safety digest 2/2005...we have to recognize that we are becoming dangerous. reading the accounts in...

SAFETY DIGESTLessons from Marine

Accident Reports2/2005

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SAFETY DIGESTLessons from Marine Accident Reports

No 2/2005

MARINE ACCIDENT INVESTIGATION BRANCH

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INVESTOR IN PEOPLE

Department for TransportEland HouseBressenden PlaceLondon SW1E 5DUTelephone 020 7944 3000Website: www.dft.gov.uk

© Crown copyright 2005

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

Further copies of this report are available from:MAIBCarlton HouseCarlton PlaceSouthamptonSO15 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.July 2005

MARINE ACCIDENTINVESTIGATION BRANCH

The Marine Accident Investigation Branch (MAIB) is an independent part of the Department forTransport, the Chief Inspector of Marine Accidents being responsible directly to the Secretary ofState 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 frominvestigations into recent accidents and incidents. It contains facts which have been determined upto the time of issue.

This information is published to inform the shipping and fishing industries, the pleasure craftcommunity and the public of the general circumstances of marine accidents and to draw out thelessons to be learned. The sole purpose of the Safety Digest is to prevent similar accidents happeningagain. The content must necessarily be regarded as tentative and subject to alteration or correction ifadditional evidence becomes available. The articles do not assign fault or blame nor do theydetermine liability. The lessons often extend beyond the events of the incidents themselves to ensurethe 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 incidentplease 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 [email protected]

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

Crown copyright 2005

Extract fromThe 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 andInvestigation) Regulations 2005 shall be the prevention of future accidents through the ascertainment of itscauses and circumstances. It shall not be the purpose of an investigation to determine liability nor, except sofar as is necessary to achieve its objective, to apportion blame.”

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

MARINE ACCIDENT INVESTIGATION BRANCH

GLOSSARY OF TERMS AND ABBREVIATIONS 6

INTRODUCTION 7

PART 1 – MERCHANT VESSELS 8

1. Don’t Just Watch it Happen 10

2. The Sitting Duck 11

3. A Perennial Hazard 13

4. Acid Attack! 14

5. Timber Deck Cargo – on the Move 16

6. Poor Planning Leads to Over Extended Stay – on the Beach 18

7. The Dangers of High Speed Loading 20

8. In Hot Water 21

9. A Not So Soft Bottom 22

10. Some Good Fortune – Only a Burned Out Clutch 24

11. Do You Check Your Wires? 26

12. Collision Involving a General Cargo Vessel and a Fishing Vessel 27

13. A Cook, Live Electrical Wires, a Wet Galley Deck – all the Ingredients 30Needed for a Shocking Day

14. Don’t Pass on Bends 31

15. A Close Call 33

16. Whiteout 36

PART 2 – FISHING VESSELS 39

17. Not a Stroll in the Park 40

18. Stability Aware? 42

19. Corrosion, What Corrosion? 44

20. ‘It Just Went off in my Hand Chief!’ 46

21. Elevated Work, Elevated Risks 47

22. Two Fires, a Flood and a Foundering 49

INDEX

PART 3 – LEISURE CRAFT 51

23. Knockdown and Total Loss off the Portuguese Coast 52

24. Lucky Escape as Spring Hook Fails During Hoisting of a Tender 53

25. Don’t Underestimate the Familiar 55

MAIB NOTICEBOARD 57

APPENDICES 58

Appendix A – Preliminary examinations started in the period 01/03/05 – 30/06/05 58

Investigations started in the period 01/03/05 – 30/06/05 58

Appendix B – Reports issued in 2005 59

Glossary of Terms and AbbreviationsAB – Able Seaman

ARPA – Automatic Radar Plotting Aid

CO2 – Carbon Dioxide

CPA – Closest Point of Approach

DSC – Dangerous Goods, Solid Cargoes and Containers

EPIRB – Emergency Position Indicating Radio Beacon

GPS – Global Positioning System

GRP – Glass Reinforced Plastic

IMDG – International Maritime Dangerous Goods Code

Mayday – Spoken distress signal

MCA – Maritime and Coastguard Agency

MCR – Machinery Control Room

MGN – Marine Guidance Notice

OOW – Officer of the Watch

PAN – The international urgency system

RNLI – Royal National Lifeboat Institution

SWL – Safe Working Load

VHF – Very High Frequency

In the few months since the last Safety Digest,there have been over 500 accidents or incidentsreported to the MAIB. Many of the root causesof these accidents are depressingly familiar. All ofus, as mariners, need to remind ourselves of whywe take precautions and why we put in placesafety checks and balances. It is all too easy at seato become complacent; but when short-cuts aretaken or safety checks skipped due to familiarity,we have to recognize that we are becomingdangerous. Reading the accounts in this SafetyDigest should remind all of us that we work in aninherently dangerous environment, where a lackof attention or forethought can be fatal.

In May 2005, the MAIB issued two SafetyBulletins, to get urgent safety messages out. One,referring to three recent accidents involving tugsmanoeuvring ships, is of particular interest to tugoperators and crews, harbour authorities and

pilots; it is available on our website:www.maib.gov.uk. The other, referring to arecent tragedy involving a rigid inflatable boat, isreproduced in our “Noticeboard” at page 57. Ifeither of them may affect you in any way, pleasetake the time to read them.

The main lesson from all accidents is: keep alert,think carefully about what you are doing and beprepared for the unexpected. In that way, we canall return home safely.

Stephen MeyerChief Inspector of Marine AccidentsAugust 2005

Introduction

7MAIB Safety Digest 2/2005

Communicating successfully with those at sea onany matter has always been an issue, and theMAIB Safety Digest is one of the most effectiveways of communicating and sharing informationon safety issues. The staff at the MAIB arecommitted to safety at sea, and theirinvestigations are aimed at finding the lessons tobe learnt from an incident, rather than simplyfinding fault. The Safety Digest allows readers toreview their own procedures and learn lessonsfrom the mistakes of others. I fully recommendthat these cases are reviewed to see if they couldbe applicable to your own operation or ship.

Accident investigation is not an easy task, it istime consuming, and there is often a naturaltendency for those involved to be defensive,especially if they have to admit to failingsthemselves. It remains a fact that human erroraccounts for the majority of accidents. Only byproper investigation and openness by thoseinvolved can we avoid repeating mistakes thatcause accidents and, in the worst cases, fatalities.

The incidents reported in this edition of theMAIB Safety Digest again show how those at seamust constantly be aware of what is going onaround them, and the hazards involved if thingsdo not go as planned. It is pleasing to see onereport (Acid Attack) where the awareness andprompt actions of a crewman, followed up by pre-planned emergency procedures, prevented amajor incident. Unfortunately, a number ofreports indicate the opposite, and show a generallack of awareness by the seafarers for what isgoing on around them. The consequences of thisare clearly illustrated in the reports.

General awareness is an essential part of carryingout any task at sea, but all too often theconsequences of failure to plan, consider all therisks, and then continually monitor, leads todamage of equipment, collision, grounding or,worse still, injury or a fatality.

A smaller number of cases show us incidentscaused by the ‘rule breaker’. These are peoplewho know what they are supposed to do, havebeen trained to do it properly, but break the ruleson their own initiative to complete a job. Whenquestioned afterwards, many of these peoplegenuinely believe they are doing this to help thecompany, or they think it is how the companyactually wants them to do the job. In well runcompanies, these accidents are sometimes themost difficult to accept, and the most difficult toaddress.

To address these issues, senior staff, ashore andafloat, must be pro-active in training, supervisingand ensuring that rules are adhered to. This doesnot mean a dictatorial approach, but a safetyculture where there is good leadership, goodcommunication, continuous improvement and ano-blame culture. The exchange of informationacross the industry is essential in assisting us inthis, and I commend these case studies to you aspart of this process.

Part 1 – Merchant Vessels

8 MAIB Safety Digest 2/2005


Stuart Greenfield is Director, Maritime Affairs for Carnival Corporation & plc based in Southampton, Hampshire.The Carnival group operates a total of 78 cruise ships under 12 different brands.

Stuart went to sea with the Peninsular and Oriental Steam Navigation Company (P&O S N Co) as a group deck cadetin 1974 serving on all types of vessels, and in 1978 was appointed to the Passenger Ship Division as Third Officer. Hecontinued to serve on the cruise ships until 1992 when he became Deputy Marine and Safety Manager for P&OCruises, based in Southampton.

In 1994 he progressed to Marine and Safety Manager, and at the demerger of the cruise division from P&O S N Co inOctober 2000, was appointed Head of Maritime Affairs for the new company P&O Princess Cruises. At the mergerwith Carnival Corporation he assumed a similar role for the dual listed company Carnival Corporation & plc.

He represents Carnival on panels at the UK Chamber of Shipping and assists in work at IMO as either an InternationalCouncil of Cruise Lines representative, or advising flag states. He has recently been appointed to the advisory board ofthe Confidential Hazardous Incident Reporting Programme (CHIRP), and is a council member of the Nautical Institute.

Narrative

While on passage, two deckhands wereinstructed by the master to prepare the vessel’ssteel uprights for the next deck cargo, but not tofit them. The weather conditions were good witha force 3 wind and slight sea, but overnight rainhad left the hatch covers wet.

The uprights were rusty, and the two deckhandsdecided, on their own initiative, to make surethey still fitted into the slots on the hatchcoaming. This proved difficult, and caused one ofthe deckhands to slip and fall overboard.

The master, who was on watch, witnessed theaccident and immediately altered course. Hethen released the man overboard smoke float,sounded the general alarm and transmitted aPAN alert on the radio. The rescue boat waslaunched, and the deckhand was safely retrievedon board within 15 minutes.

Don’t Just Watch it Happen

MAIB Safety Digest 2/2005

CASE 1

10

The Lessons

1. The master had specifically instructedthe deckhands not to fit the steeluprights. However, they chose to ignorehis instruction; something the masterwas aware of yet chose to do nothingabout.

An instruction is of no value unless it isimplemented. In this case, a risk ofsomeone falling over the side had beenidentified. The control measure was notto fit the steel uprights. The controlmeasure was overridden, and an accidentensued.

2. The master’s reaction, and that of thecrew, immediately following the falloverboard was swift and effective inenabling the deckhand to be recoveredfrom the water quickly, anddemonstrated the benefit of regulardrills.

3. The consequences of this accident couldhave been far worse if, for example, thedeckhand had struck his head whilefalling overboard, or if the master hadbeen looking elsewhere at the time. Suchtasks should be avoided, if possible.However, where there remains anunacceptable risk of someone fallingoverboard, suitable control measuresshould be employed, such as the use ofsafety lines or working lifejackets.

Narrative

A cargo vessel was overtaking a fishing vessel.Both were on a south-easterly heading. It wasdaylight with good visibility and a slight sea.

