Safety Digest 1/06 · 3. Timber Deck Cargo Shift Leads to Dangerous List in Heavy Weather 14 4. Let’s Not Get Carried Away 17 5. Bring Back the Budgie 19 6. Wrong Place – Wrong

SAFETY DIGESTLessons from Marine

Accident Reports1/2006

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SAFETY DIGESTLessons from Marine Accident Reports

No 1/2006

MARINE ACCIDENT INVESTIGATION BRANCH

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INVESTOR IN PEOPLE

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

© Crown copyright 2006

This publication, excluding any logos, may be reproduced free of charge in anyformat or medium for research, private study or for internal circulation within anorganisation. This is subject to it being reproduced accurately and not used in amisleading context. The material must be acknowledged as Crown copyright and thetitle of the publication specified.

Further copies of this report are available from:MAIBCarlton HouseCarlton PlaceSouthamptonSO15 2DZ

Printed in Great Britain. Text printed on material containing 100% post-consumer waste.Cover printed on material containing 75% post-consumer waste and 25% ECF pulp.April 2006

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 arisingfrom investigations into recent accidents and incidents. It contains facts which have beendetermined up to 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 accidentshappening again. The content must necessarily be regarded as tentative and subject to alterationor correction if additional evidence becomes available. The articles do not assign fault or blamenor do they determine liability. The lessons often extend beyond the events of the incidentsthemselves to ensure the maximum value can be achieved.

Extracts can be published without specific permission providing the source is dulyacknowledged.

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 2006

Extract fromThe Merchant Shipping

(Accident Reporting and Investigation)Regulations 2005 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (AccidentReporting and Investigation) Regulations 2005 shall be the prevention of future accidentsthrough the ascertainment of its causes and circumstances. It shall not be the purpose of aninvestigation to determine liability nor, except so far as is necessary to achieve its objective, toapportion 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 ofsuch causes and circumstances recurring in the future.

MARINE ACCIDENT INVESTIGATION BRANCH

GLOSSARY OF TERMS AND ABBREVIATIONS 6

INTRODUCTION 7

PART 1 – MERCHANT VESSELS 8

1. Insist On Cargo Trimming – It Can Save Lives 10

2. Grounding – on a Soft Bottom 12

3. Timber Deck Cargo Shift Leads to Dangerous List in Heavy Weather 14

4. Let’s Not Get Carried Away 17

5. Bring Back the Budgie 19

6. Wrong Place – Wrong Time 21

7. Lifting Equipment – Exceeding the Safe Working Load = Danger 23

8. Face The Danger 25

9. A Turn for the Worse 27

10. Fatigue Nearly Leads to Disaster 29

11. When Safety Maintenance = Hazardous Incident 31

12. From What Height Can a Lifeboat be Safely Released? 33

PART 2 – FISHING VESSELS 36

13. Poor Stability and Hull Defects Lead to Fatal Accident 38

14. The One That Got Away! 41

15. A Fire Detection System Can Help Save Your Vessel 43

16. Didn’t Feel a Thing 46

PART 3 – LEISURE CRAFT 48

17. Double Tragedy 50

18. A Tragic End to the First Trip of the Season 53

19. Alcohol Ends a Weekend Pleasure Trip 56

20. Ouch! One Very Badly Cracked RIB 59

21. A Lovely Day Ends in Tragedy 62

22. Fire: Put It Out and Keep It Out 64

23. Perilous Propellers 67

INDEX

24. Rafted Canoe Exercise Ends in That Sinking Feeling 69

25. Grounding in Perfect Weather 72

APPENDICES 75

Appendix A – Preliminary examinations and investigations started in 75the period 01/11/05 – 29/02/06

Appendix B – Reports issued in 2005 76

Appendix C – Reports issued in 2006 78

Glossary of Terms and AbbreviationsAB – Able Seaman

BA – Breathing Apparatus

CO2 – Carbon Dioxide

COLREGS – International Regulations for the Prevention of Collisions at Sea

ETA – Estimated Time of Arrival

GPS – Global Positioning System

GRT – Gross Registered Tonnes

HP – Horsepower

IMO – International Maritime Organization

"Mayday" – The international distress signal (spoken)

MCA – Maritime and Coastguard Agency

MGN – Marine Guidance Note

OBO – Oil Bulk Ore

OOW – Officer of the Watch

RIB – Rigid Inflatable Boat

RNLI – Royal National Lifeboat Institution

RYA – Royal Yachting Association

SWL – Safe Working Load

VHF – Very High Frequency

VTS – Vessel Traffic Services

IntroductionThe diverse and growing readership of the Safety Digest is indicative of the wide range ofaccidents and incidents we report. This edition has a particularly broad span of cases. Sadly,we have fewer than normal good news tales, and many more with tragic consequences,particularly in leisure craft. I deal with this more fully in my introduction to the leisure craftsection.

I will not try to précis the lessons from the accidents in this edition or offer a homily on thewisdom of risk assessment or the danger of complacency. I will leave it to each case to makeits own impact.

Nearly every accident is a tragedy – whether it be through death, injury, loss of career orsome other effect. It is difficult for MAIB inspectors to deal with these tragedies on a dailybasis, and to know that the accidents could all have been avoided . . .

Stephen MeyerChief Inspector of Marine AccidentsApril 2006

7MAIB Safety Digest 1/2006

I feel pleased to have been given theopportunity to write an introduction to thisedition of the “Safety Digest” as this, in effect,serves as my personal endorsement of thevaluable contribution to the seafaringcommunity carried out by the MAIB.

In my career at sea, spanning just over 47years, I have seen the use of the word safetyincrease year by year, and now there is hardly anautical publication that does not include theword. In particular, there is the Code of SafeWorking Practices for Merchant Seamen.

The Code of Safe Working Practices forMerchant Seamen clearly states ourresponsibilities towards safety. Of particularnote is that the Code makes the Masterresponsible to ensure that safety is enforced.The importance of the Master’s responsibilityis highlighted by the fact that non complianceis a punishable offence. There are very fewprofessions that make their senior staffaccountable to such a severe degree.Accordingly, it is of paramount importance thatofficers embrace the culture of safety very earlyin their career, and have a clear understandingof the associated legal accountabilities of the

Master. At the same time, the Master is notallowed to forget that he works for an ownerthat expects the ship to be profitable, so he isthen tasked with balancing matters of safetyagainst the requirements of making asuccessful commercial voyage.

This takes us into the realms of riskmanagement. Probably the best piece of ‘risk’advice I ever received was given to me shortlyafter I obtained my Second Mates Certificate in1961. My first trip as a Third Mate was on avery small ship called the Palaccio of theMacAndrew Line. Once or twice a week, weused to round Cape St Vincente. As weapproached the Cape, the Captain wouldcome on the bridge and take charge of theship. He would alter the course so that wepassed less than half a mile from the coast, soone could easily see people in the monasterythat was built on the edge of the high cliff. Itwas quite a fascinating manoeuvre, and it wasone that I visually enjoyed.

However, there was some risk becauseperiodically we would meet another ship doingthe same thing from the opposite direction,and often we would not see it until we hadrounded the Cape. After enjoying thisexperience for several months, an older, moreexperienced Captain took over command, andimmediately introduced an order saying that allcoastal navigation courses had to be plotted 3miles off the land in the daytime, and 5 miles offat night. Needless to say, this rule made a 4 hourspell on watch far less interesting. After a fewweeks, curiosity and frustration got the betterof me, and I plucked up courage to questionthe Captain about his rule. To question theMaster in those days was unheard of, so I wasemotionally prepared to receive some harshwords in reply. Instead, the Captain quietly said“son, you do not get any extra pay for takingunnecessary risks”, and he turned away. To thisday, I have never forgotten those words.

On our Atlantic crossings, one of the mostfrequently asked questions by passengers is

8

Part 1 – Merchant Vessels

MAIB Safety Digest 1/2006

Commodore Warwick

Commodore Warwick commenced his sea-going career at the age of 15 as a cadet at the pre-sea trainingship HMS Conway in North Wales. After obtaining his Second Mate’s Certificate in 1961, he spent the nextseveral years sailing with various companies to gain experience on different types of ships. In 1970, hejoined the Cunard Line, where he served in many ships before taking his first command, Cunard Princess.

Commodore Warwick first took command of the Queen Elizabeth 2 in July 1990, and in June 1996 wasappointed to the position of Marine Superintendent of the Cunard Line fleet. On 4 July 2002, at the keellaying of Queen Mary 2, he was appointed Master Designate, taking command of the new ship when shewas handed over to Cunard on 22 December 2003.

In 2004, Commodore Warwick received the Shipmaster of the Year award from the Nautical Institute andLloyds List, and was presented with the Silver Riband Award by the Ocean Liner Council of the South StreetSeaport Museum for his lifetime achievement in the maritime industry. In 2005 he was made an Officer ofthe British Empire in the Queen’s Birthday Honours, received an honorary Doctor of Laws degree from theUniversity of Liverpool, and was awarded the Merchant Navy Medal. He is an Honorary Fellow of theInstitute of Transport Administration, a member of the Admiralty Circle of the Maritime Museum of theAtlantic, a Younger Brother of Trinity House, a member of the court of the Honourable Company of MasterMariners, a founder member and Fellow of the Nautical Institute, Governor of the Marine Society, he isPatron of the Cunard Steamship Society, President of the Queen Mary Association and Vice President of theBristol Ship Society. The Commodore holds the rank of Honorary Captain in the British Royal NavalReserve.

MAIB Safety Digest 1/2006 9

about the Titanic. Some Captains I know feelthat it is taboo to discuss the subject, but Ihave always felt to the contrary. The sinking ofthe Titanic was a tragedy, but out of thattragedy came some good. For instance, theInternational Ice Patrol was introduced, andnew and improved safety regulations were putin place. However, we should not rely onaccidents to improve safety, but instead shouldbe pro-active and do everything we can toavoid them. Notwithstanding, accidents

continue to occur, so it is important that wetake advantage of the MAIB cases discussed inthis, and previous editions, of the “SafetyDigest” to remind ourselves and our seafaringcolleagues of the dire consequences of puttingsafety on the back burner.

Narrative

Tragedy ensued after a recently-built, 161mstate-of the-art bulk carrier carrying 23,243tonnes of gravel and stone, hit rocks whichripped a hole in her side. Within seconds, thevessel heeled over and capsized. Many of her30 crew members were trapped inside, and avaliant rescue attempt, involving cutting a holethrough the vessel’s hull, was hampered byfreezing temperatures, darkness and thevessel’s slippery hull. Eighteen seafarers losttheir lives.

A court case, aimed at establishing the cause ofthe accident, reviewed the reliability of seacharts mapping the seabed where the vessel isbelieved to have run aground. However, thereason why this modern, state-of-the-art vessel

capsized so quickly remained unclear.A technical working group was thereforecommissioned to assess the vessel’s stabilityand to help prevent a recurrence of theaccident.

The working group discovered that, when thecargo was loaded into the vessel’s single hold,the cargo was not trimmed (there was not aflat cargo surface) in accordance with currentregulations. Without trimming, the sides of thepiles of cargo took up an angle of repose ofbetween 32° and 38°.

The working group identified the very seriouseffects resulting from the consequent shift ofcargo, and produced the following lessons tohelp prevent a similar accident in the future.

10

Insist On Cargo Trimming – ItCan Save Lives


CASE 1

Photographs courtesy of Smit


CASE 1

The Lessons

1. Had the cargo been trimmed duringloading, the vessel could have sustainedangles of heel of over 30° during hervoyage, before the cargo would havebegun to shift. This would possibly havegiven the crew more time to abandonship safely.

2. It was calculated that, after thegrounding, the ingress of seawater intothe vessel through the hole in her side,would have eventually led to hercapsizing. However, the time taken tocapsize was considerably reduced due tothe shift of cargo as the vessel heeledover.

3. Many types of cargo will shift: inanother accident, untrimmed bulkcement, loaded into a large open hold,resulted in the loss of a vessel, togetherwith all her crew. The vessel had notgrounded, nor had she collided withanother vessel, but she was operating inheavy seas. It is therefore essential thatbulk cargoes are loaded and trimmed inaccordance with the requirements of theIMO BC Code1.

1 IMO 260 C ( c ) Code of Safe Practice for Solid Bulk Cargoes

Introduction

A vessel was making an approach to a pilotstation for the purpose of embarking a pilot toproceed upriver and berth. While embarkingthe pilot, the vessel ran aground. Luckily, theseabed was soft mud and no environmental orphysical damage resulted.

Narrative

The vessel, a 23,000 tonne double hullchemical/oil tanker, was carrying 16,300 tonnesof lower sulphur fuel oil. The vessel arrived atthe estuary early and proceeded to anchor in adesignated deep-water anchorage. The masterwas informed by his agent that the pilot wasbooked for 1315 the following day; the mastermade arrangements accordingly. The time of1315 allowed a 30 minute delay factor, afterwhich berthing would have to be postponed.

Although the master was familiar with theestuary, it had been nearly 10 months since hislast visit. Previously, the vessel had alwaysentered close to high water; this time entrytook place 1 hour before low water. The key

resultant difference was that, on previousoccasions the tidal stream had been setting tothe south-west, whereas on this occasion itwas setting north-easterly.

The distance from the anchorage to the pilotembarkation point was just over 10 miles. Withthe anchor aweigh at 1235, and a maximumspeed of 14 knots, allowing time foracceleration and deceleration the vessel wasnever going to achieve the programmed ETA forthe pilot of 1315. The prevailing force 6 westerlywind, and the north-east tidal stream, wereboth unfavourable. Pressing on at full speed,the vessel’s progress was being monitored bythe local vessel traffic services (VTS). Therewere no other vessels in the vicinity. The entrycourse had been planned as 262 and the initialrequest from VTS was for the pilot ladder to berigged on the starboard side. The prevailingwind was virtually right ahead, and thedesignated pilot embarkation point providedsufficient sea room to port and starboard for avessel to alter course and provide an adequatelee. In this case, however, the combination ofship speed and tidal stream meant that thevessel overshot the designated boarding point,and entered the channel close to a shoal area.

