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MARINE ACCIDENT
INVESTIGATION BRANCH
SAFETY DIGEST
Lessons from Marine Accidents
No 1/2011
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MARINE ACCIDENT
INVESTIGATION BRANCH
The Marine Accident Investigation Branch (MAIB) examines and investigates all types of marine
accidents to or on board UK vessels worldwide, and other vessels in UK territorial waters.
Located in offices in Southampton, the MAIB is a separate, independent branch within the
Department for Transport (DfT). The head of the MAIB, the Chief Inspector of Marine Accidents,
reports directly to the Secretary of State for Transport.
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 information which has 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.
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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
PART 1 - MERCHANT VESSELS
1.
Close Encounters of the Aframax Kind
10
2.
Different Interpretations
12
3.
Snagged & Dragged
14
4.
Generators Dont Just Make Electricity
16
5.
STS Run-In, No Margin for Error
18
6.
Lack of Communication, and Distraction Lead to Benzene Spill
21
7.
ECDIS Assisted Grounding?
22
8.
Last Out Turns the Lights Off!
23
9.
Davit Control Adjustments Proceed With Caution
26
10. Early Release Led to Early Demolition
28
11. Improvement Causes Unforeseen Consequences
30
12. Last Act of Defiance
33
13.
35
14. Poor Cargo Configuration Results in Hull Failure and Pollution
39
15. Know Your Systems Back to Black
41
16. When Im Cleaning Windows
42
Fire Below The Need for Effective Engineering Oversight
PART 2 - FISHING VESSELS
44
17. Balancing Act
46
18. Shooting Pots Ends Tragically
48
19. Its Foggy No Stand-On Vessels Allowed
50
20. Never Give Up
52
21. I Thought You Said the Fore Peak Was Empty
54
22. Rock and Roll
56
SMALL CRAFT
58
23.
A Plan That Went Wrong
60
24.
No Margin for Error Leads to Catastrophic Grounding
61
25.
Dont Forget When You Have Pulled the Plug
62
APPENDICES
65
Appendix A - Preliminary examinations, field deployments and investigations

started in the period 01/10/10 to 28/02/11
Appendix B - Reports issued in 2010
67
Appendix C - Reports issued in 2011
68
Appendix D Safety Bulletins issued during the period 01/10/10 to 28/02/11
68
Glossary of Terms and Abbreviations

AB
- Able seaman
MCA
- Maritime and Coastguard Agency
ARPA
- Automatic Radar Plotting Aid
MCR
- Machinery Control Room
ASD
- Azimuth Stern Drive
MGN
- Marine Guidance Note
- Celsius
MIRG
- Marine Incident Response Group
cm
- centimetre
OOW
- Officer of the Watch
CO2
- Carbon Dioxide
Pan Pan - The international urgency signal

(spoken)
COLREGS - International Regulations for the

Prevention of Collisions at Sea 1972
(as amended)
PTW
- Permit to Work
RNLI
- Royal National Lifeboat Institution
CPA
- Closest Point of Approach
Ro-Ro
- Roll on, Roll off
DSC
- Digital Selective Calling
RYA
- Royal Yachting Association
ECDIS
- Electronic Chart Display and
SMS
- Safety Management System
Information System
STS
- ship-to-ship (transfer)
ECR
- Engine Control Room
TSS
- Traffic Separation Scheme
ERRV
- Emergency Response and

Rescue Vessel
VHF
- Very High Frequency
FRS
- Fire and Rescue Service
VTS
- Vessel Traffic Services
kN
- kilonewton
- metre
Mayday
- The international distress signal

(spoken)
Introduction
Ive recently returned from the annual meeting of the
Marine Accident Investigators International Forum (MAIIF).
29 organisations were represented and its perhaps not surprising
that our wide ranging discussions covered a number of the issues
captured in this edition of the Safety Digest. This included: poor
application / knowledge of the COLREGS (Cases 2, 19); over reliance
on ECDIS combined with a widespread lack of understanding about
the limitations of this aid to navigation (Case 7); inadequate passage
planning (Cases 23, 24); and the perennial reluctance of fishermen
to wear lifejackets when working on deck (Cases 17, 18, 20).
The Forums discussions about the use of lifejackets when working
on the decks of fishing vessels struck a particular chord with me as
the MAIB is currently investigating 3 separate accidents involving fishermen who tragically have
lost their lives after falling, or being taken over the side. Arguably, the lives of all 3 could have
been saved if they had been wearing a lifejacket. My heart goes out to the families of those
concerned and I make no apology for repeating a plea to skippers of fishing boats and other
small craft that has been made in this Digest before please make sure that everyone working
on the deck of your boat wears a lifejacket. If you do this, then wearing them will become as
routine as using a seatbelt in cars has become, and lives will be saved.
There has been a small change to the format of the Safety Digest. At Appendix D you will find
details of any Safety Bulletins the MAIB has produced since the last edition.
In closing, I would like to take the opportunity to thank Don Cockrill, John Goodlad and Sarah
Treseder for the time they have given to produce the introductions to the three industry sections
of this report. MAIB is extremely lucky to be able to record the thoughts and experience of
people such as Don, John and Sarah for the benefit of its Safety Digest readership.
Until next time, keep safe.
Steve Clinch
Chief Inspector of Marine Accidents
April 2011
MAIB Safety Digest 1/2011
Part 1 - Merchant Vessels

This section of
Safety Digest once
again provides
a unique and
invaluable source
of information
for mariners of
all disciplines
to learn and
benefit from
the unfortunate
experiences of
others.
It is worth reflecting on why it is, that
despite comprehensive regulation, numerous
operational codes of practice and ever
evolving training, qualification and certification
schemes, so many accidents (or rather, failures
of risk management) still occur in commercial
shipping. Sometimes it can be a result of
equipment failure through poor design,
system fatigue or old age. However, in reading
through the following reports it is clear that as
ever, there are many cases where the accident
is attributable to some sort of operational
error arising from the fallibilities we all suffer
- the human factor elements. Such failings,
illustrated in the reports, include a common
human desire, particularly strong in seafarers,
to get the job done as a first priority. This is
often with complete disregard to personal risk,
perhaps due (especially in the current economic
climate) to minimal profit margins and so any
delay is financially damaging. Alternatively,
perhaps the programmed maintenance regime
is dispensed with to save expenditure on
parts and labour. Managerial pressures, often
(though not always) unintended are frequently
inferred by those tasked with achieving a goal
as requiring corner cutting to achieve the
quickest and most economical solution.
8
Examples are insufficient or incorrect use

of tools and equipment, excessive speed,
insufficient personnel delegated. Such inferred
pressures are not limited to those on board,
shore managers are equally susceptible.
Sometimes, we take routine tasks for granted.
Most of us have experienced finishing a task
only to realise that we have no recollection of
actually doing it. The problem is of course that
because we may not have full concentration on
the task in hand, we overlook the simplest of
unexpected and undesirable occurrences and
may make mistakes which can lead to a serious
accident. Fatigue too can play a major part in
this, not only by causing lack of concentration
but simply a sort of numbing of the mind to
the matter in hand and increasing vulnerability
to distractions. In even the apparently simplest
of tasks, there is a need for variety and frequent
breaks to ensure continuity of concentration.
Being aware of our own fallibility adds a
significant enhancement to any training regime
or the compliance with an operational code of
practice. There are numerous published works
on the subject, but one I can recommend that
is easy to read, amusing and very relevant is
the memorably titled The Invisible Gorilla.
In reading the reports that follow, consider if
you would have intentionally and knowingly
taken the same risks and/or made the same
mistakes, probably not; neither in nearly
all the cases most probably did the people
involved. Remember that even in keeping
a lookout, you may not see the obvious.
Safe sailing!
Captain Don Cockrill FNI

My seafaring adventures started in 1973 with Canadian Pacific (CP Ships) where I progressed
from cadet to master specialising in petro-chemicals. I joined the Port of London Authority as
a pilot in 1991 following a short period in the NW European Chemical tanker coastal trade with
Stolt Nielsen. In recent years I have been significantly involved in the various aspects of pilot
training and its associated professional skill standards with particular emphasis on simulation as
well as conventional processes. I have been involved in one way or another with the work of the
United Kingdom Maritime Pilots Association almost continually over the last 20 years and took
over the Chairmanship in late 2010.
CASE 1
Close Encounters of the Aframax Kind

Narrative
Two Aframax size oil tankers were underway at
a speed of 2.5 knots having just completed a
ship-to-ship (STS) transfer of diesel oil 10 miles
from shore. As the last lines were slipped, the
quarters of the two vessels closed. To check
this movement, the overseeing superintendent
on board the designated manoeuvring vessel
ordered dead slow ahead and for 10 of port
helm to be applied. However, the vessels slow
speed, direct drive engine did not start.
Observing this, her OOW immediately informed
the master and telephoned the chief engineer
in the MCR. The superintendent was told about
a minute later, by which time he had ordered
slow ahead and had increased the amount of
port helm. The superintendent immediately
broadcast on VHF radio that the vessel had
lost its engine, but he did not use ship names

and the bridge team on the other vessel did
not hear his call. No emergency signal was
sounded on the ships whistle.
As the manoeuvring vessels bow swung very
slowly to port towards the other vessel, the
superintendent ordered slow astern. This
time, the engine started and the superintendent
immediately ordered full astern followed
by a series of engine and helm orders
given in rapid succession. Seconds later,
the manoeuvring vessels port anchor struck
the starboard lifeboat on the other vessel (see
figure). The manoeuvring vessels engine failed
to start because a dirty air start pilot valve had
not allowed starting air to pass into the cylinder.
Figure 1: Damage caused to the lifeboat

10
CASE 1
The Lessons
1. When manoeuvring in close proximity
to another vessel or navigational hazard the
possibility of something going wrong must
be carefully considered. In such situations,
bridge and MCR teams need to be trained
and ready to respond quickly and effectively
to engine and steering failures.
2. Good internal and external communications
are vital when operating close to another
vessel. Dedicated communications operators,
the correct use of radio procedures and a
common language are all essential to ensure
this is achieved.
3. This was the superintendents eighth

consecutive STS operation, and the
cumulative effect of long working hours
over a 3-week period possibly adversely
affected his alertness. Proper monitoring
of rest hours helps to prevent the onset of
fatigue, but masters should also keep an
eye out for the signs of fatigue among their
crew and any person key to ship safety,
such as STS superintendents and harbour
pilots.
11
CASE 2
Different Interpretations
Narrative
A passenger ferry, on a southerly heading in
daylight and good visibility, was crossing a TSS.
The OOW was accompanied on the bridge by a
cadet and a lookout. A cargo ship was transiting
the westbound traffic lane of the TSS. The
OOW had acquired her radar echo by ARPA,
which predicted that the passenger ferry would
cross ahead of the cargo ship at a range of 1 mile.
After the ferry had crossed ahead of the cargo

ship, the yacht altered course to starboard.
The cadet reported this to the OOW, who then
altered the ferrys course to starboard to
increase the yachts passing distance to port.
The lookout reported two yachts ahead: one

fine to starboard and one fine to port; both
were on westerly courses. The OOW acquired
the radar echo of the yacht to port by ARPA,
which predicted a CPA of 0.3 mile to starboard.
He decided to maintain course and speed with
the intention of crossing ahead of the cargo
ship and then altering course to port to
increase the CPA with the yacht.
12
CASE 2
The Lessons
1. The ferry companys instructions required
its masters in normal circumstances to
accept a CPA of no less than 1 mile when
passing ahead of another vessel. If the
OOW intended a closer CPA, he/she was
required to seek approval from the master.
In this case, the OOW was content to
accept a bow crossing distance of 1 mile
with the cargo ship and a considerably
reduced CPA with the yacht, without
feeling the need to refer to the master.

