Safety Digest 3-07 PDF

MARINE ACCIDENT
INVESTIGATION BRANCH
SAFETY
DIGEST
Lessons from Marine
Accident Reports
3/2007
is an
INVESTOR IN PEOPLE
MARINE ACCIDENT INVESTIGATION BRANCH
SAFETY DIGEST
Lessons from Marine Accident Reports
No 3/2007
is an
INVESTOR IN PEOPLE
Department for Transport

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Crown copyright 2007
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December 2007
MARINE ACCIDENT
INVESTIGATION BRANCH
The Marine Accident Investigation Branch (MAIB) is an independent part of the Department for
Transport, the Chief Inspector of Marine Accidents being responsible directly to the Secretary of
State for Transport. The offices of the Branch are located at Carlton House, Carlton Place,
Southampton, SO15 2DZ.
This Safety Digest draws the attention of the marine community to some of the lessons arising
from investigations into recent accidents and incidents. It contains facts which have been
determined up to the time of issue.
This information is published to inform the shipping and fishing industries, the pleasure craft
community and the public of the general circumstances of marine accidents and to draw out the
lessons to be learned. The sole purpose of the Safety Digest is to prevent similar accidents
happening again. The content must necessarily be regarded as tentative and subject to alteration
or correction if additional evidence becomes available. The articles do not assign fault or blame
nor do they determine liability. The lessons often extend beyond the events of the incidents
themselves to ensure the maximum value can be achieved.
Extracts can be published without specific permission providing the source is duly
acknowledged.
The Editor, Jan Hawes, welcomes any comments or suggestions regarding this issue.
The Safety Digest and other MAIB publications can be obtained by applying to the MAIB.
If you wish to report an accident or incident

please call our 24 hour reporting line
023 8023 2527
The telephone number for general use is 023 8039 5500.

The Branch fax number is 023 8023 2459.
The e-mail address is maib@dft.gov.uk
Summaries (pre 1997), and Safety Digests are available on the Internet:
www.maib.gov.uk
Crown copyright 2007
MARINE ACCIDENT INVESTIGATION BRANCH
The role of the MAIB is to contribute to safety at sea by determining the causes and
circumstances of marine accidents, and working with others to reduce the likelihood of
such causes and circumstances recurring in the future.
Extract from
The Merchant Shipping
(Accident Reporting and Investigation)
Regulations 2005 Regulation 5:
The sole objective of the investigation of an accident under the Merchant Shipping (Accident
Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents
through the ascertainment of its causes and circumstances. It shall not be the purpose of an
investigation to determine liability nor, except so far as is necessary to achieve its objective, to
apportion blame.
INDEX
GLOSSARY OF TERMS AND ABBREVIATIONS
INTRODUCTION
PART 1: MERCHANT VESSELS
1.
No Easy Withdrawals From This Bank
10
2.
Odd Ship, Odd Handling
13
3.
A Bridge Too Far
15
4.
Rain, But No Rainbow
17
5.
A Tale of Two Lookouts
18
6.
Dont Take Chances in Heavy Seas
20
7.
Bridge Teams Multiple Failures Lead to Grounding
22
8.
Same Old Story
24
9.
Never Mind the Waypoint Mind the Ship
26
10. Contain Containers
28
11. Hatch Hazards
30
12. Blocked Sea Suction Prevents Engine Room Flood
32
13. I See No Ships
34
14. Unsecured Electrical Fan Causes Cabin Fire
36
15. Pretty But Dangerous
38
16. Hurry Aground
39
PART 2: FISHING VESSELS
42
17. Too Much Up Top!
44
18. Not Dressed for the Job
46
19. Shrimp Boiler Lights up the Engine Room
48
20. Spot the Difference
51
21. Trim For Safety, Not For Catching Fish
52
22. Two Sides of the Same Coin
55
PART 3: LEISURE CRAFT
58
23. Relaxing Canal Trip Ends in Tragedy
60
24. Lookout Above and Below the Water
62
25. How Safe is Your Safety Boat?
64
APPENDICES
Appendix A
Appendix B
66
Preliminary examinations and investigations
started in the period 01/07/07 to 31/10/07
66
Reports issued in 2007
67
Glossary of Terms and Abbreviations

