MAIB Safety Digest 3/1993

MARINE ACCIDENT INVESTIGATION BRANCH

Summary of Investigations No 3/93

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

Telephone : 0703 232424

With effect from the end of January 1994 our new telephone number will be: 0703 395500.

BUT THE ACCIDENT REPORTING NUMBER WILL NOT BE CHANGED.

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 1993

INDEX Page No

Introduction

Engine Room Fire whilst Alongside 1

Fatal Accident to an Engineer entering an Unventilated Space 2

Collision caused by Inadequate Lookout 3

Parting of a Lifeboat Fall Wire 5

Danger from Escaping Liquid Gas 6

Trackway Hoist Incidents 7

Unsafe Access 8

Foundering of Work Boat 9

Loss of a Beam Trawler with Loss of Life 10

Loss of Fishing Vessel after Collision with an Offshore Supply Vessel 12

Navigational Error resulting in Grounding and Damage 14

Loss of a Fishing Vessel due to Fire 16

Faulty Operation of Bilge System 18

Sea Cock Accessibility 19

Wooden Boats - Caulking above and below the Waterline 20

Dangers of Dirty Bilges and Poor Maintenance 21

Major Injury during Landing of Fish 22

Accidents caused by Footwear 23

Battery Explosion 24

Appendix A - Investigations Commenced in the Period 01/08/93 30/11/93

Appendix B - MAIB Priced Publications available from HMSO

Appendix C - HMSO Stockists and Distributors Overseas

INTRODUCTION

Investigations into accidents can serve three broad purposes: to find out what caused the accident; to determine who is to blame; to apportion liability. Occasionally the different aims of an investigation can overlap but each has its rightful place. The Branch is particularly concerned with trying to prevent the same type of accidents happening again, and to do this we need to know the causes. The way we go about trying to prevent recurrence is by making recommendations or making known as widely as possible the lessons learnt. Although accidents range from the most serious - with loss of life and major damage to vessels and property - to minor incidents where little or no harm is done, a common factor throughout is the likelihood that useful lessons are there to be learnt.

Clearly the Branch cannot investigate every single accident which occurs on UK registered vessels, and it might therefore be thought that some of the lessons to be learnt are being missed. Fortunately, however, many accidents are investigated by the Safety Officer on-board the vessel with the support of the Safety Representatives and the Safety Committee. Under the Merchant Shipping (Safety Officials and Reporting of Accidents and Dangerous Occurrences) Regulations 1982, certain vessels are required to appoint safety officials and to carry out on-board investigations. The value of these investigations ought not to be underrated; they serve an extremely useful purpose. First of all, such investigations can be carried out soon after the accident has occurred without waiting for the vessel to reach port. Secondly, all the information and the evidence is at hand. More importantly though, those on-board are in a position to take action to prevent a similar accident occurring again on the vessel. However, it is extremely difficult for those on-board to make known the lessons learnt on a far wider scale than just their own vessel. This is where the Branch comes into play.

When the details of investigations carried out on-board are sent to us, we are able to review them and include in this publication those which are of interest to a wider audience. There is no doubt that the quality of many of those investigations is of such a high standard that there is no need for the Branch to investigate further.

This introduction provides an ideal opportunity to express appreciation for the efforts of all those who carry out on-board investigations, whether they concern accidents or dangerous occurrences. By so doing you are helping to improve the safety of everyone at sea. Even if you are not required by the Regulations to have a safety officer on- board, such as on fishing vessels, please do ensure you investigate accidents and dangerous occurrences for, in many instances, you are the best placed to do that. And, of course, let us know about those investigations.

Chief Inspector of Marine Accidents

December 1993

1. ENGINE ROOM FIRE WHILST ALONGSIDE

A 1,597 gross registered tonnage motor chemical tanker had left dry dock and moved alongside a loading berth where at 1500 hours, cargo loading commenced. The engine room was in the UMS mode when at 1915 hours the Second Mate on entering the accommodation from the bridge noticed smoke coming from the engine room. The Master and the Chief Engineer were informed and cargo loading operations were stopped. Immediately the Chief Engineer and the Second Engineer donned breathing apparatus and entered the engine room to tackle the fire using extinguishers. The remainder of the crew went to their fire stations and prepared extra breathing apparatus sets together with fire hoses and other extinguishers. The shore authorities were informed and the local emergency plan put into operation. By 1933 hours, both the fire brigade and the port stand-by fire tug were in attendance. At 2015 hours, the fire was extinguished and at 2318 hours cargo loading recommenced.

Observations

1. The fire fighting actions taken by the crew on discovery of the fire were correct and showed the benefit of good organisation and proper training.

2. The seat of the fire was centred in the port main engine clutch and was the result of severe overheating of the clutch assembly. The cause of this overheating was thought to be either excessive wear down on the engaging ring or poor venting.