The fishing vessel was trawling at about 2.5knots. The cargo vessel was on passage andmaking good about 14 knots. The cargo vessel’sOOW saw the fishing vessel on his port bow atabout 3 miles range. The fishing vessel wasdisplaying her daytime fishing signal and, as thecargo vessel approached, her trawl lines wereclearly visible.

The cargo vessel’s OOW recognised hisobligation of keeping out of the way, and alteredcourse to starboard with the intention of leaving

the fishing vessel on his port side. However, bythat time, the fishing vessel’s skipper had becomeanxious that the cargo vessel was takinginsufficient action, and had altered course tostarboard.

Recognising the resulting risk of collision, theOOW then altered course to port with theintention of leaving the fishing vessel tostarboard. Unfortunately, the fishing vesselskipper, concerned by the cargo vessel’s previousalteration to starboard, altered course to port atthe same time.

Again, the OOW recognised the resulting risk ofcollision and, again, altered to starboard,eventually passing about 0.3 mile astern of thefishing vessel.

11

The Sitting Duck


CASE 2

0.3mile

1st course alterations

2nd course alterations

3rd course alteration

Cargo Vessel

Fishing Vessel

Not to scale


CASE 2

The Lessons

1. A stand-on vessel in an overtakingsituation is probably at her mostvulnerable. Rule 17(a)(i) requires her tomaintain her course and speed and,although Rule 17(b) instructs her totake action when collision cannot beavoided by the action of the give-wayvessel alone, this is unlikely to beeffective in an overtaking situation.Reliance must therefore be placed onRule 17(a)(ii), which provides an optionfor her to take action as soon as itbecomes apparent that the give-wayvessel is not taking appropriate action incompliance with the Rules. However, forthe above reason, this option needs to betaken far earlier in an overtakingsituation than in most others.

2. If a stand-on vessel needs to take earlieraction in an overtaking situation, itfollows that the give-way vessel needs totake earlier action than would otherwisebe the case. The same degree ofmagnitude needs to be applied to anycourse or speed alterations. In otherwords, any alteration of course or speedneeds to be large enough, and taken earlyenough, to be readily apparent to thestand-on vessel that sufficient action isbeing taken without need for the stand-on vessel to consider having to take anyaction of her own.

In this case, a large and early alterationof course by the cargo vessel would haveavoided any unnecessary confusion andconcern, and the enhanced risk ofcollision that resulted.

Narrative

A survey vessel, operating offshore, camealongside a mooring buoy in order to recover it.A seaman used a grapple to recover the buoy’sline and hauled it to the bulwark, where he madethe grapple fast.

He then noticed that the line had taken a ridingturn on the grapple hook, and attempted to freeit by hand. As he did so, relative movementbetween the buoy and the ship suddenly putweight on the line. This trapped three of theseaman’s fingers, leading to the loss of their tips.

13

A Perennial Hazard


CASE 3

The Lesson

Injuries, caused by weight suddenly comingon to ropes, have happened for almost aslong as men have gone to sea. All seamenshould be aware of the dangers but, as isseen here, even the best can be caught out.Vigilance and awareness is the seaman’s onlydefence.

Narrative

A ferry had just left her berth when a member ofthe forward mooring team saw a leakage from avehicle carrying hazardous cargo on the foredeck. The incident was immediately reported tothe bridge and the fore deck was evacuated.Ventilation was stopped and two teams begandonning chemical suits and breathing apparatus.Meanwhile, the driver of the vehicle was tracedand the substance identified as Phosphoric AcidLiquid, UN 1805 in a dilute form. Confirmationof the description was provided by inspection ofthe hazardous cargo stowage plan.

When questioned further, the driver of thevehicle provided information on securingarrangements: he explained that 20 litre plasticdrums were secured by shrink-wrapping onto awooden pallet, and described verbally the layoutinside the vehicle. This was vital information foran effective planned entry by thedecontamination team.

Eleven minutes after the initial sighting, thedecontamination team, now fully dressed inchemical suits and breathing apparatus, was sentto investigate. As the team entered the vehicle,they realised that the scene inside was not asdescribed by the driver. The drums had beenloosely stowed on pallets and had not beenshrink-wrapped. Several drums were laid on theirsides and not vertically stowed. On re-stackingthe fallen drums, the team identified the roguedrum. Meanwhile, the spillage was diluted with acopious amount of water following theprocedures laid down in the IMDG Codesupplement.

After the incident, a full debrief was undertakenwith all key people involved. Lessons learnedfrom the debrief are reproduced below.

14

Acid Attack!


CASE 4


CASE 4

The Lessons

1. The information provided by the driverof a vehicle will greatly assist the ship inits decision making process, and, morespecifically, the team entering thevehicle. However, always bear in mindthat for a variety of reasons, theinformation provided may not be asaccurate as one would wish for. Duringan incident of this kind, drivers will beunderstandably concerned about thesafety of their vehicles. However, oncethey have passed on all the necessaryinformation, they must be kept clear ofthe scene, remaining in a known locationand available to provide furtherinformation and advice as required.

2. The decontamination team involved inthis incident learned that the provisionof additional, but minor, pieces ofemergency equipment would have madetheir task considerably safer and moreefficient.

The lessons learned from onboardcontinuation training exercises canprompt ships to revisit their relevant riskassessments and realise the need forspecific equipment. Standard operatingprocedures can be amended or updated asrequired. This will ensure that all theequipment necessary to undertake thetask is always available and stowed in themost appropriate location.

3. Command and control was effectivelymanaged, with a good flow ofinformation, not only among crew and

officers onboard, but also to portauthorities and safety managementofficers ashore. Positive control wasestablished at the scene of the incident,and within 31 minutes of the alarm beingraised, the incident had been brought toa successful conclusion. The followingkey actions describe this time frame:

• Decontamination team mustered andcorrectly dressed.

• Location of the driver established and afull verbal description provided of thecontents inside the vehicle received.

• Hazardous cargo documentation andIMDG Code examined for correctresponse procedures.

• Vehicle entered safely and rogue drumidentified.

• Clean up executed efficiently andeffectively.

4. This incident was caused by inadequatesecuring within the vehicle. The IMDGCode is quite clear in its instructions toshippers, forwarding agents and roadhauliers:

IMO Assembly ~ Chapter 5 to theAnnex of Resolution A.533(13)

.3 the cargo in the cargo unit or vehicleis adequately stowed and secured to withstand the forces which may ariseduring sea transport.

Narrative

A 3000grt vessel loaded a cargo of sawn timberin Latvia. The planks were bound and stacked inthree tiers on top of the deck hatch covers. Thedeck cargo did not overhang the hatch coverswhen loaded. While on passage, the vesselencountered very rough confused seas withswells, causing her to roll heavily. This violentmovement resulted in the timber shifting acrossthe vessel about 1 metre, giving the vessel anangle of list of about 8° to port.

The master ordered the crew to recheck all thelashings and fit additional lashings as required.The engineers pumped ballast into the upperstarboard wing tanks and pumped out somedouble bottom tanks on the port side. Theseactions reduced the vessel’s list and allowed herto continue her intended course.

Regular checks were made on the vessel and hercargo during the remainder of the voyage, untilshe docked safely. The photograph shows thevessel alongside, being unloaded.

16

Timber Deck Cargo – on the Move


CASE 5


CASE 5

The Lessons

1. Fabric webbing lashings stretch morethan steel wire rope, so daily tensioningis especially necessary. It is oftenextremely perilous to venture on to theopen deck of a vessel during heavyweather, so at such times a crew is morelikely to miss a routine. However, itmust be remembered that in theseconditions lashings will be stretchedmore, due to greater ship motion.

2. Up-and-over lashings of this type do notadequately prevent sideways movement.They provided downward force on thedeck cargo, and this, in association withthe friction between the timber packagesand the top of the hatch cover, was allthat was preventing transverse shift. Anangle bar, or flat bar welded to the edgeof the hatch cover, or steel uprightsslotted into sockets attached to the hatchcoamings, would have helped to preventtransverse shift. Alternatively, woodenuprights, positioned along the hatch

coamings, and connected port tostarboard with hog wires, would restrictsideways movement if no suitablepermanent fittings were available.

3. Some vessels carry timber deck cargoesonly rarely. These vessels should stillcarry adequate equipment andinformation. The lashings providedshould be properly certificated, and thecargo securing manual should containspecific information for the vessel so thatthe master is armed with the best adviceto carry the cargo safely. Such adviceshould include the number of lashingswhich should be used, and the method ofrestricting sideways movement.

N.B. Following a number of marineaccidents involving timber deck cargoes,the MAIB carried out a study into thesubject and, in 2003, published itsTimber Deck Cargo Study. This can beviewed on the MAIB website:www.maib.gov.uk.

Narrative

An 1175gt general cargo vessel underwentchange of ownership, flag and crew beforedeparting her berth for an anchorage in theharbour roads to await further orders. It wasanticipated her next port of call would be to thewest.

New crew joined the vessel 18 days in advance ofsailing to familiarise themselves with the vessel.During that period, she also underwent a numberof Flag State and Classification Society surveys.As a result of one of the surveys, a condition ofclass, which required repairs to the port anchorcable within 3 months, was imposed.

After departing her berth, the pilot who was inattendance, suggested a particular anchorage inthe harbour roads, as orders for her next port ofcall were expected within 4 hours. He also

advised, should the weather deteriorate, to seek amore sheltered anchorage to the east.

Shortly after leaving the harbour, the vessel wasbrought up in a position 1 cable from the fairwaybuoy, 1.6 nautical miles from the shore, in adepth of 6 meters. Five shackles of cable weredeployed on a holding ground of sand. Anchorwatches were set and the main engine was shutdown, on 15 minutes’ notice. At that time, theweather conditions were a force 3–4 wind with aslight swell. The position of the vessel waschecked and recorded every 30 minutes with theaid of radar and GPS, but the guard zonefunction on the GPS was not used.

As the day progressed, the weather conditionsdeteriorated, and by the time the master came onwatch at 2000 the wind had increased to force7–8 with a heavy swell. No orders had yet beenreceived.

18

Poor Planning Leads to OverExtended Stay – on the Beach


CASE 6

At 2100, the master detected that the vessel wasdragging her anchor. Unknown to him, she hadbeen dragging her anchor before the 2030position was recorded. He then requested mainengine power. The master did not use the portanchor cable, afraid he might lose it, neither didhe utilise the remainder of the starboard cable.

By the time main engine power was available,some 20 minutes later, due to a combination of

the engineer’s unfamiliarity with the vessel andpoor weather conditions, she had dragged heranchor to such an extent that she grounded on anearby beach despite the master attemptingseveral engine and rudder movements.

The vessel remained hard and dry for more than2 weeks, before a salvage team eventuallyrefloated her. She sustained minor damage to herhull plating.