AB
Able Seaman
ARPA
Automatic Radar Plotting Aid
Cable
0.1 nautical mile
CO2
Carbon Dioxide
CPA
Closest Point of Approach
CPR
Cardiopulmonary Resuscitation
DSC
Digital Selective Calling
EPIRB
Emergency Position Indicating Radio Beacon
FRC
Fast Rescue Craft
GMDSS
Global Maritime Distress and Safety System
GPS
Global Positioning System
GRP
Glass Reinforced Plastic
ISAF
International Sailing Federation
ISM
International Safety Management Code
kW
kilowatt
metre
MGN
Marine Guidance Note
MOB
Man Overboard
OOW
Officer of the Watch
OSR
Offshore Special Regulations
PEC
Pilotage Exemption Certificate
RIB
Rigid Inflatable Boat
RNLI
Royal National Lifeboat Institution
RORC
Royal Ocean Sailing Club
RYA
Royal Yachting Association
SAR
Search and Rescue
SFIA
Sea Fish Industry Authority
SOLAS
International Convention for Safety of Life at Sea
STCW
International Convention on Standards of Training, Certification and Watchkeeping
TSS
Traffic Separation Scheme
VHF
Very High Frequency
VTS
Vessel Traffic Service
Introduction
I have just returned from the annual meeting of the Marine Accident Investigators
International Forum (MAIIF). Attended this year by the senior investigators of 25 countries,
it rapidly became apparent that we all had the same overriding safety concerns. Three of
these - fatigue, complacency and poor Bridge teamwork - are amply illustrated in the
Merchant Vessel section of this edition of the Safety Digest. Please read these cases and
then consider, if accident investigators from around the world all see these same issues
time and again in accidents, how confident are you that you/your ship/your company are
getting them right?
The other key concern we all shared was the apparent growth in the number of accidents
involving entry into enclosed/confined spaces. Although there are no examples in this
Safety Digest, MAIB is currently dealing with three such cases, two of them fatal, and many
other countries at MAIIF reported similar. Please look again at your systems and re-brief
your crews on the importance of correct ventilation and entry procedures. This is a critical
area, where complacency cannot be allowed to grow.
The Fishing Vessel and Leisure Craft sections again provide a cross section of accidents,
many tragic. Better awareness of risk would stop most accidents - before a trip, or before a
specific evolution, just think through with your crew: What are the dangers?; What do we
need to do to avoid each one happening?; What should we do to minimize the effect if it
were to happen?; and how would we deal with it if it does happen? Such a quick and
simple discussion could save lives.
Think safety and stay safe.
Stephen Meyer
Chief Inspector of Marine Accidents
December 2007
MAIB Safety Digest 3/2007
Part 1 Merchant Vessels

Who can afford to
ignore free advice
when it is readily
available? This MAIB
Safety Digest is
commended as a
wonderful source of
such advice. From
cradle to grave we
humans learn by
experience. It was
Oscar Wilde who
wrote (in Lady
Windermeres Fan) Experience is the name
everyone gives to their mistakes. How much
better to learn from the experience of others
and avoid the stress of making the mistakes
yourself!
continuous improvement. I have no doubt that

the most influential factor upon the safety
management system for which I am
responsible, is our standard agenda item Safe
Learning Events. This ensures that fleet
management meetings thoroughly consider all
lessons to learn from any unplanned event in
order to improve procedures and guard
against risk.
We work in a heavily regulated industry for

which most regulation can be traced back to
one of a number of major shipping casualties
that occurred during the twentieth century.
One such regulation gave us the ISM Code, an
excellent framework for robust safety
management which requires that each
companys objectives include the continuous
improvement of safety management skills. The
Code also requires procedures to ensure that
accidents and hazardous situations are
reported, investigated and analysed with the
objective of improving safety. How many of the
major shipping casualties referred to could
have been prevented by an earlier focus on
continuous improvement through learning
from mistakes?
I am convinced that the MAIB makes a major

contribution to safety at sea through its
investigation of accidents and identification of
lessons to be learned. The lessons identified in
MAIB Safety Digests and Investigation Reports
should be the staple diet of a healthy safety
management system.
Our industry has been poor at learning from

its mistakes, but as a result of the ISM Code
and a more enlightened attitude by
management, a change has taken place in
recent years to correct this weakness; there is
a gradual move towards a culture where when
things go wrong we now look for lessons to
learn rather than people to blame.
It is only by identifying the lessons to learn
from incidents that we will encourage
Safe learning events are not limited to own

company incidents but can usefully be
extended to include those published by CHIRP
(The independent marine Confidential
Hazardous Incident Reporting Programme),
MARS (The Nautical Institutes Marine
Accident Reporting Scheme) and of course the
MAIB Safety Digest.
Human behaviour is fundamental to the

