MAIB Safety Digest 2/2021

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 2/2021

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 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.”

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 an 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, Clare Hughes, welcomes any comments or suggestions regarding this issue.

If you do not currently subscribe to the Safety Digest or other MAIB publications and would like to find out more, please get in touch with us:

• By email at publications@maib.gov.uk; • By telephone on +44 (0)23 8039 5500; or • By post at: MAIB, First Floor, Spring Place, 105 Commercial Road, Southampton, SO15 1GH

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This publication and previous safety digests are available online www.gov.uk/government/collections/maib-safety-digests

© Crown copyright 2021 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.

INDEX GLOSSARY OF TERMS AND ABBREVIATIONS

INTRODUCTION 1

PART 1 – MERCHANT VESSELS 2

1. Hot stuff 4

2. Effective damage assessments 6

3. Be careful with lines under tension 8

4. A reflecting distraction 10

5. Just slipping into hospital 12

6. The charge of the ferry brigade 14

7. Love me tender 16

8. Check the passage plan... 18

9. Wet feet and red faces 21

10. Chafe, spray and ignite 23

11. Tipping point 24

12. Fender bender 26

13. A reach too far 28

14. Tend those lines 30

15. Under pressure… 32

16. A lucky escape 34

PART 2 – FISHING VESSELS 36

17. Paperwork can wait 38

18. Learning the ropes 40

19. Even the experienced can be caught out 42

20. Running on fumes and dirt 44

21. Caught on the rocks 45

22. An invisible and deadly hazard 46

PART 3 – RECREATIONAL VESSELS 48

23. Night navigation is not easy... 50

24. We booked for fishing, not swimming 52

25. Tanker, what tanker? 54

APPENDICES 56

Investigations started in the period 01/03/2021 to 31/08/2021 56

Reports issued in 2021 57

Safety Bulletins issued during the period 01/03/2021 to 31/08/2021 58

Glossary of Terms and Abbreviations 3/E third engineer m metre 4/E fourth engineer "Mayday" the international distress signal AIS automatic identification system NAABSA Not Always Afloat But Safely Aground ALB all-weather lifeboat OOW officer of the watch CCTV closed-circuit television "Pan-Pan" the international urgency signal C/E chief engineer PFD personal flotation device COLREGs Convention on the International RIB rigid inflatable boat Regulations for Preventing Collisions at RNLI Royal National Lifeboat Institution Sea (1972) ro-ro roll-on, roll-off COSWP Code of Safe Working Practices for Merchant Seafarers RSW refrigerated salt water CPR cardiopulmonary resuscitation SMS safety management system ECDIS Electronic Chart Display and TSS traffic separation scheme Information Systems VHF very high frequency kts knots VTS Vessel Traffic Service

Introduction Welcome to the MAIB’s second Safety Digest of 2021. I would like to start by thanking Matthew Easton, John Clark and Iain Elliott for writing the introductions to the Merchant, Fishing and Recreational Craft sections of this digest. As always, their perspectives on maritime safety make compelling reading. There are many aspects to safe operations and, purely by coincidence, our three introduction writers have focused on different parts of the safety effort. John Clark’s accident in 2013 was the trigger for him to focus on assessing risks and taking steps to reduce them. I will not steal his thunder by repeating his words here, but, if you read nothing else in this edition, do please read John’s introduction to the Fishing section. John’s ‘safety conversion’ occurred as a result of an accident, but the whole point of the Safety Digest is to provide readers with the opportunity to learn from others’ misfortunes. I am a great fan of safety acronyms – they are not everyone’s cup of tea, but they work for me. I will certainly be adding Matthew Easton’s PLAN/PLAY to my toolkit. Sometimes a simple acronym is all that is needed to prompt a review before commencing a task; on other occasions a checklist is required; and, if the task is new or unusual, a dynamic risk assessment and, possibly, a permit to work might be needed before commencing it. Whatever level of preparation is required they have one thing in common, which is a pause to take stock before starting work. The third element of safety in this edition is Iain Elliott’s simple message, ‘get trained’. His introduction precedes the Recreational Craft section of the digest, but astute readers will notice that many of the articles contain stories of how good training and preparation helped prevent a drama becoming a crisis. In this introduction I would like to add one safety message of my own, which is the importance of a ‘banksman’ or other form of safety supervisor when the machine operator does not have direct sight of the work area. There have been very many accidents in recent months, some reported in this digest, that have occurred because there was no intermediary to tell the crane or winch operator that the work area was clear before operations commenced, or to call “Stop!” if someone entered a dangerous zone. It is all too easy to dispense with the banksman and ‘manage’ without, but the results can be catastrophic. When there is a manpower shortage it is tempting to manage without a supervisor, controller or banksman, but, because their vigilance is what keeps people safe, they are probably the most important members of the team.

