MAIB Safety Digest 2/1990

MARINE ACCIDENT

INVESTIGATION BRANCH

Summary of Investigations No 2/90

Marine Accident Investigation Branch 5/7 Brunswick Place SOUTHHAMPTON Hants SO1 2AN

Telephone: 0703 232424

Accident Reporting Line: 071 276 6004 (24 hours)

This summary contains facts which have been determined up to the time of issue. This information is published to inform the shipping industry and the public of the general circumstances of accidents and must necessarily be regarded as tentative and subject to alteration or correction if additional evidence becomesavailable.

Extracts can be published without permission providing that the source is duly acknowledged.

Crown copyright 1990

Introduction Page No.

1. Entry into Dangerous Spaces 1

2. Collision on a River between a Coaster and Tanker 2 Barge

3. Loss of a Sailing Vessel

4. Fire in a Cofferdam of a Chemical Tanker

5. Impact Damage whilst Un-Berthing

6. Injury to Coach Passenger on a Passenger Ro-Ro Ferry

7. Loss of a Small Cargo Ship 7

8. Collision between a Hopper and a Sludge Carrier 9

9. Cargo Hold Fire 10

10. Stranding of a New Ferry 11

11. Fish Farm Dinghy Accident 13

12. Serious Injuries Sustained using a Capstan whilst 14 Purse-Seining

13. Capsize and Foundering of a Small Fishing Launch 15

14. Sinking of a Small Fishing Vessel 16

15. Danger from Mines: Sinking of a Fishing Vessel 17

Appendix 19

INTRODUCTION

The general reaction to the first Summary of Investigations has been very encouraging for us at the Marine Accident Investigation Branch (MAIB). Not only has it received favourable publicity in the shipping press, but more importantly there have been many requests for additional copies. This may have increased the Branch’s postage bill quite considerably. but it is considered a small price to pay if the messages contained in the Summaries receive wide circulation in the shipping industry and particularly on board ships where the accidents happen. I t would be nice to know that the Summaries are also being considered by the management of the shipping companies - those who make the policy decisions concerning the ships for which they are responsible. Preventing accidents cannot, and should not, just be left to those in the front line, the ship’s staff; the lead in the drive to prevent accidents must come from the top, the policy makers.

However, the true success of the Summaries will take some time to be apparent; that will be when we begin to see a drop in the number ofaccidents that occur. This point was made by a well known writer in the shipping press, who when writing a review of the first edition of the Summaries, said “This really sums up what this publication is all about. If this or any other of these examples actually prevents an accident, or perhaps even causes someone to sharpen his awareness at a crucial moment, then its publication will be worthwhile.”

This second edition of the Summaries contains a further selection of investigations from which there are useful lessons to be learnt. As before, a number of them are not really new, they could almost be called “old hat”: some of us will probably have come across them ourselves at sea. But did we do enough to prevent them happening again? Perhaps we did on the ship we were on at the time but how many times were we able to tell the details to other seafarers on different ships so that they could learn the lessons? Probably not very often.

In this collection of investigations one of the most useful lessons to be learnt is for the fishing industry, and that is that life can be saved if survival equipment is carried and used properly. How many more lives could be saved if those who work on fishing vessels, especially the smaller vessels, thought a bit more about their own well-being and not just the catch they were taking? A life lost is a very expensive way to make a good catch.

To some extent accidents can be seasonal. At this time of the year in European waters we can expect gales and bad weather with associated accidents. A number of these lead to shifting of cargo, and in some cases result in the loss of the ship. The importance of proper stowage and securing of the cargo cannot be over emphasised. Let us hope this winter will not be remembered as one where ships and lives were lost because the basics of good seamanship were neglected or forgotten.

Chief Inspector of Marine Accidents April 1990

1. ENTRY INTO DANGEROUS SPACES

After a bulk carrier had completed discharge of a cargo of coal, the terminal authorities tested the atmosphere of a hold for carbon dioxide and oxygen concentration prior to permitting entry for cleaning purposes. The tests indicated that the atmosphere was safe. The construction of the vessel was such that the access from the deck to the hold could only be gained through an access trunk. Two dockers entered the trunk, where they became unconscious and subsequently died.

Observations

It was mistakenly assumed that the hold access space would have a similar atmosphere to that of the hold itself. The space was, therefore, not tested prior to entry. The terminal authorities subsequently recognised that their procedures for permitting entry into dangerous spaces were inadequate and reviewed them to ensure that:-

1. Personnel are prevented from entering any hold or hold access space until the atmosphere has been tested and recorded as satisfactory.

2. Safety equipment used for entry into dangerous spaces is reliable and available for use on board every vessel engaged in a discharging operation.

3. Terminal staff undergo refresher courses concerning the dangers of confined spaces and the use of breathing apparatus.

Ships’ crews also need to understand and observe the correct procedures for entry into dangerous spaces on board ships.

