MAIB Safety Digest 2/2009

SAFETY Marine Accident DIGEST Lessons from Marine

Investigation branch Accident Reports 2/2009

is an MARINE ACCIDENT INVESTIGATION BRANCH

INVESTOR IN PEOPLE

SAFETY DIGEST Lessons from Marine Accident Reports No 2/2009

is an MARINE ACCIDENT INVESTIGATION BRANCH

INVESTOR IN PEOPLE

© Crown copyright 2009

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 Mountbatten House Grosvenor Square Southampton SO15 2JU

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. August 2009

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 Mountbatten House, Grosvenor Square, Southampton, SO15 2JU.

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 information which has 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, Mountbatten House, Grosvenor Square, Southampton, SO15 2JU

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 2009

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. No Room For Mistakes 10 2. Chemical Cocktail Calamity 13 3. Mussel Bound! 16 4. Wrong Input – Wrong Outcome 21 5. Get it Right First Time 23 6. A Very Sad Open and Shut Case 25 7. Not All Fires in Furnaces Are Desirable 27 8. Nothing Happened and Nobody Noticed 31 9. Beware Loose Electrical Connections 33 10. Turn Too Late 36 11. Fatal Consequences of a Caught “Chafer” 39 12. Full Ahead or Full Astern? 43 13. Trials Can Be Trying 45 14. Gone in a Trice 47 15. Not the Perfect End to an Evening on the River 48

Part 2 – Fishing Vessels 52 16. Fishing Boat Sunk by Mound of Clay! 54 17. Tragedy Resulting From Crewman Standing in Bight 57 18. Scallop Dredger Capsize and Sinking – “Be Prepared” 60 19. Burning the Candle at Both Ends? 64 20. Beware the Bight 66 21. Fast, and it all Happened so Fast 68

Part 3 – Small Craft 72 22. Flare Up 74 23. Kill Cords and Lifejackets – Your Tools for Survival 77 24. Stuck on a Cill 80 25. Well Equipped – Well Done 82

APPENDICES 84 Appendix A – Preliminary examinations and investigations started 84 in the period 01/03/09 to 30/06/09 Appendix B – Reports issued in 2009 85

Glossary of Terms and Abbreviations AB – Able seaman Hz – hertz ARPA – Automatic Radar Plotting Aid LPG – Liquefied Petroleum Gas AVR – Automatic Voltage Regulator LSA – Life Saving Appliance C – Celsius m – metre Cable – 0.1 nautical mile “Mayday” – The international distress signal CCTV – closed circuit television (spoken) CO2 – carbon dioxide MCA – Maritime and Coastguard Agency CPA – Closest Point of Approach MGN – Marine Guidance Note CPP – Controllable Pitch Propellers MRCC – Maritime Rescue Co-ordination DSC - Digital Selective Calling Centre ECR - Engine Control Room MSDS – Material Safety Data Sheet EEBD - Emergency Escape Breathing MSN – Merchant Shipping Notice Device OOW - Officer of the Watch EPIRB - Emergency Position Indicating OSV – Offshore Supply Vessel Radio Beacon PPE – Personal Protective Equipment ETO - Electro Technical Officer RIB – Rigid Inflatable Boat FRC - Fast Rescue Craft RNLI – Royal National Lifeboat Institution GPS - Global Positioning System Ro-Ro – Roll on, Roll off GRP - Glass Reinforced Plastic RYA – Royal Yachting Association GT – Gross tonnes SDS – Safety Data Sheet HP – Horsepower VHF – Very High Frequency HRU – Hydrostatic Release Unit VTS – Vessel Traffic Services

