MAIB Safety Digest 2/1992

MARINE ACCIDENT

INVESTIGATION BRANCH

Summary of Investigations No 2/92

Marine Accident Investigation Branch 5/7 Brunswick Place SOUTHAMPTON 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 shippingy 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 becomes available.

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

Crown copyright 1992

INDEX

Page No.

In trod u ct ion

Collision between a Ro-Ro Vessel and a Sea Angling Boat

Accident with a Ship’s Side Cargo Ramp

Engine Room Fire

Death of a Crewman while Loading Articulated Lorries on to a Ro-Ro Ferry 9

Collision with Quay caused by Interaction 10

Fatal Accident whilst making a Tug Fast 15

Injury to Shore Official 12

Collision between a Gas Carrier and an Anchored Oil Tanker 13

Machine Tool Failure 15

Seaman carried around Rotating Winch Drum 17

Failure to Keep to Standing Orders 18

Injury to a Ferry Passenger in Heavy Weather 19

Collision between a Bunker Barge and a Seismic Survey Vessel 20

Trainee’s Hand Crushed during Cargo Match Cover Opening Proced ure 25

Loss of a Small Fishing Vessel with her Crew 22

Loss of two Small Fishing Vessels - Liferafts incorrectly stowed 23

Loss of Small Fishing Vessel whilst working alone 24

Appendix A

Appendix B

INTRODUCTION

Before embarking upon the theme of this Introduction, it is worth highlighting that in this edition only three of the summaries concern fishing vessels; all involve vessels less than 12 metres and the incidents are very similar. The reason for including such a collection in one edition is to bring home the message that, unless proper thought is given to the job in hand, there can be tragic results: seven fishermen set sail; only two returned home.

Turning to less harrowing circumstances, everyone of us must have at some time had an unsettling experience when things go wrong with what we were doing and admitted "that it was a near thing". Joining a main road only to have an oncoming car screech to a halt inches away, or perhaps just starting to clean an electric lawn mower when the cutter blades suddenly move into action, are two random examples. It is unlikely that we bother to analyse the incident to prevent it happening again. It is equally unlikely that it has been discussed with others so that they can learn from our own unsettling experience. Perhaps the reason is that one would not want to be exposed to ridicule by friends and colleagues. Who likes to admit for example failing to check for oncoming traffic or, in the other example, ensuring that the electric mower was unplugged from the socket.

There are a number of ways, some impolite, to describe the two examples just given, but perhaps the most common is a "near miss". Another, and probably more apt term, is a “hazardous incident". In the Merchant Shipping (Accident Investigation) Regulations, a hazardous incident is defined as ''any incident or event not being an accident by which the safety of a ship or any person on board is imperilled, or as a result of which serious damage to any ship or structure or damage to the environment might be caused". Taking the two examples and applying them to sea-going activities we have the scenario of the near collision between two vessels when one of them is entering a traffic separation scheme and the engineer who very nearly loses his fingers in an electric motor because he did not isolate it electrically before starting maintenance on the motor. Clearly hazardous incidents are not confined to two vessels almost having a collision; they include all incidents which if they had progressed one stage further would have resulted in an accident taking place or would have the potential to lead to an accident.

There is no requirement for hazardous incidents to be reported; however, owners and masters are strongly urged to report them voluntarily since useful lessons can be learnt. As observed earlier, many people do not like to discuss hazardous incidents which have occurred to them because they feel it might make them look silly in the eyes of others, especially when it involves an element of human failure. This simple fact of life is appreciated, and for this reason it has been agreed that as far as it is possible reports of hazardous incidents will be treated in confidence if the person making the report wishes it to be so. It is worth mentioning that the aviation industry has a Confidential Human Factor Incident Reporting Programme, known as CHIRP, which is highly successful.

Many people appreciate the benefits which are obtained by sharing their experiences with others. Although MAIB receives quite a number of hazardous incident reports (206 in 1991) it is probable that many more incidents actually take place. In some cases there might be a reluctance on the part of seafarers to voluntarily report incidents to Government bodies such as MAIB. The non-Governmental organisations who share our concern over hazardous incidents include the Nautical Institute and the newly formed Sea Safety Group. Both these organisations have recently initiated hazardous incident reporting schemes of their own, and each is unique in the way that they are administered. Seafarers might feel more inclined to report their experiences to such independent bodies rather than MAIB. MAIB recognise the value of both these schemes because they serve the same ends as our own, namely that any useful lesson which can be learnt and which could conceivably prevent an accident occurring in the future should be promulgated as widely as possible. We all need to work together in accident prevention.

Details of how to report hazardous incidents to MAIB and what we would wish to see reported are contained in Merchant Shipping Notice number M.1383. Please help us in our endeavours to improve safety of life at sea.

