MAIB Safety Digest 2/2017

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accidents No 2/2017

is an

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This publication can also be found on our website: www.gov.uk/government/organisations/marine-accident-investigation-branch

October 2017

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 2017

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. Fuel System Maintenance – No Sparks Without Fire 4

2. A Gap in Knowledge Leads to a Gap in the Shell Plating 6

3. Oh Flip 8

4. All For a Few Centimetres 10

5. A (Fire) Triangular Error Chokes an Engine Instead of a Fire 12

6. Now You See Me… 14

7. Oooops 15

8. Heavy Weight + Shortcut = Fatal Fall 17

9. A Close Shave 19

10. Training Saves the Day 21

11. Faulty Cigarette Bin Sees Sparks Fly 23

12. Beware of Slack Ropes and No Shared Awareness… 25

13. Grounding – What Grounding? 27

14. Nuts About Bolts 29

PART 2 – FISHING VESSELS 32

15. A Bump in the Night… 34

16. Stability Matters 36

17. Another Tragic Reminder of the Hazards of Potting 38

18. A Fatal Bight 40

19. Are You Aware of the Risk of Carbon Monoxide? 42

20. Safety First 43

21. Don’t Lose a Hand Through Inexperience 45

PART 3 – RECREATIONAL CRAFT 46

22. Are You Sitting Safely? 48

23. Listen to Safety Instructions 50

24. Bunged Up 52

25. Ships? I See No Ships 54

APPENDICES 56

Investigations started in the period 1/03/17 to 31/08/17 56

Reports issued in 2017 57

Safety Bulletins issued during the period 01/03/17 to 31/08/17 58

Glossary of Terms and Abbreviations AB - Able Seaman IMO - International Maritime Organization C - Celsius kt - knot CO2 - Carbon Dioxide m - metre COLREGS - International Regulations for the "Mayday" - The international distress signal Prevention of Collisions at Sea 1972 (spoken) (as amended) OOW - Officer of the Watch COSWP - Code of Safe Working Practices for PFD - Personal Flotation Device Merchant Seamen PTW - Permit to Work DSC - Digital Selective Calling RIB - Rigid Inflatable Boat ECDIS - Electronic Chart Display and Information System Ro-Ro - Roll on, Roll off EPIRB - Emergency Position Indicating Radio SMS - Safety Management System Beacon TEU - Twenty-foot Equivalent Unit GPS - Global Positioning System UMS - Unmanned Machinery Space HSE - Health and Safety Executive VHF - Very High Frequency ICS - International Chamber of Shipping

Introduction A fire is one of the most frightening things that can happen at sea. Often, seafarers have no ready access to the emergency services when a fire breaks out and will need to rely on their own resources, courage and training to tackle and extinguish the blaze quickly to ensure the safety of the ship and everyone on board. After reading one of the cases while editing this edition of the Safety Digest, I found myself thinking about the recent fire that engulfed Grenfell Tower, a west London residential tower block. This was an horrific incident; 80 people are currently presumed to have died but the ferocity of the fire means that the final death toll may never be known for sure. Why the Grenfell Tower fire spread so quickly is the subject of intense debate but its source was attributed to a domestic fridge/freezer that overheated. Case 10 provides a reminder that fires can quite easily start in a similar way on a ship. In that case a fire was caused when a travel fridge was placed on the carpeted area of the deck in a cabin; the lack of air circulation around the unit caused the fridge to overheat… fortunately the crew were able to extinguish the fire without too much damage being done. Mobile phones, computers and other electrical devices have become an integral part of modern life but can be lethal if not used responsibly. The risk of fire from malfunctioning or misused portable electrical equipment can be substantially reduced or even eliminated if you ensure that portable equipment testing (PAT) becomes routine on your ship and that periodic examinations are made of personal electronic items to ensure they are being used sensibly. In Case 10, when the emergency occurred the ship’s crew reacted quickly and professionally because they had trained and drilled for the situation they found themselves in. The same point is also made in Cases 11 and 24. Being prepared to deal with scenarios such as fire, flooding or man overboard, is a practical prerequisite of going to sea, whatever sector of the industry you work in. Because the emergency services we take for granted ashore will likely not be there to help you when the worst happens, the importance of conducting regular drills, that are as realistic as practicable, cannot be understated. It is all very well for seafarers to receive instruction on how to deal with a range of foreseeable emergencies in theory, but they also need to be given the regular opportunity to put the theory into practice under safe, controlled but challenging circumstances. In this way, clear goals, procedure and practice will instinctively come to the fore to prevent panic and confusion at a time of very high stress. Sadly, MAIB investigators find that the emergency drills required by the SOLAS convention or domestic regulation are seen by some as a bit of a chore – something to be endured on a Saturday afternoon simply because it’s needed to fill in the official log. In these circumstances, drills are conducted at best in a cursory manner with little learning value for the crews involved. If this is a situation you recognise I would ask you to think carefully how the safety culture within your company/on your ship or boat needs to change. In closing, I would like to thank Adrian Hibbert, Robert Casson and Jonty Pearce for their excellent introductions to the merchant, fishing and recreational vessel sections of this edition. Until next time, keep safe.

