MAIB Safety Digest 3/1992

MARINE ACCIDENT

INVESTIGATION BRANCH

Summary of Investigations No 3/92

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

Telephone : 0703 232424

Accident Reporting Line 071 276 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 1992

INDEX

Page No.

Introduction

Engine Room Fire 1

Collision in Dense Fog between a Container Ship and 2 a Yacht

Grounding of General Cargo Vessel following Steering 3 System Failure

Power and Steering Loss on Ro-Ro Ferry 5

Grounding of a Coaster whilst Attempting to Berth 7

Heavy Weather Damage to a Ro-Ro Passenger Ferry 8

Hold Flooding and List 9

Hazardous Incident Caused by Wash 12

Death by Drowning whilst Boarding Coaster 13

Accident when using High Pressure Jetting Tool 14

Fall into Winch resulting in Death 16

The Grounding and Sinking of a Small Fishing Vessel 17

Accident on board a Fishing Vessel whilst working 18 with Winches and Chain

Sinking of Wooden Fishing Vessel 21

A Case to Support Survival Training and the Fitting 22 of a Liferaft

Sinking of a Day Angling Boat with Loss of Life 23

Advantages of Watertight Subdivision in Fishing Vessels 24

Sinking of Fishing Vessel due to Flooding 26

Sinking of a Small Single Handed Fishing Boat 27

Appendix A

Appendix B

INTRODUCTION

There have been many text books written on the subject of seamanship. Some of the older ones have gone out of print but remain classics in their own right, and a copy can be a much sought-after possession. Others are kept up-dated and new editions appear on the bookshelves and, then to add t o the store of knowledge available, new authors appear on the scene and present the same subject in a different manner. These text books, whether old or new, will become part of the essential library of both trainee and experienced seamen.

Good reference books help the practitioner form a sound background knowledge of the subject, but in most cases it takes practical experience before a person can really be said to be proficient. Seamanship is no different in this respect. A person can acquire any amount of knowledge from books on the work of navigating, maintaining and operating a vessel, but the all important skill aspect can only be acquired from hands-on practical experience.

Unfortunately, although experienced seafarers could be expected t o have achieved the skills associated with good seamanship many accidents which occur makes one wonder where those skills have gone. If we look at the examples of accidents which are included in this edition of Summary of Investigations, it will be readily seen that in a lot of cases poor seamanship, in its broadest sense, was a contributory factor. One would expect that seamen would realise the importance of ensuring that the bilge pumping system on their vessel would be in working order. It is in their own interest that the bilge pump is operative, that the strums are kept clear and that if a bilge alarm is fitted it is working in all respects and also the alarms are not switched off. Other examples show the dangers of high speed in fog, inadequate lookout, the effects of wash created by vessels and failure to take tank soundings.

All these are no more than examples of what one would term good seamanship but this all important factor was absent, or at least not being put into practice, in so many of these accidents. No doubt the experience was there but the skill necessary to carry out operations in the tradition of good seamanship was not, or at least, was not applied at that particular time.

A far greater emphasis has to be placed on the importance of the skills of good seamanship because if it is not accidents will continue to occur, many of them with fatal consequences, and those traditions we were so familiar with and rightly proud of will be a thing of the past. Text books on seamanship augment the skills which are so important, they cannot replace them.

Chief Inspector of Marine Accidents December 1992

1. ENGINE ROOM FIRE

A 363 gross registered tonnage passenger/vehicle ferry, propelled by twin Voith- Schneider propulsion units, and operating an inter-island service was approaching the terminal when black smoke was seen coming from the engine room vents. An immediate investigation by one of the crew established that fire had broken out in the engine room in the vicinity of the central heating boiler.

The engine room starboard door was closed, the engine room vents shut down, the boiler fuel shut off and the boiler electrically isolated. The crew then proceeded t o fight the fire using portable foam and extinguishers. The Master, after calling the Coastguard and arranging for the attendance of the fire brigade, continued to manoeuvre the vessel alongside despite damage to the main engine controls. Whilst the crew continued to fight the fire, the vehicles onboard were moved away from the engine room door.

Once alongside, the main engines and generators were shut down and the passengers disembarked. The fire brigade boarded to inspect the damage and to confirm that the fire was out. After an assessment of the damage, the vessel manoeuvred t o its proper berth on one engine where the vehicles were discharged.

Observations

1. The fire was located on the central heating boiler front and was caused by the fracture of a flexible fuel oil pipe leading from the header tank to the boiler pressure pump. The fuel, gas oil, sprayed onto a section of the boiler front which was not insulated and ignited.

