MAIB Safety Digest 3/2005

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 3/2005

is an

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 2005

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 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. December 2005

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 and incidents. 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 2005

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 2005 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”

INDEX GLOSSARY OF TERMS AND ABBREVIATIONS 6

INTRODUCTION 7

PART 1 – MERCHANT VESSELS 8 1. Ro-Ro Ferry Bow Door Failure in Port 10 2. Well Practised, Instinctive Reactions Save Vessel From Potentially 15 Serious Engine Room Fire 3. Calm Weather Leads to a False Sense of Security 18 4. Shift of Timber Deck Cargo 20 5. Lifting Appliance Survey and Testing. Are You Up to Date? 25 6. Go it Alone and See What Happens 27 7. Poor Hot Work Control Results in Costly and Potentially Fatal Errors 29 8. Scrap Metal Carrier Nearly Goes Belly Up 33 9. Get a Grip(e) With Your Brakes 35 10. Oil Stowed in Hot Uptake Area Leads to Fire, and Open Doors and 37 Hatches Leads to Loss of Vessel 11. Grounding of Ro-Ro Ferry in Strong Winds 39 12. Port Not Starboard 42 13. A Near Miss – at High Speed – in Fog 44 14. Cast Adrift 45

PART 2 – FISHING VESSELS 49 15. Lulled Into a False Sense of Security 50 16. All Action and No Talk 52 17. Vessel Saved by a Plastic Bag? 53 18. Don’t Ride the Fish Lifting Gear 56 19. Net Hauled, Only to Sink with the Vessel 58 20. Family Tragedy Averted 59 21. Alcohol and Lack of Sleep – a Lethal Cocktail 62

PART 3 – LEISURE CRAFT 65 22. Anything But Plain Sailing! 66 23. Poor Decision-Making Leads to the Death of a Skipper 68 24. A Cheap but Priceless Early Warning 71

APPENDICES 73 Appendix A – Preliminary examinations and investigations started in 73 the period 01/07/05 – 31/10/05 Appendix B – Reports issued in 2005 74

Glossary of Terms and Abbreviations AB – Able Seaman ARPA – Automatic Radar Plotting Aid CO2 – Carbon Dioxide ECDIS – Electronic Chart Display and Information System GPS – Global Positioning System GRT – Gross Registered tonnes IMO – International Maritime Organisation ISM – International Safety Management Code ISO – International Standards Organisation LOLER – Lifting Operations and Lifting Equipment Regulations “Mayday” – The international distress signal (spoken) MCA – Maritime and Coastguard Agency MGN – Marine Guidance Note OOW – Officer of the Watch PEC – Pilotage Exemption Certificate RFA – Royal Fleet Auxiliary Ro-Ro – Roll on/Roll off SMS – Safety Management System VHF – Very High Frequency VTS – Vessel Traffic Services

Introduction The wide variety of accidents and incidents One of our greatest dangers at sea is covered in this Safety Digest is an excellent complacency. We may do things a thousand reminder of just how broad our industry is – and times – and get away with them. But when what a warning that hazards lurk everywhere. we are doing becomes so second-nature to us that we do not think about it, then we have become a There are some good-news cases, where we danger to ourselves and others. In reading the should learn how others have done things well: cases in this Safety Digest, consider how they an engine room fire well handled by a practised apply to you. Hopefully they will make you and confident crew; an heroic jettison of cargo to think . . . save a listing ship; a pilot's concern at the stability of a vessel he was about to take to sea; the quick reaction of an angling boat skipper, who cut his anchor rope to avoid being run down; and the fitting of a cheap smoke alarm to a new yacht that saved a major fire. Stephen Meyer Chief Inspector of Marine Accidents But there are also tragedies, with loss of vessels December 2005 and loss of life. We need to consider these too, to see if we can make sure that such things could never happen to us.

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Part 1 – Merchant Vessels If we spent as much time on accident prevention as we do analysing the after effects of an incident there is a real possibility that we could reduce loss and suffering, and maybe we would all sleep more comfortably. There is no doubt that we can learn from our mistakes, but if we really applied the principles of the IMO International Safety Management Code, carried out thorough Risk Assessments, analysed our critical systems and ensured our Safety Management Systems were credible and healthy, most of our “losses” could be prevented.