12

Grounding – on a Soft Bottom


CASE 2

With the vessel now 20 minutes behindschedule, the pilot boat became aware of thehigh speed on approach, and called the vesselto slow down and swing to starboard toprovide a lee for boarding. Communicationbetween the pilot launch coxswain and thevessel became confused, and this led tofurther delays. Throughout this process, thevessel was being set to the north of herplanned track and no allowance had beenmade to counteract the tidal stream.

With the OOW now on deck to meet the pilot,the master was unable to effectively monitor

the vessel’s position, and when asked by thepilot to turn to starboard he did so withoutfully appreciating the very close proximity ofthe shoal patch. As soon as the pilot hadboarded, the master swung the vessel back toport, but by the time the helm had been putover, and the vessel started to swing back, itwas already too late – the vessel had grounded.

Lying on a soft mud and shingle bottom, theconsequences were not detrimental to theenvironment, and by using the vessel’s enginesalone, she was successfully refloated 2 hourslater, without sustaining damage.


CASE 2

The Lessons

1. Poor planning considerations caused thedelay in weighing anchor, which in turnrequired a high speed approach to thepilot boarding area. Always allowsufficient time to properly execute thepassage plan. All too often, attention todetail becomes blurred against theperceived need to regain lost time.

2. The bridge team did not appreciate thestrength, direction and effect of the tidalstream. Before starting to weigh anchor,it would have been prudent to conduct ashort briefing between the key membersof the bridge team. This would haveensured that everyone was familiar withall aspects of the passage plan. It wouldalso have given the master anopportunity to study the standard ofchart preparations, and revise the plan ifhe was not content.

3. The vessel’s approach to the pilotembarkation area was being monitoredby VTS. On this occasion, there wasopportunity for VTS to be moreproactive in their monitoring and, ifnecessary, advise the master of his closeproximity to navigational dangers.Notwithstanding the earlier difficultiesin communications, the request by thepilot vessel, for a swing to starboard toprovide a lee, was inappropriate given thedangers close by. This was an excellentopportunity for both VTS and pilot toco-ordinate their individualresponsibilities, each advising the other,and collectively both advising the vesselon the prevailing circumstances anddangers to navigation.

Narrative

A general cargo vessel carrying 210m3 ofpackaged timber cargo on deck encountered avery large wave on her starboard beam. Thewave caused some of the webbing lashings andpackage banding to part and the cargo to shift.The vessel was passing close to the coast instrong south-westerly gale conditions, and itwas winter. Although the conditions were notgood, just prior to the accident the vessel hadbeen making a steady 7.5 knots with onlymoderate pitching and rolling. The generalpoor weather conditions during the voyage

from the loading port had already required thevessel to seek shelter on two occasions. Themaster had also taken the precaution ofstaying within the lee of an island, and huggingthe coastline where possible.

During the early morning, and while still dark,the vessel left the protection of the island andset course in open sea conditions. Four hourslater, the master, who was on watch, noticed avery large wave on the starboard side. Thewave hit the vessel just forward of the bridge.The vessel heeled to port, to an angleestimated at more than 50°, before returning to

14

Timber Deck Cargo Shift Leads toDangerous List in Heavy Weather


CASE 3

about 35°. A brief blackout occurred when theshaft generator stopped for several secondsand the emergency generator started, but themain engine continued to run. The subsequentinvestigation discovered that the vessel’s trackhad taken her just downwind of a shallowpatch, and it is thought that this is where theexceptionally large wave was generated.

The master rang emergency stations beforeattempting to slowly bring the vessel around tohead north and put the weather on the portside. It was estimated that about 40 or 50 ofthe original 300 packs on deck had been lost,and about half of the lashings had failed. Theremaining timber packages had moved to port,but were prevented from falling overboard bystructure, at the ship’s side, which wasdesigned for the carriage of containers, and

which caused the loose timber to jam betweenit and the hatch. Crew members were assignedto cut the remaining lashings in an attempt tojettison the rest of the packages and reducethe list. However, this was mostly unsuccessful.

The master attempted to wash away the loosetimber overhanging the port side, but the listincreased to over 40°. As a result of this, thecoastguard issued a distress message on behalfof the vessel, and an RNLI lifeboat and twohelicopters were tasked to the scene.

The vessel managed to make her way to a safeanchorage, where the deck cargo could beremoved and complete packages eventually re-stowed. Fortunately, no injuries to the crew orserious structural damage to the vesseloccurred.


CASE 3

16 MAIB Safety Digest 1/2006

CASE 3

The Lessons

1. The passage planning for the final leg ofthe voyage did not consider the possibleeffect of the shallower water downwindof which the vessel was to travel. Thecombination of strong south-westerlyconditions, producing beam seas andshallower water, almost certainly causedthe large wave encountered by the vessel.Given the prevailing weather and seaconditions, this was predictable.

2. Webbing or synthetic lashings havebecome more prevalent for securing deckcargoes in recent years, but are notmentioned in the IMO Code of Practice.They are quick and easy to use, they donot rot and are easy to store. They are,however, vulnerable to abrasion and arenot suitable for really heavy-duty work.Regular and close inspection of thewebbing material should be carried out,and worn lashings replaced.Consideration should also be given tousing additional, alternative types oflashing to supplement the webbing

lashings during winter or if heavyweather is predicted.

3. Due to the low value of the timber cargo,plastic wrappings or tarpaulins were notused on this vessel. The use of protectivecoverings would have assisted in reducingthe amount of water absorption in thetimber and consequent reduction instability. It might also have reduced thepossibility of packages being broken ordistorted as a result of wave impact orheavy rolling.

4. The hatch covers were of smooth paintedsteel. This is not an effective non-slipcoating, and when wet it has aparticularly low coefficient of friction.One of the easiest methods to helpprevent movement of a deck cargo, is toensure that hatch tops are painted with ahigh friction coating. This reduces theeffective loading on the lashingarrangement and reduces the possibilityof lashing failure.

Narrative

At 2230, a 20000grt bulk carrier anchored 3nmto the south-west of a pilot embarkation pointin anticipation of entering port the followingafternoon. The master left night orders for themain engines to be at standby, and to startweighing anchor at 1315. During the night, thesecond officer prepared the passage plan tothe pilot embarkation point, which, from theanchorage position, was a single track of 030°.

At 1245, the master arrived on the bridge andsaw that an 8000grt tanker, carrying petroleumproducts, had anchored 8 cables to the north-east, and was lying on the planned track to thepilot embarkation point. Accordingly, themaster decided to leave the anchorage on anortherly course and pass to the west of thetanker. He was aware that the predicted tidalstream was easterly at 3 knots, but consideredthat his intended course would result in hisship passing clear. A course to steer to make

17

Let’s Not Get Carried Away


CASE 4

good a track of 000° was not calculated, andthe master did not observe the actual rate oftidal stream, which was shown on the ship’selectromagnetic speed log.

As the ship weighed anchor, she was headingdirectly into the tidal stream, and the enginewas put to dead slow ahead to take the weightoff the anchor cable. An AB helmsman, and thesecond officer, who was on the engine controls,accompanied the master on the bridge. Theanchor was away at 1325, and 10° of starboardhelm was used to alter course to the north.

The ship steadied on 000º at 1330, and by thattime her speed was 5 knots. The master wasaware of the close proximity of the tanker, but

did not monitor her bearing, either visuallyusing an azimuth gyro repeater, or by radar. At1335, the master realised that the ship wasbeing set down onto the tanker, and increasedspeed to slow ahead. At this point, the secondofficer plotted a fix on the paper chart. At 1336,speed was increased further to half ahead.Seconds later, the engine was put to full ahead,and the helm put hard to port to avoid thetanker. Once the bulk carrier’s bow had passedthe bow of the tanker, the helm was reversedto try and swing the stern clear. This action wasunsuccessful, and at 1337 the starboard quarterof the bulk carrier struck the tanker’s bow.

Both vessels were holed, but fortunately therewas no pollution and nobody was injured.


CASE 4

The Lessons

1. Providing there is sufficient sea room, itis safer, and in the spirit of goodseamanship, to pass astern of a ship atanchor. Passing close ahead of a ship atanchor is potentially perilous, but if it isunavoidable, the effects of the tidalstream, wind and a ship’smanoeuvrability need to be taken intoaccount.

2. Tidal stream is an extremely influentialfactor in navigation, and cannot beignored. The slower a ship’s speed, thegreater its effect will be. When planninga passage, no matter how short, if theeffects of tidal stream are not taken intoaccount by the calculation of courses tosteer in order to make good intended

ground tracks, the value and usefulnessof the passage plan is diminished. Thetime or effort taken to calculate andapply a tidal stream vector during theplanning of a passage, can save a lot ofanxiety during its execution.

3. When navigating in close proximity tonavigational dangers, including otherships, it is important that bridge teamsare effectively managed, to ensure thattasks are prioritised according to thenearest and most immediate dangers. Itis equally important that full use ismade of the equipment available, inorder to obtain as much warning aspossible of potentially dangeroussituations or conditions.

Narrative

A 22000grt general cargo vessel had recentlyarrived in port. Shortly after her arrival, shelanded ashore all her BA sets and oxygen testmeters for service and calibration – retainingnone on board for use in an emergency. Theship’s chief engineer and electrician workedlate into the night on the emergencyswitchboard. The chief engineer left theelectrician to complete the repairs, and wentto his cabin to shower. While in the shower,the chief engineer heard the fire alarm sound,and received a report over the VHF of heavysmoke in the engine room.

The second engineer made his way to theengine control room, which he found in order.The engine room, however, quickly filled withdense smoke. The second engineer wasinstructed to leave the control room and, withheavy smoke now issuing from the engineroom, the master and chief engineerconsidered it unsafe to enter. Further, they hadno BA sets on board to assist in any attempt todo so.

The master decided it would be necessary tooperate the engine room CO2 system toextinguish the fire. The crew were musteredand accounted for. The engine roomventilation was stopped and all machineryspace vents closed. All emergency stops wereoperated, however the main generatorcontinued to run. The CO2 flooding systemwas released into the engine room.

Shortly after the release of the CO2, the shorefire brigade boarded the vessel, having beenalerted by the master through the portauthority. The chief engineer entered theengine room at the upper level, without BA, toguide the fire brigade. He had considered itunnecessary to use any form of respiratory aid,or check the oxygen level in the engine roomprior to entry – in contravention of companyprocedures for entry into enclosed spaceswhich may contain a dangerous atmosphere.

While the engine room remained full ofsmoke, there was no sign of heating up of thebulkheads or any of the surrounding areas.

The fire brigade entered the engine room,with heat sensing equipment, and determinedthat the fire was extinguished. They left thevessel 31⁄2 hours after the initial alarm. About 5hours after the fire brigade had left, havinggiven no guidance as to the time span for safeentry, the chief engineer went into the upperlevels of the engine room to see if it was clearfor entry. Again, he wore no BA, nor did hecheck oxygen levels prior to entry.

Following full ventilation, all engine roomspaces were checked for satisfactory oxygencontent, after a replacement meter had beenobtained from ashore, and after having beenconfirmed as being free of CO2. Main powerwas restored 15 hours after the initial alarm.

Subsequent investigation revealed that therewas no trace of fire, and that the source ofsmoke was, in fact, a short circuit on the electricheater for the lubricating oil purifier, probablyresulting from loose electrical connections.This is thought to have resulted in overheatingand over pressurisation of the oil heater,leading to vaporisation of the lubricating oilthrough the heater relief valve. The hightemperature alarm of the purifier system hadnot operated as the wiring had fused together,possibly as a result of the short circuit.

Examination of the vessel’s CO2 smotheringsystem, after discharge, revealed that 7 out of atotal of 91 bottles had not discharged, and theoperating devices remained in the closedposition. The CO2 system had been serviced byan approved service agent 12 monthspreviously, and the next annual service had, infact, been arranged at the port of incident.Nevertheless, 7 bottles failed to operate.Examination revealed that the bottles inquestion were of an older style than theremainder of the system, and that theoperating devices of some of them were

19

Bring Back the Budgie


CASE 5

severely corroded. All bottles were removedashore, following the incident, for service andre-certification.

Investigation of the “running on” of thegenerator revealed that the fuel supply quickclosing valve had not operated, leaving the fuelsupply open. The quick closing valves were

operated by an air cylinder from outside theengine room. Air supply to the quick closingvalves came from a small tank which had acapacity to operate all valves together. Whentested individually, all valves operated.However, when operated together, minor airleakage on the valve in question prevented itfrom operating.


CASE 5

The Lessons

1. The importance of correct maintenanceand calibration of essential safetyequipment, such as breathing apparatusand oxygen measuring equipment, cannotbe overstressed. However, before landingfor service or repair, it should bepositively ascertained that sufficientequipment is retained on board, orrequested from ashore, to deal with anylikely emergency which may arise whilethe equipment is away from the vesselundergoing service.

2. A vessel’s safety management systemshould include procedures for entry intohazardous spaces. Crews should bedrilled, at regular intervals, to enhancetheir awareness of such procedures,which should include entry into spaceswhich may have a depleted oxygencontent (eg following the discharge ofCO2 “smothering” into machinery, orassociated spaces).

3. CO2 fire smothering systems areessential for the ultimate safety of avessel. Despite the annual service andcertification of such systems, plannedmaintenance schedules should includethe routine examination of all associated

equipment at regular intervals. In theevent of any doubt as to the systems’operational condition, advice should besought from the maker’s service agent,without delay, to ensure that the systemremains in good operating conditionbetween service intervals.

