MAIB Safety Digest 1/2025

SAFETY DIGEST Lessons from Marine Accident Reports

Featuring introductions by Gary Doyle | Anne Hornigold MBE | Mark Bleecker

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 correction if additional evidence becomes If you wish to report an accident or incident available. The articles do not assign fault or blame nor please call our 24-hour reporting line: do they determine liability. The lessons often extend +44 (0)23 8023 2527 beyond the events of the incidents themselves to ensure The telephone number for general use is: +44 (0)23 8039 5500 the maximum value can be achieved. The branch email address is: maib@dft.gov.uk Extracts can be published without specific permission providing the source is duly acknowledged. This publication and previous safety digests are available online: www.gov.uk/government/collections/maib-safety-digests The editor, Clare Hughes, welcomes any comments or suggestions regarding this issue. To see how the General Data Protection Regulation (GDPR) affects the If you do not currently subscribe to the safety digest way we use and store your data go to: or other MAIB publications and would like to find out www.gov.uk/government/organisations/marine-accident-investigation- more, please get in touch with us: branch/about/personal-information-charter

▶ By email to publications@maib.gov.uk; © Crown copyright 2025 ▶ By telephone on +44 (0)23 8039 5500; or This publication, excluding any logos, may be reproduced free of charge in any format or medium for research, private study or for internal circulation ▶ By post to MAIB, First Floor, Spring Place, within an organisation. This is subject to it being reproduced accurately and not used in a misleading context. The material must be acknowledged as 105 Commercial Road, Southampton, SO15 1GH Crown copyright and the title of the publication specified.

GLOSSARY OF TERMS AND ABBREVIATIONS

CHIEF INSPECTOR’S INTRODUCTION 1 INDEX

M MERCHANT VESSELS 2

DANGEROUSLY WEIGHTED HEAVING LINES 4

1. Every day is a school day 6

F 2. Is your battery safe? 8

3. A rope has two ends 10 FISHING VESSELS 30 4. I can only count to eight 12 16. Hitting all the stops 32

5. Stop splashing around 13 17. Plucked from danger 34

6. Not dolphin friendly 14 18. Plan before action 35

7. Out of sight, out of mind 16 19. Too low and too heavy 36

8. Gap analysis 18 20. Calm under fire 38

9. A concrete result 19 21. Escape from an inferno 40

10. No stronger than a nutshell 20

11. Look up, look out 21

R 12. A crunchy exit 22 RECREATIONAL VESSELS 42 13. That was not supposed to happen 24 22. High, dry, hot and stranded 44

14. Tipping point 26 23. An unguarded act 46

15. A little too much flexibility 28 24. Tender by name, sometimes by nature 48

INVESTIGATIONS 50

REPORTS 51

SAFETY BULLETINS 52

SAFETY FLYERS 64

GLOSSARY OF TERMS AND CHIEF INSPECTOR’S INTRODUCTION ABBREVIATIONS Welcome to the MAIB Safety Digest. As usual, I will start by thanking Gary Doyle, Anne Hornigold MBE and Mark Bleecker for their respective introductions to the merchant, fishing and recreational sections of this edition. Each is an expert in ° degrees their own field, and their respective industry insights help bring contemporary °C degrees Celsius context to the cautionary tales and safety messages in the following pages. I hope you will find time to read the whole edition as there is something here for 2/E second engineer everyone, but please do read the section introductions. AGM absorbent glass mat In my opening remarks, I would normally highlight some themes that stand C/E chief engineer out from the cases on the following pages. However, following the very recent collision between the container vessel Solong and the tanker Stena Immaculate cm centimetre I am going to break from tradition. This is not to offer privileged insights – it is way too early in the CO2 carbon dioxide investigation for that – but because it appears to be yet another collision that simply should not have happened. COLREGs Convention on the International Regulations for Preventing Collisions at Sea, 1972 Over the last few years, the MAIB has investigated more than its fair share of collisions. Anyone who says that merchant vessel collisions just result in some bent metal needs to think again. Recently published CPR cardiopulmonary resuscitation are the reports into the collision between the cargo vessel Scot Carrier and the split hopper dredger DfT Department for Transport Karin Høj, resulting in the loss of two lives, and the collision between the general cargo vessel Scot Explorer and the gas carrier Happy Falcon; very fortunately a glancing blow that resulted in only minor damage. DSC digital selective calling Still to publish are: the collision between the oil tanker Apache and the fishing vessel Serinah, which sank ECDIS Electronic Chart Display and Information System following the collision; the collision between the bulk carrier Polesie and the general cargo vessel Verity, resulting in the loss of five lives; and, of course, the collision between Solong and Stena Immaculate that kts knots resulted in the loss of one life, significant pollution, and the likelihood that one if not both vessels will be a m metre constructive total loss. “Mayday” the international distress signal Keeping a good lookout by all available means is, of course, key to identifying the risk of collision MCA Maritime and Coastguard Agency (COLREGs1 Rule 5). If you do not see it, it is unlikely that you will take action to avoid it. However, I have also seen a tendency by stand-on vessels (COLREGs Rule 17) to maintain their course and speed in the firm MOB man overboard belief that the other vessel must give way, despite clear evidence that the other vessel is doing no such OOW officer of the watch thing. Rule 17 requires the stand-on vessel to take avoiding action when the action by the give way vessel alone will be insufficient to avoid a collision. But why wait that long? Rule 17 also allows the stand-on PFD personal flotation device vessel to take action as soon as it becomes evident that the other vessel is not taking sufficient action, and PPE personal protective equipment it seems to me that is the sensible thing to do. Waiting until collision is imminent can leave few options for effective avoiding action, and no time to correct if the other vessel then does something unexpected. PTX pilot/tug exchange I remember as a young cyclist trying to understand the complexities of ‘right of way’ on the roads, and a STCW Convention International Convention on Standards of Training, Certification and Dale Carnegie quote that my father used when he thought I was pushing my luck: Watchkeeping for Seafarers 1978, as amended TSS traffic separation scheme Here lies the body of William Jay, who died maintaining his right of way— He was right, dead right, as he sped along, But he’s just as dead as if he were wrong. UKC under keel clearance Dale Carnegie’s words might be considered insensitive today, but the sentiment still rings true. Whatever VHF very high frequency the size of your vessel, please keep a good lookout and navigate with caution. VRLA valve-regulated lead acid

