SafetyDigest - 01 - 06 PDF
SafetyDigest - 01 - 06 PDF
SafetyDigest - 01 - 06 PDF
INVESTIGATION BRANCH
SAFETY
DIGEST
Lessons from Marine
Accident Reports
1/2006
is an
INVESTOR IN PEOPLE
SAFETY DIGEST
Lessons from Marine Accident Reports
No 1/2006
is an
INVESTOR IN PEOPLE
Printed in Great Britain. Text printed on material containing 100% post-consumer waste.
Cover printed on material containing 75% post-consumer waste and 25% ECF pulp.
April 2006
MARINE ACCIDENT
INVESTIGATION BRANCH
The Marine Accident Investigation Branch (MAIB) is an independent part of the Department for
Transport, the Chief Inspector of Marine Accidents being responsible directly to the Secretary of
State for Transport. The offices of the Branch are located at Carlton House, Carlton Place,
Southampton, SO15 2DZ.
This Safety Digest draws the attention of the marine community to some of the lessons arising
from investigations into recent accidents and incidents. It contains facts which have been
determined up to the time of issue.
This information is published to inform the shipping and fishing industries, the pleasure craft
community and the public of the general circumstances of marine accidents and to draw out the
lessons to be learned. The sole purpose of the Safety Digest is to prevent similar accidents
happening again. The content must necessarily be regarded as tentative and subject to alteration
or correction if additional evidence becomes available. The articles do not assign fault or blame
nor do they determine liability. The lessons often extend beyond the events of the incidents
themselves to ensure the maximum value can be achieved.
Extracts can be published without specific permission providing the source is duly
acknowledged.
The Editor, Jan Hawes, welcomes any comments or suggestions regarding this issue.
The Safety Digest and other MAIB publications can be obtained by applying to the MAIB.
The role of the MAIB is to contribute to safety at sea by determining the causes and
circumstances of marine accidents, and working with others to reduce the likelihood of
such causes and circumstances recurring in the future.
Extract from
The Merchant Shipping
(Accident Reporting and Investigation)
Regulations 2005 Regulation 5:
The sole objective of the investigation of an accident under the Merchant Shipping (Accident
Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents
through the ascertainment of its causes and circumstances. It shall not be the purpose of an
investigation to determine liability nor, except so far as is necessary to achieve its objective, to
apportion blame.
INDEX
GLOSSARY OF TERMS AND ABBREVIATIONS
INTRODUCTION
10
12
14
17
19
21
23
25
27
29
31
33
36
38
41
43
46
48
50
53
56
59
62
64
67
69
72
APPENDICES
75
Appendix A
75
Appendix B
76
78
Able Seaman
BA
Breathing Apparatus
CO2
Carbon Dioxide
COLREGS
ETA
GPS
GRT
HP
Horsepower
IMO
"Mayday"
MCA
MGN
OBO
OOW
RIB
RNLI
RYA
SWL
VHF
VTS
Introduction
The diverse and growing readership of the Safety Digest is indicative of the wide range of
accidents and incidents we report. This edition has a particularly broad span of cases. Sadly,
we have fewer than normal good news tales, and many more with tragic consequences,
particularly in leisure craft. I deal with this more fully in my introduction to the leisure craft
section.
I will not try to prcis the lessons from the accidents in this edition or offer a homily on the
wisdom of risk assessment or the danger of complacency. I will leave it to each case to make
its own impact.
Nearly every accident is a tragedy whether it be through death, injury, loss of career or
some other effect. It is difficult for MAIB inspectors to deal with these tragedies on a daily
basis, and to know that the accidents could all have been avoided . . .
Stephen Meyer
Chief Inspector of Marine Accidents
April 2006
Commodore Warwick
Commodore Warwick commenced his sea-going career at the age of 15 as a cadet at the pre-sea training
ship HMS Conway in North Wales. After obtaining his Second Mates Certificate in 1961, he spent the next
several years sailing with various companies to gain experience on different types of ships. In 1970, he
joined the Cunard Line, where he served in many ships before taking his first command, Cunard Princess.
Commodore Warwick first took command of the Queen Elizabeth 2 in July 1990, and in June 1996 was
appointed to the position of Marine Superintendent of the Cunard Line fleet. On 4 July 2002, at the keel
laying of Queen Mary 2, he was appointed Master Designate, taking command of the new ship when she
was handed over to Cunard on 22 December 2003.
In 2004, Commodore Warwick received the Shipmaster of the Year award from the Nautical Institute and
Lloyds List, and was presented with the Silver Riband Award by the Ocean Liner Council of the South Street
Seaport Museum for his lifetime achievement in the maritime industry. In 2005 he was made an Officer of
the British Empire in the Queens Birthday Honours, received an honorary Doctor of Laws degree from the
University of Liverpool, and was awarded the Merchant Navy Medal. He is an Honorary Fellow of the
Institute of Transport Administration, a member of the Admiralty Circle of the Maritime Museum of the
Atlantic, a Younger Brother of Trinity House, a member of the court of the Honourable Company of Master
Mariners, a founder member and Fellow of the Nautical Institute, Governor of the Marine Society, he is
Patron of the Cunard Steamship Society, President of the Queen Mary Association and Vice President of the
Bristol Ship Society. The Commodore holds the rank of Honorary Captain in the British Royal Naval
Reserve.