The OOW had become over-confident

in his ability, to the extent that he was
prepared to stretch the parameters
within which the master had permitted
him to operate autonomously. A lack of
sufficient oversight and enforcement by
the master had contributed to this
complacency.
Implementing company instructions,
motivating the crew in following them,
and verifying their compliance are
fundamental elements of a masters
responsibility.
2. Assuming a risk of collision existed

with the yacht, the ferrys OOW correctly
interpreted that his was the give-way vessel
in accordance with Rule 18(a)(iv) of the
COLREGs. His plan to alter course to
port to pass around the yachts stern would
have been appropriate had it been executed
at an early stage. However, his decision to
cross ahead of the cargo ship before doing
so meant that he was unable to take early
avoiding action as required by Rule 16.
3. In interpreting a risk of collision with the

ferry, the yachtsman initially maintained
course and speed in accordance with Rule
17(a)(i). Unaware of the ferrys intentions,
he then took avoiding action himself, in
accordance with Rule 17(a)(ii) when it
became apparent that the ferry was not
taking appropriate action.

Unlike a crossing situation involving

two power-driven vessels, the ferry
was at liberty to alter course to port in
complying with the COLREGs. This
severely restricted the options open to
the yachtsman to take last-minute
avoiding action. Whatever action he
took would have put the yacht at risk
if the ferrys OOW had subsequently
decided to alter course to port.
4. The circumstances required the ferrys

OOW to think outside the box and to
view the developing situation from the
yachtsmans perspective. Consequently, he
should have aborted his plan to cross ahead
of the cargo ship. Such action would have
been in accordance with Rule 2(a), which
requires an OOW to take any precaution
which may be required by the ordinary
practice of seamen or by the special
circumstances of the case.

Likewise, yachtsmen who find

themselves in a similar situation may
need to take earlier action than would
normally be required to avoid becoming
a sitting duck.
The resulting circumstances were

something which the OOW was able
to control; had he opted not to cross
ahead of the cargo ship, he would have
demonstrated good seamanship, as
required by Rule 8(a), in avoiding a
Figure
of cargo
vessel showing
fairlead
positions
1: Stem
closeview
quarters
situation
with the
yacht.
13
CASE 3
Snagged & Dragged

Narrative
Towards the end of his watch at sea, a motorman
was tasked by the chief engineer to mop up
some hydraulic fluid in the steering gear flat
which had been leaking onto the deck from
the steering gear rams. The motorman entered
the steering gear flat; neither the chief engineer
nor the motorman informed the bridge.
As he had leant through the gap in the rails

(Figure 2), the motormans high visibility jacket
had become snagged on a connecting rod
coupling. At the same time, a hard-over rudder
movement was executed which resulted in
him being dragged in between the connecting
rod and the raised walkway frame, where he
became trapped.
A short while later, the chief engineer went

to the steering gear flat to check on the
motormans progress. When he arrived there,
he found the motorman pinned between the
steering gear connecting rod and a raised
walkway frame (Figure 1). The coastguard was
alerted and the motorman was airlifted to the
nearest hospital, where he received medical
treatment for crush injuries to his vertebrae
and pelvic region.
Figure 1: A demonstration of where the motorman was pinned
14
CASE 3
Figure 2
The Lessons
1. On this vessel, the railings around the
steering gear were not sufficient to protect
anyone from inadvertently being dragged
into a dangerous position. Areas around
moving machinery should be securely
guarded to prevent such accidents.
4. The Code of Safe Working Practices for

Merchant Seamen advocates the use of a
permit-to-work (PTW) for appropriate
tasks. While a PTW does not in itself
make a job safe, it provides a process by
which safe working practices can be
considered and implemented. In this case,
2. Personnel should never enter or remain a PTW might have prevented this accident
alone in any unmanned machinery space by prohibiting access to the steering gear
unless they have advised the bridge of their flat while the vessel was manoeuvring.
intentions.
3. Warning notices directing the crews
attention to the likelihood of machinery
suddenly starting up and moving were not
displayed at the entrance of the space.
15
CASE 4
Generators Dont Just Make Electricity

Narrative
A crewman died in a store room on a small
merchant vessel after being overcome by
carbon monoxide in the exhaust fumes from
a portable generator.
portable petrol-powered generator. Ambulance

crews could not revive the crewman and he
was later found to have very high levels of
carbon monoxide in his blood stream.
The vessel was alongside overnight waiting

to sail when tidal conditions allowed. The
skipper went to bed early, but the crewman
continued to work in the engine room. Later
in the evening, the skipper heard the engine
room door shut and thought that the crewman
had finished work and had turned in. In the
morning, the skipper became concerned that
the crewman was not up and ready to sail, so
he went to look for him.
The generator was not part of the vessels

equipment and had been brought on board by
the crewman for his own purposes. There was
still petrol in the generators fuel tank and the
controls were set to allow it to run.
The skipper found the crewman in the vessels

forward store; he had collapsed next to a
Ventilation openings to the forward store

were still closed in the seagoing position,
and although the hatch was partially open,
carbon monoxide in the exhaust fumes built
up quickly and overcame the crewman when
he attempted to run the generator.
Figure 1: The portable generator involved in the incident
16
CASE 4
The Lessons
If you suspect an area has been
contaminated with carbon monoxide,
ventilate it thoroughly, preferably using
a fan, before you put your life at risk by
going in.
1. Carbon monoxide is a silent killer. It has

no smell or taste and works by stopping
oxygen from being carried in the blood
stream. Even very small amounts can be
fatal.
3.

2. The exhaust from small petrol-driven

engines and faulty heaters is the most
common cause of accidents involving
carbon monoxide. Petrol-powered bilge
pumps and generators should only be used
in well ventilated areas and beware of the
exhaust drifting away and collecting in the
bottom of holds, or being sucked up by
ventilation fans.
4. Simple carbon monoxide alarms are cheap

to buy and easy to install. They may be the
only warning you get.
17
CASE 5
STS Run-In, No Margin for Error

Narrative
Case 1
Before cargo ship-to-ship (STS) transfer
operations at sea could begin, two tankers had
to make fast to one another while underway
and making way; known as a run-in. The larger
243m long tanker was the constant heading
ship, making a speed of about 4.2 knots,
and the smaller 172m long tanker was the
manoeuvring ship, which had four large
Yokohama fenders made fast along her port
side. The manoeuvring ship approached the
constant heading ships starboard side from
astern, and then paralleled her course and
matched her speed at a distance of about
1 cable abeam.
helm orders to bring the tankers closer to one

another so that mooring lines could be passed
between them. Initially, he gave a port 10
rudder order, which was acknowledged on the
radio by the third officer and by direct voice
from the helmsman. When the interior bridge
rudder indicator showed that the rudder had
reached 10 degrees to port, the helmsman
shouted port 10 now. As the bow began
to swing to port and towards the other ship,
the superintendent ordered midships and
then starboard 10 to counter the swing. The
helmsman shouted starboard 10 now.
However, the port swing did not stop.
The STS superintendent was on the

manoeuvring ship and had the con, while
standing at the outboard end of the port bridge
wing. The master was close by him relaying
orders by voice and by a hand-held radio to
the third officer and helmsman inside the
wheelhouse. The third officer was relaying
the ships speed and acknowledging the helm
orders by hand-held radio to and from the
master, and was also operating the telegraph
as instructed. The helmsman had been at the
wheel for 11/2 hours and had been steering
course orders rather than specific helm orders.
The superintendent then ordered the helm to

starboard 20 and then to hard to starboard,
and an increase in speed, but the rate of turn
to port increased. Realising that something was
wrong, the master repeated the orders to the
third officer and helmsman. The bridge wing
indicator was checked at this time and found
to be reading port 20. The helmsman then
applied starboard helm and the rate of turn
to port decreased, stopped and then the ship
began to swing to starboard. However, after
having made an alteration of course of nearly
30 degrees to port, the port side of the focsle
inevitably collided with the other ship, causing
structural damage. Fortunately, there were no
resulting injuries or pollution.
Due to a delay caused by re-rigging the fenders

earlier that afternoon, the run-in was now to
occur in darkness, as agreed by the masters of
both tankers. The sea state was slight, with a
light wind on the starboard bow, and it was a
moonlit night. The exterior bridge wing helm
indicator illumination was very poor and could
not be seen from the superintendents position.
When the manifolds of the two ships were in
line, the superintendent began giving specific
18
Case 2
In a similar accident, the constant heading ship
and the manoeuvring ship had reached a stage
at which they matched courses and speed
and were about 10m abeam of each other. The
superintendent and master were on the port
bridge wing of the manoeuvring ship, with the
OOW and helmsman inside the wheelhouse.
CASE 5
The superintendent asked for stop engine,
which was carried out. The master, who
was relaying the superintendents orders to
those within the wheelhouse, then talked by
hand-held radio with the chief officer, who
was on the focsle. The superintendent asked
the master for dead slow ahead but the latter
relayed the order as dead slow astern, which
was executed by the officer in the wheelhouse.
Shortly afterwards, the helmsman reported
that he was unable to steer and the officer

reported that the engine was now running
astern. The ships port quarter was closing
the other vessels starboard quarter, so the
superintendent asked for ever increasing ahead
movements together with port helm orders.
Despite the superintendents actions the two
ships collided, causing structural damage in
way of both vessels boat decks.
Figure 1: Bridge steering console
19
CASE 5
Figure 2: Poor illumination of bridge wing instrumentation
The Lessons
1.

20
In the first case, the helmsman had been

concentrating for 11/2 hours on steering
ordered courses, and it was increasingly
important to keep these as accurate and
steady as possible as the ships approached
each other. When the superintendents
instructions changed from courses to steer
to specific helm orders, the helmsman was
relatively able to relax as he had only to
move the wheel to the desired graduation
on the wheels boss (see photograph). This
led to a lapse in concentration and resulted
in him mistakenly applying opposite helm.
It is necessary to change the helmsman
at frequent intervals so that concentration
is maintained.
2.

In the critical stages of bringing two ships

together, it is essential that orders are
relayed and executed correctly, and that
any error is immediately identified and
countered. The ambient noise and the
distance between the originator of the
orders and those carrying them out can
be such that they are not easily heard. Each
situation requires careful consideration to
ensure sufficient personnel are available
to verify that orders are relayed, received
and acted upon correctly.
3.

Bridge wing instrumentation provides an

important tool for checking that helm or
engine orders have been correctly executed.
The instrumentation needs to be regularly
maintained and checked to ensure its
functionality, particularly before critical
operations such as those described above.
A poorly illuminated indicator is of little
value at night (see photograph).
CASE 6
Lack of Communication, and Distraction

Lead to Benzene Spill
Narrative
A cargo of benzene had been discharged.
Before the cargo hose was disconnected from
the manifold, the cargo line was pressurised
with air and then blown ashore to clear it of
any residue. The manifold valve was then shut.
The cargo hose was disconnected and blanked
by shore personnel, after which it was raised
and temporarily hung in position above the
ships manifold. Two ABs, who were keeping
watch on the main deck, considered it to be
unsafe to blank the manifold while working
under the cargo hose, and deferred doing so.
The normal procedure after the cargo line had
been blown with air was to open a drop valve
The Lessons
1.

