MAIB Safety Digest 1/2020

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 1/2020

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April 2020

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 an 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.gov.uk;

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• By post at: MAIB, First Floor, Spring Place, 105 Commercial Road, Southampton, SO15 1GH

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.gov.uk

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

© Crown copyright 2020

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 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. Distracted by a Mobile Phone 4

2. A Tight Squeeze 6

3. Installation Pressure 7

4. Breaking the Chain of Events 8

5. Unplanned Inclination 9

6. A Roaring Engine 10

7. It’s Raining Containers 12

8. Nodding off the Track 13

9. A Barrel Load of Trouble 15

10. Toxic Gas Inhalation, Plus Severe Burns 16

11. The Vibrating Oil Filter 19

12. Opening a Soft Patch Should Not be Hard 20

13. Illuminated Dashboard 22

14. Good Kit Saves Lives 24

PART 2 - FISHING VESSELS 26

15. There is Not Always a Splash 28

16. The Lure of the Pub Ends in Pollution 30

17. Survival of the Luckiest 31

18. Saved From a Blaze 33

19. A Tragic Turn 34

20. Perched on a Rock 36

PART 3 - RECREATIONAL CRAFT 38

21. Bouncing on the Bank 40

22. Safety Boat Capsize 42

23. Who Rescues The Rescuer? 43

24. Take Stock of your Rudder 45

25. Over and Out 47

APPENDICES 49

Investigations started in the period 01/09/2019 to 29/02/2020 49

Reports issued in 2019 50

Reports issued in 2020 51

Glossary of Terms and Abbreviations AB - Able seaman MCA - Maritime and Coastguard Agency AIS - Automatic Identification System MGN - Marine Guidance Note BA - Breathing Apparatus OOW - Officer of the Watch BNWAS - Bridge Navigational Watch Alarm “Pan Pan” - The international urgency signal System (spoken) C - Celsius PFD - Personal Flotation Device CCTV - Closed Circuit Television RIB - Rigid Inflatable Boat DSC - Digital Selective Calling RNLI - Royal National Lifeboat Institution ECDIS - Electronic Chart Display and Ro-Ro - Roll on, Roll off Information System RYA - Royal Yachting Association HP - horsepower VHF - Very High Frequency ILO - International Labour Organisation VTS - Vessel Traffic Services m - metre “Mayday” - The international distress signal (spoken)

Introduction I will start my opening comments by thanking Kathryn Neilson, Derek Cardno MNM and Paul Glatzel for the introductions they have written for the main sections of this edition of the MAIB’s Safety Digest. Their individual perspectives provide some insightful comments and, as ever, some useful pearls of wisdom. Do please take time to read their words, which contain some powerful advice. Only a year ago, I wrote in my introduction about safe means of access, and that the MAIB had just started two investigations into fatal accidents. One accident occurred as a crewman was attempting to leave his vessel to receive mooring lines, and the other as a crewman was trying to board having just let go the lines. Unfortunately, we have just commenced yet another fatal accident investigation, this time involving a workboat landing a crewman ashore. In common with the previous accidents, the workboat was not effectively secured against movement when the crewman stepped off. They say that bad things come in 3s, and I hope this is the last time someone dies because either the mooring/unmooring operation has not been properly thought through, or a shortcut has been taken. The investigation report into this latest accident will be published later in the year, but in the meantime may I again encourage you to review your procedures for berthing/unberthing and the passing and letting go of mooring lines to ensure your operation is not putting anyone’s life at risk. If I had a £1 for every time a manager has asked me how they can ensure that their staff are ‘doing the right thing’ I would be a rich man by now. There are no simple answers: if there were, people would not be asking me the question. However, the rapport that the ‘office’ has with the ‘coal face’ has a lot to do with developing a good safety culture. Office-based personnel, no matter how experienced, will not always draft workable procedures. Consequently, it is up to those trying to get the job done to provide them with constructive feedback. Back in the office, the task is then to take on board the feedback and react positively to it. Saving a few minutes here or a few pounds there can seem pretty smart at the time, but it is unlikely to convince the next-of-kin. Plan > Do > Review; it works. Finally, it is the time of year when many leisure boaters are starting to think seriously about getting afloat again. It is also the time of year when the MAIB is inundated with reports of breakdowns, material failures and other accidents involving leisure craft. If you and your boat have had the winter off, could I encourage you to start gently, know your own and your boat’s limitations, take time to practise, and build up slowly to the more challenging trips. When you have finished reading this edition of the MAIB’s Safety Digest, please pass it to someone you feel will genuinely benefit from reading these articles. If you are reading this on-line, then send on the link: there is no limit to the number of people who can learn from the experiences of others. Be safe.

