MAIB Safety Digest 3/1994

MARINE ACCIDENT INVESTIGATION BRANCH

Summary of Investigations No 3/94

Marine Accident Investigation Branch 5/7 Brunswick Place SOUTHAMPTON Hants S 0 1 52 A N

Telephone : 01703 395500

Accident Reporting Line 01703 232527 (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 1994

INDEX

Page No

Introduction

1. Hazardous Incident whilst Mooring a Large Tanker 1

2. Two Lives Lost Inside a Cargo Hold Access Trunkway 2

3. Incidents to Hydraulically Actuated Vehicle Decks/Ramps on Ro-Ro Vessels

4. Unsafe Practice in Lifeboat Launching Preparation

5. Obstruction at Tidal Berth causes Pollution

6. Potential Dangers in the Use of Portable High Pressure Water Washer 7

7. Accidental Release of Halon into Engine Room 8

8. The Sudden Capsize of a Fish Farm Workboat 9

9. Bridge Watch Left in Charge of Inexperienced Man 10

10. Man Lost Overboard from Fishing Vessel 12

11. Fisherman Carried Overboard and Seriously Injured 13

12. Fouled Propeller Leads to Fishing Vessel Sinking 15

13. Unattended Winch Results in an Accident to Deckhand 16

14. Rapid Flooding of Fishing Vessel 17

15. Loss of a Small Fishing Vessel 19

16. Angling Vessels - The Safety Code Proves its Worth 20

17. Engine Successfully Repaired at Sea in Adverse Circumstances 22

18. Two Cockle Dredger Vessels Capsize in Separate Incidents 23

19. Single Man Operated Stern Trawler Floods and Sinks 25

20. Hull Weaknesses Lead to the Loss of Two Fishing Vessels 26

Appendix A - Investigations Commenced in the Period 01/8/94 - 31/11/94

Appendix B - MAIB Priced Publications available from HMSO

Appendix C - HMSO Stockists and Distributors Overseas

INTRODUCTION It is hoped that all concerned will be aware of the new Merchant Shipping (Accident Reporting and Investigation) Regulations which came into force at the end of August. At the same time a Merchant Shipping Notice, No M.1584, was published which explains the new regulations and particularly sets out the reporting procedures in a simple tabulated form.

The main purpose behind the new regulations is to combine the various requirements which were included in the Merchant Shipping (Accident Investigation) Regulations 1989, the Merchant Shipping (Safety Officials and Reporting of Accidents and Dangerous Occurrences) Regulations 1982 and the Fishing Vessels (Reporting of Accidents) Regulations 1985 into the one single enactment. In addition, some revision has been made to the various requirements, chiefly for clarification.

The changes do mean that there is a bit more work to do in the event of an accident. For example fishing vessel skippers now have to report dangerous Occurrences in addition to accidents to their vessels and people; they are also required to carry out their own onboard investigations but are not expected to be full time investigators. All they are required to do is look into the circumstances of these types of incident and recommend action which could be taken to prevent recurrence. It is believed that in doing this conscientiously it is likely that a skipper would have a keener awareness of safety in general and apply this knowledge. Self knowledge is worth volumes of written guidance or well intentioned advice and is more likely to be put into practice.

To give effect to the change in reporting philosophy, the need for a radical review of the existing report forms was necessary. Instead of having three separate forms, the WRE1 for reporting accidents to vessels, the ARF1 for accidents to people and dangerous occurrences on merchant ships and the ARF2 for accidents to fishermen, there is now one single form, the Incident Report Form (IRF). The new form ha5 moved away, to some extent, from the "tick box" system which made up a large proportion of the ARF1 and ARF2 forms. Instead it requires more narrative and helps focus the mind of the person who is completing the form on how the incident happened.

Changes are not always welcome, but it is hoped the changes that have been made to the regulations and the reporting system will result in seafarers developing a greater awareness of what they can do to prevent accidents recurring.

Chief Inspector of Marine Accidents December 1994

1. HAZARDOUS INCIDENT WHILST MOORING A LARGE TANKER

A large tanker (260 metres in length) was mooring at a jetty and running lines out to dolphins with the help of ''rope runner" boats. She already had one spring, two breastlines and one headline fast. One of the boats was called to come in and pick up a second headline. The headlines consisted of large wires with rope tails. The coxswain and crew member on the mooring boat made the rope tail fast to the boat and motored away from the tanker's bow, towing the mooring wire towards the dolphin. She had gone about 10 metres when she suddenly came to a halt and began being pulled astern, back towards the tanker. Soon afterwards the boat struck the bow of the tanker heavily. The crew of the boat were thrown off balance because of the violence of the impact. They were unable to operate the quick release gear because of the tension in the rope tail. Fortunately the rope tail parted before the mooring boat was overturned and the boat was able to pull away from the tanker's side. The tanker's bow thruster was operating at the time.

