MAIB Safety Digest 2/2008

SAFETY Marine Accident DIGEST Lessons from Marine

Investigation branch Accident Reports 2/2008

is an MARINE ACCIDENT INVESTIGATION BRANCH

INVESTOR IN PEOPLE

SAFETY DIGEST Lessons from Marine Accident Reports No 2/2008

MARINE ACCIDENT INVESTIGATION BRANCH

is an

INVESTOR IN PEOPLE

© Crown copyright 2008

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 2008

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.

If you do not currently subscribe to the Safety Digest, but would like to be added to the distribution list for hard copies, and/or email alerts about it or other MAIB publications, please get in touch with us: • By email at maibpublications@dft.gsi.gov.uk; • By telephone on 023 8039 5500; or • By post at: Publications, MAIB, Carlton House, Carlton Place, Southampton SO15 2DZ.

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 2008

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

Introduction 7

Part 1 – Merchant Vessels 8 1. Crew Response Prevents Major Fire 10 2. Too Fast a Swing 13 3. Hot Spots and Oil Sprays: a Lethal Cocktail 16 4. Faulty Interlocks and Structural Corrosion 19 5. Down the Hatch – Make Sure You Come Out Again 22 6. ‘Shock’ Horror! 24 7. Main Boiler Chemical Clean Ends in Fatal Explosion 26 8. Less Distraction – More Reaction 31 9. Beware of Hydraulics 33 10. Doing it all Yourself 35 11. Tell Me About It 37 12. Maintain Your Automatic Release Hook 39 13. What Goes Up, Mustn’t Go Down… 43 14. ESD Valves – Are Your Tests Effective? 45 15. Box Clever – Know the Limits 48 16. A Knotty Problem 50

Part 2 – Fishing Vessels 54 17. Small Hole – Costs a Life 56 18. Complacency Kills 58 19. Even a Short Time in the Sea Can be Fatal 60 20. Mystery Fire Sinks Potter 63 21. Insecure Fiddle Leaves Crewman in Hot Water 65

Part 3 – Leisure Craft 68 22. Keel Failure Leads to Loss of Life 70 23. Wayfarer Sailors Have Narrow Escape 73 24. Great Fun Until it all Goes Wrong 75 25. Safety Briefing Saves the Day 76

appendices 78 Appendix A – Preliminary examinations started in the period 01/03/08 to 30/06/08 78 Appendix B – Reports issued in 2008 79

Glossary of Terms and Abbreviations 2/O – Second Officer AB – Able seaman ARH – Automatic Release Hook ARPA – Automatic Radar Plotting Aid C – Celsius Cable – 0.1 nautical mile CPR – Cardio Pulmonary Resuscitation CSM – Cargo Securing Manual DPA – Designated Person Ashore DSC – Digital Selective Calling ESD – Emergency Shut Down FRC – Fast Rescue Craft GPS – Global Positioning System GT – Gross tonnes HGV – Heavy goods vehicle HP – Horsepower HRU – Hydrostatic Release Unit ISM – International Safety Management Code kg – kilogram kW – kilowatt LNG – Liquefied Natural Gas m – metre “Mayday” – The international distress signal (spoken) MBL – Minimum Breaking Load MOB – Man Overboard MSN – Merchant Shipping Notice OOW – Officer of the Watch “Pan Pan” – The International Urgency Signal (spoken) pH – Symbol representing potential for hydrogen. The measure of the acidity/alkalinity of a solution QM – Quartermaster RIB – Rigid Inflatable Boat RNLI – Royal National Lifeboat Institution Ro-Ro – Roll on, Roll off SMS – Safety Management System SOLAS – International Convention for Safety of Life at Sea SWL – Safe Working Load VHF – Very High Frequency VTS – Vessel Traffic Service

Introduction Hindsight is a wonderful thing!

Every week in the MAIB, we are briefed on the latest accidents and incidents that our teams are investigating. In virtually every case, as the incident unfolds in front of us, we can see what is going to happen. You can feel an air of disbelief in the room that the players in the accident can’t see it coming and don’t step in to stop it.

The prime purpose of the Safety Digest is to use the hindsight provided by other incidents to arm you with the foresight to avoid accidents yourself. All of us who go to sea – for work or for pleasure – believe accidents happen to other people, never to us. Thankfully accidents are relatively infrequent, so few of us have first-hand experience to warn of the hazards lurking. Regular readers of the Safety Digest tell me that it provides them with an invaluable reminder every 4 months of the dangers of seafaring.

