MAIB Safety Digest 2/2005

MARINE ACCIDENT SAFETY DIGEST Lessons from Marine

INVESTIGATION BRANCH Accident Reports

is an

INVESTOR IN PEOPLE

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 2/2005

is an

INVESTOR IN PEOPLE

Department for Transport Eland House Bressenden Place London SW1E 5DU Telephone 020 7944 3000 Website: www.dft.gov.uk

© Crown copyright 2005

This publication, excluding any logos, may be reproduced free of charge in any format or medium for research, private study or for internal circulation within an organisation. This is subject to it being reproduced accurately and not used in a misleading context. The material must be acknowledged as Crown copyright and the title of the publication specified.

Further copies of this report are available from: MAIB Carlton House Carlton Place Southampton SO15 2DZ

Printed in Great Britain. Text printed on material containing 100% post-consumer waste. Cover printed on material containing 75% post-consumer waste and 25% ECF pulp. July 2005

MARINE ACCIDENT INVESTIGATION BRANCH

The Marine Accident Investigation Branch (MAIB) is an independent part of the Department for Transport, the Chief Inspector of Marine Accidents being responsible directly to the Secretary of State for Transport. The offices of the Branch are located at Carlton House, Carlton Place, Southampton, SO15 2DZ.

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 facts which have been determined up to the time of issue.

This information is published to inform the shipping and fishing industries, the pleasure 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 available. The articles do not assign fault or blame nor do they determine liability. The lessons often extend beyond the events of the incidents themselves to ensure the maximum value can be achieved.

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

The Editor, Jan Hawes, welcomes any comments or suggestions regarding this issue.

The Safety Digest and other MAIB publications can be obtained by applying to the MAIB.

If you wish to report an accident or incident please call our 24 hour reporting line 023 8023 2527

The telephone number for general use is 023 8039 5500.

The Branch fax number is 023 8023 2459. The e-mail address is maib@dft.gov.uk

Summaries (pre 1997), and Safety Digests are available on the Internet: www.maib.gov.uk

Crown copyright 2005

MARINE ACCIDENT INVESTIGATION BRANCH

The role of the MAIB is to contribute to safety at sea by determining the causes and circumstances of marine accidents, and working with others to reduce the likelihood of such causes and circumstances recurring in the future.

Extract from The Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”

INDEX GLOSSARY OF TERMS AND ABBREVIATIONS 6

INTRODUCTION 7

PART 1 – MERCHANT VESSELS 8 1. Don’t Just Watch it Happen 10 2. The Sitting Duck 11 3. A Perennial Hazard 13 4. Acid Attack! 14 5. Timber Deck Cargo – on the Move 16 6. Poor Planning Leads to Over Extended Stay – on the Beach 18 7. The Dangers of High Speed Loading 20 8. In Hot Water 21 9. A Not So Soft Bottom 22 10. Some Good Fortune – Only a Burned Out Clutch 24 11. Do You Check Your Wires? 26 12. Collision Involving a General Cargo Vessel and a Fishing Vessel 27 13. A Cook, Live Electrical Wires, a Wet Galley Deck – all the Ingredients 30 Needed for a Shocking Day 14. Don’t Pass on Bends 31 15. A Close Call 33 16. Whiteout 36

PART 2 – FISHING VESSELS 39 17. Not a Stroll in the Park 40 18. Stability Aware? 42 19. Corrosion, What Corrosion? 44 20. ‘It Just Went off in my Hand Chief!’ 46 21. Elevated Work, Elevated Risks 47 22. Two Fires, a Flood and a Foundering 49

PART 3 – LEISURE CRAFT 51 23. Knockdown and Total Loss off the Portuguese Coast 52 24. Lucky Escape as Spring Hook Fails During Hoisting of a Tender 53 25. Don’t Underestimate the Familiar 55

MAIB NOTICEBOARD 57

APPENDICES 58 Appendix A – Preliminary examinations started in the period 01/03/05 – 30/06/05 58 Investigations started in the period 01/03/05 – 30/06/05 58 Appendix B – Reports issued in 2005 59

Glossary of Terms and Abbreviations AB – Able Seaman ARPA – Automatic Radar Plotting Aid CO2 – Carbon Dioxide CPA – Closest Point of Approach DSC – Dangerous Goods, Solid Cargoes and Containers EPIRB – Emergency Position Indicating Radio Beacon GPS – Global Positioning System GRP – Glass Reinforced Plastic IMDG – International Maritime Dangerous Goods Code Mayday – Spoken distress signal MCA – Maritime and Coastguard Agency MCR – Machinery Control Room MGN – Marine Guidance Notice OOW – Officer of the Watch PAN – The international urgency system RNLI – Royal National Lifeboat Institution SWL – Safe Working Load VHF – Very High Frequency

Introduction In the few months since the last Safety Digest, pilots; it is available on our website: there have been over 500 accidents or incidents www.maib.gov.uk. The other, referring to a reported to the MAIB. Many of the root causes recent tragedy involving a rigid inflatable boat, is of these accidents are depressingly familiar. All of reproduced in our “Noticeboard” at page 57. If us, as mariners, need to remind ourselves of why either of them may affect you in any way, please we take precautions and why we put in place take the time to read them. safety checks and balances. It is all too easy at sea to become complacent; but when short-cuts are The main lesson from all accidents is: keep alert, taken or safety checks skipped due to familiarity, think carefully about what you are doing and be we have to recognize that we are becoming prepared for the unexpected. In that way, we can dangerous. Reading the accounts in this Safety all return home safely. Digest should remind all of us that we work in an inherently dangerous environment, where a lack of attention or forethought can be fatal.

