MAIB Safety Digest 2/2007

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 2/2007

is an

INVESTOR IN PEOPLE

Department for Transport Great Minster House 76 Marsham Street London SW1P 4DR Telephone 020 7944 8300 Web site: www.dft.gov.uk

© Crown copyright 2007

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: Marine Accident Investigation Branch First Floor, Carlton House 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 2007

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 2007

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. Crew Prevents Disaster 10 2. All Secure Alongside? 12 3. Obey the 5P Rule – Prior Planning Prevents Poor Performance 15 4. Pyrotechnic Pandemonium 17 5. Follow Procedures – Don’t Rely on Your Memory! 18 6. Corrosion – The Hidden Enemy 20 7. A Question of Control 22 8. A Bridge Too Low 25 9. Shore Worker Dies in Onboard ‘Base Oil’ Fire 28 10. Keep Your Eye on the Passage 30 11. Break Out 32 12. Ferry Comes to a Grinding Halt 34 13. Overloaded Gangway 36 14. Look Before ...........! 38 15. Under Tuition 39 16. Slippery When Wet 40 17. A Turn for the Worse 41

PART 2 – FISHING VESSELS 42 18. Crush Stop! 44 19. Better to be Safe Than Sorry 47 20. A Rude Awakening 49 21. Poor Beam Trawler Practice Costs Three Lives 52 22. In Drink and in the Drink 54

PART 3 – LEISURE CRAFT 56 23. Fatal Injuries From Propeller 58 24. Mind Your Fingers 60 25. A Change of Mind 61

MAIB NOTICEBOARD 64

APPENDICES 66 Appendix A – Preliminary examinations and investigations started in the period 01/03/07 to 30/06/07 66 Appendix B – Reports issued in 2007 67

Glossary of Terms and Abbreviations 3/O – Third Officer 2/O – Second Officer AB – Able Seaman ARPA – Automatic Radar Plotting Aid CO2 – Carbon Dioxide ECS – Electronic Charting System EPIRB – Electronic Position Indicating Radio Beacon FRC – Fast Rescue Craft HMPE – High Modulus Polyethylene HSC – High Speed Craft HSE – Health and Safety Executive ISM – International Safety Management Code kN – kilo Newton MCA – Maritime and Coastguard Agency MGN – Marine Guidance Notice MNTB – Merchant Navy Training Board OOW – Officer of the Watch PPE – Personal Protective Equipment SOLAS – International Convention for the Safety of Life at Sea TSS – Traffic Separation Scheme VDR – Voyage Data Recorder VHF – Very High Frequency VTS – Vessel Traffic Services

Introduction In our Safety Digests, we always group our cases into 3 generic sections: Merchant Vessels; Fishing Vessels; and Leisure Craft. However, I would urge you all, as seafarers, to look at each of the sections, as there are lessons for every one of us in all sections. In this edition: Case 20 involves a fishing vessel and a merchant ship; Case 22 could apply to any seafarer; Case 25 involves a motor yacht and a high speed craft; and the “noticeboard” on pages 64 & 65 contains a flyer that was produced for the leisure industry, but that should be read by all. More information on this accident, and lessons for merchant vessels, can be found in the full report on our website www.maib.gov.uk.

One of the recurring themes of many of the most serious accidents is seeing and being seen:

The case for keeping a good lookout is overwhelming. Regardless of who you are, it is essential that you keep a keen visual lookout and, where fitted, a good radar watch. With closing speeds now of 20 or 30 knots, and with an ever wider utilisation of the sea, OOWs, skippers and helmsmen cannot afford to lower their guard. Make sure your radar is well adjusted, and that your visual lookout regime is right, particularly in darkness, poor visibility etc.

But there is an equal responsibility to be seen, particularly in smaller vessels. Radar is not the universal panacea that some believe; small contacts (including quite large yachts and fishing vessels) will not necessarily be seen, particularly in choppy seas. Some lights, e.g. yacht sidelights, have a visibility range requirement of only 1 mile; these visibility ranges can be further reduced by crazing of the lenses or by the vessel heeling. In many cases they will not be seen in a large ship before it is too late. It makes sense to invest in a good radar reflector, and to have a powerful light to hand to draw attention to yourself in good time.

Please use the enclosed tales of others’ misfortunes, to ensure that you stay safe.

