MAIB Safety Digest 2/1993

MARINE ACCIDENT INVESTIGATION BRANCH

Summary of Investigations No 2/93

Marine Accident Investigation Branch 5/7 Brunswick Place SOUTHAMPTON Hants S O 12 A N

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 becomes available.

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

Crown copyright 1993

INDEX Page No.

Introduction

Collision with Jetty 1

Flooding of an Offshore Support Vessel 2

Hull Damage during Cargo Loading Operations 3

Collision between a Gas Carrier and a Sail Training Yacht 4

Hydraulic Cargo Hoist Failures on Ro-Ro Ferries 6

Engine Room Fire at Sea 7

Unsafe Hot Work in Port 8

Flooding and Recovery of 16 Metre Fishing Vessel 9

Flooding and Beaching of a Small Fishing Vessel 10

Loss of a Small Single Handed Fishing Vessel 11

Overloading of a Small Fishing Boat 12

Poor Maintenance Resulting in Flooding Incidents on Two Fishing Vessels 13

Benefits of Survival Courses 15

Injury to Crew Member in Engine Compartment 16

Engine Compartment Fire at Sea 17

Flooding and Sinking of a Fishing Vessel 19

An example of the Benefits of Sea Survival Training 21

Sinking Fishing Vessel 22

Appendix A - Investigations Commenced in the Period 01/04/93 - 31/07/93

Appendix B - MAIB Priced Publications available from HMSO

INTRODUCTION

No apologies are made for the fact that in this edition of the Summary of Investigations no less than eleven of the eighteen summaries concern fishing vessels. Accidents to fishing vessels and those on board account for well over fifty percent of the work of the Branch so there is plenty of material from which to select the summaries.

Only one of the eleven incidents resulted in loss of life, but loss of property and earnings and costs of repairs must have been considerable for the others.

A number of the incidents have common factors. There are many useful lessons to be learnt from reading the accounts: perhaps the most striking, which should be driven home loud and clear, is the need for the right equipment - and that it must be kept in good order. No less than seven of the reports point out the need for a bilge alarm; and in three of the seven an alarm was fitted but it did not function.

But it is not only bilge alarms which need to be well maintained. All equipment on board, whether it be the main propulsion system, the fuel system, the fishing gear, life- saving equipment, even galley equipment, needs to be maintained in first-class condition. Equipment which is allowed to fall into disrepair or on which faults are not rectified create hazards for all concerned which can have either disastrous or costly consequences. This message of course applies not only to fishing vessels but to all vessels, irrespective of type and size.

Chief Inspector of Marine Accident

August 1993

1. COLLISION WITH JETTY

An 825 gross registered tonnage coastal tanker, registered in the UK, was fitted with a rotary vane electro-hydraulic steering gear. The two hydraulic pump units installed were each capable of being operated either singularly or in parallel. The hydraulic oil output from the pumps is directed into the appropriate rotary vane port by solenoid pilot valves. These valves are controlled from three locations; the wheelhouse steering console, by a remote wandering lead and locally at the pump. Auto-pilot control of the steering gear was also available.

The vessel, which was fully loaded with fuel oil products, left the oil terminal berth in the early hours of the morning. The projected course was to cross the harbour and then proceed seawards parallel to a disused jetty. At the time of departure the Master and the Chief Engineer were in the wheelhouse with No 2 steering gear hydraulic pump running - no steering gear test had been carried out prior to departure. During the passage across the harbour, the Chief Engineer went below whilst the steering gear hydraulic pumps were changed over from No 2 to No 1 unit. The vessel's speed at this time was about 6 knots. When the Master applied port helm to maintain his course parallel to the disused jetty, there was no immediate response. Increased port helm was applied, but the vessel swung rapidly to starboard causing her to collide with the jetty. Although damaged, the vessel was able to return to her original berth, discharge cargo and proceed to the dry dock for repairs.

Observations

Examination of No 1steering gear, showed the solenoid pilot valve to be faulty, giving rise to erratic operation and loss of control. This erratic operation is thought to have been due to foreign bodies in the hydraulic fluid combined with wear within the valve assembly.

Testing of the steering gear prior to departure would probably have identified the problem and prevented the loss of steering control. Similarly, the use of both steering gear hydraulic pumps during the passage in confined waters would have prevented this incident.

Comment

Testing of steering gears prior to the commencement of a voyage is addressed in the Merchant Shipping (Automatic Pilot and Testing of Steering Gear) Regulations 1981. In the case of coastal vessels making frequent voyages, testing of the steering gear before departure on each voyage should form part of the normal operational procedures. The Regulations also require that in areas where navigation demands special caution, the Master shall ensure that the ship shall have more than one steering gear power unit in operation when such units are available and capable of simultaneous operation.

