MAIB Safety Digest 2/1991

MARINE ACCIDENT

INVESTIGATION BRANCH

Summary of Investigations No 2/91

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

Telephone : 0703232424

Accident Reporting Line 071 276 6004 (24 hours)

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

Extracts can be published without specific permission providing t h a t the source is duly acknowledged.

Crown copyright 1991

INTRODUCTION

In this edition, there are more summaries concerning accidents to fishing vessels than in previous editions. This is not surprising when i t is remembered t h a t t h e UK fishing vessel fleet is considerably greater in numbers than t h e merchant fleet, and t h e accident r a t e for fishing vessels is higher. However, what is important, irrespective of whether t h e summary relates t o a fishing vessel or a merchant vessel, is t h e lesson t o be learnt. In many cases t h a t lesson applies t o all seafarers irrespective of t h e type of vessel they a r e serving on.

From talking t o various people, both within t h e shipping community and outside, many seem t o think t h a t MAIB only investigate major accidents. The types of accident they have in mind are those where there has been a considerable loss of life; where vessels a r e lost in unusual circumstances; and particularly those which t h e media consider worthy of a lot of attention. This of course is not t h e case: marine accidents of various types and magnitudes a r e investigated, and i t is from many of t h e smaller, less publicised, accidents that some of t h e most useful lessons can be learnt.

The majority of those lessons are not earth-shattering revelations requiring major revisions of marine legislation or ship design; however they a r e earth-shattering in t h e sense t h a t they make one wonder how those accidents could possibly happen in t h e first place. So many of t h e accidents reported t o and investigated by MAIB would not have occurred if those involved had used some commonsense.

One should perhaps reflect on t h e number of times in everyday life t h a t things happen t o us which are avoidable and afterwards we say t o ourselves, "if only". If only we had looked where we were going; if only we had not been there a t t h a t specific time; if only we had checked t h e equipment before we had used it; if only we had read t h e manufacturers instructions. The "if onlys" in everyday life a r e so many and varied; t h e same can be said about marine accidents. Many of those accidents, some of which have had disastrous Consequences, would not have occurred if only commonsense had been used.

Commonsense, or t o be more precise a lack of commonsense, is a theme in many of t h e accident investigations included in this latest edition of summaries. When preparing these summaries and drafting t h e "Comment" section, i t is noteworthy t h a t many of them could be replaced by a single remark t o t h e effect t h a t commonsense was absent. Nevertheless, we hope t h a t readers will be able t o decide for themselves as t o when some commonsense would have prevented t h e accident described in this edition and in turn relate this t o t h e work they a r e doing and consider t h e consequences t o themselves and others they work with. Perhaps then they will avoid despairingly saying t o themselves a t some later date, "if only I had used my commonsense".

Chief Inspector of Marine Accidents October 1991

INDEX

Page No

Introduction -

Carbon Monoxide Poisoning 1

Engine Room Fire in a General Cargo Vesse 2

Injury t o Deck Rating during Mooring Operations 3

Flooding and Beaching of a Dredger 4

Collision between a Cargo Ship and a Standby Vessel 5

Engine Room Fire in a Ro-Ro Cargo Vessel 6

Loss of a Beam Trawler 8

Electrical Power Failure followed by Grounding 9

Sinking of a small Fishing Vessel 10

Loss of a small Fishing Vessel with her Crew 11

Grounding of a Fishing Vessel 12

Capsize of a small Fishing Vessel 14

Collision between Two Fishing Vessels 16

Loss of a Fishing Vessel by Flooding 18

Failure of Bilge Alarm on a Fishing Vessel 19

Accidents involving Fishing for Crabs and Lobsters 20

Appendix

1. CARBON MONOXIDE POISONING

The annual survey of safety equipment was carried out on a small general cargo vessel whilst she was berthed alongside. The test run of t h e fire pump revealed t h a t t h e extended spindle t o t h e sea suction valve a t t h e bottom of a full fore peak tank was disconnected. To carry out a repair i t was decided t o pump out t h e tank using a limited lift salvage pump driven by a petrol engine. This pump was initially sited on t h e forecastle deck until suction was lost, then lowered into t h e forecastle store and pumping restarted. Suction was again lost and so t h e Chief Engineer and Chief Officer entered t h e forecastle store, with t h e Chief Engineer descending into t h e fore peak tank t o adjust t h e suction pipe. Although he was immediately affected by fumes, he managed t o re-enter t h e store space but collapsed across t h e operating engine before gaining t h e open deck. The Chief Officer raised the alarm but by this time was also affected by t h e fumes. Fortunately a number of t h e crew were nearby and pulled both men t o safety as well as shutting down t h e engine.

