MAIB Safety Digest 2/2022

SAFETY DIGEST Lessons from Marine Accident Reports

Featuring introductions by Julian Hughes | Jim Portus MBE | Rachel Andrews

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 that has been determined up to the time of issue.

This information is published to inform the merchant and fishing industries, the recreational 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 If you wish to report an accident or incident regarded as tentative and subject to alteration or please call our 24 hour reporting line: correction if additional evidence becomes available. +44 (0)23 8023 2527 The articles do not assign fault or blame nor do they determine liability. The lessons often extend beyond The telephone number for general use is: +44 (0)23 8039 5500 the events of the incidents themselves to ensure the maximum value can be achieved. The branch email address is: maib@dft.gov.uk This publication and previous Safety Digests are available online: Extracts can be published without specific permission www.gov.uk/government/collections/maib-safety-digests providing the source is duly acknowledged.

The editor, Clare Hughes, welcomes any comments or suggestions regarding this issue. To see how the General Data Protection Regulation (GDPR) affects the way we use and store your data go to: If you do not currently subscribe to the Safety Digest www.gov.uk/government/organisations/marine-accident-investiga- or other MAIB publications and would like to find out tion-branch/about/personal-information-charter more, please get in touch with us: © Crown copyright 2022 ▶ By email to publications@maib.gov.uk; This publication, excluding any logos, may be reproduced free of charge in any format or medium for research, private study or for internal circulation ▶ By telephone on +44 (0)23 8039 5500; or within an organisation. This is subject to it being reproduced accurately and not used in a misleading context. The material must be acknowledged as ▶ By post to MAIB, First Floor, Spring Place, Crown copyright and the title of the publication specified. 105 Commercial Road, Southampton, SO15 1GH

GLOSSARY OF TERMS AND ABBREVIATIONS

CHIEF INSPECTOR’S INTRODUCTION 1 INDEX

M MERCHANT VESSELS 2 1. Practice makes perfect 4

2. Pinkie is no longer perky 6

3. Out of sight, out of mind 8

F 4. A scalding injury 10 FISHING VESSELS 28 5. A case of the bends 11 15. Safety equipment saves lives 30 6. Pitch imperfect 12 16. Blinded by the lights 32 7. Leave it be 14 17. Beam drop 34 8. A bumpy shortcut 16 18. Deliver-oops 36 9. Towing trouble 18 19. Shooting yourself in the foot 38 10. It’s an accommodation ladder, not a diving board 20 20. Boats roll 40 11. Diddly-squat 22

12. Not so cool 24

R 13. In off the post 25

14. Lining up for trouble 26 RECREATIONAL VESSELS 42 21. Things did not go swimmingly 44

22. Beware the bight 46

23. Survival of the safest 47

24. A bit of a blinder 48

25. Cocktail capsize 50

INVESTIGATIONS 52

REPORTS AND PRELIMINARY ASSESSMENTS 53

SAFETY BULLETINS 54

SAFETY FLYERS 60

GLOSSARY OF TERMS AND CHIEF INSPECTOR’S INTRODUCTION ABBREVIATIONS Welcome to MAIB’s second Safety Digest of 2022. I will start in the usual manner by thanking Julian Hughes, Jim Portus and Rachel Andrews for 2/E second engineer their respective introductions to the merchant, fishing and recreational sections of this edition. Each is an expert in their own field, and their 2/O second officer industry insights to safety help bring contemporary context to the AIS automatic identification system cautionary takes in the following pages. I hope you will find time to read the whole edition – there is something here for every mariner – but please ALB all-weather lifeboat do read the section introductions. And, when you have finished, please C/E chief engineer pass the digest on so others can benefit too. C/O chief officer We tend to think of the news as something fairly transient. Our media quickly moves on to the next sensational story and, to use an old saying CCTV closed-circuit television from the days when chip shops wrapped food in newspaper to keep it CO2 carbon dioxide warm, “Today’s headlines are tomorrow’s chip wrappers”. But the real world DfT Department for Transport is not like that. Accidents have consequences, and Julian Hughes’s description of how passing through a powered watertight door affected him is a fantastic example of how ECR engine control room an accident can resonate and impact on people’s behaviour long after the event itself. EPIRB Emergency Position Indicating Radio Beacon The real trick, however, is to try and prevent accidents before they happen and people are injured, and this GPS global positioning system needs what in the trade we call precautionary thought. Something akin to this occurred last year in the lead up to my daughter’s wedding when her fiancé’s biggest concern was running out of tonic at the reception. kts knots A year on, as a family we are still drinking our way through out-of-date bottles of the stuff. Perhaps we m metre should have purchased the extra on sale-or-return, but for the event itself the risk had been identified and effective action was taken to mitigate it; the bar did not run out of tonic! “Mayday” the international distress signal MCA Maritime and Coastguard Agency Running out of tonic might not be a suitable example for a serious ‘lessons learned’ publication, but it helps emphasise the point Rachel Andrews makes in her introduction to the recreational section, Before MOB man overboard leaving…we need a plan. If I can add to that, a plan needs to consider not just what we intend to do, but also OOW officer of the watch what we will do if something goes wrong. The plan also needs reviewing and adjusting to changes, such as recovering a trawl and heading home early if the weather forecast changes for the worse. “Pan-Pan” the international urgency signal In their early stages, accident investigations can be highly pressured and intense as we try to capture PEC Pilotage Exemption Certificate perishable evidence before it is lost. But every investigation needs a plan, and time has to be set aside and PFD personal flotation device the effort made for review as the plan unfolds. Another old saying, but it works for me, “Time spent planning is never wasted”. PLB personal locator beacon Be safe. PPE personal protective equipment RIB rigid inflatable boat RNLI Royal National Lifeboat Institution RoPax roll-on/roll-off passenger ferry Andrew Moll OBE ro-ro roll-on/roll-off Chief Inspector of Marine Accidents SAR search and rescue SWL safe working load VHF very high frequency VTS vessel traffic services

