SAFETY MARINE ACCIDENT INVESTIGATION BRANCH DIGEST · again. The content must necessarily be regarded as tentative and subject to alteration or correction if additional evidence becomes

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Accident Reports1/2004

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SAFETY DIGESTLessons from Marine Accident Reports

No 1/2004

MARINE ACCIDENT INVESTIGATION BRANCH

is an

INVESTOR IN PEOPLE

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

© Crown copyright 2004

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:MAIB1st FloorCarlton HouseCarlton PlaceSouthamptonSO15 2DZ

Some of the photographs supplied courtesy of FotoFlite.

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.February 2004

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 2004

Extract fromThe Merchant Shipping

(Accident Reporting and Investigation)Regulations 1999

The fundamental purpose of investigating an accident under these Regulations is to determine itscircumstances and the causes with the aim of improving the safety of life at sea and the avoidance ofaccidents in the future. It is not the purpose to apportion liability, nor, except so far as is necessary toachieve the fundamental purpose, 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. Hands-on Training – yes – but Don’t Lose Control! 10

2. ‘Spontaneous’ Lowering of a Lifeboat 12

3. Low Pressure – Not Low Risk 13

4. A Stopper That Didn’t Stop 14

5. Late Changeover Leads to Grounding 15

6. If There is no Risk Assessment, Do Your Own 17

7. Out of Control 18

8. Unplanned Trip up the River 19

9. Tug Trauma 21

10. Ouch! 24

11. Quick Response to Vehicle Fire on Ro-Ro Ferry 26

12. What a Foul Up! 27

13. Who Put That There? 29

14. It Has Been Drained, But is it Dry? 31

15. Beware of Berths that Dry Out 33

16. Stay A Leading Light – Use Them! 35

PART 2 – FISHING VESSELS 37

17. Modifications Result in Loss of Stability, Vessel and a Life 38

18. Overloaded, Overdue, Over….. 40

19. Too Much On Top 42

20. Quick Action Saves Fishing Boat and Crew 44

21. Winch Problem Leads to Capsize 45

22. ‘Dodgy’ Alarm, So No Warning 47

23. A Fatal Override 48

INDEX

PART 3 – LEISURE CRAFT 49

24. Catamaran Capsize in Solent 50

25. Out of Sight, Out of Mind 52

26. Early Warning Headaches 54

27. Lookout! What Lookout? 55

MAIB NOTICEBOARD 56

APPENDICES

Appendix A – Preliminary examinations and investigations started in the 57period 01/11/2003 to 29/02/2004

Appendix B – Reports issued in 2003 58

Appendix C – Reports issued in 2004 60

Glossary of Terms and AbbreviationsAB – Able SeamanCO2 – Carbon DioxideCPP – Controllable Pitch Propeller

EPIRB – Emergency Position Indicating Radio Beacon

GT – Gross tons

“Mayday” – Spoken distress signal

Ro-Ro – Roll on – roll off

RYA – Royal Yachting Association

VHF – Very High Frequency

VLCC – Very Large Crude Carrier

7MAIB Safety Digest 1/2004

Welcome to the first Safety Digest of 2004.Regular readers will notice a couple of changes instyle; not only have we introduced colour, to tryto make the articles more readable, but we havealso, for the first time, asked non-MAIB peopleto write the introductions to the three sections.As part of our move to persuade the maritimecommunity to become more involved in ourwork, you will find introductions written by well-known and respected members of thecommercial, fishing and leisure industries.

Although the style might have changed, thesubstance remains the same. Here are 27accidents or incidents, all very different, reportedin (I hope) a straightforward manner, so that wecan all learn the lessons from the misfortunes ofothers. Please take the time to consider them all.

For anyone operating a vessel commercially –merchant ship, fishing boat or leisure craft –there is a legal duty to report accidents. If you arein doubt about the requirements, give us a ring,or report it anyway – we would far rather haveover-reporting than under-reporting. If youbelieve accidents are being suppressed, ratherthan reported, tell us (we have a legal duty toprotect our sources), or report it to theconfidential reporting system – CHIRP.

For those who go to sea for pleasure, there is nolegal requirement to report accidents. However,we would encourage you to reportaccidents/incidents anyway. We have recentlytracked down an unidentified ship that collidedwith a yacht and, in Case 27 of this edition, wedescribe how we followed up a near-miss incidentin the English Channel, reported to us by ayachtsman. If you don’t report things, we do notknow the scale of the problem, and we cannottry to improve matters. Do your bit for safety –report accidents/incidents.

Finally, I would like to draw readers’ attention tothe MAIB Noticeboard on page 56. Thisreplicates an important Safety Bulletin publishedas a result of an accident that occurred on 30January 2004, which had the potential to belethal. Although it happened on board a fishingvessel, all mariners should take heed.

Stephen MeyerChief Inspector of Marine AccidentsApril 2004

Introduction

8 MAIB Safety Digest 1/2004

I like a good read, and I always look forward tothe thump of the MAIB Safety Digest landing onthe doormat. And it is a good read. Draw thecurtains, make up the fire and settle into afavourite armchair. Here are exciting tales ofadventure on the high seas, groundings, fire onboard, storm at sea and others. When you read itfrom cover to cover you get a whiff of JosephConrad in these tales.

But these tales are not fiction. These are not theoutpourings of the fevered imagination of theChief Inspector, Stephen Meyer, and his crew.No imagination could have invented betterstories than these. This is cold, stark, meanreality that is laid out before us. Lurking in thesepages are not the heroes and villains of fiction.These are real, honest, decent people. Realpeople who are getting hurt. Real people who aregetting killed. They could be our colleagues; forsome they are. When this sailor returns home,adoring mothers, wives and children will not seea happy smiling face. Perhaps they may never seehis face again. More than one life can bewrecked in these adventures.

So these pages are not for entertainment; theyare for learning. And just like those collectedstories of fiction there are recurring themes,themes we have seen before on these pages andelsewhere. But unlike Conrad, these are not ofmurder, greed, desire or revenge; these are muchmore mundane and straightforward. These arethemes of inadequacy. They are about notcoming up to scratch, not cutting the mustard.

They tell us of something lacking. A lack ofplanning, risk assessment, maintenance, training,competence, pre-work briefings (called “tool boxtalks” in the offshore industry), challenge,management of change, accountability,equipment, and so on and so on. Quite a list!Quite an indictment!

And why do these accidents always seem tohappen without warning? Well isn’t that what anaccident does? But, hold on! Are they withoutwarning? Are not the warning signs there? Theyjust have to be looked for, hunted down,observed, identified and dealt with. Then we willsee them for what they are, these same themes.

If one were to choose just a few themes toconcentrate on, which should they be? If I wereto choose they would be:

• Planning – no work should be consideredwithout a plan. For the complicated andunusual tasks a proper one must be made inadvance, but for routine work it can be assimple as “tool box talks” with all those to beinvolved just before the work starts. What isthe job, what resources are needed, whatprocedures exist, who will do what, etc?

• Risk assessment – a meaningful and thoroughrisk assessment is essential to highlight thehazards and risks and the actions to take tolessen them. It will also show up the strengthsand weaknesses in training, equipment etc.The risk assessment should be a livingdocument, visited frequently and alwaysaligned with the plan.

• Management of change – widely used in theoil and gas industry, this allows you to dealwith unplanned events or changes, whichoccur during the work. Being alert to changesin weather, timing, berthing, equipment, etc.and revisiting the plan and risk assessmentwhen they occur.

Part 1 – Merchant Vessels


• Challenge – all those carrying out work mustcontinually question the work in hand and ifthey are unhappy, even that slight unease inthe gut, then they should stop the job andchallenge the process.

So let’s keep Joseph Conrad firmly on thebookshelf and make sure all the characters ofOUR stories come home safe and sound. Let’smake sure they come home to their familieswithout harm. Stop and take time to think howwe can achieve this because, make no mistake, itcan be achieved. Ask some simple questions suchas:

“How can I perform this task without injury tomyself?”

“How can I perform this task without injury toothers?”

And let’s keep this admirable Safety Digest off thebookshelf and well thumbed in the mess-roomsand canteens of our workplaces. Do you haveenough copies and do you send them out to allyour ships? Discuss the stories on board and inthe office. Take a copy to the next safetymeeting.

Ask another simple question. Can this happen tous? When reading these accounts we can allrecognise the familiar themes. Take action beforean event happens and you or your colleaguesbecome the main character in the next story theChief Inspector will write for the entertainmentof others.

Safe sailing.

David Blencowe

David Blencowe is Area General Manager of Maersk Supply Service in the UK, based in Aberdeen. He is amaster mariner who has served in passenger ships, cross channel ferries and as master of offshore vessels. Hehas a deep interest in safety of ships’ crews and is a member of the steering group on the offshore industry’sMarine Safety Forum.

MAIB Safety Digest 1/2004

CASE 1

Narrative

A ferry was leaving port in daylight. The bridgewas manned, as normal, by the master, the chiefofficer and a helmsman. However, instead of themaster handling the controls, the chief officer, aspart of his training, was manoeuvring the vesselunder the guidance of the master. The chiefofficer had only recently joined the vessel,having served a number of years as a pilot in adifferent geographical location.

The ferry, which was fitted with a Becker rudder,was required to conduct a port turn to exit theharbour between two breakwaters. Aftermanoeuvring from her berth, she proceeded atslow speed so as to keep sufficiently clear asternof another departing ferry.

After the other ferry had cleared the harbour, thechief officer, from his position at the port bridgewing control position, ordered about 40° port

helm. He moved the pitch controls of bothpropellers to 40% and then, on the master’sinstruction, to 60% ahead. The vessel startedswinging, but her rate of turn was slower thanexpected. The chief officer then applied full bowthrust to port and, on the master’s suggestion,applied astern pitch to the port propeller.

As the vessel was completing the turn, the chiefofficer applied 60% ahead pitch to bothpropellers with the helm amidships. At thispoint, the master walked to the starboard bridgewing and noted that the vessel was movingtowards the breakwater on that side, due, partly,to the tidal flow. He then ordered hard tostarboard helm and bow thrust to starboard in anattempt to prevent contact with the breakwaterknuckle. Although the ferry started swinging tostarboard, the manoeuvre failed to prevent herstarboard side from striking the knuckle. Themaster then took control and manoeuvred thevessel back alongside.

Hands-on Training – yes – butDon’t Lose Control!

10


CASE 1

The Lessons

1. The manoeuvre did not proceed asexpected. A successful outcome dependson adequate planning, execution andmonitoring, and an ability to recover asituation should things go wrong. In thiscase, the chief officer was following amanoeuvring plan which, althoughnormally achievable, was inappropriategiven the circumstances on the day.