MAIB Safety Digest 1/2006
CASE 1
Narrative
Tragedy ensued after a recently-built, 161m
state-of the-art bulk carrier carrying 23,243
tonnes of gravel and stone, hit rocks which
ripped a hole in her side. Within seconds, the
vessel heeled over and capsized. Many of her
30 crew members were trapped inside, and a
valiant rescue attempt, involving cutting a hole
through the vessels hull, was hampered by
freezing temperatures, darkness and the
vessels slippery hull. Eighteen seafarers lost
their lives.
A court case, aimed at establishing the cause of
the accident, reviewed the reliability of sea
charts mapping the seabed where the vessel is
believed to have run aground. However, the
reason why this modern, state-of-the-art vessel
10
CASE 1
The Lessons
1. Had the cargo been trimmed during
loading, the vessel could have sustained
angles of heel of over 30 during her
voyage, before the cargo would have
begun to shift. This would possibly have
given the crew more time to abandon
ship safely.
2. It was calculated that, after the
grounding, the ingress of seawater into
the vessel through the hole in her side,
would have eventually led to her
capsizing. However, the time taken to
capsize was considerably reduced due to
the shift of cargo as the vessel heeled
over.
11
CASE 2
Introduction
A vessel was making an approach to a pilot
station for the purpose of embarking a pilot to
proceed upriver and berth. While embarking
the pilot, the vessel ran aground. Luckily, the
seabed was soft mud and no environmental or
physical damage resulted.
Narrative
The vessel, a 23,000 tonne double hull
chemical/oil tanker, was carrying 16,300 tonnes
of lower sulphur fuel oil. The vessel arrived at
the estuary early and proceeded to anchor in a
designated deep-water anchorage. The master
was informed by his agent that the pilot was
booked for 1315 the following day; the master
made arrangements accordingly. The time of
1315 allowed a 30 minute delay factor, after
which berthing would have to be postponed.
Although the master was familiar with the
estuary, it had been nearly 10 months since his
last visit. Previously, the vessel had always
entered close to high water; this time entry
took place 1 hour before low water. The key
12
CASE 2
The Lessons
1. Poor planning considerations caused the
delay in weighing anchor, which in turn
required a high speed approach to the
pilot boarding area. Always allow
sufficient time to properly execute the
passage plan. All too often, attention to
detail becomes blurred against the
perceived need to regain lost time.
2. The bridge team did not appreciate the
strength, direction and effect of the tidal
stream. Before starting to weigh anchor,
it would have been prudent to conduct a
short briefing between the key members
of the bridge team. This would have
ensured that everyone was familiar with
all aspects of the passage plan. It would
also have given the master an
opportunity to study the standard of
chart preparations, and revise the plan if
he was not content.
13
CASE 3
Narrative
A general cargo vessel carrying 210m3 of
packaged timber cargo on deck encountered a
very large wave on her starboard beam. The
wave caused some of the webbing lashings and
package banding to part and the cargo to shift.
The vessel was passing close to the coast in
strong south-westerly gale conditions, and it
was winter. Although the conditions were not
good, just prior to the accident the vessel had
been making a steady 7.5 knots with only
moderate pitching and rolling. The general
poor weather conditions during the voyage
14
CASE 3
15
CASE 3
The Lessons
1. The passage planning for the final leg of
the voyage did not consider the possible
effect of the shallower water downwind
of which the vessel was to travel. The
combination of strong south-westerly
conditions, producing beam seas and
shallower water, almost certainly caused
the large wave encountered by the vessel.
Given the prevailing weather and sea
conditions, this was predictable.
2. Webbing or synthetic lashings have
become more prevalent for securing deck
cargoes in recent years, but are not
mentioned in the IMO Code of Practice.
They are quick and easy to use, they do
not rot and are easy to store. They are,
however, vulnerable to abrasion and are
not suitable for really heavy-duty work.
Regular and close inspection of the
webbing material should be carried out,
and worn lashings replaced.
Consideration should also be given to
using additional, alternative types of
lashing to supplement the webbing
16
CASE 4
Narrative
At 2230, a 20000grt bulk carrier anchored 3nm
to the south-west of a pilot embarkation point
in anticipation of entering port the following
afternoon. The master left night orders for the
main engines to be at standby, and to start
weighing anchor at 1315. During the night, the
second officer prepared the passage plan to
the pilot embarkation point, which, from the
anchorage position, was a single track of 030.
17
CASE 4
The Lessons
1. Providing there is sufficient sea room, it
is safer, and in the spirit of good
seamanship, to pass astern of a ship at
anchor. Passing close ahead of a ship at
anchor is potentially perilous, but if it is
unavoidable, the effects of the tidal
stream, wind and a ships
manoeuvrability need to be taken into
account.
2. Tidal stream is an extremely influential
factor in navigation, and cannot be
ignored. The slower a ships speed, the
greater its effect will be. When planning
a passage, no matter how short, if the
effects of tidal stream are not taken into
account by the calculation of courses to
steer in order to make good intended
18
CASE 5
CASE 5
The Lessons
1. The importance of correct maintenance
and calibration of essential safety
equipment, such as breathing apparatus
and oxygen measuring equipment, cannot
be overstressed. However, before landing
for service or repair, it should be
positively ascertained that sufficient
equipment is retained on board, or
requested from ashore, to deal with any
likely emergency which may arise while
the equipment is away from the vessel
undergoing service.