MAIB Safety Digest 2/2022 | 1

MERCHANT VESSELS Throughout my Article 2 shows the remains of a boilersuit after career and within entrapment by a powered door. As a cadet on over and shafts sometimes stopped. I have since The marine industry and technology have our organisation, watch I frequently operated and passed through been fortunate to attend factory acceptance tests moved on so far and continue to do so: data the Safety Digest the watertight door that caused this injury. Some and numerous delivery sea trials, where the full and communication allow us to be informed, and MAIB reports years later, I passed through the same door as a power of today’s automation systems sometimes understand and train by simulation; trending have informed safety manager of the vessel. To this day I think, What has to be seen to be believed but offers a huge statistics enable us to derive focus areas for moments, briefings, if? every time I pass through one. Watertight amount of confidence to those witnessing it. safety and many such items across statutory drills and campaigns doors perform an essential function, and so their Thus, my advice is to leave it in automatic and bodies and company fleets and immediately so it is a privilege safe operation should be commonplace and not then fix it, not create a work around. share them worldwide. With all these tools to be asked to write result in injury. at our disposal we are safer but nowhere near We completed a major upgrade to the where we should be. Maybe we forget or become this introduction In 1997, after 6 years working on high-pressure automation system and, confident we had done complacent about the on board risks that we and hopefully give something back, having also steam vessels, I moved to a 2-year-old motor ship. all the testing we could, flooded the dock. The pass by without a thought while performing our featured in at least one report myself. The exhaust gas boiler ruptured on the Island vessel floated without incident and we started tasks. How do I know this? Well, the PPE I have to For those of us that have been around Princess (MAIB report 37/2000)1 shortly after, the two port engines, which started and ran wear should remind me: high visibility clothing long enough, the sustained frequency and involving people I knew and had worked with of up to speed. The clutches were next and the when walking down the quayside; safety shoes number of repeated incidents, themes and whom some were injured and two killed. Having two starboard clutches alarmed. After a quick in work areas; coveralls and ear protection in recommendations continues to be a major been responsible for a steam system operating discussion the decision was made to stop, machinery spaces; and goggles and gloves to concern, and in most cases are a bit too close above 50 bars, I was horrified that a significantly manually engage the clutches and move to a lay complete tasks. The purpose is to reduce the risk to home; this was certainly true for me as I was lower pressure saturated steam system could berth; no one on board had done this before but of harm that is inherent in the vessel’s operation reading these articles. cause such devastation. One comment stays with we had an emergency response procedure in and tasks we have to perform. me from our on board discussions at the time: place for this. Working through the procedure In the 34 years I have been in the industry, the “What people forget is there’s more water in these and checklist we were able to give the master Writing this has made me stop, reflect and equipment and functions it performs remains boilers and economiser than on the high-pressure confidence to let go and safely move to the lay remember, focusing purely on safety. I hope that fundamentally the same; however, while the plant and it’s all trying to get out and expand 1700 berth for maintenance. reading this Safety Digest encourages you to do designs and controls have changed and rules times, that’s a lot of energy”. While safety around the same. have been enhanced to support safety of Unlike computers we all make poor decisions or these systems has notably improved in the form seafarers, normally post-incident, the biggest forget things, be it in on the bridge, in technical of design changes, risk assessments, procedures change for me has been the way we interact with spaces or anywhere else on board. Procedures, and recommendations, this area remains a equipment, and how it in turn interacts with us. checklists and testing exist to enable us to keep significant risk and there are still far too many Be it old technology or new, it is usually the way our vessels, crew and cargoes safe by performing occurrences. we interact with it that leads to the incident. every task correctly.