The ferry’s exit from the harbour wasdelayed, resulting in her creeping aheadto a position from which she was unableto complete her normal turn safely, giventhe prevailing cross-tidal flow. This wasbecause of her slow speed and closeproximity to the breakwater at the startof the turn.

2. The chief officer had received nospecific guidance as to how tomanoeuvre the vessel out of the harbour.He had observed previous departingmanoeuvres and did not feel it necessaryto receive a specific briefing on thisoccasion. Equally, the master consideredit unnecessary to brief the chief officersince he was aware that he had handledthe vessel before and was an experiencedpilot, albeit in a different geographicallocation.

Although the manoeuvre wasinappropriate, the master failed tointervene in sufficient time to preventthe accident. This was due to hismisplaced confidence in the chiefofficer’s ability, and the fact that hisposition on the bridge caused him toadopt an abnormal overall perspective.In other words, he was not in anappropriate position or mind-set tomonitor the chief officer’s actionseffectively.

Hands-on experience is an essentialelement of training, but the risks shouldbe carefully evaluated, and the level ofsupervision should be sufficient toensure that the master is able to restorecontrol immediately should things gowrong.

3. The effect of a Becker rudder can besignificantly different to that of aconventional rudder. Notably, theapplication of large angles of helm canreduce a vessel’s forward motion. This,together with the tidal flow, contributedto the slower than expected rate of turnon this occasion. It is essential thatoperators are made fully aware of thiseffect before being required tomanoeuvre a vessel in confined waters,particularly if they are unfamiliar withhigh lift rudder systems.

11


Narrative

During a stay in port, a cruise vessel loweredseveral of her lifeboats to the water for crewtraining and engine testing. On completion, theboats were hoisted to their stowed position andtheir gripes secured.

Shortly afterwards, two seamen noticed that oneof the boats was not in its properly stowedposition, and released its gripes to re-position it.However, before they were able to complete thistask, a senior officer instructed them to carry outanother job.

Shortly after this, the lifeboat with the releasedgripes began to move very slowly from thestowed position because its winch was payingout.

Efforts to insert harbour pins, and apply thewinch’s brake, failed to arrest the boat’s motion.Realising that the boat could safely continuelowering, and enter the water, crew entered theboat to release the combined tricing/bowsinggear. They were unable to do this properly and,fearing for their safety, they climbed from theboat.

The boat continued to slowly lower, until thetricing/bowsing gear at the forward end pulledfree. Further lowering then caused the boat’sbows to continue until they reached the water,with the boat hanging by the stern (see figure).

The unusual direction of load on the aftsuspension hook damaged the boat’s stern, butthere were no injuries.

A later examination showed that the remoterelease wire of the winch had not been set upcorrectly, and had prevented its brake from beingfully applied. Reports from the crew alsoindicated that there had been earlier incidentswhere lifeboat winch brakes had not beenapplied properly because of problems withremote release wires.

‘Spontaneous’ Lowering of aLifeboat

CASE 2

The Lessons

1. It would have been sensible for thesenior officer to ask what the ratingswere doing to the lifeboat before hediverted them to another task. He wouldthen have been aware that there was aproblem with this lifeboat.

2. The vessel’s safety management systemfailed to take account of earlier reportsof similar winch brake release wireproblems to identify a safety-related issuethat required attention.

3. Care and attention needs to be taken toensure that remote operating wires forwinch brakes are properly adjusted.

12


Narrative

A ro-ro ferry with over 400 passengers on boardwas on an overnight passage. The watchkeepingengineer was alone in the machinery spaceswhen the automatic fire alarm activated.

When he investigated, the engineer found firearound the top of a diesel generator. He rang theengineers’ fire alarm and attempted to tackle thefire using several portable extinguishers.

These efforts were only partly successful.However, he found time to start anothergenerator, transfer the load and stop the affectedgenerator. He then tried to isolate the fuel supplyto this generator by going to the lower level ofthe engine room. Although he was well aware ofthe location of the fuel shut-off valve, he wasunable to find it. Realising he was in a dangeroussituation, he left the engine room.

By this stage, all other engineers had arrived toassist, and the vessel’s full emergency procedurescame into play to effectively tackle the fire usingthe CO2 smothering system.

Later examination of the generator found that alow pressure fuel line had failed because it wasnot properly secured. This had allowed heated

fuel and vapour to escape where it was ignited,probably by the engine’s hot exhaust manifold.

Low Pressure – Not Low Risk

CASE 3

The Lessons

1. The engineer was becoming seriouslyaffected by smoke inhalation by the timehe attempted to shut off the fuel supplyto the generator. This caused his sensesto be so impaired that he was unable tofind the shut-off valve; an item withwhich he was very familiar.

2. It was most fortunate that the engineerleft the engine room at that stage, ratherthan making further efforts to locate thefuel shut-off; further delay mightliterally have been fatal.

3. This incident is the latest in a series offires caused by leakage from engine lowpressure fuel lines. It again highlights theimportance of paying as much attentionto the condition of low pressure fuellines as is normally given to highpressure systems, which are typicallyseen as those posing the greater risk tosafety.

Stairs tolower level

Generator top

13


A Stopper That Didn’t Stop

CASE 4

14

Narrative

A vessel was being warped along a quay. It wasdaylight and the weather was fine. A teamcomprising an officer and three seamen wastending the aft moorings.

A sternline was led from a roller fairlead, througha set of bitts, around a pedestal fairlead and on toa warping drum. The officer was operating thewinch. On heaving the sternline tight, one ofthe seamen used a stopper to secure the rope inreadiness for it to be turned up on the bitts. Theofficer then reversed the warping drum, and asecond seaman began removing the slack ropefrom the pedestal fairlead. While doing so, therope suddenly slipped through the stopper, thustightening, striking the second seaman andcausing him abdominal injuries.

The Lessons

1. The sternline was a multiplait syntheticrope. The stopper, which was asingleplait synthetic rope, failed to stopthe sternline slipping under tensionwhile it was being transferred from thewarping drum to the bitts.

If a stopper is to function effectively, it isessential that it is applied correctly. TheCode of Safe Working Practices forMerchant Seamen recommends the“West Country” method (double andreverse stoppering), which requires tworope tails.

Ensure you have the right equipment todo the job, and that those who arerequired to use it are properly trained todo so.

2. The casualty removed the rope from thepedestal fairlead in the expectation thatthe stopper would do its job. Both he,and the officer in charge, failed to takeaccount of the possibility of the stopperfailing. Had they done so, they couldhave ensured that he approached therope from the opposite direction, causingit to move away from him when it cameunder load.

Mooring operations, no matter howroutine they become, carry risks. Bythinking ahead, and planning for theunexpected, many of those risks can beavoided. Think on your feet and you’llstay on them!


Narrative

A UK ferry was entering a Netherlands port ingood weather. The main engine controlchangeover from sea to manoeuvring mode waslater than usual, and the engine control roomphoned the bridge to inform them that therewould be a delay in starting the bow thrusters.The master decided to continue heading for theberth at reduced speed, and to berth without bowthrusters by walking out the starboard anchor.

Five minutes later, one of the main enginesstopped, followed three minutes later by theother engines. The starboard anchor was droppedand the vessel stopped. However, she was pushedby the wind and tide into the mud on theshoreline.

After restarting two of her main engines, withinten minutes the vessel was able to continue andto berth successfully, aided by one bow thrusterand two tugs. She sustained no damage.

In this vessel, when the changeover of mainengine control from sea to manoeuvring mode isinitiated, the engine management systemautomatically synchronises another alternatorwith the switchboard. On this occasion, theautomatic process failed, and the system lockedup; preventing it from being reset. The lack ofcapacity on the switchboard made the use of bowthrusters impossible. Also, when the masterreduced speed, the main engine cooling systemcould not respond. Hence, the main enginesoverheated and shut down one by one.

The changeover from sea to manoeuvring modewas carried out at the end of passage, rather thanbefore, as required in the standing orders. Thismeant that the subsequent faults could not becorrected in time to prevent the main enginesshutting down.

Late Changeover Leads to Grounding

CASE 5

15


The Lessons

1. Given sufficient time to rectify the fault,this grounding would not have occurred.The guidance given by masters’ and chiefengineers’ standing orders is the result ofaccumulated knowledge and experience.It should not, therefore, be ignored.

2. It is essential that the master is fullybriefed by the engine control room, whenproblems affecting the safe navigation ofthe vessel are encountered. Had thismaster been informed of the full extentof the problems, which led to the bowthrusters being unavailable, he wouldhave been able to take appropriate actionto ensure the vessel’s safety. As it was,he was only aware that there was aproblem with the bow thrusters.

3. Control systems on modern vessels arebecoming ever more sophisticated.However, they can – and still do – fail.It is essential that control systems aredesigned to facilitate manual override atany time in the event of a failure, andthat ships’ staff are practised in manuallyoverriding these control systems quicklyand efficiently when necessary.

CASE 5

16


Narrative

It was standard practice on board a small UKtanker to rig a gangway from the poop deck. Thiswas secured at the top by looping chains throughroller fairleads, and securing them outboard withbottle screws about 1m down each side of thegangway.

When removing the gangway, shore riggers onthe quay would steady the lower end, while ashore crane lifted the gangway slightly to takethe tension off the securing chains. A seamanthen stepped on to the gangway and released thebottle screws, allowing the chains to be removed.The procedure had been done many times.

On this occasion, while the seaman was facingthe vessel and undoing the bottle screws, theshore riggers left the lower end of the gangway.This allowed it to tilt and sway, nearly causinghim to fall off. It is thought that the riggers leftto assist in letting go another adjacent vesselwhich was leaving the quay at the time.

No risk assessment on this procedure had beencarried out, and the seaman tasked with releasingthe chains was not using a safety harness. Hewasn’t even wearing a lifejacket.

Once the chains were released, the gangway wasnot secured to the vessel in any way. In thiscondition, it was supported by a shore crane, andwas merely ‘resting’ on the poop of the vessel.Any movement in the vessel could have led toboth it, and the seaman, dropping free and intothe water or on to the quay.

If There is no Risk Assessment,Do Your Own

CASE 6

The Lessons

1. If you are asked to do something whichyou feel is unsafe, question it! Theprocedure followed to release thegangway was incredibly dangerous. Thefact that it had been done on manyoccasions without incident was no reasonfor anyone on board to have felt contentthat it was safe.

2. A risk assessment, as described in theCode of Safe Working Practices forMerchant Seamen(Chapter 1) must becompleted, to cover the risks arisingfrom all work activities on board. Such arisk assessment would have highlightedthe many dangers associated with thisprocedure.

