MAIB Safety Digest 3/2006

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 3/2006

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INVESTOR IN PEOPLE

Department for Transport Great Minster House 76 Marsham Street London SW1P 4DR Telephone 020 7944 8300 Web site: www.dft.gov.uk

© Crown copyright 2006

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: Marine Accident Investigation Branch First Floor, Carlton House 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 2006

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 2006

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. Bulk Carrier Grounds in Fog 10 2. Fast Rescue Craft Launching – Faster Than Planned 12 3. Sleeping With One Eye Open? 15 4. Hot Stuff 18 5. “Flying” Cylinder Causes Blackout 21 6. Proper Planning Will Prevent a Pretty Poor Performance 23 7. Messenger Line Message? 26 8. Whoops! 29 9. Bridge Organisation – Use Your Experts 30 10. Needless Death 33 11. Fire in a Cargo of Coal 36 12. Closer Than You Thought 38 13. Previous Maintenance History is so Important 40 14. Hot Oil And Water Will Not Mix 42 15. Another Low Pressure Fuel Line Fire 43 16. High But Not Dry! 45

PART 2 – FISHING VESSELS 48 17. Delay Structural Repairs at Your Peril 50 18. Mobile Phone Causes Grounding 53 19. Loss of “Rulebeater” With Poor Freeboard 56 20. Aggregate Bags Sink Mussel Dredger 58 21. Are Lifejackets Really Too Much Trouble? 60

PART 3 – LEISURE CRAFT 64 22. Secure Anchorage Proves to be Anything But 66 23. Divers at Work in Port – Ensure Everyone is Fully Aware Before Signing the Permit 68 24. Kill Cords Save Lives, When Used Properly 71

APPENDICES 75 Appendix A – Preliminary examinations and investigations started 75 in the period 01/07/06 – 31/10/06 Appendix B – Reports issued in 2006 76

Glossary of Terms and Abbreviations AB – Able Seaman AIS – Automatic Identification System ARPA – Automatic Radar Plotting Aid CO2 – Carbon Dioxide FRC – Fast Rescue Craft GPS – Global Positioning System GRT – Gross Registered Tonnes HP – Horsepower IMO – International Maritime Organization ISM – International Safety Management Code kg – kilogram kW – kilowatt “Mayday” – The international distress signal (spoken) mm – millimetre OOW – Officer of the Watch “Pan Pan” – The international urgency signal (spoken) PEC – Pilotage Exemption Certificate PMS – Power Management System RIB – Rigid Inflatable Boat SOP – Standard Operating Procedure STCW – Standards of Training, Certification and Watchkeeping for Seafarers UTC – Universal Co-ordinated Time VHF – Very High Frequency

Introduction In the introduction to the MAIB Annual Report 2005, I wrote that one of our greatest concerns for safety at sea is complacency. This caused something of a stir, with a small number of people feeling that this was an affront to the professionalism of mariners, but with a much larger body of opinion agreeing that it was a serious issue that had yet to be addressed.

One of the first hurdles to overcome – before we can begin to address the issue – is the word itself. Complacency is seen to have derogatory connotations, to imply smugness or self satisfaction. That is not what is intended when used in terms of accident investigation. We are looking at the normal human response to a familiar situation. When we do something for the first time, we are intent on what we are doing and are painfully aware of the hazards or dangers; by the time we have done it a thousand times with no problems, we have lost that stimulation, we have become so familiar with the operation that we have largely forgotten the possible consequences of something going wrong, and our guard is lowered. So complacency, in this context, is not a criticism, but is an aspect of human nature – one that I believe every experienced mariner will recognize.

I would like to see this issue on everyone’s agenda, because it is the business of everyone: masters and officers; owners and managers; professional bodies, unions, fishermen, leisure sailors. It is now starting to be considered, and I hope that useful actions will be taken as a result of this work. In the meantime, what can we, as ordinary seafarers do? A starting point would be for all of us – in merchant ships, fishing vessels or leisure craft – to remember the dangers in what we are doing. Please read the cases highlighted in this edition of the Safety Digest – could something similar happen to you?