2. A vessels safety management system
should include procedures for entry into
hazardous spaces. Crews should be
drilled, at regular intervals, to enhance
their awareness of such procedures,
which should include entry into spaces
which may have a depleted oxygen
content (eg following the discharge of
CO2 smothering into machinery, or
associated spaces).
3. CO2 fire smothering systems are
essential for the ultimate safety of a
vessel. Despite the annual service and
certification of such systems, planned
maintenance schedules should include
the routine examination of all associated
20
CASE 6
Narrative
A feeder container vessel was discharging
cargo at one of her regular UK ports, using the
shore cranes. On deck, an unsupervised AB
was using a long pole to unlock the twist locks,
and the discharge of the deck load was nearing
completion. The last stack of containers to be
discharged comprised 6 metre units loaded 2
high, spanning the well between the aft end of
the hatch and the forward edge of the
accommodation. Cell guides were fixed to the
front of the accommodation, and strengthened
pads supported the after corners of the
containers. On the centreline, a ladder was
also fixed to the front of the accommodation
to provide access to the top of the containers,
and serve as an escape route from the
accommodation.
The vessel was moored starboard side to, and
the discharge of this final stack started from
the port side. It was not possible to fit twist
locks on the aft corners of these containers
MAIB Safety Digest 1/2006
CASE 6
Container
position
AB stood here
The Lessons
1. This is a hazardous operation,
particularly in the feeder trade, where
lean manning does not allow constant
supervision. It is essential that people are
routinely briefed on safety issues.
2. The company safety posters state that,
when removing twist locks, crew should
stand at least one container away from
the one being worked. This tragic
accident clearly demonstrates why.
22
CASE 7
Narrative
Engineering ratings of a foreign flagged ferry
were preparing to move an air conditioning
compressor from the auxiliary engine room to
the engineers workshop, for maintenance
purposes. The weather was moderate and
there was a 1m swell running.
The compressor/bedplate fastenings were
removed and preparations made to lift the
1.1 tonne compressor from the bedplate.
A single fabric strop was passed through
2 eyebolts on the compressor, and connected
to a chain block with a Safe Working Load
(SWL) of 2 tonnes. The strop had a recorded
SWL of 1 tonne force. The strop was tested in
December 2003, well inside the statutory
5 year testing requirement.
As the compressor was being lifted, the fabric
strop parted (Figure 1), and the compressor
MAIB Safety Digest 1/2006
CASE 7
The Lessons
With luck on his side, the engineering rating
escaped serious injury. The failure of the
strop could so easily have resulted in a
fatality. Safe Working Loads are recorded on
all items of lifting equipment, and it is clear
that these must be greater than the loads
being lifted.
Statutory Instrument 1988 No 1639 states
that no person shall operate any lifting
plant unless he is trained and competent to
do so and has been authorised by a
responsible ships officer.
24
CASE 8
Narrative
The tugs tow rope messenger was led through
a Panama lead, around the bits at a 100 angle
and on to the winch end whipping drum. The
drum end seaman was standing with his back
to the working part of the rope and the
supervisor, as he hauled on the rope.
Port
Key
1 - supervisor
2 - casualty
3 - AB
4 - AB
5 - winch controller
Winch
Drum end
2
Tug
Panama lead
Bits
Stern
(not to scale)
25
CASE 8
Position of
casualty
Position of
supervisor
The Lessons
1. Stand facing the danger: always put the
winch between the operative and the
potential danger zone. This, in itself,
creates a safety barrier, allows full visual
contact with the mooring team and
surroundings, allows controlled surging
on the drum end and keeps the operative
clear of the working part.
2. Be aware of the dangers of sharp nips
these cause excess strain on machinery,
fittings and ropes and use fair leads
wherever possible.
26
CASE 9
v
v
v
1.0
v
v
v
v
vv
1.2
Position of
grounding
nk
ba
nd
1930
Sa
nd
Green
buoy
ba
nk
Sa
0.6
Red buoy
Sandbank
Autopilot engaged
Steering motor shut down
Speed increased
Planned track
Estimated actual track
27
CASE 9
The Lessons
1. An OOW is responsible for the safety of
his ship. If he is not on the bridge, from
where he can monitor navigation and
communications, and react to, and
control on board emergencies, he cannot
fulfil this vital duty. Leaving the bridge,
albeit briefly, is not only a violation of
regulation, but it also endangers a ship
and her crew. On the occasions when an
OOW finds it absolutely necessary to
leave the bridge, it is in everyones
interest that he arranges a relief before
doing so.
2. When in restricted waters with a pilot
embarked, it is normal practice to have
sufficient machinery and equipment,
such as steering motors and radars,
operating to provide optimum
manoeuvrability and redundancy in the
event of a breakdown. When in
restricted waters without a pilot, the
need for manoeuvrability and
redundancy remains unaltered. It is the
proximity to dangers and environmental
conditions which should determine a
ships equipment readiness, not the
presence of a pilot.
3. A passage plan is a navigational risk
assessment and, as such, is crucial to the
safety of a ship during a voyage. If it is
incomplete, or more than one plan is in
28
CASE 10
Figure 1
Narrative
A 58-metre coastal cargo vessel (Figure 1) was
steaming south in the early hours of a February
morning. The mate was on watch as the ship
approached the area off the mouth of the river
Humber and there was no lookout on the
bridge. It was dark, but the first signs of daylight
were starting to appear. Visibility was good and
the wind was from the north-west force 7.
