MAIB Safety Digest 2002 — Fishing edition

Marine Accident Investigation Branch (MAIB) - Safety Digest - Fishing 2002 Contents Chief Inspector's Foreword...........................................................................................3 Case 1 Take Your Lifejacket and Phone with you......................................................6 Narrative...................................................................................................................................6 The Lessons..............................................................................................................................6 Case 2 Near Misses Involving Fishing Vessels.............................................................8 Narrative 1................................................................................................................................8 Narrative 2................................................................................................................................8 The Lessons..............................................................................................................................8 Case 3 Lone Skipper Trapped in Winch for Several Hours ....................................10 Narrative.................................................................................................................................10 The Lessons............................................................................................................................10 Case 4 Low Freeboard Causes Two Fatalities...........................................................12 Narrative 1..............................................................................................................................12 The Lessons............................................................................................................................13 Case 5 Saturated Buoyancy Causes Dory to Capsize ...............................................14 Narrative.................................................................................................................................14 Footnote..................................................................................................................................14 The Lessons............................................................................................................................14 Case 6 For Appearance's Sake....................................................................................16 Narrative.................................................................................................................................16 The Lessons............................................................................................................................16 Case 7 Fatal Accident while Shooting Pots ................................................................18 Narrative.................................................................................................................................18 The Lessons............................................................................................................................19 Case 8 Upside Down Louvres......................................................................................20 Narrative.................................................................................................................................20 Footnote..................................................................................................................................20 The Lessons............................................................................................................................21 Case 9 Attention to Safety Saves Lives.......................................................................22 Narrative.................................................................................................................................22 Footnote..................................................................................................................................22 The Lessons............................................................................................................................22 Case 10 Engine Room Flooding Leads to Loss of Vessel..........................................24 Narrative.................................................................................................................................24 The Lessons............................................................................................................................24 Case 11 Defective Bilge Alarms Lead to the Loss of two Large Vessels .................26

Narrative.................................................................................................................................26 Case 1:....................................................................................................................................26 Case 2:....................................................................................................................................26 The Lessons............................................................................................................................26 Case 12 The Invisible Killer ........................................................................................28 Narrative.................................................................................................................................28 The Lessons............................................................................................................................28 Case 13 Heavy Weather Damage in Sea Areas Rockall and Hebrides ...................30 Narrative.................................................................................................................................30 Case 1:....................................................................................................................................30 Case 2:....................................................................................................................................30 Case 3:....................................................................................................................................30 The Lessons............................................................................................................................31 Case 14 Corrosion Causes a Serious Flooding Incident ...........................................32 Narrative.................................................................................................................................32 The Lessons............................................................................................................................32 Case 15 Container Ship and Fishing Vessel Meet in Fog!........................................34 Narrative 1..............................................................................................................................34 The Lessons............................................................................................................................34 Case 16 Another Lone Fisherman Tragically Lost Overboard ...............................36 Narrative.................................................................................................................................36 Footnote..................................................................................................................................36 The Lessons............................................................................................................................36 Case 17 Grounding in Restricted Visibility ...............................................................37 Narrative.................................................................................................................................37 The Lessons............................................................................................................................37 Case 18 Vessel Sinks After Hitting Wreckage..........................................................39 Narrative.................................................................................................................................39 The Lessons............................................................................................................................39 Case 19 Man Overboard During Hauling Operation ...............................................41 Narrative.................................................................................................................................41 Footnote..................................................................................................................................41 The Lessons............................................................................................................................41 Case 20 How to Handle a Flooding Incident .............................................................43 Narrative.................................................................................................................................43 The Lessons............................................................................................................................43 Case 21 Fishing Vessel Grounds While Leaving Harbour.......................................44 Narrative.................................................................................................................................44 The Lessons............................................................................................................................44 Case 22 Use the Correct Caulking Compound.........................................................45 Narrative.................................................................................................................................45

The Lessons............................................................................................................................45 Statistics ........................................................................................................................46 Fishing Vessel Accident Statistics 1990 - 2001 .....................................................................47 Chart Major Accident Locations (provisional figures) ............................................49 MAIB Published Reports - Available free of charge from MAIB ...........................51 SAFETY DIGEST .................................................................................................................53 Glossary of abbreviations ............................................................................................54 MAIB Safety Digest/Report Request Form ...............................................................55 MAIB PUBLISHED REPORTS - free of charge ..................................................................55 Contents ........................................................................................................................56