CASE 6

The Lessons

1. It would have been prudent for themaster to have selected a more suitableanchorage, especially in light of theweather forecast. When ever choosing ananchorage, always take intoconsideration the weather forecast andholding ground, ensuring sufficient cableis deployed.

2. If poor weather is forecast, always haveengines ready for immediate manoeuvre;you never know when you will requirethem. Doing so, might have preventedthis grounding.

3. The master might also have consideredusing the port anchor cable and/oradditional starboard cable. This, too,might have prevented this accident.

4. When ever at anchor, it is imperative tocheck the vessel’s position accurately, atregular intervals. Most radars and GPSsare fitted with guard zone alarms thesedays, and their use can be invaluable indetecting a vessel dragging her anchor.

5. When joining a vessel for the first time,always take time to familiarise yourselfwith her, especially in areas of yourresponsibility. It will prove worthwhilein an emergency.

Loading operations are usually swift, noisy, busyprocedures, with a ship’s staff engaged in a flurryof duties. The following narrative illustrates theneed for extreme care to be exercised during suchtimes of heightened activity.

Narrative

A ro-ro vessel’s late arrival in port had put herloading operation behind schedule: there was notime to lose. This placed the experienced loadingofficer under increased pressure to expedite theprocess so that the vessel could proceed withoutdelay.

The loading officer directed the last 12m trailerto its parking position on board. He then movedto the linkspan, where a tugmaster unit waspushing a trailer into position. The trailer hit theloading officer and seriously crushed him. He washospitalised.

A very similar accident had occurred on boardthe same vessel some months earlier. On thatoccasion, another loading officer was struck bythe front end of a trailer when he hadn’t noticedthat the vehicle was reversing. He, too, sustainedsevere injuries.

It is important to note that a tug driver has noview of the front of the trailer he is pushing. Thisputs the onus on the pedestrian to remain alertand mindful of moving vehicles at all times. Thedriver involved in the first accident discussed wascompletely unaware that someone had beenseriously injured.

To reduce the likelihood of further similaraccidents, the ship’s operator introduced thefollowing two safety recommendations:

• Reversing warning signals to be fitted

• The speed of tugmaster operations to bereduced.

20

The Dangers of High Speed Loading


CASE 7

The Lessons

1. Operating at high speed, and without theaid of signallers, has been the cause ofseveral fatal accidents. These accidentshighlight the importance of shore-sideand ship management teams workingtogether to ensure that loadingoperations are conducted safely.

2. Ports which operate with high safetystandards require tugmasters to be fittedwith warning lights and reversing alarms.

3. To promote the safety message relating toaccidents such as these, in 1998, theMCA produced MGN 19(M). It is wellworth a read: section 5.4 will be ofparticular interest.

Narrative

Two motormen were issued with a ‘Permit toWork’ covering routine maintenance of the mainengine on board a ro-ro passenger ferry that wasberthed alongside.

The work included changing the circlips and “O”rings on the main engine rockers. Withoutgaining prior approval, the two men decided toremove an adjacent thermometer pocket in theengine’s cooling water system in order to easeaccess to the rockers.

As the pocket securing union was being removedfrom the pipe, the pressure in the system ejectedthe thermometer pocket, and hot water in excessof 75° C sprayed onto the men, badly scaldingtheir legs.

The task that the men were given did not requirethe pocket to be removed; had they followedtheir instructions the accident would not haveoccurred. However, having made the decision toremove the component, neither of the motormenmade any attempt to check the systemconditions, or make the necessary isolations toensure that the thermometer pocket was safe toremove.

Engineering staff are, of course, encouraged touse their initiative and to suggest improvementsto procedures. Unfortunately, in this case littlethought was given to the consequences of themotormen’s actions. Neither of them consideredthe risks involved in removing the thermometerpocket. Fortunately both men escaped seriousinjury.

21

In Hot Water


CASE 8

The Lessons

1. Before carrying out maintenance, thoseinvolved should ensure that they arefully conversant with the requirementand should know the extent of the work.

2. Work should be allocated according tocrew members’ competence and skilllevels.

3. Where a “Permit to Work” has beenissued, the work undertaken shouldremain within the bounds of the permit.If this is not possible, revisedinstructions should be issued.

4. Maintenance instructions should alwaysbe referred to. Where additionalcomponents need to be removed tofacilitate access, prior approval should besought and systems and equipmentcorrectly isolated.

Narrative

A small aggregates dredger operated within thelimits of a large river estuary. She had a crew offive, including the master, who had operated inthe area for many years.

When returning from a dredging operation, fullyloaded, the vessel sailed upriver on a strong floodtide. To reach her unloading berth she needed toenter a tributary. She reached a mud bank acrossthe entrance to this river, where the master knewhe would be unable to proceed until the tide rosefurther. As was his habit, he nudged his vessel’sbows into the mud bank and maintained positionwith a dead slow ahead engine speed to wait forsufficient depth of water to proceed.

The vessel had been in that position for severalminutes when the flood tide caught the stern andpushed her to one side of the narrow channel.With his extensive experience of the area, the

master thought little of this, thinking his vesselhad harmlessly touched the mud bottom.However, a few minutes later, the engineer madea routine visit to the engine room. To hissurprise, he found water just above the lowerfloor plates, and its level was rising rapidly.

On being told of this, the master then realisedthe vessel was not responding to engine andhelm. She was sitting on the bottom, with arising tide.

All crew were safely evacuated. Over the nextcouple of hours, the water level rose until itcovered the entire vessel, except her funnel andmast.

Several days later, the vessel was salvaged andmoved to a drying out berth. There, anexamination discovered a gash, 300mm × 450mm,in the otherwise sound single skin shell plating, atthe turn of bilge in way of the engine room.

22

A Not So Soft Bottom


CASE 9

Photograph showing gash in single skin shell plating


CASE 9

The Lessons

1. No matter how well an area of water isknown, there is always likely to be atime and a set of conditions which cancatch seafarers unawares; even thosewith much experience.

2. Although the riverbed was thought toconsist of soft mud, natural movementhad exposed a piece of hard materialsufficient to penetrate steel plate. This isa risk taken whenever any vessel sits on,or makes contact with the bottom.

Narrative

A vessel fitted with a pair of medium speedengines geared to each of two propeller shafts,was programmed to have some repairs done toone engine in the next port. To prepare for this,the engine was to be partially dismantled byship’s staff during the remainder of a seagoingpassage.

To begin work, the engine was taken off load, de-clutched from its gearbox and stopped from themachinery control room (MCR). The engine’sturning gear was engaged, and the engine wasthen allowed to cool before the lub-oil pump wasstopped and the cooling water system drained.

The partner engine of the pair remainedclutched-in and running.

The clutches were of the pneumatically operatedfriction type. The normal engine shut downprocedure, activating solenoid operated valvesusing the controls in the MCR, had shut off theair supply and exhausted the compressed air fromthe clutch to cause it to disengage. However,because the engine was to be worked on, thewatchkeeping engineer closed the local isolatingball valve on the clutch’s air system and openedthe system’s vent. With the aim of furtherventing the system, he also, briefly, opened avalve that by-passed the solenoid operated airsupply valve.

About half a minute later, he began to notice thesmell of burning. Smoke was coming from thegrill area of the clutch’s guard. This was quicklyfollowed by flames.

A smoke detector, positioned above the clutch,activated the vessel’s fire alarm. Assistancearrived quickly, including two teams withbreathing apparatus. Dry powder and CO2

extinguishers were used, but these were unable toremove sufficient heat to prevent re-ignition ofthe burning material; most probably the rubberair bellows that force the clutch shoes intocontact with their mating frictions surfaces.However, a fire hose was rigged and a jet of waterwas applied for about 1 minute. The other enginewas stopped, to arrest the generation of frictionalheat in the clutch, and the water fog fire-fightingsystem was activated.

These measures extinguished the fire, and thewater fog system in particular knocked downmuch of the smoke that had been generated.Although the clutch was totally destroyed, thefire had not spread outside the clutch’s guard andno other damage was done (see figure).

The vessel was able to continue her passage usingthe other engines.

24

Some Good Fortune – Only aBurned Out Clutch


CASE 10


CASE 10

The Lessons

1. Opening the by-pass valve, howeverbriefly, was an unnecessary operationthat, combined with defects in the balltype isolating and vent valves whichprevented positive operation, allowedsufficient air to enter the operatingbellows of the clutch to cause partialengagement. The lack of clear engineisolating procedures allowed this practiceto develop, and the defects in the twoball valves then allowed this extraprocess to generate an unsafe condition.Maintenance of the isolating and ventvalves clearly needs attention, but clutchisolating methods need also to be clearlyset out.

2. Fortunately, the engine’s turning gearwas engaged, effectively preventing theengine from being turned at speed by itsrunning partner, and nobody had yetstarted work on the engine.

‘Spontaneous’ engagement of the clutchcould so easily have produced disastrous– even nightmarish – consequences foranybody unfortunate enough to beworking on the engine. The nature ofthese consequences suggests there needsto be a rigorous system in place to ensureclutches cannot be engaged inadvertentlyonce shut down; at the very least,padlocking the by-pass valve, andpossibly also the isolating and ventvalves, with the keys in the custody ofthe chief engineer. Alternatively, avoidengine crankcase work when the partnerengine is running. The enhanced level ofsafety, and peace of mind, for thoseworking on the engine, would be ahandsome return for any extra troubleinvolved.

Photograph showing the burnt out clutch

Narrative

A high speed passenger ro-ro ferry had completedloading and was preparing to leave her berth. Aspart of the departure routine, the crew beganraising the aft ramps.

The port ramp was in the process of being raised,and had almost reached the fully stowed positionwhen the lifting wire parted and the ramp fellback onto the link span.

On closer inspection, it was found that thedesign of the lifting arrangement allowed thelifting wire to chafe on the ramp handrails.Additionally, the lifting blocks and wire had anatural twist, which meant that when the weightwas taken by the wire, the operator had torealign the blocks manually. This was causingadditional unnecessary wear and tear, as well asbeing potentially hazardous.

Luckily, on this occasion, no one from the shipor the shore was injured during the incident. Butwhat was the real reason for the wire parting?

The securing arrangement for the ramp consistedof two turnbuckles, one on each side of theinboard section. The turnbuckles were designedto pull the ramp tight into the ship’s side once

the lifting wire had tripped the limit switch. Indoing so, they also released the weight on thelifting wire. If the turnbuckles were not fullytightened, the weight of the ramp would remainon the lifting wire and its supporting sheaves.

Interestingly, the ramp was not able to self-adjust, and, as a result, required constantattention throughout the period of loading anddischarging, particularly when trimmed by thehead, to ensure no weight came onto the liftingwires. Modifications to the braking system arenow underway, which will provide a self-adjusting capability and assist in countering shipmovement.