Chief Inspector of Marine Accidents

August 1992

1. COLLISION BETWEEN A RO-RO VESSEL AND A SEA ANGLING BOAT

An in-bound 42,000 gross registered tonnage ro-ro cargo vessel was approaching the Sunk light vessel from an east-south-easterly direction. She was proceeding at slow speed and steering to pass to the east and then the north of the light vessel to embark her pi 1ot .

Several small boats engaged in sea angling were anchored a few cables south-east of the light vessel. It was daylight with visibility about 1 mile. There was little wind and the sea was nearly calm. The tide was flooding at about 1.5 knots in a south-westerly direction.

As the cargo vessel approached the light vessel the tide set her on to one of the anchored boats and her port side collided with the boat’s bow. The angling boat sustained only minor damage and continued fishing. The cargo vessel was undamaged and there were no injuries.

Observations

1. At the time of the collision those on the bridge of the cargo vessel were unaware she had collided with another vessel, the Master and the Officer of the Watch being on the starboard bridge wing.

2. As the cargo vessel slowed down the effect of the tide on her increased.

3. The boatman took no action to avoid the collision.

4. Another small boat anchored further to the north cut her anchor warp and so avoided collision with the cargo vessel.

Cornment

1. With a south-westerly set, the preferred manoeuvre for the cargo vessel would have been to pass to the south of the light vessel. However this option was precluded by the small boats at ahchor.

2. Manoeuvring to pick up a pilot does not relieve a vessel of the requirement to maintain a proper lookout contained in rule 5 (Look-Out) of the Collision Regulations. Equally, vessels at anchor should maintain an efficient lookout at all times and particularly in busy waters or restricted visibility.

3. Clearly the cargo vessel had an obligation to keep out of the way of a vessel at anchor by the ordinary practice of seamen; however, where the circumstances permit, a vessel at anchor should take some action to avoid the collision, for example by slipping her anchor and attempting to get underway.

4. The Sunk light vessel is a busy pilot station handling the largest of vessels. Unnecessary anchoring close to the station is un-seamanlike and presents a needless hazard for large vessels manoeuvring to pick u p a pilot, particularly in reduced visibility and with strong tides. It is also un-seamanlike t o anchor close to a light vessel, or to any navigational mark.

2. ACCIDENT WITH A SHIP’S SIDE CARGO RAMP

This incident took place on a palletised cargo vessel which was alongside a conventional berth. The vessel was to discharge pallets of food stuffs, using forklift trucks by way of the two side cargo doorways of the ship.

T h e doors when open formed the ramps for vehicles to enter the holds, one door forward and one aft. The holds had two levels and the ramps could be raised o r lowered to the required height. The ramps were moved by two single part wires at the inboard ends whilst the outboard ends were supported by two further single part wires; these were also used to pull the doors into the closed position. When the ramps were in use, the outboard ends rested on the quay.

Before commencing discharge, two forklift trucks were to be put on board on the upper deck level. This was to be achieved by driving the forklift trucks on to one of the ramps and then raising it to the required level - a distance of about 3 metres. T h e forklift trucks each weighed about 3 tonnes and the ramp when static was rated for a load of 18 tonnes.

T h e forklift trucks were driven on to the inboard end of the ramp and parked side by side, off centre towards the aft side of the ramp. The ramp was then raised and when it had travelled about 1.5 metres the aft lifting wire parted. The ramp tilted and the two forklifts toppled over. The two drivers had been sitting on their machines. O n e was thrown off the ramp and fell on to a pontoon fender between the ship’s side and the quay, luckily he only suffered severe bruising; the other driver fell between the forklifts, but he was not injured.

Observat ion s

1. The ramps were not designed to lift loads. The vessel was provided with 3 tonnes SWL hoists to move weights between decks.

2. According to the ship’s Lifting Gear Register the ramp wires and other equipment had been inspected annually. The ramp had also been statically load tested six months previous to the accident.

3. Inspection of the failed wire rope at a specialist ropeworks showed that there was a high percentage of broken wires and evidence of corrosion, rust, external abrasion and flattening of strands.

4. The construction of the doors allowed part of the inboard operating wires to be exposed to the effects of sea water when the doors were in the closed position.

Commerit

1. The ramp should not have been used for lifting the forklift trucks.

2. Moving the forklifts with their drivers riding on the machines is a dangerous practice.

3. Equipment which is used frequently or in arduous conditions should be given thorough examinations at more frequent intervals than an annual inspection. The manufacturer's maintenance instructions should be followed. In this case they recommended that the wires be inspected and preservative and lubricant applied as necessary, every month.

4. The "Code of Safe Working Practices for Merchant Seamen", Chapter 17 gives clear guidance on the use of lifting plant.