The duty officer had not checked that

the ABs had blanked the manifold after
the cargo hose had been disconnected,
which, although not a checklist item, was a
company operating procedure. Additionally,
the ABs had not informed him that they
considered it unsafe to work under the
suspended hose and had, therefore, delayed
blanking the manifold. Consequently, there
was no verification that the blank had been
put in place before the duty officer attempted
to release the pressure in the cargo line.
2.

A system of cross-checking/positive
confirmation should always be employed
when taking action or altering the status
of critical machinery or equipment that
may impact on personal or ship safety.
Associated checklists should be used to
ensure cross-checks/positive confirmation
is undertaken when required.
to release the pressure in the cargo line to a

cargo tank. This operation was to be carried
out by the duty officer stationed in the cargo
control room. On this occasion, the duty officer
was in the process of handing over his watch
to another officer and was also communicating
with the ships agent. He became distracted
and inadvertently opened the manifold valve
instead of the drop valve, and some cargo
residue sprayed onto the manifold platform
and also onto the jetty. The ABs on deck told
the duty officer by radio to close the manifold
valve, which he did immediately, but he was
unaware of the spill until a terminal representative
went on board to make enquiries about the
incident.
Fortunately, there were no resulting injuries.
3.

Opening the cargo valve to release the

pressure in the line was a simple and
routine - yet critical - action, and therefore
required the duty officers full attention.
The officer should have deferred his watch
handover and asked his relief to deal with
the agent until the pressure in the cargo
line had been released. His familiarity
with the task had caused him to become
overconfident, allowing him to become
distracted and therefore prone to error.
4.

The reporting instructions in the case of a

cargo spill were described in the discharging
plan and reiterated to the crew during the
pre-discharging meeting. The ABs claimed
they had told the duty officer about the
spill, but both the duty officer and the
relieving officer did not hear the report.
Again, positive confirmation, in accordance
with best practice, would have ensured
emergency procedures were initiated
immediately.
21
CASE 7
ECDIS Assisted Grounding?

Narrative
During the early hours of the morning a very
large container ship grounded at full speed
on a clearly marked sandbank in a busy traffic
separation scheme. The vessel was equipped
with an integrated bridge system, including
full ECDIS capability, and the OOW was relying
heavily on this despite having not been trained
in its use.
them about 0.5 mile off. He therefore

continued to steer between the lights instead
of bringing his vessel back onto track. The
officer was still unaware of the bank when
the vessel came to a sudden stop and several
alarms sounded. Luckily, there were no injuries
and only minor damage was sustained. The
vessel was refloated on the next high tide.
As the vessel approached the bank the OOW

altered course to give more room for a ship
his vessel was overtaking. Unfortunately, this
alteration put the bank right ahead, but the
contour and colour settings selected on the
ECDIS made this difficult to differentiate on
the systems display.
Even when the ECDIS recording was replayed

after the grounding, it was not easy to see the
bank. The settings selected, coloured all areas
within the 30-meter contour in dark blue,
including the bank and the buoy symbols.
The echo sounder and ECDIS depth alarms
had been set to minimum; once the buoys
marking the bank were incorrectly identified
as fishing boats, there was little left to warn
the OOW he was heading into the shallows.
Later, two flashing lights were seen, one on

each bow, which the OOW thought to be fishing
boats. He decided he could pass safely between
The Lessons
1. ECDIS is an effective aid to navigation
when used correctly. However, it has many
user-defined selections which can be set
inappropriately by an untrained user.
Officers who are appointed to ECDIS
equipped vessels, whether to be used as the
primary means of navigation or not, should
have attended an approved, generic, ECDIS
course followed by familiarisation with
the equipment on board.
3. When aids to navigation fail, or are used

incorrectly, judicious use of the Mark 1
eyeball should still avert an accident.
However, in this case the OOW trusted
what the ECDIS showed him rather than
what he could see for himself. All aids to
navigation should be treated as just that
aids and the information presented
checked by other independent means to
verify its accuracy.
2. To avoid miss-application of settings and

warning alarms the company (in its SMS),
or the master (in his standing orders),
should define the settings to be used rather
than leave it to the personal preference of
each OOW.
22
CASE 8
Last Out Turns the Lights Off!

Narrative
A dry bulk coaster had, since build, usually
transported steel rolls, wire, tubes and paper
rolls throughout Western Europe. Following
the economic downturn the trading pattern
had changed towards the carriage of dry bulk
cargoes.
The hold was cleared by the surveyor and the

wheat pellet cargo was loaded. In doing so the
pellets migrated up inside the after ventilation
trunking and covered the starboard halogen
light. Crucially, the hold lights were left on
throughout loading and after the hold hatches
were closed.
In line with this change the vessel was scheduled

to load 1900 tonnes of animal feed wheat pellets.
Figure 1: Cargo hold light
Figure 2: Ventilation terminal
The chief officer switched on the cargo hold

lights (Figure 1), which had been fitted inside
the lower end of the holds port forward
(which was forward of the moveable hold
bulkhead) and starboard aft ventilation trunkings
by the previous owners. These gave sufficient
light to assist the cargo surveyor with his hold
inspections.
No checks had been carried out on the hold

lighting system to ensure the lights were
turned off, and there were no indicators in
the wheelhouse to alert the OOW that the
lights were still burning.
The initial part of the passage to the discharge

port went without mishap. The chief officer
23
CASE 8
took the afternoon watch in the wheelhouse,
while an AB carried out maintenance duties at
the after end of the cargo hold hatch coaming.
A short time later the AB saw smoke coming
from the holds starboard after ventilation
terminal (Figure 2).
The terminals cover was immediately closed,
and the master was alerted. The crew remained
calm and carried out a search for hot spots
around the hold, and of the adjacent
compartments. None were found. The crew
had exercised for a cargo hold fire, and
immediately laid out the fire hoses for boundary
cooling as the master contacted the coastguard.
One of the ABs checked the hold lighting
switch and found it still switched on (Figure 3),
so he switched it off.
Because the situation was far from clear, a
4-man Marine Incident Response Group (MIRG)
team from the nearest Fire and Rescue Service
(FRS) was transferred to the vessel by helicopter.
Once again no hot spots were found, and the
coaster was allowed into a nearby port.
The vessel was met by the local FRS. As the

cargo hatches were opened, a small amount
of smoke was seen. About 80 tonnes of the
cargo was removed to the quayside. In doing
so a smouldering plug of pellets fell from the
holds starboard aft ventilation trunking, and
this was doused by the FRS team. There was
no other evidence of a fire or smouldering.
The smouldering was caused by the wheat
pellets covering the hot halogen lamp, which
had been left on because of inattention to the
basic post-loading checks to confirm the vessel
was safe to proceed to sea.
On investigation it was also found that the hold
lighting arrangement was not approved by the
classification society, and that the electrical
supply cable bulkhead glands did not conform
to the rules, which compromised the ability
of the bulkhead to prevent the spread of fire.
Figure 3: Hold lighting switch

24
CASE 8
The Lessons
1.

The rationale for fitting the hold lights was

to aid hold inspections and to check break
cargo securing arrangements. When carrying
break cargo (such as steel rolls), there was
no risk of any cargo covering the lights.
However, the fluid nature of the wheat
pellets meant that it was easy for them to
migrate into the ventilation trunking, and
cover the hot halogen lights. Had a more
flammable cargo been carried, the outcome
could easily have been far worse.
2.

When considering additions or modifications

to equipment, do seek professional advice,
especially from classification societies, to
ensure that the proposal is safe and within
the rules.
3.

Ensure that there is a system of checking

that heat sources in cargo holds have been
isolated. In this case no one was specifically
responsible for the checks.
4.

The 30 and 60-minute fire resistant

bulkhead specifications are for your safety.
It is very unwise to compromise this by
fitting unapproved electrical glands or
other bulkhead penetrations.
5.

The crew remained calm throughout the

incident. They prepared for boundary
cooling as previously exercised, highlighting
the importance of regular fire drills.
25
CASE 9
Davit Control Adjustments

- Proceed With Caution
Narrative
A man overboard rescue boat had been
successfully launched and trialled in accordance
with the ships monthly routine. The boat
returned to the falls, was hooked on and
hoisted clear of the water. The hoist proceeded
as normal, and once at the embarkation deck
the boat was hauled inboard on its extendable
hydraulic davit arm. However, the boat was
too low to settle onto its chocks, so the bosun
raised it up a further 2cm. Immediately after
he did this a number of the fall wire strands
parted and the boat dropped onto the chocks
(Figure 1). Fortunately none of the crew in the
boat was injured.
The cause of the failure was initially believed to
have been a faulty limit switch which had been
recently adjusted by a member of the crew.
The limit switch itself was activated by a circular

block which was lifted when in contact with the
davit hook (Figure 2). On lowering, the block
was constrained by two chains which held it at
about 0.5m below the limit switch. The design
of this particular davit arrangement meant that
there was still inertia in the winch drum that
allowed it to continue to rotate for a very short
time after the control lever was set to the stop
position. The correct adjustment of the limit
switch allowed for this, and was designed to
prevent over tensioning and stretching of the
wire, which would inevitably lead to its failure.
However, the person who adjusted the limit
switch did not seem to have been aware of this
although it was stated in the operation and
maintenance manual.
Figure 1: Man overboard rescue boat
26
CASE 9
Figure 2: Limit switch activation block and replacement constraining wires
Unfortunately there have been a number

of accidents, some fatal, resulting from a
misunderstanding of the functionality of
elements of rescue boat and lifeboat hoisting
and lowering equipment. In this case
maladjustment of the limit switch caused
the fall wire to fail. However, the design of

the circular block constraining chains had also
occasionally caused the wire to snag before the
limit switch operated. To prevent this happening,
the manufacturer replaced the chains with stiff
wires (Figure 2).
The Lessons
1. Ensure only qualified personnel operate and
carry out adjustments to boat lowering and
hoisting equipment your life may depend
upon the operator/maintainers knowledge.
2. Always refer to the manufacturers manual
when carrying out adjustments DO NOT
GUESS.
4. Where design issues, which may affect the

safe operation of the equipment, have been
identified ensure that these are reported to
your line manager, shore technical staff and
the original equipment manufacturer for
possible design modifications and issue of
safety notices where appropriate.
3. When critical adjustments are made, always

carry out a functional test, preferably using
a dummy load to prove the adjustment.
27
CASE 10
Early Release Led to Early Demolition
Figure 1: The vessel involved in the accident
*Photograph courtesy of Fotoflite
Narrative
A 235m container ship (Figure 1), fitted with a
single, right-handed fixed pitch propeller was
unmooring from a riverside container terminal.
A pilot was embarked and two tugs were assisting:
a 53 tonne bollard pull Voith Schneider tug
was made fast on the centre lead forward and
a 66 tonne bollard pull ASD tug was secured on
the centre lead aft. The aft tug was slower to
secure than usual as her secondary towing gear
was being used due to her primary gear being
defective.
The visibility was about 1 mile as the moorings
were singled up, but had reduced to less than 2
cables when the ship sailed. The pilots intention
was for the tugs to keep the vessel parallel to
the berth as they pulled her about 40m into
the river. However, during the manoeuvre the
container ships bow was pulled off further
28
than her stern, which resulted in the vessel