3. When working aloft or outboard, as inthis case, a number of safety precautionsmust be taken. These are also describedin the Code of Safe Working Practices forMerchant Seamen (15.2).

4. Using shore facilities and personnel toassist in ships’ procedures other thanthose for which they are specificallyemployed, is dangerous. They are nottrained in shipboard operations, and arenot part of a vessel’s safety managementsystem.

17


Narrative

A vessel’s lifeboat, davits, and associatedlaunching/recovery equipment had beenoverhauled, and the lifeboat was returned to thevessel by lorry.

The lifeboat was positioned under the davits, andtwo crewmen climbed into it to connect the hoistwire of a mobile crane. The mobile crane liftedthe lifeboat and suspended it below the davitheads while the crewmen attached the falls. Theydisconnected the crane hoist wire, and stayed inthe lifeboat while the crane jib was lowered. Thedavits took the weight of the lifeboat.

The maintenance work on the davit winch hadbeen performed without the aid of the winchmanufacturer’s data. Although untested, it wasthen used to hoist the lifeboat until the limitswitch shut off the power.

Suddenly and unexpectedly, the winch beganto run out and, despite efforts to apply thewinch brake, the lifeboat continued toplummet. It struck the edge of the quay andplunged into the water with the two men stillon board.

The two crewmen were slightly injured and thelifeboat suffered moderate impact damage.

Out of Control

CASE 7

The Lessons

1. Would you climb into a suspendedlifeboat knowing that the davits, lifeboatsuspension hooks, and winch had allbeen repaired but had not been load-tested properly?

2. Was this the only way to re-attach a lifeboatto the falls? The falls could have beenlowered to the lifeboat and reconnected bythe crewmen. They could then have left thelifeboat before hoisting began.

3. Does your vessel hold maintenanceinformation for the lifeboat and itsassociated equipment? If it does not, youshould raise the matter in your nextsafety meeting, since it is a requirementto carry instructions for onboardmaintenance and repair work.

4. Is the person performing themaintenance on your lifeboat competentand experienced? They should not beworking on it if they are not.

5. If you are sent to perform a task onboard, do not assume that someone elsehas considered all the hazards involved.THINK about those hazards. Can ahazard be avoided, or the risk be reducedas far as possible? If not, speak up!

This accident provides further evidence ofthe hazards in operating and maintaininglifeboats and their launching systems.

The MAIB Safety Study 1/2001 : Reviewof Lifeboat and Launching Systems’Accidents (visit our website atwww.maib.gov.uk for further information),points out that in the 10 years covering thereview, 12 seafarers died and 87 wereinjured while training on, or testing,lifeboats and launching systems.

Further examination of these accidentsfound winches to be the most frequentlyrecorded source. Although no fatalities havebeen recorded, some had the potential tocause serious accidents.

Common faults occur in several winch typeswhich employ one way clutches, brakes andswitches. Often they do not operate asintended, usually owing to shortcomings intheir maintenance, repair or adjustment.

As winches are often regarded as simpleitems of machinery, and are readilymaintained by ships’ staff or engineeringcontractors, their importance may not befully respected. As such, major overhaulsmay be carried out without the knowledge,experience or correct equipment that aspecialist contractor can provide.

18


Narrative

A 2,240gt general cargo ship carrying packagedtimber was berthed on a river wharf starboardside to, pointing downriver, during equinoctialspring tides. She was secured by 2 × 26.5cm(10.5") circumference head ropes and a 19cm(7.5") spring forward; similar sized ropes wereused aft. Soon after the onset of the flood tide,the tension on the forward ropes increased andthe bow was set slowly off the wharf.

As the chief officer made his way to theforecastle to see what was happening, the forespring parted. The starboard anchor was quicklylet go using about 10m of chain cable, but thisfailed to check the movement of the bowtowards the middle of the river. This caused theport head rope to be lost overboard after beingpulled through the bollards upon which it hadbeen turned up. This left just a single mooringrope forward, which also started to slip through

its bollards until it was secured by its eye. Theport anchor was then let go using a similaramount of cable as before, but when applyingthe brake, the windlass catastrophically failed(see figure), and its shaft containing the winchdrums and associated fittings was wrenched fromthe deck and pulled forward over the hawsepipes.

Assisted by two able seamen, the chief officermanaged to secure the anchor cables usingchain cargo lashings. He then ordered the areato be cleared because of the strain on theremaining head rope. As the chief officer wasmoving aft, however, the head rope parted andstruck him on the leg, which luckily was notbroken.

By that time, the master and engineer had beenalerted to the situation and had gone to thebridge and engine room respectively. Theengine and bow thruster had been started and,

Unplanned Trip up the River

CASE 8

19

Windlass after catastrophic failure


with the aft mooring lines having also parted,the master tried to manoeuvre the ship aheadusing full rudder. This, however, wasunsuccessful because the ship was now agroundalong some of her length. With the ship lyingacross the river, and the flood tide gainingmomentum, the ship started to list. The listincreased to over 30° within 30 minutes andcaused some of the deck cargo, which had beenunsecured in preparation for discharging, to falloverboard.

Soon after, the ship refloated on the rising tideand, although her list reduced considerably, themaster was unable to use the main engine tocontrol the ship’s movement because of anapparent problem with the CPP control system.The failure of the windlass also meant that moreanchor cable could not be paid out.Consequently, the ship drifted helplessly up theriver and collided with three ships mooredalongside, before her anchors finally held and tugassistance arrived.

CASE 8

The Lessons

1. The selection of the sizes and types ofberthing ropes used on board ships islargely a matter of commonsense andgood practice. A small coaster usingropes usually associated with VLCCsmight appear to give a large safetymargin, but if the ropes cannot beeffectively secured, are stronger than thedeck fittings, or are too heavy to behandled by the crew available, they mightprove to be a liability. It is in everyone’sinterest to ensure that mooring lines arefit for purpose. Are yours?

2. It is basic seamanship to ensure thatmooring ropes are secured by a sufficientnumber of turns around the bollards, andthat they are ‘married’. The potentialconsequences of failing to adhere tothese well tried and tested practices canbe disastrous.

3. Environmental conditions vary from dayto day, from port to port, and from berthto berth; they must never be taken forgranted. The need to keep a close eye onthe tidal and weather conditions is

particularly important in areas withstrong tidal streams and large tidalranges, where it is also prudent to seeklocal advice. It is better to think ahead,and take precautions such as putting outadditional mooring lines, or having theengine on stand-by during criticalperiods, than it is to try and respond tolines parting in the middle of the night,or with many of the crew ashore. Suchmeasures might be inconvenient andunpopular at the time, but they mightalso save the day.

4. Catastrophic failures of deck fittings andequipment are uncommon, but dohappen. Therefore, to assume that awinch or windlass is trustworthy,because it looks solid and has stood thetest of time, is fraught with danger.Don’t be complacent when working inthe vicinity of any load-bearingequipment – you will always come offsecond best.

5. It is worth remembering that mostmachinery on ships is designed to operateup to an angle of 22.5°. Little can berelied upon thereafter.

20


Narrative

When a refrigerated cargo ship, carrying emptypallets, arrived at a pilot pick-up point, the portcontrol advised that the pilot would have toboard just inside the harbour because of thestrong gale conditions. Shortly after, port controlconfirmed that the pilot was on his way and toldthe vessel ‘you can take it very easy’.

As the vessel entered the harbour, the mooringteams closed up and made ready to comealongside starboard side to. About 60m of 23cm(9") polypropylene rope was taken from itsworking drum and flaked out in readiness for useas a spring (Figure 1).

The master had anticipated that a tug wouldneed to be secured aft for mooring, and hadbriefed the aft team accordingly. As the ship wasfitted with a powerful bow thruster, the masterdid not anticipate having to secure a tug forward.Indeed, it was exceptional to secure a tug forwardin any port.

By the time the pilot boarded, the vessel hadcontinued into the harbour and was only 4.5cables from her berth. She had slowed furtherand had lost steerage. The pilot hurried to thebridge and, with the assistance of one of two tugsin attendance, turned the ship beam-on to thewind in readiness for berthing.

During this manoeuvre, the pilot advised themaster that tugs would be secured forward and aftusing ship’s lines. The master immediately passedthis information to the mooring teams, and theforward spring was quickly re-configured so thatit could be used by the tug. From its drum, it wasled between the bitts on the starboard side(Figure 2).

As soon as the tow line was secured to the tug’shook, the tug’s skipper manoeuvred aheadbecause there was a danger of the tow line (ofwhich between 30m and 50m had paid out veryquickly) fouling the tug’s propellers. The tugopened from the vessel’s port bow, until the bightwas clear of the water. At about the same time,

Tug Trauma

CASE 9

21

Polypropylene rope flaked out for use as a spring


while the cargo ship was also being manoeuvredastern and set by the wind, the officer in chargeforward ordered an AB to secure the tow line.However, as the AB moved towards the bitts, thetow line suddenly became very tight. It thenjumped over the lip at the top of the forward bitt,and struck the AB on the upper front of thebody, causing him to be thrown 2m across thedeck.

The AB was conscious but had difficultybreathing.

The officer in charge informed the bridgeimmediately, and requested medical assistancefrom ashore. The AB was taken to hospital,where he died soon after from internal injuries.

CASE 9

22

Rope led between the bitts on the starboard side

The Lessons

1. Ropes and wires are a constant source ofdanger for personnel working on deck,and cause numerous deaths and injurieseach year. Many accidents of this naturecould be avoided if basic precautions aretaken, such as not standing in the dangerzone of a rope under tension, and notstanding in a bight. Such precautions,however, are sometimes more easily saidthan done, particularly when ropes andwires come under tension withoutwarning, or the danger zone caused by arope under tension is not readilyapparent. In such circumstances,teamwork is critical; several pairs of eyesare more likely to spot the dangers thanjust one. Therefore, when working ondeck, look after number one, but alsokeep a weather eye on others. It couldsave a life.

2. Sufficient time for preparation andbriefing is beneficial when conductingroutine tasks on deck; it is essentialwhen undertaking something out of theordinary. Ensuring that everyoneconcerned, regardless of their experienceand knowledge, is made aware of what isto be done, how it is to be achieved, whatequipment is to be used, and the safetyprecautions to be taken, is a valuableinsurance policy; one which usuallyyields high dividends.

3. When working with tugs, particularlywhen securing or releasing, goodcommunication between pilots, masters,mooring teams and tugs is essential.Without it, co-ordinating the actions ofthe ship and the tug becomes extremelydifficult. Everyone needs to be kept inthe picture.

