Safety Digest 1_09 (WEB).pdf - Marine Accident Investigation Branch

Safety Digest 1_09 (WEB).pdf - Marine Accident Investigation Branch

Marine AccidentInvestigation branchSAFETYDIGESTLessons from MarineAccident Reports1/2009MARINE ACCIDENT INVESTIGATION BRANCHis anINVESTOR IN PEOPLE

© Crown copyright 2009This 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:Marine Accident Investigation BranchFirst FloorCarlton HouseSouthamptonSO15 2DZPrinted 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 2009

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.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.”

INDEXGlossary of Terms and Abbreviations 6Introduction 7Part 1 – Merchant Vessels 81. Iron in the Fire 102. Chute for Safety 123. A Close Quarters Situation 144. Not Too Much Astern 165. Poor Planning = Poor Performance 186. CO Poisoning – It’s a Gas! 207. Non-Routine Manœuvre Leads to Contact 228. Dangerous Cargo – it Did What it Said on the Tin 259. Stopped in Time – Just 2910. New Beginning, Old Problem 3111. Early Preparation Can Save a Lot of Trouble Later On 3412. Oh Dear – It’s Happened Again 3713. Close to the Edge 40Part 2 – Fishing Vessels 4414. Watch Where You’re Going 4615. Lucky to Survive 4816. Foundering – Always Check Why Bilge Alarms Sound 5017. The Blind Leading the Blind 5318. No Safety Training, Faulty Fire Detectors and Emergency Equipment – 56A Sorry Tale of WoePart 3 – Small Craft 6219. A Not So Lucky Escape 6420. Hold On Tight, If You Can 6621. Can’t See Him? Then Alter Course 7022. “It Can Happen to the Best of Us” 7223. Excess of Alcohol Contributes to Four Accidents 7424. The Importance of Electrical Isolations 7625. Two Wrongs Don’t Make a Right of Way 79

APPENDICES 81Appendix A – Preliminary examinations and investigations started 81in the period 01/11/08 to 28/02/09Appendix B – Reports issued in 2008 82Appendix C – Reports issued in 2009 84Glossary of Terms and AbbreviationsAB – Able seamanAIS – Automatic Identification SystemARPA – Automatic Radar Plotting AidC – CelsiusCable – 0.1 nautical mileEmS – Emergency ScheduleEPIRB – Emergency Position Indicating Radio BeaconGPS – Global Positioning SystemGRP – Glass Reinforced PlasticHP – HorsepowerHSE – Health and Safety ExecutiveICS – International Chamber of ShippingIMDG – International Maritime Dangerous Goods CodeIMO – International Maritime OrganizationISM – International Safety Management Codekg – kilogramm – metremm – millimetre“Mayday” – The international distress signal (spoken)MCA – Maritime and Coastguard AgencyMES – Marine Evacuation SystemMGN – Marine Guidance NoteMSN – Merchant Shipping NoticeOOW – Officer of the Watch“Pan Pan” – The International Urgency Signal (spoken)PEC – Pilotage Exemption CertificatePLC – Programmable Logic ControllerRIB – Rigid Inflatable BoatRNLI – Royal National Lifeboat InstitutionRo-Ro – Roll on, Roll offrpm – Revolutions per minuteRYA – Royal Yachting AssociationSMS – Safety Management SystemSOPEP – Shipboard Oil Pollution Emergency ProgramTSS – Traffic Separation SchemeVHF – Very High Frequency

IntroductionI was disappointed recently to learn that some of our readers still misunderstand what ourSafety Digest tries to achieve, and how it fits in with the rest of our work. An experiencedseafarer, who professed to be an avid reader of the Safety Digest, complained to me that thelessons identified were normally “pointing the finger” at the mariner rather than looking atthe broader aspects of the incident.When the MAIB investigates an accident or incident, our primary “output” isrecommendations to try to prevent such accidents recurring. We work hard with theindustry to try to identify the most appropriate recommendations, and we make them tothe apposite body. It is very rare that such recommendations are made to individualseafarers; nearly all are focused at systems, companies, trade bodies and regulators.Nevertheless, there are always lessons for the seafarer to learn, and indeed we believe thatjust reading about accidents – and so thinking about accidents – helps to make us all moresafety conscious. Thus, the Safety Digest is primarily aimed at getting the lessons fromaccidents and incidents out to the seafarer, and we have other ways of promulgating theimportant safety messages to the rest of the industry. I hope this helps clarify the focus ofthe lessons that appear in these pages.One small change we have introduced in this edition, is to re-categorize one of the threesections of the Safety Digest. The replacement of the “Leisure Craft” section by “SmallCraft” allows all appropriate incidents and accidents to be brigaded together without thepedants pointing out that, if commercially operated, they cannot be classed as leisure!However, I would still urge readers to look at every case – the more we understand aboutthe problems that other seafarers face, the more we can operate safely together in ourcommon environment.Stephen MeyerChief Inspector of Marine AccidentsApril 2009MAIB Safety Digest 1/20097

Part 1 – Merchant VesselsOn reviewing theincidents detailed inthis safety digest myfirst reaction wasconcerning the widerange of difficultcircumstances facedby seafarers as theygo about their dailyduties. It istestament to theirprofessionalism that accidents and incidentsare, thankfully, comparatively few in number.We are all aware of the wonderful science ofhindsight, and for those of us who now ‘pilot’a desk it is always an easy option to blamethe crew!A seafarer is, and always has been, a ‘Jack’ of alltrades and is expected to face challengingsituations and take the correct decisions –often under the constraints of adverseconditions and time pressure.It is not surprising to see the same lessonsbeing learned time and again: resourcemanagement, complacency and lack oftraining.The importance of bridge team training isstressed over and over again, yet frequently weread of the Master, isolated in command, beingovertaken by events with his support teamoblivious to developments. Is this a culturalissue generated by dictatorial Mastersconfident in their own invulnerability, timidjunior officers blissful in their ignorance, orcomplacency resulting from familiarity,boredom and routine?I cannot doubt that there may be poormanagement systems and that active seafarersare probably better able to write and reviewsystems than their office based counterparts.But shore management have failed in theirresponsibilities if their Masters and crews feelthey cannot, and should not, influence thedevelopment of systems; or even worse, that‘it is not worth the effort’ because nothing willbe done anyway!I also question whether in respect ofmanagement systems there may be an elementof ‘paper armour’: crew members aredelegating their safety to the ‘system’ (riskassessment, tool box talks etc.), in the belief thatcompliance with the system negates all risks andtherefore absolves them of the need to considertheir own safety and that of their colleagues.Complacency, or as coined in this report ‘taskfamiliarity’, is one of the greatest threats to themariner. Much of what we do is repetitive:planning, navigation, watch keeping,maintenance and cargo operations.Complacency is not easy to detect, particularlywhere it develops over time. When tasksbecome routine they become dangerous.Accidents can happen to the best of us; in factthey often do happen to the best of us becauseour perceived ability caused us to developfeelings of invulnerability. It is said that ‘thecapability to know and follow authoritativeguidance is the mark of a professional’.Because we become an ‘expert’ at one thing itdoes not mean that we should becomecomplacent about others; professionalism isabout being balanced.Perhaps once we recognise that a problemexists, we will be better placed to solve it. Inthe oil and gas industry, ashore and afloat,people were familiar with HSE guidance and ingeneral made efforts to put in place systemsthat were designed to manage risk and preventaccidents. By contrast, the marine world stilltends to be characterised by ‘macho’ can-doattitudes, and the belief that accidents areinevitable and simply part of getting the jobdone; act now – risk assess later.We must all show and encourage respect forevery position onboard, and recognise that8MAIB Safety Digest 1/2009

everyone onboard is a professional. If anyindividual believes that their role is not valuedthen there will be more of a tendency to slipinto ‘rogue’ behaviour.Let’s not underestimate the issue, maintainingvigilance in an atmosphere that nurturescomplacency is an awesome challenge.Management at all levels (onboard and ashore)must support a culture of compliance.Ignoring or missing a non-compliant act orcircumstance is as good as endorsing it.Finally, as we all know, there can also be atendency to know and love the rogues; ‘he’s thebest ship handler in the company and alwaysdoes it that way’…, yes he’s ‘Teflon coated’ …alright until it all goes horribly wrong.‘Experience is the best teacher’, but ‘the wisestlearn from the experience of others’.Alastair EvittAlastair is a Master Mariner and has spent over 33 years in the marine industry. He spent 15 years at seabefore coming ashore to work in Ship Management in 1990. Of his 18 years in Ship Management, 5 werespent in Cyprus as Operations/Division Manager and 8 in Singapore as General Manager/Managing Directorfor a large third party ship manager.Alastair has sat as a committee member on both the Cyprus Shipping Council and the SingaporeShipping Association and was honoured to be appointed as a Councillor to the Singapore ShippingAssociation in 2003.In 2004 Alastair returned to the UK to take up his present position as Managing Director of Liverpool basedMeridian Marine Management.MAIB Safety Digest 1/20099

CASE 1Iron in the FireNarrativeA general cargo vessel was scheduled to loadferrous cuttings which included cast ironfilings. The cargo was designated as UN 2793 –Ferrous Metal Borings, Shavings, Turnings orCuttings, and was delivered directly from theengineering works to the dockside. Ondelivery, it was noticed that the cargo alsocontained cutting oil and other combustiblematerials including plastic bottles and rags.The waste disposal contractor carried out thetemperature checks as required in the Code ofSafe Practice for Solid Bulk Cargo 2004, andalthough it was confirmed that the temperaturewas below the maximum 55°C required, thiswas not formally recorded. At 2200 cargoloading was suspended until the followingmorning but, despite it starting to rain, none ofthe hatch covers were put in place.At about 0235, the duty AB detected a smallfire in the open hold. He alerted the crew, whoattempted to extinguish the fire. However, thiswas unsuccessful. At 0308 the local fire andrescue service attended the vessel and beganto douse the cargo with water (Figure 1). Theship’s master and harbour authorities advisedagainst using large amounts of water becauseof potential stability concerns. At about 0330the fire was declared to be under control, andthree out of the five fire tenders providingassistance were released.At 0530 the cargo loading crane driver arrived,and an hour later he started to remove thesmoking cargo to the dockside, where it wascooled down once more. The temperature ofthe hold cargo was constantly monitored; itreached a maximum of 93°C (Figure 2). Thecargo and hold water removal, and cargore-load took a further 60 hours.Figure 110 MAIB Safety Digest 1/2009

CASE 1Figure 2The LessonsThe cargo was liable to self-heat and ignitespontaneously because it contained fineshavings contaminated with cutting oil, castiron borings and organic flammablematerials.The self-ignition risk was increased becausethe simple precaution of closing the holdhatches had not been taken. The Code ofSafe Practice for Solid Bulk Cargo 2004specifically highlights that cargo loadingshould not be undertaken in wet conditions,and that hatch covers should be closed whenthe hold is not being worked.The master relied on the waste managementcontractor to ensure that the cargo was safeto load. In this case, the temperature wasreported to be compliant with theregulations, but it was not recorded. Inaddition, no attempt was made to remove theorganic matter, which significantly increasedthe risk of self-ignition.To prevent the risk of self-ignition, thefollowing precautions should be taken as laidout in the Code of Safe Practice for SolidBulk Cargo 2004:1. The temperature of UN 2793 cargoesshould be recorded by the wastemanagement contractor. Prior to loading,the temperature taken from between200-350mm into the pile should notexceed 55°C.2. If the cargo temperature exceeds 90°Cduring loading, operations should bestopped until the temperature has fallenbelow 85°C.3. A vessel should not depart unless thetemperature is below 65°C and hasshown a steady downward trend for atleast 8 hours.4. Cargo loading should be suspendedduring wet conditions, and the holdhatches should be closed when the holdsare not being worked.MAIB Safety Digest 1/200911