2. FLOODING OF AN OFFSHORE SUPPORT VESSEL

A 52 metre offshore safety standby vessel was operating with a crew of 12 in very severe weather conditions. The wind strength was recorded as up to Force 12. A section of the vessel’s starboard bulwark was carried away by the seas about mid afternoon. During the early evening, with the weather still severe, a list of some 15 to starboard was noticed. Because of the weather conditions no inspection of the weather deck could be carried out, but an internal inspection found flooding within the survivor accommodation on the starboard side. The depth of flooding prevented opening of the bilge valve in the space.

Assistance was requested from the Coastguard and other vessels in the area. The majority of the crew were evacuated by helicopter.

The Master corrected the list by partial deballasting and by pumping out the flooded space using a portable emergency pump. The vessel eventually reached port under her own power.

Observations

External inspection, performed in port, established that an air vent to the survivor accommodation had been carried away, thus opening this space to any seas breaking over the deck. As this vent was in the same area as the damaged bulwark it was concluded that the damage to the bulwark and air vent probably occurred at the same time.

Comment

Although an inspection of the weather deck at the time of the bulwark damage was impossible, any damage to the vessel’s structure should have been assessed as soon and as far as was practicable. In this case ingress of water into the accommodation spaces should have been very quickly and easily identified by the simplest of internal inspections. This would have allowed the bilge valve for the space to be opened before flooding became serious, so enabling the crew to control the situation from the start of the incident.

3. HULL DAMAGE DURING CARGO LOADING OPERATIONS

A single hold general cargo vessel of 1,326 gross registered tonnage loaded a cargo of irregularly shaped scrap steel. On leaving the loading berth and making her way outward, but before reaching the sea, the vessel developed a slight but increasing list to starboard. Although the weather conditions were good the Master immediately returned to a loading berth and concurrently took onboard soundings. It was very quickly established that the main hold was flooding, but the ship's bilge system had no difficulty in coping with the ingress of water and the vessel was able to be moved to a repair berth.

Closer inspection revealed that the side shell plating of the vessel had been holed, most probably due to impact by a sharp heavy piece of scrap during the loading operation.

Observations

It was a standard practice of the Master for all cargo space bilge systems to be inspected and tested after discharge and before loading any type of bulk cargo. The value of this practice, which is set out in the IMO "Code of Safe Practice for Solid Bulk Cargoes'' (BC Code), was clearly demonstrated in this case. Had it proven to be impossible to pump out the bilges of the hold, the vessel could have been in serious difficulties.

Comment

Another recommendation contained within the BC Code is that bilges should be sounded on the completion of loading; an operation which was not performed in this case.

4. COLLISION BETWEEN A GAS CARRIER AND A SAIL TRAINING YACHT

A 1,367 gross registered tonnage gas carrier was steering a course of 250 (T) at a speed of 9 knots in the western English Channel. A 10 metre sail training yacht, on a cruise from a west of England port to the Channel Islands, was steering a course of 122 (T) at a speed of about 6 knots. It was a fine summer night with a moderate breeze from the south-west and good visibility.

From the gas carrier, a red light was sighted about three points on the starboard bow and at close range. Course was altered to port. When the ship's head had reached about course was altered back to starboard. Collision occurred when the ship had almost regained her original heading, with the yacht crossing ahead.

From the yacht, the steaming lights of the gas carrier were seen about three points on the port bow showing a green sidelight. After twenty minutes the lights appeared to be two and a half points on the bow. It was thought that the ship would pass about a mile ahead of the yacht. A little later the lights, which were now at close range, became obscured from the cockpit by the sails and the dinghy on the cabin top. The collision followed.

In the collision, the port bow of the ship struck the port quarter of the yacht. The yacht was dismasted, extensively damaged and started to flood. Pyrotechnic distress signals were used: these enabled the ship to locate the yacht and all seven of her crew were taken on board, one having suffered a fractured thumb. They were later transferred to an RNLI lifeboat and landed ashore. The gas carrier, which was undamaged, subsequently resumed her voyage. The yacht, although later salvaged, was a constructive total loss.

Observations

The radar on the gas carrier was only being used for navigational purposes on a high range scale. For collision avoidance, the lookout being kept was a visual one by the Officer of the Watch and the navigating watch rating.

The required minimum range of visibility of the navigation lights shown by the sail training yacht was one mile.

There were seven people on board the sailing training yacht: the Skipper, who held a Coastal Skipper Certificate, the Mate, the Bosun and four trainees.

Although the Skipper was aware of the approaching ship, he had gone below and handed over the con to one of the inexperienced trainees with another youngster, who was suffering from seasickness, detailed to keep a lookout. The yacht took no action to avoid the collision.

Comment

1. The gas carrier was clearly the give-way vessel, but she failed to see the yacht until the vessels were already close to one another. At that late stage the action taken was grossly inappropriate and ineffective.