Chief Inspector's Foreword When the definitive history of the British fishing industry comes to be written, it would cover the rise and fall of fish stocks and the evolution of fishing vessels from the small beach launched craft of pre-harbour days to the large ocean going pelagic trawlers of the 21st Century. It would touch on the many dramas of the seas, of fine seamen and their families, and the many hardships endured. It would also, sadly, reflect on the disasters that have befallen the fishing industry over the years. Even today people talk about events such as the great gales of the 1840s when hundreds of fishermen from Wick, Peterhead, Fraserburgh, Fife and Eyemouth lost their lives.

There would also be references to names well known to us today such as Gaul, Trident, Pescado, Ocean Hound, Wilhelmina J, Antares, Gorah Lass, Westhaven, Sapphire, Margaritha Maria, Silvery Sea, and, most recently, Solway Harvester and Tullaghmurry Lass. And there are hundreds of other vessels whose names are forever engraved on people's memories where people have lost their lives to leave families, friends and communities grieving.

Some accidents are caused by external factors but most happen because of something that happens much closer to home. The loss of any fishing vessel, even without anyone being injured or killed, is a traumatic event but, when lives are lost, the effects can be devastating.

For centuries the hazards of fishing have been well known and accepted. For hundreds of years, the design of fishing vessels has steadily improved and losses from, particularly, bad weather have gradually reduced. The number of accidents has also, thankfully, been dropping but the statistics still show that far too many vessels sink and fishermen lose their lives. The year 2000 was a particularly bad one; 40 vessels foundered and 32 fishermen were killed. Last year 33 vessels were lost and 9 fishermen died. Every one of these is one too many, and each death means a family somewhere is left to grieve the loss of a loved one.

Whenever an accident happens, questions are asked. What happened, why did it happen and could it have been prevented? They are fair questions and are, occasionally, difficult or even embarrassing to answer: nobody likes to admit they might have got something wrong. Some of the most penetrating questions come from victims' families, and MAIB inspectors are often asked if the accident could have been prevented. There are few things more heartrending than meeting a young widow, children, or grieving parents of a dead fisherman and trying to explain to them what happened and why.

In days gone by, it was all too easy to dismiss accidents as 'one of those things,' or an occupational hazard or caused by a freak wave or bad weather. Whenever a serious accident happens there is a natural instinct to blame it on something over which the fisherman has no control but, in most instances, the causes are preventable by those on board.

Since the MAIB was formed in 1989, it has spent an increasing amount of its time finding out what happened when things go wrong and, more importantly, why. We recruited a fishing vessel skipper to help us understand more fully some of the implications of what we were discovering. Underlying all our work is the thought that if we can identify the real, rather than the convenient reasons for the accidents, we can do something to prevent the same thing happening again. It is our sole aim. The Branch does not apportion blame, nor does it prosecute people and we work independently of the insurance companies and the Maritime and Coastguard Agency.

Our reports are published with one specific objective: the prevention of further accidents. The reports come in various forms, from detailed investigations with recommendations, to much briefer versions that identify lessons to be learned. The latter are published three times a year in the MAIB's Safety Digest and, in addition, we produce one fishing industry edition to come out at the same time as the annual Fishing Exhibition in Glasgow. This Safety Digest is the 2002 edition, and largely reproduces articles that have already appeared.

Each Safety Digest article briefly describes an accident and then identifies the lessons. They are written for the person at sea and many fishermen tell us they find them useful. They are also free and, if you would like to receive them, you need do no more than let us know, or, alternatively, you can access them on our website www.maib.gov.uk.

The MAIB is not only concerned with identifying specific causes of accidents, but also in detecting common factors and trends. If people can learn from the things that go wrong there is every prospect that similar problems can be identified elsewhere and put right before they, too, contribute to a tragedy. Preventing accidents is infinitely better than trying to cope with flooding in the engine room, a severed arm or losing a colleague overboard.

