MAIB Safety Digest 3/2004

MARINE ACCIDENT SAFETY DIGEST Lessons from Marine

INVESTIGATION BRANCH Accident Reports

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INVESTOR IN PEOPLE

MARINE ACCIDENT INVESTIGATION BRANCH

SAFETY DIGEST Lessons from Marine Accident Reports No 3/2004

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INVESTOR IN PEOPLE

Department for Transport Eland House Bressenden Place London SW1E 5DU Telephone 020 7944 3000 Web site: www.dft.gov.uk

© Crown copyright 2004

This publication, excluding any logos, may be reproduced free of charge in any format or medium for research, private study or for internal circulation within an organisation. This is subject to it being reproduced accurately and not used in a misleading context. The material must be acknowledged as Crown copyright and the title of the publication specified.

Further copies of this report are available from: MAIB 1st Floor Carlton House Carlton Place Southampton SO15 2DZ

Printed in Great Britain. Text printed on material containing 100% post-consumer waste. Cover printed on material containing 75% post-consumer waste and 25% ECF pulp. November 2004

MARINE ACCIDENT INVESTIGATION BRANCH

The Marine Accident Investigation Branch (MAIB) is an independent part of the Department for Transport, the Chief Inspector of Marine Accidents being responsible directly to the Secretary of State for Transport. The offices of the Branch are located at Carlton House, Carlton Place, Southampton, SO15 2DZ.

This Safety Digest draws the attention of the marine community to some of the lessons arising from investigations into recent accidents. It contains facts which have been determined up to the time of issue.

This information is published to inform the shipping and fishing industries, the pleasure 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 available. The articles do not assign fault or blame nor do they determine liability. The lessons often extend beyond the events of the incidents themselves to ensure the maximum value can be achieved.

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

The Editor, Jan Hawes, welcomes any comments or suggestions regarding this issue.

The Safety Digest and other MAIB publications can be obtained by applying to the MAIB.

If you wish to report an accident or incident please call our 24 hour reporting line 023 8023 2527

The telephone number for general use is 023 8039 5500.

The Branch fax number is 023 8023 2459. The e-mail address is maib@dft.gov.uk

Summaries (pre 1997), and Safety Digests are available on the Internet: www.maib.gov.uk

Crown copyright 2004

MARINE ACCIDENT INVESTIGATION BRANCH

The role of the MAIB is to contribute to safety at sea by determining the causes and circumstances of marine accidents, and working with others to reduce the likelihood of such causes and circumstances recurring in the future.

Extract from The Merchant Shipping (Accident Reporting and Investigation) Regulations 1999

The fundamental purpose of investigating an accident under these Regulations is to determine its circumstances and the causes with the aim of improving the safety of life at sea and the avoidance of accidents in the future. It is not the purpose to apportion liability, nor, except so far as is necessary to achieve the fundamental purpose, to apportion blame.

INDEX GLOSSARY OF TERMS AND ABBREVIATIONS 6

INTRODUCTION 7

PART 1 – MERCHANT VESSELS 8 1. Exposure to a Potential Killer 10 2. Collision in Fog 12 3. I Know Where I am, But Where am I Going? 13 4. Rule of the Road – What’s that? 16 5. Routine Maintenance Causes Engine Failure – Are Your Instructions Adequate? 18 6. Another Near Miss! – Coaster and Fishing Vessel 20 7. Too Close for Comfort 22 8. It Only Takes One Slip Up to Cause a Fatal Accident 23 9. Blackout! 25 10. Fatal Balancing Act 26 11. Risk of Collision Revisited 27 12. Working Under Pressure 28 13. When Things are Meant to go Wrong 29 14. Breakfast May Be Late 30 15. Offset in the Mediterranean 31

PART 2 – FISHING VESSELS 35 16. Are You Alone? 36 17. Deckhand Dragged Overboard and Lost While Shooting Creels 38 18. Own Goal 40 19. Another Unchecked Flooding 41 20. Fire on Unmanned Crabber 42 21. Down the Fish Room 44 22. Flooding – A Positive Outcome 47 23. Fire-Fighting Training Saves the Day 49