4. During an emergency situation, crewsmust be confident that remote fuelisolation and remote stops will operateeffectively; it may not be possible toenter a space to operate these locally.Routine testing of such essentialequipment should replicate, as near aspossible, the likely scenarios which mayarise. In this case, routine testing of thefuel quick closing valves, individually,revealed no cause for concern. However,when operated in unison, minor airleakages resulted in insufficient airpressure to operate all the valves.

5. To ensure security, switchboard andterminal box electrical connectionsshould be examined periodically under aplanned maintenance routine. Suchchecks may be enhanced by the use ofthermal imaging cameras.

Narrative

A feeder container vessel was dischargingcargo at one of her regular UK ports, using theshore cranes. On deck, an unsupervised ABwas using a long pole to unlock the twist locks,and the discharge of the deck load was nearingcompletion. The last stack of containers to bedischarged comprised 6 metre units loaded 2high, spanning the well between the aft end ofthe hatch and the forward edge of theaccommodation. Cell guides were fixed to thefront of the accommodation, and strengthenedpads supported the after corners of thecontainers. On the centreline, a ladder wasalso fixed to the front of the accommodationto provide access to the top of the containers,and serve as an escape route from theaccommodation.

The vessel was moored starboard side to, andthe discharge of this final stack started fromthe port side. It was not possible to fit twistlocks on the aft corners of these containers

because they rested in the cell guides on theaccommodation front. Once the uppercontainer had been discharged, the twistlocks had to be removed from the lowercontainer before the crane could lift it. TheAB was standing by to do this and wasstanding at the bottom of the ladder at thefront of the accommodation. He waspreparing to use the ladder to gain access tothe top of the lower container to remove thetwist locks.

The final inboard containers on the port sidewere being discharged when one of the twistlocks at the forward end failed to release. Thecombined weight of the two containers wasnot enough to set off the crane overloadalarm; the crane continued to lift. This partiallylifted the lower container by its forward end,and pitched the after end into the well. Thetop after edge of the container struck the AB,crushing him between the container and theladder. The paramedics were called, but the ABwas pronounced dead at the scene.

21

Wrong Place – Wrong Time


CASE 6


CASE 6

The Lessons

1. This is a hazardous operation,particularly in the feeder trade, wherelean manning does not allow constantsupervision. It is essential that people areroutinely briefed on safety issues.

2. The company safety posters state that,when removing twist locks, crew shouldstand at least one container away fromthe one being worked. This tragicaccident clearly demonstrates why.

3. There were no written instructionsavailable for cargo work. Instructionrelied on briefing and on-the-jobtraining. The AB had been working onthis ship for 6 years, and his workpattern was well established. It ispossible that his perception of the riskhad reduced, and that this unsafeshortcut had become his normal routine.

x

Containerposition

AB stood here

Narrative

Engineering ratings of a foreign flagged ferrywere preparing to move an air conditioningcompressor from the auxiliary engine room tothe engineer’s workshop, for maintenancepurposes. The weather was moderate andthere was a 1m swell running.

The compressor/bedplate fastenings wereremoved and preparations made to lift the1.1 tonne compressor from the bedplate.A single fabric strop was passed through2 eyebolts on the compressor, and connectedto a chain block with a Safe Working Load(SWL) of 2 tonnes. The strop had a recordedSWL of 1 tonne force. The strop was tested inDecember 2003, well inside the statutory5 year testing requirement.

As the compressor was being lifted, the fabricstrop parted (Figure 1), and the compressor

fell against the compressor oil filter, fracturingthe inlet and outlet pipes (Figure 2). Thecompressor then fell to the floor plates andbounced onto a nearby rating. The ratingsuffered an open fracture of the leg, and hadto be evacuated by helicopter to a nearby UKhospital.

Those involved in slinging the compressor didnot seek advice from a competent person. Hadthey done so, it would have been clear that theSWL of the single strop was less than theweight of the compressor, and that it wasincapable of taking the load. In addition, thestrop was being chaffed by sharp edges on thecompressor, making failure of the strop almostinevitable.

The rating involved in this case, suffered only afracture. The accident would have been farmore serious if he had been under thecompressor at the point of failure.

23

Lifting Equipment – Exceedingthe Safe Working Load = Danger


CASE 7

Figure 1: Parted fabric strop


CASE 7

The Lessons

With luck on his side, the engineering ratingescaped serious injury. The failure of thestrop could so easily have resulted in afatality. Safe Working Loads are recorded onall items of lifting equipment, and it is clearthat these must be greater than the loadsbeing lifted.

Statutory Instrument 1988 No 1639 statesthat “no person shall operate any liftingplant unless he is trained and competent todo so and has been authorised by aresponsible ship’s officer”.

The Code of Safe Working Practices forMerchant Seamen – Chapter 21 alsoprovides advice regarding lifting plant. Thisadvice includes:

1. Lifting equipment should always be indate for survey or test before it is used.

2. The line of lift should be directly underthe lifting equipment, whenever possible,in order to reduce stresses.

3. No attempt should be made to lift loadsin excess of the certified lifting plantSafe Working Load.

4. A competent person should supervise thelift.

Figure 2: Damage to the inlet and outlet pipes

A deckhand suffered multiple fractures to hisarm during a routine un-mooring operationwhile connecting a tug’s towing wire.

Narrative

The tug’s tow rope messenger was led througha Panama lead, around the bits at a 100˚ angleand on to the winch end whipping drum. Thedrum end seaman was standing with his backto the working part of the rope and thesupervisor, as he hauled on the rope.

Unfortunately the tug was not paying out slackat a controlled speed and, feeling the strain ofthe jerking motion, the drum end seamanattempted to apply more turns to thewhipping drum. During this process, themessenger rope snapped back, and thewhiplash of the working part connected with,and broke, the drum end seaman’s arm.

The supervisor, who was standing in theprecarious position of the bight of the rope,escaped injury. Had the rope come clear of thebits, the outcome for him could have beenextremely serious.

25

Face The Danger


CASE 8

Tug

Ste

rn

Bits

Key1 - supervisor2 - casualty3 - AB 4 - AB5 - winch controller

Pan

ama

lead

(not to scale)

1

2

3

4

5

Por

t

Winch

Drum end


CASE 8

The Lessons

1. Stand facing the danger: always put thewinch between the operative and thepotential danger zone. This, in itself,creates a safety barrier, allows full visualcontact with the mooring team andsurroundings, allows controlled surgingon the drum end and keeps the operativeclear of the working part.

2. Be aware of the dangers of sharp nips –these cause excess strain on machinery,fittings and ropes – and use fair leadswherever possible.

3. During our first day at sea, most of uswere made aware of the dangers ofstanding in bights of rope; a brief lapse ofattention to this ordinary practice can soeasily cause grief.

4. Watch out for shipmates and their workpractices. Ships operate on efficientteam-working, part of which involveslooking out for our shipmates andrecognising potential dangers to them. Itis so much easier to stop bad habits thanto patch up broken bodies.

Position of casualty

Position of supervisor

Messenger rope arrangement

Narrative

A 2500grt dry cargo ship sailed from port at1710 carrying a cargo of grain. A harbour pilotaccompanied the master on the bridge untildisembarking around 1845. It was dark, andvisibility was moderate, but occasionallydecreased to poor in snow showers. At about1900, when the ship was still transiting a narrowbuoyed channel (Figure), the master changedto auto from manual steering, shut down one ofthe two steering motors that were running, andincreased speed from 6 knots to 10.5 knots. Atabout this time, the master was joined on thebridge by an AB to act as a lookout.

When the ship exited the buoyed channel at1915, the master adjusted the course on theautopilot from 112° to 065°, to close awaypoint marked on the paper chart. Thiswaypoint was part of a passage plan used when

leaving an adjacent port. A passage plan for thedeparture for the port had been compiled anddrawn on the charts in use up to the end ofthe buoyed channel, but not thereafter. Themaster then switched one of the two radardisplays fitted to standby before leaving thebridge to go to the deck below.

The master was absent from the bridge forabout 2 minutes. On his return, he plotted a fixon the chart at 1930 using a radar range andbearing of a nearby fairway buoy. Course wasadjusted to 053°. Several minutes later, anotherfairway buoy fitted with a Racon was detectedat a range of 6nm fine on his starboard bow. Asthe master intended to leave this buoy to port,the course set on the autopilot was adjusted to057° to put the buoy fine on the port bow. Onthis course, the ship was still within 7 cables ofadjacent hidden dangers, which had not beenhighlighted on the paper chart.

27

A Turn for the Worse


CASE 9

Planned track

Position ofgrounding

vvv1.2

vvv

1.0

1930

0.6

vvv

Estimated actual track

Red buoy

Greenbuoy

Autopilot engaged Steering motor shut down Speed increased

Sandbank

Sandbank

Sandb

ank

Shortly after, the master noticed that the ship’sheading was drifting to port. He saw that theheading by gyro was now 040°. A largealteration to starboard was applied using theautopilot, but the ship kept turning. Breakingwaves were then seen directly ahead. Themaster put the engine to stop, started thesecond steering motor, changed to handsteering, and applied maximum starboardhelm. He then put the engine to full astern,

but the vessel was felt to ground momentslater on a gyro heading of 330°. The shipsuffered substantial damage to her rudder.

It is not certain if the autopilot failed. It wasfitted with an off course alarm, but this did notactivate. Subsequent investigation revealedseveral defects with the equipment, but nonewere related to the activation of the off coursealarm.


CASE 9

The Lessons

1. An OOW is responsible for the safety ofhis ship. If he is not on the bridge, fromwhere he can monitor navigation andcommunications, and react to, andcontrol on board emergencies, he cannotfulfil this vital duty. Leaving the bridge,albeit briefly, is not only a violation ofregulation, but it also endangers a shipand her crew. On the occasions when anOOW finds it absolutely necessary toleave the bridge, it is in everyone’sinterest that he arranges a relief beforedoing so.

2. When in restricted waters with a pilotembarked, it is normal practice to havesufficient machinery and equipment,such as steering motors and radars,operating to provide optimummanoeuvrability and redundancy in theevent of a breakdown. When inrestricted waters without a pilot, theneed for manoeuvrability andredundancy remains unaltered. It is theproximity to dangers and environmentalconditions which should determine aship’s equipment readiness, not thepresence of a pilot.

3. A passage plan is a navigational riskassessment and, as such, is crucial to thesafety of a ship during a voyage. If it isincomplete, or more than one plan is in

use, a lack of appreciation of thenavigational dangers, and uncertainty,will inevitably result. Comprehensiveand considered planning takes time, butit pays dividends.

4. Navigational buoys provide a goodindication of a ship’s position, and theiruse in this respect requires little effort.However, sole dependency on them isfraught with danger. The benefit ofcross-checking positions usingalternative methods has long beenrecognised, and with the availability ofGPS this is simple to achieve. GPS alsofrequently has the benefit of cross-trackerror indication and alarm which, if usedeffectively, can provide early warning ofa ship deviating from the intended track.

5. The use of autopilots is widespread, andis indeed essential on ships with limitedcrew. But they are fallible, and dooccasionally malfunction. In open water,such a malfunction is likely to bedetected and dealt with without anyadverse consequences. However, when inclose proximity to navigational dangers,or other shipping, the time available toreact is far more limited and the potentialoutcome is therefore more serious.Manual steering is the safer option inmany situations.

Narrative

A 58-metre coastal cargo vessel (Figure 1) wassteaming south in the early hours of a Februarymorning. The mate was on watch as the shipapproached the area off the mouth of the riverHumber and there was no lookout on thebridge. It was dark, but the first signs of daylightwere starting to appear. Visibility was good andthe wind was from the north-west force 7.

The mate had been working excessive hours,sharing a 6 hours on/6 hours off bridge watchwith the master. The master had been onboard the vessel for about a week, working as arelief for the regular master who was on leave.He undertook only bridge watches, leaving allthe cargo work to the mate. The senior seamanhad served on the vessel for about 18 monthsand had taken no leave of absence during thattime. The junior seaman had only been at sea afew days. A cook was also on board.

The mate was not fully supported by themaster. The senior seaman was probably not athis best after such a long period of duty, andthe junior seaman was of limited value as hewas very inexperienced. The mate tried tokeep the ship running in these difficultcircumstances, but as a result he was very tiredon the morning of the incident.

The mate looked out for vessels ahead whenabout an hour’s steaming from the Humberdeep water anchorage. Using his radar and avisual lookout, he ascertained four ships to bethere; all were at anchor. His intended trackpassed through the anchorage between thevessels.

About 30 minutes before the incident, a largeoil bulk ore (OBO) vessel (Figure 2) raised heranchor and began to move in preparation forpicking up a pilot. The vessel’s movement wasdisguised by two other vessels, which had theirdeck lights on.

About 15 minutes before the incident, themate left the bridge unattended, and wentbelow to call the master for his watch. Hereturned to the bridge a couple of minuteslater, but it took another minute for his nightvision to return. When the mate looked outagain, he thought that the situation aheadmight be changing. As the two vessels closed,the mate should have given way, but hecouldn’t understand what was happeningahead. He could not clearly discern the OBO’ssteaming lights against the backdrop of thebright deck lights of the other two vesselsbehind. His radar would have given him abetter understanding of the situation, but hedidn’t pay sufficient attention to it.

29

Fatigue Nearly Leads to Disaster


CASE 10

Figure 1

The OBO started to take avoiding action whenthe other vessel did not appear to be givingway. However, the mate on the small coastalvessel slowed down to give himself more time

to try to perceive what was ahead. He couldstill not understand what was happening, evenwhen the vessels were only metres apart.A collision was very narrowly avoided.


CASE 10

The Lessons

1. The mate’s inability to adequatelyinterpret the situation is consistent withfatigue. Fatigue is an insidious problem,and it can make the sufferer indecisive. Itis very important that crew members areable to recognise the symptoms of fatigue,and that they take positive action toaddress it. Don’t be afraid to say that youare tired!