Andrew Moll Chief Inspector of Marine Accidents

October 2021

MAIB Safety Digest 2/2021 1

Part 1 – Merchant Vessels The sea is an For experienced seafarers, or indeed any unforgiving experienced professionals, planning of a task is environment and undertaken very quickly. If this is broken down as such there will into sections, we get the following: always be incidents and accidents. Plan – time must be allowed for the planning Despite the passage phase, when all relevant information is gathered of time, there are and assessed. no new accidents just repetition of old Limits – when developing plans, limits must be ones. Continuing agreed at this early stage. For pilots, these could fatalities in an be wind, tidal height, under keel clearance or the enclosed space is a number of tugs. tragic example. Awareness – the building of your situational Many reports are written after an incident, awareness starts at the planning stage and is accident, or near miss (learning opportunity, constantly updated. It is a movie, a dynamic, learning event: whatever term is used in constantly changing situation. your company) but these are of little value if companies don’t have a robust system of No – if, during this phase, conditions are disseminating a copy of a report to all their not favourable, then the operation must be personnel to discuss the lessons to be learnt. In cancelled or postponed. This is the concept of lieu of the facts, the sequence of the event will the stop work procedures many companies have be altered, forgotten, or added to, thus denying implemented. However, if all aspects are within the learning opportunity for all the actual facts parameters it is a ‘yes’ and then we PLAY (Plan, of the case. Learning from incidents is adding Limits, Awareness and Yes). to what Captain ‘Sully’ Sullenberger calls his ‘bank of experience’ and depositing knowledge Although many accidents occur during routine into our long-term memory will aid us when everyday operations, many companies have encountering similar circumstances in the future. taken to having a briefing or toolbox talk prior to commencing the task; everyone involved then Because of the repeating of accidents there knows what is expected of them and, as such, it is is a common theme that runs through many hoped incidences are reduced. of them; in terms of this digest, planning and communication failures constitute the majority Having observed shipboard operations for of the reports. Indeed, through my experience as many years and read numerous accident reports, a senior Liverpool pilot and facilitator of pilot including the ones contained within this digest, resource management training, these are ever another common theme that emerges is too present themes and topics for discussion. many lone operations that end in an accident. ‘Safety First’ is a commonly used phrase among One of the biggest hurdles to planning is time; shipping companies; is it time to review the how much time do we have before carrying out ‘safe’ or ‘minimum’ manning certificates issued to the task? It is often more than we think we have. every ship? With even more scrutiny on seafarers’ Arriving into or departing a port is frequently hours of work records this intensifies the pressure a busy period for seafarers, leading to a limit on crew to complete tasks in a timely manner. on crew’s time and, as proven in some of this edition’s case studies, resulting in an accident.

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With repetition of accidents comes a repetition The person on the receiving end of the question in the language used in reports. ‘Loss of often takes it personally; this is nothing more situational awareness’ and ‘challenge’ are two than a perceived slight to their ego and they much used terms. react accordingly. Remember it is the plan, or a deviation from the plan in question, not the In many incidences the person in the middle individual. (often an OOW, master or pilot) did indeed lose their situational awareness or, as described by When the pilot boards, this briefing is generally a Principal Inspector of the MAIB at a pilot’s referred to as the master pilot exchange but is conference, their situational awareness differed that term fit for purpose? If taken literally, then from reality. As a reader of a report that includes there are only two people who ‘attend’. A ‘bridge the phrase ‘loss of situational awareness’ it doesn’t team briefing’ or ‘pilotage briefing’ would seem help in our understanding of the hows and whys more appropriate, the whole team have a shared of the loss. In order for us, the reader, to ‘learn’ mental model. This often does bring us back to from the incident it is essential that the human the number of crew on board and hence how element, the human factor, is explored and many are available to attend the briefing, as many explained in greater detail and not just under a will be resting. stock phrase. With regards to communications, we have always ‘The OOW should have challenged the master’ been taught never to assume. Accidents while or ‘the master should have challenged the mooring, again including two in this digest, pilot’ are again often used phrases in reports. could have been avoided with positive reporting, Initially, what is wrong with simply ‘questioning’ not an assumption that the ship was ready to someone? In my article (Seaways March 2019) leave the berth. I expand on this topic, suffice to say that the message marker used by VTS is ‘question’ Being open and honest after an incident will not ‘challenge’! A question will resolve most depend very much on the culture within an situations but if not then we can indeed issue a organisation. The culture comes from the very challenge. This is true for all walks of life not just top of a company so, for the benefit of all within at sea. the company and the wider industry, it needs to be one where there are thorough investigations A question or challenge to the master or pilot is and lessons learnt promulgated for all. because there is doubt as to someone’s intentions or there has been deviation from the plan. This This digest, I’m sure, will continue to inform all brings us back to how essential planning and mariners on board ship whatever their role – briefings are prior to any work being carried out. adding to their own bank of experience.