The mate had been working excessive hours,
sharing a 6 hours on/6 hours off bridge watch
with the master. The master had been on
board the vessel for about a week, working as a
relief for the regular master who was on leave.
He undertook only bridge watches, leaving all
the cargo work to the mate. The senior seaman
had served on the vessel for about 18 months
and had taken no leave of absence during that
time. The junior seaman had only been at sea a
few days. A cook was also on board.
The mate was not fully supported by the
master. The senior seaman was probably not at
his best after such a long period of duty, and
the junior seaman was of limited value as he
was very inexperienced. The mate tried to
keep the ship running in these difficult
circumstances, but as a result he was very tired
on the morning of the incident.
MAIB Safety Digest 1/2006
CASE 10
Figure 2
The Lessons
1. The mates inability to adequately
interpret the situation is consistent with
fatigue. Fatigue is an insidious problem,
and it can make the sufferer indecisive. It
is very important that crew members are
able to recognise the symptoms of fatigue,
and that they take positive action to
address it. Dont be afraid to say that you
are tired!
2. This vessel met the requirements of the
regulations, even so, a crew of five is
considered to be barely sufficient. With a
bare minimum crew it is very important
that all of them are fully qualified and
that they have frequent periods of leave.
In addition, all crew members need to do
their fair share of the work; this was
patently not the case here.
30
CASE 11
Figure 1
31
CASE 11
The Lessons
CO2 extinguishes fires by reducing the
oxygen content in the protected
compartment. It is extremely dangerous to be
in a compartment into which gas is being
discharged; several fatalities have occurred
where this has happened. Fortunately, in this
case, the main system isolating valve was
closed, and this prevented gas discharging
into the engine room. Had it been open, and
had someone been in the space, the outcome
could have been very different.
32
CASE 12
Figure 1
Narrative
A large multi-role vessel was alongside a lay-by
berth toward the end of an annual refit. As part
of the refit work, the eight, davit-launched,
fully enclosed lifeboats had been overhauled
ashore (Figure 1) and refitted on board. The
work on the lifeboats included overhauling the
on load release gear, including load testing in a
test rig.
An experienced Flag Administration surveyor
had requested that the vessel lifeboat crew
carry out two lifeboat operations, including
releasing the on load gear with the lifeboat
suspended just above the water to simulate
failure of the hydrostatic release mechanism.
On the day of the incident, the surveyor was
involved in a fatal accident investigation on
board another vessel, and had to delay the
planned lifeboat operations.
33
CASE 12
Coxswain seal
Interlock lever
Figure 2
34
CASE 12
The Lessons
1. How many readers would consider
raising an objection to releasing a lifeboat
from its falls when it is only 1.2m
(4 feet) above calm water? It doesnt
sound very high, does it, yet expert
advice indicates that the impact forces
from such a drop could be as much as
20g (gravity). Forces of this magnitude
are capable of causing spinal injuries
even to someone sitting in the correct,
upright position. If it is felt necessary to
test the operation of the on load gear, the
guidelines provided by the IMO should
be followed:
Position the lifeboat partially into the
water such that the mass of the boat is
substantially supported by the falls,
and the hydrostatic interlock system,
where fitted, is not triggered;
Additionally, it is also advisable to keep
the number of crew members on board
the lifeboat to a minimum during the
test.
2. What is evident about this accident is
that no-one was in overall control of the
lifeboat. Communications had been poor.
The surveyor was attending purely as an
observer, but because the crew had not
carried out the operation before, they
expected him to provide guidance. The
lifeboat crew did not clearly understand
the surveyors role, and the surveyor, by
accepting the initial request for guidance
on the height of the lifeboat release,
reinforced the misconception. Whether
or not a Flag State surveyor is present at
a lifeboat drill, it is the ships staff, or the
shipyards staff, who remain in charge of,
and responsible for, the operation.
35
36
After 11 years in the Army, reaching the rank of captain in the Brigade of Gurkhas, Chris returned to his
home village of Torcross in South Devon where he was brought up among the crab fishing communities of
Start Bay. He achieved his boyhood ambition in 1978 when he bought his first commercial crabber, and still
runs a small 32ft inshore crabber and operates a 15ft bass beach boat. He has been the Hon Sec of the
South Devon and Channel Shellfishermen since 1989, is Chairman of Devon Sea Fisheries Committee,
Chairman of the Crustacea Committee of SAGB and a board member of the Sea Fish Industry Authority.
MAIB Safety Digest 1/2006
37
CASE 13
Figure 1: Salvage
Narrative
An under 10m fishing vessel left her home port
early in the morning to fish the prawn grounds
off the north-east coast. The weather was
pleasant with a light westerly breeze and a
slight swell. The vessel had been fishing
successfully and the skipper and his brother, as
the only crew, looked forward to another good
days catch.
During the morning, the weather worsened.
A westerly force 6-7 developed and the sea
became very confused. Unworried, the
brothers hauled in their catch and began
steaming back to port. Just before midday, the
skipper spoke to his wife by mobile telephone
to tell her he was making his way home. Soon
afterwards, the trawler was sighted, for the last
time, by another local fishing vessel.