2. This vessel met the requirements of theregulations, even so, a crew of five isconsidered to be barely sufficient. With abare minimum crew it is very importantthat all of them are fully qualified andthat they have frequent periods of leave.In addition, all crew members need to dotheir fair share of the work; this waspatently not the case here.

3. Shipping companies should havecontingencies for dealing with fatigue,such as the option to spend time at alayover berth until the crew is properlyrested. Such a facility should be usedwhen necessary.

4. The regulations require a lookout to beposted during the hours of darkness. Inthis case a lookout would have also beenrequired in daylight, due to the proximityof navigational hazards. A bridge shouldnever be left unattended, let alone whenapproaching an anchorage. Had one beenpresent, the lookout could have calledthe master. The lookout would also havebeen able to assist with the navigationalwatch, and should have been able to alertthe mate to the fact that he wasbecoming seriously debilitated by fatigue.

5. This vessel was using a well-establishedpassage plan. Such passage plans shouldbe reviewed periodically to see if they arestill safe. The area off the river Humberhas got very much busier in recent years.This passage plan should have beenchanged to pass outside the Humber deepwater anchorage.

Figure 2

Narrative

A chief engineer was conducting routinemonthly checks on the engine room fixed CO2

fire-fighting system. Although the maintenanceinstructions were a little unclear, he felt heknew enough about the system to do the job.He first checked the control box alarms, andthen closed two system isolating valves,although it is not known which ones heoperated.

Assuming the system to be safe, the chiefengineer opened the pilot CO2 bottle pressuregauge isolating valve, to confirm the bottlepressure was satisfactory. As he did this, he was

surprised to hear gas escaping in the adjacentCO2 bottle storage room. He went to thecompartment and saw gas escaping from oneof the gas bottle neck seals (Figure 1). He alsonoticed, from a gauge, that the system hadbecome pressurised.

Believing he might have made a mistake in theprocedure, he returned to the control boxcompartment. There, he found the CO2 pilotbottle isolating valve – which controlled thegas supply to the main bottle activators –partially open. It appears that the chiefengineer’s coat sleeve might haveinadvertently become caught on the isolatingvalve, causing the system to activate.

31

When Safety Maintenance =Hazardous Incident


CASE 11

Figure 1 CO2 storage bottle neck seal


CASE 11

The Lessons

CO2 extinguishes fires by reducing theoxygen content in the protectedcompartment. It is extremely dangerous to bein a compartment into which gas is beingdischarged; several fatalities have occurredwhere this has happened. Fortunately, in thiscase, the main system isolating valve wasclosed, and this prevented gas discharginginto the engine room. Had it been open, andhad someone been in the space, the outcomecould have been very different.

1. Maintenance instructions and valveidentification should be clear andunambiguous in order to provide a safesystem of work.

2. Those involved in maintenance andoperation should be familiar with thesystems and equipment, and shouldalways refer to authorised documentationto ensure they are clear on procedures.

3. In the case of a CO2 gas discharge,planned or otherwise, the compartmentmust be thoroughly ventilated, and theatmosphere oxygen concentration provenbefore personnel are allowed to enterwithout the support of breathingapparatus.

Narrative

A large multi-role vessel was alongside a lay-byberth toward the end of an annual refit. As partof the refit work, the eight, davit-launched,fully enclosed lifeboats had been overhauledashore (Figure 1) and refitted on board. Thework on the lifeboats included overhauling theon load release gear, including load testing in atest rig.

An experienced Flag Administration surveyorhad requested that the vessel lifeboat crewcarry out two lifeboat operations, includingreleasing the on load gear with the lifeboatsuspended just above the water to simulatefailure of the hydrostatic release mechanism.

On the day of the incident, the surveyor wasinvolved in a fatal accident investigation onboard another vessel, and had to delay theplanned lifeboat operations.

When the surveyor eventually arrived, thelifeboat crew mustered and carried out a safetybriefing. During this time, the surveyor wasdistracted by mobile telephone calls about thefatal accident investigation. As a result, he wasunaware that the crew had not carried out apractical drill to demonstrate the use of the onload release gear, and he did not tell them thathe was to act only as an observer, and wouldplay no part in the command and control ofthe operation.

The five lifeboat crew, the second officer andthe surveyor embarked the lifeboat andharnessed themselves in. The water was calm.The engine was started, and lowering beganimmediately. After two brake tests weresuccessfully carried out, the surveyor wasasked if the height above the water wassuitable for operating the on load gear.Although unwilling to take charge of theexercise, the surveyor looked out of the side

33

From What Height Can a Lifeboatbe Safely Released?


CASE 12

Figure 1

hatch briefly and told the crew to lower itfurther. This was done, and the surveyor’sadvice was requested again. The surveyorremained unwilling to be directly involved inthe conduct of the drill.

Several times, the crew attempted to operatethe on load release gear before the operationof the interlock lever and main release handle

was co-ordinated and the lifeboat was releasedfrom its falls (Figure 2).

The lifeboat plummeted about 1.2m on to thecalm water, injuring several crew members.

The lifeboat suffered several fractures to itsinternal structure.


CASE 12

Figure 2

Coxswain seal Main release handle Interlock lever


CASE 12

The Lessons

1. How many readers would considerraising an objection to releasing a lifeboatfrom its falls when it is only 1.2m(4 feet) above calm water? It doesn’tsound very high, does it, yet expertadvice indicates that the impact forcesfrom such a drop could be as much as20g (gravity). Forces of this magnitudeare capable of causing spinal injurieseven to someone sitting in the correct,upright position. If it is felt necessary totest the operation of the on load gear, theguidelines provided by the IMO shouldbe followed:

Position the lifeboat partially into thewater such that the mass of the boat issubstantially supported by the falls,and the hydrostatic interlock system,where fitted, is not triggered;

Additionally, it is also advisable to keepthe number of crew members on boardthe lifeboat to a minimum during thetest.

2. What is evident about this accident isthat no-one was in overall control of thelifeboat. Communications had been poor.The surveyor was attending purely as anobserver, but because the crew had notcarried out the operation before, theyexpected him to provide guidance. Thelifeboat crew did not clearly understandthe surveyor’s role, and the surveyor, byaccepting the initial request for guidanceon the height of the lifeboat release,reinforced the misconception. Whetheror not a Flag State surveyor is present ata lifeboat drill, it is the ship’s staff, or theshipyard’s staff, who remain in charge of,and responsible for, the operation.

3. Communications broke down on anumber of levels and played a part in thisaccident:

• The surveyor failed to find out if thecrew had carried out the operationbefore, or whether they had anadequate, risk assessed procedure forit;

• The vessel’s officers failed to informthe surveyor that the crew had noexperience and no procedure for theoperation;

• The surveyor allowed himself tobecome distracted during the safetybriefing, and missed an opportunity toclarify his role and make himselfaware of the crew’s plannedprocedure;

• Although some of the crew were alittle anxious before the lifeboat wasreleased, no one raised their concernsor stopped the operation.

Everyone involved in operations like thisshould be encouraged to voice any safetyconcerns that they may have.

4. Lifeboats and their launching systems aredangerous items of equipment, and mustbe maintained and operated by suitablyqualified and experienced crew members.

5. In 2001, concerned about the highnumber of lifeboat accidents that hadoccurred, the MAIB published a safetystudy entitled, ‘Review of Lifeboat andLaunching Systems’ Accidents’. Thestudy can be found atwww.maib.gov.uk/publications.

Lessons can be learned from every accident,and most of us can relate to at least some ofthe problems that have occurred in thefollowing pages. In spite of all theimprovements in vessel safety, fishing stillremains the most dangerous industry of all,and within that industry, my own sector,potting, is probably the most dangerous.

Most of the dangers, though, can be alleviatedwith common sense and good risk assessment.How often have we heard of boats capsizingbecause they have been modified, so thatmore pots can be carried, but without thenecessary stability checks being done? Changethe centre of gravity and the boat may wellbecome unstable. How often have we read (orhad the frightening experience ourselves) of a

crew member going over the side with a ropearound his leg? Good working practices canhelp to avoid this; and how often have boatsbeen pulled under because the gear has beensnagged and the winchman has kept onhauling?

Most of these sorts of accidents can be avoidedwith good risk assessment and good training.

Yet there are accidents occurring in spite ofeveryone’s best efforts to reduce them. Asfishermen, we see more and more regulations(not just fishing regulations) being heapedupon an already struggling industry. All thesedifferent regulations and controls have forcedskippers to cut back on both maintenance andcrew, and often to put to sea in conditions inwhich they would not normally do so. Therecan be no doubt that some of these extrapressures have contributed to some of theaccidents. The Authorities need to be verycareful about making fishing more and morecostly and less and less profitable.

A typical result of increased regulations hasbeen the move of more fishermen to singlehanded working – particularly the smallerinshore potter. The increased safety risks havenot been fully appreciated, and are not beingaddressed in the safety courses we all have todo. How, for example, do you get back onboard if you have the misfortune to gooverboard? Should a personal safety device becarried and a Confidential PositioningReporting System be installed? Is there asuitable hard wearing lifejacket (buckle andtoggle free) available for constant wear? Whatextra safety equipment for watchkeeping,water ingress etc is required? Is there such athing as a “dead man’s cut out”? etc.

36

Part 2 – Fishing Vessels


There is so much that we as skippers/owners(no matter what the size of boat) can dowithout having yet more regulations forcedupon us. Let us have education, not regulationand use the MCA Pre-Sailing Checklist everytime we put to sea, along with a check of alllikely water ingress points like sea cocks andstern glands.

No matter how careful we are, though,accidents do happen, but it is up to all of us todo our very best to lessen the possibilities andto be in a position to counter them should webe unfortunate enough to be involved.

We are never too old or too experienced tolearn, and the following reports offer us all asalutary lesson in sea safety. Don’t becomeanother statistic!

After 11 years in the Army, reaching the rank of captain in the Brigade of Gurkhas, Chris returned to hishome village of Torcross in South Devon where he was brought up among the crab fishing communities ofStart Bay. He achieved his boyhood ambition in 1978 when he bought his first commercial crabber, and stillruns a small 32ft inshore crabber and operates a 15ft bass beach boat. He has been the Hon Sec of theSouth Devon and Channel Shellfishermen since 1989, is Chairman of Devon Sea Fisheries Committee,Chairman of the Crustacea Committee of SAGB and a board member of the Sea Fish Industry Authority.

MAIB Safety Digest 1/2006 37

Narrative

An under 10m fishing vessel left her home portearly in the morning to fish the prawn groundsoff the north-east coast. The weather waspleasant with a light westerly breeze and aslight swell. The vessel had been fishingsuccessfully and the skipper and his brother, asthe only crew, looked forward to another goodday’s catch.

During the morning, the weather worsened.A westerly force 6-7 developed and the seabecame very confused. Unworried, thebrothers hauled in their catch and begansteaming back to port. Just before midday, theskipper spoke to his wife by mobile telephoneto tell her he was making his way home. Soonafterwards, the trawler was sighted, for the lasttime, by another local fishing vessel.

Late afternoon, the families of the two men,and local fishermen, became concerned thatthere was no sign of the vessel. The coastguardwas informed and an air and sea searchconducted, assisted by 15 local fishing vessels.Unfortunately there was no sign of the trawler,or of her crew.

Subsequent events included a search for thewreck. The wreck was located, and anunderwater survey was carried out, duringwhich the liferaft was found on the seabed anddamage to the radar dome noted. The trawlerwas salvaged (Figure 1) to enable a moredetailed structural survey, metallurgicalexamination of the hull plating and stabilitytests to be conducted. Neither of the brothers’bodies was found on board.

38

Poor Stability and Hull DefectsLead to Fatal Accident


CASE 13

Figure 1: Salvage

The investigation found the vessel to be in apoor structural condition. There were splitsand holes to her upper deck, hull shell platingand steering gear compartment forwardwatertight bulkhead (Figures 2, 3 and 4). Inaddition, the rudder stock gland was leaking,the engine room high level bilge alarm floatswitch had been disconnected, and one of herbilge pumps was not operational. It was alsofound that the vessel’s inherent stability wasmarginal, making her unsuitable for offshorefishing; this was a major factor in her loss.

Understandably, the skipper/owner purchasedthe vessel believing it to be suitable to copewith the rigours of offshore fishing. Proud of

his vessel, he sought to improve her by addinga winch and deck shelter. Unfortunately, indoing so, this additional top weight decreasedthe vessel’s stability.

All the evidence indicates that the trawlerbegan to take water in her steeringcompartment and her engine room, furtherreducing her limited stability. The floodingwent undetected until the latter stages, whenit is believed an attempt was made to pumpout the bilges. During the process, the vesselwas swamped by seas, downflooding occurredthrough the open steering gear compartmenthatch and she sank rapidly by the stern. Therewas no time to transmit a “Mayday”.


CASE 13

Figure 3: Vee split in hull

Figure 2: A frame supporting frame to deck split


CASE 13

The Lessons

1. The purchase of a fishing vessel is amajor undertaking, and sometimes aclean and shiny appearance can cloudgood judgment. Skippers/owners areurged to seek expert advice whenconsidering purchasing a vessel, toensure that it is fit for the purposeintended. This advice also extends tochanges to structure, to ensure thatstability, and therefore safety, is notcompromised.

2. Structural maintenance is an essentialelement in ensuring a vessel’s watertightintegrity. Although expensive, it is ofcomparatively little cost for a potentiallygreat return: preventing the possible lossof a vessel. Hull repairs should be giventhe highest priority if downflooding andinternal flooding is to be prevented.

3. Bilge level automatic alarms, operationalbilge pumps and effective discharge non-return valves are part of the skipper’sarmoury to deal with flooding. It isessential that they are kept in goodworking order. Unfortunately, far toomany vessels are lost because high-levelbilge warning alarms and pumpingsystems are defective.

