MAIB Safety Digest 3/1990

MARINE ACCIDENT

INVESTIGATION BRANCH

Summary of Investigations No 3/90

Marine Accident Investigation Branch 5/7 Brunswick Place SOUTH AMPTON Hants SO1 2AN

Telephone: 0703 232424

Accident Reporting Line: 07 1 276 6004 (24 hours)

This summary contains facts which have been determined up to the time of issue. This information is published to inform the shipping industry and the public of the general circumstances of accidents and must necessarily be regarded as tentative and subject to alteration or correction if additional evidence becomes available.

Extracts can be published without specific permission providing that the source is duly acknowledged.

Crown copyright 1990

INDEX

Introduction Page N o

1. Engine Room Fire

2. Grounding of a Ro-Ro Paper Carrier 3

3. Sinking of a Harbour T u g 3

4. Defective Asbestos Insulation 4

5. Accident involving a Liquified G a s Carrier 5

6. Accidents to Personnel on board Offshore Support Vessels 7

7. Fire in a Fuel Oil Tank Certified for Hot Work 9

8. Carbon Monoxide Poisoning 10

9. Injury and Heavy Weather D a m a g e on a Coastal Tanker 11

10. Grounding of a Fishing Vessel 14

11. Sinking of a Small Fishing Vessel 15

12. Life-raft saves another Four Lives 16

13. Accidents involving the Fishing Gear on Beam Trawlers 17

14. Loss of a Fish Factory Trawler 19

15. Loss of two Men from a Fishing Tender 21

Appendix

INTRODUCTION

In the Introduction to the first Summary of Investigations i t was pointed out that the recommendations resulting from an investigation are reflected in the “Comment” section which forms a part of each summary. Obviously the investigation which follows an accident and the associated recommendations can be very varied and in a number of cases ‘the recommendations are not new. They will have been made in the past but unfortunately are not always heeded. One important way in which recommendations are passed on to the industry is through the system of Merchant Shipping Notices, or as they are more often referred to, M. Notices. These are addressed to various sectors of the industry, depending on the subject content of each Notice, and there is a statutory requirement for them to be carried on most United Kingdom registered vessels. They are issued only after most careful research and, if applicable. studies of accident trends. Some M. Notices were issued many years ago, however they are kept constantly under review.

It will be noted that in a number of the summaries in this publication attention is drawn to a variety of M. Notices covering such diverse subjects as the keeping of a safe navigational watch on board fishing vessels to the health hazards and precautions associated with asbestos. If more attention had been paid to the extremely valuable recommendations and information contained in the Notices referred to in these summaries some of the accidents would not have taken place. The important message is that it serves no useful purpose to require that copies of M. Notices are carried on board if they are not read and followed where applicable.

Summary of Investigations No 1/90 contained summaries which referred to prosecutions under the Merchant Shipping Acts. The purpose was to emphasise that the circumstances of some accidents do merit prosecutions and that disciplinary action or prosecution can be a recommen- dation arising from the investigation of an accident. The question has been asked whether it is right or indeed fair of us to include this information in the summaries. Disciplinary action can range from a confidential verbal reprimand by the appropriate authority to action being taken against an offender’s certificate of competency or service or to prosecution of the shore based management. It is of course only considered when there has been a clear breach of the Merchant Shipping Acts or, perhaps, local bye-laws. As disciplinary action can be so wide ranging and is a very personal matter for those concerned it has been decided that this information will not be included in the summaries in future. However it must always be borne in mind when reading the summaries that, where appropriate, disciplinary action will have been taken and that individuals will be suffering the consequences of their actions or inactions.

Although there is no requirement under the Merchant Shipping (Accident Investigation) Regulations 1989 for accidents to or on pleasure craft to be reported to MAIB, the details of a number of such accidents do reach us and some of these require investigation. The summary of our investigation into such an accident is included in this publication and it concerns the use of a heater fuelled by liquified petroleum gas. What is important about this incident is that the lessons to be learned are just as important to other seafarers, as well as owners and users of pleasure craft. The same goes for many of the accidents included in these summaries and just because they concern a particular type or size of vessel must not be viewed in the light, “that does not concern me”. We can all learn from the mistakes and misfortunes of others and that is why it is hoped that this publication will be read by as many people as possible who are concerned with ships and the sea, whether for business or for pleasure.