38
CASE 13
39
CASE 13
The Lessons
1. The purchase of a fishing vessel is a
major undertaking, and sometimes a
clean and shiny appearance can cloud
good judgment. Skippers/owners are
urged to seek expert advice when
considering purchasing a vessel, to
ensure that it is fit for the purpose
intended. This advice also extends to
changes to structure, to ensure that
stability, and therefore safety, is not
compromised.
2. Structural maintenance is an essential
element in ensuring a vessels watertight
integrity. Although expensive, it is of
comparatively little cost for a potentially
great return: preventing the possible loss
of a vessel. Hull repairs should be given
the highest priority if downflooding and
internal flooding is to be prevented.
40
CASE 14
41
CASE 14
The vessel sustained no damage to her hull
when she beached, but she did suffer serious
water damage to machinery and electrics.
Subsequent inspection showed various
contributory factors to the flooding: the
sheared sea inlet was threaded into a pad on
the boats side; the inlet fitting was unduly
The Lessons
1. The vessel had no bilge alarm fitted.
Decked vessels should be fitted with
effective bilge alarms to give earliest
possible warning of water ingress.
Owners may also wish to consider the
benefits of an extension klaxon and/or a
strobe light to give warning when the
wheelhouse is unattended.
2. Frequently, overboard discharge lines are
fitted with non-return valves to reduce
the risk of backflooding. Had this been
the case in this instance, the speed of
flooding would have been greatly
reduced.
3. The skippers action in plugging the
water entry point with a simple broom
handle shows the effectiveness and
benefit of carrying a selection of
different size plugs to drive into holes or
42
CASE 15
Narrative
In darkness, while on passage from one port to
another, the deck lights of a potting fishing
vessel suddenly lit up. Taken by surprise, the
skipper/owner turned the wheelhouse switch
to the off position, but the lights remained on.
He then tried, unsuccessfully, to switch on the
galley lights.
Because the fuse boxes were in the forward
auxiliary generator hold, the skipper went out
on deck and opened the access hatch to the
space. He was met by thick black acrid smoke.
He quickly closed the hatch and returned to
the wheelhouse, where he alerted the
coastguard that he had a fire on board.
The skipper switched on the cabin lights and
called the two deckhands, who were sleeping.
But the lights would not illuminate. He then
returned to the forward hatch and, on opening
it, saw flames in the hold.
MAIB Safety Digest 1/2006
CASE 15
44
CASE 15
The Lessons
1. The fishing vessel was not fitted with a
fire detection system in either her
forward auxiliary generator hold or her
engine room. Had one been fitted, this
would have alerted the crew at a much
earlier stage and would have given them
a chance to fight the fire before it had
time to take hold.
2. The electrical fault, which was probably
the cause of the fire, also affected the
charging of the emergency batteries and,
45
CASE 16
Narrative
On completion of a 2-week refit, a fishing
vessel sailed for the fishing grounds. During
the departure, the skipper realised that the
buoys and navigational tracks had been
removed from the chart plotter, which had
recently been upgraded. These were
re-installed as the passage progressed. The
navigational watch was then handed over to a
deckhand, and the skipper went to the engine
room to conduct several routine checks before
going to bed.
Forty five minutes later, during the early hours
of the morning, the fishing vessel collided with
the port quarter of an 86,000grt ore carrier,
which was anchored in a designated area.
The skipper was woken by the boat
manoeuvring. He went to the wheelhouse
from where he saw the ore carrier directly
astern. The deckhand on watch admitted that
he had nodded off but stated that there had
been no collision. As the deckhand was
46
CASE 16
The Lessons
1. After extended periods alongside, it is
prudent to make sure that all systems are
working correctly before sailing. This is
sometimes easier said than done,
particularly during the latter stages of a
refit or maintenance period, when there
is a rush to complete work outstanding,
and masters and skippers are frequently
under pressure to sail as soon as possible.
However, the time and effort invested in
testing equipment alongside can save
serious embarrassment at sea.
2. Numerous accidents at sea result from
lone bridge and wheelhouse
watchkeepers falling asleep, particularly
during the early hours of the morning.
Fatigue is a persistent problem, which
can only be properly overcome by
ensuring watchkeepers are well rested,
and that their body clocks have adapted
to working unusual hours. Where this is
not possible, by ensuring that
watchkeepers are not left alone, and that
watch alarms are fitted and used, at least
they can be prevented from falling asleep
for extended periods during which
dangerous situations can develop.
47
48
49
CASE 17
Double Tragedy
Narrative
When on a short coastal passage, a 4m sailing
dinghy capsized 7 cables from the nearest
point of land. On board were its owner, an
adult crewman and two children. All were
dressed in shorts and T shirts. The owner was
wearing a lifejacket, and the remainder of the
crew wore buoyancy aids. Following capsize,
two attempts were made to right the dinghy,
which had fully inverted. Despite the wind
being between force 5 and 6, and waves at a
height of about 1.5m, the boat was rotated to
an upright position on both occasions, but
quickly capsized and inverted again.
Following the attempts to right the dinghy, it
was noticed that the dinghys owner had not
been able to inflate his lifejacket.
Consequently, the adult crewman located and
pulled the toggle fitted to his lifejacket
(Figure), which then inflated. However, the
lifejacket did not appear to be fitted correctly,
and the owner struggled to keep his mouth
clear of the water. He died from a combination
of hypothermia and drowning about 10
minutes after the initial capsize.
