MAIB Safety Digest 1/2022

SAFETY DIGEST Lessons from Marine Accident Reports

Featuring introductions by Bob Baker | Pete Dadds | Pip Hare

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 that has been determined up to the time of issue.

This information is published to inform the merchant and fishing industries, the recreational 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 If you wish to report an accident or incident correction if additional evidence becomes available. please call our 24 hour reporting line: The articles do not assign fault or blame nor do they +44 (0)23 8023 2527 determine liability. The lessons often extend beyond The telephone number for general use is: +44 (0)23 8039 5500 the events of the incidents themselves to ensure the maximum value can be achieved. The branch email address is: maib@dft.gov.uk Extracts can be published without specific permission This publication and previous Safety Digests are available online: providing the source is duly acknowledged. www.gov.uk/government/collections/maib-safety-digests

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GLOSSARY OF TERMS AND ABBREVIATIONS

CHIEF INSPECTOR’S INTRODUCTION 1 INDEX

M MERCHANT VESSELS 2 1. Best of intentions, worst of outcomes 4

2. “I didn’t know that... !” 6

3. Stick to the plan 8

F 4. Don’t throw in the towel 10 FISHING VESSELS 38 5. Pitching into trouble 12 17. A handy solution 40 6. A bumper catch of workboats 14 18. Water, water, everywhere 43 7. The stress of catastrophic engine failure 16 19. The price of FAME? 44 8. Washed away 18 20. It came off in my hand 45 9. Belt and braces 20 21. Lookout for anchored vessels 46 10. No going back 22 22. A simple step... into danger 50 11. Fretting failure in gearbox 24

12. The fog of illusion 26

R 13. Making your mark 28

14. Drip, drip, drip, bang 30 RECREATIONAL VESSELS 52 23. Too close, too fast 54 15. On the rocks! 32 24. Don’t swim near moving boats 56 16. One small step for man 34 25. Last orders at the bar 58

INVESTIGATIONS 60

REPORTS 61

SAFETY BULLETINS 64

SAFETY FLYERS 70

GLOSSARY OF TERMS AND CHIEF INSPECTOR’S INTRODUCTION ABBREVIATIONS Welcome to MAIB’s first Safety Digest of 2022. I would like to start by thanking Bob Baker, Pete Dadds and Pip Hare for their introductions to the merchant, fishing and recreational sections of this digest. They each have a °C ° Celsius wealth of experience in their respective fields, and their introductions are 2/E second engineer very thought-provoking. If nothing else, please read their articles. That said, I hope you will read much more than that. There is a cautionary tale here for ABP Associated British Ports everyone, and when you have finished reading the digest please pass it on AIS automatic identification system so others can benefit too.

ARPA automatic radar plotting aid Bob Baker asks the questions, Why did the officer of the watch switch off guard alarms on radars/ECDIS? And why is failure of the bridge team and poor CCTV closed-circuit television communications such a fundamental issue and the most frequent cause of incidents in coastal/port waters? He goes on to talk about the need for a cultural change C/O chief officer in the way we embrace safety and in our approach to understanding why COLREGs Convention on the International Regulations for Preventing Collisions at Sea (1972) accidents happen. I could not agree with him more. CPP controllable pitch propeller Like Bob, I started bridge watchkeeping in the pre-digital age. Satellite navigation was in its infancy, radars were unreliable, ARPA did not exist, and the ship’s position was plotted and projected ahead on a paper DfT Department for Transport chart. In coastal waters, watches were busy, sometimes hectic, and if the watchkeeper did not collect and ECDIS Electronic Chart Display and Information Systems assimilate the necessary information, they would not know what was happening around them. Compare this to the modern bridge where all that manual work is being done automatically, and all the watchkeeper EEBD emergency escape breathing device needs to do is look at the screens (and out of the window!) to see what is going on. Watches have ceased to be as stimulating and occupying as they were, but the watchkeeper still keeps a 4 or 6-hour stint on the FAME Fatty Acid Methyl Ester bridge. The frequency of accidents that have occurred when a watchkeeper has decided to keep alert or IMO International Maritime Organization awake by occupying themselves with their mobile phone, tablet or PC seems to be on the rise, probably because they are insufficiently engaged by their duties. I would therefore add to Bob’s call for a cultural kts knots change to safety and say that the role of the human in the digital workplace needs a serious rethink; if we don’t, it is us that will be asleep at the wheel. LOTO lock-out/tag-out MGN Marine Guidance Note Few people have the courage to tell a “When I…” story as powerful as Pete Dadds’ account of his capsize, and I am grateful that he shared his experience with us. The first thing that stands out for me is the old saying, nm nautical mile “Never turn your back on the sea”, because it always has the capacity to be unpredictable. The second is that Pete and his crew were wearing PFDs and so were able both to survive the initial shock of immersion in OOW officer of the watch cold water and stay afloat long enough to be rescued. I think the message about wearing PFDs when on PEC Pilotage Exemption Certificate the working deck is slowly getting around. However, too many of MAIB’s customers were unfortunately not wearing a PFD when they entered the water, with often tragic results. Pete’s story shows that it is possible to PFD personal flotation device survive going over the side, but to do so you need to be wearing a PFD. RIB rigid inflatable boat Pip Hare writes about the risks of being a single-handed round the world sailor, about mitigating the foreseeable risks in advance, and being ready to change her plans in the face of changing circumstances. At RNLI Royal National Lifeboat Institution MAIB we often talk about safety margins, and how easily these are eroded. Going a bit fast in poor visibility, RoPax roll-on/roll-off passenger ferry rushing a maintenance task, loading more catch than is safe, staying out for one more haul in deteriorating weather, show-boating (in all its forms); it is all too easy to erode the safety margins. A few years ago, the ro-ro roll-on/roll-off Royal Yachting Association ran a campaign entitled Know Your Limits and the detail is still available on its VHF very high frequency website:

VTS vessel traffic services https://www.rya.org.uk/knowledge/safety/know-your-limits Whatever your means of getting afloat, it is worth a read.

Andrew Moll Chief Inspector of Marine Accidents

MAIB Safety Digest 1/2022 | 1

MERCHANT VESSELS I am now well into patience. The marine industry has traditionally the same attitude and training, while needed, operations, particularly for pilots and port my 47th year in the been built around command and control rather must be appropriate. Changing culture seems authorities. Pilot ladder deficiencies top our marine industry. than a structure that encourages the watch to be one of the most difficult things to achieve, Port of London incident report statistics by a When I went to officer to question the master or pilot; “I was just yet it is the subject most frequently raised considerable margin. After a long campaign sea there were trying to get the job done” is a fateful phrase that and discussed in training courses, seminars, involving all elements of the industry, we are very few electronic I have heard many a time. companies’ strategies, etc. The word culture and starting to see a gradual improvement in the navigational examples of poor safety or professional culture condition and rigging of pilot ladders, but focus aids available, Until improvements are made in these softer even feature heavily in our day-to-day life and cannot be lost in ensuring this vital piece of technology was skills, we will struggle to understand why it is frequently mentioned in mainstream news equipment is correctly rigged. Asking a pilot to limited and the individuals take the decisions that ultimately reports into incidents and failings. step from a moving boat onto a rope ladder and processes and lead to incidents and accidents. I am sure the climb up the side of a ship demands the highest procedures we use MAIB has the statistics, but how many incident It seems obvious and simple when discussed; standards of safety, without compromise. today, such as risk investigations attributed the cause either fully or however, it is not, and to make that step change assessment, passage plan, bridge team, ISM, etc., substantially to human error rather than delving to improve safety everyone in the marine We are all human and we all make mistakes. had yet to be developed. I have therefore had deeper into the underlying contributory factors industry must embrace new thinking. Acknowledging this and asking, “Why?” will the benefit and privilege of seeing the maritime that influenced the incident? Do investigators hopefully contribute to the provision of a safer or companies take the time to establish and Finally, it is good to see the MAIB include the work environment. industry improve, develop and expand safety explore why an individual decided not to follow serious issue of pilot ladders in this edition of training, culture and systems. I have also seen the procedures, conduct a risk assessment or the Safety Digest. This is a critical part of our the advent of smaller crews, quicker turnaround in port and ever-increasing use of technology and follow their training? Why did the officer of the sophisticated systems. watch switch off guard alarms on radars/ECDIS? And why is failure of the bridge team and poor The human interface and what can be described communications such a fundamental issue and as human and organisational contributory factors the most frequent cause of incidents in constantly feature in incident reports, not just coastal/port waters? the MAIB’s but all of our own. In an industry that continues to introduce new procedures, I do think we are all sometimes guilty of processes, safety systems and technology, we still taking action after an incident that focuses seem to fail when it comes to understanding the on producing another procedure rather than human element. evaluating why the existing procedures or training, which are probably perfectly fit for purpose, were not followed. To understand Everyone should be why these issues occur, the cultural approach to aware of their cultural investigations and the actions stemming from the recommendations need to become more as well as technical open, collaborative and cooperative. If we can BOB BAKER | Chief Harbour Master, Port of London Authority competence be less defensive and more open when being investigated, we may learn more as to why Bob became the Port of London Authority (PLA) chief harbour master in May 2016. He is responsible It is therefore vitally important, and even more individuals act the way they do. Unfortunately, for all operational and navigational matters, including vessel traffic management, pilotage, harbour so now as the concept of alternative fuels, in a society where liability, compensation and services and port security. He sits on the PLA board and is a member of the authorities Licensing autonomous vessels and artificial intelligence are litigation appear to be the priority, these become Committee. Bob joined the PLA from Forth Ports, where he was chief harbour master and a director of coming over the horizon, that our ship personnel, major barriers to establishing this. Forth Estuary Towage from 2001. Bob’s seagoing career lasted from 1975 to 1991, mainly sailing on bulk carriers that traded worldwide. Following his sea career Bob worked as a superintendent in Africa for a VTS officers, pilots, tug crews, harbour masters, As with everything safety-related, if we are number of years, primarily overseeing the discharge and distribution of aid cargoes. Returning to the etc., are properly trained and experienced going to shift the cultural dial it is everyone’s UK, he worked at the Port of Tilbury, latterly as general manager of conventional cargo operations and enough to meet the challenges of this fast- responsibility to willingly participate. Yes, harbour master. evolving industry. Everyone should be aware of their cultural as well as technical competence, companies and management have to create the Bob chairs the UK Major Ports Group (UKMPG)/British Ports Association (BPA) Marine Pilot Group developing and improving on skills such as right environment for this more collaborative and sits on the Department for Transport’s steering group for the Port Marine Safety Code. A Master collaborative communication, empathy and approach, but everyone involved needs to adopt Mariner, Bob also holds an MBA from Henley Management College.