In May 2005, the MAIB issued two Safety Bulletins, to get urgent safety messages out. One, referring to three recent accidents involving tugs Stephen Meyer manoeuvring ships, is of particular interest to tug Chief Inspector of Marine Accidents operators and crews, harbour authorities and August 2005

MAIB Safety Digest 2/2005 7

Part 1 – Merchant Vessels General awareness is an essential part of carrying out any task at sea, but all too often the consequences of failure to plan, consider all the risks, and then continually monitor, leads to damage of equipment, collision, grounding or, worse still, injury or a fatality.

A smaller number of cases show us incidents caused by the ‘rule breaker’. These are people who know what they are supposed to do, have been trained to do it properly, but break the rules Communicating successfully with those at sea on on their own initiative to complete a job. When any matter has always been an issue, and the questioned afterwards, many of these people MAIB Safety Digest is one of the most effective genuinely believe they are doing this to help the ways of communicating and sharing information company, or they think it is how the company on safety issues. The staff at the MAIB are actually wants them to do the job. In well run committed to safety at sea, and their companies, these accidents are sometimes the investigations are aimed at finding the lessons to most difficult to accept, and the most difficult to be learnt from an incident, rather than simply address. finding fault. The Safety Digest allows readers to review their own procedures and learn lessons To address these issues, senior staff, ashore and from the mistakes of others. I fully recommend afloat, must be pro-active in training, supervising that these cases are reviewed to see if they could and ensuring that rules are adhered to. This does be applicable to your own operation or ship. not mean a dictatorial approach, but a safety culture where there is good leadership, good Accident investigation is not an easy task, it is communication, continuous improvement and a time consuming, and there is often a natural no-blame culture. The exchange of information tendency for those involved to be defensive, across the industry is essential in assisting us in especially if they have to admit to failings this, and I commend these case studies to you as themselves. It remains a fact that human error part of this process. accounts for the majority of accidents. Only by proper investigation and openness by those involved can we avoid repeating mistakes that cause accidents and, in the worst cases, fatalities.

The incidents reported in this edition of the MAIB Safety Digest again show how those at sea must constantly be aware of what is going on around them, and the hazards involved if things do not go as planned. It is pleasing to see one report (Acid Attack) where the awareness and prompt actions of a crewman, followed up by pre- planned emergency procedures, prevented a major incident. Unfortunately, a number of reports indicate the opposite, and show a general lack of awareness by the seafarers for what is going on around them. The consequences of this are clearly illustrated in the reports.

8 MAIB Safety Digest 2/2005

Stuart Greenfield is Director, Maritime Affairs for Carnival Corporation & plc based in Southampton, Hampshire. The Carnival group operates a total of 78 cruise ships under 12 different brands.

Stuart went to sea with the Peninsular and Oriental Steam Navigation Company (P&O S N Co) as a group deck cadet in 1974 serving on all types of vessels, and in 1978 was appointed to the Passenger Ship Division as Third Officer. He continued to serve on the cruise ships until 1992 when he became Deputy Marine and Safety Manager for P&O Cruises, based in Southampton.

In 1994 he progressed to Marine and Safety Manager, and at the demerger of the cruise division from P&O S N Co in October 2000, was appointed Head of Maritime Affairs for the new company P&O Princess Cruises. At the merger with Carnival Corporation he assumed a similar role for the dual listed company Carnival Corporation & plc.

He represents Carnival on panels at the UK Chamber of Shipping and assists in work at IMO as either an International Council of Cruise Lines representative, or advising flag states. He has recently been appointed to the advisory board of the Confidential Hazardous Incident Reporting Programme (CHIRP), and is a council member of the Nautical Institute.

MAIB Safety Digest 2/2005 9

Don’t Just Watch it Happen Narrative The master, who was on watch, witnessed the accident and immediately altered course. He While on passage, two deckhands were then released the man overboard smoke float, instructed by the master to prepare the vessel’s sounded the general alarm and transmitted a steel uprights for the next deck cargo, but not to PAN alert on the radio. The rescue boat was fit them. The weather conditions were good with launched, and the deckhand was safely retrieved a force 3 wind and slight sea, but overnight rain on board within 15 minutes. had left the hatch covers wet.

The uprights were rusty, and the two deckhands decided, on their own initiative, to make sure they still fitted into the slots on the hatch coaming. This proved difficult, and caused one of the deckhands to slip and fall overboard.