effectiveness of even the healthiest safety
management system. Any procedure is only as
good as the behaviour of those tempted to
violate it. Unchecked, humans easily succumb
to complacency. We should rise above this
weakness and extract the learning points from
all unplanned events, whether in our
experience or the experience of others. In this
context we should also ensure and encourage
a level of reporting that enhances
organisational learning and fosters continuous
improvement in safety management.
The case studies included in this section of the
digest clearly reflect the significant risks to safe
ship operation, although it might be argued
that the number of fire incidents reported is
disproportionately light. The majority of
studies relate to collision or grounding which
resulted from weak bridge team management
and inadequate briefing. It is notable that one

third of these navigational incidents occurred
with a pilot advising on the conduct of the
ship. It is essential that the pilot effectively
interfaces with the bridge team who, if
adequately briefed, can properly monitor
compliance with the intended voyage plan.
Nearly all the case studies were the result of
complacency in decision making or in the coordination of actions. Complacency is the
temptress that lures seafarers into violation of
safe procedures, the modern equivalent of the
sea nymph Siren, and can only be resisted by
highly professional individual behaviour at all
times.
How professional is your behaviour? How

strong is your Human Element? If you learn
from every available opportunity and do not
allow complacency to get the better of you,
you will strengthen the influence of the human
element upon the safety management system
that your company operates. In that way we
can all contribute to making our industry safer.
Let us start now by putting into practice the
lessons identified in the following pages.
Safe sailing and best practice always.
Captain Simon Richardson

Captain Richardson is Head of Safety Management for P&O Ferries. He has 30 years experience in the ferry
industry, 9 years of which was spent in command. Since coming ashore into fleet management 10 years ago
he has held the positions of P&O Group Marine Audit Manager, Fleet Manager for P&O Stena Line and
moved into his current role upon the restructuring of P&O Ferries to include all the companys ferry
operations.
He is a Fellow of the Nautical Institute, a member of the Marine Advisory Board for CHIRP and a Younger
Brother of Trinity House. His preferred leisure activities include walking and narrowboat holidays.
CASE 1
No Easy Withdrawals From This

Bank
Narrative
At 1544, an 1857gt general cargo ship slipped
from her berth. Before departing, the pilot and
master had agreed that the pilot would
disembark before the ship reached the port
limits because of the potential difficulty in
getting off in the swell which could be seen
towards the open sea. They did not discuss the
ships engine power, which the master
considered was 1000kW, but which was actually
600kW. By 1551, the ship had turned off her
berth and was heading toward the departure
channel. The channel was 50m wide, just over
1 mile long, and its centre marked by two sets
of leading lights. It was semi-darkness, raining,
and the wind was a force 5 to 6 from the
south. The master was on the helm and was
steering courses as advised by the pilot, who
monitored the ships position using leading
lights astern. Speed was increased to 6 knots.
At about 1600, course was adjusted to follow

the second set of leading lights astern, the
base course of which was 091, to clear the
channel. The pilot then advised the master
that he was disembarking into the pilot cutter,
and that the master should put the engine to
full ahead, and aim for the red buoy marking
the south side of the entrance to the channel
as soon as he was clear.
Escorted by the chief officer, the pilot
disembarked at about 1602. The ship was
fewer than 5 cables from the end of the
channel and about 7 cables from the pilots
usual disembarkation position. The master
then increased to full ahead, but the ship
started to be set to the north. This was seen
by the pilot following in the cutter astern,
and he immediately repeated his previous
advice to the master via VHF radio. To assess
the ships position, the master used the
Figure 1: Damage to the vessels steering gear
10
CASE 1
16:28:29
16:11:20
16:00:11
16:00:54
16:02:16
16:03:22
16:06:13
15:59:10
Figure 2
lateral buoys ahead, supported by single

radar range and bearing fixes provided by the
chief officer on his return to the bridge, and
was not immediately aware of the degree of
the set being experienced. When he did
realise the ship was to the north of the
channel, the master was reluctant to alter too
far to starboard because of the narrowness of
the channel and the dangers on its southern
side.
At about 1605, the ship started to pitch heavily
and slowed quickly as she started to take the
ground on a sandbank. Her main engine was
kept at full ahead, but was stopped when the
chief engineer reported to the master that the