Introduction This edition of the Safety Digest contains a number of important safety lessons. None of them is new, but they all need re-emphasising; please ensure you think about the lessons, and take the appropriate precautions, to safeguard your own life and those of your crew: • Case 4 – which is of note to fishermen as well as merchant seafarers – is a classic over reliance on technology. Technology provides a wonderful aid to seafarers, but does not replace the application of professional knowledge and good seamanship. In this case, the visual aspect of the other vessel, and its relative vector on radar, should have alerted the OOW and the master to the fact that the ARPA was dangerously in error. Do not blindly take information from electronic aids at face value! • Case 6 is another example of a seafarer tragically being killed by a watertight door. MAIB has just published its report into a similar fatality on board Eurovoyager (www.maib.gov. uk/publications/investigation_reports/2009/Eurovoyager.cfm). Companies and masters must ensure that watertight doors are always operated in ‘local’, except in an emergency, and all seafarers must adhere to the correct procedures for passing through such doors. • Cases 17 and 20 are stark reminders of the dangers posed by bights. Everyone must take extra care when working ropes and wires, and ideally a supervisor should be free to watch out for everyone’s safety. • Cases 17, 18, 21 and 23 clearly demonstrate that lifejackets are no use if they are not worn. Even having them “readily to hand” is rarely enough, as accidents often happen without warning. I would ask everyone to read the heartfelt first-hand account (see page 52) of a skipper who, earlier this year, watched one of his crew die for want of a lifejacket. Modern lifejackets can be worn without encumbrance – please make sure that everyone on deck in a fishing vessel or other small craft routinely wears one. Within a short time, they will become as routine as wearing seatbelts in cars. • Cases 18 and 21 show how important liferafts are, and the importance of fitting them, even if they are not a legal requirement. In both cases, it is likely that the crew would have died if it hadn’t been for their liferafts. • Finally, Case 25 is a good news tale. In a leisure angling boat, which had no legal requirement for any safety equipment, a man's life was saved by wearing a lifejacket and because the boat carried a VHF radio and flares.

Stephen Meyer Chief Inspector of Marine Accidents August 2009

A note to our readers: please be aware that our address has changed to: MAIB, Mountbatten House, Grosvenor Square, Southampton SO15 2JU Our telephone/fax numbers remain unchanged

MAIB Safety Digest 2/2009 7

Part 1 – Merchant Vessels The MAIB strives to another mooring operation etc. But can share with us all the experience serve to desensitise as well? – hard learned lessons I think so. I can see in this ‘Digest’ examples of others to help of where experienced professionals have been make our daily work caught out by years of ‘feedback’ which is onboard that bit safer; saying to them subconsciously “routine we all need to go operation, no past incidents, low risk”. This home in at least as can then lead to reduced vigilance or even to good a condition as other tasks being inappropriately prioritised. when we joined the ship. Reading the articles in this edition of the ‘Complacency’. It’s an ugly word isn’t it? ‘Digest’ again illustrates the challenge we all Definitely uncomfortable. It is a word however face in delivering consistently safe operations that describes the trap of falling into a onboard our ships. There is no magic bullet desensitised routine operation where you may that will cure all our ills; it is simply a matter make some assumptions about the outcome of persistent commitment to safe working without really thinking it through. You don’t practices by all of us whether ashore or at sea, think you need to think it through, you’ve day and night. done it lots of times before, you know how it will work out, or the other guy has always The one thing that strikes me about all the done what he was supposed to, and it’s been articles is that there are no new risks in there. OK before hasn’t it? There is nothing that we haven’t seen before, but that is not to belittle the people involved – So how do we break out of that cycle? Well, “there, but for the grace of God, go I”. So what I am sure you will get a list as long as your arm is it that lies behind these incidents? Could from the all embracing ‘safety culture’ through I venture the word ‘complacency’? It feels to its separate components, but the one thing pretty uncomfortable doesn’t it? So, what does that we can all do is revisit some of these that word mean to me in our industry, let’s routine tasks and try to work out where they explore that a bit… could go wrong – a ‘risk assessment’. That risk assessment might identify inadequacies in Knowledge and Experience are two very vessel design, in equipment, in operating different things. Knowledge is academic and procedure or in the competencies required for learnt in the classroom, Experience is gained an activity. Once identified, we are in a position on the job, doing the job. Experience provides to start doing something about it, BUT, only if us with real life ‘feedback’, we get actual it is a robust, ‘from the heart’, risk assessment. sensations and feelings not available in the If we take any other approach to it and get a classroom. The time we had our first near miss tick in the box, we will have only served to on the bridge as junior navigators will be steepen the slippery slope of complacency. crystal clear to us even today – mine certainly is! Experiences like that work for the better in So, if I am going to hang my hat on risk the future, we have become sensitised to assessment as a good place to start, what particular situations and we are more alert to would my one piece of advice be? It would be them in the future; we become more cautious Think, Think, Think. When you do a risk or vigilant. But, what about an operation that assessment is it a piece of paperwork that is we have conducted dozens, maybe hundreds, put together to ‘allow’ an operation to go of times and have experienced no problems ahead, one that you are going to do anyway during it, for example – going alongside a because ‘you have to’, is it used to justify the familiar berth, doing another boat drill, plan you had or the way you already do it?