Best of intentions, worst of outcomes cargo vessel | flooding

A small dry cargo vessel was in harbour and its indicated as shut on the ballast control panel. The block the strainer lid flew off and engineers were investigating why ballasting 2/E then went to the engine room and manually seawater began flooding into operations were taking longer than normal. shut the isolation valve between the strainer and the engine room. The engineers Their plan was to clean the ballast system’s the pump (Figure 1). tried unsuccessfully to replace the seawater strainer and then check the ballast lid, then decided to evacuate the pump’s condition. With the chief engineer present, the 2/E loosened engine room and raise the alarm. the strainer lid’s retaining bolts and tried to lever To isolate the strainer, the second engineer (2/E) the lid off with a screwdriver, but it would not In the engine room, the water went to the ballast control panel and shut the budge. The engineers then rigged a chain block level rose over the bottom plates automatic butterfly hull valve between the hull to the strainer lid, having completely removed until the seawater pressure inlet and the strainer (Figure 1). The hull valve all the bolts. As the weight came onto the chain equalised and the vessel settled with the engine room partly flooded (Figure 2). The vessel was For illustrative purposes only: not to scale made watertight after a diver fitted an external patch over Sea Engine room the hull valve. Thereafter, the Lifting eye contaminated water was pumped Strainer box lid out to road tankers for disposal and the vessel was dry docked for Test plug repairs. Gasket After the accident, a technical Strainer lid bolts investigation identified that the Manual gate valve automatic butterfly hull valve was defective, and had remained Actuator partially open when indicated as shut on the ballast control panel. To pump This investigation also found that the strainer was clean but that a Automatic butterfly valve Strainer box ballast pump defect had caused the slow ballasting operations. The company has provided a Perforated strainer revised safe system of work for strainer cleaning. Figure 2: The flooded engine room Figure 1: Ballast water valve and strainer arrangements

The Lessons 1. Procedure → The strainer lid was fitted with a test plug (Figure 1), provided to make sure the system was 2. Check → Given that the hull valve indicated shut on the ballast control panel, it was reasonable of the not still under pressure before the lid was removed. However, the engineers involved in this accident neither engineers to assume this was correct. However, where there is doubt or, for instance, when reducing a system followed an approved procedure for the strainer clean nor opened the test plug and so were unaware of to single valve isolation to sea, it is good practice to visually inspect the valve’s mechanical position indicator the faulty hull valve that meant the system was still open to sea pressure. Additionally, when they tried to as well as checking its remote indication. A further precaution is to loosen the nuts, then use wedges to crack remove the lid with a screwdriver, the absence of any leakage underpinned their assessment that the system the lid open; if water floods out, the retaining nuts can be retightened to seal the strainer lid. was isolated.

“I didn’t know that... !” passenger ferry | grounding

In the early hours of a stormy winter’s day, a roll-on/roll-off passenger ferry (RoPax), which was laid up