steering gear was badly damaged (Figure 1).
The ship was now on a south easterly heading,
and as she continued to be set to the north by
the wind and the swell, her forward part made
contact with a green lateral buoy marking the
north side of the channel. Both anchors were
then let go and the ship came to rest at about
1628.
The ships ground track from leaving her berth
until 1630 is at Figure 2. She remained
aground for 6 days, and was only refloated
after her bunkers and some of her cargo were
removed.
11
CASE 1
The Lessons
1. The need for compulsory pilotage is
based on a risk assessment undertaken by
the relevant port authority. It is therefore
likely to be appropriate for such a
requirement to apply in highly adverse
conditions, particularly those which
make boarding or landing a pilot too
dangerous. These conditions inevitably
make the safe passage through restricted
waters more difficult than usual, and the
premature departure of a pilot can place
the master in an extremely difficult
situation, and one which he might lack
sufficient experience and local knowledge
to successfully resolve. Therefore, where
circumstances dictate that a pilot is
unable to disembark or embark as
intended, the postponement of a sailing
or arrival must be seriously considered by
both the port authority and the master
concerned. As a minimum, the port
authority should satisfy itself that the
ship and crew are prepared and capable of
safely navigating within the port limits
without the benefit of a pilot.
2. Without basic manoeuvring information,
such as the power output of a ships
engine, it is impossible for either a
master or a pilot to properly assess a
vessels suitability to transit very
restricted waters in adverse conditions.
12
In the first instance, such information

needs to be accurate, and where marginal
conditions make the manoeuvrability of a
vessel a major consideration, it should be
discussed between the master and the
pilot before sailing.
3. Where there is little margin for error in a
narrow channel, the use of leading marks
or lights in transit frequently provides
the quickest and most accurate means of
keeping a ship safe. However, the use of
these aids at night and when they are
astern is not always easy. Unfortunately,
although the use of buoys is much easier,
it is far less reliable, and fixes based on
single radar ranges and bearings are
nowhere near as accurate.
4. Bridge organisation is an extremely
important aspect of navigation through
restricted waters, and adjustments to
normal practice are occasionally required
to meet the demands of differing
situations. In this case, the master was
alone on the bridge during the
disembarkation of the pilot, and had to
focus much of his attention on the helm.
The use of a helmsman would have
allowed the master to move around the
bridge to monitor the leading lights
astern, to keep an eye on the pilot
transfer, and to maintain a good overall
situational awareness.
CASE 2
Odd Ship, Odd Handling

Narrative
A 4,966gt ship, originally built for service on
the large rivers of Russia, was approaching a
port in the UK. The ship had an unusual
propulsion and manoeuvring system
consisting of twin propellers in steerable
nozzles with a single centreline rudder.
Normally the rudder and nozzles acted
together to steer the ship but, for
manoeuvring, both the rudder and each
nozzle could be operated independently. The
vessel was also fitted with a bow thruster.
Before boarding the ship, the pilot had
decided that tug assistance would not be
needed for berthing because the northwesterly winds were light and her two
propellers and bow thruster should have made
her quite manoeuvrable. Once on board, the
pilot handed the master a 2-page ports
pilotage passage plan, on which was marked
the proposed route. The pilot and master

discussed the vessels speed, and it was
confirmed that she had two fixed propellers
and a bow thruster. The master did not give
the pilot a ship-specific pilot card, and he did
not tell him about the two steerable nozzles
around the propellers or that there was a
single centreline rudder.
The engines were placed on full ahead, giving
a speed of about 7.5 knots, and the ship
started her approach. The master was
stationed at the two telegraphs and the chief
officer was steering the vessel, with the pilot
giving a mixture of helm orders and courses to
steer. As the ship approached the inner
harbour, speed was reduced to half ahead,
giving about 4.5 knots.
The pilot was judging his approach to the
inner harbour, by eye, watching the movement
of navigational lights against the shore lights in
Steering position (also note the two controls for steerable nozzles)
Telegraphs
The bridge showing the telegraph and steering positions
13
CASE 2
the background. The ebb tide was causing the

ship to set to starboard, and because of her
slow speed and poor manoeuvrability she did
not return to her planned track. She was still
trying to regain the centreline of the channel
as she passed very close to the inner
breakwater, on a heading 30 to port of the
planned track. Just inside the breakwater,
there was a planned track alteration to
starboard of a further 30. The ship was now
required to alter course through 60 to follow
the plan. She was slow to respond. The pilot
gave orders for increasing amounts of
starboard helm, until the rudder was hard-tostarboard. Realising that the ship was still not
turning fast enough, the pilot ordered the
starboard engine to full astern, and the bow
thruster full bow to starboard. In an effort to
The Lessons
1. The pilot had noted that the ship was
fitted with twin shafts and a bow
thruster, and considered that a ship with
this arrangement would be very
manoeuvrable. Unfortunately, the
master/pilot exchange was short, and the
particular manoeuvring characteristics of
this ship were not passed on to the pilot.
The pilot was not prepared for the ships
low power and poor turning ability.
2. Although a navigational checklist for
arrival in port had been signed by the
OOW to verify, among other things, that
a completed pilots card had been given
to the pilot, and that the master and
OOW were monitoring the vessels
progress, it was clear that most of the
actions on the checklist had not been
taken. The checklist is there for a
purpose: to remind the OOW of the
actions he must take to prepare the ship
for a safe pilotage, and to record that the
actions have been carried out. Signing
14
increase the rate of turn further, he also