One of the most striking discoveries when analysing an accident is that, no matter how big or small, it is rarely caused by a single event. Accidents are invariably the result of several little things going wrong in turn. It only needs one of them to go right to interrupt the causal chain. It therefore follows that accident prevention is all about identifying problems at the time, and putting them right before it is too late.

'Problems' come in different guises and could be anything from sailing with a known defect, to having an out of date liferaft lashed down so it cannot break free. It could be putting to sea short handed, or asking a young lad to do something for which he has not been trained such as keeping a watch on his own with no knowledge of navigation or Rule of the Road. Every time a blind eye is turned to a known problem, or someone deliberately takes a short cut, 'because it is quick', could well be the trigger that causes an accident. Many of the known problems have been highlighted in past Safety Digests and have included findings such as sailing with a malfunctioning automatic bilge alarm. To do so means you are denied the one means available to give timely warning of flooding. Without it you may have insufficient notice that water is flooding into the engine room to the extent that, eventually, the vessel sinks.

Fishing vessels of 12m and above are supplied with stability books. Several fishermen have told us that although these books are carried on board, they are never looked at from one end of the year to another. Many do not appear to understand them and argue they aren't as good as hard won experience and intuitive feel. This reluctance to refer to the stability book, or follow what it says, is often found to be a major factor in founderings. Stability books provide essential information about such things as the amount of fish that can be carried, and the importance of keeping weathertight doors and hatches shut at sea when not in use. Skippers who ignore what is said run the risk of losing their vessels and crew.

When on passage, everyone on board is totally reliant on the watchkeeper maintaining a good lookout, navigating safely and understanding the Rule of the Road. The MAIB knows that in some vessels this ideal combination of knowledge, experience and reliability is, to put it mildly, distinctly suspect. Leaving the wheelhouse unattended for a while, or allowing oneself to be distracted can have unfortunate consequences. If your inattention leads to a collision or grounding your colleagues could well lose their lives.

Injuries occur from a number of reasons, but among the more common are situations where something jams, very often when recovering fishing gear. Someone then attempts to free it without thinking through the consequences. A freed wire suddenly springs back, a net is suddenly pulled over the side or heavy gear starts to swing freely. Somebody is in the way and unable to prevent the potentially damaging consequences. People lose limbs and sometimes their lives as a result.

This Safety Digest contains a number of recent incidents together with useful lessons to be learned. It is so much easier, and infinitely cheaper, to read about other people's misfortunes and absorb the lessons. By doing so you may well save your vessel, and the lives of everyone else on board.

Of course accidents can happen, but the development of a safety culture is all about preventing them in the first place.

John Lang Chief Inspector of Marine Accidents

Case 1 Take Your Lifejacket and Phone with you Narrative

The 5.8m Orkney fast liner open fishing vessel, Northern Kiwi, which was powered by a 37.2kW (50 HP) outboard, was being operated single handedly. The skipper was hauling crab pots, and had twelve on board when the line tightened on the hauler. A pot or line had snagged on the rocky bottom in a depth of 46 metres. A northerly force 3 wind was blowing, and the sea was slight with a chop and a southerly ebbing tide.

The normal practice in such situations was to throw the recovered pots back overboard, and then start the recovery from the opposite end of the string. The skipper began this process, but having payed out 2 fathoms of rope, found it had caught in the outboard's propeller. Moments later, the rope came bar tight and the engine cut out. The skipper tried to raise the outboard, but the load on the rope prevented this.

The boat was, in effect, anchored. It was also lying with the stern so low that water had started to come inboard over the transom. The skipper attempted to lighten the boat by ditching some of the embarked pots, but this made little difference. He thought of diving down to cut the rope, but with the tide running, thought better of it and chose instead to contact the coastguard on VHF via a local vessel.

Meanwhile, water continued to be shipped over the stern. The skipper was wearing a lifejacket and, once in the water, began to recall the advice he had received in survival training. It served him well. About 10 minutes later he was recovered by another fishing vessel.

The Lessons

This incident could have turned out so very differently. The skipper owes his life to following the advice so frequently put out by the MAIB:

1. Wear a lifejacket at all times.

2. Let people know if you are in trouble before it is too late.

3. Don't make matters worse by diving in, cutting the rope and then, perhaps, watching your craft drift gently away before you can re-board it.