2. The yacht, although initially required to maintain course and speed, was permitted under Rule 17 of the Collision Regulations to take action herself, when it became apparent that the other vessel was not doing so. The Skipper should have been on deck, hands should have been called to stand by to handle the sails and efforts should have been made to draw attention, for example, by using the signalling lamp both to call up the other ship and to illuminate the sails.

3. When the situation had developed further and collision could not be avoided by the action of the give-way vessel alone, the yacht was required, also by Rule 17, to take such action as would best aid in avoiding the collision. This she could have done by putting the helm hard over to starboard into the wind, allowing the ship to pass to the south.

4. This collision could have had tragic consequences. It illustrates the vital necessity of proper lookout by all available means and appropriate action in ample time to avoid collision.

5. HYDRAULIC CARGO HOIST FAILURES ON RO-RO FERRIES

Incidents involving the failure of hydraulic cargo hoists have been investigated. In four cases the main actuating cylinders have failed allowing hydraulic cargo hoists to fall uncontrollably to their lowest positions. In these cases the cause of failure has been the sudden fracture of all the set screws holding down the stuffing box of the hydraulic ram and bulk release of hydraulic fluid.

Observations

Investigations have shown that the failure in turn was due to over extension of the cylinder ram travel resulting in metal to metal contact and fatigue of the set screws because of:

1. Malfunction of electrical limit switches due to poor maintenance.

2. Absence of any mechanical stops designed and installed to limit the travel of the hydraulic ram.

Comment

Against this background it is appropriate to draw attention to the Merchant Shipping (Hatches and Lifting Plant) Regulations 1988 and its various provisions with regard to the design, testing, service and maintenance of the cargo hoist plants of vessels and the records to be kept on board for inspection. The relevant Regulations are numbers 7 to 10, and further detailed guidance is provided in Chapter 17 of the "Code of Safe Working Practices for Merchant Seamen" (1991 edition).

6. ENGINE ROOM FIRE AT SEA

A 1,409 gross registered tonnage motor tanker was on passage in ballast when at 2030 hours the Chief Officer noted smoke issuing from the engine room skylights. The fire alarm was sounded and the crew mustered to their emergency stations. At about the same time, the Second Engineer left the engine room to report a severe fire on the main engine exhaust manifold.

At 2033 hours the Chief Engineer shut down the engine room ventilation fans and tripped the main engine fuel valves. Instructions were given to close all vents etc and an unsuccessful attempt was made to put out the fire by directing a portable foam extinguisher onto the fire from the engine room access. The main engine stopped approximately 3 - 4 minutes after closure of the fuel valves. The Chief Officer and an AB then entered the engine room wearing self contained breathing apparatus and tackled the fire locally with portable foam extinguishers. The fire was extinguished at 2040 hours.

A Pan message was sent at 2042 hours, but after the smoke had cleared and an inspection by the Chief Engineer and Chief Officer had been carried out, the Pan message was cancelled at 2059 hours. The main engine exhaust cladding was removed and No 3 unit cylinder head was found to have been blowing excessively. The fuel pump for this unit was removed and at 2310 hours the vessel continued her voyage to the UK at reduced revolutions.

Observations

1. No injuries to the crew or damage to the machinery have been reported.

2. This incident was probably brought about by hot exhaust gases leaking from No 3 cylinder head igniting dust, dirt and oily residues on the main engine exhaust trunking.

3. The subsequent actions of the crew in fighting the fire were correct and may well have prevented a more serious fire developing.

Comment

The watchkeeping and also the maintenance standards practised on this vessel must be in question. A cylinder head leaking to the extent that it causes a fire, is both very noisy and obvious to an efficient watchkeeping engineer. In the event that the leak had been reported, then particular vigilance in that area of the engine room should have been called for.

7. UNSAFE HOT WORK IN PORT

A standby/diving support vessel was in port undergoing repair. Hot work was being undertaken in a tank located adjacent to an accommodation space. The work generated a gradual increase of heat in the divisional bulkhead linings which eventually caught fire. The fire was subsequently extinguished by the shore fire brigade.

Observations

1. There were no resultant injuries to personnel but fire damage extended throughout the accommodation and into the wheelhouse.

2. Linings had previously been removed from the immediate area of the divisional bulkhead in which hot work had been intended.

3. The fire water main on board was not readily available for use.

4. Although a fire watch patrol was in process, no person was assigned to specifically oversee the progress of the hot work concerned.

5. The ship manager and the shore contractor did not have a clear agreement as to who was responsible for fire watchkeeping.

Comment

1. Chapter 13 of the "Code of Safe Working Practices for Merchant Seamen" (1991 edition) and Merchant Shipping Notice No M.957 highlight the precautions which should be taken prior to and during welding and flamecutting operations.

2. Merchant Shipping Notice No M. 1267 specifically addresses fire prevention and fire fighting aboard ships in port and emphasises the need for ship and shore staff to establish clearly defined instructions and practices.

8. FLOODING AND RECOVERY OF 16