MAIB Safety Digest 2/2024

SAFETY DIGEST Lessons from Marine Accident Reports

Featuring introductions by Jeremy Dale | Robert Greenwood | Samantha Ward

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 regarded as tentative and subject to alteration or correction if additional evidence becomes If you wish to report an accident or incident available. The articles do not assign fault or blame nor please call our 24-hour reporting line: do they determine liability. The lessons often extend +44 (0)23 8023 2527 beyond the events of the incidents themselves to ensure The telephone number for general use is: +44 (0)23 8039 5500 the maximum value can be achieved. The branch email address is: maib@dft.gov.uk Extracts can be published without specific permission providing the source is duly acknowledged. This publication and previous safety digests are available online: www.gov.uk/government/collections/maib-safety-digests The editor, Clare Hughes, welcomes any comments or suggestions regarding this issue. To see how the General Data Protection Regulation (GDPR) affects the If you do not currently subscribe to the safety digest way we use and store your data go to: or other MAIB publications and would like to find out www.gov.uk/government/organisations/marine-accident-investigation- more, please get in touch with us: branch/about/personal-information-charter

▶ By email to publications@maib.gov.uk; © Crown copyright 2024 ▶ By telephone on +44 (0)23 8039 5500; or 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 post to MAIB, First Floor, Spring Place, within an organisation. This is subject to it being reproduced accurately and not used in a misleading context. The material must be acknowledged as 105 Commercial Road, Southampton, SO15 1GH Crown copyright and the title of the publication specified.

GLOSSARY OF TERMS AND ABBREVIATIONS

CHIEF INSPECTOR’S INTRODUCTION 1 INDEX

M MERCHANT VESSELS 2 1. A step too far 4

2. A hidden trap 6

3. Fire in the hold 7

F 4. It all makes sense now 8 FISHING VESSELS 28 5. It was all back to front 10 17. You spin me right round 30 6. Feeling a little ripped off 12 18. Diesel disaster 32 7. Barrel of laughs 14 19. Worry about inaction, never action 34 8. Jumping into trouble 15 20. Unprepared and asleep 36 9. Time and tide wait for no one 16 21. Bouldered over 38 10. Mooring deck tragedy 18 22. Stay in lane 40 11. Loose logs 20

12. Pan pan 21

R 13. Man down 22

14. Knocked over 24 RECREATIONAL VESSELS 42 23. Hip hop crew 44 15. Do not keep watch on the small print 25 24. That wreck is there all right 45 16. Push me, pull you 26 25. Houseboat tragedy 46

INVESTIGATIONS 48

REPORTS 49

SAFETY BULLETINS 50

SAFETY FLYERS 56

GLOSSARY OF TERMS AND CHIEF INSPECTOR’S INTRODUCTION ABBREVIATIONS Welcome to the second MAIB Safety Digest of 2024. As usual, I will start by thanking our guest introduction writers, Jeremy Dale, Robert Greenwood and Samantha Ward, for introducing the merchant, fishing and recreational sections °C degrees Celsius of this edition. Each is an expert in their own field, and their insights to safety AIS automatic identification system help bring contemporary context to the cautionary tales in the following pages. I hope you will find time to read the whole edition – there is something here for C/E chief engineer every mariner – but please do read the section introductions. And, when you have C/O chief officer finished, please pass the digest on to others.

CCTV closed-circuit television Jeremy Dale makes the point that safety has come a long way since he was first in the industry. Risk assessments, toolbox talks, and personal protective equipment cm centimetre (PPE) are all examples of genuine attempts to improve safety that have developed over the last few CO carbon monoxide decades so we can all return home intact at the end of a trip. Safety, in one form or another, is usually a standing agenda item at board meetings, and whole safety management systems are devoted to the COLREGs Convention on the International Regulations for Preventing Collisions at Sea, 1972 topic. However, as Jeremy also points out, the “It won’t happen to me” attitude prevails. Further, in the DfT Department for Transport Efficiency-Thoroughness Trade-Off, safe behaviours are often early casualties (if you will excuse the pun). DP dynamic positioning So, what is to be done? ft foot/feet Regular readers of the MAIB Safety Digest and the introductions to each of its sections will have kts knots detected that planning is a regular theme. Not just planning how to achieve a particular goal, but also precautionary planning for dealing with unwanted events. As I have written before, a wise captain once m metre told me, “It is not what happens but how you deal with it that matters”. Preparing for unfortunate events needs nm nautical mile a shift of mindset from “It won’t happen to me” to thinking about those we are responsible for. If 'it' did happen, what would be the effect on my team, my family, and others I am responsible for? OSV offshore supply vessel “Mayday” the international distress signal Events have consequences, and a good safety culture starts with everyone taking responsibility for their decisions and actions, and the possible outcomes. As you read the articles in this digest, once you are over MGN Marine Guidance Note that sense of smug self-satisfaction at others' misfortunes, ask yourself whether, in similar circumstances, “Pan Pan” the international urgency signal you would have made safer choices.