Stephen Meyer Chief Inspector of Marine Accidents December 2006

MAIB Safety Digest 3/2006 7

Part 1 – Merchant Vessels American Admiral However, despite this high safety record, every Chester Nimitz said, incident, however small, receives a great “No officer, regardless amount of publicity and attention, thus of rank should flatter overshadowing all the positive/incident free himself that he is operations. This leads us to safety and the immune to the need to prevent incidents, however minor. inexplicable lapses in judgement and slips Safety is more than a concept. Companies and of the tongue which mariners need to adopt it as a culture and had led many fine support it as a way of life on board. Indeed, officers to disaster”. the International Management Code for the Safe Operation of Ships and Prevention of Another wise individual said, “You must learn Pollution (ISM Code) has devised a remarkably from others’ experience as you may not live effective method to ‘simplify, standardise, long enough to do all the mistakes yourself ”. specify, supervise and scrutinize’ the effective implementation of safety and continual Reading the above, the connection and improvement in safety awareness, and benefits from MAIB’s reports contained in this emergency preparedness. issue of “Safety Digest” are obvious. Under the Code, all ship operation and ship The 16 case studies that follow point to a range management activities may be broadly of lapses, including deficiencies in knowledge, categorised under routine or emergency seamanship, navigation and engineering operations, with the common thread of safety practice, design, communication, running through both. Routine activities may understanding, risk assessment, supervision, include loading and discharge of cargoes, improper use of available tools/information, ballast and fuel, embarking and disembarking poor organisation, resource management and of passengers, planning and conduct of one reckless and easily avoidable case of passage, operation and maintenance of alcohol abuse. machinery, inspection of external hull, internal spaces. Emergency-related activities may By circulating such reports, MAIB provides the include personal safety familiarisation and shipping industry in general and seafarers in training, planning and conduct of emergency particular, with valuable learning opportunities drills, proper response to actual emergencies. that ultimately benefit society at large. Personnel on board and ashore are required to be able to perform all the above activities to a Merchant shipping moves about 90% of uniformly high standard. This is achieved by international trade in volume terms. The documenting written procedures in simple dependence of the world economy on this vital language, mandating training, and the transportation sector is seldom appreciated by widespread use of detailed checklists. the public at large. Furthermore, water transport is by far the most energy-efficient and Safety of navigation, especially, has benefited environmentally friendly mode, and technical tremendously from these management and regulatory steps are being taken to methods. If these systems are properly continuously improve performance in both these understood and used, an incident-free passage areas. Statistically too, shipping has a consistent is virtually assured. record of very high safety, which means that the vast majority of voyages are successfully For cargo ships, the properties of cargoes that completed without any loss or damage. are permitted to be carried on each ship have

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an important bearing on safety. The varieties, It is natural that individual traits and cultural quantities, methods of packaging and shipping factors do condition human behaviour and of cargoes have increased enormously in responses. However, experience shows that keeping with global industrial progress, modern training methods such as behaviour- economic growth and trade volumes. based safety can be used to effectively overcome these barriers. This process has two A number of codes of safe practice, most of main objectives – to identify barriers to them created under IMO auspices, exist to working safely and to address the unsafe address the multiple risks and hazards behaviours that lead to incidents. The barriers associated with cargoes. These codes provide a mentioned can be anything from incomplete system of risk assessment, risk control and safe procedures to the correct tools not being carriage and handling. available, and are normally easily identified and remedied. Addressing at risk behaviour An accident can be defined as an unexpected involves the use of positive reinforcement and hazardous occurrence caused by unsafe constructive feedback, which requires training practices that arise from inadequate to manage properly. This demands a knowledge, improper training, and failure to substantial commitment from company follow proper procedures, and usually management whose role cannot be resulting in loss of life or injury to personnel, underestimated. damage to property and the environment. Above all, mariners must fully recognise and Besides these, accidents also cause ‘intangible’ appreciate their unique work environment, the losses, such as loss of earnings, reputation and heavy burden of individual and joint employment. responsibility and, most significantly, the terrible consequences that can result from Unfortunately, a disturbingly large proportion even a momentary lapse of concentration. of accidents are directly attributable to failure to follow procedures that are invariably clearly Is “zero incident” attainable? Only when we stated in the Company manuals. This certainly believe and act towards it, can the answer be points to a ‘communication gap’, in the sense yes. Let’s do it. that the relevance and the value of following the (written) procedures have not clearly been fully appreciated by personnel.

