MAIB Safety Digest 2/2015

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accidents No 2/2015

is an

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October 2015

MARINE ACCIDENT INVESTIGATION BRANCH

The Marine Accident Investigation Branch (MAIB) examines and investigates all types of marine accidents to or on board UK vessels worldwide, and other vessels in UK territorial waters.

Located in offices in Southampton, the MAIB is a separate, independent branch within the Department for Transport (DfT). The head of the MAIB, the Chief Inspector of Marine Accidents, reports directly to the Secretary of State for Transport.

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 receive an email alert about this, 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: MAIB, First Floor, Spring Place, 105 Commercial Road, Southampton, SO15 1GH

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 email address is maib@dft.gsi.gov.uk

Safety Digests are available online www.gov.uk/government/collections/maib-safety-digests

© Crown copyright 2015

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 2012 – Regulation 5:

“The sole objective of the investigation of a safety investigation into an accident under these Regulations shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of such 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 1

PART 1 - MERCHANT VESSELS 2

1. Rule 13* – Unlucky For Some 4

2. Uninsulated Exhaust Leads to Boat Loss 9

3. Blind Pilotage 11

4. Changing the Plan Alters the Risk 13

5. Overlook, Overfill, Overflow, Overboard 15

6. Unsupervised Mooring Operation Proves Fatal 18

7. Retain Control to Achieve Your Goal 20

8. Assess the Risk and Maintain the Controls 23

9. No Pitch = No Steering! 26

10. The Weakest Link 28

11. The Unaware Meets the Unqualified 30

12. Lack of Maintenance Can Result in You Coming Unstuck 33

13. Messenger Rope Kills Ship’s Carpenter 35

14. Mirror, Signal, Manoeuvre 37

15. A Bridge Too Near 40

16. From Rags to Riches 42

PART 2 - FISHING VESSELS 44

17. Three Lives Lost When Angling Boat Capsizes 46

18. Carbon Monoxide – the Silent Killer 48

19. Got a Screw Loose? 50

20. Flood, Flood, Flood 53

21. Bilge Alarms: Disconnect at Your Peril 55

22. Singled-Handed Fishing Needs Proper Planning 57

PART 3 - SMALL CRAFT 60

23. Family Boating Trip Ends in Tragedy When Engine Kill Cord Was Not Used 62

24. Wayfarer Capsize in January 65

25. The Case for Clear Communications 67

APPENDICES 69

Investigations started in the period 01/03/15 to 31/08/15 69

Reports issued in 2015 70

Safety Bulletins issued during the period 01/03/15 to 31/08/15 71

Glossary of Terms and Abbreviations AB - Able seaman MCR - Machinery Control Room AED - Automated External Defibrillator MOB - Man Overboard AIS - Automatic Identification System MSN - Merchant Shipping Notice ALB - All-Weather Lifeboat OOW - Officer of the Watch ARPA - Automatic Radar Plotting Aid PFD - Personal Flotation Device BA - Breathing Apparatus PMS - Platform Management System C - Celsius PPE - Personal Protective Equipment CCTV - Closed Circuit Television RA - Risk Assessment CO - Carbon Monoxide RIB - Rigid Inflatable Boat COLREGS - International Regulations for the RNLI - Royal National Lifeboat Institution Prevention of Collisions at Sea 1972 Ro-Ro - Roll on, Roll off (as amended) RYA - Royal Yachting Association CPA - Closest Point of Approach SMS - Safety Management System CPP - Controllable Pitch Propellers SOLAS - International Convention for the CPR - Cardio-Pulmonary Resuscitation Safety of Life at Sea DSC - Digital Selective Calling SOP - Standard Operating Procedure GRP - Glass Reinforced Plastic TSS - Traffic Separation Scheme ICS - International Chamber of Shipping VHF - Very High Frequency LPG - Liquefied Petroleum Gas VTS - Vessel Traffic Services m - metre “Mayday” - The international distress signal (spoken)