heading away from the line of the berth at an
angle of about 15.
The aft tug was then released in anticipation
that it would take longer than usual to recover
her gear. The container ship then came to dead
slow ahead with the forward tug still secured
to assist the vessel to negotiate a nearby bend
in the river. Almost immediately, the vessel
entered dense fog. As a precaution, the forward
tug was released before the container ship
gathered excessive headway.
With both tugs slipped the vessel approached
the turn in the river, but it failed to respond
to full port rudder and increased engine
revolutions. The pilot stopped the engine and
then went astern and applied full thrust to port
CASE 10
with the bow thrust. The forward tug was also
requested to push on the starboard bow.
However, this did not prevent the vessel from
making contact with a disused jetty. The damage
to the vessel was minor and she was able to

continue on passage. The damage to the jetty,
which was scheduled for demolition, was
significant (Figure 2).
Figure 2: Damage caused to the jetty
The Lessons
1. The state of the visibility is key in many
operations, and where there are signs that
it might reduce considerably, it is frequently
better to abort a manoeuvre early rather
than risk being caught out half way through.
2. Although mooring and unmooring
operations are usually achieved using the
mark one eyeball, this is not possible once
visibility has reduced and visual references
are lost. In such circumstances electronic
aids, such as compass repeaters and radar
are available to enable a vessels heading
to be accurately monitored.
3. When making way, tugs are most effective

when secured, and need to be attached
in good time when approaching a berth.
Similarly, when leaving a berth, tugs should
remain attached for as long as they are
needed. The safety of tugs and the vessel
being assisted must be taken into account
at all times, but this is usually best ensured
by proceeding at a sensible speed, rather
than by premature release.
29
CASE 11
Improvement Causes Unforeseen

Consequences
Narrative
After discharging her cargo, a small product
tanker departed from an oil terminal in a busy
port. Within a few minutes of clearing the
terminal, as the vessel was increasing speed,
an alarm sounded indicating the main engine
cooling fresh water temperature was too high.
The chief engineer called the master, and
was asking him to slow down when the high
cooling water temperature safety cut-out
shut down the main engine. The pilot
immediately called for tugs, which arrived
shortly afterwards, and the vessel was taken to
a safe anchorage where the crew discovered
that the sea water inlet filter of the fresh water
cooler was blocked. After cleaning the filter,
the vessel was able to resume her passage.
Investigations revealed she had a history of
sea water cooling system failures.
The vessels main sea water system supplied
all sea water pumps, including two high
capacity ballast pumps, drawing from two low
sea suction and one high sea suction intakes.
The crew always kept both low suction intakes
open because when both ballast pumps were
used together, one intake could not cope with
the demand. As the vessel was engaged in a
busy short sea trade, the crew did not isolate
either of the sea suction intakes as a matter
of routine once ballasting operations were
complete. The high sea suction was never used.
30
The fresh water cooling system on board was

a combined low and high temperature cooling
system, with two thermostat-controlled threeway valves controlling the differential
temperatures. However, the system relied on a
single fresh water cooler. Having experienced
cooler blockages in the past, the ships staff
had fitted a back-flushing system at the sea
water outlet side of the cooler. A subsequent
improvement was the installation of a filter
box with a plate strainer at the sea water inlet
to the fresh water cooler. It was this strainer
which was found blocked when the incident
happened.
The new filter was not a duplex type, nor was
it fitted with a by-pass valve. There was no high
temperature alarm at the fresh water cooler
outlet, and the low sea water pressure alarm
switch fitted at the inlet to the cooler was
defective. When the chief engineer received
the high temperature alarm at the fresh water
inlet to the main engine, it was already too late.
CASE 11
Figure 1: Freshwater cooling system
Figure 2: Circuit diagram for the main engine cooling system
31
CASE 11
The Lessons
1. The sea water filter installed at the inlet to
the fresh water cooler functioned as intended
by preventing weeds from fouling the cooler.
However, there was no means of by-passing
the filter if it became blocked. As the entire
fresh water system relied on a single cooler,
the loss of sea water to this cooler resulted
in the ship losing its main engine. When
implementing an improvement, it is imperative
that all possible knock on effects are
considered.
2. The vessel lost her main propulsion
engine in restricted and busy waters.
Had she grounded in the narrow channel
or collided with another vessel, the
consequences would have been disastrous.
A means of by-passing the filter in an
emergency could have kept the cooler
functional while the crew cleaned the filter.
Similarly, had there been a high temperature
alarm at the cooler outlet, it would have
alerted the crew to the developing situation
several minutes earlier, giving them time to
take preventative actions.
32
3. Although in this incident the main sea

water filters were not blocked, there had
been a number of previous incidents caused
when both of the vessels main sea suction
filters became blocked in shallow waters.
Good practice dictates that high sea suction
intakes should be used in shallow waters to
reduce the risk of the vessel ingesting mud
and weed, and an intake should always be
kept isolated and ready for use in an
emergency. These requirements should be
incorporated into the design of vessels
cooling systems. However, if these basic
requirements cannot be met, consideration
should be given to modifying the system
instead of compromising safety.
CASE 12
Last Act of Defiance

Narrative
A decommissioned and unmanned coaster had
just been beached and secured with the vessels
mooring ropes by shore workers on a slipway in
an estuarial port (Figure 1). Two hours later, on
a falling tide, the vessels stern, which projected
into the river and had remained afloat, lowered,
causing the vessel to trim aft. As weight came
on the aft spring line, it surged and slipped off
the mooring bitts on board. This resulted in the
other two mooring lines progressively parting
and the vessel sliding astern and entering the
main channel in dense fog.
The vessels radar echo was acquired and
tracked by the VTS officer, who made several
attempts to establish communications with
the unknown contact which was heading
downstream. Initially, a pilot launch was tasked
to identify it, and when it struck a buoy and

came within 2.5nm of an oil terminal, two tugs,
which were on station, were also tasked to
investigate. The oil terminal and the dock master
were informed of the situation and possible
threat to the installation, and cargo operations
were stopped. In the dense fog, one of the tugs
managed to identify the vessel and transfer a
crew member across onto her deck. Although
one tug was able to make fast a tow line to the
vessels stern, the strong ebb tide and restricted
visibility hindered the efforts of the tugs, which
could not prevent the vessel from making
contact with the oil terminal structure.
The terminal remained shut for 18 hours due
to the damage to the support structure of the
oil pipelines on the jetty roadway.
Figure 1: Mooring arrangements
33
CASE 12
The Lessons
1. The mooring ropes used to tie up the vessel
were in very good condition, but the vessel
had not been secured effectively. Pre-planning
of such operations should be undertaken,
especially in cases where the vessel will
remain unmanned and/or has to use an
unusual or non-standard mooring
arrangement.
3. Careful thought should be given to the lead

of the lines so as to avoid creating sharp
angles. In this case, the eye of the breast
line was secured to a cleat forming part
of the fairlead (Figure 2). A sharp edge on
the fairlead effectively cut through the rope
as the vessel oscillated alongside before
breaking free.
2. The aft spring line slipped as weight came

on it because the rope had not been secured
correctly. Synthetic fibre ropes should be
made fast using two round turns around the
leading post of the bitts before finishing it
off with at least three figure of eight turns.
Figure 2: Fairlead with cleats
34
CASE 13
Fire Below The Need for Effective

Engineering Oversight
Narrative
It was another day of tug escort duties. Once
again the usual 5-man crew of a tug had been
allocated to a different vessel because of manning
cutbacks and rostering arrangements. They
had become quite used to this procedure,
which meant they only spent about 60% of
their time on board their own allocated tug.
Pre-sailing checks were completed and there
was nothing to raise the concerns of either the
tug master or chief engineer. About 20 minutes
after the escort duties started, the fire alarm
sounded and the detection panel indicated a
fire in the engine room. The chief engineer
looked into the engine room through the

engine control room (ECR) windows (Figure 1)
and saw diesel fuel being sprayed onto the
deckhead and cascading down onto the hot
exhaust in the vicinity of number 4 cylinder
head of the port main engine. He immediately
advised the tug master to break off escort
duties. As he did so, the fuel spray ignited. The
chief engineer attempted to fight the fire using
an extinguisher, but was quickly driven back
into the ECR. He then stopped the engine at
the same time as the tug master advised the
pilot and harbour authorities of the situation.
Figure 1: The view from ECR
35
CASE 13
Having called for muster stations, the tug
master went to the ECR. On seeing the fire he
advised the chief engineer to prepare to flood
the engine room with CO2. He returned to the
bridge to assess the navigational situation, and
decided to stop the starboard main engine
and drop the anchor. Meanwhile, the ABs shut
the engine room ventilation flaps as the chief
engineer operated the emergency quick shut-off
fuel valves. He heard four out of the five valves
slam shut, but the fifth one, which supplied
the running generator, failed to shut and so the
generator continued to run, with the high risk
of feeding the fire with diesel fuel.
The chief engineer then operated the CO2 system
to the engine room. However, he thought he
heard gas going into an adjacent machinery
space. He opted to open that space to the gas
system, unaware that the full set of bottles was
required to extinguish an engine room fire.
Conscious of the need to carry out boundary
cooling, the tug master instructed the ABs
to start the emergency fire pump, which was
located in the after hold. As they opened the
hatch they were confronted with CO2, which
had somehow leaked into the compartment.
Consequently they re-secured the hatch. Now
unable to set up boundary cooling, the crew
could only monitor the deck temperatures until
they were evacuated from the vessel a short
time later.
Fortunately, other company tugs were quickly
on the scene, and set up boundary cooling.
About 3 hours later the water was turned off.
As there was no evidence of the decks warming
up, or other evidence of fire, the tug master
and chief engineer went back on board and
cracked open the engine room vents before
returning to the rescue vessel. In the meantime
the local FRS had carried out a thermal image
camera assessment of the vessel from a launch,
and confirmed there were no unidentified hot
spots.
36
As the engine room vents had already been

opened, the FRS agreed to carry out an
assessment of the atmosphere in the engine
room to ensure it was free of CO2. This was to
allow the hydraulic pumps to be started to enable
the anchor to be lifted and the vessel to be
brought alongside and checked out by the FRS.
The investigation found the port engines
number 4 cylinder fuel injector leak-off
pipe had suffered extensive chafing (Figure 2)
because of its inadequate bracketing
arrangements. The pipe failed and sprayed
diesel fuel onto the hot engine, where it
ignited.
Disappointingly, most of the other leak-off
pipes on the port and starboard engines,
and others in the same vessel class, had also
suffered from severe chafing. While some of
the pipes had been braze-repaired, there was
no evidence of the defect being reported to
the company ashore, so no proper engineering
solution was developed to prevent the fire risk.
The investigation also found that the failure of
the fuel quick shut-off valve was known to the
regular chief engineer who knew how to set it
to ensure it would operate. However, this had
not been reported, or passed on to the other
engineers who also manned the vessel.
The CO2 flooded the hold when a pressure
sensor pipe was pulled through a union
(Figure 3) while the system was being
pressurised. This was caused by missing
support bracketing.
CASE 13
Figure 2: Failed CO2 sensing pipe
Figure 3: Failed leak-off pipe
37
CASE 13
While tug escort duties could be managed by
transferring manpower between the various
vessels, something had to give as a result of
this lack of vessel ownership:
There was no proper maintenance plan.
Defects were not properly reported or
addressed.
The long-term gapping of a technical
manager and a technical superintendent
meant the only remaining superintendent
was severely stretched and did not have
the time to regularly visit all vessels. Had
he done so, the defects might have been
identified and corrective action taken.
The frequent crew changes also meant

that individual crew members had not
carried out emergency drills on all the
vessels they were expected to operate.
This clearly compromised their ability
to deal effectively with emergency
situations because of variations in vessel
equipment and procedures, and their
unfamiliarity with them.
The Lessons
1. Effective management oversight, ashore
and afloat, is a vital element in ensuring
proper engineering standards are observed
and complacency is prevented.
2. Managers should ensure effective closed
loop engineering defect reporting processes
are established to provide warning of dangers
which may affect other vessels in the company
and to ensure that defects are addressed
promptly.
3. Chafing fuel and oil pipes present a very
real fire hazard. Do take the trouble to make
regular checks of this often hidden
danger, and ensure that systems are properly
bracketed/supported. Machinery which
suffers from vibration, such as reciprocating
engines, is particularly vulnerable. In this
case the CO2 pipework also failed because it
was unsupported.
38
4. Be aware of the dangers of using crews

across a number of vessels. Financial
expediency may drive managers down this
route, but with it come the dangers of
declining engineering standards and poor
emergency preparedness.
5. Crews should have a good understanding
of their vessels fixed fire extinguishing
system. In this case, the engine room
required the total outfit of gas bottles to
provide the concentration of CO2 required
to smother a fire. As another compartment
was opened the concentration was reduced,
but the crew were unaware of the implications
of this action and the consequent risk of fire
re-ignition.
CASE 14
Poor Cargo Configuration Results in