Andrew Moll OBE Chief Inspector of Marine Accidents 1 Convention on the International Regulations for Preventing Collisions at Sea, 1972. MAIB Safety Digest 1/2025 | 1

MERCHANT VESSELS As you approach the port authorities, and it has been encouraging to during berthing and unberthing can be similarly when it all goes wrong. They are forcing us to twilight zone before see how the marine departments have recently catastrophic: Who is watching the team to reflect on key safety considerations: What is retirement you look collaborated on safety initiatives, regardless of ensure they do not get caught in that bight our infrastructure resilience to an impact from back over your career the commercial aspects. or walk off the quay edge? Who has noticed today’s larger vessels? Do our procedures, risk and can sometimes the ship’s crew trying to embark/disembark assessments and control measures consider be guilty of Living and working in the marine industry is inappropriately? Our ports have experienced all this? As an operator of lock entry to dock systems reminiscing through an experience unlike any other, demanding three during my tenure, one with a fatal outcome we are as concerned by the power supply and rose-tinted glasses; respect, discipline and adaptability as situations that, although not directly one of our operations, control resilience as the potential physical remembering can switch from calm to unpredictable danger happened in our Statutory Harbour Authority impact of vessels or the pressure of the high the good times, in a moment. Our focus as harbourmasters is and prompted a lot of soul-searching and an tides. What redundancy do we have and what skimming over the to ensure we have the correct procedures and in-depth review of our group policies, training are our cyber protection protocols? More broadly, bad but above all safety culture, with appropriately trained teams and PPE provision. From a marine perspective have today’s vessel maintenance and regulatory remembering the to manage day-to-day marine operations safely it was interesting to see how many people had enforcement requirements also moved with the people you worked and served with. The one and respond effectively to an unexpected event not experienced what it was like to ‘fall in the times? Have we the transparency of reporting constant is safety, and how the individual and or crisis. I have tried to stick to the following water’ and know how their PPE would work, and required to enable authorities to ‘accommodate’ team approaches it, though it would be fair to principles that have developed over the years: perhaps understand how there was a degree and manage any declared issues with additional say I have witnessed a considerable change for respect for the procedures; awareness and of complacency. It is now compulsory for the control measures? the better in the 45 years since I walked through teamwork; preparation and training; and mental marine department and anyone from the wider the gates to join the Royal Navy. resilience. Also, remembering that just because company wishing to embark a vessel to have Lastly, safety is both a physical and psychological a good plan did not work out did not make it a completed that course. quality and therefore requires mental resilience. The work of the MAIB and the safety digest, bad plan – stuff happens, it is how we react that Managing stress, fatigue and isolation are certainly in my last 8 years at Peel Ports, has matters! While I admit that my application of Which brings me on to preparation and training. critical to ensure sound decision-making in been in sharp focus with the principle of a no these standards was not always successful, the Invest in marine staff, train them appropriately difficult moments. How well do we know our blame culture and the desire to find out what intent was there. and conduct regular drills to reinforce readiness teams and can we spot an issue? happened to stop reoccurrence is one we as for emergencies and give them the confidence an industry should be thankful for. Besides Adherence to safety guidelines is to act. Analysis of our incident statistics over In summary, I would describe this approach my surface career, I was also fortunate to non‑negotiable and there needs to be effective the last 8 years reveals that the number one to safety as more than just adhering to a set serve in the Fleet Air Arm and there are many communication to ensure the workforce are issue has been mechanical breakdown on of thought-out safety practices; it is about common and transferable approaches to safety aware of these golden rules and empowered to board vessels. The recent Dali incident, and complementing them with a mindset where management within the aviation and maritime enforce them, halting operations or stopping to a differing degree that of Evergiven, are caution and awareness are part of daily life. sectors. One that we used to good effect was a sailing or indeed an arrival, often in the face stark reminders of the evolving challenges in the ’Cockpit Article’. Following a transgression of considerable commercial pressure. We must maritime safety and the impact these have or emergency event the ‘perpetrators’ were respect the procedures and do what is written encouraged to write an article entitled down. Yes, we need dynamic risk assessments ‘I learnt about flying from that’. This was part when things change, but these again are a of a no blame culture that allowed the rest of measured operation. GARY DOYLE | Group Harbour Master, Peel Ports Group us to understand how it happened but, more Gary joined Peel Ports in 2017 as Group Harbour Master and Statute Harbour Master for its seven harbour Awareness and teamwork is important because importantly, what was going through their authorities. He is responsible for leading and developing the Group Marine Operations Strategy, the safety depends on group as well as individual minds, how they got themselves into that evolution of marine operations through the embracing of technological advancements to ensure safety actions. There are a number of incidents were situation, and how they got out of it! It also standards are maintained. He is the current chair of the British Ports Association/UK Major Ports Group better communication or better use of resource helped those involved to exorcise their demons. Marine Pilot Working Group. would have avoided tragedy. The ability of A rhetorical question for us all: How good are someone to stand back and take a holistic we as an industry at sharing best practice and Gary first went to sea in 1980 as a Royal Navy officer cadet, serving in various positions from officer view is vital, especially during pilotage when learning from incidents that do not make it of the watch to captain throughout his 38-year career as a seaman/warfare officer on vessels ranging bridge resource management to support the into the digest? I am pleased to say that safety from patrol boats to aircraft carriers. He also qualified as a helicopter observer, serving on a number of pilot is a crucial collective responsibility. The is the number one priority at Peel, as it is in all frigates as a member of the embarked flight and latterly as the Fleet Air Arm senior operator to the duty consequences of an incident on the dockside holder responsible for operation safety. Gary’s introduction to harbourmastering was a brief spell as a Queen’s Harbour Master watchkeeper in Port Stanley in 1982.