3. The discovery of the fire by the Second Mate was fortuitous as the automatic fire alarm did not sound. Subsequent investigation showed that whilst the fire alarm system was in working order, the system had been activated at some time in the recent past but had not been reset. This could have had serious consequences for both the vessel and crew if the fire had developed further before it was discovered.

4. A further observation was that the alarm panel’s indicator lights were so small and faint that the crew failed to notice the status of the alarms when passing the fire alarm panel.

5. The Owner subsequently incorporated status checking of the fire alarm system in UMS procedures together with the fitting of easily seen alarm and system status indicator lights.

Comment

1. In this incident, there were no casualties to the crew and only minor damage to the vessel. It does however graphically illustrate the need for thorough testing and/or checking of fire and safety systems.

2. It also emphasises the necessity of allowing for human error when producing UMS or any other operational procedures.

2. FATAL ACCIDENT TO AN ENGINEER ENTERING AN UNVENTILATED SPACE

A foreign-registered split-hull hopper barge while at a repair berth in the UK was preparing for her Classification Survey. The ship's Engineer, a very experienced person, was required to open up the void spaces for ventilation before the surveyor attended. When this Engineer did not return for lunch the crew became concerned and mounted a search. H e was seen through the open manhole of one of the buoyancy tanks. One of the crew took a deep breath and descended the ladder into the tank and confirmed that the Engineer was not moving. After this the crewman was instructed to leave the tank. The Master and crew assembled at the tank manhole with a breathing apparatus, but none of the crew was able use it. A shipyard painter with experience in the use of breathing apparatus entered the tank and tried to resuscitate the Engineer, but without success. The fire brigade recovered the Engineer from the tank and he was taken to hospital but found to be dead on arrival from asphyxiation.

Observations

From visual evidence it was thought that the Engineer went into the tank to retrieve his torch and pen which may have fallen in while he was opening the manhole. The tank oxygen level was checked about five hours later and found to be considerably below the minimum safe limit.

Comment

1. There have been many similar accidents which, on occasion, have led to multiple deaths when crew have tried in vain to recover colleagues from enclosed spaces. The guidance regarding safe entry is clearly set out in:

1.1 The "Code of Safe Working Practices for Merchant Seamen" (1991 Edition), Chapter 10 - Entering Enclosed or Confined Spaces;

1.2 A MARITIME SAFETY CARD published by the International Maritime Organization which sets out basic precautions on tank entry and provides a safety check list.

2. It is extremely disturbing that there are still vessels operating with crews who do not know how to use the breathing apparatus provided.

3. COLLISION CAUSED BY INADEQUATE LOOKOUT

An offshore supply vessel had weighed her anchor and was proceeding towards a production platform. The Officer of the Watch (OOW) was alone on the Bridge while two crew members were securing the anchor forward. A trawler was towing her gear on a nearly reciprocal course, such that the vessels would pass port to port at close range. It was dark and both vessels were exhibiting appropriate navigation lights. The weather was fine and clear with a slight sea and a low swell.

The OOW of the supply vessel saw the red sidelight of the trawler fine on his port bow and interpreted her bearing to be opening. He then went to the aft manoeuvring console in order to communicate with the production platform by radio. In doing so, h e temporarily lost sight of the trawler.

The sole watchkeeper aboard the trawler was attempting to navigate his vessel along a Decca lane by adjusting the autopilot heading as necessary. Unaware of the presence of the supply vessel on his port bow, he altered the course of his own vessel to port. He then saw the supply vessel rapidly approaching on his starboard side, but expected her to keep out of the way. When it became apparent that no avoiding action was being taken the watchkeeper called the Skipper, who went to the Bridge.

Upon his return to the forward part of the Bridge, the OOW of the supply vessel saw the green sidelight of the trawler on his port bow at close range and took avoiding action by altering the course of his own vessel to starboard. The Skipper of the trawler also took avoiding action by taking the propeller out of gear. However, these actions were too late to avoid a collision.

Substantial damage was caused to the forepart of the trawler but, fortunately, there were n o serious injuries to personnel on either vessel. The supply vessel was only slightly damaged and both vessels safely returned to port.

Observations

1. The immediate cause of the collision was the failure of both vessels to maintain a proper lookout.

2. The duties of the 00W of the supply vessel prevented an all-round visual lookout from being maintained.

3. The watchkeeper of the trawler was primarily concerned with adjusting the heading of his vessel in order to maintain a planned track. H e did not take account of the need to keep a proper lookout.

Comment

1. Rule 5 of the Collision Regulations requires every vessel to maintain a proper lookout at all times.

2. So as to maintain a proper lookout during the hours of darkness, The Merchant Shipping (Certification and Watchkeeping) Regulations 1982 require a lookout to be posted in addition to the OOW. Similarly, Merchant Shipping Notice No M.1190 recommends that two men should be on watch aboard fishing vessels at such times.