Hull Failure and Pollution
Narrative
A 55 year old dumb barge suffered a
catastrophic failure of her hull while lying
alongside in a dock. Although the barge was
loaded with approximately 1850m3 of gas oil,
the swift and effective actions of the terminal
and port staff limited the release of oil into the
water to only 50m3, which was contained close
to the barge. No one was injured, but the
vessel was a constructive total loss.
The accident occurred suddenly and without
warning when only the vessels midships tanks
were full, creating a maximum bending moment
in the sagged condition. The hull failed along
the line of a welded deck seam close to the
tank hatch coamings (Figure 1), causing
buckling of the main deck and ship sides
(Figure 2).
The barge had lain idle for 2 years before

entering service as a floating oil storage vessel.
In accordance with local regulation, the barge
had undergone annual fit for purpose surveys
confirming her suitability for her intended use.
The surveys were basic, and did not identify
the need to provide a stability information
book, including bending moment information,
and the vessel had not been dry docked for
survey.
Cargo loading operations were controlled by
the companys terminal staff, and discharge
operations by the crew of vessels accepting the
cargo. A lack of barge ownership meant that
operations had become disjointed. There were
no written procedures for loading or discharge
to ensure safe operation and that the vessel
remained in a seaworthy condition.
Figure 1: Hull failure
39
CASE 14
Figure 2: Buckling of the ships sides
The Lessons
1. Fortunately, oil pollution response plans
and drills are not frequently required to be
used in anger, but when an incident does
occur their value is immense and can
significantly reduce the environmental
impact of a spill.
2. A barge is a ship - and must be treated as
such, whether it is being used as a floating
service station or as a houseboat. Even if a
vessel is permanently moored alongside,
routine precautions when loading and
discharging tanks are still required.
40
3. Fit for purpose is an all encompassing

term that is frequently used without
reference to the scope of factors that need
to be considered when making this
judgment. In this case, given the nature
of the barges intended use, in hindsight
her survey would have been more
comprehensive had it also verified the
availability of stability information and
procedures to be followed for the loading
and discharging of cargo.
CASE 15
Know Your Systems Back to Black

Narrative
A ferry was sailing through the night when the
duty engineer noticed an alarm indicating low
compressed air pressure. He went to investigate
and found that both main air compressors
were running, but the air receivers were empty.
The discharge pipe from one of the compressors
had sheared, and because of the way the system
was designed he could not isolate the leak.
The duty engineer tried to make a repair, but
had to stop after 30 minutes to respond to a
high water temperature alarm on the main
engines. The duty engineer called for help and
the chief engineer and first engineer came
down immediately.
Unfortunately, by this time the air had gone
from the control system and both main engines
stopped. The shaft generators came off load
as the shafts stopped, and there was no air left
to start the main generators. The emergency

generator started, but did not run for long
because its ventilation openings were left shut,
causing it to overheat.
Fortunately the ferry was in open sea and in no
immediate danger. Nevertheless, the owners
called a tug to stand by while repairs were
carried out.
During the time the engineers took to repair
the air system, the fuel for the main engines
had gone cold. Consequently, the passengers
spent nearly 2 hours in the dark before the
engineers got the main generators started.
The ferry finally got underway again 5 hours
after the duty engineer first noticed the low
pressure alarm.
The Lessons
1. Ask for help promptly. When machinery
breaks down, the first priority must be to
prevent the situation from getting worse.
This can be very hard to do if you are on
your own, particularly if you then get
involved in repairs.
2. It is essential to understand how the
machinery systems depend on one another
and then think ahead to prevent damage
and make recovery easier. In this case, loss
of starting air also led to loss of the main
engine control system, a high temperature
alarm and the engines shutting down. This
might have been avoided if the link had
been appreciated early on.
3. More advanced systems may cost extra,

but a few additional valves to isolate systems
or bypass leaks can be worth considerably
more during an emergency.
4. Take time to check that emergency
generators and fire pumps are going to run
properly. You never know when you might
need them.
41
CASE 16
When Im Cleaning Windows

Narrative
A dredger was on her routine passage to the
dredging grounds. There was a chop to the sea
and the wind was about force 5 as the third
engineer went to the engine control room to
take the 0400-1200 engine room watch on his
own. He was a little annoyed at the smears on
the control room windows which gave visibility
into the engine room (Figure 1).
Figure 1: Door to the control room
The machinery was running well and there

was still some time to go before the start of the
dredging operations, so he decided to clean
the windows. At about 0810 he completed
cleaning the inside of them. He checked the
machinery parameters in the control room and
then went into the engine room to clean the
42
outside of the windows. Access was difficult,

but instead of using a long-handled cleaner or
a safety harness to protect himself, he opted to
stand with his right foot on the step of a ladder
accessing the lower floor plates and with his
left foot on a 4cm flat steel extension bar
welded to the front of the control room
bulkhead. His right hand grasped a small bore
Figure 2: Position of the third engineer
pipe also fitted to the control room bulkhead

(Figure 2).
As he steadied himself, his left foot slipped off
the flat steel bar. He lost his balance and let go
of the pipe.
CASE 16
The engineer slipped over the ladder handrails
and fell 3 metres onto the lower floor plates,
landing heavily onto his left side. He lost
consciousness for about 1-2 minutes, after
which he managed to struggle back to the
control room from where he contacted the
bridge and informed the OOW about the
accident. The chief mate and bosun were alerted,
and found the engineer sitting in a chair in

the control room. He had suffered cuts to his
head, which were cleaned and dressed. He
was relieved of his watch and was later landed
ashore. The engineer was repatriated to his
home country where it was discovered that he
had also suffered a hairline crack of his left hip
bone. He was advised to take 2 weeks off work.
The Lessons
1. Working at height merits careful
consideration of the risks. Without support
it may not be possible to give full attention
to the job and at the same time guard
against falling. Whenever possible, use
extendable equipment; where this is not
possible wear a safety harness or a fall
arrestor.
4. The third engineer was fortunate in that

he only lost consciousness for a short
period and was able to raise the alarm
himself. It is good practice to have a second
person in attendance when working at
height in case difficulties are encountered.
That second person can then also administer
first-aid if necessary.
2. Where there are no strong points to connect

the harness or arrestor, consider if the task
is really necessary. If it is, can a ladder be
used or can the job be deferred until
alongside when scaffolding or staging can
be set up?
Further advice on working at height is

available in the MCAs publication Code
of Safe Working Practices for Merchant
Seaman, Chapter 15. The publication can
be accessed from the MCAs website at:
www.mcga.gov.uk.
3. If it is necessary to work at heights, consider

the effect of the sea conditions and passing
traffic. What may appear to be a stable
platform can suddenly change into an
unstable one under the effect of wave
motion.
43
Part 2 - Fishing Vessels

Health and safety
is a given in the
work place and
all industries
obviously strive
to achieve this.
It is however
usually much
more challenging
to achieve this
objective with an
industry that is
based on the sea
as opposed to
the land. Whether on board a fishing boat or a
fish farm vessel there is always the ever present
danger of unpredictable weather, a constantly
moving deck and machinery handling gear
under considerable strain.
Over the past couple of decades there have
been several factors which have improved
safety at sea for fishermen and fish farmers.
In the first place there have been very
considerable improvements to vessels. Probably
the greatest improvement has been in the
white fish fleet where most boats are now fitted
with full length deck shelters. Within the fish
farming industry, the greatest improvement has
been the move away from converted fishing
boats to purpose built vessels which are much
better laid out and suited for their job. The
much improved safety equipment which is
now mandatory aboard both fishing and fish
farm vessels has also greatly improved safety
at sea.
This growing awareness of the importance

of safety at sea is in no small part due to the
impressive range of training courses now
available for fishermen and fish farmers. It
is now hard to believe that, prior to the mid
1980s, there was no training for most young
fishermen. They simply left school and went to
sea where the quality of the on the job training
was at best variable. Since that time virtually all
young fishermen, and more recently fish farmers,
have been able to undertake high quality
vocational training where safety at sea, fire
fighting and first aid are all given high priority.
This has undoubtedly helped foster and
develop the growing safety culture.
But despite all these improvements accidents
still happen. The publication of the Safety
Digest by the MAIB provides a sobering review
of just how dangerous the sea continues to
be. But more than that, the Safety Digest,
in its case by case summary, describes what
happened and the lessons to be learned in an
easily understood way. It is therefore a valuable
and valued contribution to the ongoing
challenge of improving safety at sea for all
seafarers.
Not that long ago life jackets were rarely

used by fishermen and fish farmers. This
has changed dramatically in recent years and
reflects the growing safety culture amongst
seafarers.
44
John Goodlad
John Goodlad was born and brought up in the Shetland fishing village of Hamnavoe.
He has held a number of senior positions within the fishing industry including CEO of the
Shetland Fishermens Association, Vice President of the Scottish Fishermens Federation and
President of the European Association of Fish Producers Organisations. John is also a past
Chairman of the Board of Trustees of the North Atlantic Fisheries College in Shetland which
provides an impressive range of courses for the fishing and fish farming industries.
More recently John was Managing Director of his own fish farm, which reared organic salmon,
before selling this business in 2007. He is currently Chairman of both the Scottish Pelagic
Sustainability Group and the pelagic fish processing company, Shetland Catch. He also sits
on the committees of a number of international fisheries organisations including the Marine
Stewardship Council and the Association of Sustainable Fisheries.
45
CASE 17
Balancing Act
Narrative
A deckhand on board a scallop dredger fell
overboard as he was emptying a dredge bag.
He had been standing on the port dredge
beam, which was suspended and almost level
with the gunwale when the dredge bag lifting
becket parted.
The deckhand was a seasoned fisherman but
was new to scallop dredging and had worked
on board for only 5 weeks. He had signed the
Seafish Fishing Vessel Safety Folder to confirm
that he had received a safety induction from
the skipper, which included maintaining a
secure hold of a suspension chain while attending
to the dredge bags. However, he had not
attended a safety awareness course and the
risk assessment form neither identified any
significant risk nor recorded any control
measures against falling overboard.
The deckhand was not wearing a personal