CASE 2Chute for SafetyNarrativeA ro-ro passenger ferry was conducting aroutine deployment of one of its MarineEvacuation Systems (MES) as part of a plannedinspection. The ferry was alongside andarrangements had been made for 50 crewmembers to use the system and then to berecovered from the liferafts. The equipmenthad been installed between decks and wasmounted on a carriage that slid out from theship’s side. Liferafts, connected to the ship byvertical chutes, were then tipped into thewater.Representatives from the equipmentmanufacturer were in attendance. They madetheir own checks of the system and confirmedthat it was configured correctly. The crewactivated the evacuation system, and soonafterwards heard loud noises coming from theoperating system. The carriage was seen tomove outboard, but it caught on the forwardof the two outer doors, which was onlypartially open. It moved upwards and twisted,breaking the deck plates loose. One shoot boltengaged at the end of the sliding travel, butthe other did not operate and the carriagetwisted, causing the hydraulic operating ramsto shear off their mountings. The liferafts weretipped off the carriage and landed in the water,where they inflated as normal.Once the carriage had stopped moving, thedamage was inspected. The boarding area wasdistorted, grab rails could not be assembled,and it was not possible to determine howsecurely the chutes were attached to the ship’sside. The risk of using the chute wasconsidered too great.With all the preparations in place, it wasdecided to deploy a second MES on board.This was checked by the manufacturer’srepresentatives and operated by the crew. Thecarriage began to move outboard but, again,had difficulty opening the outer doors. Thedoors opened further than on the previoustest and the carriage was able to move to itsrequired position. The rafts and chutesdeployed, but during the process of heaving inthe bowsing wires to secure the raftsalongside, the wires were snagged by heavycorrosion in the guiding channels, and theyparted under tension. The evacuation exercisewas cancelled and an investigation began.Inspection of the outer door mechanisms ofboth MESs found that the outer door hingeswere extremely stiff to move and could not beopened as intended. The hinges weremounted on the outside of the ship and,although designed for use in a marineenvironment, had deteriorated significantly. Inthe first instance, the carriage had then caughton the door structure, causing it to ride up asit moved outboard. Manufacturing errors inthe shoot bolt prevented it from engagingcorrectly, allowing the carriage to twist anddamage the hydraulic cylinders.In the second instance, the liferaft bowsingwires had seized in their aluminium channels,on the ship’s side, due to a build up ofcorrosion deposits within the channels.Although the crew conducted weekly andmonthly inspections of the equipment, therewas no requirement for them to test ormaintain the door hinges, and these were onlyever operated during the annual deploymentor service exchange of liferafts. Inspection ofthe other outer doors on the vessel, and on asister vessel, found they were all difficult tooperate and had the potential to disrupt thedeployment of the MES. Access to the hingesand bowsing wire mechanism could only beachieved by using specialist equipment fromashore, and the time available to do this waslimited by the vessel’s operational schedule.The equipment manufacturers conducted aninvestigation into the failures and identified anumber of system modifications designed toprevent future, similar deployment problems.12 MAIB Safety Digest 1/2009

CASE 2MES System showing liferafts connected to ship by vertical chuteThe LessonsOperators of ships fitted with MESs shouldsatisfy themselves that all the components inthe activation and release system areincluded in an inspection and maintenanceroutine. Time and resources must beallocated to ensure that this essentialequipment is in an acceptable condition andwill work correctly when required.MAIB Safety Digest 1/200913

CASE 3A Close Quarters SituationNarrativeA large passenger ship was transiting the southwest lane of a Traffic Separation Scheme (TSS),steaming at 21 knots at night in good visibility.A cross channel ferry was departing port tohead for the continent. Once clear of thebreakwater, the ferry’s master assessed thetraffic in the TSS before deciding how to crossit. He observed both visually, and on radar, thepassenger ship on his port side at a range of 6miles, almost on a steady bearing, which wouldresult in the two vessels passing very close toeach other in 12 minutes.The ferry’s master decided to set his courseand speed to make it clear that his was thestand-on vessel, and that the passenger shipwas the give-way vessel. Once steady on coursethe master handed over to the OOW,remaining on the bridge to monitor thedeveloping situation.The passenger ship’s bridge team for thetransit of the strait consisted of a senior OOW,Screenshot from Traffic Separation Scheme data14 MAIB Safety Digest 1/2009

CASE 3a junior OOW and a lookout. For the transit ofthe TSS, the team was supplemented by thedeputy master, who was observing andchatting to the senior OOW. The senior OOWnoted the ferry’s departure from port, but hedid not discuss this with the other bridge teammembers as he was engaged in conversationwith the deputy master. The senior OOW,himself an experienced ferry officer, expectedthe ferry to set a course to pass clear aroundthe passenger vessel’s stern, and hissubsequent monitoring of the ARPA failed toidentify that the ferry’s bearing was almoststeady.Acting in accordance with the COLREGS, theferry’s OOW maintained his course and speed(18 knots) as he and the master monitored theactions of the passenger ship. Noting that thepassenger vessel was not giving way, theyrepeatedly signalled, using five or more shortflashes by Aldis Lamp to indicate they wereunsure of her intentions. As the distancebetween the two vessels closed to 2 miles, withthe anticipated passing distance being 0.3 mile,the ferry’s master considered that thepassenger ship was taking insufficient action toavoid a collision, and instructed the OOW toreduce speed to around 12 knots.As the passenger ship passed 0.6 mile ahead ofthe ferry, the ferry’s master called thepassenger ship by VHF radio to advise them ofhis actions and to give his opinion on theapparent poor seamanship of the passengervessel’s bridge team.The Lessons1. The passenger ship’s bridge team did noteffectively assess the risk of collisionwith the approaching ferry, so took noaction as the give way vessel. Specifically:• The senior OOW’s mistake in notidentifying the risk of collision wentunnoticed by the other bridge teammembers as they were notcommunicating effectively.• The ship’s deputy master was notintegrated into the team and hispresence probably hindered, ratherthan helped, the bridge team.• Neither the junior OOW nor thelookout supported the team in alertingthe senior officers to the approachingdanger.Effective bridge teams require more thanadditional personnel; successfulcommunication can be achieved only wheneach team member is fully aware of theirrole.2. In choosing how to cross the TSS, theferry’s master had the option to avoid aclose quarters situation developing.However, he chose to act as the stand-onvessel and so created the risk of the twovessels colliding.3. By the time it was apparent to the ferry’smaster that the passenger vessel wastaking no action to avoid a collision, thevessels were only 2 miles apart andclosing at 25 knots. Had the passengership altered course to starboard as theferry slowed down, the situation wouldhave become confusing and the risk ofcollision significantly increased.MAIB Safety Digest 1/200915

CASE 4The Lessons1. The tanker was equipped with groundstabilised radar, log and GPS, all ofwhich indicated that she was makingsternway. However, because the berthingpilot had positioned himself on the portbridge wing, he was unable to monitorthe instrumentation. He was thereforeestimating the vessel’s movement by eye,a particularly difficult task at night withfew visual clues. The master, OOW andsea pilot were all in the wheelhouse, andwere in a position to advise the berthingpilot of the vessel’s movement and of theproximity of the container ship. Yet theyfailed to do so.2. Part of the bridge team’s job is tomonitor the actions of the pilot and,where doubt exists, confirm with him hisintentions. The team should also providesupport to the pilot as appropriate.Equally, the pilot should be proactive inrequiring support from the vessel’s bridgeteam. Once the turn had started, thebridge team failed to alert the pilot to thefact that the ship was gaining sternway,or to give updates on the position andmovements of the container ship. Themaster had positioned himself on thestarboard side of the bridge, from wherehe could see the container ship, but hecould not see the pilot. He was thereforenot in a position to effectively monitor,or question, his actions.3. As the incident occurred close to thetime of high water, there was sufficientdepth of water available for the containership to pass outside the main channel.The pilot of the container ship couldhave altered the vessel’s course to passthe channel marker buoys on the “wrongside”, thereby increasing the passingdistance with the tanker. This is amanoeuvre that is discussed during pilottraining, but it was not carried out onthis occasion.4. The VHF radio conversations betweenthe pilots of the two vessels lackedformality, and relied on task familiarityto correctly interpret intentions. Theagreement for the container ship to passwhile the tanker was still turning, tookinsufficient account of where in thechannel the tanker would be at the timeof passing, or how much room thecontainer ship would require to passsafely.5. The port in question operated a TrafficOrganisation Service and recognised thatlarge laden tankers transiting through itincreased the dangers within the port.However, no specific requirements werepromulgated for other vessels to remainclear while the turn for berthing wascarried out.MAIB Safety Digest 1/200917

CASE 5Poor Planning = Poor PerformanceBerthed vesselApproaching vesselCCTV footage of vessel approaching occupied berthNarrativeA 17,000 tonne ro-ro vessel had justcommenced a new time charter and wasmaking her first entry into one of the ports onher new route. The bridge team was relativelyinexperienced and had not worked togetherbefore. The team consisted of the master, whohad recently joined the vessel and had noprevious experience of ro-ro vessels; the chiefofficer, who was newly promoted and was onthe bridge for only the second time in thisrole; and a charterer’s representative, whoheld a Pilotage Exemption Certificate (PEC) forthe port but had no ship handling experienceand had only joined the vessel the eveningbefore the accident.As the vessel approached the port, which wasentered from a river via a lock, the master, chiefofficer and PEC holder discussed the tidalconditions and the manoeuvre required forentry to the lock. It was not clarified as to whowould perform the manoeuvre and there wasan assumption on behalf of the master and thePEC holder, based on their previousexperience, that the other would be taking thecontrols. In the event, the vessel wasmanoeuvred into the lock with both the masterand PEC holder making control interventions.In the lock, the PEC holder sought to reassurethe master, who was clearly uncomfortable andunfamiliar with manoeuvring a vessel in aconfined area. Once the lock had filled, thevessel entered the dock and made her waytowards the berth which the PEC holderassumed she would be using. Proceeding sternfirst, both men again were making controlinterventions as she approached the berth,which was not visible from the bridge wingcontrol position from which the master andPEC holder were controlling the vessel. Anofficer, who was stationed aft, relayed thedistances of the stern from the shore andother vessels in the dock.18 MAIB Safety Digest 1/2009

CASE 5When the vessel was close to the berth, theofficer aft started to report a rapidly decreasingdistance from another vessel, which the PECholder assumed was on an adjacent berth,until the officer reported that the stern wasless than 10 metres from the other vessel,which they were about to hit.The PEC holder ran across to the other bridgewing and realised, just as contact was made,that the other vessel was, in fact, on the berthhe had expected his vessel to occupy. Thecontact caused material damage to bothvessels.The Lessons1. If the passage had been properly plannedfrom berth to berth, and discussed, thecollective lack of ship handlingexperience and training within the bridgeteam would have been highlighted at anearly stage, and consideration could havebeen given to employing a pilot.2. In addition to passage planning, had thechief officer and the officer aft beenproperly briefed for the berthing operation,they would have been able to contributefully to its successful completion.3. A few days before the accident, theCompetent Harbour Authority for theport added the vessel to the PEC holder’scertificate. The addition was made on thebasis that the vessel was similar in size toanother vessel already on his certificate.However, no check had been made toensure the PEC holder was a competentship handler before issuing him with hiscertificate.4. When the vessel was chartered, the PECholder was appointed to the vessel as thecharterer’s representative to performpilotage duties. He was not signed on thevessel’s crew agreement and was not herbona fide master or first mate as requiredby the Pilotage Act 1987, and he wasnot therefore fully integrated with thevessel’s bridge team.5. An assumption was made by thecharterer that the vessel’s master wouldbe trained and experienced in shiphandling. The owner, in turn, assumedthat the PEC holder would be trainedand experienced in ship handling.In the event, neither had the necessarytraining or experience, and they wereplaced in a difficult situation that couldhave been avoided if their respectivemanagers had made an appropriateassessment of their ship handlingexpertise before appointing them to thevessel.MAIB Safety Digest 1/200919

CASE 6CO Poisoning – It’s a Gas!NarrativeDuring the winter months, the crew of a riverlaunch started to suffer from headaches,nausea, dizziness, sore throats and, in somecases, fast and irregular heartbeats. When oneof the crew visited his doctor, he wasdiagnosed with asthma and was prescribed aninhaler. However, his symptoms persisted.Blood tests were conducted on all the crew,which indicated they were suffering fromcarbon monoxide poisoning.The source of the carbon monoxide wasinitially thought to be a space heater fitted inthe river launch, which had been experiencingmechanical problems. The heater wasremoved, serviced and tested. As its carbonmonoxide emissions were found to be normal,it was then re-fitted to the launch. However,the crew’s symptoms continued.Further checks were made and a small splitwas found in the heater’s exhaust piping in thewheelhouse (figure). It was also determinedthat the heater’s air intake piping had beenmodified. Instead of drawing air from thewheelhouse, the air supply for the heater wasfrom the engine compartment. Consequently,air contaminated by leaked engine exhaustgases was being supplied directly into thewheelhouse.After the heater’s exhaust piping was repairedand its air intake ducting reconnected to a ventgrill, as intended, no further illnesses werereported. A carbon monoxide detector wasalso fitted in the wheelhouse.Heater exhaust pipe with crack indicated at the 4cm mark on the ruler20 MAIB Safety Digest 1/2009

CASE 6The LessonsSpace heaters are widely used in launches,fishing boats and tugs, usually withoutproblem. However, as this case shows, wherea space heater is fitted incorrectly or ispoorly maintained, the possibility of carbonmonoxide poisoning is increased. Therefore:1. Space heaters, including their air supplyand exhaust ducts need to be regularlymaintained and inspected.2. Crew should be protected by the fittingof carbon monoxide detectors and by thesupply of fresh air to compartmentsserved by space heaters.3. All personnel need to be aware of thepotential health hazards which can arisefrom both noxious and less obviousfumes.MAIB Safety Digest 1/200921