2. The resultant fire damaged the motor, fan and fuel pump before melting part of the aluminium burner casing causing the assembly to break away and fall onto the floor plates. The fire spread to the immediate bulkhead and deckhead, severely damaging electric cabling in the vicinity.

Comment

1. This incident is similar to those quoted in Merchant Shipping Notice No M.1456 where particular emphasis is laid on the use of flexible fuel pipes and their suitability for the installation proposed. Regular checks of flexible pipes and their connections should be undertaken and the manufacturer’s projected life of such fittings strictly adhered to.

2. The provision of a suitable fire detection system within the space would have alerted the crew at an earlier stage and might well have reduced the amount of fire damage suffered.

3. The action of the crew in promptly tackling the fire using portable extinguishers undoubtedly prevented the fire developing into a serious engine room fire.

2. COLLISION IN DENSE FOG BETWEEN A CONTAINER SHIP AND A YACHT

A large container vessel was proceeding under pilotage within a narrow channel in dense fog. A small catamaran yacht was crossing the channel at right angles from port to starboard. O n seeing the bow of the container vessel on his starboard side, the Skipper of the yacht applied full port helm and full astern revolutions on his port engine. The yacht turned onto a heading parallel to that of the container vessel. However the flare of the bow of the container vessel made contact with the top of the yacht's mast causing it to break. Two crew members were thrown from the yacht as a result of the contact. They were subsequently recovered from the water with only minor injuries. The ship was unaware of the collision.

Observations

1. In the container vessel the bridge was manned by the Master, an officer, the pilot, a lookout and a helmsman; two radars were in operation and the appropriate sound signals for a vessel in fog were being made. However, the ship was proceeding at a speed of 16.5 knots, and no lookout was positioned forward. The yacht was neither seen nor observed on radar at any time.

2. The yacht was proceeding at between 6 and 7 knots with no operational radar. She was not sounding the appropriate signals required by the Collision Regulations.

Comment

1. The container vessel was not proceeding at a safe speed under the prevailing circumstances and conditions. A lookout should have been posted forward; even if he had not seen the yacht in time to avert the collision, he would at least have been able to report it. As it was, with the ship unaware of the accident, the two men thrown into the water were fortunate to survive. Merchant Shipping Notice No M.1348 draws attention to a number of previous accidents. t o ships which have resulted from serious disregard for the basic principles of good seamanship and prudent navigation in bad visibility.

2. It was not prudent for the yacht to attempt to cross the narrow channel in the prevailing circumstances and conditions. Further, at all times in fog the proper sound signals should be made and a keen aural lookout kept for other vessels' signals.

3. It is vital that small craft use a radar reflector and instal it to achieve the optimum effect, as recommended in Merchant Shipping Notice No M.1497. Conventional reflectors should be rigged in the "rain-catch" position, point upwards.

3. GROUNDING OF GENERAL CARGO VESSEL FOLLOWING STEERING SYSTEM FAILURE

A general cargo vessel of 985 gross registered tonnage was approaching a narrow stretch of navigable water. The Master and a rating were on watch and the vessel was being steered by autopilot. The Mate arrived on the bridge with the purpose of taking over the watch. While the Master and the Mate were speaking in the vicinity of the chart table, the off-course alarm sounded.

The vessel was observed to be swinging to port with 10" of port helm applied. The green light associated with the electrical steering system was illuminated, indicating a starboard helm order, but the rudder remained at to port.

The Master changed over to the hand tiller (electro-hydraulic) steering mode and ordered the Mate to apply full starboard helm. The Mate reported that the rudder was still not responding to the starboard helm order. The Master stopped the main engine and changed over to the direct hydraulic manual steering mode. The rudder then responded to the full starboard helm order and the Master put the main engine to full astern. Such action failed to prevent the vessel from grounding.

Observations

1. Damage was sustained to the fore peak tank and to No 1 double bottom tanks.

2. The failure of the electrical steering system was traced to a loose connection in way of the starboard contactor.

3. The contactors had recently been changed and it was found that the old type of connection on the wire ends was not suitable for use with the terminals of the new type of contactor.

4. The off-course alarm was set to operate after the heading of the vessel had deviated 20" from the intended heading.

Comment

1. Merchant Shipping Notice No M.1471 warns against the use of automatic steering systems in restricted waters. The delay in changing over to the direct hydraulic manual mode of steering following the failure of the auto-pilot was exacerbated by the fact that the Master failed to appreciate that the fault associated with the auto-pilot would also affect the hand tiller (electro- hydraulic) steering mode of operation.

2. The off-course alarm was set too high to provide an early warning of a steering malfunction; it has since been re-set at 10" in order t o provide an earlier warning of any deviation from the intended heading.