So how do we, as responsible operators, implement acceptable, compliant, proactive It is a privilege to be asked to write an and cost effective loss control? I strongly introduction to the Safety Digest, but it came believe in the principles of the ISM Code, and as some surprise to note that one of the case am convinced that the most effective tool in its studies covered an incident with which I was armoury is the requirement to identify and very familiar. However, I was pleased to note analyse critical systems; it is unfortunate that that the lessons learned were in line with my this obligation appears in section 10 under own analysis of the incident, and reinforced “Maintenance of Ship and Equipment” and my belief that challenges will always rise up to implies that a critical system is equipment confront the best of Safety Management related. However, the principles can clearly be Systems. applied to people, management systems and processes. If applied across this broader Isn’t hindsight marvellous! It enables all of us spectrum, we can really start to be proactive. to explain in extremely articulate and As you read this issue of the “Safety Digest”, knowledgeable terms why the incident test each case with the ISM criteria “the occurred and, more importantly, how it would sudden operational failure of which”, apply never have occurred had we been in charge! this across the SMS and decide if your own You only have to read “the lessons” that follow systems are sufficiently robust to withstand each set of case notes in the “Safety Digest” to close scrutiny. see that most of these incidents could have been prevented if the individuals or organisations involved had really thought about how they managed their activities.

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David Preston

David Preston is a Captain in the Royal Fleet Auxiliary and has recently finished a three year appointment as Chief Staff Officer (Engineering) with the Royal Navy’s Commander in Chief Fleet. His responsibilities included Availability Management, Flotilla Safety Officer and DPA. He has now been seconded to Rolls Royce for two years to develop his programme management and business development skills.

David started his Officer Cadetship with the Royal Fleet Auxiliary in 1973 and rapidly gained his Class 1 Steam and Motor Certificates of Competency. He has served on all types of RFA, undertaking military operations across the world including the Persian Gulf, Falkland Islands and Sierra Leone. He has also worked within the headquarters unit specialising in Nuclear, Biological, Chemical Defence and Damage Control, Occupational Health and Safety and Quality Management Systems.

He is a Chartered Engineer, Fellow of IMarEST and a Member of the Institute of Occupational Safety and Health. He has been a member of the Maritime Advisory Board of the Confidential Hazardous Incident Reporting Programme (CHIRP) for two years.

MAIB Safety Digest 3/2005 9

Ro-Ro Ferry Bow Door Failure in Port Narrative while the vessel continued to operate normally. During a routine inspection of the bow door space of a ro-ro passenger ferry, by ship’s staff, At a European port 5 days later, the vessel had cracks were found in the upper hinge completed discharge and loading, and was assembly of the starboard bow door (Figures preparing for departure when the upper hinge 1a and 1b). The company, classification society of the starboard “clamshell” type bow door and flag administration were informed. The failed. As soon as the operating lever for the following day, a classification society surveyor bow door’s hydraulic operating cylinders was inspected the cracks to determine a suitable moved to the “door close” position, a bang was and safe course of action. heard and the door was seen to drop. The 20 tonne weight of the door came to bear on the Taking into account a number of factors, hydraulic cylinder and the lower hinge including a reasonable weather forecast, the assembly. The door came to rest partially surveyor placed a condition of class on the supported by the cowcatcher (an external vessel, which allowed the company time to structure attached to the bow, which enabled organise permanent repairs. Over the the vessel to connect to the linkspan), with the following few days, the technical staff on board lower part of the door submerged about a maintained regular inspections of the cracks, metre in the water (Figure 2).

Hinge plate Stiffener

Upper bearing cheek plates Door arm Figure 1a: Starboard door upper bearing arrangement

10 MAIB Safety Digest 3/2005

Cracks Stiffener

Upper cheek plate Hinge plate

Figure 1b: Starboard door upper bearing hinge in detail showing crack

The starboard door could not be closed and and 3b) and that there had been a history of the vessel was rendered unseaworthy. The previous cracking to its support structure. passengers and their vehicles were However, this was not recognised as a disembarked via the stern doors, and the recurrent problem by ship’s staff or vessel was moved to a lay-by berth for management, despite repairs, involving temporary repairs. A condition of class was welding of cracks and replacing distorted issued which allowed the vessel to sail to steelwork, having been necessary on a number another port for permanent repairs. of occasions. The ship’s classification society Unfortunately, the failed hinge components had not been aware of this history. were disposed of without any analysis being carried out. The investigation found that the contact between the door and the cowcatcher caused The subsequent investigation discovered that, the operating cylinder to overload the door for a number of years, the starboard bow door operating equipment and supporting had been making contact with the cowcatcher structure, which led to the cracking. when it was in the open position (Figures 3a