PART 3 – LEISURE CRAFT 51 24. Three Family Members Lost on Angling Trip 52 25. Leisure Craft and Commercial Vessels – a Conflict of Interests? 55 26. Fishing for Disaster 56

MAIB NOTICEBOARD 58

APPENDICES 60 Appendix A – Preliminary examinations and investigations started in the 60 period 01/07/2004 to 31/10/2004 Appendix B – Reports issued in 2004 60

Glossary of Terms and Abbreviations AB – Able Seaman ARPA – Automatic Radar Plotting Aid CCTV – Closed Circuit Television CO2 – Carbon Dioxide CPA – Closest Point of Approach FRC – Fast Rescue Craft GPS – Global Positioning System GT – Gross tons HS – Hydrogen Sulphide IR – Infrared LSA – Lifesaving Apparatus “Mayday” – Spoken distress signal MCA – Maritime and Coastguard Agency OOW – Officer of the Watch RIB – Rigid Inflatable Boat RNLI – Royal National Lifeboat Institution Ro-Ro – Roll on – roll off TSS – Traffic Separation Scheme VHF – Very High Frequency VTS – Vessel Traffic Services

Introduction Herewith another batch of salutary tales from the In the Fishing Vessel section, it is heartening to sea. Please take the time to read them – we all read two good news stories (cases 22 and 23). In fall into bad habits; complacency is probably the both cases, potentially lethal situations were greatest danger at sea. Hopefully these articles dealt with most professionally, so that vessels and will remind mariners of every kind that ours is crews were saved. Forethought, good equipment, not a forgiving environment, so we must all training and calm leadership carried the day. constantly be alive to hazards. Would you be ready to deal with such situations in your boat? Yet again, there are a number of collisions, groundings and near misses in this edition. Eion In the Leisure Craft section, there are two tragic Lyons, in his excellent introduction to the cases involving sea anglers. For fishermen, the Merchant Vessel section, stresses officers of the boat is merely the means of enjoying their sport, watch making wrong decisions. I echo his so it often does not receive the attention and sentiments. But nearly all officers of the watch, care that is essential. including all those involved in these incidents, know and appreciate “the Rules”, so why are they Please pass these articles on to sea anglers that not being universally and appropriately applied? you know, so that they can enjoy their sport in Here we must consider two factors: the growing safety. plethora of things to distract the OOW on the bridge, and fatigue. The former is something that companies, masters and OOWs must address – the OOW must not be distracted from his prime task. The latter is still poorly understood. Too many mariners consider that the only effect of Stephen Meyer fatigue that they need to be concerned about is Chief Inspector of Marine Accidents falling asleep. This is patently nonsense. Fatigue December 2004 affects a person’s alertness, comprehension, decision making abilities, judgment, awareness of danger and many other capabilities essential to the OOW. Our Bridge Watchkeeping Safety Study (published in July 2004 and available on our website or in hard copy from MAIB) identifies fatigue as a major causal factor in collisions and groundings. This has to be addressed.