3. There is no evidence to suggest that the steering gear was not properly tested prior to departure. The electrical fault has since been rectified to the approval of the classification society concerned.

4. All Masters and Mates in the management company have since been reminded of their duties and responsibilities under Statutory Instrument No 571, The Merchant Shipping (Automatic Pilot and Testing of Steering Gear) Regulations 1981, and the advice given in Merchant Shipping Notice No M.1471.

4. POWER AND STEERING LOSS ON RO-RO FERRY

A 2495 gross registered tonnage ro-ro ferry with cargo but n o passengers was on its regular coastal passage south.

The weather at this time was south-easterly, gale force with wind speeds of 40 knots. The Master was on the bridge with the Chief Officer and two seamen. T h e vessel was on a south-easterly course with reduced engine revolutions to suit the conditions, when the vessel encountered a large trough followed by a very steep breaking sea. The vessel moved downwards into the trough but before she could rise to meet the oncoming sea, it broke on board burying the bow and hitting the bridge front windows with such tremendous force that all four windows were broken.

The ingress of large quantities of sea water tore down the wheelhouse deckhead and rendered all the bridge equipment immediately useless. The wheelhouse personnel were washed from one side of the wheelhouse to the other, suffering cuts and bruises with the Master receiving a cut on the back of the head and becoming semi-conscious. The vessel lost steering control and one engine stopped. She fell away to leeward and lay in the trough rolling violently.

Due to the proximity of the shore, the partial disablement of the vessel and the severe weather, the Chief Officer who had assumed command, put out a Mayday call using a hand-held V H F set. The rescue services were alerted and some of the crew airlifted off the vessel. Limited power was restored and the second main engine restarted but steering was still not available. The vessel continued to steam in 1 to 2 mile diameter circles with the nearest point to land being less than 1 mile away.

Due to the loss of the internal communication system, the Chief Officer requested, and was passed, a number of portable radios. Ten more people were lifted from the vessel at this time. During this period, partial control was regained and the vessel steered by the emergency steering system away from the coast and finally to a safe anchorage. The vessel subsequently continued her voyage under tow.

Observations

1. The vessel’s course and speed prior to the time of the incident was acceptable, she was pitching but not violently and only shipping light water forward. The wheelhouse windows were stated to be 12 - 15 millimetres thick with no apparent deformation of the frame occurring when the glass shattered.

2. The bridge/chartroom contained the radiotelephone and V H F equipment normally used for external communications. This equipment, together with all the bridge control, internal communication and information systems were put out of action due to the ingress of sea water.

3. The failure of the steering control mechanism and the apparent long delay before the emergency steering could be put into operation was due to the angle of helm on the vessel at the time the electrical failure occurred and the need to re-establish some form of communication between the bridge and steering gear flat. A considered decision was made to leave the vessel circling until some order and control had been established. When communication was regained, the emergency steering was operated by means of hand control of the solenoid valves.

4. The shut down of one engine was due to the short circuiting of the engine control system on the bridge. The remaining engine was kept running in order that the vessel could maintain steerage and avoid further damage.

Comment

1. Seafarers should never under estimate the power of the sea in a gale, and the damage that can be caused by a single wave.

2. Despite the failure of various control and communication systems, the prompt action of the crew prevented this incident turning into a major disaster. It illustrates the importance of sound professional training, good inter- departmental communication and effective safety procedure drill.

3. This case illustrates the value of having back-up equipment (such as portable VHF sets) stored separately from the main communications equipment.

5. GROUNDING OF A COASTER WHILST ATTEMPTING TO BERTH

A coaster of 800 gross registered tons was attempting to berth alongside a jetty in a small port. The jetty was orientated north/south and the vessel was on the west side of it heading north. The wind was easterly force 2 - 3. The sea was slight but, after previous strong winds, there was a heavy easterly swell. The vessel was moving alongside the jetty and had two ropes out forward and one rope aft.

forward The Mate and one seaman were forwar and one seaman was aft. The aft rope had been run out in a bight, ie the eye of the rope was secured on the bitts a n d t h e rope then ran from the vessel round a mooring post on the jetty and back to the aft capstan. Since the vessel was running too far ahead, the Master used the bridge controls to put the engine astern. The result of this action was that the bow turned towards the berth and the stern swung off the berth.

It is probable that the seaman aft had not completed putting turns on t o the capstan. He was unable to check the rope and the stern continued t o swing off the berth until the vessel grounded aft on rocks opposite the jetty. The vessel was able to clear the rocks under her own power then went to anchor off the port. The vessel had suffered damage to the keel plating, the rudder stock and propeller blades, and had to be towed to another port for dry docking and repair.

Observations

1. The stern moved off the jetty as a result of transverse thrust