Andrew Moll Chief Inspector of Marine Accidents

April 2020

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Part 1 - Merchant Vessels Fatal, catastrophic, permits or risk assessments completed and no serious are just some understanding of the serious implications of not of the words used following safety procedures. by the MAIB when reporting accidents Whilst we review and discuss findings and and incidents at lessons learnt from accident reports, we sea. We know fatal must remember the great work already being incidents involving implemented by Shipping companies and our seafarers can maritime organisations pushing to raise safety be caused by standards on board to change the way their human error and workforce manage safety. The Chamber of inadequate training, Shipping’s Safety Culture Charter launched complacency and last year by the Shipping Minister at London fatigue are amongst the most common causes International Shipping Week is designed to of accidents and incidents at sea. Whilst the be used to supplement and complement the MAIB accident investigations are limited to work already being done by shipping companies establishing cause, promoting awareness of risks in terms of their safety objectives and safety and preventing recurrence is a huge part of management systems (SMS). the work they do and must be highlighted and communicated across the industry if we are to The aim of the Charter is simple: to reduce reduce the number of accidents currently being incidents and accidents at sea. Shipping reported. companies are already addressing their safety culture and working with their employees to So how can we ensure the next generation of improve it, but the Charter allows a collaborative seafarers understand the importance of a strong way of working where shipowners share lessons and effective safety culture on board? And learned and the barriers faced in the pursuit of how can we instil the message that safety is making shipping safer. not one person’s responsibility, but everyone’s responsibility? Many shipping companies continue to support their employees in all aspects of safety in the Throughout every phase of our seafarers’ training, workplace and have instilled a strong and our Maritime cadets and apprentices receive effective safety culture on board. By simply the best possible education to ensure they are changing shift patterns to reduce fatigue, equipped with the necessary skills to operate designing and implementing more relevant, task a vessel safely and effectively whilst protecting specific training programmes, providing better the lives of the seafarers and in some cases, fitting PPE, these small changes can and do have the passengers on board. They are taught that a positive impact on safety standards. there are no half measures where safety is concerned and the thinking they adopt on Safety Changing the way people think about safety at Sea is always “ABOVE AND BEYOND is a challenge, but we must ensure our young COMPLIANCE!” seafarers in training are equipped with the knowledge and the confidence to challenge All too often the Merchant Navy Training Board any colleague when they find themselves in a receive reports from cadets and ratings returning situation where their from sea who have witnessed serious incidents safety and the safety of whilst on board. Incidents involving experienced others is compromised. crew carrying out tasks under hazardous conditions without the required PPE, no work

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KATHRYN NEILSON, DIRECTOR, MNTB Kathryn started her career as a teacher and spent much of the early part of her career working within the training and development sector. When the opportunity arose in 2011 to branch off into Maritime Training, she jumped at the chance. For seven years, she worked for Royal Caribbean Cruise Line as their Safety and Compliance Officer responsible for the UK fleets certification and Compliance and was also responsible for overseeing their UK and International Cadet Training Programmes. She took over the responsibilities of MNTB Director in August 2017. As the Director of the Merchant Navy Training Board, she is responsible for the overall operation of the MNTB, overseeing and facilitating its technical work, new entrant training programmes, careers promotion strategy, the new Recognition Services and managing the charitable work of the Maritime Educational Foundation.