Steve Clinch Chief Inspector of Marine Accidents

October 2017

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Part 1 – Merchant Vessels Having spent crew; that is used by the head office as a tool to three years as an protect them from any possible blame relating Inspector with to an accident at sea; that relies on checklists to the MAIB, I was initiate skill, seamanship and best practice rather delighted to be than have those values as part of the day to day asked to write the working environment misses the point of the forward to the ISM Code. latest edition of the Safety Digest. The As you will read in the report concerning the Branch produces rescue boats that flipped when being hoisted on excellent reports in their lifting strops, a good SMS used correctly scrupulous detail of and coupled with open and honest reporting of the accidents that any incident will not only help prevent accidents it investigates and from those reports seafarers, at the time, but will also help others learn and shore management and sadly on occasion next of prevent potential accidents elsewhere. You kin get a full understanding of what happened. will also read accidents such as a tug and tow collision that could have been avoided with a However, it is probably the Safety Digest that is simple team discussion or ‘tool box talk’ – no the most widely read of the MAIB publications; paperwork required. the style and size of reports are perfect for the seafarers’ ‘smoko’, quick read in the mess room or However, if a company is operating with an sharing lessons at Health and Safety Committee SMS that isn’t fit for purpose, the blame cannot meetings. Of course, if you so wish you can now be laid solely at the ship owner or manager’s read these reports on line, but there is something door. The ISM Code allows ample opportunity reassuring when I visit one of my ships and see a for the officers and crew of a vessel to raise well dog-eared copy in the engine control room their concerns to the highest level within any or on the bridge. organisation. If a vessel is working to an SMS that is not suitable or is not capable of being Sadly, although the format of the MAIB reports followed as required and yet the master has not may have changed, the nature of the accidents raised this as part of his Master’s Review or as a has, to a large degree, not. Complacency and non-conformance with the DPA, then there is overconfidence remains a common theme and little that the shore manager can do. both might be considered human factors related to the individual seafarer’s character rather Similarly, if an internal ISM audit involves somewhat out of the control of the ship owner; merely checking that documents, records and but is there more the ship owner can do? checklists are complete and up to date but the auditor does not take the time to stand Now that I sit firmly on the side of the ship back and observe if the records reflect the true owner, I would argue that there is much that working practices on board, this too is a wasted those of us based in shore positions can do to opportunity and against the original intention of support our colleagues at sea beyond hiding the Code. The best SMS will always be the result behind the ISM Code or relying on STCW to of inputs from both ship and shore and will be a dictate the standards. living document – constantly under review and challenge. To create a Safety Management System (SMS) that is overburdening on the end user; that Accidents at sea will happen. By nature it is a requires form after form to be filled in before dangerous environment and it is the duty of us the most simple tasks can be started; that keeps all to minimise the likelihood and severity of it an officer at a desk rather than overseeing his happening to us or any of the people under our