Dangerously weighted heaving lines Photographs courtesy of Peel Ports and the MCA

The MAIB has been recording incidents involving Other heaving line weights are homemade and dangerously weighted heaving lines used in come in an even wider variety of ‘innovative’ British ports for the last 2 years. While there have designs, from the classic monkey’s fist, filled with fortunately been few cases of injury or damage metal scrap and occasionally painted to give it a the risk remains, and is a continuing concern. hard exterior, to unusual constructions such as paint and metal scrap poured into a plastic bottle A member of the public was recently injured by and left to harden to form a weight. Metal scrap a heaving line sent from a sail training vessel. is both heavy and sharp and can cause serious The weight used on the heaving line was of injury if it strikes someone. rubber construction and bounced when sent ashore, striking the person as they walked past. The marina was accessible to the public and busy with foot traffic at the time of the accident. A single member of harbour staff was assisting with mooring operations and was not in the area ▲ ▼ Dangerous monkey's fists filled with metal scrap where the line was thrown ashore. The member of the public sustained head and eye injuries that continued to affect their health and functioning ▲ Metal scrap for a long time afterwards. In another incident, poured into a the weight on the end of a heaving line was plastic bottle enough to result in the window of a pilot boat being broken.

Types of weighted heaving line Heaving line weights come in various shapes Although such weights might seem like a and sizes and present different risks to people. practical solution to sending heaving lines ashore Mass produced heaving line weights from outside easily, their dangerous design and composition ▲ Rubber weight (metal core) ▲ Iron weight the UK can be made of rubber, or rubber with a poses a significant risk of harm and they are metal core. This presents a risk to the public due illegal in the UK. The penalties for a vessel include to the likelihood of the weight bouncing and fines and confiscation of the offending item. Safe, highly visible sandbag ▶ striking people under the chin, on the face, or on other areas not protected by a safety helmet. Many ports in the UK are willing to provide Additionally, rubber weights with a metal core safe alternatives such as sandbags