4. This vessel carried a liferaft, despite notbeing required by regulations to do so.Sadly, in this case, it failed to fullydeploy, probably because it becametrapped under the radar dome, causingthe casing to flood and thus it lostpositive buoyancy. Skippers are stronglyadvised to check stowage positions ofliferafts to ensure that they are free fromoverhead obstructions such as radardomes, fishing gear and mast stays.Further comprehensive advice isprovided in MGN 267(F).

Figure 4: Steering compartment forward bulkhead hole

Narrative

The skipper and crewman of a fairly new,under 10 metre trawler completed haulingtheir afternoon tow and were making ready toshoot away again. The weather conditionswere good with a slight swell running.

The skipper went into the wheelhouse tomanoeuvre the boat for shooting, and spottedwater washing about down below in theaccommodation area. Dashing below, he foundwater overflowing from the toilet and wellingup from drainage holes in the toilet floor. Heopened the engine room door and foundwater almost covering the engine. The skipperimmediately notified his crewman of thesituation and sent out a distress call. Onre-entering the engine room, the skipperattempted to shut off the sea inlets but,unfortunately, by that time they were toodeeply submerged.

The men donned their lifejackets and madepreparations to abandon the vessel. Anothertrawler fishing nearby came immediately to

their rescue and, after attaching a towline, tookboth men on board. Both were unharmed. Therescuing vessel set off towards the beach,which was fairly close, with the sinking vesselunder tow. She was successfully beached inshallow water just as she finally foundered.

At low tide, the skipper rowed out in a dinghyand went aboard the boat with a salvagepump. As much water as possible was removedfrom her engine room, and a search wascarried out for the cause of ingress. Sea watercould be seen welling up through the hull atone point and, upon investigation, the skipperpulled on a sea inlet pipe to find that thesanitary supply line was adrift from the hull ata point below the shut off valve. The skipperprobed in the water with a broom handle andcould see that at times he was reducing thesurge. He shaped the end of the handle into aplug and, after locating the ingress point,drove the broom handle into the sheared inlethole, thus preventing further ingress. Thevessel was then pumped dry, and at high tideshe was refloated and towed to port forinspection and repair.

41

The One That Got Away!


CASE 14

Sheared fitting after accident

The vessel sustained no damage to her hullwhen she beached, but she did suffer seriouswater damage to machinery and electrics.Subsequent inspection showed variouscontributory factors to the flooding: thesheared sea inlet was threaded into a pad onthe boat’s side; the inlet fitting was unduly

long and set at a convenient height forstanding on; the vessel did not have non-return valves in her overboard discharges; nobilge alarm was fitted; holes were bored in thewatertight toilet deck into the engine room toassist drainage when cleaning.


CASE 14

Similar sea water inlet before accident

The Lessons

1. The vessel had no bilge alarm fitted.Decked vessels should be fitted witheffective bilge alarms to give earliestpossible warning of water ingress.Owners may also wish to consider thebenefits of an extension klaxon and/or astrobe light to give warning when thewheelhouse is unattended.

2. Frequently, overboard discharge lines arefitted with non-return valves to reducethe risk of backflooding. Had this beenthe case in this instance, the speed offlooding would have been greatlyreduced.

3. The skipper’s action in plugging thewater entry point with a simple broomhandle shows the effectiveness andbenefit of carrying a selection ofdifferent size plugs to drive into holes or

sheared pipework. Had he received earlywarning, by a bilge alarm, the hole mighthave been plugged even earlier andprevented the distress situation.

4. Fittings are greatly weakened bythreading; sea inlets of the stub pipe andflange type have been found to besuperior. They are best positioned wherethey are not convenient to be stood on,and the supporting of associatedpipework reduces leverage and vibration.

5. Many vessels have foundered due towater being able to flow betweencompartments. During this incident,watertight integrity was compromised bysomeone boring drain holes in the floor,again speeding up the flooding process aswater flowed back up through theseholes.

Narrative

In darkness, while on passage from one port toanother, the deck lights of a potting fishingvessel suddenly lit up. Taken by surprise, theskipper/owner turned the wheelhouse switchto the off position, but the lights remained on.He then tried, unsuccessfully, to switch on thegalley lights.

Because the fuse boxes were in the forwardauxiliary generator hold, the skipper went outon deck and opened the access hatch to thespace. He was met by thick black acrid smoke.He quickly closed the hatch and returned tothe wheelhouse, where he alerted thecoastguard that he had a fire on board.

The skipper switched on the cabin lights andcalled the two deckhands, who were sleeping.But the lights would not illuminate. He thenreturned to the forward hatch and, on openingit, saw flames in the hold.

He went back to the wheelhouse and tried tocall the coastguard again, but found that theVHF radio would not transmit or receive. Helooked in the compartment under thewheelhouse deck where the emergencybatteries were fitted, and saw smokeemanating from it. He then tried to use thehand-held VHF set, but the battery was flat.

One of the deckhands went to the forwardhatch and touched it with the back of hishand. It was hot. He took the continuouslyrunning deck wash hose and cooled the hatchwith seawater. Once it was sufficiently cool, hewas able to open the hatch and direct thewater into the hold. But this had little effect, sohe closed the hatch and sealed it to restrict thesupply of oxygen to the fire.

In the meantime, following the initial call fromthe fishing vessel, the coastguard had alertedother vessels in the vicinity of the casualty. Thenearest, which was 4 miles away, was a large

43

A Fire Detection System Can HelpSave Your Vessel


CASE 15

ferry, which then diverted from her passagetowards the reported position of the casualty.

Using searchlights, the ferry found the fishingvessel, created a lee for the casualty andilluminated the scene. Soon after arriving onscene, the ferry’s staff could see flames on thefishing vessel’s deck. The RNLI lifeboat soon

arrived on scene, took the three crewmembers off the fishing vessel and returned toher station.

The fishing vessel remained afloat and on fireuntil later that afternoon, at which time thefuel tanks exploded and the vessel foundered.


CASE 15


CASE 15

The Lessons

1. The fishing vessel was not fitted with afire detection system in either herforward auxiliary generator hold or herengine room. Had one been fitted, thiswould have alerted the crew at a muchearlier stage and would have given thema chance to fight the fire before it hadtime to take hold.

2. The electrical fault, which was probablythe cause of the fire, also affected thecharging of the emergency batteries and,

in turn, the power to the radio sets.Therefore, it is essential to ensure thatbackup hand-held VHF sets are fullycharged at all times.

3. The crew member who attempted toextinguish the fire used correct fire-fighting techniques, such as touching hotspots with the back of his hand andsealing a space which is on fire to starveit of oxygen. He clearly demonstrated thevalue of having attended a fire-fightingcourse.

Narrative

On completion of a 2-week refit, a fishingvessel sailed for the fishing grounds. Duringthe departure, the skipper realised that thebuoys and navigational tracks had beenremoved from the chart plotter, which hadrecently been upgraded. These werere-installed as the passage progressed. Thenavigational watch was then handed over to adeckhand, and the skipper went to the engineroom to conduct several routine checks beforegoing to bed.

Forty five minutes later, during the early hoursof the morning, the fishing vessel collided withthe port quarter of an 86,000grt ore carrier,which was anchored in a designated area.

The skipper was woken by the boatmanoeuvring. He went to the wheelhousefrom where he saw the ore carrier directlyastern. The deckhand on watch admitted thathe had ‘nodded off ’ but stated that there hadbeen no collision. As the deckhand was

obviously tired, the skipper woke anotherdeckhand to take the watch. The skipper thenreturned to bed. The vessel was fitted with awatch alarm, but this had been disabled duringthe refit.

The ore carrier reported the collision to thelocal port authority, which relayed theinformation to the coastguard. The coastguardthen contacted the fishing vessel via VHF radioto check that she was OK. The deckhand onwatch confirmed this to be the case. Theprevious watchkeeper had admitted to himthat he had ‘bumped the boat’, but did notamplify further.

When the crew mustered for work about3 hours after the collision, the skipper wasinformed of the call made by the coastguard.He immediately turned on the deck workinglights and saw that a davit arm was damaged.As this meant the vessel was unable to fish, theskipper decided to return to harbour.Fortunately, the damage to neither vessel wasserious (Figures).

46

Didn’t Feel a Thing


CASE 16

Damage to fishing vessel


CASE 16

The Lessons

1. After extended periods alongside, it isprudent to make sure that all systems areworking correctly before sailing. This issometimes easier said than done,particularly during the latter stages of arefit or maintenance period, when thereis a rush to complete work outstanding,and masters and skippers are frequentlyunder pressure to sail as soon as possible.However, the time and effort invested intesting equipment alongside can saveserious embarrassment at sea.

2. Numerous accidents at sea result fromlone bridge and wheelhousewatchkeepers falling asleep, particularlyduring the early hours of the morning.Fatigue is a persistent problem, whichcan only be properly overcome byensuring watchkeepers are well rested,and that their body clocks have adaptedto working unusual hours. Where this isnot possible, by ensuring thatwatchkeepers are not left alone, and thatwatch alarms are fitted and used, at leastthey can be prevented from falling asleepfor extended periods during whichdangerous situations can develop.

3. A ship can only operate safely if therelationships among her crew are openand honest. Every person is likely tomake an error or lapse at some stage.When a mistake is made, or something isseen which is not as it should be, it isextremely important that it is reported assoon as possible. If it is not, valuabletime is lost in investigating resultantproblems, and the taking of remedialaction. Honesty is the best policy.

4. The occasions on which a master orskipper is required to be called, variesconsiderably between companies and theindividuals concerned. There are no hardand fast rules. However, when a masteror skipper does not formalise theoccasions he wishes to be called, throughwritten orders, a heavy reliance is placedon the judgment of a watchkeeper. Inthis respect, many masters and skippershave been disappointed, embarrassed,and probably furious.

Shell plating damage on ore carrier

Aficionados of the Safety Digest will recognizethat there are dramatically more cases in thisleisure craft section than ever before. This isnot by chance.

Most of you will know that accidents/incidentsin leisure craft (not including commerciallyoperated leisure craft) do not need to bereported to the MAIB. All other accidents in UKwaters, and to UK registered vessels worldwide,must be reported. The result of this is that mostMAIB investigations are of accidents/incidentsinvolving merchant ships or fishing vessels.However, by July 2005, there were five fullinvestigations of leisure craft accidentsunderway in the MAIB, more than half of thosestarted in the year. This made us take a look atwhat was happening in the leisure world.

For the 2 months 8 August – 10 October, wecompiled a register of leisure craft accidentsand incidents in UK waters, using the criteriaagainst which merchant ships and fishingvessels report to the MAIB. With little effort,we identified an astonishing 1162 leisure craftaccidents/incidents in UK waters. By the end of2005, we were aware of 23 deaths in leisurecraft accidents in the UK.

We all know that statistics can be misleading,particularly when we are dealing with relativelysmall numbers, but better statistics would help

to identify trends, and so make our pastimesafer. Please report accidents to the MAIB: itonly takes a few minutes, and your report is intotal confidence.

Alcohol has played a major part in four of thedeaths we investigated in 2005. Sadly, the MAIBhas heard from people who have bought aboat because they could not use their car topub crawl; after accidents we have takenevidence from people who have stated thatthey would not have dreamt of driving a car inthe state they were in, and we have heardarguments from apparently intelligent peoplethat “it can’t be that dangerous or thegovernment would have done somethingabout it”. Any sane person knows that boatingof any form is hazardous, and that you needyour wits about you. Alcohol lessensinhibitions, clouds judgment, impairs yoursenses, slows your thought processes andreactions, and reduces your physical ability tosurvive in the water. In two accidentinvestigation reports, published in Februaryand March 2006, the MAIB has recommendedthat early legislation be introduced to establishlimits on the amount of alcohol which may beconsumed by operators of leisure craft.

Please take time to read all the cases in thissection, and think how you can ensure thatsuch things could not happen to you.

48

Part 3 – Leisure Craft



Narrative

When on a short coastal passage, a 4m sailingdinghy capsized 7 cables from the nearestpoint of land. On board were its owner, anadult crewman and two children. All weredressed in shorts and ‘T’ shirts. The owner waswearing a lifejacket, and the remainder of thecrew wore buoyancy aids. Following capsize,two attempts were made to right the dinghy,which had fully inverted. Despite the windbeing between force 5 and 6, and waves at aheight of about 1.5m, the boat was rotated toan upright position on both occasions, butquickly capsized and inverted again.

Following the attempts to right the dinghy, itwas noticed that the dinghy’s owner had notbeen able to inflate his lifejacket.Consequently, the adult crewman located andpulled the toggle fitted to his lifejacket(Figure), which then inflated. However, thelifejacket did not appear to be fitted correctly,and the owner struggled to keep his mouthclear of the water. He died from a combinationof hypothermia and drowning about 10minutes after the initial capsize.

The remaining crew held onto the upturnedhull, until they were seen by a passing charterfishing vessel, and recovered on board. Theyhad spent at least 11⁄2 hours in the water. Bothchildren were taken to hospital by helicopter,but the youngest child was pronounced deadon arrival; he died from hypothermia. Thedinghy was towed to the shore and beached inits inverted condition. The flares carried insidethe dinghy’s cabin were found to be out of date.

The dinghy was purchased at a boat show 4months before the accident. Its crew was veryinexperienced, and was not aware of thepredicted wind or sea conditions. Affixed tothe boat was a builder’s plate which indicatedthat its maximum occupancy was threepersons, and that the dinghy conformed to thestability and buoyancy requirements of theRecreational Craft Directive for a boat ofDesign Category C (Inshore Waters). However,tests conducted after the accident (see figures)showed that the dinghy did not meet theserequirements. Although a generic manualrelating to maintenance was provided with theboat, information specific to the operation ofthe dinghy was not.