MAIB Safety Digest 3/2004 7

Part 1 – Merchant Vessels account of ever-evolving technology and working practices. Whilst that debate will undoubtedly continue ad infinitum, I would suggest that the fundamental problem is not with the regulations, but with the failure of some watchkeeping officers to properly adhere to them. Whether it is failing to maintain an effective lookout (Another Near Miss!!), acting on the basis of inadequate information (I Know Where I Am, But Where Am I Going?), passing at an inappropriately close distance (Too Close For Comfort; Risk of Collision Revisited!), When approached by Stephen Meyer with an failing to take full account of the prevailing invitation to provide an introduction to the circumstances and conditions (Collision in Fog) Merchant Vessel section of this edition of the or blatant failure to comply with the most basic Safety Digest, I felt both flattered and privileged requirements of the COLREGS (Rule of the because of the opportunity that was presented to Road – What’s That?), it is clear that on too me. During the last few years, the Safety Digest many occasions officers of the watch are making has evolved significantly and is now renowned the wrong decision. In every one of these throughout the industry for the positive incidents, the difference between what actually contribution it provides to improving safety happened and a major incident was purely good awareness and performance within the UK fleet fortune. It is incumbent on all of us in positions and far beyond. However, the Digest is mainly of responsibility within the industry; regulators, dependent upon the source material, and the educational establishments, ship operators, continued submission of comprehensive incident shipmasters and watchkeeping officers alike, to reports is therefore actively encouraged. make every possible effort to ensure better understanding and implementation of the Rules Consistently, the Safety Digest has provided of the Road. readers with a broad selection of reports demonstrating the sometimes horrifying Obviously the saddest incident reports appearing consequences of our errors or omissions, and this in the Safety Digest are those during which edition is no different. Although the incidents someone loses their life. There are three such are only a very small sample of those reported to incidents in this edition, all of which could have the Marine Accident Investigation Branch, and been avoided if only the risks involved had been recognising that the reports published in the properly assessed and appropriate preventative Digest are not selected on any statistical merit, it measures put in place. Whilst neither scientific is nevertheless disturbing and disheartening to nor definitive, the evidence available from my note that almost half occurred because of failures own fleet indicates that in excess of 90% of all to properly adhere to the Collision Regulations. safety related failures are entirely avoidable, if Whether this is evidence of a developing trend only greater care and attention had been devoted or not, I am provided with ample justification for to the planning, execution and monitoring of the reminding all seafarers charged with the task being undertaken. responsibilities of bridge watchkeeping duties to maintain their knowledge of and adherence to Whilst the other incidents are all important, one the provisions of the COLREGS. There has been in particular struck a familiar chord with my own much debate over recent years during which it experiences. Several years ago, in order to satisfy has been suggested that the regulations require the requirements of a contract, it was necessary yet further amendment and revision to take for my company to purchase a vessel. Except for

8 MAIB Safety Digest 3/2004

initial inspection, access to the vessel was denied It is the responsibility of all seafarers and shore- and a handover to our incoming crew was not based managers to promote and develop an allowed. Investigation of a potentially serious effective safety culture within individual ships, incident that occurred soon after purchase shipping companies and thereby across the entire identified that the vessel could not have been industry. This cannot be done independently operating under previous ownership in without reference to events and initiatives accordance with the procedures left on board at elsewhere within the industry. Consultation and time of sale. An effective familiarisation period exchange of information are essential to best aid would have identified this anomaly and the reduction in safety related incidents and I prevented the incident. “Blackout” highlights commend this edition of the Safety Digest to you the importance of ships’ staff having the as an effective part of that improvement process. opportunity to become familiar with their working environment. When this involves the acquisition of an existing vessel, it is essential that every effort is made to ensure cooperation between the leaving and joining crew.

Eion Lyons

Eion Lyons is Marine Director and Head of Technical Department of F.T. Everard & Sons Limited. Based at Dartford in Kent, Everard operate a fleet of petroleum product tankers around the UK, Ireland and close continent. Eion went to sea in 1977 with Hunting & Son, joined Bolton Maritime Management in 1981 gaining command in 1988 before spending some time with Sealink. His sea service encompassed tankers, bulk carriers, ro-ro passengers and OBOs. He joined Everard as an Assistant Marine Superintendent, progressed to Quality Manager and was promoted to his current role in 1995.

A Fellow and Council Member of the Nautical Institute, Eion is an Elder Brother and Assistant Marine Director of the Corporation of the Newcastle Upon Tyne Trinity House. He represents Everard on panels at the UK Chamber of Shipping and at other industry organisations.