Complacency is one of the greatest threats to the mariner. Much of what we do – planning, navigation, watchkeeping, maintenance, shooting and recovering fishing nets, cargo handling – is repetitive. When these tasks become routine, they become dangerous. Please take time to read the cases in this edition of the Safety Digest. Remind yourselves of the hazards that are lurking. Are you being as safety conscious as you could be? Do you have things in place to ensure that none of these accidents could happen to you? As I say, hindsight is a wonderful thing – let's use it with these cases to stop accidents in the future.

MULTIPLE DEATHS

Just as I finished drafting this introduction (11 June) news came in to the MAIB of two seamen unconscious in a ballast tank on board Saga Rose in Southampton. Tragically one of the two died.

We are also currently investigating the deaths of three seamen on board Viking Islay on 23 September 2007 and two seamen on board Sava Lake on 18 January 2008; all died after entering enclosed spaces. A similar upsurge of enclosed space fatalities is being reported around the world.

Please, please, please ensure that procedures for entry into enclosed spaces are absolutely rigorously applied in your ship.

Stephen Meyer Chief Inspector of Marine Accidents August 2008

MAIB Safety Digest 2/2008 7

Part 1 – Merchant Vessels I am very pleased to this opportunity to publicly praise them. have been asked to Unfortunately, what people do tend to write this remember when thinking about the Port of introduction as I Southampton is the link to one of the most hope that my small tragic maritime accidents in history, namely the contribution will loss of the RMS Titanic. encourage people to read the accident Ninety-six years ago the Titanic sank with the summaries that loss of over 1500 men, women and children. follow and learn the This accident led to a real focus being placed lessons that upon maritime safety and the result was a inevitably come from them. The purpose of number of significant improvements, both in this publication and the more detailed MAIB overall awareness and in technological investigation reports is not to identify who is developments. Yet I wonder whether the real to blame but, more importantly, why accidents lessons have ever been learnt, I venture to have happened and how they could have been suggest that the sinking of the Titanic does not prevented. Whilst we all benefit from our own really fit comfortably within the definition experiences I suggest that there is great merit mentioned earlier. Clearly the sinking of the in benefiting from the experiences of others, Titanic was unintentional, but, could it really and there are some salutary lessons detailed be that proceeding in an area where an within this particular Digest. encounter with ice was probable, at a speed of 22 knots, a resulting accident could be An accident may be defined as something considered unexpected? which happens unexpectedly and unintentionally and which often damages Fast forward to the present; is it really something or injures someone. Therein lies a unexpected when people suffer death or key lesson that I believe is often missed and serious injury from entering enclosed spaces which the MAIB publications serve to highlight. without following the correct procedures? By way of explanation I offer the following. There are two such examples within this Digest. Would you really be surprised if As the Harbour Master of Southampton I am communication techniques and equipment did proud to be associated with the past and not perform as planned when they have not present glories of this magnificent Port, a Port been fully tested in the work environment? where there has always been and where there There is an example within this Digest. We all continues to be a focus upon providing safe know the importance of the pilot/master and efficient marine operations. The efforts of exchange and the clear need for passage the professionals who make up the marine planning to include berth to berth transit, team at Southampton go largely unnoticed by again there is an accident report linked to this the general public and therefore I shall take within the Digest.

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There are further summaries within this Digest accidents are unexpected? Once again I associated with fatigue, bridge team suggest that it is time to start learning from management, acting in haste and repenting at the experiences of others, it is time to start leisure, failures in maintenance and putting in place measures that minimise the communications; the list is all too familiar. potential for incidents and it is time to learn that we must expect the unexpected. So we come full-circle. If the modern day list Reading and remembering the contents of of accidents and their causes is familiar and this Digest might be considered a good place recognisable can it really be that future to start.