Sitting on a waste bin in the engine workshop Unlike computers we mid-Atlantic, head in my hands, I was exhausted all make poor decisions and frustrated that, despite our best efforts JULIAN HUGHES CEng CMarEng FIMarEST | V.Ships Leisure Technical Director and after working all day with the team to keep or forget things Julian is a Chartered Marine Engineer, Fellow of IMarEST and a qualified chief engineer unlimited the plant going, we were going to be late into The motor ship was my baptism of fire into motor or steam ships. He joined V.Ships Leisure 5 years ago as a Saga Cruises newbuild project the turnaround port. I felt a fitter’s hand on my the world of integrated machinery and bridge manager and has since moved into the role of Head of Ship Management for Saga Cruises, which he has shoulder followed by the wise words, “It’s lots automated control systems, a step change combined with that of V.Ships Leisure Technical Director over the past year. of pieces of metal, boss, it doesn’t have feelings, it’s from the fully manual environment I was used Julian ran his own marine consultancy business for 4 years, which included acting as an expert not trying to upset you, sometimes it gets tired too”. to. I quickly realised it was not an option to witness for legal cases and technical assessor for the United Kingdom Accreditation Service while also This sticks with me because the same applies tap the monitor if I disliked the reading and delivering project management and specialist services to the maritime industry. for the injuries, or worse, suffered by seafarers learnt that putting things on remote, manual and others on board. The object that caused the Julian started his maritime career in 1988, as an engineering cadet. He qualified in 1991 and spent the or local was not a good idea because the system injury is not trying to damage or injure us, it is next 18 years at sea on passenger vessels, progressing to chief engineer through the various ships, roles would control what it could to counteract my generally doing what we have asked it to. and ranks. In 2007, Julian was seconded ashore as a superintendent and was promoted to senior fleet intervention; engines started, pumps changed manager and then technical operations director for Carnival UK, where he was also a Merchant Navy 1 https://www.gov.uk/maib-reports/rupture-of-exhaust-gas-boiler-on-passenger-cruise-ship-island-princess-while-undergoing-sea-trials-in-the-bay-of- Training Board technical committee representative, before leaving to set up his consultancy business. naples-ltaly-with-3-people-injured-and-loss-of-2-lives

Practice makes perfect passenger ferry | machinery

A laden roll-on/roll-off (ro-ro) ferry was nearing the switchboard and manually disconnect the The senior engineer returned to the ECR and and power management system to automatic the end of its sea passage and preparing to shaft alternator (Figure 1). During this operation, saw that the second generator was running but control, immediately restoring power. On enter harbour. In the engine control room the first diesel generator engine tripped on not supplying the main switchboard as both the restarting the main engines, the vessel resumed (ECR), the engineering team were preparing low lubricating oil pressure and the vessel lost engine and power management system were passage without further incident. the main propulsion plant for entering harbour. electrical power. The main engines continued to under manual control. He switched the generator The plant consisted of two propeller shafts run for a few minutes before they stopped due to that were each driven by a main engine via a a lack of fuel pressure. clutch and gearbox. Each individual power train had a shaft alternator that supplied power to On the bridge, the officer of the watch (OOW) either the main switchboard or a dedicated turned the ferry away from danger and an bow thruster motor. Two additional diesel anchor was prepared for letting go. The vessel’s generators supplied auxiliary power to the main emergency generator automatically started switchboard when the shaft alternators were supplying critical systems such as steering and connected to the bow thruster motors. A power communications when the power failed. management system automatically maintained the electrical integrity of all supplies.

An engineer in the ECR attempted a remote start of one of the diesel generators but it failed to start. The engineer then went to the machinery space and started the engine in local control. The second diesel generator was also started. At the same time, the senior engineer went to investigate a stabiliser room bilge alarm that had activated.

At the main switchboard in the ECR, the Figure 1: Main switchboard engineer set the power management system to manual to connect the running generators to Figure 2: Lubricating oil purifier Figure 3: Diesel generator

The Lessons

1. Equipment → Let the system do the work. The vessel had a fully operational power management oil level check may have indicated that there was a problem. The failure to start was associated with the low system for maintaining electrical power. When the system was set to manual to connect the incoming diesel oil level in the sump; it is good practice to check running machinery before standby to ensure that potential alternators to the main switchboard, the power management system was thereafter unable to automatically critical failures are identified. restore power. This extended the period when the vessel was not under command. The design intent for the power management system was to quickly and efficiently detect and isolate power generation issues when 3. Maintain → Conduct rounds. The low oil level in the generator was caused by a fault with the lubricating operating in automatic mode. oil purifier cleaning the engine’s oil. The purifier had started to dump the oil to a waste tank (Figure 3). Regular and comprehensive machinery rounds may have picked this up before the situation became critical. 2. Check → Be inquisitive. After a local engine start, it is