Chief Inspector of Marine Accidents September 1990

1. ENGINE ROOM FIRE

A general cargo ship of 985 gross registered tonnage was on passage off Lands End with a cargo of stone. At 23 17 hours in calm weather, a fire broke out in the engine room which fortunately was quickly seen by the Engineer Officer on watch. He reported it to the Master, who informed the Coastguards and then co-ordinated the mustering of the crew, the closing down of all air inlets and outlets to the engine room, the discharging of the engine room C 0 2 gas smothering system and the running out of the ship’s fire-fighting equipment. The crew moved to the forward end of the ship because there were fears of a possible engine room explosion. During this period i t was not possible to use the VHF communication on the bridge. When it was considered safe to return to the bridge, the Master requested from the Coastguards expert advice to establish if it was safe to enter the engine room. A Royal Navy helicopter was scrambled and, in conjunction with the Fire Brigade and the Coastguards, the local ‘Fire-fighting at Sea Plan’ was activated, resulting in a team of three fire-fighters being landed on the ship. The team made regular surveys of the engine room surrounding structures and, when it was considered safe to do so, entered the engine room wearing breathing apparatus and with a fire hose. When the fire was out and after venting the engine room it was discovered that the cause of the fire was the failure of a compression joint on the lubricating oil system, causing oil to spray under pressure onto a hot exhaust manifold which ignited the oil.

Observations

1. This is not an unusual type of accident. Badly fitted compression joints and unsupported pipework systems are among some of the more common causes of serious fires in ships’ engine rooms.

2. In this case, fortunately, there were no injuries to persons on board, but the ship was put out of operation for a few weeks during which extensive repairs to the engine room were found necesssary.

3. Following discovery of the fire, the ship’s crew, some of whom had previously attended fire-fighting courses, all acted in a calm, professional manner. The value of attending courses was demonstrated.

4. Although not required, the ship had a spare set of life-jackets at the muster station (the bridge) which was over and above those in Merchant Shipping Notice No M. 1238. This provision proved itself by saving time and avoiding re-entry to the accommodation deck.

Comment

1. This accident illustrates the importance of good workmanship in the fitting of pipework and regular maintenance which should include inspection of all piping particularly where subject to vibration and/or where fitted in spaces containing hot surfaces.

2. Merchant Shipping Notice No M. 1229 highlights some causes of fires and recommends precautions to be taken to reduce the risk of fire in machinery spaces.

i

2. GROUNDING OF A RO-RO PAPER CARRIER

A partly laden 4.929 gross registered tonnage ro-ro paper carrier grounded near the port of discharge in Finland. whilst under pilotage on passage through an archipelago.

An alteration o f the rudder angle by the helmsman. from hard a-port to port 10, contrary to the Pilot'\ instructions. caused the ship to override the next leading line. This occurred during a manoeuvre which involved a large alteration of course to port in an area of restricted sea room.

The helm was returned to hard a-port in an attempt to regain the leading line, soas to pass between two shallow parches close ahead, and was then put hard a-starboard to counteract the port swing. However, the how closed shoal water north of the channel. and then swung rapidly to starboard causing the ship to cross the leading line. Although attempts were made to correct her course and to decelerate the forward motion. the ship grounded in an area to the south of the channel.

Observat ions

1, The wind was east by south force 6 with clear daylight visibility and a slight choppy sea.

2, The ship was proceeding at approximately 12.5 to 13 knots with a trim of 25cms. by the head.

3. The bridge was manned by the Master. Pilot. Second Officer and a seaman who was steering by hand to the Pilot's instructions.

4. All the bridge equipment in use was operating satisfactorily immediately before, and at the time o f , the grounding.

Comment

I. The rudder indicator was not being properly monitored, resulting in a delay in the detection of a rudder position contrary to the Pilot's instructions.

9 The ship passed close to the \hallow water north of the channel as a result of a delayed instruction to the helmsman to apply starboard helm.

3. When the bow ofthe ship began to swing to starboard, the rate of the swing was enhanced by the effect of the large rudder angle applied. the high speed, and by the resultant "channel effect" caused by the close proximity of the port side of the bow to the ground.

4. The passage might have been safely undertaken had the ship been trimmed to provide maximum manoeuvrability and conducted at an appropriate speed.

3. SINKING OF A HARBOUR TUG

A general cargo coaster of 497 gross registered tonnage (grt) set sail despite very bad weather which was forecast. At the time of the incident the wind was south-westerly force 7/8 with a 1-1.5 metres sea in the lee of the land. It was a dark night with good visibility.

A tug (of 57 grt) was hired to assist the coaster, which was having engine trouble due to contaminated fuel, enter harbour. Whilst manoeuvring to pass up a tow rope at the bow of the coaster, the tug was turned across her bow by the forces of interaction and subsequently sunk.

The coaster had just taken on the Pilot and was making a speed of between 3 and 4 knots. The tug, under the command of an experienced tug Skipper, was being manoeuvred towards the starboard bow. The interactive forces caused by the pressure wave at the coaster’s bow canted the tug across the stem which struck the tug just aft of midships. The tug was rolled heavily to starboard and pushed down by the stem. The sea entered the engine room through an open hatch and the tug sank by the stem.

The pilot boat was fortunately still on scene, and very rapid and proper action by the coxswain allowed the tug’s three crew to climb out of the wheelhouse window and onto the pilot boat. This feat of seamanship was made more difficult by ropes from the tug fouling one of the pilot boat’s propellers and by the fact that the coxswain was alone in the boat.