In this particular case, it is probable that thesecuring turnbuckles were, as routine, onlysecured hand-tight. The combination of rollingand vibration associated with normal in-serviceoperating conditions, could easily have resultedin wear and tear of the wire at a vulnerableposition. Maintenance records confirmed thatseveral seized blocks had been replaced and freedover the preceding 4 months.

Planned maintenance history sheets showed agood audit trail of maintenance and equipmentrectification throughout the in-service period.

26

Do You Check Your Wires?


CASE 11

The Lessons

1. Securing of ramps, using the turnbucklemethod, should be carefully monitored,especially the initial tension and anycreep back while in use. In this case, thelong-term aim is now to significantlyimprove the securing arrangement by apermanent modification.

2. Although no personal injuries weresustained, and the quayside was properlycontrolled, the case shows theimportance of not allowing personnel inthe vicinity of ramps during lifting andlowering operations.

3. Planned maintenance records were wellmaintained, however, the importance ofthorough and thoughtful visualinspections cannot be over emphasised.This accident could probably have beenavoided by careful inspection by theoperator on a routine basis and as part ofa standard operating procedure.

Narrative

A 64 metre, 1109gt cargo vessel was underway indaylight off the east coast of England. She washeading on a north-westerly course at a speed of8 knots. The master had begun his navigationalwatch at 0600. No additional lookout waspresent on the bridge; indeed, this vessel did notemploy additional lookouts even at night. Thevisibility was between 2 and 2.5 miles due tolight drizzle, and the wind was moderate.

At about 0610, the master checked the radarscreen, which was set on the 6-mile range, andsaw no targets. After a visual check around, andseeing no other vessels, he left the bridge togather some papers from his cabin.

Meanwhile, an 8.5 metre single-handed long linefishing vessel was underway and heading on asouth-easterly course at about 8 knots. Theskipper had just hauled his lines onboard and washeading for another fishing ground. He wasstanding just outside the after door to hiswheelhouse, facing forward and to starboard. Hewas gutting his catch while maintaining a visuallookout and watch on his radar, which he couldsee through the doorway. The skipper had onlyreceived about 2 hours sleep in the previous 24hours.

The skipper suddenly noticed the bow of a shipheading straight towards him at less than 0.5mile and fine on his starboard bow. He wronglyassumed that the other vessel was the give-wayvessel under the Collision Regulations. He raninto the wheelhouse and, using his fixedsearchlight, tried to signal to the other vessel. He

then attempted to call her using one of his VHFradios. This call was not heard by the coastguardand might, therefore, have been made using thewrong radio. The skipper then began alteringcourse to port by pressing the 10° incrementalautopilot course change button three times.

As the fishing vessel was swinging to port, theice-strengthened bow of the cargo vessel collidedwith her starboard quarter, causing severedamage to her glass fibre hull. She heeled over toport as water gushed on board through thefreeing ports. Her bow then swung violently tostarboard and struck the starboard shoulder ofthe cargo vessel as she passed, causing furtherdamage.

The master of the cargo vessel felt the impact ashe returned to the bridge. Once he was on thebridge, and had seen the fishing vessel lyingastern of his vessel, he rang the general alarm toalert his crew.

Fortunately, the fishing vessel remained afloat.The skipper sent a “Mayday” message to thecoastguard to apprise them of the situation.

The general cargo vessel was undamaged, andstood by the fishing vessel until an RNLI lifeboatarrived and escorted her to her home port. Thecoastguard released the cargo vessel and sheproceeded to her next port, where she arrivedsafely the next morning.

The fishing vessel had not been sighted visuallyor by radar, despite being painted bright yellowand having a radar reflector on her mast andfishing float radar reflectors in her rigging.

27

Collision Involving a GeneralCargo Vessel and a Fishing Vessel


CASE 12


CASE 12

Fishing float radar reflectors

Photograph showing door to wheelhouse


CASE 12

The Lessons

1. Leaving the bridge unattended, even fora short period of time, is absolutelyunacceptable. The fact that it occursfrom time to time is of grave concern toeveryone at sea. A poor attitude towardswatchkeeping on the cargo vessel wasalso evidenced by the fact that nodesignated lookout was posted at night –despite an international requirement forthere to be one.

2. It is a wise precaution to bear in mindthe possibility that the bridge of theother vessel may be unattended or thewatchkeeper may be distracted: TheMAIB has come across this all too often,so in this situation it is essential thatearly action is taken by your vessel. Inthe future, this fisherman will certainlybe taking decisive action much earlier soas to avoid a repetition of this accident.

3. The skipper was a very experiencedfisherman. However, it appears from thefacts that he wrongly assessed thesituation; it was an end-on collisionsituation between two power-drivenvessels underway and, as such, bothvessels had a responsibility for action.The decision to act as a stand-on vessel,the delay in taking action, the confusionwith the radios and the action he finallytook in altering to port, might have beencaused, in part, by his fatigued state.Fatigue can have an insidious effect oneven the most experienced seafarers: allseafarers must guard against fatigue.

Damage to cargo vessel

Narrative

The galley deck on a ro-ro vehicle and passengerferry was renewed during the vessel’s last periodin dry dock. Pending full removal of thecompactor, the electrical supply was isolated andthe wire ends taped over.

During subsequent routine washing down of thegalley deck, the cook noticed the wires and,assuming they were isolated from the supply, helifted them clear of the deck. He immediatelyreceived an electric shock to his left hand andarm.

The cook was landed ashore for hospitaltreatment. Luckily, he suffered no long-termeffects.

It was later found that the power supply had beenreinstated without any checks being made.

30

A Cook, Live Electrical Wires, aWet Galley Deck – all theIngredients Needed for a ShockingDay


CASE 13

The Lessons

1. All bare electrical cables pose a threat tolife and must be treated as though theyare live until proven otherwise by acompetent person.

2. Part of the equipment removal processand work specification should includeinstructions for the isolation, removal(where appropriate) of power suppliesand correct termination requirements.The ship’s drawings should alsoaccurately reflect these changes.

3. Before restoring any electrical supplies,checks should be made to ensure that theend user equipment is not being workedon. Ship’s staff should be especiallyvigilant when work is being undertakenby contractors, to ensure that the correctcontrols are in place.

Narrative

Two vessels collided while passing one anotheron a bend of a busy river. Both vessels had pilotson board and were regular visitors to the river.

The inbound vessel was running with the tide atabout 7 knots over the ground, while theoutbound vessel was making 5 knots over theground against the 4 knot tide. Both vessels hadbeen responding normally to helm, and the pilotshad agreed by VHF that they would pass on aparticular bend in the river. This meant thatneither vessel would have to slow down and thebend was relatively wide and open. Both pilotshad passed vessels on this bend previously.

Although the outbound vessel was known tohandle poorly at low speeds, at a speed throughthe water of about 9 knots this was not seen as aproblem. However, this speed was reduced as thevessel approached the bend by bringing back thepitch on the controllable pitch propeller. As thevessel entered the bend, the inbound vessel wasabout 180m ahead, on a reciprocal course, andlooked safe to pass about 30m apart.

The pilot on the outbound vessel applied 10°starboard helm to bring his vessel more towardmid-river, but noticed the bow swinging slowlyto port. He therefore increased helm to hard-a-starboard, but, since there was no effect, heinstructed the master to kick the engine ahead.

When the vessels were about 50m apart, with theoutbound vessel’s bow still falling off to port, thepilot ordered full astern to reduce the inevitableimpact.

The inbound vessel’s pilot had seen the othervessel shear to port and had asked his intentionsby VHF. He then also ordered full astern, but thevessels collided seconds later.

It is thought that the outbound vessel wassubject to a combination of bank effect and theconfused water flow on the inside of the bend,leading to a slight shear to port. Once this hadstarted, the faster flowing stream on the outsideof the bend would have quickly taken the bowfurther to port.

31

Don’t Pass on Bends


CASE 14

Damaged vessel


CASE 14

The Lessons

1. This accident would not have occurredhad the pilots agreed to pass on a straightsection of the river. A slight delay of onevessel was all that was needed to ensurethat the vessels met in a straight, eitherside of the bend.

2. The manoeuvrability of the outboundvessel was known to be poor at slow

speeds, and reducing speed on acontrollable pitch propeller would havehad the effect of creating a baffle to theflow of water over the rudder,exacerbating this problem. This effectcould have been minimised by ensuringthat the speed was reduced gradually. Anearlier reduction of speed would alsohave allowed power to be increased againjust before the helm was applied, thusmaximising the flow over the rudder.

Narrative

When about 3 miles from a harbour entrance,the master of a small container ship called theharbour radio and pilot via VHF radio to confirmintentions for embarking the pilot. Speed wasthen gradually reduced from 15 knots to 10knots. The ship was on a course of 310° in handsteering, and the master was accompanied on thebridge by the chief and second officers. Severalsmall vessels were visible on the starboard bow,the closest of which had been assessed by radar tobe passing about 5 cables astern. Visually,however, this vessel did not appear to bemaintaining a steady course. The vessel inquestion was a fishing vessel, which in fact wasalso heading for the harbour entrance; she wason a course of about 290° in autopilot, at a speedof 7.5 knots.

When the container ship was about 1.5 milesfrom the harbour entrance, speed was further

reduced to about 6 knots on the advice of thepilot, who was approaching in his cutter; coursewas also adjusted to 300°. The container vesseland fishing vessel continued to close, and theskipper of the fishing vessel became soconcerned that he tried to contact the containership, which was on his port quarter, via VHFchannel 16 – the working channel for the port.These calls were not heard on board thecontainer ship.

Shortly after, because the master of thecontainer ship decided that the fishing vessel’serratic movement was now putting the twovessels unnecessarily close, he stopped hisengine and applied port helm. Maximum helm,however, was not used because of the proximityof fishing floats on the container ship’s portside. At about the same time, the fishing vesselaltered hard to starboard and turned through360° to pass under the stern of the containership.

33

A Close Call


CASE 15


CASE 15


CASE 15

The Lessons

1. There is little doubt that distrust existsbetween many merchant mariners andfishermen regarding adherence to thecollision regulations. Tales of fishingvessels behaving in totally unpredictableways, even when not fishing, and ofmerchant ships not taking action to avoidcollisions, because of incompetent orabsent watchkeepers, are common.Undoubtedly, there are rogues in bothcamps, but tarring each vessel type withthe same brush does not help matters. Itwould be more beneficial for each to gaina better understanding of the other’smethods, goals and constraints. At theend of the day, it pays for allwatchkeepers to expect the unexpected,regardless of the types of vesselencountered.

2. The aspect of fishing vessels canfrequently change because of theirrelatively small size and slow speed,particularly in bad weather. Thisincreases the difficulty in determiningtheir courses, speeds, and CPAs, whichmust be taken into account whendetermining the risk of collision andaction to be taken. Where aspect isdifficult to determine, caution isrequired.