Introduction This latest edition of the Safety Digest contains 25 articles about mariners who have had a bad day at the office – sometimes with tragic consequences. The sole purpose of the Safety Digest, as explained in the preamble to this document, is to prevent similar accidents from happening again. My hope is that, by reading the articles, mariners will learn from the mistakes of others, become more risk averse and avoid similar outcomes. When you are reading the articles, please take time to consider how you might have avoided the problems they describe. Better still, use the opportunity to discuss the articles with your shipmates or colleagues. The safety lessons listed at the end of each article are not necessarily exhaustive, you may identify others, and discussion of such issues is an excellent way of improving safety awareness. I am once more indebted to three very experienced individuals from our industry for providing their thoughts about the issues highlighted in this edition. Chris Adams’, Mike Montgomerie’s and David Pugh’s comments are based on many years’ experience in their respective fields and I would urge you to read their introductions carefully. Some of David’s comments struck a particular chord with me: in essence David reminds us that anyone who goes afloat, be it on a commercial vessel, or simply for pleasure, should constantly ask “what could go wrong?” and take precautionary action accordingly; he also highlights the responsibility of every skipper to lead by example and be seen to be following the safe working practices he/ she may urge their crews to adopt. In closing, I draw your attention to the MAIB Safety Bulletin at Appendix C. Although the accident which prompted the Bulletin related to the use of mooring ropes used mainly by larger commercial vessels, many of the safety lessons are pertinent to all sectors and vessel sizes. Handling of mooring ropes is a task that seafarers do on a routine basis – it is also one that regularly leads to serious injury or worse. When you are on mooring stations please ensure you remain vigilant and aware of the potential risks involved when handling ropes under tension. If you are acting in a supervisory role, ensure you are always able to maintain an overview of the task in hand so that risks can be identified and dealt with. “Tool Box Talks” before any mooring operation are a good way of ensuring that everyone involved has a good understanding of the plan, especially when crew are also empowered to stop operations should the plan begin to go wrong. Until next time, keep safe.

Steve Clinch Chief Inspector of Marine Accidents

October 2015

MAIB Safety Digest 2/2015 1

Part 1 - Merchant Vessels This edition of seafarers continue to succumb unnecessarily the MAIB’s to well-recognised risks such as those Safety Digest involved with stepping into the bight of a contains rope. It is one thing when death or injury summaries results from an unforeseeable or novel cause, of the factual but such needless loss of life or injury from circumstances a risk that all seafarers should be trained to of sixteen foresee, is cause for concern. accidents involving Another notable feature of this edition merchant ships. of the Safety Digest is the number of In bringing collisions that are reported. Three of these together this occurred whilst vessels were underway at condensed sea and involved familiar issues of lookout, collection of incidents that it has been called assessment of the risk of collision, and action upon to investigate, the MAIB provides an to avoid collision. In two incidents the lack enormously valuable service to the shipping of qualification or inexperience of the watch- industry. keeper was a contributory factor. Once again issues such as this are not new and training, More importantly, it is our seafarers who have superintendence and shipboard procedures the most to gain from studying this review should properly address and control these since human conduct is almost invariably risks. at the root of maritime incidents. It is often the case that the hardest lessons we learn Also reported are three incidents in confined in life are those that we learn from our own waters where the vessel was being assisted mistakes. The impact of those can be keenly by a local pilot. In two of the cases there felt and as we learn sometimes painful lessons were inadequacies in the master/pilot from those mistakes, we tend not to repeat exchange of information that contributed them. In the absence of our own mistakes to the causes of these accidents. It is vitally to use as an educational tool, the next best important that there is a full and detailed thing is to learn from the mistakes of others. exchange of information at the outset of It is for this reason that the MAIB’s work in any passage under pilotage so that there publishing this digest is so valuable. is full understanding of the passage plan, contingency response, the responsibilities The incidents covered by this review vary of the bridge team, and the technical considerably in their severity. It is extremely capabilities and/or limitations of the vessel regrettable that two of these resulted in and its equipment. The incidents reported fatalities. Two others might well also have here illustrate very clearly what can go wrong done so as their circumstances had the when there are shortcomings in the exchange potential to result in much more severe of information. injuries than those actually sustained. Two individuals had lucky escapes and should Several of the incidents reported may well count their blessings. have been avoided or mitigated with a thorough risk assessment of the intended It is notable that of the four cases that operation. Properly conducted risk involved either fatality or personal injury, assessments confer the benefit of thorough three occurred during mooring operations or identification of the risks involved and the whilst handling lines. The hazards involved controls that are necessary to mitigate these. in such operations are well known and yet

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There are important lessons to be learned If, as a result, behavioural change is achieved from reading this edition of the Safety Digest and just one personal injury is avoided, this that seafarers ignore at their peril. Ship review will have done much to achieve its owners and operators are therefore strongly purpose. It is to be hoped of course that it recommended to circulate this publication to will do much more. their vessels in order to maximise its potential benefit.