MAIB Safety Digest 3/2005 11

Figure 2: View of damaged starboard bow door

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MAIB Safety Digest 3/2005

Figure 3a: Diagram of starboard outer bow door looking down on top hinge – door open

Starboard bow door Deck 3 vehicle ramp

Figure 3b: Starboard door in contact with ‘cowcatcher’

The Lessons 3. Had a suitable method of Non- Destructive Testing (such as Magnetic 1. The bow doors on a ro-ro ferry are Particle Inspection) been carried out on critical items of equipment, and the the door hinge components, after the consequences of their failure have been cracks were discovered, it might have tragically demonstrated in the past. been possible to determine the depth and Although class requirements for their extent of the cracks. This, in turn, might construction have been updated in recent have provided the surveyor with valuable years, this incident clearly illustrates that information on which to base his serious failures can still occur. Bow decision. Consider all the options doors must be treated with the greatest available to assist in diagnosing a fault of respect, and any problems associated condition rather than relying purely on with their structure or operating the Mk I eyeball. equipment must be dealt with urgently. 4. The investigation was hampered because 2. If repeated repairs to vessel structure or the failed components were removed and equipment are required, think about why disposed of before they could be they are occurring and what can be done thoroughly analysed. After any to prevent further problems. If a problem significant incident or accident, ensure persists, consult the vessel’s classification key evidence is retained for forensic society, which will be able to provide examination so that the root causes can suitable technical expertise to help be identified. resolve a recurrent fault.

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Well Practised, Instinctive Reactions Save Vessel From Potentially Serious Engine Room Fire Narrative engineer who had just left the bridge. Unable to do so, he called the electrician who was in A ro-ro ferry was 8 miles from its destination the engine room annex, and immediately sent when the navigating officer noticed, what he him to the engine room. Simultaneously, he thought to be, smoke or vapour on the engine advised the captain to bring the port engines room camera monitor situated on the bridge. to idle. The captain was content with the The chief engineer, whose position was also navigational situation; the vessel was in safe on the bridge, quickly scanned the display water and so the engines were set to idle. channels. He, too, saw the smoke/vapour and advised the captain to bring the starboard Flames were clearly visible on the bridge engines to idle, which he did. monitor. The chief engineer followed the correct emergency routine for an engine room While the chief engineer was looking at the fire, and initiated the compartment shutdown display, he saw the vapour ignite and heard the procedure. In doing so, the starboard engines fire alarm immediately sound. The chief were shut down, fuel systems isolated and the engineer attempted to contact the assistant compartment ventilation flaps closed. The

Banjo bolt arrangement Fuel injection pump

Compression joint Low pressure fuel rails Worn lagging pad Figure 1: Low pressure fuel pipe arrangement

MAIB Safety Digest 3/2005 15

Figure 2: Failed low pressure fuel pipe

electrical load was also transferred from the As the assistant engineer vacated the engine starboard generators to the port units, and the room, he was replaced by the fire party, who busbar-linking breaker opened. Almost were wearing breathing apparatus. They immediately, the flames were seen to abate. dampened down the area and kept a presence in the engine room throughout the remainder The reduction in vessel speed, and of the passage in case of re-ignition. Meanwhile, interruptions in the electrical supplies alerted the captain kept the passengers fully informed the assistant engineer. He contacted the chief of the situation as the vessel continued her engineer and was immediately ordered to the passage on the port main engines. engine room. Meanwhile, the ship’s emergency party was activated and the passengers advised On investigation, it was found that one of the of the situation by the captain. low pressure fuel pipes, supplying a cylinder fuel injection pump, had failed. The steel pipe On entering the engine room, the assistant (Figure 1) had a banjo fitting at the pump engineer took the foam extinguisher from the connection, and a steel ferrule compression electrician and proceeded forward along the fitting at the low pressure fuel rail. The pipe floor plates to fight the fire on the engine, had