CASE 7Non-Routine Manœuvre Leads toContactDamage to fendersNarrativeAn 18,425 tonne passenger ro-ro vessel wasdeparting from port in strong winds when itmade contact with fendering at the edge of themain channel.The vessel’s routine departure, in favourableweather conditions, was to depart stern-firstbefore turning around when clear of thebreakwaters. On the night of the accident, thewind was strong to gale force, producing aheavy swell outside the harbour. The master,who held a Pilotage Exemption Certificate,decided to swing the vessel at the berthbecause he did not wish to depart stern-first insuch conditions. He had seldom performedthis manoeuvre previously.Before departure, the master had briefed theofficers on the intended manoeuvre to ensurethe vessel was turned as tightly as possibleowing to the relatively confined swinging area.The swing progressed to plan until the vesselcame beam on to the strong wind when herstern started to slide along the berth. Themaster then applied more power to enginesand thrusters to speed up the swing.This additional power caused the vessel to gofurther ahead than anticipated, and increasedthe size of the swinging circle such that, oncompletion, she was closer than planned tothe starboard side of the channel. With thevessel now at the edge of the channel andclose to shallow water, she experienced bankeffect. This drew her into the bank and22 MAIB Safety Digest 1/2009

CASE 7resulted in her starboard side making contactwith wooden fendering at the side of thechannel as she proceeded out of the port.Once clear of the breakwaters the masterreported the accident to the port authority. Itwas then discovered that water was enteringone of the vessel’s void spaces. Havingestablished that the vessel’s bilge pumps werecapable of coping with the rate of water ingress,the master decided to continue on passage tothe vessel’s next port. He contacted the shipmanager’s crisis team and kept them advised ofthe situation, but did not advise the coastguard.On arrival at the next port, an inspection of thehull was carried out, which revealed that thevessel was holed below the waterline. She wastaken out of service for almost 2 weeks whilerepairs were undertaken. The contact causedsignificant damage to a large area of fendering,which led to the port authority revising itsguidelines for the berthing and unberthing ofvessels in strong winds.Damage to hullMAIB Safety Digest 1/200923

CASE 7The Lessons1. The master decided to perform a nonroutinemanoeuvre when he judged thatthe weather was too poor for the vessel’snormal departure manoeuvre. Themanoeuvre had been seldom performedpreviously and had not been practised infavourable conditions. Ship managers,particularly of vessels operating onregular runs, should ensure that crewsare properly trained and remain capableof performing all requisite manoeuvresfor their vessels.2. The planning of non-routine manoeuvresrequires special consideration and goodplanning to ensure that everyoneinvolved understands their role in theexecution of the plan. The chief officercame to the bridge just before departureand was not fully briefed. He would havebeen able to provide more effectivesupport to the master if he had beeninvolved in the planning process.3. The port authority had introducedweather limits for berthing andunberthing large vessels. However, theeffects of strong winds from varyingdirections on different berths within theport had not been fully considered.When undertaking risk assessments inaccordance with the requirements of thePort Marine Safety Code, portauthorities should consider the impactwinds of varying strengths and directionshave on the safe use of the port.4. The master held a Pilotage ExemptionCertificate (PEC) for the port, which heobtained following satisfactorycompletion of assessment trips invarying wind conditions. Despite this,he was not prepared for the conditionson the night in question as he did notregularly perform the manoeuvre.Competent Harbour Authorities shouldensure that PEC holders remainexperienced in manoeuvring their vesselsin all relevant weather conditions whenrenewing the certificate on an annualbasis.5. The vessel was holed and making water.Fortunately, the vessel’s pumps were ableto deal with the water ingress on thisoccasion. The master should have alertedthe coastguard to the situation as soon ashe was aware that his vessel was makingwater. Also, the ship managers shouldhave ensured that the coastguard wasinformed of the situation as part of theircrisis response plan. Early notificationand regular updates to the coastguardwill ensure they are able to provide amore effective response should asituation deteriorate.24 MAIB Safety Digest 1/2009

CASE 8Dangerous Cargo – it Did What itSaid on the TinFigure 1NarrativeA 20 foot container was stowed on top of a 30tonne tank container. When the 20 footcontainer was lifted during discharge, theautomatic midlocks securing the container tothe tank container did not immediatelydisengage as designed. Consequently, the tankcontainer was lifted between 30cm and 50cmbefore it dropped back to deck. The impactcaused the tank frame to buckle and resultedin the release of a small quantity of the tank’scontents (Figure 1). The crew immediatelyplugged the deck scuppers and spreadsawdust over the deck to absorb the spilledliquid.MAIB Safety Digest 1/200925

CASE 8Figure 226 MAIB Safety Digest 1/2009

CASE 8The chief officer quickly identified the contentsof the tank as hydrogen peroxide, and consultedthe appropriate substance information sheet onthe ship’s dangerous cargo database. Themaster informed the shore authorities of thespillage while the crew were mustered on thepoop deck; the ship’s ventilation was alsoisolated. As no inert absorbent material wascarried on board, additional sawdust was spreadaround the container by crew wearing positivepressure breathing apparatus, rubber glovesand boots. Approximately 15 minutes after thespillage, the local emergency services arrivedand established an exclusion zone around thevessel. Several of the crew were medicallyexamined by shore-based medical staff and,although an AB was sent to hospital for tests,there were no injuries.Following inspection, the tank was transferredashore (Figure 2) and, shortly afterwards, thesawdust on the deck was swept up and putinto open plastic containers. These were thenplaced with the SOPEP equipment in thefoc’sle store. Before leaving the vessel, thelocal emergency services advised the vesselthat sawdust was not an appropriate absorbentmaterial to deal with IMO class 5.1 oxidisingagents such as hydrogen peroxide due to therisk of self-ignition.About 1 hour after the sawdust had beencleared, smoke was seen coming from thefoc’sle store. The alarm was raised and thecrew were again mustered on the poop deck.Two fire-fighting teams, wearing breathingapparatus and fire suits, fought the fire usingwater hoses, and it was extinguishedapproximately 20 minutes after beingdiscovered. The local emergency servicescleared the compartment of smoke andinspected the damage (Figure 3).Figure 3MAIB Safety Digest 1/200927

CASE 8The fire was started by the self-ignition of thehydrogen peroxide-impregnated sawdust,which generated oxygen and heat as itdecomposed. All of the contaminated sawdustwhich had not been burned was taken ashoreand disposed of as hazardous waste.The Lessons1. The inadvertent release of a harmfulsubstance usually requires immediateaction to be taken. However, if suchaction is not in accordance with theguidance provided in the IMDG CodeEmergency Schedules (EmS), thepossibility of injury to personnel, harmto the environment, and damage to thevessel is increased considerably. In thiscase, the applicable schedule recommendsthat hydrogen peroxide be washedoverboard using water hoses, or absorbedwith an inert material – NOT sawdust.Had either of the recommendedmeasures been taken, the subsequent firewould have been prevented.2. The spillage of a dangerous substancecannot be safely dealt with if theequipment recommended in the IMDGCode is not carried, or if insufficientquantities are held. Has your companygiven any thought to what might berequired to deal with the substancescarried?3. Materials impregnated with a harmfulsubstance following a spillage are liableto be hazardous in a number of ways, andtherefore must be treated with extremecaution. Disposal ashore – at the earliestopportunity – is the easiest way ofminimising the exposure to any risk.28 MAIB Safety Digest 1/2009

Stopped in Time – JustCASE 9NarrativeA ro-ro ferry was fitted with moveable cardecks which could be raised to a stowageposition at the deck head, or lowered for use.When in use, the deck was lowered to allowthe cars access, and then raised to a halfwayposition to allow further cars to be stowedunderneath. When in the halfway position, aseries of solenoid activated pins was engagedwith the ship’s structure to secure the deck inplace.A deck with a full load of cars had been liftedto the half-way position. An attempt was thenmade to activate the solenoid to engage theforward pins. However, the solenoid failed,and the pins had to be engaged manually. Thisheld the deck safely in position for the voyage.The ship’s electrician exchanged the defectivesolenoid for a spare during the voyage, but hewas unable to test the replacement owing tothe cars stowed on the deck.On arrival at the next port, the cars below themoveable deck were discharged. Because ofthe previous problem, the electrician and thesecond engineer were in attendance while anAB started the procedure to lower the deck. Ashe operated the controls for the solenoid towithdraw the securing pins, the fuse blew,leaving the pins engaged. It was decided tooperate the deck raising/lowering system onemergency override, which used storedhydraulic pressure. To release the securingpins, the deck first had to be raised to removethe weight on the pins. The electrician tried todo this by manually operating the appropriatehydraulic valve, but there was insufficienthydraulic pressure to lift the deck so thesecond engineer started the hydraulic pump topressurise the system. Almost immediately, thedeck started to rise. The stop button on thecontrol panel was pushed in an attempt to haltthe movement. However, this had no effect, sothe second engineer ran back to the hydraulicpump controls to stop the pump.Unfortunately he was unable to do so beforesome of the cars had been damaged.MAIB Safety Digest 1/200929

CASE 9The Lessons1. The hydraulic valve operated by theelectrician had become stuck in the“raise” position. This meant that as soonas the system was pressurised, the deckbegan to rise. Maintenance routines havesince been amended to ensure thecontinued cleanliness of the valves andactuators in all of the hydraulic systemson board.2. Operating the emergency stop had noeffect in this case. The design of thesystem was such that the emergency stopoperated on the Programmable LogicController (PLC), the “brain” of thesystem. Since this had been overridden,it was only when the hydraulic pumpwas stopped that the deck stoppedmoving. What does your emergency stopbutton do?Following this accident, the company, inpartnership with the hydraulic system’smanufacturers, reviewed the emergencystop system on the moveable car decks,and also on the other ramps and doorswithin the ship to determine what wasstopped when the emergency stop buttonwas activated. Where necessary, thesystem was modified to ensure that theemergency stops not only shut down thePLC, but also shut off the power to thehydraulic pumps, ensuring that inwhichever mode the system was beingoperated, pressing the stop button wouldstop the operation at source.3. The practice was to lower the moveablecar deck with the passengers seated intheir cars. On this occasion, with theoperating system not functioningcorrectly, the passengers remained intheir cars, while attempts were made tolower the deck by alternative means. Themalfunction which caused the deck torise, and to continue rising, wasfortunately remedied in time to preventany injuries, but not before some carshad been damaged. This routine has nowbeen changed, such that if the systemfails to operate, passengers are instructedto leave their cars until the deck hasbeen safely lowered.Manually overriding a system requirescareful assessment to ensure that it doesnot introduce unacceptable risks to theoperation.30 MAIB Safety Digest 1/2009

New Beginning, Old ProblemCASE 10NarrativeA ro-ro ferry had arrived in a UK port from drydock, where she had undergone a conversionfor operations offshore and been surveyed tostart the process for transferring her to the UKflag. The ship then remained in port, completingremedial work identified during the survey. Sixweeks later, she prepared to sail for her new taskfor the first time. She had been issued with anInterim Safety Management System (SMS)Certificate, and had not yet developed full SMSprocedures. Due to her size, both lock gatesallowing access to the river needed to be open,so departure was timed for high water.The pilot boarded, two tugs were inattendance and the crew went to stations. Themaster agreed to the pilot’s suggestion that hewould manoeuvre the ship off the berth andturn her, and then that the pilot would takeover to negotiate the locks and the riverpassage. During the process of letting go,sailing was temporarily delayed while it wasconfirmed that all passengers had boarded.Letting go having resumed, the pilot wentinside the bridge to collect his radio, and onreturning to the bridge wing found the shipalready moving off the quay.The master manoeuvred the ship sideways,parallel to the quay, and then began turningher to starboard. The pilot was standingforward of the engine control console, fromwhere he could see the position of the engineand bow thrust controls. However, he couldnot monitor the amount of rudder appliedbecause the steering gear was operated bypush button controls, and he was unable tosee the rudder angle indicator.Figure 1: The port quarterMAIB Safety Digest 1/200931

CASE 10No instructions had been given to the secondofficer stationed aft on the poop with respectto reporting clearing distances. However, sincethe poop was divided by the stern door, hehad stationed an AB on the port side, with aVHF radio and instructions to call the bridgewith distances off the quay if closing. As theturn progressed, and with the port quarterclosing the quay, the AB called the bridge byVHF radio several times, counting down thedistance. This was heard by the second officeron the starboard poop, but by no one on thebridge. The port quarter made contact, andscraped along the quay for approximately 30metres, dislodging a set of quayside bollards,before the pilot, who had now taken control,manoeuvred the ship clear.The ship then continued without furtherincident into the river. As the pilot boat’scoxswain passed the ship’s stern to take off thepilot, he reported to the master and pilot thathe could see a hole in the ship’s port quarter.Having inspected the damage internally andfrom the pilot boat, the master decided toreturn to port for repairs.Figure 2: The hole32 MAIB Safety Digest 1/2009