3. The use of shapes to indicate that avessel is fishing has fallen into disreputein recent years, largely due to the factthat they are constantly hoisted in many

vessels, even when in harbour. As aresult, many watchkeepers on merchantvessels either don’t bother to look forsuch signals, or ignore them. This is notin the interests of the safety offishermen, but the onus is squarely ontheir shoulders to use the shapescorrectly if this trend is to be reversed.

4. When other shipping or navigationalhazards prevent an alteration of courserequired to avoid a collision or increasethe CPA of another vessel, slowing rightdown or stopping are often the onlycourses of action left. Like any actiontaken to avoid a close quarters situationor collision, however, the earlier suchaction is taken, the greater the chancesof its success.

5. Slowing down and altering course to pickup a pilot can be difficult, especiallywhen navigationally constrained in atideway, with other vessels in the area.In such situations, although a focus onthe manoeuvring required to get the pilotcutter alongside is natural, it is importantto maintain an overview of the wholesituation and keep a close eye on howsuch manoeuvring affects others. Thecollision regulations must not beforgotten in such circumstances.

6. When a close quarters situation hasdeveloped, it is seldom resolved by theuse of VHF radio. Positive action is farmore effective.

Narrative

A 2500grt general cargo ship, carrying a timberdeck cargo, was heading towards the entrance toa 300m wide buoyed channel, on a course of004° in autopilot. She was travelling at a speedof 13.5 knots. An AB lookout had been stooddown because it was getting light, and the OOWconsidered there was little for him to do. TheOOW was content with the navigationalsituation, as the two buoys marking the southernlimit of the channel were clearly visible on theradar, and had been acquired by ARPA.

At 0747, the OOW called the master viaintercom to wake him in preparation for takingover the watch at 0800. At about the same time,he recorded the visibility in the deck log, whichhe assessed to be about 2 miles in light snow. The

weather forecast had predicted snow withmoderate to poor visibility. At 0750, when 8.5cables from the channel entrance, course wasadjusted on the autopilot to 345° in accordancewith the passage plan. The tidal stream at theentrance to the channel was easterly at 2 knots.No tidal stream information was shown on thechart but was contained in the relevant sailingdirections.

Minutes later, visibility was suddenly reduced toless than 100m by heavy snow, which alsodegraded the radar picture to the extent that thechannel buoys were no longer displayed. TheOOW immediately changed to hand steering,reduced speed to 12 knots and called the mastervia intercom to hurry to the bridge. The OOWhad very little experience of manoeuvring theship in hand steering.

36

Whiteout


CASE 16

Distorted propeller blades

The OOW then saw the nearest red lateral buoyat about 40m off the starboard bow. Port helmwas applied to manoeuvre the ship clear. TheOOW did this while watching the buoy over thetimber deck cargo from behind the starboardradar display; he did not monitor the amount ofrudder used, or the rate the ship was turning. Thebuoy was seen to be passing very close down thestarboard side when it disappeared from view.

As the master arrived on the bridge, the OOWrealised the ship was now swinging to port, andapplied starboard helm in order to check thismovement. Seconds later, the ship hit the buoywith her starboard quarter. The ship’s propellerblades were distorted (Figure) and the buoy wassevered from its moorings.


CASE 16

The Lessons

1. Night watches can be boring, and theneed for both an OOW and a lookout tobe on the bridge is frequently questioned.The usefulness of having a secondperson on the bridge sometimes onlybecomes obvious when the unexpectedoccurs. In this case, had the lookout notbeen stood down as the ship approacheda narrow channel and with poor visibilityforecast, he might have alerted the OOWto the approaching blizzard, been put onthe helm, or used to monitor the buoy.Any of these actions would have been ofbenefit to the OOW.

2. Charts are usually comprehensive, butthey are not a font of all knowledge. Notreferring to other sources of informationsuch as sailing directions when planning,and during a passage, can lead toembarrassment, or worse.

3. When buoys do not mark a danger, theyare the danger, and knowing the extentof safe water around a buoy is invaluableif forced to take avoiding action. Leavingthe buoy on the wrong side might bepossible and, in some situations, the bestcourse of action, particularly when tidalstream is a factor.

4. A reduction of speed when encounteringa problem is usually a sensible

precaution. To be effective, however,such a reduction must be sufficient tobuy enough time to allow remedial actionto be taken. The smaller the reduction,the less time will be available.

5. Being unfamiliar with handling a ship,and having to manoeuvre to avoid adanger only several meters away, withminimal visual references available, isakin to parking a new car while wearinga blindfold. Providing opportunities forbridge watchkeepers to become familiarwith manoeuvring characteristics, andencouraging them to use all of the toolsavailable, such as rudder angle and rateof turn indicators, can only help preventsuch undesirable situations from arising.

6. On every passage there are some areaswhich, through the proximity tonavigational dangers or traffic density,are potentially more hazardous thanothers. It is not always easy for mastersto decide whether or not to be on thebridge when transiting these areas, andthere are no hard and fast rules.However, having identified a potentiallyhazardous area, it is worth bearing inmind that it is easier for a master toinfluence the outcome of a dangeroussituation from the bridge, than it is fromhis cabin. The OOW might call, but thefew seconds taken to reach the bridge,might be a few seconds too many.

Part 2 – Fishing Vessels

It’s the same the whole world over. In myworking lifetime in the fishing industry, I haveexperienced many highs and lows, includingincidents and accidents with both minor andmajor consequences. Some I have been close to,others more distant from, but the commonthread is one of identity. I and others within theindustry can identify and sympathise with thoseinvolved in the incident concerned.

Indeed, when such an event occurs, it is oftenthe subject of much discussion and debate. Whathappened? How did it happen? What could besthave been done (with the benefit of hindsight)to prevent the accident? Frequently, conjecturebased on something less than a full appreciationof the facts and circumstances leads to erroneousconclusions.

This process is common to fisher folk all over theworld. Besides involvement in the UK fishingindustry, I have also experienced the extremes ofartisanal fishing in the Pacific Islands andindustrial fisheries of Japan. The only difference

appears to be in mode of communication.Among Pacific Islanders, it was word of mouthwhile reclining under a coconut tree, on theJapanese ships it was electronic newsletters andsatellite communications. The theme was thesame: accident at sea – how, why and wherenow?

This brings me to the publication I have beenasked to write about in the form of anintroduction. The MAIB Safety Digest is apublication which gives factual insight into thoseaccidents and incidents we have such aseemingly morbid interest in.

However, I commend the reading of this to youall, as the Digest does give us the facts andcircumstances of each and every incident, and, indoing so, fulfils two important functions. Firstand foremost it makes us safety conscious,reminding us of how easy it is to get caught up incircumstances which potentially could lead todisaster. Secondly, it gives us the knowledge(otherwise gained only through costlyexperience), which better prepares us forincidents which will happen to us at some timein the future.

Subconsciously, that is what we all are trying todo in our own individual and group assessment ofsuch situations. Here, we have a publicationwhich puts the facts and issues to us to assist inour learning and appreciation process. Read thisSafety Digest well, relate to the incidents, andlearn. It could help you one day – perhapswithout you being fully aware of it.


Dick James’s lifetime in the industry started as an academic with a chosen path in marine biology but always with aninterest in the practical and commercial side of fish and fishing. Taking the route of Government Fishery Officer (in thosedays development oriented) through to boat ownership and running a business. Dick worked in overseas fisheries for 10years, both for the United Nations and UK Overseas Development Program before returning to his first place of work,Northern Ireland, to take on the role of Chief Executive to the Northern Ireland Fishermen’s Federation and P.O.

For the past 20 years, Dick has been actively involved with the Maritime and Coastguard Agency, Fishing IndustrySafety Group and its working groups.

Narrative

A 16 metre wooden fishing vessel, with a crew ofsix, was making an overnight coastal passage toher usual fishing grounds. One crewman was onwatch, the rest were asleep in theaccommodation.

A couple of miles before reaching a positionwhere an alteration of course was necessary, thecrewman stepped from the wheelhouse into thegalley area just behind the wheelhouse. Whilethere, the watch alarm sounded. Moving quicklyto silence the alarm, he jumped up a step intothe wheelhouse. In doing so, he struck hisforehead very hard on the low door frame.Although managing to take the two steps toreach the wheelhouse chair, he lostconsciousness.

The vessel continued on its course, at almost 8knots, and the course alteration was missed.Minutes later, she struck the almost vertical cliffface of a small headland; a headland that thecourse alteration would have caused her to avoid.

The noise and shock of the impact awoke therest of the crew. Entering the wheelhouse, theskipper found the watchkeeper barely consciousin the chair. Engine room and hold bilge alarmswere sounding. The skipper instructed the othersto prepare the liferaft for launching and pressedthe emergency button on the DSC/VHF.Recognising he needed to get out of thewheelhouse because of the vessel’s rapidlydeteriorating state, he was unable to hold down

the DSC button for long. One of the crewopened a forward hatch, to be met by a rapidlyrising level of sea water. Even in the dark, it wasclear to all that the vessel was in a desperatestate.

The liferaft was launched and all six menclimbed in. They pushed themselves away fromthe stricken boat, and watched her as the enginestopped and the stern light went underwater. Shewas soon sitting on the bottom, with only hermasts visible above water (see figures).

Realising they would be unable to get ashore byclimbing the steep cliffs, the survivors decided topaddle along the coast. They had great difficultyin opening the liferaft’s equipment pack becausethere was no light fitted to the canopy. Two ofthe men had had the opportunity to collectlifejackets during their evacuation, and the lightson these were used to give some rudimentaryillumination. Once the pack was open, thepaddles were found, as were three hand-heldflares and a torch. The torch did not work, evenafter the batteries were changed for the sparesthat were also in the pack. One flare was set offin the hope of attracting somebody’s attention,but the remaining two were saved.

At that stage, some of the men were confusedbecause of the apparent shortage of kit in theliferaft’s pack. In the words of the skipper: ‘wewere becoming angry because we did not find the kitwe knew should have been there. We could notunderstand why there was not more gear. I expectedto find some parachute flares at least’.

40

Not a Stroll in the Park


CASE 17

A moderate wind assisted them to paddle alongthe coast, and they found a place to clamberashore nearly an hour after the grounding.

Once ashore, the men found themselves in veryremote terrain, with no shelter, cold, in the dark,in drizzly rain and with no signs of habitation,apart from a single light a couple of miles away.Nobody had any warm clothing and one manhad no shoes. However, they began to walktowards this light.

During their walk, attempts were made to call forassistance using a mobile telephone.Unfortunately, due to its remoteness, the areahad no coverage. Their trek lasted nearly 2hours. However, they finally managed to reach aprivate house, where they raised the alarm.

All the men suffered some degree of distress dueto the cold and wet. The watchkeeper who hadstruck his head was taken to hospital, where hewas detained.