Captain Nand Hiranandani Capt. Nand Hiranandani is the Master of Company of Master Mariners of India and has over 4 decades in the maritime industry. He works for Chevron Shipping Co. San Ramon, California as HR Manning Manager for India and the Philippines. He is extensively involved with professional bodies, seafarer welfare activities and maritime education. He lives in Mumbai with his wife, Sarla, and daughter, Ambika, who is a budding lawyer.

MAIB Safety Digest 3/2006 9

Bulk Carrier Grounds in Fog

Figure 1

Narrative (all times UTC) Not wishing to go closer to the shallows on his starboard side, he tried repeatedly to call the A bulk carrier laden with 47,000 tonnes of bulk vessels, using VHF radio, but he received no mineral sand from Australia, with a draught of reply. The two crossing vessels appeared to be 11.8 metres, was navigating in the North Sea taking no action. bound for a port on the east coast of England. The master decided to make a further At about 0710 hours, the visibility was less than alteration of course to starboard in the hope 500 metres in fog and the vessel was steering a that he could cross ahead of the two vessels course of 328° at full sea speed. The master, and clear the end of the sandbank, which was OOW and lookouts were on the bridge. Three only about 2 miles ahead. However, as a result radar targets were being tracked as they of the course alterations to starboard, and the crossed from the port side. The master was strong effect of the local tidal stream, the aware that his vessel was hampered on her vessel ran aground before the sandbank could starboard side by a large sandbank with a be cleared. charted depth over it of less than 8 metres. The echo sounder was not being used. The vessel’s master called the local coastguard station and apprised them of the situation. The master altered course to starboard to Fortunately, the vessel had grounded very avoid a close-quarters situation with the first of shortly after low water, and, as the tide rose, the vessels while still keeping a safe distance she refloated without tug assistance after from the sandbank. However, this now put about 3 hours. him in a close-quarters situation with the other two vessels.

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The Lessons 3. A vessel’s passage plan should take into consideration the anticipated traffic 1. The vessels were navigating in restricted density, especially crossing traffic and visibility, and Rule 19 of the fishing vessels. Courses should be chosen International Regulations for Preventing to allow ample sea room for anti-collision Collisions at Sea applied. Section (e) of purposes where possible. the rule states: “every vessel … which cannot avoid a close-quarters situation 4. Long range radar scanning, to give with another vessel forward of her beam, warning of close-quarters situations, is shall reduce her speed to the minimum at crucial, especially in fog, to give the which she can be kept on her course. She OOW or the master time to take the shall if necessary take all her way off and appropriate action. in any event navigate with extreme caution until danger of collision is over”. 5. When deciding to take action to avoid a Bearing in mind the lack of sea room on close-quarters situation, the person with his starboard side, the master should the con should be fully aware of the have slowed down or stopped when the impact the manoeuvre will have on other close-quarters situation was detected. In vessels. The trial manoeuvre facility, any case, the bulk carrier should not which is available on many types of have carried on at full sea speed when radars, should be used. the poor visibility had been encountered. 6. When navigating close to shallow water, 2. The master placed too much reliance on careful watch should be kept on the echo being able to call the other vessels on sounder, and the depth alarm should be VHF radio, and lost valuable time in the set. process. He should have taken earlier avoiding action, as indicated in Lesson 1, above, instead of using his time attempting to call them by radio.

MAIB Safety Digest 3/2006 11

Fast Rescue Craft Launching – Faster Than Planned

Figure 1 – FRC davit

Narrative

A newly built, 165 metre long, specialist ro-ro vessel was alongside undertaking various commissioning exercises prior to entering service. One of the exercises undertaken was a manoverboard drill, which required the launch and recovery of the vessel’s fast rescue craft (FRC) to simulate the rescue and recovery of a person from the water.

The FRC, a 7 metre long rigid hulled inflatable boat, was stowed in a dedicated davit and launched using a single wire arrangement (Figure 1). The boat was connected to the wire via a quick release hook (Figure 2), which operated in the “off-load” mode, such that when the boat was lowered into the water, the hook automatically released once the weight of the boat on the hook was reduced to below 12kgs. Figure 2 – Quick release hook

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Figure 3 – FRC davit controller

The davit itself was hydraulically operated and release of the hook.