4. When using VHF radio, althoughexpressions such as take it very easymight be understood by most people,they are open to interpretation,particularly when english is not therecipient’s first language. Such phrasesare, therefore, best avoided wheneverpossible. Precise instructions might needa little more thought, but they reduce thepotential for confusion, and possibleembarrassment.

5. When experiencing rough anduncomfortable conditions at sea, the lureof an alongside berth can be difficult fora master to resist. Berthing in extremeconditions, however, can be risky and isseldom easy. It therefore requires carefulconsideration. Although staying at seamight be unpopular, occasionally it canbe the safer option.


CASE 9

Narrative

A surveyor requested a demonstration of a rescueboat being launched from a 70m vessel while inport.

To lift the boat from its chocks, the motorcontrols were operated, but there was nomovement of the winch. The second engineer wascalled to investigate and, with a view to raisingthe boat by hand, the manual winding or crankhandle was inserted on to the winch brake shaft.

A crewman began to turn the handle to raise theboat. Meanwhile, another crewman depressed the‘hoist’ button on the winch’s remote control box.This started the winch’s motor, which, in turn,rotated the crank handle. The crewman turningthe crank handle was struck by it, before it flewfrom its shaft into the sea. His arm was broken.

An investigation found the safety cut-off switch,which should have isolated the power supply to

the winch’s motor with the crank handle inplace, was defective. An external indication ofthe defect, was the switch’s operating lever beingable to rotate about 330°, rather than the 60°quoted by the manufacturer (see figures).

This excessive movement allowed the internalcam to move the switch’s contacts from theclosed, to the open, and then to the closedposition. This final closed position allowed thewinch motor to be started with the crank handlein place. However, with the movement limitedto 60° the switch would have moved just fromclosed to open, as intended.

Further examination found that the switch’soperating cam had been modified several yearspreviously. This modification allowed theexcessive movement.

As an interim measure, a substantial externalstop was welded to the winch’s body to preventunwanted movement of the switch lever.

Ouch!


CASE 10

Interlock switch lever

Correct position of interlock switch lever


CASE 10

The Lessons

1. Using replacement or modifiedcomponents that are not tomanufacturers’ specification can haveconsequences that are not always easy topredict. Particularly on safety-relatedequipment, it is always prudent to usemanufacturers’ replacement parts.

2. Having recognised the dangers of theswitch lever’s excessive movement, theowners and crew sensibly madeimmediate efforts to make the systemsafe, by fitting an external stop.

3. Changes in operational procedures werealso made, by requiring the winch’sremote control box to be unpluggedwhenever the crank handle was in place.

25

330° rotation of interlock switch lever

Incorrect position of interlock switch lever


Narrative

A ro-ro passenger ferry was in the process ofloading vehicles on to her main vehicle deck.Towards the end of the loading period, the deckcrew directed a lorry to the starboard sideamidships.

When the driver of the lorry switched off theignition, after having parked in the designatedposition, a small electrical fire started in thevehicle cab. He quickly informed the deck crew.

The response from the deck crew was immediate.

A CO2 extinguisher was used initially, followedby a fire hose, to quench the fire and cool thesurrounding area. The master assessed thesituation, and decided the fire brigade need notbe called. He also ensured that the passengerswere kept fully informed throughout.

When the fire had been extinguished, a small‘shunter’ truck was sent on board to tow the fire-damaged lorry ashore.

The driver of the lorry suffered minor smokeinhalation. The ferry eventually sailed 10minutes late.

Quick Response to Vehicle Fire onRo-Ro Ferry

CASE 11

The Lessons

This case is one in which the crew put theirmeticulously practised procedures into place,which led to a successful outcome. Thelessons are therefore positives ones:

1. Incidents such as this one can happen atany time where vehicles of unknowncondition are loaded onto a ro-ro vessel.It is, therefore, imperative that crew arevigilant at all times, and make regularinspections of car decks, both before andduring sailing, so that a small fire is notallowed to escalate into a larger one.

2. Any fire on board a passenger ferry canlead to panic and confusion amongpassengers if the crew do not respondeffectively and professionally. Bydemonstrating their training in dealingwith such an emergency, these crewmembers were able to reassure thepassengers, maintain calm and preventthe outbreak of panic.

Keeping passengers informed about whatis happening, as was done during thisincident, will have the added benefit ofeliciting a much more helpful responsefrom them in the event of evacuation.

3. The ultimate decision as to whether thefire brigade should be called to tackle afire lies with the master. Remember, thefire brigade would rather arrive at thescene of a fire, and find it alreadyextinguished, than deal with a far moreserious incident – caused by hesitationon the part of the crew in seeking theirhelp.

26


Narrative

A totally enclosed lifeboat was boarded by itscrew and a number of others for a practice drill.All were on board with their seat belts secured.

Once everyone was ready, the cox’n pulled onthe winch brake’s remote release wire. Thedavit’s arms began to swing out and theautomatic gripes released.

The process continued without a hitch until thedavit arms were fully swung out and the boatbegan to lower. The boat started to lean intowards the ship, its stern continuing to lowerand its bows not moving. As lowering continued,the rotation increased until the boat was almoston its beam-ends and with its stern hangingdown. At this stage the aft lower block came free

from the suspension hook. Operation of thebrake stopped, with the boat hanging from theforward suspension hook.

Some of those in the boat slipped involuntarilyfrom their seat belts. Various pieces of gear brokefree and tumbled about the boat’s interior. Therewere a number of minor injuries.

The aft suspension hook was re-engaged and thelifeboat was safely lowered to the water. Therewas serious damage to the davit’s arms, and theunit was taken out of service.

An investigation concluded that the ring on thereleased end of the forward gripe, instead ofsafely sliding over the lifeboat’s canopy duringlowering, had fouled on the gripe bobbinattached to the lifeboat (see figure).

What a Foul Up!

CASE 12

27

Gripe bobbin


CASE 12

The Lessons

1. This incident could have had much moreserious consequences. It shows that evenwell maintained systems can suffer themost unexpected problems.

2. During practice launchings, it is prudentto have a person on deck who can ensurethat all is running freely, and who is ableto halt the operation in the event ofproblems.

3. If the gripe wire end rings are largeenough to fit over an attachment on thelifeboat’s exterior, be sure that eventuallyit will happen, and probably duringlaunching. Consider changing the rings’dimensions or attachments so thatfouling is impossible.

28


Narrative

Immediately after a ro-ro ferry, with 54passengers and 40 crew on board, entered theapproach channel of a port she routinely visited,she grounded at a speed of 8 knots. The ferry’sdraught was 5.8m, the charted maintained depthof the channel was 6m, and the height of tide

was 1.42m. The approach channel was prone tosilting, and a warning to this effect was shown onthe appropriate Admiralty chart.

Fortunately, because the bottom was soft silt,nobody was injured and the ship was undamaged.She was refloated about 2 hours later on therising tide.

Who Put That There?

CASE 13

29


CASE 13

The Lessons

1. When a channel of ‘maintained’ depth isshown on a chart, it is probably notunfair to assume that most marinersconsider the depth shown to be reliable.Unfortunately, this is not always thecase. Some areas are particularly proneto silting at varying rates depending ontidal and weather conditions. This canmake it very difficult for port authoritiesto maintain channels to the depthsadvertised, and their failure to do so canspoil a master’s day, particularly if nowarning is given. Don’t take maintaineddepths in channels, or at alongsideberths, for granted; make sure you havethe latest information from the port orharbour authority. Where doubt exists,at least proceed with caution.

2. Echo sounders appear to be used less andless, possibly due in part to the improvedaccuracy and reliability of both chartsand navigation systems in recent years.When in restricted waters, however,particularly where survey information isold or scant, or where the nature of theseabed is known to change, it isfoolhardy to ignore them. Take theopportunity to compare actual againstexpected depths. It costs nothing, andmight prevent your aspirations becominghigh and dry.

3. Warnings, cautions, and notes onnavigational charts are there for areason. Don’t ignore them!

30


Narrative

A 3,500 tonne ro-ro cargo vessel was on passagein restricted waters to carry out sea trialsfollowing her main engine being converted torun on gas oil. About 4 hours after leaving herberth, the fire detection system in thewheelhouse indicated there was a fire in theengine room.

The engine room was manned, and the chiefengineer reported to the master within 5 minutesof the alarm sounding, that there was a fire in theeconomiser and that it was being attacked withhand-held extinguishers. The general alarm wassounded and the crew were mustered. It becameapparent that the fire could not be controlled byhand-held extinguishers, and the master andchief engineer decided to use the CO2 fixed fire-fighting system. With the master’s permission,the chief engineer stopped the main engine andthe vessel grounded lightly on the mud-linedshore.

Twenty five minutes after the initial alarm, thecrew were all accounted for and the engine roomwas battened down ready for CO2 flooding. Thefirst charge of CO2 was released and the firebrigade was called. Boundary cooling wasestablished, and 10 minutes later, two of the fireofficers boarded the vessel. A second charge ofCO2 was released as a precautionary measure.

Ninety minutes after the first release of CO2, andon the fire brigade’s advice, the engine room wasopened up to allow ventilation of the space. Afire party in breathing apparatus entered theengine room after a further 40 minutes. Theyreported that the fire had been successfullyextinguished, and 41⁄2 hours after the initialalarm, the fire brigade confirmed that the engineroom was safe to enter without breathingapparatus.

The vessel was towed back to her berth, wherethe cause of the fire was investigated. Since shehad been converted to run on gas oil, there was

It Has Been Drained, But is it Dry?

CASE 14

31


no longer any need to heat the fuel. This led tothe thermal oil waste heat unit being drainedand isolated, as it was no longer needed. Themanufacturers stated that it was safe to operatewith the unit drained and opened to atmosphere.This was done by removing the oil inlet andoutlet headers at the bottom of the unit.

However, the horizontal tubes took the form ofcoils, so some thermal oil remained in the unit.When the exhaust gasses heated it sufficiently,this oil ignited.

CASE 14

The Lessons

1. When taking equipment out of service, itis essential that all possible dangers areidentified and eliminated. Had it beenknown that the tubes were coiled, itwould have been clear that oil residueswere likely. The unit could then havebeen flushed through. An assumptionthat the unit was fully drained led to aserious fire.

2. The fire was tackled quickly andeffectively. The decision to use CO2 wastaken early enough to ensure the bestpossible outcome. As a result, there wereno injuries and the damage was minorand local to the seat of the fire.

3. The assistance of the fire brigade wasuseful and very welcome. Not only werethey able to give the master good advice,they also assisted with specialistequipment and in ensuring that the firewas fully extinguished.

