the local Fire and Rescue Service. destroyed and a cab unit and six trailers After evacuating surplus crew, some of the suffered severe damage (Figures 2 and 3). cargo was discharged in order that access Other vehicles suffered from radiated heat to the fire could be gained. The firefighters damage.

1-1.5m gap between louvres

Figure 1: Ventilation jalousie and louvres arrangement

MAIB Safety Digest 1/2015 5

Burnt out truck

Burnt out van

Figure 2: Burnt out truck and van it was carrying

Damaged vehicles

Trailers

Figure 3: Damaged vehicles

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The Lessons

Many of the vehicles on this particular trading 3. Crew should report to their muster route had been de-registered and not used station, or report in by radio as quickly