Captain Philip Holliday Captain Philip Holliday, 40, commenced his seagoing career as a 16 year old cadet when he joined Ropner Shipping Services. After a five year period he moved to Souter Shipping, where he served for a similar amount of time before gaining his Class 1 (FGN) Masters certificate. A spell at University saw him gain a 1st class BSc (Hons) degree in Business Information Studies and then came a move into port operations when he joined Associated British Ports (ABP) in 1998. Having undertaken a number of roles within ABP, including that of Marine Manager for the ABP South Wales Ports, he currently works as both the Harbour Master for the ABP Port of Southampton and the ABP Marine Advisor, fulfilling the functions of the Designated Person for ABP’s twenty one UK ports. Philip has taken the lead role representing ABP in areas such as developing industry guidelines for Port Marine Safety, regulating the standards associated with Vessel Traffic Services and ensuring ABP remains compliant with the requirements of the Port Marine Safety Code. Philip is married with two young children.

MAIB Safety Digest 2/2008 9

Crew Response Prevents Major Fire Narrative while the chief engineer took charge of the other. Wearing breathing apparatus, one team A ro-ro ferry was on passage without cargo or entered the engine room via a pipe tunnel passengers when a fire alarm was activated in from forward and the other through the the engine room. Moments later, the main control room. Both teams were able to locate engine stopped, electrical supplies were lost the source of the fire at the main engine and it and the vessel blacked out. was soon put out using portable dry powder extinguishers. The engine room fixed fire- The crew mustered on the bridge and the fighting system was available, but was not chief engineer went to the engine control used. room to investigate. Dense black smoke escaped as he opened the control room door, The fire had caused serious damage to the so he shut it quickly, realising that the fire was main engine, so the vessel was towed to a serious. Despite struggling in the thick smoke repair port. The Designated Person Ashore emitting from the engine room ventilation (DPA) was informed and began an ducts on the upper deck, the crew managed to investigation immediately. The investigation shut the fire flaps and seal off the air supply to determined that the fire was caused by a the fire below. fracture in a low pressure pipe that supplied fuel to the main engine. Although it was made The master transferred command to the mate of steel and supported by clamps at regular and prepared to lead one fire-fighting team, intervals, a section of fuel pipe approximately

Figure 1 – Burst fuel pipe

10 MAIB Safety Digest 2/2008

Figure 2 – One metre from the start of the fire

Figure 3 – Port side of main engine under deck

MAIB Safety Digest 2/2008 11

100mm long had become detached. Pre- and numerous fittings on the deck head were heated fuel oil had then spilt between the two destroyed. banks of the V configured main engine and, despite splash guards being in place, ignited. The investigation by the company rightly praised the prompt and determined response The fire caused severe damage in an area of of the crew, whose efforts certainly prevented 6m radius around the fractured pipe. Engine a serious fire from escalating dangerously. controls, the governor, cables, a turbocharger

The Lessons 4. Fire flaps can be awkward to close, particularly when dense black smoke is 1. In this case, the master courageously pouring out of them. Managers and crew decided to lead the attack on the fire should satisfy themselves that flaps can himself. It is up to the master on a case- still be operated safely, even with smoke by-case basis to decide whether coming out of ventilation openings. personally to lead a team that is responding to such a danger, or whether 5. The team re-entered the engine room his experience is better utilised in without protection from fire hoses or overseeing and co-ordinating the whole water mist. This left firefighters and the operation. rest of the ship more vulnerable to the effects of heat, and increased the risk of 2. Fuel and lubrication pipework should be the fire flashing over as entrances to the inspected regularly and replaced if there compartment were opened and fresh air are signs of any leakage or wear. was introduced.

3. While it is always good practice to clamp pipework securely, clamps must fit correctly so that they do not introduce more stresses into the pipework.

12 MAIB Safety Digest 2/2008

Too Fast a Swing Narrative either misheard or misunderstood the pilot and applied 50° of helm. After boarding a 2000gt dry cargo ship, a harbour pilot discussed with the vessel’s The ship started to turn quickly to port and master his plan for the vessel’s first entry to the pilot was not aware of the amount of helm the port, which was accessed from the open the master had applied. As the ship sea via a 30m wide river. During the discussion, approached the intended heading, the pilot the pilot was not made aware of the type and recommended 20° of starboard helm to steady performance of the vessel’s rudder, nor was he the vessel, but this had no immediate effect. shown the vessel’s pilot card or wheelhouse Maximum starboard helm was then poster which were displayed on the bridge. recommended and applied and, although the rate of turn reduced, it was evident that the The approach to the entrance of the river was ship was leaving the navigable channel. The made on a course of 355° at a speed of 10 engine was put to full astern and the bow knots, aiming to leave a beacon