32


Narrative

A 58m length general cargo vessel entered a porton the north coast of France to load a cargo ofstone. The vessel had used the port on manyoccasions in the past without problems. Therewas a high tidal range at the port, and the berthdried out at low water. Normally, the sandybottom was level, but a westerly gale had blowninto the harbour, which had caused sand to buildup at the ends of the berth.

A substantial amount of cargo had been loadedby the time the vessel took the bottom, with the

tide still falling. She broke her back. The doublebottom was unaffected, but the deck platingcrumpled around amidships when the hull saggedon the uneven surface. The ship’s sides werecrumpled in a “V” shape, with a deformation ofabout 200mm at the deck edge, tapering down tonothing at the double bottom.

The cargo was discharged, and when she floatedshe straightened out. Although the ship wasdamaged, it was considered safe for her to sail toa port of repair. This was reached withoutincident.

Beware of Berths that Dry Out

CASE 15

33


CASE 15

The Lessons

1. Using berths that dry out can be safe,but the hull must not be overloaded. Inthe case of a flat-bottomed vessel, themaster should satisfy himself that thesurface of the ground at the berth isfairly level, before heavy cargo is takenon board. This check is not so importantwith soft mud, but it could be crucial ifthe bottom is hard sand, as was the casewith this accident.

2. When a vessel uses a port regularly it iseasy to assume that everything will befine. If the bottom is hard sand, don’tmake this assumption. If the flatness of aberth is in doubt, it should be allowed todry out, and an inspection should becarried out before a vessel uses it to loadheavy cargo.

34


Narrative

On arrival at her port of discharge, an oil tankercarrying about 3000 tonnes of gas oil was advisedthat the conditions were too severe to allow herto enter. The tanker’s master, who had recentlyjoined the ship and had never previously visitedthe port, decided to anchor in its approaches.

Early the next morning, after a smaller vessel hadentered the port without difficulty, the harbourauthority considered that the conditions hadmoderated sufficiently to also allow the tanker toenter. The wind at the time was onshore between25 to 30 knots, with a moderate swell and a floodtide. It was dark.

After weighing anchor, the master, who wasaccompanied on the bridge by an AB helmsman,

was advised by the pilot embarked in a cutter,that in view of the conditions, he would board atthe harbour entrance rather than the normalembarkation point in the vicinity of the fairwaybuoy. He was also instructed to manoeuvre wellsouth of the fairway buoy before making anapproach. The tanker, however, initially passedto the north of the fairway buoy, and about 15minutes later, was still about 0.5 cable north ofthe intended track of 236°, indicated by leadinglights. At this point, the master altered courseabout 25° to port, to bring the ship further south.Although the tanker then crossed the intendedtrack, course was not adjusted back to starboard,and shortly after, the tanker grounded just insidethe harbour entrance.

She was later refloated on the rising tide, andthere was no pollution.

Stay A Leading Light – Use Them!

CASE 16

35


CASE 16

The Lessons

1. Entering a port for the first time,without a pilot and in adverse conditions,while feasible, carries additional risks. Ifin doubt, don’t do it. Nobody will thankyou for trying, but getting it wrong.Equally, it would be prudent for harbourauthorities to determine the master’sexperience before inviting him to enterwhat would normally be areas ofcompulsory pilotage.

2. Ignoring navigational advice given byport authorities can be perilous.Sometimes, such advice might seemirrelevant or unnecessary, but it isusually based on experience and theknowledge of local conditions; unlessthere are sound safety reasons for notdoing so, such advice is best adhered to.

3. It is important that bridge organisationand manning is adjusted to meet thechanging navigational situation. Passagethrough restricted waters, particularlywithout the assistance of a pilot, isusually very demanding and requires amaster’s unerring concentration. Withthe presence of numerous distractions ona modern bridge, this can only really beachieved if there are enough peopleavailable to share the load. Good bridgemanagement is an essential requirementto keep any ship safe. Is yours up toscratch?

4. When operating in restricted waters, inadverse weather or strong tidal streams,the importance of the use of headmarks,

transits, leading lights, and radar parallelindices, should not be underestimated.When applied correctly, these methodscan provide a real-time indication ofposition relative to planned track, give arapid assessment of the set and leewayinduced by the prevailing conditions, andallow the ship to be navigated with greataccuracy. Successful application,however, requires the methods in use tobe continuously monitored, cross-checked, and practised. Sadly, however,with the advent of electronic charts, andthe reliance on pilots, there is a tendencyfor bridge watchkeepers to dispense withleading lights and other visual pilotagetechniques. Such skills are not purely thegift of pilots, so don’t let them fade away.

5. Running a transit ahead, like mostthings, takes practice, and when left totheir own devices, inexperienced officersare usually only on track when theycross it!

Nothing can replace practical experience,but a few tips when running a transit areworthy of mention:

• A quicker assessment of tidal set andleeway is usually achieved by gettingon track early;

• Take care not to overshoot; and

• Beware of the fact that the sensitivityof transits, which is a function of thedistance between the two marks,relative to your range from them,varies considerably.

36

Having been asked to write this introduction tothe fishing vessel section of the Safety Digest, itstrikes me that many fishermen are unaware ofthe role that the MAIB carries out. The MAIBinvestigates accidents which occur in ourindustry, and produces a report of the accident sothat we, as fishermen, may learn lessons toreduce the possibility of this occurring again inthe future.

In this issue of the Safety Digest, you will readabout a number of accidents and incidents whichhave occurred to all types of fishing vessels. In anumber of cases here, a key area is stability.Stability is difficult for most of us to understand,but in some of the cases you are about to read,what becomes clear is that stability has beengreatly affected by modifications. These changes

sometimes occur over a period of time wherebythe vessel has been constructed for one particularfishing pattern, and has changed to another.Other effects on stability can be the overloadingof fishing gear on deck, along with the unwantedfastener/boulder which may occur at any timewhilst fishing.

So what is stability in fishing vessels? Stability isthe ability of your vessel to right itself to theupright position after it has been forced over byan external force. But if modifications are madeto the vessel, these changes can severely restrictthe vessel’s ability to come to the uprightposition, and can, in extreme cases, cause thevessel to overturn.

So what can we, as fishermen, do to ensure thestability of our vessels? We need to ask advicefrom a suitably qualified person before we makeany modifications to our vessels, no matter howsmall that change may be. We need to be awareof the capabilities of our vessels, and be preparedfor the unexpected. Remember, stability cannotbe measured, it needs to be calculated.

Take care when fishing, return home safely.

Part 2 – Fishing Vessels

George Geddes

An experienced seine net and trawl skipper, who is also a representative of the Scottish Fishermen’sFederation. George is currently a part-time instructor for the basic fishermen’s safety courses, and has recentlycompleted a diploma in Safety and Risk Management. He is skipper/owner of a 21m twin rig trawler workingout of north east Scotland.



Narrative

A 10-metre vessel was single-handedly trawlingfor prawns. It was dark, and the weather was fineand clear with light winds.

While hauling, it became apparent that a heavyobject had entered the net. The skipper tried toclear it by hauling on the dog rope, but thisparted under load. He then wound as much ofthe net as he could on to the net drum andstarted to tow the heavy object towards port,where he intended to get help to remove it.

During the tow, the skipper established radiocontact with the coastguard, butcommunications were suddenly lost. A search forthe missing vessel was initiated.

The vessel was subsequently found on theseabed. The skipper’s body was recovered fromthe wheelhouse, and the vessel was later raisedand inclined to establish her stability at the timeof her loss. The heavy object was found to be alarge rock.

The inclining experiment, and its subsequentanalysis, indicated that her inherent stability hadbeen poor. The vessel had been modifiedextensively: the gunwale had been raised and ashelter and net drum had been fitted, all ofwhich reduced her inherent stability. The resultwas that it would have taken little to capsize herso suddenly that the skipper did not even have achance to get out of the wheelhouse.

Modifications Result in Loss ofStability, Vessel and a Life

CASE 17


CASE 17

The Lessons

1. Without a stability standard, adequatestability awareness, and knowledge of theloading limits of their particular vessel,skippers of fishing vessels under 15metres in length are severely hamperedin their ability to judge when it is safe tolift, tow or carry heavy loads.

Knowledge of a vessel’s stability and herloading limits is, therefore, an essentialcontrol measure aimed at reducing therisk of capsize. To this end, skippersshould take advantage of the one-daysafety awareness course offered bySeafish, and seek professional advice,particularly following any significantmodifications.

2. The Code of Practice for the Safety ofSmall Fishing Vessels does not stipulateany stability requirements for fishingvessels under 15 metres in length.However, it does require the fitting of abilge alarm, which provides earlywarning of flooding, and ensures thoseon board have time to react. This vesseldid not have a bilge alarm. Therefore,her skipper would not have beenautomatically alerted to any ingress ofwater which would have affected thevessel’s freeboard and stability.


Narrative

A 6.5m creel boat failed to return to port asplanned. A search began, and she was foundpartly submerged several hours later. The vesselwas recovered, but there was no sign of her crewof two. It was concluded that the vessel was lostbecause of poor stability caused by materialalterations, overloading and water ingress.

During the creel boat’s 25 years in service,substantial modifications had been made to her.In particular: the raising of gunwales, the fittingof a deck (which was not watertight),enlargement of the wheelhouse, the addition ofan hydraulic pot-hauler and the fitting of ballast.

All would have significantly changed herstability characteristics. The insertion of freeingports above a non-watertight deck would alsohave increased the probability of wateraccumulating in the bilge.

The vessel had recently changed ownership, andthe previous operator’s maximum load on deckwas sixty creels. At the time of her loss, she wascarrying ninety.

The vessel was not fitted with a bilge alarm, andher electrical bilge pump was defective.Lifejackets were found in the vessel, but a liferaftwas not carried.

Overloaded, Overdue, Over…..

CASE 18

Estimated loading condition after recovery


CASE 18

The Lessons

1. Most vessels are modified over thecourse of their time in service so thatthey keep pace with technology, are moreefficient and comfortable, or as a resultof a change in the type of fishingconducted. Consequently, some vesselshave ‘grown’ considerably since build.However, any structural modificationshave the potential to adversely affect avessel’s stability, which might not beobvious. So before making anysignificant alterations, such as adding awinch, extending a wheelhouse, fitting adeck and freeing ports, and adjustingballast, it is always wise to seek theadvice of a qualified person.

2. The overloading of small fishing vesselsis an ever-present danger, and almosttotal reliance is placed on skippers’experience and knowledge of their boatsto guard against it. However, after achange of ownership, in most cases anew skipper will not be familiar withhow a vessel handles. It is thereforeimportant, when buying a second-handboat, that its maximum loading and

limiting conditions be included amongthe information passed on from itsprevious operators. Without this, askipper’s assessment is reliant on trialand error. Unfortunately, some crewsdon’t get a second chance when suchassessments are misjudged.