50
CASE 17
51
CASE 17
The Lessons
1. Although the conditions might appear to
be benign when taking to the water, it is
wise to bear in mind that they can
change very quickly. Many boat owners
have been caught out in this respect.
Before putting to sea, where adverse
conditions threaten the safety of many
small boats, the checking of the local
inshore weather forecasts, via the radio,
internet, local newspapers, or coast radio
stations, is a simple and cost free
precaution to take.
2. When putting on a lifejacket, take a few
seconds to ensure it is worn correctly. If
it is not, the jacket will tend to ride up
when inflated, and will be more of a
hindrance than assistance. This will
decrease, rather than increase, an
individuals chances of survival.
3. Even in the summer, when the
temperature of the sea around the UK is
about 16C, its debilitating effects
should not be under-estimated. This is
still 20C below body temperature, and
well below the temperature of most
swimming pools. When in boats such as
sailing dinghies, where the danger of
capsize is ever present, and when in
remote areas where assistance is not
readily at hand, the effects of cold water
immersion must not be ignored when
deciding what clothes to wear.
52
CASE 18
Figure 1
Narrative
The owner of a high powered, rigid inflatable
boat (RIB) was well known to have been a
keen and competent yachtsman. He always
made a point of wearing his lifejacket, and
ensured that his yacht was properly equipped
to cope with emergencies. In sum, he was
considered to be very safety conscious.
About 2 years before the accident, he had
moved into the faster paced RIB craft arena.
He enjoyed the excitement of driving his boat,
and decided to replace it with a larger, more
powerful, 6.4 metre RIB with a 150
horsepower engine, providing a top speed of
about 50 knots (Figure 1). It was very doubtful
if the boat was subjected to regular
maintenance or a professional survey prior to
purchase, but the outward appearance was of a
smart, well presented craft.
MAIB Safety Digest 1/2006
CASE 18
During the early part of the trip, the elder
daughter took the wheel. She found steering
the RIB rather difficult, and soon after, her
father took over. He was sitting on the most
forward seat, with his younger daughter on the
seat behind and with her sister standing beside
her. After a period of weaving the RIB about, the
owner steadied on a course and set the throttle
at full ahead. The RIB then unexpectedly
lurched to port, throwing the father and his
younger daughter into the cold water.
Because the engine kill cord had not been
connected, the RIB continued at high speed
until the elder daughter was able to scramble
to the steering console and reduce the engine
power. Despite the haphazard steering, she
managed to drive the RIB back towards her
father and sister. Without a VHF radio or flares,
she could not raise the alarm, but on the way,
54
CASE 18
Figure 3
The Lessons
All the evidence points towards a mechanical
failure of the RIBs steering system (Figure
2) causing it to lurch uncontrollably. It was
found that the system had non-standard
components fitted, and that the hydraulic oil
level was low, due to oil leakage from the
helm/shaft pump boss (Figure 3). This
allowed air and moisture to enter the system,
causing intermittent steering control, and
water ingress causing corrosion to internal
components.
It is tragic that a number of contributory
factors to this accident have also been causal
in other fatal leisure craft accidents. Most
are obvious, and include:
1. Good preparation cannot be over
emphasised the use of lifejackets,
carriage of flares and a VHF radio will
greatly improve your chances of survival
you owe it to yourself and your
passengers to carry them on board.
55
CASE 19
56
CASE 19
57
CASE 19
The Lessons
1. Dont drink and drive on land and
water.
2. Travelling in restricted waters, in
darkness and at high speed, requires good
vision, good judgment and quick reaction
times. Alcohol causes reduced vigilance,
lower inhibitions, poor night vision,
affected perception and deterioration of
judgment: all of which played a large part
in this accident.
58
CASE 20
Narrative
It was another very pleasant, balmy summers
day in a popular seaside resort; just the sort of
day to take the family out for a short,
exhilarating, boat trip. Indeed, what better way
to round off a holiday than to do this onboard
a high speed, 12 passenger, 9 metre, Rigid
Inflatable Boat (RIB) (Figure 1).
Full of expectations and a little trepidation,
12 passengers, 6 of whom were children, were
given a rudimentary safety briefing by the
fiance of the RIBs skipper. She had no
marine experience. The briefing only covered
the use of the lifejackets, and emphasised that
the red manual inflation toggle should not
be pulled while in the RIB. Unfortunately, the
passengers were not told when the toggle
should be pulled. With the passengers now
safely on board, the skipper and his fiance
took up their positions at the steering console.
59
CASE 20
Figure 4: Construction
60
CASE 20
this vessel was used for commercial purposes,
it was subjected to detailed examination under
the auspices of the MCA. However, in common
with many other RIBs, there was no access to
the under deck areas, so it was very difficult to
assess the true condition of the hull.
It was also found that the operating company
had conducted no risk assessments of their
operation, and neither was it aware of the
The Lessons
The owner of the RIB operating company
identified a niche in the leisure market for
high speed boat rides. He purchased the
RIB, and operated it in good faith, believing
that it had been built to the European
Recreational Craft Directive (RCD)
standards (which came into force in 1996
for recreational craft between 2.5 and 24
metres). As such, the craft should therefore
have been able to withstand the loads
expected for its intended operation. This
assumption was further reinforced because
the RIB had been examined for commercial
use.
Fee paying passengers should expect to be
carried in a safe manner, in a seaworthy
vessel capable of coping with the predicted in
service loads. Equally, they should expect
that the operation has been assessed as being
safe, part of which includes the skipper being
fully trained and qualified for his role in
order that he can competently deal with
emergency situations.