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Distracted by a Mobile Phone Narrative A small cargo vessel was on sea passage and The vessel was also proceeding towards an area heading towards the coastline of the country where there was a voluntary reporting zone of its next port of call. The OOW had taken and a VTS area. Watchkeepers ashore noticed over at 0200 and soon thereafter had started that the vessel was heading into danger, and watching music videos on his mobile phone. made verbal warnings. However, the OOW Between about 0230 and 0430 the vessel was did not respond in sufficient time to prevent slowly set off the planned track by the tidal grounding heavily on rocks (figure). stream in the area. This resulted in the vessel heading towards some outlying, uninhabited The vessel was badly damaged by the accident rocky islands, marked by a lighthouse. and remained aground for several days until However, the risk of grounding had not been the cargo had been removed and sufficient tugs observed by the OOW. were available to haul it off the rocks.

Figure: The cargo vessel aground with the lighthouse visible in the background

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The Lessons

1. The accident happened primarily because Bridge teams need to heed warnings from the OOW was distracted from navigation shore and establish exactly what is being by the use of a mobile phone. This is a reported and what action to take. In this hazard that must be guarded against by case, the OOW was not comprehending appropriate policies for the use of mobile the importance of the warnings being phones at sea. transmitted.

2. Fatigue was also a potential causal factor. 4. Passage planning is not limited to the It was the middle of the night and the intended track on the chart or in the OOW was alone and bored on a warm ECDIS. A comprehensive passage plan bridge. These were conditions that induced should identify all the hazards ahead and a high risk of falling asleep - and he might determine the safest route. This should have done so from time to time. include identifying all navigation marks, lights and buoys, which should then be Combatting boredom and fatigue is positively identified when observed and about ensuring high levels of supervision cross-checked with other navigational data and that safeguards, such as the bridge to ensure accuracy of the passage. This navigation watch alarm (BNWAS), are in vessel was approaching land and the rocky use. In this case, the BNWAS was switched area where it ran aground was marked by a off and there were no other alarms in place lighthouse, which would have been visual to warn the OOW of the looming danger. for a long time as the vessel approached. This was vital, visual navigational 3. The shore authorities offered verbal information that did not feature in the warnings to the OOW that the vessel passage plan and was not subsequently was heading into danger. These warnings utilised for navigational safety on board. were made in sufficient time for action to be taken to avoid the grounding.

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A Tight Squeeze Narrative A tug was on a sea passage relocating to a The alarm was raised with the coastguard new harbour when the fire alarm sounded. and the tug was subsequently towed back The chief engineer went to the engine room to harbour, where the local area fire brigade and saw flames around the port main engine. attended. Some of the port main engine He immediately isolated the fire by shutting exhaust pipe lagging was found to still be off the fuel supply to both engines, shutting hot, so this was cooled with water by the fire all ventilation flaps and stopping the fans. brigade as a precaution against re-ignition. The vessel’s fixed fire-fighting system was not initiated as the chief engineer’s actions had been effective in extinguishing the fire.

The Lessons

1. Post-accident analysis established that the source of the fire was from fuel that had sprayed onto the port engine from a failed compression joint (figure) on small bore pipework to a fuel supply pressure gauge. This stainless steel fitting had failed because it had been sealed with a brass olive (or compression ring). In metal compression fittings, the pipework should Figure: The failed compression fitting (olive not shown) be a ‘softer’ metal than the olive. In this case, the brass olive was ‘softer’ than the steel pipework and it had deformed and under control and preventing further failed, rather than compress and seal the damage or risk of injury. The fixed fire- pipework, which would have been the case fighting system remained available had the had a ‘harder’ stainless steel olive been situation deteriorated. The crew’s actions used. were a result of good system knowledge and worthwhile crew training. The benefits 2. The chief engineer’s response to the fire of conducting regular drills to ensure was both rapid and effective. These actions that safe practices are in place cannot be contained the fire, bringing the situation overestimated.

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Installation Pressure Narrative A landing-craft style fish farm support vessel the release of pressurised hydrogen peroxide, was alongside with contractors on board who spraying onto the contractor. The crew doused were completing the installation of storage the contractor with fresh water to rinse off tanks for