CASE 10The Lessons1. The ship was new to all the crew and,apart from two moves along the quay,had remained alongside during her 6weeks in port. This was their firstsailing, and it would be expected that themaster would talk his team through hisrequirements for sailing and theinformation he expected to receive fromeach member of the team, and how it wasto be reported. This failed to happen onthe basis that “we all know what we aredoing”. Did they? Do you?2. The master’s ship handling experiencehad been mostly with single screw ships.He was confident that his “twin-screw”experience was sufficient to enable himto safely manoeuvre the ship off theberth. However, since this was the firsttime he had manoeuvred this particularship, it would have been prudent to havethe pilot perform this manoeuvre.3. The pilot, by positioning himself wherehe could not see exactly how the masterwas manoeuvring the ship, was unable tomonitor his actions or to offer any advicewith respect to the ship handling. Therewere no other members of the bridgeteam in a position to monitor themaster’s actions either.4. The ship was operating with an interimSMS Certificate, as permitted for a shipnew to a company. Although procedureswere starting to be developed, thesemight not have been expected to beperfect for the first sailing. Advice isavailable from, among other sources, theICS Bridge Procedures Guide and theMCA ‘M’ Notices. These will assist informulating interim procedures whichwill, at the very least, provide a basis forsafe ship operation to which ship specificrequirements can be added at a laterstage.During the contact, a set of bollards wasknocked over, and the stern scraped alongthe quay, both of which had the potential tohole the hull. Yet no action was taken toassess the damage, either by contacting thepersonnel on the quay or by checkinginternally. Had the pilot boat coxswain notnoticed the hole, the ship would have sailedand the damage come to light only once thesteering gear compartment began to fill withwater. Owing to the position of the hole, thiswould probably have been during adverseweather, when repair would have been farmore difficult to carry out.MAIB Safety Digest 1/200933

CASE 11Early Preparation Can Save a Lotof Trouble Later OnNarrativeA 77,750 deadweight product tanker, in ballast,with a draught of 8.3m aft, was brought up to 8shackles on the port anchor in a bad weatherrefuge anchorage, in 20 metres of water. Theship had been arranged to berth in the nearbyharbour to make permanent repairs to a fracturein the hull and to replace the main engine turbocharger, which had failed the day before. Theturbo charger had been locked and the ship’sspeed was reduced to dead slow ahead, giving amaximum speed of about 4.5 knots.The master had chosen to anchor in thefurthest point in the anchorage from the leeshore, which was about 1 mile to the north ofthe ship’s position. He also chose this positionbecause it was in the lee of a prominentheadland and it was outside the main tidalstream. Knowing that bad weather wasforecast, the master considered using bothanchors in an open moor but decided that, inthe prevailing conditions, he did not have theengine power to obtain a wide enough spreadbetween the anchors. Consequently, thestarboard anchor was not made ready. Afteranchoring, the engine was placed on 10minutes’ notice.The wind overnight was south-west force 6 to7, and the morning’s forecast predicted southwestwinds of force 7 to severe gale 9,occasionally storm force 10, decreasing 4 attimes.At 0936, the ship began to drag her anchor tothe north and towards the shore line. TheOOW notified the master and the engine roomand, at 0951, the engine was started and theanchor party began weighing anchor. Themaster intended to anchor again in the originalposition. Following a temporary suspension inoperations due to a hydraulic line failure, theanchor was aweigh at 1039. With limitedengine power available, the master was unableto manoeuvre his ship to the south and shewas set in a westerly direction towards an34 MAIB Safety Digest 1/2009

CASE 11anchored coaster. The master went astern onhis engine to avoid the coaster, and the shipagain drifted to the north towards the leeshore. The anchor party was initially unable todrop the port anchor as the chain haddeveloped a twist. However, at 1111, the twistwas cleared, the anchor was dropped and theship was brought up to 9 shackles in the water.This arrested her drift at about 2 cables fromthe 10 metre sounding line.The master requested the assistance of aharbour tug to hold the ship’s head into wind,while he attempted to manoeuvre the shipback to her original anchor position. Onoverhearing communications between themaster and the harbour authority, thecoastguard mobilised a salvage tug, which wasalongside in the nearby harbour. At 1254, thesalvage tug made her tow, was made fast, andthe ship was towed alongside, arriving at 1700.MAIB Safety Digest 1/200935

CASE 11The Lessons1. The master was faced with a bad weatherforecast, the ship was anchored inrelatively close proximity to land, with ahigh freeboard giving a large windage areaand with very limited engine power. Inthis situation it would have been wise tohave increased the length of cabledeployed and to have prepared thestarboard anchor for letting go in case theship began to drag her port anchor.Additionally, the master could havelowered the starboard anchor onto the seabed to decrease the amount of yawing.2. Although the engine was placed on shortnotice, by the time the dragging wasdetected and the engine started, the shipwas already drifting at a significant rate.In not preparing the starboard anchor, anopportunity was lost to immediatelydeploy a second anchor. Additionally,more cable could have been veered onthe port anchor as an immediate measureto bring the rate of drift under control.3. In this case, the ship’s limited enginepower gave the master little choice otherthan to anchor in the shelter of the land.An alternative option would have beento heave to at sea. It must beremembered that anchoring equipment isdesigned and manufactured only formooring a vessel in moderate seaconditions, and for relatively shortperiods, while awaiting berth availability,orders or change of tide. The equipmentis not designed for anchoring off fullyexposed coasts in rough weather, whenhigh energy loads can cause damage tothe windlass and its components.36 MAIB Safety Digest 1/2009

CASE 12Oh Dear – It’s Happened AgainNarrativeA 79-metre cargo vessel was steaming southwestin calm weather and good visibility. Shehad loaded a cargo of timber and departed herload port earlier that evening. Although thevessel’s passage plan allowed for her to passoutside of a small island, the master, alone onwatch and with no lookout, chose to take theinshore route, passing between the inside ofthe island and the mainland. It was dark, andshortly after making an initial course alterationto effect his chosen route, the master fellasleep. He awoke 20 minutes later as the vesselgrounded on the island. It was close to hightide, and she listed heavily to port as the tidefell.A number of the crew were evacuatedovernight as a safety precaution. Theyreturned the following morning when thevessel was refloated on the rising tide, with tugassistance. Fortunately no pollution or injuriesoccurred, and following a diver’s examination,which revealed damage to the forepart of theunderwater hull, the vessel was allowed toproceed to a nearby port for furtherexamination and repairs.While alongside in port, a minor quantity ofgas oil was discharged overboard duringballasting operations. This had resulted from asplit between the ballast tank and an adjacentbunker tank, which had been caused duringthe grounding.Damage to hullMAIB Safety Digest 1/200937

CASE 12Vessel discharge38 MAIB Safety Digest 1/2009

CASE 12The Lessons1. The vessel was manned in excess of therequirements of its Safe ManningCertificate. However, although herrecorded hours of work and restappeared to comply with STCWrequirements, under deeper scrutinythese were seen to be impossible toachieve given the vessel’s tradingpatterns and working time in port.Owners and managers should ensure thatthe manning of their vessels takes intoaccount the demands of the vessels’trade, and not simply the statutoryminimum requirements.2. All too often, the MAIB receivesinformation about incidents involvinglone bridge wachkeepers. A number offactors can affect the lone watchkeeperincluding fatigue, lack of stimulation and“stuffy” bridge atmospheres. All can leadto drowsiness and, in the worst case,falling asleep. The benefits of a bridgelookout in addition to the watchkeepercannot be overemphasised regarding theircontribution to vessel safety. Owners andmanagers should ensure that, not onlyare their vessels adequately manned, butalso that personnel are utilised to theirbest effect in providing a safe lookout atall required times.3. While safety management systems are aprerequisite to any good managementsystem, whether under ISM or not, auditprocedures should be robust, to ensurethat “what is written is what ishappening”. Owners and managers shouldcontinually review their audit proceduresto ensure they remain strong and target allareas of the vessel’s safe operation.4. Following suspected damage, a diver’sexamination can, at best, give only anindication of the condition of theexternal hull, and this is very muchdependent on the diver’s experience, andthe conditions during the dive (visibilityetc). Masters and superintendents shouldbe aware that following a grounding,internal damage – which is notimmediately apparent – may be present,so they should proceed with cautionuntil the vessel has been thoroughlyexamined, both externally and internally,in way of any areas of damage.MAIB Safety Digest 1/200939

CASE 13Close to the EdgeNarrativeA container vessel was in dry dock, undergoingrepairs when a fitter fell to his death in anopen cargo hold.The fitter was carrying out general weldingwork on deck, which included welding andburning of cargo hatch fittings. Meanwhile,crew were cleaning ballast tanks throughaccesses in the cargo hold beneath where thefitter was working. The ship’s SafetyManagement System (SMS) required workpermits to be issued for confined space entry(ballast tanks), hot work outside theworkshop, and for working aloft (higher than2 metres). Work permits had been issued forthe ballast tank and hot work operations, butnot for working aloft as, with the hatchesclosed, there was no danger of falling morethan the specified 2 metres.Despite a requirement under the vessel’s SMSprocedures for hot work to be supervised, thisparticular hatch top work was not monitored,and after completing several hot work tasksthe fitter left his tools on the hatch cover whilehe took his lunch break. Meanwhile, the chiefofficer opened the after half of the hatch coveron which the fitter had been working to allowlight into the hold to help the crew who werecleaning in the ballast tank below. Beforeopening the hatch cover he moved the fitter’stools, leaving them close to the unguardededge of the adjoining forward hatch cover.When the fitter returned from lunch he foundThe tools used by the fitter40 MAIB Safety Digest 1/2009

CASE 13Vessel's cargo holdMAIB Safety Digest 1/200941

CASE 13the after section of the hatch cover open andhis tools moved forward. He then continuedhis work close to the edge of the forwardhatch cover some 10 metres above theunprotected open hold.About 5 minutes into this work, the fitterrequested that the after hatch cover be closed,to allow him to continue working safely.However, in response, the chief officer, whowas working in the hold below, told him tomove his equipment and go and work on theclosed hatches further forward. Shortly afterthis the fitter fell from the edge of the openhatch cover into the hold. He was killedinstantly.The Lessons1. The vessel’s SMS required hot work tobe supervised, more for fire preventionthan to avoid accidents of this nature.Had this operation been supervised by acompetent person, the fitter would nothave been allowed to carry out hiswelding and burning work above anunguarded 10 metre drop.2. By continuing to work adjacent to theopen hatch cover, and a 10 metre drop, anew hazard was created. Crew membersmust be aware of their own personal dutyunder The Merchant Shipping andFishing Vessels (Health and Safety atWork) Regulations 1997, whereby theytoo are responsible for their own healthand safety and that of any other personon board who may be affected by theiractions.3. It was not recognised by anyone onboard that the opening of the after hatchhad created a “working aloft” situationthat required a work permit to be issued.The controls required by the workpermit would have prevented thisaccident.4. Ships’ staff should always remain alert tochanging circumstances and any newhazards such changes may pose. Forexample, the proximity of the fitter’stools to the unguarded hatch cover edgeexposed the crew, working below, to thepotential of being struck by fallingequipment. This should have beenrecognised and appropriate measurestaken to protect the crew before thehatch cover was opened.5. The vessel’s cargo holds were securedunder 2 hatch covers which hinged openinto the vertical position and offered theoption of opening either one, or bothhatches over a common coaming. Whenonly one hatch was opened, a danger wascreated for anyone remaining on top ofthe other hatch cover. However, openingboth hatches would have blocked offeither end of the coaming, thuspreventing easy access to the area.42 MAIB Safety Digest 1/2009

MAIB Safety Digest 1/200943

Part 2 – Fishing VesselsHaving spent themajority of myworking life as adeckhand andskipper in theindustry, I amdelighted to havebeen asked to writethis introduction.Fishing remains themost dangerous occupation within the UK;fishermen are 115 times more likely to suffer afatal accident than those within the generalworkforce, and 24 times more likely than thoseworking within the construction industry. Therates of fishing fatalities have not shown anyimprovement in recent years.Like most fishermen, I have encountered many‘close calls’ which act as a timely reminder asto how dangerous the fishing industry can be.We do learn from these experiences, but weoften only learn the errors of our ways bymaking mistakes. I recall an incident (and I amnot ashamed to admit that it involved me)whereby a self-inflating lifejacket which hadbeen worn for months but had not beenregularly checked, had to be inflated by mouthas the less than balmy waters of The LittleMinch lapped under my chin. The CO 2 canisterhad not fired due to it becoming unscrewed.Thankfully the incident happened in shelteredwaters and I was rescued almost immediately.We relate these incidents to each other, andthey often come to mind when we are in asituation where we are reminded of another’smisfortune. The MAIB Safety Digest gives us awealth of such information, which not onlyacts as a reminder as to the day to day dangerswhich we all face, but it is where we can learnfrom the experience of others. The role of theMAIB is purely to discover the facts, not toapportion blame or culpability. These facts canbe sobering reading, but they are beneficial toall mariners.We read time and again how poor maintenance(how many times have we come across a stuckor seized valve?) or lack of training is the rootcause or has been a compounding factor in apredicament. Many incidents which result in aserious emergency can be prevented or thesituation can be recovered when crew with theright training are able to act efficiently.Skippers and engineers employ routine checkssuch as checking engine and gear oil levels,inspecting bilges for unusual water levels andensuring bilge pumps are serviceable etc.These can be expanded a little further to theinspection of smoke alarms, fire fighting andlife saving equipment and checking that valvescan be opened and closed fully. Even a bit ofmundane housekeeping can make thedifference; keep personal effects stowed away(sea-boot socks that have been worn forseveral days and then draped over a heater arenot only offensive, but are also downrightdangerous). Take time to involve the crew inthese tasks, which will allow familiarity withprocedures and equipment, and in the eventof an emergency will buy valuable time.I left the industry last year to work in marineengineering. There are many aspects I do notmiss: fishing is demanding, torturous,frustrating and can be the most demoralisingwork. However, it is also exhilarating,rewarding and incredibly exciting, and thecamaraderie and brotherhood are unique. Iwish all fishermen many safe and successfultrips.44MAIB Safety Digest 1/2009