flotation device or a safety harness when he
stepped onto the elevated dredge beam, and
it was not the practice for deckhands to do so.
On this occasion, he let go of the suspension
chain (Figure 1) to facilitate the emptying of
one of the dredge bags. As he grasped the
dredge bag with both hands, the lifting becket
parted, causing him to fall forward and, with
no protection from the bulwark, to continue
to fall overboard.
Despite the quick reactions of the skipper and
crew, the deckhand sank below the sea surface
before he could be rescued. Although an
extensive search and rescue operation followed,
his body was not recovered.
A demonstration of where the crewman was standing immediately prior to the accident
46
CASE 17
The Lessons
1. The lifting becket parted at a point of
attachment to the dredge bag which was
prone to wear. A robust inspection and
maintenance regime for the working gear
might have identified the wear and have
prevented the failure. Ensure you have a
regime that does so.
2. Risk assessments for the bag lifting/dredge
discharge activity had been incorrectly
calculated by the skipper - despite him
having previously attended a safety
awareness course - and indicated a lack of
understanding of the concept. Guidance
on risk assessment is provided in the MCAs
Marine Guidance Note (MGN) 20 (M+F),
the Seafish Fishing Vessel Safety Folder
and the Fishermens Safety Guide. Risk
assessment is an important tool to help
identify and reduce risks to safety in a
dangerous working environment. Make sure
you understand the process and then apply it.
4. The wearing of a lifejacket would have

significantly improved the deckhands
chances of survival. The provision of a
lifejacket or other personal flotation device
is mandatory where there is a reasonably
foreseeable risk of a crew member falling
overboard. Develop a habit of always
wearing one when working on deck.
5. Although the crew responded rapidly to
the man overboard, they were ill-prepared
to mount a successful recovery. Equipment
required to assist the recovery of a person
from the water was not available on board
and no emergency drills had been conducted
which would otherwise have ensured that
correct procedures were followed.
3. The fitting of a tipping bar, commonly

used on scallop dredgers, would have
enabled all the dredge bags to be inverted
at the same time and have avoided the need
for deckhands to step onto the dredge beam
or to lean over the gunwale. The best way
to control a risk is to remove the hazard
altogether.
47
CASE 18
Shooting Pots Ends Tragically

Narrative
At the end of a day at sea spent fishing and
relocating sets of gear before the onset of bad
weather, the owner of a potter was throwing
the last set of pots overboard before heading
for home.
The potter was fitted with a stern shooting
door that enabled a single set of pots to be
shot over the stern with the crew safe in the
wheelhouse. When more than one set was
carried, such as when moving gear, the stern
door was closed and the more traditional, and
riskier, method of lifting the pots overboard
was employed.
As one of the last pots was being lifted overboard,

the crewman in the wheelhouse heard the
owner shout; he turned round and saw the
owner standing at the stern, with the backrope
caught around his leg. The owner did not have
a knife to hand and the crewman threw the
engine control full astern. Unfortunately, the
weight on the backline was too great and the
owner was pulled overboard.
The crewman reacted quickly. He led the
remaining backline up to the hauler and pulled
the owner back to the surface. The owner was
unconscious. With some difficulty, the crew
pulled him back on board but, sadly, despite
valiant efforts to revive him and a swift airlift
to a nearby hospital, he died.
Figure 1: Stern view of potter

48
CASE 18
Figure 2: Forward view of potter
The Lessons
1. The most common cause of death on creel
boats is falling or being dragged overboard.
Most of these accidents happen while shooting
pots. The greatest risk to crew working on
creel fishing boats is becoming caught in the
back rope. Separating crewmen from the
back rope, by methods such as using a stern
shooting door, reduces the chance of them
becoming entangled. Where this is not
possible, other ways of keeping people clear
of the back rope should be carefully
considered. The fitting of rope pounds or
dividers can create an effective barrier,
with little lost deck space. Seafish1 provides
practical guidance on possible ways to
reduce the dangers while potting.
www.seafish.org/resources/publications
2. The owner did not carry a knife and there

were none available for him to use to cut
the back rope. Carrying a knife, or having
one immediately available, could mean the
difference between life and death.
3. None of the crew wore lifejackets or
personal flotation devices. In most cases,
lifejackets would assist rather than hinder
the wearer to keep afloat, even if the wearer
is trapped in a backline.
4. The owner and crew had never considered
how to recover a trapped, unconscious
crewman back on board. In the event, they
found it was much more difficult than they
had imagined. Think carefully how you
might recover someone from the water on
your boat and practise this drill regularly.
49
CASE 19
Its Foggy No Stand-On Vessels Allowed

Narrative
A gill netter was steaming between wrecks on
an easterly heading at about 7 knots. A large
beam trawler was returning to port on a
south-easterly heading at about 10.5 knots.
It was foggy and the visibility was severely
restricted. Both vessels had operational radar
and the skippers were alone on watch.
The gill netters skipper saw an echo on his
radar to the north and broad on his port bow.
He put the cursor over the echo and, after a
short while, judged that the other vessel would
pass astern. He was of the opinion that, with
respect to the COLREGS, his was the stand-on
vessel and the other vessel, being a crossing
vessel, had the obligation of keeping out of the
way. A short time later, the skipper saw the
trawler out of the port side wheelhouse window
at close range and just abaft the beam. He

reacted by applying full starboard helm.
Although the trawler had both of her radars in
operation (one on 6-miles range and the other
on 12-miles range), her skipper was focused
on other radar echoes in the vicinity and did
not detect the gill netter until she appeared out
of the fog on his starboard bow. By that time,
the vessel was so close that the skipper
decided to apply full astern propulsion rather
than attempt to alter course.
The action taken by both skippers was
insufficient to prevent the vessels colliding.
The gill netter sustained significant damage
and had to be escorted back to her home port.
This beam trawler sank affer a collision in dense fog - all of the trawlers crew were lost
50
CASE 19
The Lessons
1. The COLREGS require all vessels to
maintain a proper lookout by sight and
hearing, as well as by all available means
appropriate in the prevailing circumstances
and conditions so as to make a full appraisal
of the situation and of the risk of collision.
Wheelhouse manning, equipment and
procedures all contribute to complying
with this requirement and are all the more
important in conditions of restricted
visibility. Neither vessel maintained a
proper lookout: the gill netters skipper
failed to accurately monitor the trawlers
approach and the trawlers skipper failed to
detect the gill netter until it was too late to
take effective avoiding action.
2. The gill netters skipper held a common

misconception that the same rules apply in
restricted visibility as for when vessels are
in sight of one another. Consequently,
having determined by radar that this was
a crossing situation, he maintained course
and speed. Rule 19 of the COLREGS
applies to vessels not in sight of one another
when navigating in or near an area of
restricted visibility. It requires every vessel
to determine if a close-quarters situation is
developing and, if so, to take avoiding
action in ample time.
The Rule does not distinguish between
types of vessels so all vessels are obliged
to take avoiding action.
51
CASE 20
Never Give Up
Narrative
A crewman was dragged overboard when his
foot became entangled in a creel dhan rope
during routine self-shooting operations.
After being dragged overboard, the weight of
attached fishing gear pulled him down to the
seabed. The skipper succeeded in recovering
the casualty to the boats side by hauling back
the rope which had initially dragged him
overboard.
However, these were stopped after a few

minutes as they appeared to be having no
effect on the seemingly lifeless casualty.
During the recovery process a crewman from

another fishing vessel transferred across and
helped pull the casualty back on board.
Following the casualtys recovery to his vessels
deck he was given first-aid by way of chest
compressions and mouth to mouth resuscitation.
The casualty was transferred to hospital, but

died as a result of his underwater exposure.
Half an hour later, an RNLI lifeboat arrived and

lifeboat men transferred to the fishing vessel
and recommenced artificial resuscitation to
the casualty, despite being unable to detect
outward signs of life.
Figure 1: The position of where the crewman was standing before he was dragged overboard
52
CASE 20
Figure 2: Onboard working area
The Lessons
1.

The accident happened during a normal

creel shooting operation which, despite
having been carried out routinely for several
years, had not been properly evaluated to
make the operation as safe as possible.
The shooting operation required the casualty
to work in close proximity to unguarded
ropes strewn on deck. A simple dividing
barrier separating crew from ropes could
have prevented this entanglement and
should be considered on all static gear vessels.
2.

Had the casualty been able to free his leg

from the rope, a flotation device might
have assisted him to the surface and
therefore increased his chances of survival.
3. Never give up on apparently lifeless

casualties unless advised to do so by
medical experts. Seemingly deceased
hypothermic and drowned casualties have
been known to be resuscitated, despite
them showing no visible signs of life
for a prolonged period.
53
CASE 21
I Thought You Said the Fore Peak

Was Empty
Narrative
A 30m scallop dredger was at sea in moderate
weather. The crew felt that the vessel was
behaving as though the fore peak tank was
ballasted, whereas they believed it to be empty.
They started the ballast pump and began
pumping out water. After some time, water was
still being pumped out and the crew decided
to investigate further.
They removed the tank lid from the fore peak
and were alarmed to find the sea washing in
and out through a hole in the starboard side.
Leaning over the side of the boat, they could
see a section of shell plating at the waterline,
opening and closing the hole as it moved
about in the seaway.
The skipper revised his fishing plans and
headed straight for the nearest major port.
Shell plating damage
54
They arrived safely and took a drying out berth.

At low tide, the full extent of the damage was
revealed, with a hole of about 1.8m x 0.8m in
the shell plating on the starboard side.
Detailed examination of the fore peak found
that of the four frames, two had wasted and
come away from the shell plating completely,
and another was attached by only half its
length. The shell plating had been unsupported
and flexed as the boat moved through the sea.
The plating was in good condition, but a crack
had developed which had then spread, allowing
the sea to leak in. The crack had then got
bigger, until the force of the sea tore the plating
open like a tin can. Fortunately, the collision
bulkhead, at the aft end of the fore peak tank,
was in good condition and saved the vessel
from flooding uncontrollably.
*Photograph courtesy of MCA
CASE 21
The Lessons
1.

The crew have since recognised the need

to check ballast tanks and void spaces
periodically for signs of damage or general
deterioration. If you know what it should
look like, it is much easier to spot potential
problems. Get into the habit of thoroughly
checking one compartment each month.
2.

When you are checking compartments,

look carefully at coatings, and remove
them if necessary to look at the material
underneath. In this case the coating looked
fine, and it was only when crew looked
more closely at the frames that their true
condition was discovered.
3.

Before you enter a ballast tank or void

space, make sure it is properly ventilated.
Corrosion uses up the oxygen in the air,
and there are cases where people have gone
into a tank, collapsed and died2. Sometimes
crew mates try to rescue them and, sadly,
they too have lost their lives in the attempt.
In this case, the compartment had been
well (if unintentionally) ventilated, but in
normal circumstances it is good practice to
use ventilation fans to blow fresh air into
the compartment for 24 hours and use
analysing equipment to check that the
atmosphere is safe to breathe before entering.
4.

It is always a good idea to tell the

Coastguard if your vessel has been damaged,
even if you do not need help or are in
immediate danger. This helps them to be
more prepared and to take action if the
situation does get worse.
5.

