INVESTIGATION

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INDEX GLOSSARY OF TERMS AND ABBREVIATIONS INTRODUCTION 1 PART 1 – MERCHANT VESSELS 2 1. A Catastrophic Outcome 4 2. Fatal Short-Cut to Using the Gangway 6 3. Isolated Working Leads to Girting 8 4. No Pool Attendant, No Rescue 10 5. A Snake’s Wedding 11 6. Exploding Grinding Disc 13 7. Damaged Butterfly Lets in Water 14 8. Maintenance Blindness 16 9. Where’s He Going? 19 10. The Fatal Consequence of a Routine Task 21 11. The Engine That Ran Away 24 12. Blinded By Caustic Soda 26 13. When Steel Meets Granite 27 14. Uncontrolled Release Clouds Discharge Operations 30 PART 2 – FISHING VESSELS 32 15. Cold Water Can Kill in as Little as 2 Minutes 34 16. An Unheard Alarm Means No Alarm 36 17. Fishermen DON’T Have to Die 38 18. Let It Go And Come Back Later 40 19. Stay Dry, Stay Alive 42 20. Keep a Lookout 45 21. Entrapment in Winch Leads to Severed Fingers 47 22. One Hand For You, One For Your Chips 49
PART 3 – RECREATIONAL CRAFT 52 23. Never, Ever Assume 54 24. Alone, No Kill Cord, No Lifejacket, No Chance 57 25. Petrol Fumes Plus Bow Thruster Equals Explosion 58 APPENDICES 60 Investigations started in the period 1/09/16 to 28/02/17 60 Reports issued in 2016 61 Reports issued in 2017 62 Glossary of Terms and Abbreviations AB - Able seaman AIS - Automatic Identification System C - Celsius CCTV - Closed Circuit Television CO2 - Carbon Dioxide CPR - Cardio-Pulmonary Resuscitation DSC - Digital Selective Calling ECDIS - Electronic Chart Display and Information System EPIRB - Emergency Position Indicating Radio Beacon ESD - Emergency Shutdown gt - gross tonnage IMO - International Maritime Organization kt - knot LPG - Liquefied Petroleum Gas m - metre “Mayday” - The international distress signal (spoken) MCA - Maritime and Coastguard Agency MGN - Marine Guidance Note MOB - Man Overboard MSC - Maritime Safety Committee OOW - Officer of the Watch P&I - Protection and Indemnity PFD - Personal Flotation Device PLB - Personal Locator Beacon PPE - Personal Protective Equipment rpm - revolutions per minute SRV - Safety Relief Valve UHF - Ultra High Frequency VHF - Very High Frequency XTD - Cross Track Distance
Page 1 and 2: MARINE ACCIDENT INVESTIGATION BRANC
Page 3 and 4: © Crown copyright 2017 This public
Page 5: The role of the MAIB is to contribu
Page 9 and 10: Part 1 - Merchant Vessels It is an
Page 11 and 12: CASE 1 A Catastrophic Outcome Narra
Page 13 and 14: CASE 2 Fatal Short-Cut to Using the
Page 15 and 16: CASE 3 Isolated Working Leads to Gi
Page 17 and 18: CASE 4 No Pool Attendant, No Rescue
Page 19 and 20: CASE 5 he set the pitch of the port
Page 21 and 22: CASE 7 Damaged Butterfly Lets in Wa
Page 23 and 24: CASE 8 Maintenance Blindness Narrat
Page 25 and 26: CASE 8 The Lessons 1. Accommodation
Page 27 and 28: CASE 9 The Lessons 1. Hydrodynamic
Page 29 and 30: CASE 10 Figure 1: Reconstruction of
Page 31 and 32: CASE 11 The Engine That Ran Away Na
Page 33 and 34: CASE 12 Blinded By Caustic Soda Nar
Page 35 and 36: CASE 13 The master thought that the
Page 37 and 38: CASE 14 Uncontrolled Release Clouds
Page 39 and 40: Part 2 - Fishing Vessels I was hono
Page 41 and 42: CASE 15 Cold Water Can Kill in as L
Page 43 and 44: CASE 16 An Unheard Alarm Means No A
Page 45 and 46: CASE 17 Fishermen DON’T Have to D
Page 47 and 48: CASE 18 Let It Go And Come Back Lat
Page 49 and 50: CASE 19 Stay Dry, Stay Alive Narrat
Page 51 and 52: CASE 19 The Lessons 1. Shooting and
Page 53 and 54: CASE 20 The Lessons 1. A vessel tha
Page 55 and 56: CASE 21 Door opening away from winc
Page 57 and 58:
CASE 22 Harbour wall ladder handrai
Page 59 and 60:
Part 3 - Recreational Craft ‘Cros
Page 61 and 62:
CASE 23 Never, Ever Assume Narrativ
Page 63 and 64:
CASE 23 The yacht’s skipper was m
Page 65 and 66:
CASE 25 Petrol Fumes Plus Bow Thrus
Page 67 and 68:
APPENDIX A INVESTIGATIONS STARTED I
Page 69 and 70:
APPENDIX B Aquarius Fatal man overb
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INVESTIGATION

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