Gavin MorrisonGavin currently works as an engineer for SMS Salcombe, Devon. He left the fishing industry in January2008 to pursue this career. Gavin has been fishing on and off since he left school in 1987; his first job wasas a deckhand on a lobster boat in the Western Isles. Most recently, from 2003 to 2008 he skippered a viviercrabber in the English Channel, Irish Sea and waters around the Inner Hebrides. Gavin’s fishing career hasbeen punctuated with employment in the offshore oil industry and some time with an airline.MAIB Safety Digest 1/200945

CASE 14Watch Where You’re GoingNarrativeAt about 0300, an 18m wooden hulled prawntrawler left her port of landing for her fishinggrounds. Once through the breakwaters, thetwo deckhands, who had helped letting go,turned in, leaving the skipper alone on watchin the wheelhouse. Although the skipper wenthome at weekends, during the working weekhe was receiving only about 4 hours sleep anight when the vessel was alongside. He wasmaximising the time spent fishing for prawnsduring the long summer daylight hours.When the vessel cleared the approaches to theharbour, the skipper set a course on theautomatic helm to pass on his port side a smallisland, which lay about 2 miles to the southwest.The tidal stream was flowing north tosouth.The skipper then went to the aft-facing charttable to process the previous evening’slanding receipts. Shortly afterwards, thevessel grounded on an outlying shoal to theisland, waking the deckhands who were allturned in. They quickly checked the vesseland ascertained that she was not takingwater. The skipper was unable to drive thevessel off the shoal and he decided to waituntil high water before making furtherattempts to refloat. He did not alert thecoastguard of his situation, but he did informthe harbour authority, which later alerted theemergency services. The coastguarddispatched an all-weather lifeboat and aninshore lifeboat to standby the groundedvessel.The skipper was able to obtain theassistance of two passing fishing vessels totow his vessel off the shoal at the next highwater. The trawler then returned toharbour, where it was found that damagewas limited to the forefoot and the steelkeel band.46 MAIB Safety Digest 1/2009

CASE 14The Lessons1. It is essential that watchkeepers maintaina proper navigational watch at all timesand do not undertake any other dutiesthat would interfere with the safenavigation of the vessel. Further adviceon best navigational practice can befound in the MCA’s MGN 313 (F).2. Skippers should take full account of thequality and quantity of rest taken whendetermining fitness for duty, and useadditional crew members as necessary toensure that a proper lookout ismaintained.3. In this case, the skipper did not alert thecoastguard because he believed that hewas in a stable position, and that hisvessel would refloat safely at high water.It is always wise to alert the coastguardas soon as possible following an accidentor incident, even if assistance is notneeded immediately. Do not adopt a falsesense of security. Incidents candeteriorate rapidly. Forewarnedemergency services can respond moreeffectively.MAIB Safety Digest 1/200947

CASE 15Lucky to SurviveNarrativeAn 8m fishing vessel, trawling in an estuary onthe west coast, was preparing to haul her gearwhen the net snagged on the sea bed. Thecrew of two attempted, unsuccessfully, toknock the winch out of gear in order toslacken the warp, and also attempted to turnthe boat back to starboard as the vessel took ashear and a heel to port.Before the vessel snagged her net she hadbeen towing down-tide, and when sheinitially heeled over, waves started to comeonto her deck, causing her to heel over evenfurther. A short time later she started tocapsize, and the crew were pushed back intothe wheelhouse by the power of theonrushing water, leaving them no time tosend a ‘Mayday’.After the vessel had capsized, the crew foundthemselves inside the now inverted andflooded wheelhouse. One of them managed toswim clear quite quickly, while the other reliedon a pocket of air to survive the initial capsizeVessel with illustration of trawler assembly48 MAIB Safety Digest 1/2009

CASE 15until he, too, was able to swim out of theupturned wheelhouse. Although his clothingsnagged on the winch, he was able to gethimself to the surface and clear of the vesseljust before she began to settle by the stern,shortly after which she sank.Once clear of the vessel, the crew joinedtogether and clung onto a lifebuoy, whichfortunately had floated free as the vessel sank.However, they were now at the mercy of astrong tidal current, and a mile off a sparselypopulated shoreline, which they were unableto reach owing to the strength of the tide.After an hour in the water, the crew were seenfrom the shore by a member of the public,who alerted the coastguard, and they weresoon rescued by the local inshore lifeboat.Had they not been spotted at that time, theycould potentially have been in the water for avery long time as there were no paths or roadsclose to the shore further up the estuary.The Lessons1. The crew were young and inexperienced;when they got into difficulties they wereunable to react quickly enough to releasethe trawl warp. They also attempted topower the vessel back to starboard, whenit would have been prudent to reduce thepower and de-clutch the engine. Alwaysensure that, in accordance with theguidance given in MGN 20 (M&F) andMGN 265 (F), a risk assessment isundertaken of work activities, andpersonnel are suitably trained andpractised in resolving foreseeableproblems.2. The crew were fortunate in that theywere able to cling to a lifebuoy whichhad floated free of the sinking vessel.MSN 1813(F) lists the minimum safetyequipment requirements for small fishingvessels, and recommends the carriage ofa liferaft and EPIRB. In this case neitherwas carried; had they been, the crewwould not have had to place suchreliance on good luck and the vigilanceof a member of the public to ensure theirsurvival.MAIB Safety Digest 1/200949

CASE 16Foundering – Always Check WhyBilge Alarms SoundNarrativeA successful, wooden gill netter sailed for herroutine 7 day trip with a skipper and threecrew on board. The team were well trained,they had completed all the mandatory safetytraining courses and were serving in a vesselthat had a reputation for being well maintainedand run.For the first couple of days the fishing wasvariable, so it was decided to move to newgrounds. Luck was not with them. The weatherdeteriorated and the vessel was hove to for aday. A day later things looked up, at least forwhile; the weather improved and, with it, thefishing. At about 1400 on the sixth day, the netswere being hauled on board when the engineroom bilge alarm sounded in the wheelhouse.The skipper was not overly concerned becausethis frequently happened during trips. Asusual, he cancelled the alarm, switched on theelectric bilge pump and continued hauling.Significantly, he did not investigate the causeof the alarm.At about 1410, the haul was completed. Theskipper then went to the engine room tode-clutch the hydraulic pump from the mainengine while the rest of the crew made lunch.As he entered the engine room he found thatthe bilge water level was up to the floor plates,but he could not see where it had originatedfrom, and there were no obvious signs ofleakage. He re-configured the on-engine pumpfrom deck wash supply to bilge pump suctionbut was unable to shut the seacocks as theywere under water. The skipper immediatelyreturned to the wheelhouse. He informed thecrew about the flooding and, as a precaution,instructed them to don their lifejackets, whichwere stowed in the wheelhouse.Immediately afterwards, the skipper startedthe second electric bilge pump, but the twoemergency hand-operated bilge pumps couldnot be used as these were stripped down formaintenance. The skipper then contacted anearby fishing vessel and told them of theproblem. Afterwards he returned to the engineroom and found that the water level had notreduced but had increased by a further 20cm;it was now well above the floor plates and halfway up the main engine. To determine theextent of flooding, the skipper checked thefish room and found water at the same level asthat in the engine room. He also checked theforepeak and found that to be dry.The situation was clearly deteriorating. Theskipper was unable to determine the cause ofthe flooding so he made a “Pan Pan” call byVHF radio, to which the coastguardresponded. The skipper advised thecoastguard that he expected to remain afloatfor about 1½-2 hours. Despite this, thecoastguard recommended that the skipperremove the EPIRB to ensure that it floatedfree, and to launch his liferaft. The skipper didthis, but it inverted as it inflated. A “MaydayRelay” was also broadcast by the coastguard,and a number of vessels responded. Thecoastguard then tasked a rescue helicopter anda lifeboat to assist.50 MAIB Safety Digest 1/2009

CASE 16Figure 1Figure 2MAIB Safety Digest 1/200951

CASE 16The skipper checked the accommodation areaand found that the cabin deck was just underwater. Sensibly, he did not enter thecompartment because at about the same timethe vessel made a sudden lurch and began toroll to starboard. The skipper immediatelyinstructed the crew to jump into the water.They had insufficient time to right the stillinverted liferaft, so opted to swimapproximately 100 metres to the fishing vesselwhich had responded to the “Mayday Relay”.At 1509, the vessel sank. Fortunately, therescue helicopter was overhead at about 1510and winched the crew members to safety(Figures 1 and 2).The LessonsWithout the vessel being available to inspect,the cause of the flooding is a matter ofspeculation. However, the rate of floodingcalculations suggested that a 60mm diameterhole or comparable split would have causedthe conditions which led to the foundering.The skipper was unable to see the source ofwater ingress, which suggested that it wasunder the engine room floor plates, belowthe water level. It is noteworthy that themain engine sea water cooling system used60mm diameter pipes.The flooding of the fish room confirmed thatthe forward watertight bulkhead had beenbreached. The fish room bilge suctionflexible hose had been passed into the fishroom through an oversize hole which wouldhave allowed water to enter the fish roomfrom the engine room and vice versa.Had the cause of the bilge alarm beenpromptly investigated, there would have beena good chance that the cause of the floodingwould have been found and effectivemeasures could have been taken to deal withthe problem. The following lessons can bedrawn from this accident:1. Investigate bilge level alarms on everyoccasion. It is all too easy to becomecomplacent and switch on the bilge pumpwithout identifying the cause of thealarm.2. Use suitable components whenpenetrating watertight bulkheads so as tomaintain, so far as is practicable, thewatertight integrity.3. Consider fitting extended spindles to seavalves that are not already required byregulation to be fitted, and regularlycheck the condition of related pipework.4. Ensure that all bilge pumps, includinghand-operated emergency pumps, aremaintained ready for immediate use.5. Conduct regular emergency drills.6. Consult MGN 165 (F) – FishingVessels: The Risk of Flooding. Thispublication, which is available on theMCA’s website, provides comprehensiveadvice on flooding prevention measures,and makes essential reading.52 MAIB Safety Digest 1/2009

The Blind Leading the BlindCASE 17NarrativeDuring the first week of a planned 2 week pairtrawlingtrip, one of the vessels suffered afailure of its satellite gyro compass. Theskipper changed over to another compass butwas unsure exactly what equipment it nowsupplied. A check of the magnetic compassrevealed that the card was 180° displaced. Theskipper borrowed a large magnet from theengine room, placed it close to the binnacleand managed to turn the card 180°, butthereafter the compass’s reliability was foundto be somewhat suspect.After some good fishing, the vessel returnedearly to port and landed its half catch. Visibilitywas good for entering harbour, the catch wassoon discharged, and the crew stood downuntil the vessel’s planned sailing time of 2000that evening.When the skipper and mate returned to thevessel, the visibility had reduced to between 20and 50 metres. The reduced visibility did notchange the skipper’s plan to sail at 2000.The bridge equipment was switched on, and at2010 the vessel left the quayside. With thewheelhouse windows open, the mate stoodlooking out of the port window and theskipper looked out of the forward facingstarboard window. Each had an electric tiller athis side, and they shared the responsibility forthe manoeuvring.Feeling their way out of harbour and only justable to see their own forecastle, alterations ofcourse were made whenever a vessel orstructure was identified. The skippercontinued outbound, but although becomingmore and more concerned as the visibilitycontinued to decrease, at no time did either heSome of the damage caused by the groundingMAIB Safety Digest 1/200953

CASE 17Vessel's track – recorded from electronic chart plotteror the mate make use of the electronicnavigational aids – despite the two radars andelectronic chart plotter being switched on, andon suitable range scales.By chance, the mate glanced at the rudderindicator and saw that the rudder was set hardto starboard. He immediately alerted theskipper, who started to bring the helm back toport. As the rudder returned to amidships, thenoise of the vessel grounding could be heard.The mate de-clutched the main engine andthen reduced the pitch and revolutions to zero.Port control contacted the vessel when it wasno longer held on radar, and the skipperadvised them that he had grounded. The crewchecked for water ingress; none was found.The skipper decided to wait for a rise in tidebefore attempting to refloat, and 12 minuteslater the vessel was afloat. The skipper andmate carefully made their way back into theharbour, this time making use of the chartplotter. On their arrival, the coastguard noticeda considerable amount of pollution in thevicinity of the propeller, and the decision wastaken to remove the vessel to a nearby slipway.54 MAIB Safety Digest 1/2009