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At this point it is vital that the ship’s staff are of complacency and we need a good buddy to properly encouraged and supported by their pull us back. Think, Think, Think, what are the shore based colleagues. Was the risk real risks, how I could get hurt, how could this assessment carried out by people who go ‘pear-shaped’, what can I do to look after understand the risks and have the necessary my shipmates? experience (it’s the double edged sword; does experience = near miss scare, or, experience Next time you fill in a confined space entry = nothing ever goes wrong)? Do you really permit, tick the boxes in the arrival/departure push hard to consider all the things that could checklist, or carry out a risk assessment, think go wrong if you had a really bad day? Have you about who you are doing that for – it should done it to keep yourself and your colleagues be you and your family. free from harm? Oh! Before I go, that near miss you still have The MAIB is part of our industry, their role is etched in your memory. Have you shared it non-judgemental, they don’t seek to apportion with others and used it to explain why a blame or prosecute; their one objective is to particular behaviour or practice is so important make the world of the seafarer safer. If, like to you now. Share your “good” experience, me, you are a regular reader of the ‘Digest’ not the bad. and dive straight into the articles, I need not encourage you further. If however, you are Stay safe. new and have got to me early on, then I encourage you to keep going and really reap the benefits of this publication produced for the benefit of all, by our colleagues.

And, finally, I would ask you all to look after each other. We are all fallible, fragile human beings, not machines. We can have bad days when our experience takes us down the road

Captain Robert W. Fleming MNI Started as a Navigating Cadet with BP Tanker Company in 1971 serving in crude and product tankers worldwide. A period with BP Exploration & Production saw service on a semi-submersible in the North Sea and then a two year shipyard period with a new build dynamically positioned offshore production vessel. In 1989 Bob came ashore into the BP Shipping office and has progressed through various roles including marine manager, safety manager, vetting manager, DPA & CSO. He is also a non-executive director of MENAS (Middle East Navigation Aids Service), a member of the Honourable Company of Master Mariners, a Younger Brother of Trinity House and a member of the Nautical Institute.

MAIB Safety Digest 2/2009 9

No Room For Mistakes Narrative equipped with azimuth stern thrusters and a bow thruster, but the bow thruster fitted to An offshore supply vessel (OSV1) and a sister OSV1, which was the easterly of the two vessel (OSV2) moored stern to stern vessels, was defective. As OSV2 was available alongside the south side of a tidal basin to assist if required, the master of OSV1 (Figure 1), were instructed to exchange decided not to request the attendance of a berths by the port control. Each vessel was harbour tug.

Figure 1

OSV2 slipped, manoeuvred into the centre of who was keeping a lookout astern. The bow of the basin, and then proceeded astern. During OSV1 was soon influenced by the 10-15 knot this manoeuvre, OSV1 also let go all ropes, and south-easterly wind and was blown towards as soon as OSV2 was on the port beam, went the centre of the basin. To check this astern (Figure 2). At this point the master of movement, the master moved to the forward OSV1 was controlling the vessel’s propulsion control station and adjusted the stern azimuth from the aft-facing control station. He was units. accompanied on the bridge by the chief officer,

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Figure 2

The bow moved back towards the quay, but movement. However, the vessel did not the vessel’s stern then started to swing respond as expected, and OSV2 was too rapidly towards a number of small pleasure distant to assist. As a result, the port quarter craft moored alongside a ro-ro link span on of OSV1 made contact with the small the north side of the basin (Figure 3). pleasure craft and the link span. Three Alerted by the chief officer, the master again pleasure craft sank (Figure 4) and three moved to the aft control station and others were damaged. The link span was put adjusted the azimuth units to arrest this out of action for several weeks.

Figure 3

MAIB Safety Digest 2/2009 11

Figure 4

The Lessons can be misplaced. Tugs are invariably built for purpose, and their crews are 1. Moving berths is a routine task