4. Carry a VHF radio and make sure it works. If battery-operated, ensure the batteries are fully charged, or are connected to a suitable power source such as the boat's batteries.

When looking back on his experiences afterwards, the skipper discussed the advantages of carrying a liferaft for use in such emergencies. As with many similar craft, there was very little room onboard as the pots took up most of the available space.

There is no doubt that when the chips are down, and there is every prospect of your vessel foundering, the existence of a liferaft could well make the difference between life and death. Skippers of small craft must make the choice. Take up commercially useful space or give yourself a

good chance of survival. Friends, family and next-of-kin may have uncompromising views about which choice to make. Ask them.

Case 2 Near Misses Involving Fishing Vessels Narrative 1

Having landed her catch, a fishing vessel was returning to the fishing grounds. It was dark, visibility was good, the sea moderate, and the wind south-southwest force 5. On leaving harbour, she was steering 135° at a speed of 7 knots and displaying sidelights, stern light and a masthead light.

When still within 2 miles of her port of departure, the skipper detected a radar contact 2 miles on his port bow, and shortly afterwards sighted masthead and starboard sidelights along the same bearing. He estimated this vessel, a general cargo ship, was on a southerly course at about 8.5 knots, and that a risk of collision existed.

By the time the two vessels closed to within 1 mile, the cargo vessel had failed to take any action as the give-way vessel.

This prompted the skipper to call her on VHF radio, channel 16. Unable to get a response, he altered to starboard and eventually took all way off to prevent a collision. Radio contact was finally established when the vessels were very close and the merchant vessel's OOW felt it was too late for him to alter course or stop. The OOW, who was alone on the bridge, had been working a 6 hour watch routine, and did not detect the fishing vessel by radar, or see her visually, until she was at close range.

Narrative 2

A stern trawler was south of Plymouth, towing her gear on a course of 180° at about 3 knots. She was displaying an appropriate shape to indicate that she was fishing. It was a clear sunny day, visibility was good and the sea was slight. There was little wind. A tanker was sighted about 6 miles on the port beam, on a westerly course and making good about 13 knots. She was on a steady bearing.

As the tanker closed, the trawler's skipper became increasingly concerned and, when the range had closed to about 1 mile, tried calling her on VHF channel 16. There was no reply, and the skipper was forced to increase to maximum speed to pass ahead of the tanker, leaving it very close astern. Her OOW, who was alone on the bridge at the time, did not recollect being in a close-quarters situation, or hearing any calls on VHF radio.

The Lessons

Both instances will be familiar to anyone with extensive experience of watchkeeping. You find yourself the stand-on vessel, and detect another vessel on your port bow or beam closing on a steady bearing. You ask yourself 'has he seen me?' and "is he going to give way?" Too often the answer to the first question is "No" because a proper lookout is not being kept and "No" to the second because he is unaware of your presence.

Keeping a good lookout and complying with the Rules of the Road pays dividends. Had both fishing vessel skippers not maintained a proper lookout, or manoeuvred to prevent a collision, the MAIB would probably be investigating two serious accidents rather than near misses.

To maintain a proper and effective lookout watchkeepers must be alert, look out of the windows, use binoculars, monitor the radar on an appropriate range scale, and listen for sound signals and to the VHF radio. Too often watchkeepers will spend a seemingly quiet period doing something other than keeping an efficient watch. It could be anything from progressing paperwork to reading a magazine. He might be distracted by monitoring GMDSS or making a lengthy telephone call. There is also the tendency for either a tired or very bored watchkeeper to fall asleep. Any of these could endanger people's lives.

If you feel you are under pressure to do something that will prevent you keeping an efficient lookout, or you are too tired to do it properly, tell someone. The MAIB receives a number of reports from people in such a predicament, and each one is treated in total confidence. It provides the Branch with the ammunition to do something about it.

When the OOW is busy, a dedicated visual lookout is an invaluable safety net. When all is quiet, he is a second pair of eyes and ears, and helps to keep a tired OOW alert. You are required to have a dedicated lookout at night.

VHF radio is convenient, but it relies on the watchkeeper