CASE 17The Lessons1. It had been some considerable time sincethe skipper had attended a radarsimulator course. Although he wasfamiliar with the electronic navigationequipment on board, he had not graspedthe navigational techniques necessary tonavigate in fog. The need forcontinuation training in blind pilotagetechniques and electronic navigationalaids should not be underestimated.2. There was no heading readout availablebecause of the defective satellitecompass. This was the main factorbehind the disorientation suffered by theskipper. The absence of essentialnavigational equipment, in this case aheading display, changes the risksinvolved in sailing. A further assessmentof the risks should be made and, ifnecessary, sailing deferred until theequipment is repaired.3. A probable reason for the rudder beingapplied hard to starboard was thelocation of the tiller next to the skipper.With his attention focused on looking forvisual navigation marks, he had failed torealise that he had nudged the tiller overto starboard. Given the prevailingconditions, it would have been better tohave a dedicated helmsman on the wheel,which would have allowed the skipperand mate to concentrate on navigatingand looking out.4. The echo sounder was switched off whileleaving and entering harbour, a scenariooften identified by the MAIB. In suchwaters, the echo sounder is an essentialpiece of navigational equipment,particularly if it is fitted with a depthalarm facility. However, remember tocheck whether the datum is set to showdepth below the keel, or depth below thewaterline.MAIB Safety Digest 1/200955

CASE 18No Safety Training, Faulty FireDetectors and EmergencyEquipment – A Sorry Tale of WoeNarrativeA 33 metre, UK registered long-liner left herhome port for the 4 day passage to her fishinggrounds. The skipper had been with the boatfor about a year, but for the majority of the 15mixed nationality crew, none of whom hadcompleted any of the mandatory safetytraining courses, this was their first time onboard.Familiarisation training was never carried outand emergency drills were not consideredimportant enough to waste time on. Most ofthe emergency equipment, includingventilation shut-off valves and the emergencyfire pump, were not properly maintained andno-one could remember when they were lasttested. To make matters worse, the skipperknew that the fire detector heads in the crew’scabins were routinely covered to prevent thealarms sounding as the crew smoked, but heturned a blind eye to this dangerous practice.What the skipper did not know was that thecabin dividing bulkheads stopped short of thedeckhead, and that cabin power supply cableswere draped over the sharp edges, andconsequently the insulation had been badlychafed (Figure 1). The crew also connectednumerous electrical devices to untestedelectrical extension leads.So, all in all, the boat was poorly prepared todeal with the emergency which was just overthe horizon.Figure 1: Cable chafing56 MAIB Safety Digest 1/2009

CASE 18Figure 2: Blistering of the paint on the main deckAt 0100 the skipper called the crew to recoverthe long-line. They left their cabin doors latchedopen and went on deck. At 0630, a fishermanlooked up the accommodation alleyway andsaw thick black smoke coming out of one of thecabin doors – notably, the fire detection systemhad not alarmed. At the same time, a fishermanon the port side heard the shout of “fire” andheaded towards its source. But he was beatenback. The second engineer had more success,and tackled the fire with a water extinguisheruntil he, too was beaten back; no one closed thewatertight doors to contain the fire within assmall an area as possible.The skipper sensed something was wrongwhen the crew mustered in front of thewheelhouse. He opened the rear wheelhousedoor to the alleyway below and was confrontedby the heat from the fire, and the wheelhousefilled with smoke. It became clear to him thathe had a major incident on his hands.The crew stayed in front of the wheelhouse,unsure of what to do next. Fortunately, thebosun had the presence of mind to confirmthe crew were all accounted for. The skipperthen decided to establish a fire/smokeboundary, and arranged for the watertightdoors to be closed. Because the doors had notbeen closed early during the incidentevacuation, the boundary encompassed overthree quarters of the accommodation and fishprocessing areas. At the same time, the skipperalerted a nearby long-liner of his problems.At about 0640 the skipper asked the chiefengineer to start the fire pump. He could notdo so because the electrical control supplieshad been burnt through. No attempt was madeto cross-connect the general service sea waterpump to the fire main, nor was any attemptmade to try the emergency fire pump, so therewas no pressurised water supply to deal withthe fire. It is noteworthy that most of the crewwere unaware of the existence of theemergency pump which, in any case, was laterproven to be defective.The situation worsened as the paint on thestarboard side of the main deck started toblister (Figure 2). The skipper decided toMAIB Safety Digest 1/200957

CASE 18starve the fire of oxygen. However, theventilation closing flaps were seized andcould not be closed. He then set aboutstuffing rags around the ventilation outlets tostop oxygen reaching the fire. At about 0700one of the cabin scuttles fractured from theheat of the fire. The skipper and bosundonned safety harnesses, went over the side,and managed to throw buckets of sea waterthrough the scuttle. However, this hadvirtually no effect. No thought was given tousing the submersible salvage pump toprovide boundary cooling, which was laterproven during the investigation to have beena viable option.At about 0815, the skipper contacted thevessel’s owners. They advised him to “sit itout” and see if the fire would burn itself out.As the morning wore on, the crew becameimpatient and persuaded the skipper to try tomake a re-entry to the fire despite therebeing no breathing apparatus on board andno fire suits (none were required by theregulations). At 1215 the rags were removedfrom the ventilators and large volumes ofsmoke were seen to issue from the brokenscuttle as the fire re-ignited. This finallypersuaded the skipper to notify thecoastguard of the emergency, some 6 hoursafter the fire was discovered.A lifeboat, rescue helicopter, patrol aircraft anda warship were all involved in the rescue. Thewarship put a fire-fighting team on board andextinguished the fire. The boat, under escort,made her own way into port.The fire was caused either by a short circuitwhere the electrical cables were draped overthe non-continuous bulkheads, or by anoverheating electrical device belonging to oneof the crew. It caused widespread damagethroughout the accommodation area,alleyways, galley and mess room. The 220 voltelectrical distribution panel outside the engineroom access was totally destroyed (Figures 3, 4and 5).58 MAIB Safety Digest 1/2009

CASE 18Figure 3: Cabin damageFigure 4MAIB Safety Digest 1/200959

CASE 18Figure 5: Damage to the 220v distribution panel60 MAIB Safety Digest 1/2009

CASE 18The LessonsFortunately there were no serious injuries asa result of the fire. However, the skipper andvessel’s owners paid scant attention to theimportance of safety training and contractingqualified crew who had attended themandatory safety training courses. Attendingthe fire-fighting course would not necessarilyhave prevented the fire, but it would haveenabled the crew to act more instinctively,and they might have dealt with the fire moreeffectively had the emergency equipmentbeen properly maintained and available.What perhaps is particularly disappointing isthat the fire detection system had beenintentionally disabled by the removal of thecontrol panel fuses. The importance of acorrect detection system cannot be overemphasised.It provides the first line ofdefence and the chance to deal with the firebefore it gets a real hold.The following lessons can be drawn fromthis accident:1. Make sure that properly trained crewsare employed. Once on board, carry outregular emergency and familiarisationdrills – your own survival may depend onit.2. Maintain and check the correct operationof the emergency equipment – in thiscase, the emergency fire pump was in anenclosure on the upper deck and sufferedfrom the crew’s attitude of “out of sight,out of mind”.3. Make sure that fire detection systems arealways fully functional. Test themregularly – especially before sailing – andrepair any defects without delay.4. Adopt a closed door policy. In this casethe cabin doors were of B Classstandard but were left open, allowingthe fire to quickly spread into theaccommodation alleyway. In the eventof a fire being discovered, establish aboundary as close as possible to the seatof the fire.5. Skippers should not hesitate to alert theemergency services to a major incident,which this clearly was. Fires can escalateunexpectedly and rapidly, and delays canso easily compromise the chances of asafe rescue.6. In March 2008 the MCA published the“Fisherman’s Safety Guide – A Guide toSafe Working Practices and EmergencyProcedures for Fishermen”. The guideprovides useful information on fireprevention, training, drills, andmaintaining emergency equipment, and isavailable in foreign languages onapplication to the MCA headquarters.Owners and skippers are encouraged torequest copies, which are free of charge.MAIB Safety Digest 1/200961

Part 3 – Small CraftSafety has been amajor concern forseafarers from theearliest days ofsailing and whereasin the old daysmariners were willingto put their fate inthe lap of the gods, today’s sailors prefer toplay safe by taking additional precautions. Themany thousands of miles that I spent sailing onthe oceans of the world have taught me tohave a profound respect for the forces ofnature and not to take anything for grantedbut be always prepared for the worst. Safetytherefore has been my first priority, both onmy own yachts and as organiser of variousoffshore sailing rallies whose commendablesafety record speaks for itself.Over the years my concern with safetyprompted me to undertake a number ofsurveys among my fellow sailors. Puzzled bythe large number of groundings, collisions andeven fatal accidents that still seem to occur inspite of the recent improvements innavigational and safety equipment my latestsurvey attempted to find the reasons for thisapparent contradiction. By looking closely atrecent accidents involving cruising yachts whatis striking is that in many of the cases in whichboats were lost as a result of grounding, thisappears to have been caused, just as in the olddays, by a navigational or human error.Looking at a number of incidents of near ortotal losses, I drew the inevitable conclusionthat whereas in pre-GPS days boats were oftenlost because sailors didn’t know where theywere, nowadays boats are lost becauseskippers know where they are. Or so theythink!Indeed, one conclusion that could be drawnfrom these findings is that many of today’ssailors seem to have a self-confidence thatalmost borders on arrogance and as aconsequence are prepared to set off on avoyage believing that all those wonderfulgadgets will make up for their lack ofexperience. If, as in some of the examples citedon these pages, alcohol is mixed withinexperience and a dash of ignorance, theresulting cocktail can lead to fatalconsequences.The main aim of my latest survey was toanswer the question whether sailing generally,and cruising in particular, was safer. PersonallyI believe that cruising generally is safer, and Iam relieved that the findings of my survey bearthis out. Boats still get lost but certainly not asfrequently as during the days ofastronavigation. What I found, however, is thatwhereas offshore cruising is indeed safer, thesituation is not so good when it comes tocoastal cruising or navigating close to land.Bearing in mind the thousands of milestravelled by cruising yachts, sailing in distantwaters is probably the safest way to see theworld. Unfortunately, just as in the case ofmotoring where most accidents occur within afew miles from home, so with sailing where itis the home waters that pose the greatest risk.This is why the Marine Accident InvestigationBranch is so right to focus its efforts on makingsafety on our very doorstep its main priority.One of the most valuable lessons I learned inmy life is to learn from both my own and otherpeople’s mistakes and do my best not torepeat them. This is why even the mostexperienced mariner can still find somethingto learn from the case studies discussed in thisexcellent publication.62 MAIB Safety Digest 1/2009

Jimmy CornellAn accomplished sailor and successful author, Jimmy Cornell has sailed 200,000 miles in all oceans of theworld including three circumnavigations as well as voyages to Antarctica, Alaska and Spitsbergen. His 43 ftAventura III is currently based in the Eastern Mediterranean. Jimmy Cornell is a member of the RoyalOcean Racing Club.Many of Jimmy Cornell’s 14 books have been translated into various languages and his World CruisingRoutes, described as the bible of offshore sailors, has sold over 100,000 copies and is one of the best-sellingnautical publications in the world. Jimmy Cornell’s latest book “A Passion for the Sea, Reflections on ThreeCircumnavigations”, which is a memoir of his sailing life, was published in 2007 and can be ordered via hiswebsite: www.jimmycornell.comAs the founder of the highly successful ARC transatlantic rally, Jimmy Cornell is credited with havingdevised the offshore cruising rally concept. Until his retirement in 2000 Jimmy Cornell had organized 24transatlantic and five round the world rallies. His latest project, the website, is currentlythe main source of practical information for cruising sailors on the internet and lists details of facilities andformalities in 183 maritime nations and over 4,000 ports worldwide. Fluent in six languages, Jimmy holdscruising seminars at various international boat shows.MAIB Safety Digest 1/200963

CASE 19A Not So Lucky EscapeNarrativeAn instructor and three trainees wereoperating a 5.3m RIB with a 60hp outboardengine during the second day of an RYApowerboat level 2 training course. Theweather was fair and the sea state was calm;the wind was force 2. During the morning, thetrainees practised manoverboard drills andhigh speed ‘S’ and ‘U’ turns. On completion,the instructor decided to let the traineesconduct ‘high speed tight turns’, which hedemonstrated with the engine fully trimmeddown at 5200rpm. He then gave the helm toone of the trainees, who was a teenage boy.The other trainees, a mother and her teenageson, who had been alarmed by the tightness ofthe turn and the angle of bank during theinstructor’s demonstration, sat on thestarboard inflatable tube in the vicinity of thesteering console.The trainee’s first attempt at the tight turn didnot go as intended because the wheel was notturned sufficiently hard. During his secondattempt, the boat turned tightly to port andheeled over. As it encountered waves createdby its own wake, the RIB’s hull suddenly andunexpectedly ‘dug in’. This caused the RIB tojolt and abruptly change direction, throwingthe trainees on the starboard tube overboard.The mother was thrown clear and inflated herlifejacket, but her son was hit by the boat’spropeller.The instructor immediately took over the helmand manoeuvred the RIB to recover thetrainees from the water. He quickly realisedthat the teenage boy was injured and headedback to the training base at best speed, callingthe emergency services en route. The injuredtrainee was landed and taken to hospital byambulance where he was found to havesuffered a fracture, lacerations and bruising tohis right arm (Figure 1).Figure 164 MAIB Safety Digest 1/2009