Chris Adams BSc (Hons), AFNI, MRIN STEAMSHIP MUTUAL

Chris Adams served at sea as a navigating officer with Ellerman City Liners. He holds a degree in Nautical Studies from the University of Southampton and joined The Steamship Mutual Underwriting Association Limited as a claims executive in 1979, initially specialising in handling collision and other admiralty incidents. He has been a partner of Steamship Mutual’s management company since 1998 and is Head of the Club’s European Syndicate and Head of Loss Prevention. In the latter role he has developed the Club’s series of loss prevention DVDs which include programmes on Collision Avoidance, Groundings and Piracy, the latter winning the Seatrade Award in the Safety at Sea Category. In addition, in over 20 years of cooperation with Videotel Maritime International, more than 90 onboard safety training programmes have been jointly produced, the content of which greatly benefit from the Club’s claims experience. He is an Associate Fellow of the Nautical Institute, Member of the Royal Institute of Navigation, Liveryman of the Worshipful Company of Shipwrights, and a Trustee of the Maritime London Officer Cadet Scholarship Scheme.

MAIB Safety Digest 2/2015 3

Rule 13* – Unlucky For Some *“any vessel overtaking any other shall keep out of the way of the vessel being overtaken” Narrative A general cargo vessel and an LPG tanker port side. At 1000 the OOW noticed on the were in collision while proceeding in the same AIS receiver that the general cargo vessel direction of a TSS. The visibility was about was 3.0nm astern with a CPA of zero. The 3nm, with fog patches, the wind was light and OOW could not see the general cargo vessel the sea state was slight. No lookout was posted visually, but as it was overtaking the tanker he on either vessel. was confident it would keep out of the way in accordance with Rule 13 of the COLREGS. The master was the OOW of the geared, general cargo vessel, which was on a course At 1012 the tanker’s master, who happened to of 231°, speed 22kn1 and, due to the vessel’s be outside the vessel’s accommodation, looked busy schedule, he had not taken much rest up and saw the general cargo vessel very close in the previous 20 hours. At 0937 the master astern and on a collision course. He ran to acquired a radar target directly ahead of the the bridge and put the helm hard-a-port. The vessel, range 6.5nm. The target vessel’s details tanker began to swing to port and its heading were displayed on the AIS receiver but the had changed from 233° to 194° when the option to display the target’s information collision occurred. on the X-band radar, which was fitted with ARPA, was not taken. The master had elected On the general cargo vessel two guests were to show radar targets with true vectors and on the bridge with the master and they were true trails. joined at 1008 by the second officer, who arrived to take orders for goods from the The target vessel was the LPG tanker, which bonded store. At 1013, after a light-hearted was in ballast and was on a course of 228°, conversation, the second officer left the bridge, speed 8.0kn. The tanker’s OOW was the third and a minute later the master exclaimed “Oh officer and he was alone on the bridge. At 0943 look ahead – we’re going to hit”. the OOW detected the general cargo vessel on radar and noted on the AIS receiver that it was The general cargo vessel’s port bow collided overtaking and its CPA would be 0.3nm to with the LPG tanker’s starboard quarter and starboard. the hulls of both vessels were breached above their respective waterlines. Both vessels were The ARPA functionality on the LPG tanker’s directed by the coastal state to a nearby port of radar was not working as there was a known refuge for inspection and repairs. gyro compass repeater fault. The vessel had received approval from port state inspectors The general cargo vessel was repaired and and its Classification Society to make its resumed normal service a week later while voyage, subject to the posting of a lookout repairs to the LPG tanker lasted a month. The when “manoeuvring in coastal waters”. coastal state authorities prosecuted the master of the general cargo vessel for COLREG At 0950 the OOW on the LPG tanker made offences, and he was fined $2,400. a 5° alteration of course to starboard to avoid a small fishing vessel that passed down its

ISO 80000-3 2006, knot (symbol kn): 1 nautical mile per hour

4 MAIB Safety Digest 2/2015

Collision damage

Area in which the master was working

Collision damage

Figure 1: Damage to both vessels

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Key General cargo vessel Tanker

Showing the tracks of both vessels before and after the collision

Key General cargo vessel Tanker

Reconstruction at 1014:09 showing the relative positions of the vessels at the time of collision

31.2 93.7

Figure 2: Reconstruction

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The Lessons

1. The collision occurred because neither by the presence of various non-operational OOW was keeping a proper lookout personnel on the bridge immediately as required by the COLREGS. Always prior to the collision. Access to the bridge ensure that a proper lookout is maintained should be controlled at all times, especially at all times, using all appropriate means. when a vessel is navigating in areas of high traffic density such as a TSS. 2. No dedicated lookouts were posted on either vessel and neither OOW monitored 4. By failing to move around