Comment

This accident illustrates the importance of laying down and observing the correct procedures for entry into dangerous spaces; these are addressed in the Merchant Shipping (Entry into Dangerous Spaces) Regulations 1988, and Merchant Shipping Notice No M. 1345.

2. COLLISION ON A RIVER BETWEEN A COASTER AND A TANKER BARGE

A 459 gross registered tonnage (grt) coaster, in ballast. left a river berth to proceed to sea. A 295 grt tanker barge. loaded with heavy fuel oil was on her way up the same river. It was a clear night with a light wind and the tide was flooding.

Just after the coaster cleared her berth. the lights of another vessel were seen coming upriver. fine on the port bow and showing ‘green’. As the other vessel closed i n range, her relative bearing changed to fine on the starboard bow. still showing ‘green’. Although the other vessel was now close. the bearing seemed to be continuing to open to starboard. so the coaster turned to port, to give more room for a ‘green to green‘ passing. At about the same time the other vessel turned to starboard.

I t had been the intention of the tanker barge to enter a lock on the port side of the river. As the lock was approached, the tanker barge reduced speed and turned slightly across the channel to bring the lock fine t o port. At this time. the lights of another vessel coming downriver were seen. The other vessel was showing both sidelights and appeared to be near the middle of the river. The tanker barge altered course to starboard, anticipating that the passing would be ‘red to red’ and then called on V H F a number of times to confirm this. There was no reply and by now the other ship was close and appeared to have turned to port, as her red light was lost to view. The two vessels collided.

Observations

1. Time was lost in waiting for a reply on VHF, the use of which in such situations is discouraged by Merchant Shipping Notice No M.845.

2. The use of sound signals, in partnership with ‘early and substantial action’ by both vessels would have avoided this collision.

Comment

Fortunately both vessels had little way on when the collision occurred. Nevertheless, the tanker barge was holed and about 20 tonnes of oil were released into the river. The collision resulted from unjustified assumptions. on each vessel, as to the other’s intended action.

3. LOSS OF A SAILING VESSEL

A traditional sailing craft was lost with both her crew, while on what should have been a short coastal passage. The vessel was wooden built, 12.2 metres in length, and reputed to have been about 140 years old. She was rigged as a gaff cutter with a single mast and had been fitted with a 7 5 horse-power diesel engine.

When the vessel began the passage, there was a southerly wind, force 5-6 with intermittent heavy rain. The forecast was for the wind to veer and later decrease to force 4. The general course for the intended passage was northerly

The vessel was sighted by fishing vessels at least three times, apparently in no difficulty. However, some four and a half hours after she had sailed, she broadcast a MAYDAY as a result of which Coastguards initiated search and rescue action. Nothing was found until the following day, when the body of one of the crew was recovered, and also some small items of wreckage. The other member of the crew was not found.

Observations

1. It appeared that a weather front, with an associated severe squall, crossed the area where the vessel must have been at about the time the MAYDAY was heard. These frontal conditions were not specifically predicted in the weather forecast given to the vessel, but they should have been recognised as possible in association with the existing winds at the start of the passage and the predicted wind shift.

2. The vessel’s design, with the large open cockpit, made her vulnerable to flooding. It is probable that she was struck by a squall, knocked down and flooded very quickly.

3. It was known that the vessel had carried little, if any, life-saving appliances.

Comment

This accident emphasises the importance of owners and skippers of small yachts:-

1. Paying great heed to both actual weather and to forecasts.

2. Carrying life-caving appliances, including a life-raft.

4. FIRE IN A COFFERDAM OF A CHEMICAL TANKER

During tank cleaning operations on a chemical tanker of 1259 gross registered tonnage, a small fracture was detected in a bulkhead between the cargo tank and the adjacent cofferdam. The fracture was in a weld and approximately 5 cms above the tank bottom. The tanker had previously discharged a cargo of vinyl acetate monomer and was at anchor. The leaking liquid had an acetate smell.

It was decided to flush fresh water into the cofferdam from hoses and then educt the cofferdam. The educting was terminated when the leak into the cargo tank was seen to have stopped. At this stage a sounding of the cofferdam indicated 5 cms of water. After a zero reading had been obtained by testing the atmosphere in the space with a portable gas indicator, ventilation of the space was continued overnight.

The following morning ship staff commenced repairing the fractured weld from within the cargo tank. While grinding out the weld, water again started seeping into the tank so further educting of the cofferdam took place. When the leak stopped, preparation for welding of the fracture resumed. Welding was started but after only a few minutes it was detected that the bulkhead in the immediate vicinity of the weld was extremely hot and a fire was seen within the cofferdam. Fire hoses were brought to bear into the cofferdam and within a short period flames could no longerbe seen but smoke continued to come from the cofferdam. Boundary cooling was initiated from within the cargo tank, but there was concern that this was not having the desired effect. The vessel had just left the anchorage to enter port and permission was granted for the vessel to continue in. The local fire brigade met the vessel on arrival and after consultations it was decided to flood the cofferdam. The space was duly flooded and the fire was extinguished.