Finally, the collision bulkhead saved the

boat from being lost. Collision bulkheads
have more uses than their name suggests,
and should be kept in good condition.
MAIB report into the death of three crewmen in an enclosed

space on the ERRV Viking Islay. Report No 12/2008 July 2008
55
CASE 22
Rock and Roll
Vessel on slipway after recovery
Narrative
The skipper and crewman of a 10 metre fishing
vessel were on the aft deck, preparing bait and
listening to music via a loudspeaker as the vessel
headed towards the first string of pots due to
be hauled that day. The vessels wheelhouse
was thus unmanned when the men noticed
that she was listing and starting to bodily sink.
Before the men had time to send a distress call
or get to their lifejackets, the vessel rolled over
and sank.
56
Fortunately for the men, who were left in the

water clinging to pot marker buoys which had
floated free as the vessel sank, the sinking had
been seen by a nearby fishing vessel, which
proceeded to the scene and recovered them
from the water. They were taken back to port;
wet, but otherwise unharmed.
CASE 22
The vessel was later salvaged and the cause
of the sinking was found to have been water
entering the engine space via a sea water
suction hose, which had become detached
from the sea cock. This was a valve with a 2
inch diameter, through which water would
have flowed into the engine space at
approximately 350 litres per minute. This
meant that, on average, 1 tonne of water would
have entered the vessel for each music track
the men had listened to!
The vessel had two bilge pumps, one of which

was fitted with an integral bilge alarm. The
alarm sounder was located on the instrument
panel in the wheelhouse, but this was not
heard by either of the men outside, above the
loud sound of the music.
The vessel sank very rapidly and the skipper,
who was not a strong swimmer, realised that
in different circumstances he and his colleague
might not have been rescued. He subsequently
attended a swimming course at a local swimming
pool and now fully understands the importance
of wearing a lifejacket when working on deck.
The Lessons
1. This case illustrates the importance of
someone remaining in the wheelhouse
when on passage. This is obviously
essential to meet the requirements for
keeping a proper lookout, but it is equally
important to be able to monitor alarms,
including the bilge alarm, to enable
corrective action to be taken in sufficient
time to prevent the loss of the vessel.

2. The men found themselves in the water
- without lifejackets and without having
the time to transmit a Mayday. Once
again, the importance of wearing lifejackets
when working on deck is clearly
demonstrated.
3. Music playing via a loudspeaker meant

that the crew were unable to monitor audible
alarms or their VHF radio while they were
on deck. This was not a safe way of
operating the vessel, and it is notable that,
later, when installing a new engine and
rewiring the boat, the owner ensured that
the bilge alarm and not the music channel
was connected to the deck loudspeaker.
57
Part 3 - Small Craft

One memorable
Pirelli tyre advert
featuring an
Olympic sprinter
in red stilettos
carried the strap
line power is
nothing without
control.... The
feeling of power
we get from
piloting an
exhilarating and
well equipped boat is only as good as our ability
to exercise good judgement in controlling it.
The human brain is the single most important
piece of safety equipment on any vessel.
Despite advances in artificial intelligence, the
brains ability to respond to complex and fast
changing circumstances is unsurpassed. Our
first priority should always be to safeguard this
primary piece of safety equipment: to keep it
warm, hydrated and fed, to stimulate it with
planning and information, to stretch it with
training and experience; to use it to tell us
where our limitations lie.
However, neither the most carefully laid plans
nor the most extensive experience are definitive
protection against accidents. It can happen, it
does happen, and it can happen to you. The
MAIB is best known for investigations after the
fact but it aims to prevent rather than cure
and sharing the lessons learnt from such diverse accidents provides an invaluable wake up
call. Reading the Safety Digest is far too close
to home for me to ever be a pleasurable task,
but every time I pick it up it helps remind me
of the risk of complacency.
58
Complacency appears to be the root cause in

so many incidents. Over-confidence, failure to
appreciate the complex and often compounding
factors in the lead up to an accident, retracing
a route navigated many times before in different
conditions: all fall under the umbrella of
complacency and it is something almost all
industries struggle with. How many of us can
say we listen to every word of the aircraft safety
briefing? Or complete a full mirror signal
manoeuvre process at every junction?
The cases in this edition of MAIB Safety Digest
underline the very fine dividing line between
enjoyable and emergency. How many seconds
separate a quick response which may save
lives from a dangerous knee-jerk reaction?
When does a careful and thorough safety
briefing turn into information overload? How
do we promote independence and challenge,
without overburdening beginners with too
much responsibility? The unfortunate reality
is that learning from our mistakes is an
indispensible part of how we all gain experience.
Happily, in all these cases tragedy was averted.
No lives were lost, or serious injuries sustained.
But help may not always be so close at hand.
The importance of self-reliance and knowing
what you can do to fix things in an emergency
is difficult to over-emphasise.
Sarah Treseder
Sarah became Chief Executive of the RYA in February 2010, after a 20 year career in industry. She
started sailing as a small child and has cruised and raced for pleasure whenever time has allowed.
The RYAs role is to promote and protect enjoyable, safe and successful boating and covers
power and sail, offshore and inland, racing and cruising, for individuals of all ages and abilities.
Each combination presents unique safety challenges. Although the RYA Training Scheme is
arguably the best in the world, with over 22,000 RYA qualified instructors working in 44 countries,
the Associations core ethos remains one of individual responsibility and all training is voluntary.
59
CASE 23
A Plan That Went Wrong

Narrative
A sail training vessel departed port on a late
summer evening. No passage plan was prepared,
and as the weather conditions were benign the
skipper opted to execute the 3 hour passage to
the next port under power, rather than sail.
On clearing the breakwater, the skipper
ordered the helmsman to head in a northerly
direction. About 10 minutes later, he estimated
the vessel to be sufficiently clear of off lying
dangers, and ordered the helmsman to alter
course to port and head towards a visual
reference point. No further position monitoring
was undertaken, and soon after that the vessel
ran aground on a charted rock. Fortunately

none of the three crew or three passengers was
injured when they were thrown forward as the
vessel ground to a halt.
The skippers initial reaction was to put the
engine astern in an unsuccessful attempt to
get the vessel off the rock. He then broadcast
a Pan Pan message on VHF radio that was
acknowledged by the coastguard. A rescue
operation involving a helicopter, an inshore
lifeboat and an all weather lifeboat ensured
that the crew and passengers were landed
safely ashore.
The Lessons
60
1.

Although both the skipper and mate held

the required qualifications to operate the
vessel, they were complacent in not following
navigational best practices. Complacency is
a natural human response to repeated
exposure to situations in which no adverse
consequences are experienced. This
inevitably results in people losing awareness
of potential hazards, and it induces an
attitude of over-confidence in ones own
ability. In turn, this leads to shortcuts being
taken and procedures being disregarded.
2.

Regulations require all vessels proceeding

to sea to plan their passage accordingly.
While small vessels do not require a passage
plan to be written down, there is still a need
for prior planning. In this case, identifying
navigational dangers that may be
encountered during the passage would have
required checking an up-to-date chart and
marking off the intended track.
3.

Navigational best practices require the

vessels position, speed and course to be
checked at frequent intervals so as to
ensure that she follows the planned track.
Position monitoring should preferably be
carried out by more than one method
whenever circumstances allow.
4.

Many yachtsmen instinctively put the

engine astern on grounding, but this is
usually when the vessel has grounded on
soft mud and in familiar waters, with no
resulting damage. In this case, the grounding
came as a complete surprise. The skipper
should have first established the condition
of the vessel, the crew and passengers
before attempting to refloat her. Had the
vessel refloated with a breached hull, the
outcome might have been significantly
worse.
CASE 24
No Margin for Error Leads to

Catastrophic Grounding
Narrative
A Bavaria 36 was being sailed by five crew on a
bareboat charter between various ports. All five
were gaining sea-time, miles and experience
as part of a fast-track course for the RYA
Yachtmaster qualification.
They left a river estuary under power late in
the evening at the beginning of a passage of
about 80 miles that would take them to a port
on the North African coast. It was dark and the
breeze was blowing slightly onshore at around
12 knots. The crew had been taking it in turns
to act as skipper and navigator, and the one
with responsibility for this passage had identified
a fairway buoy and a westerly cardinal mark as
crucial turning points on the way out of the
estuary.
On rounding the westerly cardinal, the acting
skipper ordered a course of 160T, the genoa
was unfurled, and the engine put into neutral.
The yacht was brought onto the desired

heading and was making about 41/2 knots when
she grounded violently, and after a few bounces
took on a substantial angle of heel. The crew
tried to extricate themselves straightaway using
the engine, but with no success. There was
a swell of about 1.5m running and the yacht
continued to be pounded onto the rocks. The
engine overheated and was shut down.
A Mayday call was put out, and while the crew
were waiting to be rescued the yacht began
to take on water as the hull sustained serious
damage. When the lifeboat arrived on scene
they were unable to get close enough to effect
a rescue, so a helicopter had to be mobilised.
All five crew were safely winched off but the
yacht was a total loss.
The Lessons
1.

Seemingly correct mark rounding does

not guarantee safety. The westerly cardinal
was warning of the danger of a well-charted
area of exposed rocks, however the mark
was rounded, leaving it just 20-30m on the
beam. Coming immediately onto their
course of 160, the combination of excessive
leeway as the yacht was gathering way,
and the onshore swell, quickly placed them
in danger. A safer option would have been
to leave far more sea room before altering
course, and carefully monitoring their
position as they sailed around a dangerous
obstruction.
2.

The decision to try to motor off

immediately after such a heavy grounding
was questionable. The natural instinct to
try to undo what youve just done needs
to be tempered by an awareness that
serious damage might have already been
caused. These rocks were surrounded by
deep water leaving a vessel that may be
flooding in a yet more hazardous situation.
61
CASE 25
Dont Forget When You Have Pulled

the Plug
Narrative
62
A boat hire company operating on a stretch of

water with access to the sea had recently taken
ownership of six new, shallow draught moulded
boats capable of carrying 8 passengers (the hire
company limited the number to six persons).
The boats were designed with a continuous
void space between the two hull skins and
A family group of six persons won a charity

raffle prize for the day hire of one of the boats.
The boat they were to use was out of the water
and on a trailer, and the engineers were busy
checking the engine when the hire group
arrived full of expectations of an enjoyable
day on the water, including a spell of fishing.
Figure 1: Deck layout post-incident
Figure 2: Rear engine view with drain plug missing
they were very well equipped with lifesaving

equipment, VHF radios and bilge pumps. The
owner was particularly happy with the boats
stability which, together with the bow ramp
access, made them suitable for hirers with
disabilities (Figure 1).
The engineers had previously removed the

hull drain plug (Figure 2) which emptied
accumulated water from between the two hull
skins. They had completed these tasks many
times before and it was considered unnecessary
to have a checklist to ensure that all tasks were
completed and that the boat was safe for use.
CASE 25
As the hire group assembled around the boat,
the engineers were diverted from their checks
to provide the routine 40-minute safety briefing.
This included information on steering, use of
the liferaft, flares, hand-operated and electrical
bilge pumps and control switch positions,
hand-held radio, and console-mounted VHF
radio, which was equipped with an emergency
Digital Selective Calling (DSC) button. The
group were advised of the need to hold down
the DSC button for at least 5 seconds, after
which the transmission would be acknowledged
by a beep. The briefing checklist was
completed and signed by the hire company
representative and the lead member of the
hire group.
The group were individually fitted with 150kN
lifejackets and felt safe and ready for a good
day out as the boat was launched and they set
off towards a recommended fishing spot.
Importantly, no one realised that the engineers
had forgotten to fit the hull drain plug, the
consequences of which were soon to
become evident.
Although the boats handling didnt feel
quite right, none of those on board were
boat-experienced, and they did not realise
that the odd motion of the boat was due
to the accumulation of free surface water
between the two hull skins.
The group fished for a short while and then
moved to a new location to continue fishing.
The engine was shut down and the boat drifted
while the group, who were evenly distributed
around the boat, continued to fish. A short
time later, the engine well started to fill with
water from the stern. The senior group member
operated the bilge pump switch to what he
believed to be the on position.
Some of the group stood up, and as they made
their way towards the stern the boat started
to roll about lazily, and the group became
concerned that it was in danger of sinking.
The senior member momentarily pressed the