CASE 17

The Lessons

1. The watch alarm could not be heardoutside the wheelhouse and galley area.Without a second person being awakeand in the vicinity of the wheelhouse,the vessel was not under control oncethe watchkeeper had been disabled.Unless able to alert others, a watchalarm has no value when, for whateverreason, the watchkeeper is disabled.

2. No “mayday” signal was sent becausethe skipper was unable to hold down theDSC button for the necessary 5 seconds.An audible signal is usually given whenthe 5 seconds have elapsed and a messageis sent. In the event, the rather loudbilge alarms would have prevented theskipper hearing the signal in this case.

3. Because of an administrative error, theliferaft was a type not approved by theMCA for carriage on fishing vessels ofthis size. An approved liferaft wouldhave carried parachute flares and had acanopy light, just as this crew hadexpected and been trained to use. This

crew now appreciate the value of some ofthe equipment the MCA requires.

4. Another feature of the liferaft was thatits manufacturers recommendedservicing every 36 months, rather thanthe more common 12 months. It was lastserviced 30 months before this accident.Although the failure of the liferaft’storch cannot be attributed to the timesince the last service, the shorter serviceinterval is likely to reduce the chances ofequipment becoming faulty.

5. It is important that skippers and ownersappreciate the significance of thedifferences between liferafts made andequipped to MCA standards and thosethat satisfy other bodies. This is not justa matter of satisfying regulations: crews’lives might depend on it.

6. Although the liferaft was not equippedor serviced to the usual MCA standards,and the crew were rather upset at itslimited equipment, it almost certainlysaved their lives.

Narrative

Families were left mourning their loved onesafter the entire crew of a 17m fishing vessel waslost in force 6 winds and a strong tidal stream.The following narrative provides the detail ofthis tragic incident.

The vessel and her crew of four headed for herregular fishing grounds and started trawling.After about 4 hours, the cod end was hauled onboard and the catch was stowed down below.The skipper turned in during the second tow,leaving one of his crew on watch. The wind waseast-north-easterly force 6, and a strong tidalstream was running with the vessel when hertrawl gear became snagged. Water entered thevessel through vents and other openings, causingher to capsize to starboard.

The vessel sank suddenly and her crew of fourwas lost.

The vessel’s EPIRB was released and startedtransmitting, prompting an extensive air and seasearch. That day, only the EPIRB and debriswere found. The following morning, the liferaftwas recovered, inflated but with a severed

painter. The wreck was located on the seabedand two of the crew members’ bodies wereretrieved from it.

The vessel was later raised to enable a thoroughexamination to be made, including an assessmentof her stability. The results were alarming: thevessel had very poor stability, well below therequired standard for a vessel of her size. Thechart below shows righting lever (GZ), which isa measure of a vessel’s ability to return to uprightwhen heeled, against heel angle. The greater therighting lever, the greater the force restoring thevessel to upright. It was later found out that sometime before the accident, concerns had beenraised about her stability.

During the detailed examination of the vessel, afuse, which supplied both the fire alarm and thebilge alarm, was found pulled in the wheelhouse,rendering these two safety systems inoperable.The bilge alarm sensors were blocked withdebris, the fixed bilge pumping system was also ina poor state and had lacked proper maintenance.Reliance appears to have been placed on a singleportable electric bilge pump to cope with anyflooding.

42

Stability Aware?


CASE 18

Fishing Vessel GZ Curve Comparison

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0 10 20 30 40 50 60

Heel Angle (Degrees)

GZ

Rig

htin

g L

ever

(m

)

Example of healthy GZ curve

Example minimum requirement GZcurve

Best GZ curve for vessel in this case

Dow

nflo

odin

g an

gle


CASE 18

The Lessons

1. An awareness of stability and itsimportance is vital to the safe operationof a fishing vessel. If your vessel requiresstability approval, make sure it is up todate and that the vessel has notsubsequently been modified or changedits operation significantly. If it has, thevessel’s stability must be checked by anexpert.

2. Snagging places you and your vessel atgreat risk. Ensure you have minimisedthe risk of becoming snagged whentrawling: know your ground and use thecorrect length of trawl warp. Althoughyou might have survived numerousoccasions of your fishing gear becomingsnagged, this does not mean your vesselis immune from capsize.

3. The bilge alarm is the main line ofdefence against flooding, giving youadditional time to react promptly to anincident. Make sure yours is workingand test it before every trip to sea. Younever know when you might need it.

4. Pulling the fuse on safety systems suchas the bilge alarm or fire/smoke alarmputs crews’ lives at greater risk. If asystem is giving false alarms, get it fixed.Remember the systems are there for youand your crew’s safety.

5. Make sure your float-free liferaft can dojust that! Position the raft to maximisethe chances of it deploying successfullyand not entangling the painter. Andmake sure your raft has been servicedand that any hydrostatic release is indate.

Narrative

This accident occurred to a 9.8m creel boat. Shewas built of GRP and had a wheelhouse forward,with the hauler and additional engine andsteering controls on the starboard side. She waswell maintained and always operated with a two-man crew, who were also the owners of the boat.

The vessel had been fitted with a vivier tankbelow decks some time after her initial build. Apump for circulating water had been fitted belowdeck in the space aft of the tank. This hadthrough hull fittings to supply the pump. Whenthe owners bought the boat, they intended tooccasionally leave the pump running overnightunattended. They thought it would be dangerousto site the pump below decks, since any pipeworkfailure might have meant water filling the boat.They therefore moved it up on deck, but left theoriginal sea cocks in place.

As delivered, the boat was fitted with a toilet,but this was considered unnecessary so wasremoved and the space used as a store. Again, thesea cocks for the toilet system were left in place.

The vessel had sailed early in the morning, andthe crew were working their second string ofpots. At about midday, the bilge alarm sounded.A check of the bilge in the engine space showedthat there was a fair amount of water present, sothe deck wash pump suction was switched overfrom the sea suction to the bilge suction. Thewater in the bilges continued to rise, so thevivier circulating pump was started and the

suction put into the bilges. At that stage, theskipper made a call to the coastguard indicatingtheir problems – but not their position.

Shortly after that, the main engine stopped dueto the amount of water in the bilges, and thisstopped the deck wash pump, which was drivenfrom this engine. The crew donned theirlifejackets and launched their liferaft. The boatwas feeling very sluggish and, with the water stillrising in the bilges, a second and final call wasmade to the coastguard. This time they gavetheir position, which was read from the GPSreceiver.

The crew took to the liferaft and were winchedto safety by helicopter. The fishing vessel waslost.

The exact reason for the boat sinking has notbeen established. However, the number ofelectrically isolated through hull metal fittingssuggests that undetected corrosion of one ofthese, eventually caused a failure of the fittingand the subsequent loss of the boat.

44

Corrosion, What Corrosion?


CASE 19


CASE 19

The Lessons

1. The boat was well supplied withsacrificial anodes, the bolts of onepassing through the hull. The earthingstraps from the pipework systems wereconnected to it, providing electricalcontinuity and therefore protecting thesesystems from galvanic corrosion. Therewere no earthing straps connected to theredundant sea cocks, and therefore noelectrical connection between them andthe sacrificial anodes. It is possible thatone of the sea cocks became corrodeddue to galvanic action. It failed, allowingunrestricted flooding of the boat. Toavoid areas of severe galvanic corrosion,redundant hull fittings on GRP hullsshould, ideally, be removed andappropriate repairs made to the GRP.Where this is not possible, care shouldbe taken to ensure that any redundanthull fittings retain electrical continuity.

2. The boat was not required to have aliferaft on board. The fact that one wascarried, and deployed early, combinedwith prompt calls to the coastguard,saved the crew from a long, cold and wetafternoon.

3. By not giving the coastguard the vessel’sposition during his first call, the skipperpresented the rescue services with aquandary. Although the helicopter thatwas scrambled to provide assistance wasdeployed towards the general direction ofthe fishing vessel, valuable time was lostuntil the second call provided thecoastguard with a more accurate fix ofthe boat. In other circumstances, theadditional time taken by the rescuehelicopter to reach the crew men mighthave made the difference between lifeand death. It is imperative that theposition of your vessel is passed to therescue authorities as soon as anemergency situation begins to develop.

Narrative

An 18 metre beamtrawler had justreturned to port aftera successful fishingtrip. Good husbandryis always to beencouraged, and inthis case the skipperwasted no timeinstructing the crewmember to thoroughlyclean out and wash

down the accommodation area. Keen to please,the crew member set about his task with gustoensuring no stone was left unturned and nolocker remained untouched!

While tidying and cleaning one of the lockers,the crew member removed a rocket line-throwing appliance in order to gain better access.Shortly afterwards, the line-throwing appliancewas detonated. Travelling diagonally across theaccommodation, and lodging itself in thestarboard aft bunk, a fire broke out immediately.After raising the alarm, the fire was quicklyextinguished by the crew member, ably assistedby shore staff and the crew of an adjacent vessel.

The fire brigade was called and attended theincident as a precaution, but were satisfied thatthere was no chance of re-ignition.

46

‘It Just Went off in my Hand Chief!’


CASE 20

The Lessons

1. Skippers should ensure that the lockercontaining a vessel’s pyrotechnics islocated on or near the bridge in a secure,dry and readily accessible location. Thelocker should be clearly marked with thecontents.

2. The crew member in this case appearedunaware of the dangers and theconsequences of operating a rocket line-throwing appliance. It is a sensible

precaution for a skipper to include,within a crew member’s joininginstructions, the designated stowage andthe operation of all pyrotechnics carriedonboard.

3. Thankfully, in this case no personalinjury was sustained. Circumstancescould have been very different and theoutcome very much worse. Quickreactions by those involved in fightingthe fire also helped keep physical damageto a minimum.

Narrative

It was a very pleasant day, which provided theopportunity to carry out routine maintenance onboard a UK flagged trawler. Some of the crewwere working aft on the trawl wires, the skipperwas in the wheelhouse and the chief engineerwas on the main deck. The engineer noticed thatthe port main deck floodlight situated on the 4metre high platform (Figure 1) between theforward masts had a “crazed” glass. This was notunusual; a combination of the hot glass and coldsea spray had caused this before, and theengineer was accustomed to changing the glass.

Having obtained a new glass, the engineerclimbed the ladder to the platform. He waswearing safety shoes, but no other personalprotection equipment. He was not wearing asafety harness, although six were on board and allwere in date for test. The engineer informednobody that he was going aloft.

The engineer accessed the platform through anunguarded gap in the guardrails (Figure 2). Theplatform (Figure 3) was wet, did not have a non-slip finish and contained several tripping hazards.He stepped over these, knelt down and rotatedthe floodlight to remove the damaged glass.

The next thing the engineer recalls was ahelicopter hovering overhead preparing totransfer him to hospital.