50

Double Tragedy


CASE 17

Figure 1: Owner’s lifejacket


CASE 17

Test report photograph – dinghy being capsized

Test report photograph – cockpit fully swamped


CASE 17

The Lessons

1. Although the conditions might appear tobe benign when taking to the water, it iswise to bear in mind that they canchange very quickly. Many boat ownershave been caught out in this respect.Before putting to sea, where adverseconditions threaten the safety of manysmall boats, the checking of the localinshore weather forecasts, via the radio,internet, local newspapers, or coast radiostations, is a simple and cost freeprecaution to take.

2. When putting on a lifejacket, take a fewseconds to ensure it is worn correctly. Ifit is not, the jacket will tend to ride upwhen inflated, and will be more of ahindrance than assistance. This willdecrease, rather than increase, anindividual’s chances of survival.

3. Even in the summer, when thetemperature of the sea around the UK isabout 16°C, its debilitating effectsshould not be under-estimated. This isstill 20°C below body temperature, andwell below the temperature of mostswimming pools. When in boats such assailing dinghies, where the danger ofcapsize is ever present, and when inremote areas where assistance is notreadily at hand, the effects of cold waterimmersion must not be ignored whendeciding what clothes to wear.

4. Flares need to be accessible and in date ifthey are to be of use when needed.

5. Experience cannot be taught, howevermany of the dangers associated withsailing and power-boating, along with thetips of the trade, can be learned throughvarious levels of RYA training courses.The completion of such courses providesa sound foundation from which to start,and to increase proficiency in theseactivities.

6. The maximum loading of a boat shouldbe shown on the builder’s plate affixed toits hull, and in the owner’s manualprovided by its manufacturer. The risk ofcapsize and swamping is increased whenthis is exceeded.

7. When buying a boat, it is important thatthe purchaser is fully aware of itslimitations. For new under 24mrecreational craft, purchased within theEU, this information should be availableon: the affixed builder’s plate; theowner’s manual provided by themanufacturer specific to the boat model;and the manufacturer’s declaration ofconformity with the Recreational CraftDirective. It is worth taking the time tocheck this information, and where suchinformation is incomplete, or containsanomalies that cannot be reconciled bythe vendor, further investigation isprobably warranted before completingthe purchase.

Narrative

The owner of a high powered, rigid inflatableboat (RIB) was well known to have been akeen and competent yachtsman. He alwaysmade a point of wearing his lifejacket, andensured that his yacht was properly equippedto cope with emergencies. In sum, he wasconsidered to be very safety conscious.

About 2 years before the accident, he hadmoved into the faster paced RIB craft arena.He enjoyed the excitement of driving his boat,and decided to replace it with a larger, morepowerful, 6.4 metre RIB with a 150horsepower engine, providing a top speed ofabout 50 knots (Figure 1). It was very doubtfulif the boat was subjected to regularmaintenance or a professional survey prior topurchase, but the outward appearance was of asmart, well presented craft.

The owner was pleased with the RIB’sperformance, but as the weather deterioratedduring the latter part of the year, he decidedto lay up the boat for the winter. As theweather improved, during the early part of theNew Year, he took the opportunity to take theRIB on its first run of the season. As a treat, healso decided to take his two teenagedaughters on the trip. Although clear andbright, it was a chilly day, the wind was force 4,the air and water temperatures were at 5°Cand 3°C respectively, so the group wore warmclothing.

Once at the slipway, the owner realised that hehad left the three lifejackets at home, but notwishing to disappoint the girls he decided togo ahead with the trip. Also contrary to hisnormal practice, he had no VHF radio or flareson board, with which to raise the alarm ifanything untoward happened.

53

A Tragic End to the First Trip ofthe Season


CASE 18

Figure 1

During the early part of the trip, the elderdaughter took the wheel. She found steeringthe RIB rather difficult, and soon after, herfather took over. He was sitting on the mostforward seat, with his younger daughter on theseat behind and with her sister standing besideher. After a period of weaving the RIB about, theowner steadied on a course and set the throttleat full ahead. The RIB then unexpectedlylurched to port, throwing the father and hisyounger daughter into the cold water.

Because the engine kill cord had not beenconnected, the RIB continued at high speeduntil the elder daughter was able to scrambleto the steering console and reduce the enginepower. Despite the haphazard steering, shemanaged to drive the RIB back towards herfather and sister. Without a VHF radio or flares,she could not raise the alarm, but on the way,

she raised an arm to try to alert a passingcruiser to her predicament. Unfortunately,they mistook this to be a greeting andcontinued on their way.

Once close to her family, the elder daughterjumped into the water in an attempt to rescueher sister. The cold water was too much tobear and, despite her very brave rescueattempts, she had to climb back into the RIB.Tragically, without the support of lifejackets,her father and sister disappeared from view.

The elder daughter then drove the RIBtowards two fishermen in a boat, told them ofthe situation and they raised the alarm bymobile telephone.

Despite long and rigorous searches, the fatherand his younger daughter were not seen again.


CASE 18

Figure 2: Steering system


CASE 18

The Lessons

All the evidence points towards a mechanicalfailure of the RIB’s steering system (Figure2) causing it to lurch uncontrollably. It wasfound that the system had non-standardcomponents fitted, and that the hydraulic oillevel was low, due to oil leakage from thehelm/shaft pump boss (Figure 3). Thisallowed air and moisture to enter the system,causing intermittent steering control, andwater ingress causing corrosion to internalcomponents.

It is tragic that a number of contributoryfactors to this accident have also been causalin other fatal leisure craft accidents. Mostare obvious, and include:

1. Good preparation cannot be overemphasised – the use of lifejackets,carriage of flares and a VHF radio willgreatly improve your chances of survival– you owe it to yourself and yourpassengers to carry them on board.

2. Do take the opportunity to regularlymaintain your equipment in accordancewith the manufacturer’s instructions.

3. Always investigate fluid leaks and do notdelay rectification – your life may dependupon it. Pools of fluid are obvious signs ofleakage, but also look for staining andpaint detachment on components aspossible indicators of problems. It isimportant to do this during, and following,lay up because systems can develop leaksas seals can become dry and brittlethrough under use.

4. Always connect your engine kill cord –remember your boat may be the onlylifeboat available – you do not want tosee it disappear from view.

5. Make sure that those on board are awareof the internationally recognised methodof signalling distress: raising andlowering of the arms outstretched at eachside of the body.

Figure 3

Narrative

Four married couples set out from a marina fora weekend trip on board an 8 metre long, fastmotor boat. Their destination was a popularsmall harbour, where they intended to stayovernight in a hotel.

The couples were in high spirits, and they hadbrought with them alcohol and food for thetrip. During the passage, one of the men waterskied behind the motor boat, and theystopped at a landing stage and had lunch in awaterside hotel. Later in the afternoon, theyanchored the boat in a bay, and two of thewives went swimming. Alcohol was consumedthroughout the passage and at the hotel.

The owner of the boat had taken the helm formost of the day, but, as they approached their

destination, one of the other husbands tookover. They entered the harbour, and the boatwas made fast to one of the pontoons. Thecouples went ashore and enjoyed an eveningof singing, dancing, eating and consumingmore alcohol.

At 12.30am, three of the couples took the boatout again, to visit a prominent tourist featureabout 2 miles away. They reached the featureand then began their return to the harbour.The owner was sitting in the port cockpitchair, with the other man sitting in thestarboard chair and in control of the steeringand the engine throttle control. One of thewives was standing between them. It becamecold during the return passage, so the othertwo wives and one of the husbands movedforward and stood behind the chairs to takeshelter behind the windscreen. The boat

56

Alcohol Ends a Weekend PleasureTrip


CASE 19

A view looking forward from the stern of the cockpit area

Engine throttle control

turned into the outer harbour, whichfunnelled down to a narrow entrance to theinner harbour. As the boat approached theentrance, it made a sharp turn to starboardand crashed into an unlit low cliff.

A yachtsman had seen the navigational lightsof the motor boat travelling at speed andapproaching the harbour. The boatdisappeared from view and he heard a loudcrash.

Realising something had happened to theboat, the yachtsman called the emergencyservices immediately. He and his crew headedfor the stricken motor boat. When theyreached it, they found it lying heavily in thewater, with only one man and one woman stillconscious. They took them on board the yachtand, concerned that the motor boat was indanger of sinking, the yacht towed the motorboat to a slipway on the other side of theharbour where medics and ambulances werewaiting.

Three of the boat’s occupants were killedduring the accident; the other three sustainedserious injuries.

The survivors cannot remember the events ator around the time of the accident, so it is notknown why the motor boat turned suddenly tostarboard.

Post accident investigations found:

• The three fatalities resulted from severechest injuries, which were caused by beingthrown against the forward part of thecockpit at the time of the impact with thelow cliff.

• The severe damage to the motor boat, andthe spread of debris field on the low cliff,showed that it must have been travelling athigh speed when it approached the narrowentrance.


CASE 19

Damage to starboard forefoot and bow forward

• The toxicology tests at the post mortemexaminations showed that those who losttheir lives had levels of alcohol in theirbloodstreams which were more than twicethe legal limit for driving a car.

• There were no other vessels moving eitherin the outer harbour, or the inner harbour,and the navigational light at the entrance tothe inner harbour was clear andun-obscured.

• There were no mechanical faults with theboat.

• The weather was fine and calm, and thevisibility was good.

• The owner and the helmsman had manyyears of experience on motor boats andyachts, and held RYA Powerboat Level 2certificates.


CASE 19

The Lessons

1. Don’t drink and drive – on land andwater.

2. Travelling in restricted waters, indarkness and at high speed, requires goodvision, good judgment and quick reactiontimes. Alcohol causes reduced vigilance,lower inhibitions, poor night vision,affected perception and deterioration ofjudgment: all of which played a large partin this accident.

3. Even experienced and qualified people,travelling on well founded vessels, canmake fundamental mistakes whenadversely affected by alcohol.

4. It is wise to gradually reduce a boat’sspeed when approaching a narrowentrance, where manoeuvrability isrestricted. This gives those in controlmore time to assess the situation and thehazards to navigation.

Narrative

It was another very pleasant, balmy summer’sday in a popular seaside resort; just the sort ofday to take the family out for a short,exhilarating, boat trip. Indeed, what better wayto round off a holiday than to do this onboarda high speed, 12 passenger, 9 metre, RigidInflatable Boat (RIB) (Figure 1).

Full of expectations and a little trepidation,12 passengers, 6 of whom were children, weregiven a rudimentary safety briefing by thefiancée of the RIB’s skipper. She had nomarine experience. The briefing only coveredthe use of the lifejackets, and emphasised thatthe “red” manual inflation toggle should notbe pulled while in the RIB. Unfortunately, thepassengers were not told when the toggleshould be pulled. With the passengers nowsafely on board, the skipper and his fiancéetook up their positions at the steering console.

The skipper rounded off the safety briefing byinstructing his passengers to raise a handshould they become concerned at any timeduring the trip.

The skipper connected his engine kill cord tothe steering console, started the engines andleft the harbour entrance, while thepassengers settled down for their big treat.They were not disappointed. With the waveheight at about 0.5 metre, the skipperconducted a number of exhilarating, highspeed manoeuvres before reversing his courseto pass the nearby headland and into moreopen seas.

By now, the wave height had increased toabout 1 metre. The passengers, now a littlemore nervous, were being bumped about theirseats as they passed a nearby, small, singlehanded fishing vessel at about 25 knots, butnone raised a hand to indicate concern. After

59

Ouch! One Very Badly Cracked RIB


CASE 20

Figure 1: Broad on, port perspective

manoeuvring off a nearby beach, the skipperset his course to return to the harbour. Soonafter, the RIB drove into the back of a wave inthe following sea.

The skipper felt the RIB’s handlingcharacteristics change. The deck heavedslightly, there was a loud crack and the forwardpart of the hull momentarily adopted an angleof about 45 degrees from the horizontal. Thefront bench seat was torn from its deckmountings, plunging two of the children intothe water (Figure 2). One female passengeralso trapped her legs between the splitsections of the marine ply deck before beingpulled back by her husband. In the meantime,the skipper ran forward, the engines stoppedas the kill cord was activated, and he droppedboth his anchors and launched the lifeboat,although he was unsure how to do this. TheRIB, although still afloat, had its bow sectionfully open to the sea, with port and starboardsplits to the hull extending to over half theRIB’s length (Figure 3).

Luckily, the two children in the water werequickly recovered by their father, who haddived into the sea to rescue them. Theskipper of the fishing vessel saw the RIB indifficulties and immediately hauled in his linesand made his way towards the RIB. Lifeguardsfrom the nearby beach also sped to the sceneon a jet ski as the emergency services wereactivated.

The passengers were transferred to the fishingvessel, a jet ski, and the inshore lifeboat, andwere landed at the harbour shortly afterwards.Surprisingly, none suffered serious injury.

The subsequent investigation found that theRIB was supposedly built to the EuropeanCraft Directive’s standards, but there was nodocumentation to support this claim. Inparticular, there was no specification for thehull structure or its construction to justify itsdesignation to cope with 4 metre seas, thestructure lacked longitudinal stiffness and wasof extremely light construction (Figure 4). As


CASE 20

Figure 2: Front bench Figure 3: Hull lifted to expose split

Figure 4: Construction

this vessel was used for commercial purposes,it was subjected to detailed examination underthe auspices of the MCA. However, in commonwith many other RIBs, there was no access tothe under deck areas, so it was very difficult toassess the true condition of the hull.

It was also found that the operating companyhad conducted no risk assessments of theiroperation, and neither was it aware of the

need to do so. The skipper lacked some of themandatory qualifications and endorsements,and the local harbourmaster was unaware ofthe qualifications required for the RIB’soperation, despite having endorsed theventure. Although the RIB had been examinedfor commercial use, the required certificationhad not been issued. While this had no impacton the accident, the vessel was, nevertheless,ineligible to carry fee paying passengers.