Repairs were eventually made to the fracture after pumping out the cofferdam and inerting it with nitrogen.

Observations

1. Due to the construction of the vessel and restricted access to the cofferdam, it was difficult to mount a fire watch in that space. During welding operations in the adjacent cargo tank greater attention should have been paid to providing an alternative safe system of work.

2. As the previous cargo had been vinyl acetate monomer, and liquid leaking from the cofferdam smelt of acetate, greater care should have been taken when educting the cofferdam to ensure that any residual liquid was only water.

3. Consideration should have been given to the fact that the cofferdams were painted and these coatings could catch fire from the heat generated by welding.

Comment

The managers of the vessel have subsequently issued “Notices to Masters” emphasising:-

1. The importance of taking appropriate fire precautions during repairs. ____~_~__--___- 2. Procedures for entry into enclosed or confined spaces.

3. The need for maintaining cofferdams in an empty and dry condition.

5. IMPACT DAMAGE WHILST UN-BERTHING

An 80,000 deadweight tonne tanker was leaving a United Kingdom port, assisted by three tugs. The vessel was berthed starboard side to, heading inwards, and it was therefore necessary to swing through 180 degrees once clear of the jetty. The tanker was in ballast; it was daylight with good visibility, a light breeze on the port bow (as the vessel lay alongside) and an ebb tide of about 1 knot.

Two of the assisting tugs were made fast, one forward and one aft, and the third was initially pushing amidships. When the tanker let go her mooring lines the third tug lay off and moved aft, the intention being that she would assist the swing as soon as the tanker was well off the berth by pushing just forward of the bridge. Soon after the tug made contact in order to carry this out, oil was seen to be escaping from a hole in the tanker’s side, at the point of impact.

The oil came from the port bunker tank; action was quickly taken by plugging the hole from the outside and transferring the oil out of the tank, but just under 90 tonnes nonetheless escaped. Examination showed a fracture some 30 cms in length at the centre of the plating which was indented to a depth of 5 cms, with a deep score beginning 30cms from the fracture and extending about 23 cms further aft. Apart from this damage, the plating was in good condition.

Observations

1. The tug had bow fendering made up of 9 lengths of 12 cms thick rubber tubing, held in place by vertical steel pins. The pins extended some 17 cms above the top of the rubber and each pin was rivetted into its own steel lug, this whole assembly being attached to the fender steel support structure. In elevation, the forward top comer of the lug presented a sharp edge, which was unprotected: see Figures 1 and 2.

2. Ordinarily, this did not matter when the tug was pushing against the vertical ship’s side, for the impact was taken by the rubber fendering. In this instance, however, the point of contact between the tug and the ship was abaft the vertical side, so that the retaining lugs came into direct contact with the hull before the rubber fenders could cushion the blow. Moreover, for the same reason impact was concentrated on a much smaller area of contact than would be normal.

Comment

This accident would have been avoided if protection had been provided for the projecting part of the support assembly, by fitting additional rubber fendering. When this is not done, tugs with similar fender arrangements to that described above should be restricted to pushing only the vertical side of the ship being assisted.

6. INJURY TO COACH PASSENGER ON A PASSENGER RO-RO FERRY

A passenger suffered leg injuries when attempting to re-board a coach during the discharge of a passenger ro-ro ferry. The accident occurred on the upper vehicle deck of the ferry at a time when discharge operations on that deck were being controlled by the Second Officer and three seamen.

A double-decker coach had been stowed on one side of the deck adjacent to an access door to the accommodation. The passenger door of the coach, in this position, was at mid-length on the inboard side. A lorry towing a trailer had been stowed next to the coach, facing the same way, at a distance of about 50 to 70 cms from the coach.

Two elderly passengers had been delayed in returning to the coach and discharge operations had commenced before their arrival at the vehicle deck. The coach passenger door started to close as the couple, both carrying hand baggage, approached it to re- board. At this time, the adjacent lorry and trailer started to move and both passengers lost their balance and fell.

One passenger’s right leg was crushed and badly broken by the wheels of the freight vehicle.

Observations

1. The Second Officer and the three seamen did not observe the two elderly passengers walking along the vehicle deck in order to re-board their coach.

2. The coach driver and his assistant were not fully aware of how many passengers were still to come and they did not direct or assist their passengers in boarding the coach.

3. The coach should have been stowed with the passenger door to the bulkhead and greater space allowed between the vehicles for the free passage of the passengers.

Comment

1. Greater space should be allowed between passenger vehicles and adjacent vehicles.

2. Discharge of freight vehicles should not commence whilst passengers are joining coaches or cars on the same deck.

3. Late arrival passengers should be held