CASE 19The Lessons1. Included among the major attractions ofa RIB is the ability to turn very tightly atspeed. Unfortunately, although exciting,manoeuvring in this manner carries therisk of the boat’s bow ‘digging in’without warning, causing a sudden joltand change in direction. Occasionally,this is sufficiently violent to eject peopleout of a boat; coxswains and overseeinginstructors should be mindful of suchpotential danger when conducting verytight turns at speed, particularly in aseaway or when crossing wakes.2. The seating arrangements in RIBs varyconsiderably, and the use of the inflatableside tubes for this purpose is verycommon. At slow speed or in calmwaters, this practice is generally safe andtrouble-free. However, whenmanoeuvring at fast speed or navigatingin disturbed waters, the risk of falling offthe tubes, either into the boat or over itsside, is increased dramatically. Thepossibility of back injuries to personssitting on tubes is also considerablygreater due to the twisted position of thespine and the shock of the boat hittingthe water. Therefore, when operatingunder such conditions, it is far safer tolimit the number of persons on board aRIB to the number of dedicated seatingpositions fitted, rather than by themaximum number allowed on itsbuilder’s plate.MAIB Safety Digest 1/200965

CASE 20Hold On Tight, If You CanNarrativeA rigid inflatable boat (RIB) was beingemployed as a support boat for an event onthe water. The 6.3 metre RIB was powered by a115 horsepower outboard engine, giving apotential top speed in excess of 30 knots. TheRIB was just over a year old but had only beenused for a 4-month period prior to beingbought by the current owner 2 monthspreviously.On the day of the accident, the boat was beingused to transport event personnel out tobarges. At the time of the accident, there werethree people on board: the helmsman waspositioned at the controls, standing astride thestarboard seat pod; a passenger was seated inthe port seat; and a second passenger wasstanding behind the two seats, holding on tothe seat backs. There was a settee ahead of theinstrument console, but this was unoccupied.Having dropped off his two passengers at abarge, the RIB loitered nearby. To collect them,the helmsman manoeuvred his vessel acrossthe 3-4 knot ebb tide back alongside. With thethrottle set ahead to counter the tidal stream,he removed the kill-cord from his left wrist andstepped across to the port side of the RIB tohold on to the barge while his two passengersboarded. He then returned to his seat,replaced the kill-cord and manoeuvred clear ofthe barge. Having asked his two passengers ifthey were holding on, he commenced a turnto starboard to head down stream. As the RIBturned, there was a loud crack and all threeoccupants were thrown into the water, alongwith the two seat pods.With no one at the helm, the boat careered onout of control because the kill-cord had fallenoff the helmsman’s wrist, and not operated.The RIB then collided with another vesselduring which the console top was broken freeVessel's deck showing outline of consoles – note lack of deck preparation and adhesive66 MAIB Safety Digest 1/2009

CASE 20Kill cordof its fixings and the throttle hit the deck,pushing it to full ahead. Fortunately, the crewof a nearby support boat brought the runawayRIB under control very quickly, preventingserious injuries to those in the water. The autoinflatinglifejackets worn by the three menoperated successfully, and within a fewminutes they were rescued by other supportcraft, having suffered only minor injures.The seat pods and boat were examined afterthe accident. The glass reinforced plastic(GRP) seat pods had each been attached using6 × 25mm stainless steel self-tapping screwswith penny washers and a bead of a sealantlikesubstance. The deck was constructed from18mm plywood, with a 2-3mm GRP skin whichwas impregnated with small plastic granules tocreate a non slip surface. Analysis of the sealantwas unable to positively identify it as anyparticular product, but it was established thatit was polyurethane-based. Polyurethaneadhesive sealants normally provide goodadhesion, but in this case poor surfacepreparation had resulted in ineffectiveadhesion to the deck, leaving the self-tappingscrews as the only means of securing the seats.Over time, water had seeped into the six screwholes and softened the plywood, resulting inthe screws pulling out as the RIB turned tostarboard, and the weight of the occupants wasforced laterally against the seats.MAIB Safety Digest 1/200967

CASE 20Vessel's seatnote: wide spacing of securing screws and poor coverage of sealant68 MAIB Safety Digest 1/2009

CASE 20The Lessons1. The RIB’s three occupants were veryfortunate not to have been moreseriously injured during this accident.The potential consequences of RIB seatpods or consoles coming adrift, especiallyat speed, can be very serious indeed.Owners and operators should regularlycheck that their RIB seats and consolesremain secure, particularly if adhesivesealant and screws are the method ofattachment. Do not take your seatfixings for granted.2. The kill-cord must be attached properlyif it is to be effective. Either secure itaround your leg, or clip it to a hard pointon your lifejacket. As demonstrated inthis accident, simply looping it aroundyour wrist can result in it pulling free. Itwas only the skill of another boat’s crewthat prevented this runaway boat fromcausing serious harm.3. Do not force yourself into unsafepractices by being undermanned and forthe sake of expediency. The helmsmanwas leaving his throttle ahead to counterthe tide and then removing the kill-cordfrom his wrist in order to hold on to thebarge. A proper assessment of the taskwould have identified the need, in theseconditions, to carry an additionalcrewman to secure the RIB, leaving thehelmsman free to remain at the helm andin control.4. Where possible, ensure that allpassengers on board are seated beforeincreasing speed. Ideally, there should besufficient seating without employing theRIB side tubes. Having passengersstanding up can all too easily lead toinjury.MAIB Safety Digest 1/200969

CASE 21Can’t See Him? Then Alter CourseNarrativeA privately owned motor yacht was headingnorth east in thick fog at night. Heading southwest along the same stretch of coast was a smalltug towing a dumb barge. On board the yachtwere the owner and a friend, and they weresharing the watches “hour about” through thenight. The radar was operating, navigation lightswere on, and they were occasionally soundingthe appropriate fog signal. On board the tug, theskipper was on watch alone. Both the tug andthe barge were showing appropriate navigationlights, the radar was operating, and from time totime the fog signal for a vessel engaged intowing was being sounded.At almost the same time, each watchkeepernoted the presence of the other vessel onradar right ahead. The tug skipper monitoredthe approach of the yacht, noted that theywere on a collision course, and decided to takeaction once the yacht closed to 1-mile range.The owner of the yacht was on watch. Henoted the target ahead, and monitored itsmovements. However, he became confusedbecause the target appeared to occasionallydivide into two separate targets, and he wasuncertain whether they would pass to port orto starboard. He decided to maintain courseand speed and to trust that he would be ableto see whatever it was in time to take avoidingaction as necessary.When the radar target ahead closed to 1-milerange, the tug skipper started to alter courseand then to slow down. Both actions werecarried out in steps to avoid the tug beingoverrun by the barge. Continuing to observethe target on radar, he watched as itapproached, merged with and moved awayfrom the radar target of the barge.70 MAIB Safety Digest 1/2009

CASE 21Concerned that he had not been able to see theapproaching craft, the owner on the yacht calledhis friend to the wheelhouse and asked him togo forward and act as lookout. Shortly after thisthey saw the lights of the tug to port. However,the radar was still showing a target ahead and,seconds later, the friend shouted a warning thathe could see the barge. The owner put thewheel hard to starboard and the engine controlsastern, but it was too late; the yacht collidedwith the barge. The impact threw the owneragainst the wheel, breaking two of his ribs.The Lessons1. The COLREGS require that risk ofcollision should be assessed, and thatearly action be taken to avoid collision.There is no doubt that the yacht ownerwas aware of the risk of collision; it isalso clear that he took no action to avoidone until it was too late. Had he alteredcourse when it first became clear that arisk of collision existed, a close-quarterssituation could have been avoided.2. The tug’s action, although ultimatelyresulting in a substantial alteration ofcourse to starboard, was not carried out“in ample time” as required by Rule 19of the COLREGS. Early action, which isreadily apparent to the other vessel,ensures that the vessels involved willpass safely, and avoids any confusion asto actions taken.3. In restricted visibility, every vessel whichdetects by radar alone the presence ofanother vessel, and that a close-quarterssituation is developing and/or a risk ofcollision exists, is required to takeavoiding action. There is no stand-onvessel in restricted visibility.4. Neither watchkeeper had undertakenany formal training in the use of radar.Such training might have highlighted thefact that, at a range of 5 miles and withthe vessels approaching at a combinedspeed of 15 knots, there are only 20minutes in which to notice the otherradar target, monitor its movement andtake action to avoid collision. Everyminute’s delay brings the target ¼ milecloser, and will require a larger alterationof course and/or speed to avoid collision.MAIB Safety Digest 1/200971

CASE 22“It Can Happen to the Best of Us”NarrativeThe crew of an inshore, rigid inflatable lifeboatwere conducting a routine training exercise incoastal waters, close to their base. It was a finesummer’s day and the sea was very calm.The boat was fitted with three seats: for thecoxswain, navigator and radio operator. It alsohad hand-holds intended for passengersseated on the inflatable sponsons around theedge of the boat. In addition to the usual threecrew, a trainee crewman was on board. He hadbeen out on the boat many times before andhad completed the boat-handling elements ofhis training.The crew had been working hard practisingmanoeuvres to rescue casualties from rockyoutcrops, and were intending to move to anopen sandy bay to practise anchoringtechniques. The boat was stopped in the waterand the crew had gathered round, discussingthe exercise. Two crew members had sat onthe port and starboard inflatable sponsons inthe forward part of the boat, facing inwards tothe control console. Another member of thecrew took the wheel, and the coxswain sat onthe starboard inflatable tube, next to theengine throttles, to take control if necessary.They expected to make the short transit to thesandy area and then gather in the forward partof the boat to discuss the next part of theexercise.The crewman on the helm increased speed tobetween 20 and 25 knots and, to satisfy himselfthat the boat was manoeuvring as expected,began to make a series of fast turns to port andstarboard. Despite holding on and appearingto be comfortable, the crew member seated onthe port sponson near the centre console felloverboard during a turn to starboard. He wasstruck on the head at least three times by the72 MAIB Safety Digest 1/2009

CASE 22propellers, piercing his protective helmet intwo places. The boat was quickly turned roundand the casualty was recovered back on board.It was clear that the injuries were very serious,so the crew reported the accident to thecoastguard, requesting an ambulance to meetthe boat as it returned to the beach. Thelocation was not described precisely, and thisled to some confusion between the coastguardand ambulance controllers as to where theambulance should be sent. When theambulance arrived, it was unable to cross thebeach to meet the boat, and there was somedelay while the casualty was transferred using acoastguard vehicle.The casualty suffered severe head injuries.The Lessons1. Fast turns in rigid inflatable boatsgenerate large forces which can throwpersonnel overboard, despite their bestattempts to hold on. Before commencingsuch manoeuvres, coxswains shouldensure that all occupants are aware ofthe impending manoeuvre and the needto be securely seated and “hold ontight”.2. The arrangement of the boat and angle ofheel in the turn meant that once thecrewman had fallen from the boat, it wasalmost inevitable that he would be struckby the propellers. It is thereforeimperative that all persons are securewithin the boat, such that they cannotfall overboard.3. Although the crewman’s protectivehelmet was substantial, it could notprotect his head against the rotatingmetal propeller blades; the boat had notbeen fitted with propeller guards as itwas considered this would compromiseits performance and ability to respond toan emergency. Recognising the need forperformance in any rescue situation,serious consideration should be given tothe use of propeller guards on any boatlikely to be used for the recovery ofpersons from the water, in view of theextreme dangers created by open bladedpropellers.4. When reporting casualties, to minimisedelay take care to report your position asaccurately as possible and seek advice onthe best place to rendezvous with theemergency services.MAIB Safety Digest 1/200973

CASE 23Excess of Alcohol Contributes toFour AccidentsNarrativeSeveral accidents to persons on small crafthave been reported recently to the MAIB inwhich the consumption of alcohol has been acontributory factor.Case 1:In one, a small boat collided with a police boatas it approached a slipway while travelling atnight, at excessive speed and with nonavigation lights. Although the police boattook evasive action, a collision occurred, whichresulted in injuries to the two occupants of theboat as well as causing it considerable damage.The occupants of the small boat were notwearing lifejackets.While helping the occupants of the first boat,the two policemen on board the police boatestablished that the driver had consumed anexcessive amount of alcohol, which hadaffected his judgment and ability to navigatethe boat in a safe manner.Case 2:In another tragic case, two lives were lostwhen sailors were returning, in a tender, totheir yacht which was on a mooring in themiddle of an east coast river. The men werefriends, had spent the evening together inlocal hostelries and were last seen headingback to the tender in the late evening of anautumn day. The two men were experiencedyachtsmen who were accustomed to using atender in similar weather conditions to thoseprevailing at the time of the accident.Their bodies were discovered the followingmorning, close together, on the edge of theriver. The tender was recovered nearby andfound to be intact and dry. The men had notbeen wearing lifejackets.There is no doubt that alcohol affected theirjudgment and ability to make a safe passageback to their yacht that evening, and this tragiccase demonstrates that alcohol and boatingsimply don’t mix.Recovered damaged RIB74 MAIB Safety Digest 1/2009