PFD personal flotation device PLB personal locator beacon PPE personal protective equipment Andrew Moll OBE RIB rigid inflatable boat Chief Inspector of Marine Accidents RNLI Royal National Lifeboat Institution ro-ro roll-on/roll-off UKC under keel clearance VHF very high frequency

MERCHANT VESSELS It is fascinating to look expand my laminating skills and to be trained I believe that the noncompulsory wearing of back over one’s life to see how safety has in the art of spray lay up; there was no clean air or filters for such processes in those days. The lifejackets when going afloat recreationally contributes to the “It’s never going to happen ...it is worrying that this changed. Or has it? business moved to Stone Pier Yard in Warsash to me” attitude towards safety in this sector also applies to commercial As a teenager I was and my duties increased from running the laminating shop to being the only person able and generates a lack of understanding about lifesaving products and their upkeep. A high lifejackets that come to us lucky enough to live in to drive all the yard equipment, which included proportion of recreational lifejackets are not for a service Helford in Cornwall, a a travel lift, tractor and crane. I was very capable, serviced annually because people dislike quintessential English practical and safety conscious, but there was spending money on things they do not use. SeaSafe Systems has helped several companies village of twenty or no training for any of the equipment and not a and individuals to get their safety products to so houses, two tea hard hat, hi-vis jacket or steel-toed boot to be Our service department is staggered by the market and sometimes those organisations have rooms, a post office, seen anywhere. number of lifejackets that would prove unfit for become competitors. You might wonder why I a pub, a boatyard purpose in an emergency for reasons such as support the development of such products and and a sailing club being repacked without a CO2 bottle or firing situated on the banks of a small creek opening ...people did not want to cap or having a slit in the bladder. It is great my answer is simple: What if that product could save someone’s life? We know there have been out to the Helford estuary. In my early teenage be seen dead in hi-vis news that we are seeing an increasing number two occasions in the last 5 years when products years, I spent my holidays hiring out boats at of lifejackets with personal locator beacon (PLB) that we helped to market have done just that. the boatyard and loved every minute of it. There Moving forward to my late twenties I started products; however, a high percentage of these was no such thing as PPE back then; these days, a hunting, shooting and fishing clothing products will never work as intended because wearing thigh-high waders and no lifejacket and manufacturing company. Safety was at the very few are fitted correctly and it is worrying running across the foredecks of eight to ten hire forefront of my mind and we were very much that this also applies to commercial lifejackets boats to reach the boat at the end of the pontoon ahead of the curve when we launched the only that come to us for a service. It appears would not be an option. full range of hi-vis clothing for horse riders, but there is no understanding of how to fit these people did not want to be seen dead in hi-vis products correctly. back then. Dead being the operative word. Oh, Lifejackets were never how things have changed. worn, and extra PPE was Having been directly involved with maritime never carried safety for over 30 years, I can compare my own experiences with today’s standards and be in no JEREMY DALE OBE Hon FNI | Director, SeaSafe Systems Limited At 16 years old I started a boatbuilding doubt things have moved on. From lifejackets apprenticeship at a bespoke yacht manufacturer to protective footwear, a full range of PPE is Jeremy’s career has taken him from Cornwall to Hampshire and back again. Following the sale of the in Falmouth. During this period, I was also an now required for anyone to work in a boatyard family’s Southampton-based boatbuilding business Jeremy returned to the Helford River and started a active member of the Helford River Sailing Club or near the water. The commercial world has boat repair business. He established one of the first windsurfing schools in the West Country and became and became responsible for rescue boat duties. definitely upped its game, but the recreational director of Helford Hotels, which owned the Ferryboat Inn and the 30 or so flats and properties in the While there was always a rescue boat to support side is still lacking in safety awareness. It is quite surrounding area as well as the boat hire, ferry operation and windsurfing school. Some years later, Jeremy club races there were times that the borrowed ridiculous that, were a commercial maritime was persuaded to move out of Cornwall to join a boat manufacturer in Southampton. boats used for the task had to be rescued training organisation and a recreational training It was during this time that he set up a hunting, shooting and riding clothing company, which flourished for themselves. Lifejackets were never worn, and enterprise to be located alongside one another, 10 years until the recession of the early 1990s. It was around this time that Jeremy happened upon SeaSafe extra PPE was never carried. The most important both teaching the same marine courses, the on the Isle of Wight, which he has now owned for over 30 years. thing was to make sure that the R flag was flying commercial training organisation would Alongside the day-to-day running of SeaSafe Jeremy has served as a local school governor for 7 years, taken somewhere on the vessel. reprimand you for leaving dry land without an active role in the Isle of Wight Rotary, was a member and area chairman of British Marine, served two wearing a lifejacket while the recreational I finished my apprenticeship and moved to 3-year terms as a Cowes harbour commissioner and is currently chair of the Miss Isle School of Sip & Puff enterprise would not. Sailing, Cowes Yacht Haven and Cowes Town Waterfront Trust. Southampton to join the family boatbuilding business. This gave me the opportunity to In 2016, Jeremy was made an Honorary Fellow of The Nautical Institute and an Honorary Member of the United Kingdom Maritime Pilots’ Association. In 2021, he was awarded an OBE for his services to maritime safety in the Queen’s Birthday Honours.