Observations

This incident happened in daylight and in good weather. It appears that it was caused by the tanker's crew paying out the mooring line too quickly. The combined effect of the weight of the bight of wire in the water and the drag of the bow thrust on that bight of wire pulled the boat back towards the tanker.

The evidence from the boat's crew indicated that nobody on the forecastle of the tanker was watching the boat as the wire was fed out.

Officers and ratings on large ships should be aware that paying out a mooring line too quickly can put the mooring boat and its crew in a dangerous position. They should carefully monitor the situation overside during such operations.

In addition, Masters and officers should be aware that the operation of bow or stern thrusters during berthing operations can cause serious dangers for mooring boats and their crews, as well as providing the more obvious risk that mooring lines, heaving lines or messengers may be dragged into thruster intakes. Good communication of the relevant information between mooring positions and the bridge is essential to avoid such dangers.

2. TWO LIVES LOST INSIDE A CARGO HOLD ACCESS TRUNKWAY

A single-hold general cargo vessel of 996 gross registered tonnage was alongside in port and had commenced discharging her cargo of timber. The timber consisted of approximately 3 metre length cut hard wood logs of up to 30 cm in diameter with bark attached. The logs were loaded inside the cargo hold up to the level of the hatch coaming and also as deck cargo on top of the closed hatch covers.

Prior to opening the hatch covers, it was normal practice for the crew to sweep up any remaining debris on top of the hatch covers upon completion of the deck cargo discharge. In preparation for this task, the Mate instructed one of his crew to fetch some brooms, which were stored both in the forward storerooms and also at the bottom of the cargo hold aft access trunkway.

A few minutes later, the attention of the Mate was drawn to the crew member, who was now lying at the bottom of the aft access trunkway. While assistance was being summoned, the Mate entered the trunkway and was subsequently found lying on top of the first crew member. Another crew member entered the trunkway but, after experiencing difficulty in breathing, climbed back out. A shore worker then attempted to enter the trunkway but was prevented from doing so by another member of the crew.

After being alerted to the emergency, the Master started the cargo hold fan and then entered the trunkway wearing a self-contained breathing apparatus set. Both men were removed from the trunkway using a block and tackle but subsequent attempts to revive them failed.

Observations

1. The cargo hold and access trunkways had not been ventilated since the logs were loaded approximately 6 days before the accident.

2. Although the vessel carried gas detection equipment, no means were provided for remote detection.

3. Brooms were stored at the bottom of the trunkway for the purpose of sweeping the cargo hold upon completion of discharge.

4. In order to confirm the probable condition of the atmosphere inside the trunkway at the time of the accident, atmospheric tests were conducted under similar conditions upon the vessel’s next arrival at the port. The test results included a minimum oxygen reading of 1.9% and a maximum carbon dioxide reading of 10.5%.

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1. The two men died when they entered a dangerous enclosed space, which was deficient in oxygen and contained gas products of the timber cargo.

2. The Merchant Shipping (Entry into Dangerous Spaces) Regulations 1988 (as amended) apply to UK vessels and to non-UK vessels when in a UK port. They require that entrances to unattended dangerous spaces should be secured against entry and that procedures for safe entry should be laid down and enforced. A conscientious regard for the training of crew and for the strict enforcement of clearly understood procedures would probably have prevented this accident.

3. Although it is generally known that a depletion of oxygen may occur in cargo spaces filled with certain types of wood cargoes, the danger associated with the carriage of logs requires increased attention.

3. INCIDENTS TO HYDRAULICALLY ACTUATED VEHICLE DECKS/RAMPS ON RO-RO VESSELS

Two similar incidents occurred, on separate Ro-Rovessels, which involved involuntary movement of hydraulically actuated vehicle decks or ramps. Although the vessels were not ships", the ramps, hydraulics and control systems were similar.

In preparation for unloading the vehicle decks, drivers and passengers had made their way to their vehicles. The main vehicle deck was then unloaded and ship's staff stood by the control panels which served the upper decks and their respective ramps.

On both vessels it proved impossible to move the required ramps using only the control panels; mechanical operation of the solenoid operated hydraulic control valves being also necessary. Suitable extra persons were made available to manually actuate the solenoid valves and act as signallers.

These personnel arranged themselves so that one person operated the control panel, one operated the solenoid valves and one acted as signaller between the other two. The lowering of a part of the vehicle deck commenced. Unfortunately, the incorrect solenoid valves were operated causing a part of the vehicle deck to rise which was out of sight of all three persons.

On one vessel several vehicles were damaged due to contact with the deckhead of the vehicle space. In neither incident was there any injury but, naturally, the occupants of several vehicles were shocked.

Observations

1. It was impossible for the person at the control panel to see the person operating the solenoid valves, or for the person operating the solenoid valves to see the ramp he was attempting to move.

2. The identification labels on the solenoid valves were in a language which was not the mother tongue of the person delegated to operate these valves.

3. Blocking safety devices, normally functional when the control panels were employed, were overridden by local operation of the solenoid valves.