CASE 23Damage to steering wheel following impact of the skipperCase 3:Yachting regattas are a popular and intrinsicpart of the summer season for the majority ofrecreational sailors. However, a number ofaccident reports received last year indicatethat, for a minority of sailors, attending aregatta is synonymous with consuming anexcessive amount of alcohol.Two accidents occurred during the week of apopular south coast regatta, in which theconsumption of alcohol was a contributoryfactor. In the first, several people were injured,+ly, when a RIB (see photographs), with sixpersons on board, struck a breakwater at night.The boat was proceeding outside the mainchannel, without navigation lights, and hadignored police advice not to head out to sea.Witnesses report that several of those on boardwere drunk and no one was wearing lifejackets.The Lessons1. Alcohol and boats don’t mix. In all theabove cases alcohol was a contributoryfactor to the accident.2. The effects of alcohol on perception andjudgment are well known, and marinersCase 4:In the second, a speedboat sank afterapparently colliding, at night, with a litnavigation buoy when returning home fromthe regatta. The seven occupants of the boatincluded three children, only one of whomwas wearing a buoyancy aid; none of the adultswas wearing a lifejacket. As the boat sank, oneof the adults was able to use a mobiletelephone to make a distress call to thecoastguard, which organised a search.Through extreme good fortune, everyone wasrescued from the water and transferred, via alifeboat, to a local hospital where they weretreated for the effects of hypothermia.Witnesses remarked on the fact that the adultsappeared intoxicated, smelling heavily ofalcohol.should be aware that their ability toperform routine and familiar tasks willbe adversely affected if they consumeexcessive amounts of alcohol.3. Always wear a lifejacket; in all of thesecases only the police officers were doingso.MAIB Safety Digest 1/200975

CASE 24The Importance of ElectricalIsolationsNarrativeA small, wooden, angling charter boat was tiedup alongside having completed its last anglingtrip 3 days earlier. The skipper had been onboard during the morning to replace the wornmain engine fan belt. Having completed thework the skipper successfully tested theengine. He then checked the boat over,including the bilge levels and mooring ropesbefore locking the wheelhouse and making hisway home.Significantly, the skipper did not open themain electrical supply switch that isolated thebatteries from the rest of the boat. The reasonwas because the switch was seized and thesquare headed key, required to operate theswitch, was damaged, and had been for sometime, so power remained connected to theboat’s electrical circuits.About 30 minutes after leaving the boat theskipper received a call from the harbourmastertelling him the boat’s wheelhouse was on fire.The skipper immediately returned to the boatand was astounded to find the main enginerunning but the wheelhouse still locked. Theattending fire and emergency services were atthis time cutting through the wheelhouse doorlock. They made an entry to the smallwheelhouse and found that the fire had selfextinguishedthrough lack of oxygen.There was smoke damage throughout thewheelhouse (Figure 1). A small plastic casedtelevision had been completely destroyed, andthe plastic engine monitoring panel containingthe engine key start switch, which was situateddirectly above the television, was badly burnt.On investigation, it appeared that thetelevision was left in the stand-by conditionbecause power had not been isolated to theboat’s electrical circuits. It is likely that thetelevision’s capacitor broke down, igniting thetelevision’s plastic casing. The flames from thetelevision then damaged the enginemonitoring plastic panel, burning the cableinsulation outside the panel (Figure 2). This, inturn, shorted out the engine start circuit,causing the engine to start. Fortunately thewheelhouse was reasonably airtight, and thefire was short-lived.76 MAIB Safety Digest 1/2009

CASE 24Figure 1Figure 2MAIB Safety Digest 1/200977

CASE 24The LessonsBattery isolating switches can betroublesome. Switches designed for use incaravans are often fitted to small boats, andthese are invariably of the sealed type,making maintenance virtually impossible.These types of switches are not designed foruse in the harsh marine environment.Verdigris often builds up on the contacts andthe operating mechanisms, causinginterruptions to power supplies and makingthem difficult, and sometimes impossible, tooperate.1. Be cautious about taking the cheapoption when fitting electricalcomponents. Select those designed foruse in the marine environment and seekprofessional advice if in doubt.2. When fitting battery isolating switches,consider the supplies needed to run anautomatic electric bilge pump when theisolating switch is in the open position.Normally a separate fused supply is rundirectly from the battery to the bilgepump, avoiding the need for the isolatingswitch to be closed.3. There have been a number of occasionswhen fires have been caused by electricalcircuits remaining powered up onunattended boats. It is always good fireprevention practice to switch offelectrical equipment when not in use,and to isolate batteries from electricalcircuits when no one is on board.4. Do not delay rectifying defectiveelectrical components. Short circuits caneasily occur, causing excess currents tobe drawn, leading to overheating and arisk of fires developing.78 MAIB Safety Digest 1/2009

CASE 25Two Wrongs Don’t Make a Rightof WayNarrativeIt was twilight in the western approaches; thesea was rough and there was a force 5 wind.A 24m, 250 tonnes displacement steel beamtrawler powered by a 500HP engine wasworking her home grounds. Her beams weredown, she was fishing – displaying both daysignals and lights – and was making about 4knots. The mate, who was on watch, saw a blipon the radar and realised that it was a smallyacht that he could see about 0.5 mile away.He anticipated that the yacht would passunder his vessel’s stern.The 6.5m carbon fibre yacht displaced about800kg. A high performance design, it wasmaking over 10 knots upwind on port tack andunder autopilot. The mast head tricolournavigation light was on, and a “rain-catcher”radar reflector was hoisted.On board the yacht the racing skipper wastrying to get some sleep. He was training for amajor single-handed transatlantic race and, asa result, had been sleeping for variable periodsof around 20 minutes per hour during thehours of darkness for the last 4 days. The yachtwas fitted with a timing device specificallydeveloped to allow single-handed sailors toFigure 1: Beam trawlerMAIB Safety Digest 1/200979

CASE 25take short naps. The skipper saw the fishingvessel, and having assessed the situation assafe he went below, set the timer anddeliberately went to sleep.The trawler’s mate saw the yacht closing, butdecided to act too late; hampered by his gearhe was unable to avoid a collision. Thetrawler’s derrick struck the yacht as it passedvery close by, destroying the mast, boom andsails, and causing serious damage to the deckand hull mouldings. Fortunately, the trawler’sderrick passed over the head of the sleepingyachtsman. The undamaged trawler stoppedto provide assistance, and the lifeboat wascalled. The RNLI towed the yacht in to port;her race was over. Fortunately there wereno injuries.Figure 2: A similar Mini-Transat yachtThe Lessons1. The race for which the yacht wastraining has been described as “Alegendary ocean race…spectacular,adventurous, extreme and dangerous”.The dangers to be faced in training, morethan equalled anything that might beencountered during a single-handedocean crossing.2. Sailing alone, under autopilot in thisbusy area, in challenging weatherconditions and at night was at bestfoolhardy, and the decision to sleep whena trawler was known to be fishing closebycould perhaps be consideredsomewhat reckless. When embarking onany single-handed voyage, consider allthe risks, including the risks to thoseyou encounter and those who may haveto rescue you.80 MAIB Safety Digest 1/2009

APPENDIX APreliminary examinations started in the period 01/11/08 – 28/02/09A preliminary examination identifies the causes and circumstances of an accident to see if it meets the criteria required towarrant a full investigation, which will culminate in a publicly available report.Date ofAccidentName of Vessel Type of Vessel Flag Size Type of Accident06/11/08 Faithful Friend II Fishing vessel UK 54 Foundering11/11/08 Queen Elizabeth II Cruise ship UK 70327 Grounding24/11/08 Cantara Fishing vessel UK 212 Accident to person(1 fatality)26/11/08 Georgie Fisher Fishing vessel UK 15.10 Capsize27/11/08 Haven Harrier Pilot boat UK 24 Accident to person13/12/08 Ropax One Ro-ro vehicle/passenger ferryUK 33163 Contact19/01/09 Sinegorsk General cargo Russia 7095 Hazardous Incident06/02/09 Saline General cargo Netherlands 1990 Fire11/02/09 Jubilee Star Fishing vessel UK 29.84 Capsize18/02/09 Mercurius Fishing vessel UK 95 Man overboard(1 fatality)22/02/09 ANL WangarattaFu Xin ShanContainerGeneral cargoUKChina3990613823Contact25/02/09 VallermosaBW OrinocoNavion FenniaChemical tankerTankerOil tankerItalyPanamaBahamas250634379751136ContactInvestigations started in the period 01/11/08 – 28/02/09Date ofAccidentName of Vessel Type of Vessel Flag Size Type of Accident02/11/08 Abigail H Harbour dredger UK 325 Foundering03/11/08 Eurovoyager Ro-ro freight/vehicle ferryCyprus 12110 Accident to person10/11/08 Maersk Newport Container vessel UK 25888 Heavy weatherdamage15/11/08 Maersk Newport Container vessel UK 25888 Fire24/11/08 Princess RoseHMS WestminsterOther passengervesselNaval craftUKUKUnk3500Accident to person28/01/09 Ville de Mars Container vessel UK 37235 Accident to person(1 fatality)Stena VoyagerHSC Vehicle/passenger ferryUK 19638 Cargo handlingfailure12/02/09 Maggie Ann Fishing vessel UK 111 Accident to person(1 fatality)MAIB Safety Digest 1/200981

APPENDIX BReports issued in 2008Audacity/Leonis – collision at the entranceto the River Humber on 14 April 2007Published 25 JanuaryCFL Performer – grounding, HaisboroughSands, North Sea on 12 May 2008Published 17 DecemberCosta Atlantica/Grand Neptune – closequarters situation in the Dover Strait on15 May 2008Published 19 NovemberDublin Viking – parting of a mooring linealongside at Berth 52 in the Port of Dublin,Ireland, resulting in one fatality on 7 August2007Published 31 MarchFigaro – inadvertent release of carbondioxide and the disabling of the vessel off WolfRock on 6 December 2007Published 14 AugustFlying Phantom – loss of the tug whiletowing Red Jasmine on the River Clyde on19 December 2007 resulting in 3 fatalities and1 injuryPublished 30 SeptemberLady Candida – fire and subsequent sinkingoff Corsica on 28 July 2007Published 18 FebruaryLady Hamilton/Blithe Spirit – collisionbetween fishing vessels in Falmouth Bay,Cornwall on 3 October 2007Published 15 AprilLast Call – foundering of the motor cruiser atWhitby on 23 November 2007 with the loss ofthree livesPublished 30 JuneLogos II – two accidents during berthing andunberthing, St Helier, Jersey on 20 and 26 June2007Published 22 JanuaryMSC Napoli – structural failure in the EnglishChannel on 18 January 2007Published 22 AprilPacific Star – heavy weather damagesustained by passenger cruise ship while onpassage in the South Pacific Ocean on 10 July2007Published 29 FebruaryPartner 1 – console detachment of the rigidinflatable boat, Studland Bay, Poole on 20 April2008Published 30 OctoberRigid Raider (Army Cadet Force RigidRaiding Landing Craft) – capsize of craft inLoch Carnan, South Uist in the Western Isles ofScotland on 3 August 2007, resulting in onefatalityPublished 18 MarchSava Lake – dual investigation of the deathsby asphyxiation of two crewmen while thevessel was approaching the Dover Strait on18 January 2008Published 23 SeptemberSea Mithril – grounding of the cargo vesselon the River Trent on 18 February 2008Published 26 September 2008Shark/Royalist – dual investigation reportinto fire on board Shark on 19 January 2008and foundering of Royalist on 23 January 2008Published 12 AugustSichem Melbourne – product carrier makingheavy contact with mooring structures atCoryton Oil Refinery Terminal on 25 February2008Published 17 OctoberUrsine & Pride of Bruges – contactbetween two vessels, King George Dock, Hullon 13 November 2007Published 30 May82 MAIB Safety Digest 1/2009

APPENDIX BViking Islay – loss of three lives, 25 miles offthe East Yorkshire coast on 23 September 2007Published 9 JulyYoung Lady – vessel dragging anchor 5 mileseast of Teesport and snagging the CATSpipeline, resulting in material damage to thepipe on 25 June 2007Published 1 FebruaryAnnual Report 2007 Published July 2008Safety Digest 1/2008 Published 1 AprilSafety Digest 2/2008 Published 1 AugustSafety Digest 3/2008 Published 1 DecemberFishing Vessel Safety Study 1992-2006 –analysis of UK fishing vessel safetyPublished 28 NovemberLeisure Safety Digest (2nd edition)Published MarchMAIB Safety Digest 1/200983

APPENDIX CReports issued in 2009Antari – grounding Near Larne, NorthernIreland on 29 June 2008.Published 19 FebruaryAstral – grounding on Princessa Shoal, east ofIsle of Wight on 10 March 2008.Published 29 JanuaryMoondance – electrical blackout andsubsequent grounding of the ro-ro cargo shipin Warrenpoint Harbour, Northern Ireland on29 June 2008.Published 10 FebruaryMV Norma – hazardous diving incident in theDover Strait on 21 June 2008.Published 21 JanuaryPlas Menai RIB 6 – capsize of the Plas MenaiRIB 6 while undertaking unauthorised RIBriding activity near Caernarfon, Wales on 1 July2008, resulting in one injured student.Published 18 FebruaryPride of Canterbury – grounding in “TheDowns” – off Deal, Kent on 31 January 2008.Published 14 JanuarySaga Rose – fatality on board the passengercruise ship in Southampton, England on11 June 2008.Published 6 January84 MAIB Safety Digest 1/2009

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