From the subsequent investigation, it was clearthat the glass had been replaced and that thefloodlight was returned to its original position.The engineer then either stepped back throughthe guardrail gap, or fell from the mast ladderonto the wheelhouse roof, landing on his backand cutting his head. No one saw him fall,although the skipper heard him land on thewheelhouse roof.

Sadly, this accident resulted in the engineersevering the lower part of his spinal cord.

47

Elevated Work, Elevated Risks


CASE 21

Figure 1: General view from stern Figure 2: Port ladder and access showing unguarded gap


CASE 21

The Lessons

While we cannot be sure whether the lack ofa non-slip finish, or the open guardrailcontributed to this accident, the followinglessons should be learned from this tragicaccident:

1. Safety harnesses or other restrainingdevices must always be used whenworking aloft in accordance with theCode for Safe Working Practices. Thereshould be no exceptions to this rule.

2. Safety chains should be fitted to openaccesses in guardrails. If they have to beremoved to gain access, they should bere-instated immediately.

3. A non-slip finish should be applied tohazardous working deck areas, or whererisk assessments have identified there isa risk to personnel.

4. When working aloft, crew should tellothers of their intentions, and theyshould be aware of any potential hazards.

5. Risk assessments should be conductedwhere personnel are exposed todangerous or unusual activities.

Figure 3: Port side of the platform

Narrative

In less than 5 weeks, a twin rig trawler sufferedtwo engine room fires, a flood and a foundering.The second fire and the subsequent floodingresulted in her total loss.

In the first incident, the vessel had been trawlingfor about 3 hours when the skipper noticedsmoke emitting from the outlet of the engineroom exhaust ventilator. He immediately headedfor the engine room, where he attempted toisolate the fuel systems, without success. Hisattempt to then operate the CO2 system (despitethe compartment ventilation flaps remainingopen) also failed because the system had beenpoorly maintained. Unaware that the CO2 hadnot been successfully discharged, a short timelater he entered the engine room with the ship’sengineer to see if the fire had been extinguished.

The fire had actually died out without the use ofthe CO2. The trawl wires were subsequently cutand the vessel towed into port.

Five weeks later, following extensive repairs,including a complete overhaul of the CO2 fire-fighting system, the vessel sailed to recover hertrawl gear. She suffered another engine room fire.The crew were alerted; this time the ventilationflaps were closed and the main engine shutdown. The CO2 system was activated and thefuel shut off valves were closed. Despite thedangers posed by the toxic effects of combustionand CO2, the skipper then attempted to enter

the space. He was beaten back by the gases.Water entered the engine room, probably fromfailed water pipework systems, and the vesselquickly adopted a list to port.

A lifeboat’s salvage pump was transferred byhelicopter, but the pump was renderedineffective by debris blocking its suction. Thewater level increased rapidly, so the decision wastaken to abandon the vessel. Within a shortspace of time, the vessel plunged by the stern.

49

Two Fires, a Flood and a Foundering


CASE 22

General smoke damage

CO2 bottle and operating arrangement Replicated fuel leakage from main engine duplex fuel filters


CASE 22

The Lessons

1. In the event of a fire, your life and thelives of your colleagues may well dependon the proper maintenance of fixed CO2

fire-fighting sytems and remotelyoperated emergency shut off valves. Alltoo often, an “out of sight, out of mind”approach to these systems results in theirneglect.

2. CO2 extinguishes fires by smotheringand reducing a compartment’s oxygencontent. The compartment must,therefore, be isolated and the ventilationflaps closed prior to its use. The spacemust then not be opened and ventilateduntil crew are confident that the fire isfully extinguished and the compartmentis cool. Failing to do this, will mean therisk of re-ignition.

3. Skippers and crew should be aware ofthe dangers of entering a compartmentthat has been subject to CO2 smothering.

The residual toxic gases from bothcombustion and CO2 can be fatal if acompartment is entered before it hasbeen adequately ventilated and oxygenlevels checked to be satisfactory. In thefirst instance, seek the coastguard’sadvice.

4. Only by conducting drills will actionsbecome instinctive and crew be able tocope with emergency situationseffectively, thus improving everyone’schances of survival. This includes beingfamiliar with the operation of emergencyfacilities such as smothering systems,pipework isolations and pumping sytems.

5. Debris from the engine room renderedthe lifeboat’s salvage pump ineffective.Equipment must be correctly andsecurely stowed, debris must be removedand bilge areas must be kept clear ofanything which may affect pumpingoperations. A vessel that is clean, tidyand secure is a safer vessel.

For any seafarer, at any time, complacency is akiller. As a solo sailor myself, I perhaps know thismore than most, as my very existence can, attimes, depend totally on a rigorous adherence tosafe practices and procedures whatever thecircumstance. Whilst my colleagues and I seldomformalise such procedures, it is our individualself-discipline and experience that keeps us frommaking fatal errors.

This self-imposed discipline, if applied everytime, is the best security for every mariner. Thelessons which can be gained from the experiencesof those who have encountered serious problems– whether fatal or not – serve to highlightpotential areas of risk for all of us who put to sea.

This constant process of review is one very closeto my heart as the Vice President and TechnicalPresident of the IMOCA 60 class that controlsthe safety rules in the Open 60 monohull class(the 60ft Vendee Globe yachts). As afundamentally derestricted class, these yachtshave, in the past, had serious flaws in theircharacteristics – perhaps most notably beingunable to self right. Now, through anextraordinary cooperation between individualsailors, and across national boundaries, suchincidents have been all but eliminated throughcareful management of the rule.

IMOCA works tirelessly to address the issue ofsafety in the solo sailing environment. Thisvigilance has paid dividends, and we are pleasedto say that the sailors now enjoy safer racing thanever before. However, we recognise that you cannever be too safe, and that this is an everlastingquest; practices are constantly evolving andimproving. Life teaches us time and time again tonever underestimate the power of the ocean, andit is important to explore and experience it withrespect, caution and vigilance.

Part 3 – Leisure Craft

Mike GoldingThe first person to have sailed round the world both ways, Mike Golding just can’t get enough of sailing and competition.His sailing profile is as long as a “no wind day”, and many fellow sailors consider him to be one of their fiercestcompetitors. He beat the Global Challenge in 1992-1993 solo, won the BT Global Challenge in 1996-1997, crewedand moved onto the IMOCA Open 60 monohulls Class. Challenging the French supremacy, he was the first Britishsailor to share all the podium places with the top skippers of the Class. 2004 was a year of great achievement for Mike ashe went one step further, winning Le Défi Atlantique and The Transat. As he set off to win the Vendée Globe 2004-2005, Mike proved, once again, the extent of his talent by being the fastest boat from Cape of Good Hope to the finish;unfortunately, that was just an ounce too short to win the race. He did finish spectacularly though, by crossing the finishline in Les Sables d’Olonne with no keel, proving his great seamanship too. Mike is currently IMOCA World Championand is leading the 2005 IMOCA and FICO Championships.


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Narrative

An 11.3m sailing yacht was being used for anintensive 13 week Yachtmaster training course.The instructor and four crew had already spentalmost 2 months on board sailing on the southcoast of England and then to the ChannelIslands, Brittany and western France beforeheading across the Bay of Biscay for Spain andPortugal in mid-November.

By this time, the students had amassed a gooddeal of experience and the instructor decided itwas time for them to skipper the yacht withouthim being on board. A passage of around 75miles southwards down the coast was planned,and the instructor stepped ashore. Winds wereforecast to be a force 4 westerly, veeringnortherly force 5.

However, while on passage, the winds increasedto gale force from the north-west. The skipper onboard phoned the instructor ashore and it wasagreed that the original destination was going to

be too dangerous to approach in the prevailingconditions as there was a bar at the harbourentrance and the pilot book suggested this maybe dangerous. An alternative destination wasagreed, which was thought to offer a saferapproach but which was another 30 miles furthersouth.

The designated skipper became incapacitatedwith seasickness as the severe conditionscontinued, so another student, the mostexperienced of the four, took over. With sailsfurled and the engine on, they made theirapproach but were knocked down to anestimated 110° by a breaking wave.

The acting skipper was on the helm and waswashed overboard. He had been clipped on butwas unable to get back on board. The next wavetook the yacht past the harbour entrance, andshortly afterwards she hit the beach. The actingskipper suffered cracked ribs, but he and the restof the crew were otherwise unscathed. The yachtwas damaged beyond repair.

52

Knockdown and Total Loss off thePortuguese Coast


CASE 23

The Lessons

1. The decision to continue to analternative port further south wasunderstandable, but an approach to anyport on a lee shore in the conditionscarried risks. Although unpalatable tothe crew, staying out at sea wouldprobably have saved the yacht. TheMAIB has looked into other accidentswhere the crew were less fortunate, andsuch action would have saved lives.

2. Leaving experienced students aboardwithout their instructor has the value ofensuring that the skipper knows he orshe really is in charge, and must stand orfall by the decisions made. However, theinstructor should carry out a particularlythorough risk assessment with the fullinvolvement of the students.

Narrative

A large, UK registered luxury motor yacht wason charter and was berthed “stern to” in aMediterranean port. The guests had completedtheir water sports for the day so the vessel’stender was sent to collect them. They were thendisembarked onto the diving platform on thevessel’s stern. The tender was then positionedimmediately below the vessel’s crane, which wasused to hoist the tender and transfer it to itsstowage position on the sun deck.

The eye of the three-legged strop (Figure 1) wasconnected to the crane hook and the coxswainattached each of the spring hooks (Figure 2) tothe tender’s lifting points. The coxswainremained in the tender as it was hoisted about500mm clear of the water. This was to ensurethat the spring hooks were correctly positionedas the crane took the weight.

He then prepared to disembark into another ofthe vessel’s small boats so that the tender couldbe hoisted the remaining 8 metres to its stowageposition. As he was about to leave the tender,one of the spring hooks catastrophicallydeformed (Figure 3). The tender, now supportedby only two hooks, became unbalanced and thecoxswain was thrown into the sea. The coxswainwas uninjured.

53

Lucky Escape as Spring Hook FailsDuring Hoisting of a Tender


CASE 24

Figure 1: Lifting strop – crane hook eye

Figure 2: Shackle as supplied

Figure 3: Failed shackle

The crane and lifting strop arrangement were allin date for test. However, the combined weightof the tender and the coxswain put thearrangement close to its Safe Working Load(SWL). The situation was likely to have beenfurther exacerbated by wash from other vesselscausing the tender to “snatch” at the strop andprobably prompting the deformation process.

None of the yacht’s team had conducted or werefamiliar with risk assessment procedures.However, precautions were taken: surplus weighthad been removed from the tender, and thecustom and practice was for the crew to leave thetender as it was hoisted.


CASE 24

The Lessons

Although not documented, a mental riskassessment had been undertaken, and someof the risks associated with hoisting thetender with crew on board had beenrecognised. However, no one appeared torealise how close to the SWL they had beenoperating, and what effect the additional“snatching” would have on the system. Hadthe snap hook failed when the tender was atits highest lift of 8 meters, with someoneonboard, the outcome would have been verydifferent.