In this case, the crew and passengers were
very lucky to escape serious injury.
This accident has highlighted the following
lessons appropriate to operators of small,
high speed leisure craft, especially for those
in commercial use:
61
CASE 21
Narrative
On a pleasant summers day, the helmsman of
a 6.55m cabin cruiser spent the day with
various friends, cruising between near-by
harbours, visiting the local public houses as
they went. A local harbourmaster had
particular reason to note the vessel that day, as
it had twice sped out of his harbour,
generating excessive wash.
Just after sunset, the cabin cruiser, with its
helmsman and three passengers, completed
the short 10-15 minute crossing to a small
harbour for a drink. Thirty five minutes later,
and being aware it was getting dark, the
helmsman decided to head back to the main
harbour. The vessels navigation lights
consisted solely of a combined side light (the
pole mounted all-round white light being
broken), however it was doubtful that the
helmsman turned this on.
62
CASE 21
The Lessons
1. Using a leisure craft while under the
influence of alcohol is dangerous and
puts your and others lives unnecessarily
at risk. Alcohol will lead to:
deterioration of night vision
63
CASE 22
Narrative
The owner and his wife were half way through
a four week holiday, cruising the Western Isles
of Scotland when fire gutted their 12.5m steel
hulled yacht, forcing them to abandon ship.
Fortunately no-one was hurt, but the yacht was
burnt out.
The yacht was on a daytime passage between
two ports. On sailing, the weather had been
clear, but around midday the wind had
dropped and visibility reduced to less than
1 mile, so they were motor-sailing. About 112
hours later, the crew noticed smoke coming
up the companionway, and the skipper went to
investigate. On lifting the companionway
steps, the skipper saw flames on the starboard
side of the engine in the vicinity of the wiring
loom. He fetched a fire extinguisher from the
forepeak and with 3-4 blasts put the fire out.
The engine had remained running throughout.
There was a lot of smoke below, so the skipper
went on deck for some fresh air before
64
CASE 22
65
CASE 22
The Lessons
1. Never assume a fire is out. To burn, a
fire needs 3 ingredients: combustible
material, oxygen and a source of ignition.
Depriving the fire of any of these will
put it out, temporarily. Fire-fighting
must always be followed by action to
permanently deprive the fire scene of at
least one of the 3 key ingredients.
2. If you do suffer a fire on board, always
check adjacent compartments and spaces
for hot spots and secondary fires. If
possible, dampen down hot spots, but at
least monitor the area until any residual
heat has dissipated.
66
CASE 23
Perilous Propellers
Narrative
A 12 metre long, twin screw charter boat was
hired by a team of divers for 2 days of diving.
This vessel had been used by one of the team
on a previous occasion, with good results. It
was known to some of the others by
reputation and was operated under the
Maritime and Coastguard Agencys Code of
Practice; it was a Coded boat.
The boats skipper met with the team the
evening before the first dives and discussed
buddy arrangements and dive sites.
The following morning all met at the boat,
which then headed for the area of the first
dive. This was just off an area of rocks where
seals were common. Once at the site, the
boats skipper gave the dive team a briefing.
This included details of the underwater terrain,
an area of possible strong tidal streams, the
use of delayed surface marker buoys and
procedures to be followed after surfacing.
Water depth was between 20 and 24 metres.
Four pairs of divers entered the water. Surface
conditions were reasonable, with only a slight
swell and breeze. After about 30 minutes, they
began to surface close to the rocks. The swell
MAIB Safety Digest 1/2006
CASE 23
The Lessons
1. The Maritime and Coastguard Agencys
Code does not cover the safety of
recreational diving operations; it is
concerned primarily with the safety of
the boat and those on board. A boats
compliance with the Code does not
automatically indicate its suitability for
diving.
68
CASE 24
Narrative
A group of 8 middle managers were taking part
in a corporate team-building course, part of
which involved a harbour crossing of about 1.6
miles using two rafted canoes provided by an
outdoor activities centre. The canoes were
accompanied by a small 4-man capacity safety
boat. None of the group had any waterborne
experience. The course was managed by a
separate, third party specialist company, but the
outdoor centre provided the training facilities
and some specialist instructors. In this case, it
included the safety instructor for the harbour
crossing exercise. The instructor had previously
been involved in the crossing, but he had never
led this exercise before. Safety had always
received high priority, and the centre had a
comprehensive safety policy. However, they
had not conducted a specific risk assessment
covering the rafted canoeing exercise.
MAIB Safety Digest 1/2006
CASE 24
TOWING ARRANGEMENT
Safety
boat
Safety
boat
Safety boat
towing bridle
Bowlines allowed to travel along
the safety boat towing bridle and
canoe tensioning rope
Canoe stem
tensioning rope
connecting spar
Figure 2
70
CASE 24
plunging everyone back into the cold water.
Using his mobile telephone, the instructor
advised the outdoor centre of the situation
but, despite the worsening situation, the
emergency services were not alerted and the
canoes and course members drifted towards a
deep channel.
The Lessons
The course members were extremely
fortunate that the oilrig supply vessel was in
the vicinity to make a speedy recovery,
especially as the group were drifting quickly
towards deep water, and the cold was rapidly
sapping their strength. The appropriate
control measures were not in place to
minimise the risks, because the risk of rafted
canoes becoming swamped had never been
properly assessed. Had they been, it is
probable that an alternative exercise would
have been conducted.