The Lessons 3. The consequences of this accident could have been far worse if, for example, the 1. The master had specifically instructed deckhand had struck his head while the deckhands not to fit the steel falling overboard, or if the master had uprights. However, they chose to ignore been looking elsewhere at the time. Such his instruction; something the master tasks should be avoided, if possible. was aware of yet chose to do nothing However, where there remains an about. unacceptable risk of someone falling overboard, suitable control measures An instruction is of no value unless it is should be employed, such as the use of implemented. In this case, a risk of safety lines or working lifejackets. someone falling over the side had been identified. The control measure was not to fit the steel uprights. The control measure was overridden, and an accident ensued.

2. The master’s reaction, and that of the crew, immediately following the fall overboard was swift and effective in enabling the deckhand to be recovered from the water quickly, and demonstrated the benefit of regular drills.

10 MAIB Safety Digest 2/2005

The Sitting Duck Narrative the fishing vessel on his port side. However, by that time, the fishing vessel’s skipper had become A cargo vessel was overtaking a fishing vessel. anxious that the cargo vessel was taking Both were on a south-easterly heading. It was insufficient action, and had altered course to daylight with good visibility and a slight sea. starboard.

The fishing vessel was trawling at about 2.5 Recognising the resulting risk of collision, the knots. The cargo vessel was on passage and OOW then altered course to port with the making good about 14 knots. The cargo vessel’s intention of leaving the fishing vessel to OOW saw the fishing vessel on his port bow at starboard. Unfortunately, the fishing vessel about 3 miles range. The fishing vessel was skipper, concerned by the cargo vessel’s previous displaying her daytime fishing signal and, as the alteration to starboard, altered course to port at cargo vessel approached, her trawl lines were the same time. clearly visible. Again, the OOW recognised the resulting risk of The cargo vessel’s OOW recognised his collision and, again, altered to starboard, obligation of keeping out of the way, and altered eventually passing about 0.3 mile astern of the course to starboard with the intention of leaving fishing vessel.

1st course alterations 2nd course alterations 3rd course alteration

Ca rg o Ve sse l

Fis hin gV es se l

0.3mile

Not to scale

MAIB Safety Digest 2/2005 11

The Lessons 2. If a stand-on vessel needs to take earlier action in an overtaking situation, it 1. A stand-on vessel in an overtaking follows that the give-way vessel needs to situation is probably at her most take earlier action than would otherwise vulnerable. Rule 17(a)(i) requires her to be the case. The same degree of maintain her course and speed and, magnitude needs to be applied to any although Rule 17(b) instructs her to course or speed alterations. In other take action when collision cannot be words, any alteration of course or speed avoided by the action of the give-way needs to be large enough, and taken early vessel alone, this is unlikely to be enough, to be readily apparent to the effective in an overtaking situation. stand-on vessel that sufficient action is Reliance must therefore be placed on being taken without need for the stand- Rule 17(a)(ii), which provides an option on vessel to consider having to take any for her to take action as soon as it action of her own. becomes apparent that the give-way vessel is not taking appropriate action in In this case, a large and early alteration compliance with the Rules. However, for of course by the cargo vessel would have the above reason, this option needs to be avoided any unnecessary confusion and taken far earlier in an overtaking concern, and the enhanced risk of situation than in most others. collision that resulted.

12 MAIB Safety Digest 2/2005

A Perennial Hazard Narrative The Lesson

A survey vessel, operating offshore, came Injuries, caused by weight suddenly coming alongside a mooring buoy in order to recover it. on to ropes, have happened for almost as A seaman used a grapple to recover the buoy’s long as men have gone to sea. All seamen line and hauled it to the bulwark, where he made should be aware of the dangers but, as is the grapple fast. seen here, even the best can be caught out. Vigilance and awareness is the seaman’s only He then noticed that the line had taken a riding defence. turn on the grapple hook, and attempted to free it by hand. As he did so, relative movement between the buoy and the ship suddenly put weight on the line. This trapped three of the seaman’s fingers, leading to the loss of their tips.

MAIB Safety Digest 2/2005 13

Acid Attack! Narrative Eleven minutes after the initial sighting, the decontamination team, now fully dressed in A ferry had just left her berth when a member of chemical suits and breathing apparatus, was sent the forward mooring team saw a leakage from a to investigate. As the team entered the vehicle, vehicle carrying hazardous cargo on the fore they realised that the scene inside was not as deck. The incident was immediately reported to described by the driver. The drums had been the bridge and the fore deck was evacuated. loosely stowed on pallets and had not been Ventilation was stopped and two teams began shrink-wrapped. Several drums were laid on their donning chemical suits and breathing apparatus. sides and not vertically stowed. On re-stacking Meanwhile, the driver of the vehicle was traced the fallen drums, the team identified the rogue and the substance identified as Phosphoric Acid drum. Meanwhile, the spillage was diluted with a Liquid, UN