3. In a decked vessel, the easiest way toensure that an accumulation of water inthe bilge does not pass unnoticed, is to fita high level alarm. Physical checks of thebilge can tend to fall towards the bottomof the priority list when fishing, andeven when automatic bilge pumps areworking, they might mask, or not copewith, a serious ingress.

4. There will not always be time to graband don a lifejacket when things go pear-shaped. Think about wearing them at alltimes when on deck, particularly whenconditions are marginal.

5. Just because a vessel is not required tocarry a liferaft, does not mean that hercrew will never need one. If there isroom to carry one, do so. It’s not theregulators’ lives which are at risk.


Narrative

The owner/skipper of a 10-metre steel fishingvessel operated her for several years as a prawntrawler. He then decided to convert her to cockledredging for operations in local rivers and a largeestuary.

For this conversion, he removed the trawl winchand fitted a large diesel-driven water pump, asuction pump, a powered riddle and an ‘A’ framefor handling the gear. The two pumps weremounted on deck, and the riddle on the portbulwark. These three items were of substantialweight. Some extra ballast was added in an effortto compensate for this topweight.

The vessel was operated with few problems for acouple of months by the skipper and onecrewman.

On this occasion, the skipper agreed that a thirdperson could join him for a day. The day wentwell, with a substantial catch of cockles. Thesewere stowed in large bags, each holding anestimated one tonne. Two bags were stowed inthe fish hold, three on deck and one on the fishhatch forward of the wheelhouse.

The skipper decided this was their limit, andhauled the dredging gear on board. The boat wasin a narrow part of a river, and the skipperneeded to turn her, to return to their landingquay.

As he knocked the boat out of gear, to begin athree-point turn in the narrow river, the boatbegan to heel to port. This heeling continued.The three men realised something was amiss, andmanaged to jump into the water before the boatcompletely capsized.

Fortunately, all three men managed to kick offtheir boots etc and swim to the shore. Onemanaged to walk to a nearby house, where theemergency services were called. None sufferedany serious injury.

Too Much On Top

CASE 19

The Lessons

1. The weight of cockle bags on deck wassubstantial for a boat of this size. Thistopweight, coupled with the unknowneffects of the modifications made to theboat, generated a condition where shehad no reserves of stability. For boats ofthis size, which are not required tocomply with any formal stabilitystandards, it is vital that owners andskippers take great care when modifyingand loading them, so that they retainsome reserve of stability.

2. Fortunately, all three men were able tomake their way to the bank of the river.In less friendly conditions they mighthave been less fortunate. Permanentwear buoyancy, that is comfortable towear while working, can provide vitalsupport in such circumstances. Allfishermen should consider wearing suchaids.


CASE 19

Diesel-driven pump ‘A’ frame

Pump


Narrative

The skipper of a 22-metre fishing vessel wasreading in his bunk at about 2130, when henoticed a strong smell of burning plastic. Hequickly left his cabin and checked the engineroom. Although the engine room was clear ofsmoke, there was a light smoky haze in theaccommodation.

On carefully opening the galley door, the skippersaw that the area was full of smoke. He shut thedoor immediately, and raised the alarm byshouting for all the crew to get up and bring theirlifejackets to the bridge. He told the cook to shutoff the power to the cooker, and then went up tothe wheelhouse. Once there, he again raised thealarm over the tannoy, and was met on thebridge by the rest of the crew. Not all hadbrought their lifejackets.

Having told the crew that there was a fire in thegalley, he called the coastguard on Channel 16.The coastguard put out a “Mayday” distress call.

The smoke by that time was very heavy, and thecook shut the hatch down from the wheelhouseand checked that the entry to the forward shelterwas shut.

An offshore stand-by vessel in the vicinityreacted to the “Mayday” and sent its fast rescueboat to the fishing boat, with 4 lifejackets and abreathing apparatus set. The stand-by vessel thencame in close, and trained its fire monitors on tothe hotspot on the lower accommodation.

The fire was brought under control, and thefishing vessel was able to return to port under herown power, having first evacuated three of thefive crew members as a precaution.

Investigation showed that the fire had beenstarted by a survival suit coming into contactwith a ‘black heater’ in the drying room whenthe vessel had started rolling, about 30 minutesbefore the fire was noticed. This spread through abulkhead to the galley area.

Quick Action Saves Fishing Boatand Crew

CASE 20

The Lessons

This incident shows how a difficult situationcan be brought under control by clearthinking and quick action.

1. By opening the galley door carefully, andonly a little, the skipper prevented thefire from spreading, and ensured his ownsafety.

2. Immediately raising the alarm andinstructing all the crew to muster on thebridge allowed further action to be takenonce all the crew were accounted for.

3. Ensuring that all available hatches andopenings were closed, contained the firelong enough for it to be brought undercontrol.

4. The unguarded ‘black heater’ has sincebeen fitted with a guard six inches allaround it, and the bulkhead to the galleyhas been replaced by a steel one. Thinkabout where you dry wet clothing.


Narrative

A large vessel was fishing to the west ofScotland. The wind was north-west force 3, therewas a heavy swell, the visibility was moderate topoor in rain, and it was dark. A crew of six wason board.

In the late evening, the port fishing gear becamesnagged on an underwater obstruction. Whiletrying to pull it free, the winches stopped. Thiseffectively anchored the vessel to the seabed inthe heavy swell, which caused her to take a largelist to port. Because she was rolling either side ofthe port list, the port engine intakes went belowthe waterline. This, in turn, caused the engineroom to flood. Between 5 and 10 minutes later,the vessel capsized to port.

After the winches stopped, all six hydraulicpumps that powered them were restarted, butbefore the load could be taken off the port winch,the system failed again. The computer-controlledwinch system on the vessel was very complex. Ithas not been possible to identify clearly thereason why the winches stopped. However, hadthe emergency start been used, it is possible thatthe load on the port winch could have beenreleased. Also, it was not necessary to re-start all

six hydraulic pumps. Starting one of them thatsupplied the port winch might have beensufficient to release the load. However, there wasvery little time to consider the options, becausethe capsize and foundering were very rapid.

The brakes were set up so that they came onautomatically when the winches stopped. Thewinch control system could have beenconfigured so that the brakes stayed off. Had thesafety brake been enabled, and worked asintended, it might have saved the vessel.

The engine intakes were low on the port side.Although this arrangement met the requirementsof the regulations, these intakes should havebeen positioned higher up and/or further inboardto avoid the risk of downflooding.

Events happened so quickly that the crew didnot have time to radio for help before theyabandoned their vessel. Five of them successfullyboarded the liferaft; tragically one man was lost.The five survivors were wet and very cold; it wascrucial that they were rescued without delay. TheEPIRB saved the day; the coastguard were able topinpoint the accident, and immediatelydispatched a helicopter which rescued thesurvivors.

Winch Problem Leads to Capsize

CASE 21


CASE 21

The Lessons

1. If your vessel is fitted with a complicatedwinch control system, be sure that youwould know what to do if faced with thissort of emergency. If a safety brakefeature is fitted, it should be enabled.

2. If your vessel is fitted with vulnerableengine intakes, be aware of the risk ofdownflooding. Such intakes shouldideally be moved further up and/orfurther inboard.

3. The liferaft and EPIRB almost certainlysaved five lives:

• Without the liferaft, the five menwould have found themselves in roughseas and darkness. Their survival timewould have been severely limited.

• The EPIRB alerted the coastguard andenabled the recovery to be initiated.

In cases like this, the value of such safetyequipment is clearly demonstrated.

Winch control panel


Narrative

A 9.9 metre length wooden stern trawler wasoperating with a crew of two. She left her homeport in the early morning and, after steaming forabout five hours, shot her gear. The weatherconditions were very good.

After towing for about 11⁄2 hours, the skipper,suspecting a problem with the gear, decided tohaul it in. The gear was hauled on board and thecod end emptied on to the deck. The skipper’ssuspicion was unfounded; the gear was in goodorder and was shot again.

After gutting and boxing the small amount offish caught, the crewman asked the skipper toturn on the deck wash water. The skipper didthis by switching on the electromagnetic clutchof the deck wash pump from the wheelhouseconsole.

When the crewman reported there was no watercoming from the deck wash hose, the skipperopened the engine room hatch in thewheelhouse to investigate. He immediately sawwater halfway up the engine. This surprised him,as there had been no sound from the bilge alarm,

all the electrics were still working, and during hislast look into the engine room, about three hoursearlier, he had seen no problem.

Inspection of the fish room confirmed that theflooding was widespread and serious.

After telling his crewman to remove his leggingsand boots, and to fetch the lifejackets, theskipper called a nearby fishing vessel on the VHFradio, asking for assistance. The two men thenlaunched and inflated their liferaft, and thecrewman climbed on board. In the meantime,the skipper had broadcast a “Mayday”. Thefloodwater on their boat had reached deck level.

Before any further assistance was required, thenearby fishing boat came alongside and tookboth the skipper and his crewman on board.

Not long after evacuating their boat, the twomen watched it sink.

This was a well-maintained boat, and there wasno obvious cause for the flooding. However,there is some suspicion that there was a failure ofa flexible hose in the engine’s seawater coolingsystem.

‘Dodgy’ Alarm, So No Warning

CASE 22

The Lessons

1. The boat was fitted with a bilge alarm,but the last occasion the skipper hadheard it sound was about a year beforethis accident. A routine for testing thealarm, before departure and duringnormal working conditions, would haveallowed any defect to be detected andremedied as soon as it developed. Hadthe bilge alarm sounded early in thisaccident, it might have given the skippertime to take corrective action, such asclosing seacocks.

2. This boat was not required to carry aliferaft by the code of practice governing

its operation. However, the skipperprudently carried one on board, and hadit serviced annually. It worked duringthis accident and, had the nearby fishingvessel been a little slower in coming toassist, could have proved vital to thesurvival of the two men.

3. Although the cause of the flooding hasnot been established, because of their age,some suspicion has fallen on the flexiblehoses fitted to the engine’s seawatercooling system. Flexible hoses have alimited life span and, where their use isunavoidable, best practice is to inspectthem regularly, together with any wormdrive clips used to secure their ends.


Narrative

An 11-metre prawn trawler was normallyoperated by her skipper and a deckhand.However, on this occasion, the skipper wasunable to employ anybody as a deckhand sodecided to sail single-handed.

The vessel’s layout was conventional: a fishingwinch amidships, just aft of the forwardwheelhouse, and a net drum mounted on a sterngantry. The winch and net drum werehydraulically-powered from an engine-drivenpump.