MAIB Safety Digest 3/2004 9

Exposure to a Potential Killer Narrative tank, so that the senior first officer could test the atmosphere and complete the Permit to Work. On board a passenger ship, a crossover line Immediately on lifting the lid, the ratings between the port and starboard ballast/treated noticed a strong smell of sewage. They inserted black water/grey water tanks passed through an the fan extension hose into the tank and vacated adjacent cofferdam. The pipework in the the area. cofferdam had suffered corrosion, and this allowed sewage to build up in the tank. Ship’s A short while later, the senior first officer arrived staff were aware of the problem, and permanent to conduct the routine atmosphere test. While repairs were planned for the next refit which was approaching the tank, his multi-gas detector due within a few months. registered an alarm and recorded a hydrogen sulphide (HS) reading of 98 parts per million. Because of the amount of liquid that had leaked The compartment was immediately evacuated into the cofferdam, it was decided to empty the and the watertight access doors closed. contents using a portable salvage pump. The cofferdam had been opened on a number of The cofferdam lid was re-secured 15 minutes occasions without cause for concern. later by a rating wearing full compressed air breathing apparatus. The appropriate tank rescue equipment was assembled in the vicinity of the tank lid, in The ship’s senior doctor examined the two accordance with the company’s ‘Permit to Work ratings who had removed the cofferdam lid, and – Entry into Confined Spaces’ procedures. Two treated them for exposure to hydrogen sulphide. ratings removed the port aft lid to ventilate the They remained fit for duty.

10 MAIB Safety Digest 3/2004

The Lessons 4. It is advisable to test the atmosphere on opening tank lids, because potentially 1. Over-exposure to the potentially lethal lethal levels of HS can be released if tank toxic gases was prevented because the levels are high and the surface is ratings vacated the area immediately disturbed by the ship’s movement. In after opening the cofferdam lid. The addition, it is prudent to don breathing senior first officer fully recognised the apparatus when opening tank lids if the dangers, and understood the meaning of atmosphere in the compartment is the multi-gas detector alarm and reading unknown. levels. His direction to fully isolate the compartment stabilised the situation and 5. Whenever corrosion or component prevented the possible contamination of failure compromises the integrity of other areas. sewage systems, every effort should be made to repair the defect as soon as 2. The need to quickly replace the possible to prevent exposure to toxic HS cofferdam lid was recognised, and this gases. If sewage systems, or was achieved in a controlled, safe compartments suspected of containing manner, making use of the compressed sewage, are opened, there will be a air breathing apparatus to provide safety danger from the release of HS gas. to personnel. Concentrations as low as 10 parts per million are toxic, as indicated in Marine 3. Strict adherence to the company’s Permit Guidance Note 33 (M+F). It should also to Work procedures ensured that all be noted that HS might be released from appropriate safety equipment was stagnant bilge areas that contain animal, immediately available, and procedures vegetable or mineral oils which have were followed which reduced the risks been mixed with salt water, especially associated with this potentially when the surface has been disturbed. dangerous activity.

MAIB Safety Digest 3/2004 11

Collision in Fog Narrative 12 knots. Minutes later, however, the visibility deteriorated, and speed was reduced again to 8 A ship was on a river passage with a pilot knots. A tug pushing three barges loaded with embarked. As the visibility was about one cable, containers was then seen at about one cable on the bridge organisation was configured to the ship’s head. At about the same time, the conduct blind pilotage. Also, the navigation VTS advised that a tug was one cable ahead, and lights were switched on, a fog lookout was a small radar target was seen separating from the positioned on the forecastle, engines were ready clutter in the vicinity of one of the container for immediate manoeuvre and speed was vessels berthed alongside. Full astern was moderated to 8 knots. On the advice of the pilot, ordered, quickly followed by emergency full sound signals were not sounded. astern.

As the ship approached a container terminal, Fortunately, although the ship’s starboard bow visibility improved to about one mile, so the fog hit the tug’s port quarter, neither vessel was lookout was stood down and speed increased to damaged and there were no casualties.

The Lessons 3. Don’t be caught out by relaxing the precautions taken for restricted visibility