1. Risk assessments are an essentialmechanism in identifying those activitiesthat require control measures to be putin place to prevent the likelihood of anaccident. They should be regularlyreviewed to ensure their currency.

2. Crew should not be permitted to remainin a lifeboat for any longer thannecessary during the lowering or hoistingprocedures.

3. Regular examination and testing oflifting equipment is an essential elementof safety management and risk reduction.

4. Due account should be taken of thelikely additional weights on boardboats/tenders and the “snatching” effectof the boat’s motion when consideringthe suitability of the SWL of relatedlifting equipment.

Narrative

On a windy spring morning, two professionalmariners from a popular, small, estuary harbourwent out within the mouth of the estuary to lay ayacht mooring, which was required for thefollowing holiday weekend.

Both men were very experienced in small boatwork and knew the area intimately. The weatherconditions were, however, very poor. The springtide was in full ebb, running about 6 knots, andthe winds were gusting up to force 7, against thetide. This led to breaking crested wavesthroughout the harbour and especially at theestuary mouth. The sea temperature was 9°C.

One of the men was wearing a dry suit and swamout to his boat, a 4.5m dory, on its moorings nearthe quay. Having prepared the boat, he thenmotored to the quay to collect his assistant whowas wearing jeans and a hi-vis jacket. They thenloaded the mooring onto the dory.

The mooring consisted of two legs of chain, eachleading from a mid-link to an anchor. A chainriser then ran from the mid-link to a hippo buoy.The complete mooring weighed 240kg and wasplaced on the bow of the dory [see photo].

Once loaded, they were seen motoring away fromthe quay towards the mouth of the estuary, whichthey would have to cross to reach the intendedsite of the mooring.

When they could not be found at 5 o’clock thatevening, the alarm was raised. Tragically, anddespite an extensive search and rescue operation,they were not found until their bodies were washedashore some time later. Both men had drowned.

One of the men’s lifejacket was found washedashore on the evening of the accident and, whileit was inflated, the seat belt-style buckle was notdone up. The other man was not wearing alifejacket, but was relying on a buoyancy aid; thistoo was found washed ashore that evening.

The outboard motor on the dory had failed on anumber of occasions in the past and, based on itscondition after the accident, it is likely that itfailed as the dory was crossing the mouth of theestuary. The vessel would have been swept outinto rougher water very quickly and foundered.The position in which the dory and the mooring(which was recovered from the seabed) weresubsequently found supports this scenario,although it will never be known exactly whathappened.

55

Don’t Underestimate the Familiar


CASE 25

Photograph showing the mooring placed on the bow of the dory


CASE 25

The Lessons

1. The more senior of the two professionalswas very conscientious and had [as partof his job] assessed the risks of theharbour during a series of written riskassessments. He had revised these onlymonths before the accident, and they hadcovered all of the dangers present on theday of the accident. Specifically, theymade reference to the danger of smalldinghies capsizing, or being carried awayto heavy seas at the mouth of theestuary, by strong tidal streams withinthe harbour, especially during springtides or in the event of machinerybreakdown. The control measuresidentified for these risks included toarrange a system to establish successfultransit with someone ashore and forpeople to wear lifejackets.Unfortunately, these risk assessmentswere aimed at leisure users of theharbour, and he had not assessed therisks involved in his own work.

2. The dory was completely unsuitable forthe task of laying moorings. While it wasdesigned as a stable platform for fishing,it was not designed to have 240kg ofsteel sitting on the bow. It was notoverloaded, but the loading led to verylittle freeboard forward, and the boat

would have been shipping a considerableamount of water in the prevailingconditions. This would have made theboat less stable and brought the outboardmotor closer to the water, allowing it tobecome swamped more easily.

3. While one of the men was wearing adry-suit, it would seem that his lifejacketwas either not done up or not worn. Theother man was not wearing appropriateclothing or a lifejacket. Buoyancy aidsare never suitable replacements forlifejackets.

4. Had a specific risk assessment been doneon the work to be carried out that day, itis likely that the dangers of the weather,the unsuitability of the boat and the needfor appropriate clothing and lifejacketswould have been addressed.Unfortunately, this was not done andtwo experienced professionals died as aresult.

5. Quite apart from the tragic consequencesof this accident, professional marinerswho work closely with the public have aduty to lead by example. They mustensure that they are seen to be taking allthe necessary safety precautions andapply best practice at all times.

The Accident

The owner of a 6m RIB took his two teenagedaughters for a day trip in sheltered waters. It wasthe first of the season, the boat having been laid-up for the winter. The RIB was powered by a150hp outboard, and was capable of speeds inexcess of 50 knots. The water temperature was 3o

C, the air temperature about 5o C and the windstrength was force 4. All were wearing warmclothing, but were not dressed for entering thewater and were not wearing lifejackets.

During the day out, the RIB’s steering wasdescribed as difficult, the wheel needing manyturns to achieve any movement of the engine. Ontheir way back to the launch point at the end oftheir day, the owner was steering, the youngerteenager was sitting behind him, and the elder girlwas standing behind the seat holding the backrest.The RIB was travelling at full speed when itsuddenly lurched, throwing the owner and hisyounger daughter out of the boat. The elderteenager was thrown to the deck but remained inthe boat which, because the kill-cord was not inuse, continued away from the two people in thewater. Although the elder girl managed to controlthe RIB and return, with difficulty, to the casualties,there was insufficient time to rescue them beforethey disappeared below the surface. There wereno flares or radio onboard the RIB so thesurvivor was unable to raise the alarm immediately.

After the accident, investigations discovered the oillevel in the hydraulic steering system in the RIB tobe very low, and there were indications that thesystem had been leaking for some time. It isprobable that air in the system caused the engineto lurch unexpectedly to one side, causing theaccident.

Safety Lessons

Any unintended movement of the outboard engineon a planing craft can be highly dangerous. It istherefore essential that owners and users ofpowerboats ensure that steering systems are fullyoperational before using the boat. It is especiallyimportant to ensure hydraulic systems are toppedup as required and are checked for leakage. If theowner or user is in any doubt about the conditionof the steering system, they should seekprofessional advice.

All powerboat users are further strongly urged toensure that:

• Kill-cords, where fitted, are used correctly.

• All crew and passengers are wearing suitableclothing and lifejackets.

• They have the means to summon assistance:ideally a VHF radio, or in the very least distressflares.

MAIB Safety Bulletin 1/2005

Two Fatalities from a High-Speed RigidInflatable Boat Accident


MAIB NOTICEBOARD


APPENDIX A

A preliminary examination identifies the causes and circumstances of an accident to see if it meets the criteria required towarrant an investigation, which will culminate in a publicly available report.

Date of Name of Vessel Type of Vessel Flag Size (grt) Type of AccidentAccident

07/03/05 Bro Traveller Chemical tanker Sweden 7973 CollisionIsland Gem Bulk carrier Greece 17065

20/03/05 Corner Brook Specialised carrier Bermuda 7587 Fire

27/04/05 Sonas Fishing vessel UK 41.47 CollisionUnion Pearl General cargo Barbados 22.36

28/04/05 Bitfjord Chemical tanker Sweden 1573 Fire

10/05/05 Maranatha Fishing vessel UK 242 Flooding/foundering

19/05/05 Murmansk Tanker/combination Russia 10321 Fatal Accidentto person

21/05/05 Lerrix General cargo UK 1992 Grounding

21/05/05 Etoiles des Ondes Fishing vessel UK 40 Fatal Accidentto person

23/05/05 Bounty Fishing vessel UK 10 Capsize

02/06/05 OOCL Malaysia Container vessel Liberia 66283 CollisionIBIS Yacht UK N/A

18/06/05 Queen Zenobia Liquid gas carrier Panama 16770 Accident to person

19/06/05 Speedboat (un-named) Pleasure craft UK N/A CollisionSpeedboat (un-named) Pleasure craft UK N/A

21/06/05 Siesta Yacht Unknown N/A Fatal accidentto person

30/06/05 Auriga Fishing vessel UK 4.42 Flooding/foundering

Preliminary examinations started in the period 01/03/05 – 30/06/05

Date of Name of Vessel Type of Vessel Flag Size (grt) Type of AccidentAccident

01/03/05 Orade General cargo Antigua & 1354 GroundingBarbuda

13/03/05 RHIB Loch Lomond Pleasure craft UK N/A Fatal Accidentto Person

06/04/05 Brenscombe Kayaks Commercially operated UK N/A Capsize

08/04/05 Lykes Voyager Container UK 23540 CollisionWashington Senator Container Germany 34454

113/04/05 Stolt Aspiration Oil/chemical tanker Liberia 7901 CollisionThorngarth Tug UK 365

Investigations started in the period 01/03/05 – 30/06/05

59

Reports issued in 2005


APPENDIX B

Albatros – accident on board the commercialsailing vessel Albatros, Thames Estuary, on 22August 2004, resulting in one fatalityPublished 8 April 2005

Attilio Ievoli – grounding of the Italianregistered chemical tanker on Lymington Banksin the west Solent, South Coast of England on 3June 2004Published 7 February 2005

Coral Acropora – escape of vinyl chloridemonomer onboard Coral Acropora, Runcorn,Manchester Ship Canal, on 10 August 2004Published 8 March 2005

Daggri – contact made by the UK registeredro-ro ferry Daggri, with the breakwater at Ulsta,Shetland Islands, on 30 July 2004Published 5 April 2005

Jackie Moon – grounding of Jackie Moon,Dunoon Breakwater, Firth of Clyde, Scotland on1 September 2004Published 23 March 2005

Nordstrand – fatal accident on board mvNordstrand at Agencia Maritima Portillo, Seville,Spain on 20 September 2004Published 15 April 2005

RFA Fort Victoria – investigation of the lifeboatrelease gear test on Fort Victoria which causedinjuries to two people at Falmouth ship repairyard on 10 September 2004Published 18 May 2005

Scot Explorer and Dorthe Dalsoe – collisionbetween Scot Explorer and Dorthe Dalsoe, Route‘T’ in the Kattegat, Scandinavia, on 2 November2004Published 10 June 2005

Star Clipper – failure of a mooring bollard fromthe Class V passenger vessel Star Clipper,resulting in a fatal accident at St Katherine’sPier, River Thames, London on 2 May 2005Published 18 February 2005

Waverley – grounding of the passenger vesselWaverley, South of Sanda Island, west coast ofScotland on 20 June 2004Published 1 February 2005

Annual Report 2004 Published May 2005

Safety Digest 1/2005 Published April 2005

A full list of all publications available from theMAIB can be found on our website atwww.maib.gov.uk

safety digest 2/2005...we have to recognize that we are becoming dangerous. reading the accounts in...

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