CASE 20

The Lessons

The owner of the RIB operating companyidentified a niche in the leisure market forhigh speed boat rides. He purchased theRIB, and operated it in good faith, believingthat it had been built to the EuropeanRecreational Craft Directive (RCD)standards (which came into force in 1996for recreational craft between 2.5 and 24metres). As such, the craft should thereforehave been able to withstand the loadsexpected for its intended operation. Thisassumption was further reinforced becausethe RIB had been examined for commercialuse.

Fee paying passengers should expect to becarried in a safe manner, in a seaworthyvessel capable of coping with the predicted inservice loads. Equally, they should expectthat the operation has been assessed as beingsafe, part of which includes the skipper beingfully trained and qualified for his role inorder that he can competently deal withemergency situations.

In this case, the crew and passengers werevery lucky to escape serious injury.

This accident has highlighted the followinglessons appropriate to operators of small,high speed leisure craft, especially for thosein commercial use:

1. If you are considering buying a boat thathas been built since 1996, ensure that itcarries a CE identifying plate confirmingit has been built to the RCD standards.

2. Purchasing a new build vessel is a majorfinancial undertaking – check with thebuilder that he holds a comprehensiveTechnical File supporting his buildprocess. This should contain thenecessary calculations proving the hullstrength is suitable for the intendedoperation.

3. If considering buying a re-sale boat, youwill wish to check the condition of thehull structure. This is often difficultwith a GRP RIB as under deck access isfrequently impossible. If this is the case,the builder may well have a set ofphotographs taken during build. These,coupled with the information in theTechnical File, will aid you and yoursurveyor to determine the suitability ofthe vessel’s construction for your needs.It is also wise to check the vessel’shistory for any major hull repairs.

4. Are you aware of the qualifications andendorsements required to skipper acommercial craft, and of the need forrisk assessments? These are laid out inthe MCA’s Marine Guidance Note280(M) colloquially known as the“Harmonised Code”.

Narrative

On a pleasant summer’s day, the helmsman ofa 6.55m cabin cruiser spent the day withvarious friends, cruising between near-byharbours, visiting the local public houses asthey went. A local harbourmaster hadparticular reason to note the vessel that day, asit had twice sped out of his harbour,generating excessive wash.

Just after sunset, the cabin cruiser, with itshelmsman and three passengers, completedthe short 10-15 minute crossing to a smallharbour for a drink. Thirty five minutes later,and being aware it was getting dark, thehelmsman decided to head back to the mainharbour. The vessel’s navigation lightsconsisted solely of a combined side light (thepole mounted all-round white light beingbroken), however it was doubtful that thehelmsman turned this on.

Earlier in the evening, a 4.4m dory, with threepeople on board, had travelled from the smallharbour to the main harbour for an eveningout. After several drinks, again as it was gettingdark, the helmsman decided to head home.The dory had no navigation lights.

The dory and the cabin cruiser, both unlit,sped towards each other at a combined speedof over 45 knots. At the last moment, thehelmsman of the dory saw the bow wave of thecabin cruiser. But it was too late to avoid acollision. The helmsman of the cabin cruisersaw nothing ahead, and only felt his vesseljump up as it hit and flew over the dory, andthen stop as it landed back in the water.

No-one in the cabin cruiser was injured, andthey were now able to see the vessel they hadhit, also stopped in the water. They could see aperson in the water, but could not renderassistance as the stern drive of their own vessel

62

A Lovely Day Ends in Tragedy


CASE 21

was badly damaged. However, using a mobilephone they raised the alarm. Neither vesselhad a VHF radio, flares or other lifesavingequipment.

On board the dory, one occupant wasknocked unconscious and another was throwninto the water. Fortunately, he remained

conscious and managed to swim back to theboat. Tragically, the helmsman was killed inthe collision.

The lifeboat arrived quickly and evacuated theinjured. After the accident, it was found thatboth helmsmen were over twice the alcohollimit permitted for driving a car on UK roads.


CASE 21

The Lessons

1. Using a leisure craft while under theinfluence of alcohol is dangerous andputs your and others’ lives unnecessarilyat risk. Alcohol will lead to:

• deterioration of night vision

• deterioration of peripheral vision

• increased reaction times

• greater risk taking as judgmentbecomes impaired.

To be safe, employ the same practices asyou would on the road, and ensure anexperienced helmsman stays sober.

2. Navigation lights form a vital role on thewater after sunset. They make youvisible at night, give information on yourvessel’s aspect, provide an indication asto what sort of craft you are and thedanger you may present. Having nonavigation lights is inherently unsafe andwill lead to a far greater risk of having acollision in the dark. The COLREGS2

detail what navigation lights you mustcarry.

3. Adjust your speed to suit the conditions,especially at night. Travelling at a slowerspeed will provide more time to react andlessen the damage resulting from anyimpact. Be aware that your night visionwill not be good just after leaving a litarea, and remember other craft may behidden by background light from theshore.

4. Associated with speed is washgeneration. Once a modern powerboat isfully planing, its wash may beinsignificant. However, as a boat isclimbing on to the plane, the washgenerated can be considerable and canrepresent a real hazard to swimmers andsmall craft. Ensure you keep your washto a minimum, and show someconsideration to other water users inconfined and busy areas of water.

5. The requirements to travel at a safespeed and to show navigation lights areboth detailed in the COLREGS. A goodawareness and understanding of theseessential ‘rules of the road’ is vital whentravelling on the sea, and you ignorethem at your peril. There are plenty ofpublications available which explain theCOLREGS quite simply, and the RYAteaches the basics on its numeroustraining courses.

2 The International Rules for the Prevention of Collisions at Sea

Narrative

The owner and his wife were half way througha four week holiday, cruising the Western Islesof Scotland when fire gutted their 12.5m steelhulled yacht, forcing them to abandon ship.Fortunately no-one was hurt, but the yacht wasburnt out.

The yacht was on a daytime passage betweentwo ports. On sailing, the weather had beenclear, but around midday the wind haddropped and visibility reduced to less than1 mile, so they were motor-sailing. About 11⁄2hours later, the crew noticed smoke comingup the companionway, and the skipper went toinvestigate. On lifting the companionwaysteps, the skipper saw flames on the starboardside of the engine in the vicinity of the wiringloom. He fetched a fire extinguisher from theforepeak and with 3-4 blasts put the fire out.The engine had remained running throughout.

There was a lot of smoke below, so the skipperwent on deck for some fresh air before

inspecting the damage. While on deck, henoticed that the instruments were no longerworking, so assumed the fire had damaged thecables. He decided not to dampen down thefire area or stop the engine as he might havetrouble re-starting it, and there was insufficientwind to sail out of any trouble. However, hewas unable to commence repairs due toresidual smoke in the engine space, so he leftthe hatches open to try and clear it.

Fifteen minutes later, the skipper had gonebelow and forward to collect tools to beginrepairs when he heard a shout from his crew,alerting him to black smoke emitting from theengine space and the wet locker area. As heleft the cabin, he saw flames coming from thevicinity of the wet locker, and within minutesof his arriving in the cockpit, flames were risingthrough the companionway. At that point, theskipper decided to abandon ship and he andhis wife, both wearing lifejackets, inflated andboarded their dinghy safely. Without a portableVHF in the liferaft, the skipper alerted thecoastguard using his mobile phone.

64

Fire: Put It Out and Keep It Out


CASE 22

The skipper and his wife were rescued by anearby motorboat, and the local RNLI lifeboatfought the fire before taking the yacht in tow.Unfortunately, the extent of damage below wasso great that it was not possible to determine

the exact cause of the original fire, norwhether the second fire was a re-ignition ofthe first, or another fire caused by heat transferinto the wet locker.


CASE 22


CASE 22

The Lessons

1. Never assume a fire is out. To burn, afire needs 3 ingredients: combustiblematerial, oxygen and a source of ignition.Depriving the fire of any of these willput it out, temporarily. Fire-fightingmust always be followed by action topermanently deprive the fire scene of atleast one of the 3 key ingredients.

2. If you do suffer a fire on board, alwayscheck adjacent compartments and spacesfor hot spots and secondary fires. Ifpossible, dampen down hot spots, but atleast monitor the area until any residualheat has dissipated.

3. Review your fire-fighting appliances.Have you enough? Are they the righttype? Are they in date? Are theypositioned sensibly? Do you and yourcrew know how to use them?

4. Finally, review and, if possible practiceyour abandon ship drill. Check youknow the contents of the liferaft and, ifnecessary, use a grab bag to holdsupplementary kit such as a handheldVHF and GPS.

Narrative

A 12 metre long, twin screw charter boat washired by a team of divers for 2 days of diving.This vessel had been used by one of the teamon a previous occasion, with good results. Itwas known to some of the others byreputation and was operated under theMaritime and Coastguard Agency’s Code ofPractice; it was a Coded boat.

The boat’s skipper met with the team theevening before the first dives and discussedbuddy arrangements and dive sites.

The following morning all met at the boat,which then headed for the area of the firstdive. This was just off an area of rocks whereseals were common. Once at the site, theboat’s skipper gave the dive team a briefing.This included details of the underwater terrain,an area of possible strong tidal streams, theuse of delayed surface marker buoys andprocedures to be followed after surfacing.Water depth was between 20 and 24 metres.

Four pairs of divers entered the water. Surfaceconditions were reasonable, with only a slightswell and breeze. After about 30 minutes, theybegan to surface close to the rocks. The swell

had increased noticeably, as had the wind,which was tending to blow the boat towardsthe rocks; a lee shore. As instructed in thebriefing, they swam towards the boat, and thefirst pair of divers boarded without incident.

One of the second pair to surface had difficultygetting on the boarding ladder. On the firstattempt, he slipped off, largely because of theboat’s movement in the swell. He again swamtowards the boat for a second attempt.However, the skipper was concerned that hisboat was being pushed too close to the rocks.Thinking the diver was still on the ladder,having not seen him slip off, he put his enginesin reverse gear to move away from the rocks.

The diver quickly found himself beneath theboat, with his regulator knocked out. He triedto lose buoyancy, to get clear of the boat, butbefore he could do so his legs became caughtin one of the propellers. He lost one leg andseriously injured the other.

Another, much faster boat in the arearecovered the injured man and his buddy, andlanded them ashore. During this short trip, thecoastguard was alerted by VHF radio andarranged for both an ambulance and an airambulance to attend.

67

Perilous Propellers


CASE 23


CASE 23

The Lessons

1. The Maritime and Coastguard Agency’sCode does not cover the safety ofrecreational diving operations; it isconcerned primarily with the safety ofthe boat and those on board. A boat’scompliance with the Code does notautomatically indicate its suitability fordiving.

2. Many Coded boats still operate with justa skipper; he may have no secondcrewman. A skipper working alone maynot always be able to take steps to ensurehis boat’s safety, and at the same timemonitor divers at the surface or comingto the surface. If possible, any of the diveparty already on the boat should act as asecond pair of eyes for the skipper,monitoring divers at or near the surfaceand making the skipper aware of theirposition.

Narrative

A group of 8 middle managers were taking partin a corporate team-building course, part ofwhich involved a harbour crossing of about 1.6miles using two rafted canoes provided by anoutdoor activities centre. The canoes wereaccompanied by a small 4-man capacity safetyboat. None of the group had any waterborneexperience. The course was managed by aseparate, third party specialist company, but theoutdoor centre provided the training facilitiesand some specialist instructors. In this case, itincluded the safety instructor for the harbourcrossing exercise. The instructor had previouslybeen involved in the crossing, but he had neverled this exercise before. Safety had alwaysreceived high priority, and the centre had acomprehensive safety policy. However, theyhad not conducted a specific risk assessmentcovering the rafted canoeing exercise.

The evening before the exercise, a teambriefing was held, during which an alternativeexercise to the crossing was briefly discussed.However, the young instructor interpreted thatthe managing company wanted the crossing tobe completed despite the forecasted south-westerly wind force 4-5, increasing to force 5-6.

The next day got off to a bad start. A wheel felloff the trailer carrying the safety boat, and whiletowing the two canoes to the start point, one ofthem capsized. This caused further frustratingdelays to the already tight programme. To makematters worse, the weather had deterioratedand there was the additional pressure from thecourse manager to recover the programme. Tomake up lost up time, extra instructors weresent to help the course members build therafted arrangement using spars and ropes, andone extra instructor embarked in the safetyboat with the safety instructor (Figures 1 and 2).

69

Rafted Canoe Exercise Ends inThat Sinking Feeling


CASE 24

Figure 1: Rafted canoe arrangement

Despite the worsening conditions and heavychop to the surface of the sea, the instructordid not consider cancelling the exercisealthough this had been done on previousoccasions. Lifejackets were issued, andpaddling and steering instruction was given asthe group started off across the open water.

Following a review of earlier canoeing riskassessments, the centre had decided that theexercise should be conducted within 250metres of the shore, instead of the previouslimitation of 400 metres. However, theinstructors were not made aware of this and

the group continued with the open watercrossing About 30 minutes later, the groupbecame very tired, and made little headway,having lost the lee of the land. It was decidedto take them in tow, although no thought hadbeen given to the best towing method. Thecanoes yawed badly and became quicklyswamped (Figure 2).

Unperturbed, the instructors attempted torelease the spars and empty the canoes, thecourse members clung on, or floated nearby.When the crews attempted to climb back intothe canoes, the canoes were swamped again,


CASE 24

Figure 2

Figure 3: Safety boat

Safetyboat

Safetyboat

Bowlines allowed to travel alongthe safety boat towing bridle andcanoe tensioning rope

Canoe stem tensioning rope

connecting spar

Fixed towing point oncanoe towing bridle

Bowline free to travel along safety boat towing bridle

Safety boat towing bridle

TOWING ARRANGEMENT ALTERNATIVE TOWING ARRANGEMENT

plunging everyone back into the cold water.Using his mobile telephone, the instructoradvised the outdoor centre of the situationbut, despite the worsening situation, theemergency services were not alerted and thecanoes and course members drifted towards adeep channel.