3. ENGINE ROOM FIRE

A 1,583 gross registered tonnage bulk carrier/general cargo vessel was outward bound in ballast after its annual drydock and repair period. Considerable main engine work had been carried out including the conversion of the fuel system from diesel oil operation to heavy fuel operation.

Amongst the requirements for this conversion was the changing of the main engine fuel injectors from uncooled nozzles to water cooled nozzles. A reputable local firm undertook this work, and not being able to get the replacement nozzles from its normal supplier, obtained a supply from another source. The re-built injector assemblies were successfully pressure tested, (including spares), and then returned t o the vessel for installation.

During dockside engine trials, fuel oil was found to have contaminated the cooling water in the fuel valve cooling header tank. The cooling system was drained down, refilled and all main engine fuel injectors re-tested. Two injectors were found to be defective; leaks occurring between the fuel and water sides of the injector assembly. The injectors were replaced, engine trials completed and the vessel sailed later that evening. The following morning, the fuel valve cooling system low pressure alarm sounded. A low water level in the header tank gauge glass suggested lack of water in the system.

The fresh water filling line was opened, but the header tank overflowed almost immediately showering a mixture of oil and water down over the main engine exhaust trunking and indicating further trouble with the fuel injectors. A check of the header tank gauge glass valves showed them to be shut.

The main engine was stopped at 1048 hours for repairs and the testing of fuel injectors. During this work, water was seen leaking from the fuel inlet pipe indicating a leak between the water and fuel sides of an injector. Repair work continued on the main engine for about one hour when suddenly flames appeared in the region of the main engine exhaust lagging at engine top level. The fire and smoke spread rapidly causing the Chief, Second and Third Engineers to hurriedly leave the engine room.

The crew were mustered, all the engine room vents closed, and the remote fuel pump stops and fuel tank valve trips operated. Carbon dioxide was released into the sealed engine room at 1155 hours. The emergency generator cut in automatically and provided lighting and power for the emergency fire pump. Access doors were checked for overheating and boundary cooling carried out on local hot spots. Coastguards and Owners were informed of the situation. At 1400 hours two crewmen wearing breathing apparatus and protective clothing re-entered the engine room and reported that the fire appeared to be out although the space was still full of smoke and very hot. The space was monitored at hourly intervals by the crew wearing breathing apparatus and protective clothing. At 1700 hours it was confirmed that the space was cooling down, smoke was slowly dissipating and there was no further risk of re-ignition.

At 1815 hours a tug took the vessel in tow arriving off the port at 0800 hours and alongside at 1318 hours the following day.

Observations

1. The cause of the fire was the impregnation of the main engine exhaust lagging with fuel oil resulting from the overflow of the fuel valve cooling water header tank situated immediately above the exhaust line. Residual heat in the main engine exhaust system led to spontaneous ignition, despite the engine having being shut down one hour earlier.

2. The actions of the crew on the outbreak of fire, the methods adopted to contain and extinguish the fire, and the monitoring of the situation prevented the incident developing into a serious engine room fire; and the damage was limited to the effects of heavy smoke, heat damage to electrical wiring and various items of control equipment. The failure of the engineering staff to check the gauge glass valves before topping up the header tank indicates a basic lack of attention to detail.

3. The sensible use of both the self-contained breathing apparatus and the smoke helmet enabled the state of the engine room to be monitored without unnecessary risk despite the presence of carbon dioxide and smoke.

4. The initial testing of the fuel injectors was carried out by a reputable firm following accepted pressure testing procedures which would normally identify faulty components and/or assemblies. The action taken by the engineering staff on the discovery of fuel oil in the header tank during engine trials was correct. All defective fuel valve injectors were replaced and the cooling water within the system changed.

Comment

1. The failure of engineering staff to clean up the spillage of fuel oil and water, albeit a small quantity, resulted in an engine room fire and disablement of the vessel. This emphasises the essential need for sea staff to maintain safe working practices at all times.

2. Although the new water cooled nozzles were stated to have been manufactured to the required specifications, when sectioned longitudinally through the middle, it was seen that incorrect drilling of the water passages had produced a very thin wall thickness between the high pressure fuel oil side and the low pressure water side. Subsequent usage of the injector in the engine with its normal cyclic hydraulic pressure stresses, caused a fatigue failure in the separation wall and contamination of the water cooling system. This manufacturing defect would not be detectable by normal testing procedures and illustrates the importance of quality control during the manufacturing process. Furthermore, in as much as the choice was dictated by spare part delivery times, it demonstrates the importance of good forward planning and advisability of using only genuine manufacturers items.

3. This incident is a positive illustration of the importance of training in fire fighting including the use of breathing apparatus. Given the complexity of the modern engine room and the reduction in crew levels, it is essential that all crew members are familiar with the fire fighting equipment onboard and with the correct method of its operation.