3. Additionally, The Merchant Shipping (Certification and Watchkeeping) Regulations 1982 require that the lookout must be able to give full attention to the keeping of a proper lookout and no other duties shall be undertaken or assigned which could interfere with that task.

4. It is evident that this collision could have been avoided if additional lookouts had been posted in both vessels in accordance with the above required and recommended practice.

4. PARTING O F A LIFEBOAT FALL WIRE

While an offshore supply vessel was berthed alongside in port, it was decided to launch one of her lifeboats. The boat was lowered into the water, taken away and exercised satisfactorily for about 30 minutes. When it was re-stowed, the Chief Officer was not satisfied that the limit switches had operated correctly and decided to lower the boat again so as to test them. The crew disembarked and the lifeboat was then lowered a few feet. On inspection, the tripping arm of the aft limit switch was found to be missing. The forward limit switch was found to be inoperative.

The Chief Officer then instructed the Leading Hand to hoist the lifeboat to its stowed position using the winch motor. The aft davit arm reached its stowed position but the winch motor was kept running until the forward davit arm had also reached its stowed position.

The aft davit fall wire then parted which caused the aft end of the lifeboat to drop until its motion was arrested by a combination of the ship’s structure and the forward davit arm.

Observations

1. The lifeboat sustained damage although there were no injuries to personnel.

2. The fall wires were less than 2 years old and had been end-for-ended 7 months prior to the incident.

3. Maintenance records indicated that the fall wires had last been greased 6 months previously and that the fall blocks had last been drifted, examined and greased 9 months prior to the incident.

4. Subsequent inspection of the fall blocks revealed that none of the sheaves could be turned by hand although they appeared to be well greased.

Comment

1. The aft fall wire parted as a result of overloading caused by the action of the winch motor when the aft davit arm reached its stowed position.

2. Although relatively new, the fall wire may have been progressively weakened by frictional loadings due to the inability of the fall block sheaves to rotate freely.

3. This incident highlights the need to ensure that all davit safety devices, including limit switches, are working correctly before the recovery and stowage of a lifeboat under power.

4. In practice, during the period between overhauls, the free movement of fall block sheaves can normally only be checked when a lifeboat is either launched or recovered and every opportunity should be taken, at these times, to confirm whether or not the sheaves are rotating correctly.

5. DANGER FROM ESCAPING LIQUID GAS

In preparation for the task of repairing the expansion valve on a main refrigeration system, a member of the ship’s engineering staff pumped down the gas system and isolated the section which contained the expansion valve. However, due to problems with the vessel’s electrical supply, the pumping down operation could not be completed. Other operational difficulties, not directly connected with the refrigeration system, prevented the repair from being delayed until power became available to complete the pumping down operation. The ship’s Engineer therefore proceeded with the repair by slackening the expansion valve retaining nuts. On freeing the joint liquid Freon escaped from the system and sprayed onto his chest, arm and leg causing cold burns.

Observations

In order to save time the Engineer neglected to obtain and wear any extra protective clothing or equipment, even though the risk of escaping liquid gas was recognised.

Comment

Although there may well have been compelling reasons why this job was progressed before the relevant part of the gas system was properly pumped down, pressure to complete a task should never be allowed to relegate safety to a subordinate position.

6. TRACKWAY HOIST INCIDENTS

Two recent incidents involved the unsafe operation of a trackway hoist.

Case 1

A load was being transported across the engine room by manually moving a trolley hoist in its trackway. The intended path of the trolley was via a trackway turntable. However, the turntable was incorrectly aligned which caused the trolley to take an alternative route. The trolley ran off the end of the trackway resulting in injury to the operator.

Case 2

Following a period of maintenance during which the trackway end stops of a trolley hoist had been removed, the hoist was used to transport a load across the engine room. The trolley ran off the end of the trackway narrowly missing a crew member working below.

Observations

Case 1

1. The turntable had not been properly aligned and locked into position prior to operating the trolley hoist.

2. Trackway end stops were not fitted. The management company now intends to fit stop pins at the end of each fixed trackway.

Case 2

1. Ship’s staff failed to identify that the trackway end stops had not been replaced prior to operating the trolley hoist.

2. The management company has since issued instructions for trackway end stops to be painted a conspicuous colour and for ship’s staff to check that they are in position before the lifting plant is operated.

Comment

1. The Merchant Shipping (Hatches and Lifting Plant) Regulations 1988 require that any lifting plant is not to be used other than in a safe and proper manner.

2. With respect to the above requirement, these incidents highlight the need to ensure that trackway end stops are in position and that any turntables are properly aligned and locked prior to use.

9. LOSS OF A BEAM TRAWLER WITH LOSS OF LIFE

A 21 metre beam trawler was dredging for scallops when the crew suspected her gear had snagged, and