A step too far passenger vessel | accident to person

A task involving a ladder had unfortunate sought at the ship's medical centre where, after consequences for a crew member on board assessment, the crew member was deemed to be a berthed cruise ship. The crew member was unfit for work for 72 hours. The crew member was standing on the top step of a small folding subsequently transferred to hospital at the cruise Failed metal support under top step stepladder to secure lighting power cables when ship’s next port of call for further comprehensive the step gave way, causing the crew member to medical evaluation. fall to the ground. An investigation was conducted on board and The impact resulted in back and head injuries, established that the accident was caused by the leading to a brief loss of consciousness and severe failure of the welds securing the stepladder’s top back pain. Immediate medical attention was step supporting rod to the frame (Figures 1 and 2).

Figure 1: The stepladder, showing the location of the failed metal support

Figure 2: The points of failure and damage

The Lessons 1. Equipment → It is unlikely that the weight of the crew member would have been sufficient to cause the 3. Maintain → Accidental damage to equipment can sometimes occur. A just culture working environment catastrophic failure of a metal support on a new stepladder. The stepladder used in this incident was of an balances fairness, learning and shared accountability and supports staff to adopt an open and honest approach indeterminate age but was not being overloaded so it is almost certain that the damage to the metal support was to reporting incidents. Where damaged equipment could affect the next user, a just culture is essential to pre-existing. understand why the failure occurred and how to prevent it happening again.

2. Check → The Provision and Use of Work Equipment Regulations 1998 require work equipment to be thoroughly inspected before use to make sure it is fit for the intended purpose. Work equipment should also be maintained in good repair and, where applicable, with maintenance and inspection logs kept up‑to‑date.

A hidden trap Fire in the hold charter angling boat | machinery bulk carrier | fire

Sometimes, it is the smallest things that cause positioned at the inlet to the fuel filter and so Arriving in harbour late at night the crew of a significant condensation dripping onto the cargo the biggest problems. In this case, a 38ft charter exposed to a flow of fuel that had not yet been bulk carrier prepared to offload their cargo of from the hatch cover beams. Once wet, this cargo angling boat became stranded due to a tiny cleaned (see figure). The restrictions in the loose animal feed pellets the following morning. could start to ferment, heat up and catch fire. mechanical fault while at sea with eight anglers chamber where the buoyant aluminium ball sat The pellets were an International Maritime and a lone skipper aboard. had become clogged with debris over time and Solid Bulk Cargoes Code group C cargo, classified When the cargo hold hatches were opened, a eventually jammed the ball, stopping the flow of as neither a liquefaction hazard nor a chemical large cloud of smoke was seen. The cargo was The angling boat was some 800m from shore fuel to the engine and causing it to stall. hazard, and had low inherent fire risk when dry. smouldering heavily in places. Crews from the and in an area prone to fast-running tidal Weather conditions were cold but dry when the local fire services, a tug equipped with a fire streams when the engine stopped. Attempts to Source: RacorStore first loads of cargo were taken ashore. monitor, and the ship all teamed up to fight the get it going again proved unsuccessful and the fire. Unfortunately, approximately 40% of the skipper used very high frequency (VHF) radio Sometime later, the stevedores noticed that some cargo was destroyed. to call for assistance. The local Royal National of the cargo was wet and very warm. On checking Lifeboat Institution (RNLI) all-weather lifeboat Fuel filter element the warehouse, the stevedores found that some Condensation​ Salt water ingress was dispatched and towed the angling boat of the pellets had started to burn and these from the hatch beams back into port, where the anglers and their catch were quickly broken up and extinguished. An were landed ashore. A simple tale with a happy investigation of the hold found that small areas of outcome, but certainly one to learn from. damp cargo were smoking; these were removed to the quayside and dealt with. Cargo operations The skipper investigated and found the Fuel outlet Fuel inlet were suspended to allow surveyors to board and problem with the engine after many hours of examine the situation. head‑scratching. Within the fuel filter was a ball Ball