Stephen Meyer Chief Inspector of Marine Accidents August 2007

MAIB Safety Digest 2/2007 7

Part 1 – Merchant Vessels It gives me great not sufficient for ship and shore personnel to pleasure, as Chairman be technically competent; they must also have of the Merchant Navy the skills to ensure that operating standards Training Board are established and maintained at a level (MNTB), to be asked commensurate with the risks inherent in to provide the shipping activities. We also see in these introduction to the incidents examples of good leadership and Merchant Vessels training serving to mitigate the effects of an section. incident.

Since its inception in 1937, the MNTB has Leadership and management are areas that existed as the UK shipping industry’s body for have not necessarily received the same level of developing and promoting the training and training as technical competence. The MNTB qualification of seafarers. has recently moved to degree level training with a Foundation Degree as the main entry Today, the MNTB is the authoritative centre of route and prime Officer Trainee programme, expertise and information on careers, and has used this opportunity to place greater qualifications, training opportunities, training emphasis on leadership and management as provision and skill needs and issues in the an integral part of this programme. industry. The MAIB Safety Digest enables us all to see The MNTB brings together shipping examples of what can so easily go wrong; good Employers, Trade Unions, Training Institutions leadership will take these lessons and embed and the MCA to ensure that the Merchant Navy them into daily shipboard operations. suite of certificates and qualifications meets the needs of industry, regulator and seafarers.

The work of the MAIB in identifying and publishing the causes of incidents provides valuable information which assists in identifying areas of deficiency in training. It is only by understanding the causes of accidents and incidents – and taking action on the findings – that we can continue to improve safety at sea.

Most incidents are preventable. They are the result of a chain of events that can be broken by properly trained people operating good equipment with appropriate working practices and procedures.

Many of the incidents in this edition of the Safety Digest are the result of poor (or no) risk assessment, or complacency when performing familiar operations. To prevent this requires good leadership – onboard and within shipping company and port management. It is

8 MAIB Safety Digest 2/2007

Nigel Palmer, OBE

Captain Palmer commenced his career at sea as a Cadet with BP Tanker Co. in 1967 and served on a variety of ship types before attaining command in 1984. He subsequently gained experience in a number of shore appointments before attending Business School in London and Japan in 1988.

He was seconded in 1991 to the Australian North West Shelf LNG Project in Tokyo and Melbourne, returning in 1997 to BP Shipping in the UK to head up the Operations Group, with responsibility for the management of 30+ Oil, Gas & Offshore vessels. From August 2002 he became Director, Group Marine Assurance and subsequently Government & Industry.

Following retirement from BP Shipping in 2004 he continues to be involved in the shipping industry, and formed his own company in 2005 providing general industry marine advice.

Captain Palmer has been Chairman of the Merchant Navy Training Board since 2000 and the Maritime Skills Alliance (which brings together the Merchant Navy, Ports, Fishing and Leisure industries on maritime training issues) since its formation in 2004. He is a Trustee of the Slater Fund, CHIRP and the Shipwrecked Mariners Society and sits on the Boards of Glasgow and Cork Nautical Colleges. He is also a member of the Sea Vision UK National Core Group. Captain Palmer has just received an OBE in the Queen’s Birthday Honours list.

He lives in Felixstowe, Suffolk and is married with three adult children. Hobbies include sailing and golf.

MAIB Safety Digest 2/2007 9

Crew Prevents Disaster Narrative began to escape, and the chief engineer shut the door tightly, while the master told the A tug boat crew had come on duty shortly mate to get the boat alongside as quickly as before midnight to escort a container vessel to possible. sea from her berth in a busy UK port. The master, mate and chief engineer didn’t Once alongside, the chief engineer shut the normally sail together and were providing remote fuel valves and machinery space cover over the summer leave period. While ventilation flaps while the master requested preparing the assigned tug, the chief engineer assistance via the local VTS station. The mate found a defect on the salt water system that checked the ventilation flaps and closed other could not be rectified quickly, so the crew doors, while the master and chief engineer decided to use a relief vessel instead. The tug discussed operating the CO2 drench system. escorted the container vessel safely and With the engine room door getting hotter, headed back to her berth with the mate at the both agreed that the CO2 drench should be helm. activated.