This accident has highlighted the following
lessons appropriate to the outdoor activity
industry:
1. Risk assessments need to be thorough,
and must consider every element of the
activity. Hybrid activities, such as the
rafted canoe exercise, warrant their own
risk assessment.
2. Although rafted canoes provide a stable
platform, they are less able to ride
with the sea conditions than a single
canoe, and are therefore more susceptible
to swamping.
71
CASE 25
Narrative
A 48m luxury yacht grounded in good weather
on a well charted reef. The vessel was badly
holed and sank to a semi-submerged position.
Two days later, the vessel slipped off the reef
and disappeared below the surface.
The yacht had been cruising for 2 days with its
passengers on board and had anchored in a
bay overnight. The chief officer, who had
joined the vessel 4 months previously, was up
early as usual, assisting the crew and weighing
anchor. He then went to the bridge to take
over the watch from the master, and was
informed by him of their days destination.
The weather was excellent, with good visibility
and only a light breeze, and the plan was to
make for a bay some 2-3 hours steaming down
the coast.
The chief officer was responsible for
navigation, and he drew a planned track on the
small scale chart. He also made use of some
72
CASE 25
73
CASE 25
The Lessons
Sadly, the lessons learnt from this accident
are not new and are common to many
accidents investigated by the MAIB.
1. Passage planning is not an optional extra.
It is vital, if you are to avoid grounding
on clearly charted obstructions, as is the
case in this accident. There may have to
be a great deal of flexibility in where a
vessel goes, but this is no excuse for not
conducting proper passage planning
beforehand.
74
APPENDIX A
Name of Vessel
Type of Vessel
Flag
Size (grt)
Type of Accident
07/11/05
Sammi Superstars
Bulk carrier
Korea
28327
Mach. failure
15/11/05
George Lyras
Cormill
Corglen
Corheath
Corhaven
Kenmouth
Bulk carrier
Barge
Barge
Barge
Barge
Barge
Greece
UK
UK
UK
UK
UK
22322
Unknown
Unknown
Unknown
Unknown
Unknown
Collision
17/11/05
Arctic Ocean
Marie Af Hovrik
UK
Sweden
6326
146
Collision
22/11/05
Golden Bells II
Plato
Fishing vessel
General cargo
UK
Barbados
24.94
1990
Collision
23/11/05
Varmland
UK
6434
29/11/05
Solent Fisher
Product tanker
Bahamas
3368
Hazardous incident
10/12/05
Lisa Leanne
Scallop dredger
UK
9.76
Fire/explosion (fatal)
18/12/05
Sovereign
Fishing vessel
UK
164
Grounding
Dublin Viking
Ro-ro passenger
UK
21856
Grounding
19/12/05
St Georgij
Bulk carrier
Panama
14971
Fire/explosion
20/12/05
Black Friars
Oil tanker
UK
992
Grounding
08/01/06
Jolbos
Bulk carrier
Cyprus
18813
07/01/06
Mounts Bay
UK
Unknown
Mach. failure
21/01/06
Rubino
Linda Kosan
Oil/chemical tanker
LPG carrier
Italy
Isle of Man
5045
2223
Haz. Incident
27/01/06
UK
31333
30/01/06
Pamela S
Fishing vessel
UK
24.50
21/02/06
Pride of Calais
Ro-ro passenger
UK
26433
Machinery failure
27/02/06
Stena Leader
Ro-ro passenger
Bermuda
12879
Contact
Name of Vessel
Type of Vessel
Flag
Size (grt)
Type of Accident
04/11/05
Harvester
Strilmoy
Pair trawler
Offshore supply
UK
Norway
154
3380
Collision
05/12/05
Dieppe
Ro-ro passenger
France
17672
Grounding
Arctic Ocean
Maritime Lady
UK
Gibraltar
6326
1857
Collision
CP Valour
Bermuda
15145
Grounding
09/12/05
13/12/05
Noordster
Beam trawler
Belgium
84
Capsize (fatal x 3)
05/01/06
Berit
General cargo
UK
9981
Grounding
18/01/06
Emerald Star
Beam trawler
Belgium
296
Contact
19/01/06
Green Hill
Fishing vessel
UK
74
Flooding/foundering
(fatal x 2)
13/02/06
Kathrin
General cargo
Switzerland
2999
Grounding
75
APPENDIX B
76
(trilogy)
- Emerald Dawn capsize and foundering,
with the loss of one life on 10 November
2004
Published 5 August 2005
- Jann Denise II foundering 5 miles SSE of
the River Tyne on 17 November 2004 with
the loss of two crew
Published 5 August 2005
- Kathryn Jane foundering 4.6nm west of
Skye on, or about, 28 July 2004 with the loss
of the skipper and one possible crew
member
Published 5 August 2005
Hyundai Dominion/Sky Hope collision in
the East China Sea on 21 June 2004
Published 30 August 2005
Isle of Mull contact between two vessels,
and the subsequent contact with Oban Railway
Pier, Oban Bay on 29 December 2004
Published 22 July 2005
Jackie Moon grounding, Dunoon
Breakwater, Firth of Clyde, Scotland on
1 September 2004
Published 23 March 2005
APPENDIX B
77
APPENDIX C
78