The safety boat carried no flares, nor was aVHF radio carried to raise the alarm.Fortunately, soon after, an oilrig supply vesselappeared nearby and the instructors managedto catch the crew’s attention. The vesselinformed the coastguard of the situation.

In an effort to warm up the course members,the instructors decided to put the entire groupinto the 4-man capacity safety boat (Figure 3).As the last person was pulled on board, thesafety boat became swamped and all 10 peoplewere, once again, plunged back into the coldwater. The boat capsized.

Luckily the supply vessel arrived quickly andrecovered those in the water. They werethen transferred to a lifeboat andsubsequently to hospital for check-ups; allwere later released and the canoes and safetyboat recovered.


CASE 24

The Lessons

The course members were extremelyfortunate that the oilrig supply vessel was inthe vicinity to make a speedy recovery,especially as the group were drifting quicklytowards deep water, and the cold was rapidlysapping their strength. The appropriatecontrol measures were not in place tominimise the risks, because the risk of raftedcanoes becoming swamped had never beenproperly assessed. Had they been, it isprobable that an alternative exercise wouldhave been conducted.

This accident has highlighted the followinglessons appropriate to the outdoor activityindustry:

1. Risk assessments need to be thorough,and must consider every element of theactivity. Hybrid activities, such as therafted canoe exercise, warrant their ownrisk assessment.

2. Although rafted canoes provide a stableplatform, they are less able to “ride”with the sea conditions than a singlecanoe, and are therefore more susceptibleto swamping.

3. Changes to risk assessments should bepromulgated to staff as soon as possible.

4. It is always prudent to validate riskassessments by scenario-based training.By doing so, other risks and appropriaterescue actions are often identified. Inthis case, the best method of towingwould probably have been identified.

5. Outdoor centres should ensure that theyare fully involved in exerciseprogramming and planning when “thirdparty” managers are conducting training.

6. Instructors should be fully conversantwith any limitations (wind force, seastate, visibility) imposed on an exercise,and should never be reluctant to cancelexercises if there is a risk to personalsafety. The importance of having anagreed alternative plan should be fullyrealised.

7. It is essential for instructors to recognizewhen a “normal” recovery situationturns into an emergency situation.

8. Emergency services should be alertedearly when people are getting intoserious difficulty.

Narrative

A 48m luxury yacht grounded in good weatheron a well charted reef. The vessel was badlyholed and sank to a semi-submerged position.Two days later, the vessel slipped off the reefand disappeared below the surface.

The yacht had been cruising for 2 days with itspassengers on board and had anchored in abay overnight. The chief officer, who hadjoined the vessel 4 months previously, was upearly as usual, assisting the crew and weighinganchor. He then went to the bridge to takeover the watch from the master, and wasinformed by him of their day’s destination.The weather was excellent, with good visibilityand only a light breeze, and the plan was tomake for a bay some 2-3 hours steaming downthe coast.

The chief officer was responsible fornavigation, and he drew a planned track on thesmall scale chart. He also made use of some

waypoints of key headlands that he hadpreviously programmed into the GPS. Thecourse chosen was close to the shoreline toensure a good view for the passengers, andthey cruised at 10 knots. During this time, themaster was never far away, but there were nopositive handovers of watch between themaster and the chief officer. On nearing theirdestination, the switch was made to a largerscale chart. Only 2 fixes were made on thischart, about 30 minutes apart, each time usinga single radar range and bearing from aheadland, backed up with a GPS check.

About the time of the second fix, the masterstudied the shore and decided to head toanother bay slightly further down the coast.Between their position and the intended baywas a charted, but unmarked, reef, a small partof which was visible above the sea surface.Both officers were aware of the hazard, andthe master asked the chief officer whetherthey were clear of the reef. The chief officerreplied that they were and, after glancing at

72

Grounding in Perfect Weather


CASE 25

the radar, the master was happy to continue.The master watched as the depth on the echosounder decreased, as he expected, believingthat his vessel would cross a plateau tostarboard of the shallowest part of the reef.The vessel then shuddered to a halt. Theofficers rushed to the port bridge wing andwere able to see over the side the rock theyhad grounded on.

The master went into the engine room andsaw flood water rising in the bilges. He

returned to the bridge and alerted thecoastguard. The chief engineer stopped themain engines and started the bilge pumps, butthey did not stem the inflow of water. Thechief officer then mustered the passengers andcrew, the vessel’s own two craft were loweredto the water, and the passengers wereevacuated very calmly. Four of the crew stayedon board and rigged an emergency pump, butit had little effect and shortly before theweather deck immersed, the remaining crewabandoned ship.


CASE 25


CASE 25

The Lessons

Sadly, the lessons learnt from this accidentare not new and are common to manyaccidents investigated by the MAIB.

1. Passage planning is not an optional extra.It is vital, if you are to avoid groundingon clearly charted obstructions, as is thecase in this accident. There may have tobe a great deal of flexibility in where avessel goes, but this is no excuse for notconducting proper passage planningbeforehand.

2. Ensure you use all the tools available tomonitor your position. When workingclose inshore:

• fix regularly

• do not rely on a single bearing andrange for position fixing

• use clearing bearings

• use parallel indexes on your radar.

All of the above are aids to keeping yourvessel safe.

3. Make sure the officer responsible fornavigation is provided with sufficienttime to complete a passage plan. Once onpassage, it is too late, and ‘localknowledge’ is not always reliable.

4. Ensure your vessel’s management has anexternal review. Relying solely on themaster to effectively manage andcommand a vessel may mean unsafe andsloppy practices creep in unnoticed andunchecked.


APPENDIX A

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

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

07/11/05 Sammi Superstars Bulk carrier Korea 28327 Mach. failure

15/11/05 George Lyras Bulk carrier Greece 22322 CollisionCormill Barge UK UnknownCorglen Barge UK UnknownCorheath Barge UK Unknown Corhaven Barge UK UnknownKenmouth Barge UK Unknown

17/11/05 Arctic Ocean Dry cargo container UK 6326 CollisionMarie Af Hovrik Fishing vessel Sweden 146

22/11/05 Golden Bells II Fishing vessel UK 24.94 CollisionPlato General cargo Barbados 1990

23/11/05 Varmland Dry cargo container UK 6434 Acc to person (fatal)

29/11/05 Solent Fisher Product tanker Bahamas 3368 Hazardous incident

10/12/05 Lisa Leanne Scallop dredger UK 9.76 Fire/explosion (fatal)

18/12/05 Sovereign Fishing vessel UK 164 Grounding

Dublin Viking Ro-ro passenger UK 21856 Grounding

19/12/05 St Georgij Bulk carrier Panama 14971 Fire/explosion

20/12/05 Black Friars Oil tanker UK 992 Grounding

08/01/06 Jolbos Bulk carrier Cyprus 18813 Acc to person (fatal)

07/01/06 Mounts Bay Naval support RFA UK Unknown Mach. failure

21/01/06 Rubino Oil/chemical tanker Italy 5045 Haz. IncidentLinda Kosan LPG carrier Isle of Man 2223

27/01/06 P&O Nedlloyd Genoa Dry cargo container UK 31333 Heavy weather damage

30/01/06 Pamela S Fishing vessel UK 24.50 Acc to person (fatal)

21/02/06 Pride of Calais Ro-ro passenger UK 26433 Machinery failure

27/02/06 Stena Leader Ro-ro passenger Bermuda 12879 Contact

Preliminary examinations started in the period 01/11/05 – 29/02/06

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

04/11/05 Harvester Pair trawler UK 154 CollisionStrilmoy Offshore supply Norway 3380

05/12/05 Dieppe Ro-ro passenger France 17672 Grounding

Arctic Ocean Dry cargo cont. UK 6326 CollisionMaritime Lady General cargo Gibraltar 1857

09/12/05 CP Valour Dry cargo cont. Bermuda 15145 Grounding

13/12/05 Noordster Beam trawler Belgium 84 Capsize (fatal x 3)

05/01/06 Berit General cargo UK 9981 Grounding

18/01/06 Emerald Star Beam trawler Belgium 296 Contact

19/01/06 Green Hill Fishing vessel UK 74 Flooding/foundering (fatal x 2)

13/02/06 Kathrin General cargo Switzerland 2999 Grounding

Investigations started in the period 01/11/05 – 29/02/06

Albatros – accident on board the commercialsailing vessel, Thames Estuary on 22 August2004, resulting in one fatalityPublished 8 April 2005

Amenity/Tor Dania – collision betweenvessels, south of Grimsby Middle, RiverHumber, UK on 23 January 2006Published 7 November 2005

Attilio Ievoli – grounding of the Italianregistered chemical tanker on LymingtonBanks in the west Solent, south coast ofEngland on 3 June 2004Published 7 February 2005

Balmoral – grounding of passenger vessel,Gower Peninsula on 18 October 2004Published 29 July 2005

Brenda Prior/Beatrice – collision, LambethPier, River Thames on 17 December 2004Published 11 August 2005

Brenscombe – Brenscombe Outdoor Centrecanoe swamping accident in Poole Harbour,Dorset on 6 April 2005Published 2 December 2005

British Enterprise – grounding in AhirkapiAnchorage Area, Istanbul, Turkey on11 December 2004Published 30 December 2005

Cepheus J and Ileksa – collision in theKattegat on 22 November 2004Published 20 July 2005

Coral Acropora – escape of vinyl chloridemonomer, Runcorn, Manchester Ship Canal on10 August 2004Published 8 March 2005

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

(trilogy)

- Emerald Dawn – capsize and foundering,with the loss of one life on 10 November2004Published 5 August 2005

- Jann Denise II – foundering 5 miles SSE ofthe River Tyne on 17 November 2004 withthe loss of two crewPublished 5 August 2005

- Kathryn Jane – foundering 4.6nm west ofSkye on, or about, 28 July 2004 with the lossof the skipper and one possible crewmemberPublished 5 August 2005

Hyundai Dominion/Sky Hope – collision inthe East China Sea on 21 June 2004Published 30 August 2005

Isle of Mull – contact between two vessels,and the subsequent contact with Oban RailwayPier, Oban Bay on 29 December 2004Published 22 July 2005

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

Loch Lomond RIB – two people beingthrown from a high-speed rigid inflatable boatin Milarrochy Bay, Loch Lomond, with the lossof their lives on 13 March 2005Published 21 December 2005

Nordstrand – fatal accident at AgenciaMaritima Portillo, Seville, Spain on20 September 2004Published 15 April 2005

Orade – collision of general cargo vessel withthe Apex Beacon, River Ouse on 1 March 2005Published 14 December 2005

76

Reports issued in 2005


APPENDIX B

RFA Fort Victoria – investigation of thelifeboat release gear test, which caused injuriesto two people at Falmouth ship repair yard on10 September 2004Published 18 May 2005

Sardinia Vera – grounding of the passengerro-ro ferry, off Newhaven on 11 January 2005Published 21 September 2005

Scot Explorer and Dorthe Dalsoe –collision, Route ‘T’ in the Kattegat, Scandinaviaon 2 November 2004Published 10 June 2005

Star Clipper – failure of a mooring bollardfrom the Class V passenger vessel, resulting ina fatal accident at St Katharine’s Pier, RiverThames, London on 2 May 2005Published 18 February 2005

Stolt Aspiration/Thorngarth – collisionbetween vessels, River Mersey, Liverpool on13 April 2005Published 28 November 2005

Stolt Tern – grounding, Holyhead, Wales on1 December 2004Published 9 September 2005

Swan – capsize of the passenger launch onthe River Avon, Bath on 14 October 2004Published 15 July 2005

Waverley – grounding of the passengervessel, south of Sanda Island, west coast ofScotland on 20 June 2004Published 1 February 2005

Recommendations Annual Report 2004

Published July 2005

Annual Report 2004 Published May 2005

Safety Digest 1/2005 Published April 2005

Safety Digest 2/2005 Published August 2005

Safety Digest 3/2005 Published December2005

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


APPENDIX B

Abersoch RIB – a serious injury sustainedwhen falling overboard on 7 August 2005Published 3 February 2006

Auriga – loss of fishing vessel off Portavogie,Northern Ireland on 30 June 2005Published 3 February 2006

Big Yellow – hull failure of RIB, PorthmeorBeach, St Ives Bay, Cornwall on 26 August 2005Published March 2006

Blue Sinata – foundering in Weymouth Bayon 8 September 2005, with the loss of one lifePublished 2 March 2006

Border Heather – explosion and fire inGrangemouth, Firth of Forth, Scotland on31 October 2004Published 16 February 2006

Bounty – capsize and loss 4 miles off BerryHead, South Devon on 23 May 2005Published 2 February 2006

Carrie Kate/Kets – collision near CastlePoint, St Mawes, Cornwall resulting in onefatality on 16 July 2005Published 24 February 2006

Lykes Voyager/Washington Senator –collision in Taiwan Strait on 8 April 2005Published 10 February 2006

Mollyanna – capsize of sailing dinghy, offPuffin Island, North Wales, resulting in twofatalities on 2 July 2005Published March 2006

Portland Powerboats – collision during ajunior racing event at Portland Harbour,1 serious injury, on 19 June 2005Published March 2006

Savannah Express – engine failure andsubsequent contact with a linkspan atSouthampton Docks on 19 July 2005Published 7 March 2006

Sea Snake – grounding at high speed ofleisure powerboat near the entrance to Tarbertharbour, Loch Fyne on 10 July 2005, with theloss of three livesPublished March 2006

Solway Harvester – capsize and sinking offishing vessel 11 miles east of the Isle of Manon 11 January 2000 with the loss of 7 livesPublished 20 January 2006

78

Reports issued in 2006


APPENDIX C

Documents

Safety Digest 1/06 · 3. Timber Deck Cargo Shift Leads to Dangerous List in Heavy Weather 14 4. Let’s Not Get Carried Away 17 5. Bring Back the Budgie 19 6. Wrong Place – Wrong