The tank was eventually drained down via small holes drilled in t h e collision bulkhead, t h e sea suction valve spindles modified, reconnected and t h e pump successfully tested. Both men recovered although the Chief Engineer was off work for some time due t o burns suffered a f t e r collapsing over the pump engine.

Observations

1. The use of a portable internal combustion engine in a confined space without adequate ventilation or an extension of t h e exhaust t o t h e open deck positively ensured t h a t a build-up of poisonous gas would occur.

2. Despite t h e Chief Officer being t h e Safety Officer for t h e vessel, no s a f e t y procedures were followed either prior to commencing t h e tank discharge or afterwards.

Comment

This serious incident could and should have been avoided had t h e advice in Merchant Shipping Notice No M. 1345 concerning entry into confined spaces been followed by both Officers.

2. ENGINE ROOM FIRE IN A GENERAL CARGO VESSEL

A 1,596 gross registered tonnage general cargo vessel was on passage with a cargo of coal when a fire broke out in t h e engine room. A t t h e t i m e of t h e incident t h e main engine was on bridge control, and t h e Master and Chief Engineer were both on t h e bridge. Heavy smoke was seen issuing from t h e funnel housing so t h e main engine control was put to stop. The Chief Engineer entered t h e engine room, wearing a fireman's outfit and smoke hood, found t h e workshop floor plates red hot and attempted t o establish t h e seat of t h e fire by descending t h e port side engine room ladder t o t h e generator flat. It was confirmed t h e fire was a t this lower level, a t t h e forward end of t h e engine room, but due t o t h e restricted movement allowed by t h e smoke hood no actual fire fighting could be carried out.

On his return t o t h e deck and i t having been first checked t h a t all crew were accounted for, t h e engine room was sealed and t h e fixed carbon dioxide gas total flooding system was operated a t 1040 hours. By this time all t h e engine room emergency stops and fuel trips had been operated. After a cooling-off period t h e engine room was again entered a t 1150 hours a t which time t h e fire was confirmed as being out. The space was then vented and an inspection of t h e damage carried out at 1500 hours. Due t o t h e apparent severe damage t o t h e forward main engine turbo blower and electrical cables in t h e area, t h e Owners were informed t h a t t h e vessel would be unable to resume her voyage and t h a t a tug would be required.

The vessel was towed into port for repair.

Observations

I t is thought t h a t securing bolts on t h e main engine fuel oil filters failed, allowing fuel t o spray on t o t h e nearby exhaust trunking and/or forward turbo charger casing. The subsequent fire destroyed deckhead electrical cables and main engine equipment.

Comment

1. The failure of these bolts has not been satisfactorily explained as normally they would not b e under any significant stress. The effect of vibration may have been a contributory cause (one bolt was found t o be missing a f t e r t h e fire) but only if they had been inadequately tightened in t h e first place.

2. The crew took all measures necessary so t h a t t h e carbon dioxide total flooding system was used t o good effect. The early decision to use i t prevented a more serious fire.

3. INJURY TO DECK RATING DURING MOORING OPERATIONS

A rating was stationed forward and handling t h e polypropylene backspring during t h e berthing of a ro-ro ferry. In order t o hold t h e vessel alongside during the mooring operations, lateral thrust was applied by the directional propellers. This trapped t h e backspring between t h e berth and the ship's belting.

As the rating looked over the top of the bulwark the mechanical thrust was decreased and t h e ship moved away from the berth, releasing t h e tensioned rope. The rope recoiled hitting the rating on t h e forehead resulting in him needing three stitches t o a c u t above his right eye. He also suffered probable "eye trauma".

Observations

The Master and Chief Officer when berthing t h e vessel were able t o observe t h e mooring operation from the bridge wing. From this position, they had communications with t h e mooring party and direct control of t h e propellers.

Comment

1. Before tensioning mooring ropes, the mooring party should check t h a t they are clear of obstructions.

2. Personnel on the bridge should be attentive t o deck operations, particularly when holding a vessel alongside using main engines.