The control levers for the winch and net drumwere both self-centring, so whenever they werereleased, each returned to the ‘stop’ or safeposition.

The skipper left his home port early in themorning and sailed for about an hour until heshot the gear. It was probably at the end of hisfirst tow that he ran into trouble.

He hauled the gear until the doors were hungfrom the gantry. He then attached the bridle tothe net drum, and began hauling to bring the netin. However, he latched the spring-loaded leverof the drum control into the ‘haul’ position,using a bent wire hook, so he could stand aft ofthe drum to guide the net on to it.

For some reason, he put his hand on to a swivelshackle on the bridle as it came on to the netdrum; probably to lay the shackle flat. But hisgloved hand became caught in the shackle and,as he was out of reach of the control lever, hewas unable to stop the drum.

He was dragged around with the moving drumuntil he was covered by a number of turns of thebridle. The force in the bridle fatally crushedhim.

Meanwhile, the vessel was still steaming undercontrol of the autopilot. She slowly sailed on herpre-set course for several hours until shegrounded on a headland. There she was found,with her engine still running and with the deadskipper horribly wrapped around the net drum.

A Fatal Override

CASE 23

The Lessons

1. A fishing vessel of this size is required tooperate under The Fishing Vessels’ Codeof Practice for the Safety of Small FishingVessels Under 12 Metres in Length. ThisCode requires that a risk assessment beperformed on the operations carried outon board. In this case, no risk assessmenthad been done. Ideally, a risk assessmentshould have identified the unsuitabilityof this vessel for single-handed operationas a trawler.

2. A risk assessment should also haveshown that the self-centring controllevers of the net drum and the winchwere critical safety devices, and essentialto the safety of those on board.Overriding these safety featurescompletely removes a vital controlmeasure, makes a nonsense of any riskassessment performed, and places crew inserious danger.

Learning by personal experience is probably thebest way of retaining knowledge and skills.However, no sensible recreational skipper woulddeliberately put either themself, or their boat, atrisk in order to learn what actions to take wheneither life or their boat is in danger.

This unique contribution that the Safety Digestmakes to avoiding mishaps and accidents, is thatwe can all learn from the properly documentedand analysed experiences of others.

Not all incidents can be avoided; using the seaand inland waters always has a certain element ofrisk attached to it. Indeed, it is the propermanagement of those risks that attracts manypeople to both the freedoms and responsibilitiesassociated with all forms of boating.

The RYA believes that a lifelong commitment tolearning and, when necessary, training, should bean integral part of every skipper’s mindset. Safetyat sea is not just a list of equipment on a properlymaintained vessel. It is a “golden thread” linkingall aspects of maintaining, equipping and, mostof all, skippering a small boat.

The value judgments that a good skipper or crewapply to passage planning, navigation orseamanship can be critical in ensuring a safepassage. Complacency, particularly that borneout of an over familiarity with a particular boator venue, can become an infectious attitude thateventually leads to sloppy practices andaccidents.

The lack of awareness of the needs andrequirements of other water users is a constantreoccurring theme in these reports. It is everyskipper’s responsibility to be familiar with the keyprovisions of the collision regulations,particularly those associated with largecommercial vessels.

All recreational boat skippers need to assesswhether their boat and equipment is appropriatefor the planned voyage, use their judgment andskill in managing their boat and crew to besteffect, and plan to be self reliant and resourcefulif the unexpected does happen.

Part 3 – Leisure Craft

Rod Carr, RYA Chief Executive

Rod Carr has been Chief Executive of the RYA since December 2000. Among his many sailing achievements,he was Crew Boss for the Admirals Cup campaign in 1981 on board Yeoman, he coached the Olympic teamfor the Los Angeles games in 1984, the Seoul and Barcelona Olympics in 1988 and 1992 before beingappointed overall team manager for the Savannah games in 1996. He was appointed RYA Racing Managerin 1997.

MAIB Safety Digest 1/2004 49


Narrative

A catamaran was being sailed by her new ownerswho had taken delivery from Portsmouth. Theskipper and three crew were experienced andwere wearing suitable clothing for a blusteryApril evening. The boat was equipped with VHFradio and a good selection of emergencyequipment, although no EPIRB was carried.

It was getting dark, and with the wind blowing20 to 25 knots from SSW, the crew were sailingunder a double-reefed mainsail and reefedheadsail. They tacked on to starboard and soonafterwards an unusual wave pattern hit theweather hull, reported to be travelling againstthe direction of the wind and swell. It lifted thehull so far that the boat lost stability andcapsized.

Catamaran Capsize in Solent

CASE 24


The catamaran inverted almost immediately,leaving the crew to find safety on the upturnedhulls. Because the capsize had happened soquickly, there had been no time to retrieve the‘grab-bag’ containing flares and other equipment.The VHF was now out of action, as well as beinginaccessible, and the mobile telephones weredown below.

Skipper and crew had no option but to huddletogether for warmth, and hope for a rescue.

Luckily, they were less than a mile offshore fromStansore Point in the Solent, but it was nowcompletely dark.

It was not until about 0700 the following day, asit grew light, that their distress signals (raisedand lowered arms) were spotted from the shoreand the alarm was raised. All four were taken offby the inshore lifeboat, and taken to hospitalsuffering from mild hypothermia. Fortunately, allmade complete recoveries.

CASE 24

The Lessons

1. The importance of correct clothing forthe conditions cannot be overemphasised. All four members of thecrew were wearing thermalunderclothing, midlayer garments, aswell as heavy weather jackets and hightrousers. They were also wearinglifejackets and harnesses. Despite low seaand air temperatures, all four survivedeleven hours on the upturned hullsrelatively unscathed.

2. Locate the grab-bag somewhere so that itcan be reached if the boat becomesinverted. This is obviously particularlyimportant with a multi-hull, which, onceinverted, will stay inverted.

3. An EPIRB mounted in the cockpitwould have raised the alarm withinminutes of the capsize, and would havespared the crew a long, cold andextremely uncertain night.

4. The skipper told the MAIB that he wasgrateful that they had all eaten a goodmeal before departure, and had stayedaway from alcohol. He also highlightedthe importance of keeping morale highand “believing in the rescue”.

Narrative

A family hired a 13 metre-long wooden motorcruising boat for a week’s holiday on the NorfolkBroads. The boat had nine berths and adisplacement of about 8 tonnes.

The family sailed downstream on the ebb tideand approached a closed swing bridge. Becausethey were towing a dinghy with a mast too highto pass under the bridge, three long blasts, thesignal required for the bridge to be opened, weregiven. However, on closer approach, it wasobvious that the bridge was not going to open intime. The person in control of the boat had todecide quickly whether to let go the dinghy or togo alongside the jetty adjacent to the bridge. Hechose the latter. On approaching the jetty atsome speed, one of the family’s young sonsjumped ashore holding a rope, which had beenmade fast to a metal cleat attached to the deck ofthe boat, and put a few turns around a woodenbollard on the jetty. The intention was to use therope to swing the boat’s head into the ebb tidebefore making her fast alongside. The young manwas bent down near the bollard as the tensioncame on to the rope. The momentum of theboat, enhanced by the tidal current, came to bearon the metal cleat which broke free of the deckand flew back along the line of the rope. Thecleat struck him in the face with great force. Hesuffered severe injuries.

An inspection of the metal cleat found that thetwo mild steel holding-down bolts were severelycorroded. One of them had failed some timebefore the accident, the other one had failedbecause it could not take the force of the ropeunder tension.

The boat owner had no set maintenanceprogramme for his boats, and did not look atfittings on a regular basis. The last time the boltshad been inspected and replaced was 8 yearsbefore the accident.

52

Out of Sight, Out of Mind


CASE 25

View from under sheared bolts before removal


CASE 25

The Lessons

1. Boat owners should ensure regularservicing procedures for all equipment onboard are in place. That includes“standing” equipment, integral parts ofwhich cannot be seen withoutdismantling. In a salty atmosphere, mildsteel bolts should be visually inspectedannually and, if necessary, replaced everytwo years. Better still, stainless steelbolts should be fitted.

2. When berthing a boat, it is preferable toturn her to stem the stream beforemanoeuvring alongside, as she will thenbe under easy control due to the brakingeffect of the current.

3. Always be aware of the hazards involvedin berthing, especially from ropes andwires coming under tension, and theneed to maintain a safe distance fromthem.

View from above

Above view of adjacent cleat (incident cleat would have looked exactly like this)


Narrative

Four members of a family were on their 15 tonne,twin screw motor yacht for a winter holiday. Shewas berthed at a marina. It was cold, so theyturned on the oil-fired cabin heater during oneevening.

While the family was having an evening meal,two of them complained of feeling unwell. It wassuspected that they were suffering from the earlystages of ‘flu and they went to bed with headachesand sore throats. The cabin heating was turnedoff overnight, and all felt fine the next morning.

The following evening, the heating system wasagain used. This time, all four members of thefamily began to feel unwell. It was at this stagethat suspicion fell on the heating system.

These suspicions were confirmed when aprofessional examination showed that there werevarious defects which allowed exhaust gases fromthe heater to be drawn into the cabin.

It is most fortunate that nobody sufferedanything worse than a headache. Fatalities fromcarbon monoxide poisoning could so easily haveresulted.

Early Warning Headaches

CASE 26

The Lessons

1. A simple carbon monoxide detector inthe cabin could have given an earlywarning of the problem.

2. In the absence of a detector, complaintsof headaches or sore throats fromanybody on board should be takenseriously when any gas or oil-fired cabinheater is in use. It is better to turn offthe heater, and shiver, than to sufferfatalities.

3. Because of the dangers that may becaused by poor or defective installations,it is always prudent to use qualified andexperienced personnel to install androutinely check these systems to ensuresafe operation.


Narrative

A yacht, under sail, was crossing the EnglishChannel, which is a busy waterway requiringincreased levels of vigilance regardless of theprevailing weather conditions. It was daylight,and the weather was fine with good visibility.A cargo ship was seen approaching from thestarboard side, and a series of compass bearingswas taken, which confirmed a risk of collision.

As the ship closed, the yachtsmen becameconcerned and called the ship on VHF radioChannels 16 and 13, without response. Noavoiding action was taken by the ship, and theyacht finally hove to, resulting in the shippassing ahead at a range of about 0.25 mile.

Those on the ship were unaware of the incident.

Lookout! What Lookout?

CASE 27

The Lessons

Sadly, this is not an uncommon story.