VHF radio DSC button, but did not hold it
down and did not hear the acknowledgment
beep. He then set about firing off a red flare.
Immediately afterwards, the bow lifted out of
the water and all six occupants were thrown
into the water as the boat suddenly capsized.
The red flare was seen by other boats, and
fortunately the group were rescued in rapid
succession and landed at the hire company
jetty. Happily there were no injuries. The
capsized boat was later towed to the jetty,
where it was found that the hull drain plug
was missing.
The boat capsized because water had entered
the hull void space through the open drain
plug connection, causing free surface effect.
As the freeboard reduced, water entered
the engine well. The senior group member
thought that the bilge pump was not working.
He recalled from the safety briefing that
there were various bilge pump control switch
positions, and he moved the switch from the
auto position to the off position. This
allowed even more water to accumulate. As
the group members stood up, the centre of
gravity rose and the boats instability increased,
eventually causing it to capsize.
While the safety briefing was thorough, the
group forgot that the DSC button should have
been depressed for 5 seconds, so the emergency
call was not transmitted. It was fortunate that
other boats were nearby to effect the rapid
rescue.
Crucially, no engineering checklist took place.
The engineering items had been checked many
times and were well known to the engineers.
However, on this occasion, the engineer was
distracted while giving the safety briefing, and
forgot to replace the hull drain plug. Had he
worked to a checklist, it is most unlikely that
the drain plug would have been forgotten.
63
CASE 25
The Lessons
1. Avoid over burdening staff with multi tasking if it impacts on their ability to
complete safety-related activities.
2. Use checklists to ensure that all pre-hire
checks are completed (eg drain plug in place
and fully tightened), and that the boat is
safe for use.
4. When delivering safety briefings, emphasise

the functionality of the VHF radio DSC
button, the need to keep it depressed for at
least 5 seconds, and the audio sound to be
expected from the set to confirm the
message has been transmitted.
3. Ensure that checklists are periodically

reviewed to ensure their currency.
64
APPENDIX A
Preliminary examinations3 and field deployments commenced in the period
01/10/10 to 28/02/11
From 01/01/11, preliminary examinations were discontinued. Thereafter most field deployment will result in the
production of an MAIB report.
Date of
Accident
Name of Vessel
Type of Vessel
Flag
Size (gt)
03/10/2010
Fitnes
Bulk/oil carrier
Antigua
20234

09/10/2010
Flying Cloud
Fishing vessel
UK
3.68

4
11/11/2010
Stena
Ro ro vehicle/
UK
64039

Britannica
passenger

Fairplay-22
Tug
Antigua &
496

Barbuda
25/11/2010
Maxime
General cargo

11/12/2010
Antonis
Bulk carrier

Type of Accident
Accident to person
(1 fatality)
Accident to person
(1 fatality)
Collision
(2 fatalities)
Netherlands,
1554
Antilles & Aruba
Machinery
failure
Greece
Contact
25935
13/12/2010
Joanna
General cargo
St. Vincent
1525

03/01/2011
Karen
Fishing vessel
UK
50

Accident to
person (1 fatality)
31/01/2011
Jack Abry II
Fishing vessel
France
840

11/02/2011
Boxford
Container
Marshall
25324

Islands

Admiral Blake
Fishing vessel
UK
136
Grounding
15/02/2011
K-Wave
Grounding
Collision
Container
UK
7170
Grounding
26/02/2011
SBS Typhoon

Offshore
supply vessel
UK
2465
Contact

Vos Scout

Standby
safety vessel
Bahamas
516

Ocean Searcher

Offshore
supply vessel
Bahamas
1472
A preliminary examination identifies the causes and circumstances of an accident to see if it meets
the criteria required to warrant a full investigation, which will culminate in a publicly available report.
This investigation, by agreement, is being led by The Dutch Safety Board

http://www.onderzoeksraad.nl/en/index.php
65
APPENDIX A
Investigations started in the period 01/10/10 to 28/02/11
Date of
Accident
Name of Vessel
Type of Vessel
Flag
Size (gt)
Type of Accident
03/10/2010
Discovery
Fishing vessel
UK
5.65

Accident to person
(1 fatality)
Cardiff Bay Yacht Club Pleasure craft

27/10/2010

RIB

06/01/2011
Blue Angel
Fishing vessel

passenger ferry

12/01/2011
Sapphire II
Fishing vessel

Silver Chord
Fishing vessel

UK
Unknown
Accident to person
UK
5.46
Accident to person
UK
UK
29.71
78
Collision
20/01/2011
Breadwinner
Fishing vessel
UK
15.29

Grounding
(1 fatality)
07/02/2011
Tombarra
Vehicle carrier
UK
61321

Hazardous incident
(1 fatality)
66
APPENDIX B
Reports issued in 2010

Aquila capsize of the fishing vessel, with
the loss of three lives, Bo Faskadale Reef,
Ardnamurchan on 20 July 2009
Published 15 April
Kerloch grounding and subsequent

foundering at Crow Rock, off Linney Head,
Wales on 20 February 2010
Published 6 October
Ben-My-Chree unintended movement

of the ro-ro passenger vessel during loading
operations at Heysham on 26 March 2010
Published 21 December
Korenbloem fatality resulting from a man

overboard from the fishing vessel, Dover Strait,
on 6 November 2009 (part of Trilogy)
Published 19 May
Bro Arthur fatality of a shore worker in

No 2 cargo tank on board the oil/chemical
tanker at the Cargill Terminal, Hamburg,
Germany on 19 February 2010
Published 19 August
Llanddwyn Island fatality on board the

workboat, Roscoff, France on 1 March 2010
Published 18 November
Dover powerboats collision between

two offshore circuit racing powerboats Sleepwalker (A2) and Harwich 2011 (A89) in Dover Harbour on 8 August 2009, resulting
in one fatality
Published 7 July
Etoile des Ondes/Alam Pintar collision
between fishing vessel and bulk carrier 15
miles north of the Cherbourg Peninsula on
20 December 2009, resulting in one fatality
and the loss of the fishing vessel
Published 16 September
Ever Elite uncontrolled descent of an
accommodation ladder from the container ship
in San Francisco Bay on 10 September 2009,
resulting in one fatality
Published 14 July
Ijsselstroom loss of the tug in the port
of Peterhead on 14 June 2009
Published 9 April
Isle of Arran contact with the linkspan
at Kennacraig, West Loch Tarbert, Kintyre
on 6 February 2010
Published 14 October
Maersk Kendal grounding on Monggok

Sebarok reef in the Singapore Strait on
16 September 2009
Published 16 March
Olivia Jean injury to a fisherman on board
the fishing vessel, 17nm south-south-east
of Beachy Head in the English Channel on
10 October 2009
Published 26 August
Optik fatality resulting from loss overboard
of a crew member from the fishing vessel 8
miles south east of Arbroath on 18 November
2009 (part of Trilogy)
Published 19 May
Osprey III fatality resulting from a man
overboard from the fishing vessel in the Moray
Firth on 11 November 2009 (part of Trilogy)
Published 19 May
Saetta and Conger collision between
Saetta and Conger on completion of a ship to
ship transfer 9.5 miles south east of Southwold,
UK on 10 August 2009
Published 25 March
Wellservicer - fatal accident on the diving
support vessel 3 miles south east of Aberdeen,
Scotland on 1 April 2009
Published 20 January
67
APPENDIX C
Reports issued in 2011

Delta 8.5m RIB injury to a passenger on board a Delta 8.5m RIB
on the River Thames, London on 6 May 2010.
Published 27 January 2011
Homeland/Scottish Viking collision between the fishing vessel
Homeland and the ro-ro passenger vessel Scottish Viking 4.2 miles
off St Abbs Head on 5 August 2010 resulting in one fatality.
Published 17 March 2011
Oscar Wilde machinery space fire on board Oscar Wilde in
Falmouth Bay on 2 February 2010
Royalist sea cadets fatal accident on board the sail training ship
TS Royalist in Stokes Bay in the Solent on 2nd May 2010
APPENDIX D
Safety Bulletins issued during the

period 01/10/10 to 28/02/11
RMS Queen Mary 2 - catastrophic failure of a capacitor, and an explosion,
in an 11kV harmonic filter on board the passenger cruise vessel RMS Queen Mary 2
Issued 3 December 2010
68
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MARINE ACCIDENT

Crown copyright 2011

If you wish to report an accident or incident

The telephone number for general use is 023 8039 5500.

PART 1 - MERCHANT VESSELS

Close Encounters of the Aframax Kind

Snagged & Dragged

Generators Dont Just Make Electricity

STS Run-In, No Margin for Error

Lack of Communication, and Distraction Lead to Benzene Spill

ECDIS Assisted Grounding?

Last Out Turns the Lights Off!

Davit Control Adjustments Proceed With Caution

10. Early Release Led to Early Demolition

11. Improvement Causes Unforeseen Consequences

12. Last Act of Defiance

14. Poor Cargo Configuration Results in Hull Failure and Pollution

15. Know Your Systems Back to Black

16. When Im Cleaning Windows

Fire Below The Need for Effective Engineering Oversight

PART 2 - FISHING VESSELS

17. Balancing Act

18. Shooting Pots Ends Tragically

19. Its Foggy No Stand-On Vessels Allowed

20. Never Give Up

21. I Thought You Said the Fore Peak Was Empty

22. Rock and Roll

A Plan That Went Wrong

No Margin for Error Leads to Catastrophic Grounding

Dont Forget When You Have Pulled the Plug

Appendix A - Preliminary examinations, field deployments and investigations

Appendix C - Reports issued in 2011

Appendix D Safety Bulletins issued during the period 01/10/10 to 28/02/11

Glossary of Terms and Abbreviations

- Maritime and Coastguard Agency

- Automatic Radar Plotting Aid

- Machinery Control Room

- Azimuth Stern Drive

- Marine Guidance Note

- Marine Incident Response Group

- Officer of the Watch

Pan Pan - The international urgency signal

COLREGS - International Regulations for the

- Royal National Lifeboat Institution

- Closest Point of Approach

- Roll on, Roll off

- Digital Selective Calling

- Royal Yachting Association

- Electronic Chart Display and

- Safety Management System

- Engine Control Room

- Traffic Separation Scheme

- Emergency Response and

- Very High Frequency

- Fire and Rescue Service

- Vessel Traffic Services

- The international distress signal

MAIB Safety Digest 1/2011

Part 1 - Merchant Vessels