3. Shore rope handlers should inform the ship's staff immediately when they observe a problem with trapped or snagged ropes.

4. FLOODING AND BEACHING OF A DREDGER

A 530 gross registered tonnage sand dredger, having discharged her cargo, was returning down a small river estuary t o t h e sea. I t was early evening and close t o high water. The navigable channel, which dries a t low water, is bordered on each side by training walls built up from small blocks of copper slag and surmounted by posts. The width of channel between t h e training walls is 75 metres.

The ship's bridge was manned by the Mate, who was steering by magnetic compass, and a seaman. The engine was building up t o full speed. As t h e estuary widened, t h e dredger encountered an unexpected short, steep swell and started t o pitch. As t h e bows rose and t h e stern fell, a heavy thump was felt and water started to spurt into t h e engine room (which was a f t ) through a hole on t h e port side, below t h e waterline. The space rapidly flooded and t h e water level soon reached t h e generators.

The machinery had t o be shut down and t h e engine room abandoned. Fortunately a launch was in t h e vicinity and was able t o assist t h e dredger out of t h e channel and in beaching her. As t h e tide fell, t h e engine room drained, and i t was possible t o plug t h e hole temporarily. The vessel was refloated on a later tide and taken to a drydock for permanent repairs.

Observations

I t was initially thought t h a t the sudden pitching motion had led t o t h e stern landing on an obstruction on t h e bed of t h e channel. This was discounted as t h e after draft was less than half t h e depth of water; t h e channel bed was inspected at low water and no obstruction which could have caused this holing was found.

I t was fortunate t h a t t h e engine room was manned a t t h e time, enabling t h e bridge t o be quickly notified of t h e situation. There was therefore time t o beach t h e vessel before she sank in t h e channel and closed t h e port.

The Master had handed over t o the Mate and left t h e bridge shortly before t h e accident. Both he and t h e Mate held valid pilotage exemption certificates for t h e port.

Comment

The bridge was not properly manned and the vessel was not being properly navigated. The Mate should have been conning the vessel along t h e narrow channel by visual pilotage and t h e seaman should have been on the wheel and steering t o t h e Mate's orders. I t is most likely t h a t t h e vessel, although she may well have been on t h e correct compass course, was too near t h e port hand training wall. When t h e ship pitched, t h e stern landed on one of the blocks on t h e inside of the wall.

5. COLLISION BETWEEN A CARGO SHIP AND A STANDBY' VESSEL

This collision took place off the entrance t o a large estuary. A 1,570 gross registered tonnage (grt) cargo ship was in-bound whilst a 320 grt oil rig standby vessel was proceeding outwards t o take up standby duties.

The weather was good, with a light breeze, a slight sea and good visibility.

The vessels were crossing with the cargo ship about ten degrees on t h e starboard bow of the standby vessel. When they were about four cables apart t h e cargo ship, seeing no avoiding action being taken by the standby vessel and receiving no response t o either VHF or whistle signals, put her helm hard t o starboard.

A t about the same time, for navigational reasons, the standby vessel's course was altered about t o port. Despite the clear weather, the cargo ship had still not been seen. After this alteration, t h e Officer, who was alone on t h e bridge of t h e standby vessel, started t o engage the auto-pilot. As part of this operation he had t o kneel on the wheelhouse deck and use a spanner t o operate valves on t h e hydraulic steering system. When he stood up from this task he saw the cargo vessel. He immediately put the engine control t o full astern, but despite an instant engine response there was contact between the starboard bow of t h e standby vessel and t h e port quarter of the cargo ship.

While there was only slight damage t o the cargo ship, the standby vessel had t o return to port for repairs which took about a week.

Observations

1. The standby vessel was fitted with two radars, which were both operational.

2. Until just before t h e course alteration there had been two Officers on t h e bridge of the standby vessel, though one had been engaged in steering.

3. The Officers of t h e standby vessel had many years experience sailing in and out of this estuary.

Comment

1. The cause of the collision was gross failure of look-out.

2. Familiarity with a particular sea passage does not reduce the need for proper lookout and responsible watchkeeping.

6. ENGINE ROOM FIRE IN A RO-RO CARGO VESSEL

A 2,644 gross registered tonnage ro-ro cargo vessel loaded with vehicle trailers, was negotiating t h e lock entrance at t h