It should never be assumed that a ship willautomatically keep out of the way of a vesselunder sail. In this case, the yachtsmencorrectly took a series of compass bearings toascertain if a risk of collision existed. Theythen continued to monitor the situation, andtook appropriate action to avoid a collisionwhen it became apparent that the ship didnot intend to do so.

Following this incident, the MAIB helddiscussions with the merchant vessel’scompany. As a result of these discussions,the ship’s master will ensure that, whiletransiting the area in the future, VHF radiocontrols are correctly set, watches aredoubled, and an additional lookout is postedforward.

This article re-emphasises the importance ofnotifying the MAIB of incidents andaccidents. Only by receiving notification, canthe MAIB take action by suggestingimprovements to safety and passing thelessons on to others. Our role is toencourage discussion, which, by increasingawareness, hopefully then reduces the risk ofa recurrence.

• We do take note of incidents which arereported to us.

• And we do endeavour to implement andfollow up any recommendations to emergeas a result.

• But we need your help to do this.


Background

At 2300 on 29 January 2004, a twin rig 23.92 metretrawler sailed to her fishing grounds.

The vessel had been towing her twin rig gear for about3 hours when the skipper saw smoke coming from theoutlet of the engine room exhaust ventilator. He went tothe engine room immediately, where he discovered a fire.The skipper attempted to isolate the fuel systems, butwithout success. He then transmitted a "Mayday". About30 minutes into the incident, he tried to operate the fixedCO2 system. However, this failed because the systemhad been badly maintained, and the crew’s knowledgeof the operating procedures was, at best, superficial. Atabout this time, smoke from the engine room began toreduce, and the skipper was under the impression thatCO2 had been successfully discharged. A short timelater, he, together with the ship’s engineer, entered theengine room to see if the fire had been extinguished.

In this case, the fire died out without the use of the CO2.However, the outcome could have been very different,and this case highlights the need for effectivemaintenance and testing, and knowledge of how to usethe system.

Even more importantly, the skipper and ship’s engineerwere unaware of the potentially lethal dangers they facedwhen they re-entered the compartment. Had the CO2

system been successfully discharged, the engine roomwould still have contained dangerous levels of CO2 atthis time, and it is highly likely that the decision to entercould have resulted in the death of both men.

Safety Recommendations

Skippers and crews are reminded that the Regulationsrequire that all crew onboard UK registered fishingvessels have completed the compulsory one day "FirePrevention and Fire-Fighting" training course. Thiscourse can be arranged by contacting SEAFISH on01482 327 837.

In the event of a fire in the engine room, skippers andcrews should ensure that they are fully conversant withthe operation of the remote controls for the isolation of

fuel oil, hydraulic oil and ventilation systems from thespace. They must also have a good understanding ofthe operation of fixed CO2 fire extinguishing systems.

In particular:

1. Whenever it has been necessary to release CO2 intothe engine room to extinguish a fire, ventilation ofthe space should not be resumed until it has beenconfirmed that the fire is out and the space hassufficiently cooled to prevent re-ignition.

2. Thereafter, entry into a space that has containedCO2 should only be attempted by personnel usingbreathing apparatus. If breathing apparatus is notcarried on board, and it really is impossible to waitfor assistance from ashore, entry should only beattempted when the space has been thoroughlyventilated with clean air, and all residues of CO2have been removed. It is strongly recommendedthat this should include the need to obtain expertadvice from ashore before any attempt at re-entry ismade.

Additionally, all fishing vessel skippers and crews arerecommended to:

1. Ensure remote controls for fuel oil and hydraulicpumps, quick closing fuel oil valves and closingdevices for ventilators, emergency stops forventilation fans and CO2 fixed fire-fighting systemsare tested regularly and maintained in good order.

2. Ensure clear instructions for operating CO2extinguishing systems are displayed near thedistribution control valves and near the gascylinders.

3. Ensure audible alarms for warning personnel withinthe engine room, that the CO2 fire extinguishingsystem is about to be operated, are regularly testedand maintained in working order.

Near lethal use of CO2 onboard fishing vessel30 January 2004

MAIB SAFETY BULLETIN 1/2004

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 Type of AccidentAccident

29/11/03 La Belle Trois Fishing vessel UK 15.59 Fire

14/07/03 Lord Nelson Commercial sail UK 368 Hazardous inc.training vessel

07/12/03 Onward Star Fishing vessel UK 39.53 Acc. to person

08/12/03 Dart 9 Ro-ro cargo Bermuda 22748 Acc. to person

08/12/03 Nora Dry cargo vessel Estonian 2351 Acc. to person

27/12/03 Unnamed speedboat Pleasure craft UK Missing vessel

28/12/03 Reliance Yacht UK — Capsize/Listing

04/01/04 Telesis Fishing vessel UK 20.05 Hazardous inc.

04/01/04 Amenity Tanker UK 1453 Hazardous inc.

05/01/04 Ann Marie Fishing vessel UK 5.02 Flooding

07/01/04 Roseanne Fishing vessel UK 9.94 Hazardous inc.Sven Dede Dry cargo Antigua Barbuda 3815 Hazardous inc.

22/01/04 Sea Riss Dry Cargo Netherlands 1595 Fire

31/01/04 Adamant Crewboat, twin-hull UK 134 Collision

02/02/04 Aalskere Fishing vessel UK 242 Acc. to person

13/02/04 Transcend Fishing vessel UK 48.86 Fire

25/2/04 Tian Tong Feng Bulk carrier Hong Kong 39042 Grounding

Preliminary examinations started in the period 01/11/03 – 29/02/04

Date of Name of Vessel Type of Vessel Flag Size Type of AccidentAccident

01/11/03 Donald Redford Dredger UK 681 Contact

03/12/03 H.C. Katia Passenger ferry UK 186 Contact

29/01/04 Scot Venture Dry Cargo UK 2594 Hazardous inc.

30/01/04 Elegance Fishing vessel UK 357.00 Fire

Investigations started in the period 01/11/03 – 29/02/04

57

Amber – loss of fishing vessel in the Firth ofForth on 6 January 2003 with the loss of one lifePublished 23 October

Arco Adur – investigation of a fatal accident onthe River Medway on 25 February 2003Published 25 September

Ash/Dutch Aquamarine – collision between mvAsh and mv Dutch Aquamarine in the SW lane ofthe Dover Strait TSS, with the loss of one life,on 9 October 2001Published 20 March

Bro Axel/Noordhinder – near miss between BroAxel and Noordhinder, and the subsequentgrounding of Bro Axel at Milford Haven on5 December 2002Published 16 September

Claymore – investigation of the entanglement inmoorings, St Margaret’s Hope, on 11 March 2003Published 3 October

Diamant/Northern Merchant – collisionbetween vessels 3 miles SE of Dover on 6 January2002Published 4 April

Flamingo – capsize of fishing vessel east ofHarwich on 7 July 2002Published 12 June

Jambo – grounding and loss of the Cypriot-registered general cargo ship off Summer Islands,West Coast of Scotland on 29 June 2003Published 17 December

Kirsteen Anne – loss of vessel at Firth of Lornon 31 December 2002 with the loss of her twocrewPublished 31 July

Kodima – cargo shift, abandonment andgrounding in the English Channel on 1 February2002Published 21 January

Marbella – collision between UK-registeredfishing vessel and offshore platform in the RoughGas Field about 25 miles south-east ofFlamborough Head on 8 May 2002Published 26 April 2003

Maria H –vessel striking the Keadby railwaybridge on 29 May 2002Published 28 March

Nedlloyd Vespucci/Wahkuna – collisionbetween container ship and yacht in the EnglishChannel on 28 May 2003Published 19 December

Norsea – fire in the aft engine room of ro-ro ferryon 2 September 2002Published 30 June

Nottingham Princess – investigation ofNottingham Princess striking Trent Bridge,Nottingham, on 15 November 2002Published 22 August

Ocean Star – failure of a warp block on boardthe UK registered fishing vessel north of theShetland Islands, resulting in one fatality on26 November 2001Published 13 May

Osprey – fatal accident to a man overboard fromthe fishing vessel in Lochinver Harbour on20 April 2002Published 3 February

P&OSL Aquitaine – investigation of a fatalaccident during a vertical chute evacuation drillfrom the UK registered ro-ro ferry P&OSLAquitaine, in Dover Harbour, on 9 October 2002Published 25 July

Portsmouth Express – wash wave incident offEast Cowes on 18 July 2002Published 3 June

Pride of Bath – investigation of a barbecue firein the galley of Pride of Bath on the River Avon,Bath on 20 July 2002Published 25 February


Reports issued in 2003

APPENDIX B


Pride of Portsmouth – collision between Pride ofPortsmouth and HMS St Albans, PortsmouthHarbour on 27 October 2002Published 5 August

Pride of Provence – contact between the vesseland The Southern Breakwater, Dover Harboureastern entrance, on 18 April 2003Published 13 November

Pride of the Dart – grounding of the class VIpassenger vessel on Mew Stone rocks near theentrance to the River Dart on 28 June 2002Published 30 April

QE2 – flooding of aft engine room of passengercruise ship QE2 on 21/22 May 2002Published 31 March

QE2 – escape of steam and hot water on boardQE2 in mid-Atlantic, resulting in one fatality on23 June 2002Published 8 July

Radiant – capsize and foundering about 45 milesnorth-west of the Isle of Lewis, with the loss ofone life on 10 April 2002Published 24 January

Solway Harvester – summary report oninvestigation of the capsize and sinking 11 mileseast of the Isle of Man on 11 January 2000, withthe loss of seven livesPublished 13 June

Stena Explorer – fire on board HSS StenaExplorer entering Holyhead, 20 September 2001Published 17 February

Tullaghmurry Lass – sinking of fishing vesselTullaghmurry Lass, with loss of three lives, in theIrish Sea on 14 February 2002Published 3 February

Annual Report 2002 Published June 2003

Safety Digest 1/2003 Published April 2003

Safety Digest 2/2003 Published August 2003

Safety Digest 3/2003 Published December 2003

Timber Deck Cargo Study Published August2003

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

APPENDIX B


Breakaway 5 – investigation of the capsize ofthe hire boat, on the Norfolk Broads, resulting inone fatality, 19 July 2003Published 12 February

Elhanan T – investigation of the flooding andfoundering of the fishing vessel east-north-east ofFraserburgh, 14 August 2003Published 4 March

Trident VI – investigation of grounding of theinter-island passenger vessel off Herm Island,near Guernsey, in the Channel Islands,23 August 2003Published 30 January

Reports issued in 2004

APPENDIX C

60

Documents

SAFETY MARINE ACCIDENT INVESTIGATION BRANCH DIGEST · again. The content must necessarily be regarded as tentative and subject to alteration or correction if additional evidence becomes