CAPTAIN MATTHEW EASTON CMMAR AFNI LIVERPOOL PILOT Matthew is a senior, Class 1, Liverpool Pilot, a recipient of the Merchant Navy Medal for Meritorious Service and a Chartered Master Mariner. In addition to piloting duties he has, for 12 years, developed and delivered bridge resource management courses for pilots and has presented on this subject at pilot conferences. Courses have been held in the UK, Europe and the Middle East. A member of the International Standards of Pilotage Organisation (ISPO) Board (ISPO is a safety and quality management system by pilots for pilots). A Younger Brethren of Trinity House and chair of their Northern Regional Grants Committee. A Liveryman of the Honourable Company of Master Mariners. Chairman of the Merchant Navy Honours Consultative Committee (formerly the Merchant Navy Medal Committee), liaising with the Department for Transport in all aspects of the Merchant Navy Medal for Meritorious Service.

MAIB Safety Digest 2/2021 3

Hot stuff Narrative A large ro-ro passenger ferry was on passage (see figure). Leaking oil from the pump then when, in the early hours of the morning, the reignited and, again, the 3/E extinguished the engine room fire detection system activated. fire with a portable extinguisher. The fourth engineer (4/E) was in the engine control room and observed that the fire The C/E then took charge of the situation: detection system was indicating a fire in the further crew arrived on scene armed with zone containing the shaft alternator and portable extinguishers, and full fire-fighting thermal oil pumps. However, the CCTV teams were prepared in the event of the view of the area was obscured due to smoke situation escalating. Once the situation was building up in the engine room. under control, a standby thermal oil pump was started, and additional generators were brought The 4/E raised the alarm with the bridge and online to protect the vessel’s power supply. The the chief engineer (C/E) then stopped the engine room ventilation was then configured running thermal oil pumps and requested for smoke clearance. a speed reduction from the bridge. At the same time, the third engineer (3/E) grabbed The cause of the fire was later found to be a portable fire extinguisher, rapidly proceeded a failed pump bearing that had overheated, to the scene and extinguished the fire that had damaging the adjacent mechanical seal. The broken out on one of the thermal oil pumps failure of the seal resulted in oil spraying out and igniting on the bearing’s hot surfaces.

Figure: The scene of the fire, showing the fire damage around the coupling and leaked oil

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The Lessons

1. Drills, training, exercises and toolbox breathing apparatus to give protection talks all pay a big dividend when real from the smoke if the seat of the fire is not emergencies occur. This was a well- easily accessible. organised ship’s team that had conducted regular training and fire drills. As a result, 3. The 3/E had to gain access to the fire the on-watch team took rapid and effective using an emergency escape ladder, as action to bring the situation under the engine room’s main access ladder control, preventing escalation. Follow-up had been removed to facilitate ongoing actions were also effective in restoring the repairs unrelated to the fire. Potential availability of full propulsion capability consequences of even temporary blocking for the bridge. In summary, the alarm was of main access routes should be carefully raised in a timely manner and effective considered. The engine room is a high-risk actions were taken. compartment, especially when operating at sea. It was fortunate that the scene of 2. Smoke inhalation can be an immediate the fire could be accessed by using the source of injury from a fire, so it was emergency escape. If access to