Close to the berth, the fire alarm activated on The crew evacuated to the jetty, where the fire the bridge, and the master and chief engineer brigade was arriving. Using fire plans taken went below to the damage control cabinet. from the tug, the master and chief engineer The alarm panel indicated that a fire had been briefed the fire officer. Hoses were rigged, but detected in the upper engine room. The were not required as the CO2 took effect, and engine room door was only slightly warmer in the early hours of the morning fire officers than normal, so the master undid the upper re-entered the engine room wearing breathing dog and cracked the door open. Thick smoke apparatus. The fire was confirmed as being

Fuel injector spill return pipe and associated fittings

10 MAIB Safety Digest 2/2007

extinguished, but a main engine fuel spill engine. In an attempt to prevent earlier return pipe was found to be broken, and fuel problems of fuel dilution of the main engine was seen to be draining back into the engine lubricating oil, a non return valve had been room from the service tanks above. fitted in the spill line close to the engine, and the return pipework terminated in a Further investigation identified that the fuel gooseneck at the top of the service tank. injector spill return pipe had not been fitted Unfortunately, the failure occurred correctly. Several compression fittings had downstream of the non return valve, and with been used in a very short run of pipe to the base of the gooseneck immersed in the accommodate valves and changes to the pipe’s fuel tank, a siphon allowed fuel to drain back diameter. The pipe was inadequately down to the seat of the fire, despite operation supported and exposed to vibrations from the of the remote fuel shut off valves.

The Lessons 3. Although the fuel injector spill return was a low pressure system, its failure 1. The crew acted promptly and correctly, allowed fuel to leak onto hot, main rightly earning a commendation from the engine components, causing the fire. All senior fire officer on the scene for fuel system pipework should be properly preventing a more serious fire and, mounted and use appropriate fittings to indeed, probably saving the vessel. minimise the risk of failure.

2. The company’s recognition that crews 4. Once the pipework had broken, fuel changed frequently and used differently could drain under gravity from the configured vessels had prompted it to service tanks onto the fire below, despite instigate a formal familiarisation operation of the emergency fuel shut off programme. This ensured that the crew valves. All pipework to and from fuel knew where all the necessary equipment tanks should be examined to ensure that, was located and how to use it properly, if the fuel shut off valve has to be despite not working together or using operated, fuel can not drain out by other this particular vessel regularly. means.

MAIB Safety Digest 2/2007 11

All Secure Alongside? lite To shore mooring buoy ee St tra Ex m m 44 6t 14

To mooring dolphin

.9t m 67 28m Dynex lite Stee

55t 56mm line 8 Fyba 30 t mm ne 40 Movli

Mooring arrangement

Narrative backed up on the bitts. On the forward mooring deck a 28mm HMPE rope on a A ro-ro ferry approached port after an captive winch drum was employed as a breast uneventful passage. The ship called port line; a 56mm polyester mix rope on a captive control, who gave the wind as 15-20 knots winch was also used as a breast line; a 40mm from the north-west, well within the limits for nylon rope, which normally acted as a forward berthing safely. The ship entered the port and spring, was used as an additional breast; and, moored port side to, on a north-by-east finally, a 44mm HMPE rope was used as a head heading. The ship was secured with four lines line. The two ropes were again secured by forward and four lines aft. Cargo discharging round turns on the drum end, backed up on via the stern door commenced at 1830. the bitts.

The vessel’s mooring arrangement consisted The bridge was left unattended but the master of two mooring winches forward and two aft, and chief officer returned regularly to monitor with captive drums and drum ends. However, the weather. At 2020 the master noticed the the types of lines employed for securing the wind increase in strength to a steady 25 knots vessel differed significantly. On the aft mooring from the NW, with 35 knots gusts. This deck, a 28mm wire rope on a captive drum surprised the master slightly as the forecast was used as a spring; a 28mm HMPE1 rope on had given a mean wind speed of 20 knots the other captive winch drum was used as a increasing to 22 knots by midnight. He breast line; a second breast and stern line were ordered the main engines and bow thrusters 56mm polyester mix rope and both were to immediate notice, and he and the chief secured by round turns on the drum end, officer remained on the bridge. High Modulus Polyethylene

12 MAIB Safety Digest 2/2007

At 2105 there was a gust of 45 knots recorded by port control. This caused a mooring line to part on the foredeck and the captive winches started to pay out, slowly at first, then quickly. The master ordered the engines to be started