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1. The systems should be correctly maintained in order that operation can be performed from the proper control panels thus maintaining the integrity of the system's safety blocking arrangements.

2. The labelling of ramp control equipment should be clear and precise and in a language which is clearly understood by the operators.

3. It is advisable that passengers should be kept clear of ramps when local operation of the solenoid valves is necessary.

4. UNSAFE PRACTICE IN LIFEBOAT LAUNCHING PREPARATION

A large high sided passenger Ro-Ro ferry, equipped with large partially-enclosed lifeboats, was alongside its normal berth. The opportunity was taken to have a lifeboat launching training session for a group of ratings.

The lifeboat selected for the exercise was lowered to the embarkation deck. With the boat being held in to the side of the ship by the tricing pennants several of the ratings boarded, two of them climbing onto the boat’s aft canopy. In preparation for swinging out the boat one of the ratings on the aft canopy removed the safety pin on the tricing pennant release gear. Shortly afterwards the gear released completely, allowing the aft end of the boat to swing away from the side of the ship.

This sudden movement caused both men on the aft canopy to lose their balance. One fell from the canopy into the water, the other managed to grasp the tricing pennant and was quickly recovered by the crew on the embarkation deck of the ship. The rating who fell into the water swam to a nearby ladder built into the dock wall and climbed ashore.

Observations

1. The men tasked to release the tricing pennants were standing on the boat’s canopy rather than leaning through the access hatch provided.

2. The launching procedure being adopted on this occasion bypassed the bowsing in of the boat, using bowsing tackle, before release of the tricing pennants.

3. The two men who fell from the aft canopy of the boat were fortunate to suffer no apparent injury.

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1. Failure to employ bowsing tackles to pull the boat hard in to the side of the ship in order to unload the tricing pennants will, when the tricing pennants are slipped, result in a sudden transfer of load from the tricing pennants to the fall wires. In a boat fully laden with people this shock loading may be great enough to cause damage to the davits, or even their failure.

2. The strength of tricing pennants is usually such that they are not designed to take the loads which may be imposed on them by fully loaded lifeboats. It is thus possible for them to fail whilst embarking people.

3. The importance of performing training drills using tricing and bowsing gear in the correct fashion cannot be overemphasised.

5. OBSTRUCTIONAT TIDAL BERTH CAUSES POLLUTION

A 60 metre coastal' tanker arrived at a tidal berth to load 1176 tonnes of light crude oil. Loading was completed in the afternoon and it was then necessary to wait for the next tide and sufficient water for the tanker to sail. Low water occurred in the early evening, during which time the vessel took the ground.

Shortly before midnight, about an hour before high water, the crew turned out to prepare for sailing. It was then noticed there was crude oil on the water surface around the vessel. A report was made to the harbour authority and the Department of Transport Marine Pollution Control Unit was notified. While the source of the leak was being investigated, the crew deployed the buoyant mooring ropes as an emergency containment measure. Oil booms were placed downstream of the berth to prevent pollution of other parts of the harbour. At about 0100 hours it was established that the oil had leaked from No 4 starboard cargo tank. The shore hose was connected and discharge of No 4 tank was commenced. This was completed at about 0400 hours.

The tank was opened up and water was seen to be leaking in to it, evidently through a hole in the bottom. The remainder of the cargo was transferred ashore, this being completed by about 1000 hours. After gas freeing No 4 starboard tank, an internal inspection of it revealed a rounded and cracked indentation in the bottom plating. The ship was moved to a nearby slip for repairs.

Observations

1. Fortunately the pollution was not serious: it was calculated that less than two tonnes of the cargo was lost and it was all successfully contained in the vicinity of the berth. Much of it was recovered by skimming equipment.

2. A search was made off the berth during the following low water. A large lump of concrete about one metre square with a length of steel rail protruding from it was found (see photographs). This was without doubt the cause of the holing and consequent pollution. Although there had been dredging off the berth about a year before, it had since been in frequent use, with vessels usually taking the ground at low water. The source of the piece of concrete could not be traced.

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There are many tidal berths in United Kingdom ports and it is common for coastal vessels using them to take the ground at low water, as was the case here. However, extremely careful consideration needs to be given before allowing a loaded vessel to take the ground. Excessive stresses will be exerted on the hull if the ground is irregular or fouled and a dangerous loss of stability can happen in certain circumstances. So far as coastal tankers are concerned, in particular those carrying dangerous and polluting cargoes, the cargo operations should be planned so that when loaded the vessel remains afloat at all times.

6. POTENTIAL DANGERS IN THE USE OF PORTABLE HIGH PRESSURE WATER WASHER

A team of seamen were employed cleaning a cargo space with a portable high pressure washer. The washer was a diesel driven unit capable of producing high pressure hot water at 180bar and 155°C. After starting the unit a small leak in the flexible hose was discovered. In order to prevent the water from this leak impinging on an area sensitive to water, one of the crewmen placed his foot over