2 MAIB Safety Digest 2/2017

care. If it happens it is also our duty to ensure Most in the shipping industry do not get that our crew are trained and prepared to deal visibility of the small support team that with it. Again, there are good and not so good makes that deployment happen; the diligent examples of this in this Safety Digest. approach to investigation and peer review Given that accidents will happen and that ensures that the reports are accurate therefore must be investigated, I’d like to take and recommendations appropriate; the work the opportunity to pay tribute to my former of the publications team to create a report colleagues at the MAIB who take enormous that is easy to read and supported by suitable responsibility when deploying to an accident graphics; and the follow up work of the scene, often in difficult to get to locations and Inspectors who show great empathy when always at short notice. dealing with those directly involved in the accident or their relatives and friends.

ADRIAN HIBBERT Adrian began his sea going career in 1990 with a cadetship at P&O and Princess Cruises. Trading in all major cruising areas including three full world cruises, he left P&O Princess after 10 years as First Officer of the company’s new build Aurora. After a short period outside of the industry, Adrian returned to cruising with First Choice Holidays’ start-up operation Island Cruises. Initially as Chief Officer and then as Deputy Captain, he spent 3 years spending summer in the Mediterranean and winter in Brazil but, like many seafarers, a new marriage and the demands of family life had him looking for opportunities a little closer to home. In 2004 Adrian was appointed as Master on a new fast ferry service operating between Dover and Boulogne where he remained for two and a half years. However an opportunity to please his wife even more came along when his former employers at First Choice knocked on his door and offered Adrian his first shore based position as Fleet Manager for Island Cruises (with a short stint as relief master), based in his home town of Brighton. Two years later, the merger of Thomson and First Choice saw the relocation of Island Cruises Head office to Luton. This was the catalyst that allowed Adrian to fulfil a long held ambition to join the Marine Accident Investigation Branch (MAIB) as a Nautical Inspector. In 2012, after three years with the MAIB, an offer to re-join the cruise industry as Operations Director for Thomson Cruises was too good to miss and Adrian made the difficult decision to leave the Branch. In his first years in the role he has worked hard to restructure the Operations department and its practices and procedures to reflect many of the best practices seen in his work with the MAIB but without burdening the seafarer with extra, unnecessary administrative responsibilities.

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Fuel System Maintenance – No Sparks Without Fire Narrative A UK registered vessel operating in coastal Having discovered a fuel leak on the low waters suffered an engine room fire that pressure fuel return from the main engine, the resulted in the death of an engineer officer. duty engineer decided that he could complete a temporary repair without needing to shut The vessel normally operated with its down the engine. He collected tools from machinery space unmanned (UMS), but at the workshop and began the task. It became the time of the accident it was performing apparent that to access the leak he would need a task that required the engine room to be to remove a pipe support bracket. The pipe run manned. The UMS patrol alarm was not was under the engine room floorplates, and on deemed practical for use with the engine room inspection the pipe, bracket and securing bolts manned and, as a result, an ad hoc system of were found to be in poor condition. In order communication between the duty engineer to remove the bracket, he decided to crop the and the deck OOW had been developed to support using a portable angle grinder (Figure maintain contact. Over the course of several 1). years the frequency of communication had reduced to such an extent that the lone engine In order to progress the repair, the engineer room worker could operate for several hours climbed into the bilge to access the bracket. without contact with the rest of the crew. Fuel from the leaking pipe atomised on contact with the surrounding structure (Figure 2) and On the day of the accident, the duty engineer soaked the engineer’s coverall with diesel. had completed the required operational tasks Sparks generated during the cutting process and was attempting to carry out repairs in the ignited the atomised diesel, setting light to the engine room. He had informed neither the engineer’s coverall and starting a