Observations

1. The tug Skipper was very experienced and considered himself well aware of the dangers of interaction.

2. The pilot boat was manned only by the coxswain.

3. The Master of the coaster was alone on the bridge just prior to the accident

Comment

1. Merchant Shipping Notice No M.930 describes the effects of interaction between ships and specifically between ships and attendant tugs.

2. Merchant Shipping Notice No M. 1306 makes recommendations on the manning of pilot boats by two persons (not including the Pilot).

3. The pilot boat coxswain was commended for his action in rescuing the tug’s crew.

4. It would have been more prudent to have waited until the Pilot had safety boarded and reached the bridge before attempting to make the tug fast. This would have allowed the Master to concentrate fully on each separate operation and to have had assistance on the bridge.

5. Merchant Shipping Notice No M.748 recommends that openings situated on the weather deck which provide access to spaces below the deck should be kept closed during towing operations.

4. DEFECTIVE ASBESTOS INSULATION

Narrative e

An area ofloose asbestos insulation was discovered in the engine room workshop o fa passenger/ cargo ro-ro ferry . The shore management company were informed and promptly engaged specialist asbestos contractors to remove o r seal the loose asbestos. The repairs were unsuccessfuI. Also. on further inspection o f other engine room spaces. extensive areas of damaged asbestos insulation were f'ound. Several attempts were made by the specialist contractors to repair the affected areas before the vessel was taken out of service so that permanent repairs could be completed and adequate precautions taken to ensure the safety of personnel.

I. Although a degree ofcontrol was exercised by ship's staf'fwith respect to entry to the site of the repairs in progress. they did not at first fully appreciate:-

a) the actual extent of defective asbestos within the main engine room space

c) the recognised precautions to he taken

2. Subsequently. w h e n i t was appreciated that the original repair had failed to permanently seal the area of defective insulation. a more conscientious approach was adopted. The ship’s staff determined the extent of the defective asbestos and looked up the guidance from appro p ri at e Merc hant S h i p p i n g N o t ice s a nd S t a t uto try Ins t r umen t s re I at i ng to the safety precautions to be taken.

I. I t was not u n t i l the vessel was taken out of' service that the repair work was undertaken in a satisfactory manner using the correct equipment and applying adequate safety precautions.

2. The management company subsequently addressed the matter by equipping its vessels w i I h a p p ropri ale re s p i rat ory sam p I i ng and pro t ect i ve eq u i pme n t a nd p ti bl is hed an annex to its FI eet Reg it I at ion s/Operat io ns Boo h dra w i ng at te n t i on t o Me rc han t Shipping N o t ice N o M. 1354 and stating the procedures to be followed when dealing with asbestos.

5. ACCIDENT INVOLVING A LIQUIFIED GAS CARRIER

A 26,802 gross registered tonnage liquified gas carrier with a cargo of Propane and Butane was proceeding under pilotage inward bound on the River Thames. (See Figure 1 ). The wind strength was force 7; it was cloudy with good night visibility. Approximately 20 minute5 after embarking the Pilot, the ship struck Sunk Head Tower. There were no injuries but the ship sustained fractures to the hull plating which opened the Forward Deep Tank to the sea. However, the cargo containment was not affected.

Observations

1. The Master had anticipated taking the Kings Channel and the ship was in a position inward of the designated pilot boarding position; this was at the request of the pilot cutter.

2. The initial Pilot/Masterexchange of information was incomplete and an adequate pilotage passage plan was not formulated.

3. Although the progress of the ship was monitored, the course was not projected ahead on the chart and, therefore, the imminent risk of collision with Sunk Head Tower was not appreciated.

4. Plotted charted positions were disregarded in favour of assessing the position of the ship by visual observation of the relative bearings of lights of buoys. The misinterpretation of the light of a distant buoy for a reported erratic flashing of the light of a closer buoy resulted in the ship being in a position different from that assumed.

Comment

1. Merchant Shipping Notice No M.854 and the Department of Transport publication “A Guide to the Planning and Conduct of Passages” contain guidance on navigation safety and proper passage planning.

2. When a Pilot is to be taken, he should ideally be embarked as early as possible. This would enable the necessary initial Pilot/Master exchange of information and passage planning to be conducted prior to the ship entering an area where navigation was potentially hazardous.

6. ACCIDENTS TO PERSONNEL ON BOARD OFFSHORE SUPPORT V ES SE Ls

During 1989 and 1990, there have been several accidents to personnel on board offshore support vessels involved in the discharging and loading of cargo to and from offshore installations. Some specific cases are summarised below.

Case 1 - two crew members went to the stern of their vessel to hook on a skip to the platform crane for discharge. As they returned forward up the starboard walkway, a wave came over the stem roller and knocked the two men over. One of them sustained fractured ribs.

Case 2 - also involved