instructed the pilot boat to push on the port
bow.
The ships head began to turn to starboard,
but it soon became apparent that she was
closing the shallows and would not be able to
complete the turn. The pilot ordered full
astern on both engines and the ship began to
slow. But these efforts were not enough to
prevent the ship from grounding forward on a
mixture of mud and sand, and on a falling tide.
Attempts to refloat her, even with the
assistance of two tugs, were unsuccessful until
the tide had risen after low water.
An underwater survey by divers found there
was no damage to the ship.
the checklist without completing the
actions totally undermines the ships
ISM procedures, which are designed to
promote safe ship operation.
3. The port mentioned in this article
requires pilots to decide whether or not
tug assistance is needed. This decision
depends on the ships manoeuvrability,
weather conditions, and it also takes
account of the wishes of the master.
Although this ship had visited the port
before, there was no guidance from the
port authority for its pilots, which would
have identified the particular
characteristics of this ship and might
have prompted the pilot to arrange tug
assistance.
4. SOLAS V requires that the plan should
be from berth to berth, to ensure that the
ships staff can monitor the pilots
actions. The passage plan for this voyage
finished at the outer breakwater, so it
was not possible for the master or OOW
to monitor the passage.
CASE 3
A Bridge Too Far
Damage to the vessels bow
Narrative
A laden cargo vessel made contact with the
supports of a bridge when making her way
upriver, at night, before a 2.5 knot tidal stream.
The vessels pilot was very experienced and
was an expert at negotiating this difficult
stretch of water, which had a history of
accidents. The bridge was situated about a
cable beyond a bend in the river, allowing little
room for error in the run-up to the bridge.
Due to the moonless sky and very still river it
was extremely difficult to visually differentiate
between the water and the riverbank. As the
vessel made its way upriver, on the flood
stream, it was essential she made enough way
to maintain steerage. There were transit lights
on the bridge; no other marks or lighting were
available to guide masters and pilots during
their approach.
As the pilot neared the bend in the river, he

reduced the vessels speed from 10 knots over
the ground, but did not check to confirm his
new speed. His view from the wheelhouse was
affected by the flood-lighting on the bridge,
which coincidentally was in line with the
vessels very low wheelhouse windows and
caused a dazzle effect as the ship neared the
bridge; this was exacerbated by the reflection
of the lights from the mirror-like surface of the
river. The pilot misjudged the vessels position,
and by the time this became apparent to him it
was too late to take corrective action to
prevent her from hitting the bridge, causing
substantial damage to the cargo vessel and
bridge supports. Fortunately no one was
injured.
15
CASE 3
The Lessons
1. Even the most experienced mariners can
make mistakes, and the risk of this
happening can often be exacerbated
when performing tasks that have been
done many times before. Familiarity and
complacency can lead to shortcuts being
taken, often with tragic consequences.
Do not rely on experience alone when
negotiating difficult waterways; use the
navigational aids provided to assist you
to navigate safely, no matter how
confident you may feel about the
developing situation.
2. The vessel was running before a 2.5
knot tidal stream, and a further 3 to 4
knots were needed to maintain steerage,
giving a speed over the ground of at least
5.5 knots. Although the pilot did
instinctively take action to reduce the
speed of the vessel from 10 knots before
16
attempting to negotiate the bend in the

river and pass under the bridge, he did
not verify that the vessel was proceeding
at a suitable speed before she reached the
bridge. No matter how experienced the
bridge team, difficult areas should always
be transited at the minimum safe speed,
thus allowing more time for corrective
action to be taken and damage to be
minimised if things do go wrong.
3. Over the years, numerous accidents
involving this bridge had occurred at
night, yet nothing had been done to
assist masters and pilots to better
position their vessels during their
approach to it. Harbour authorities have
an obligation to ensure that appropriate
navigation marks and lights are in place
in areas under their jurisdiction, and
thus to help protect harbour users, their
facilities and the environment from
harm.
CASE 4
Rain, But No Rainbow

Narrative
Shortly after a large container ship had cleared
an area of restricted waters, involving an
extended period of slow speed manoeuvring, a
fire was noticed in the top tier of the deck
containers aft of the funnel. The unit affected
was an empty flat rack with a wooden floor.
The fire alarm was sounded, fire parties
mustered and the vessels speed reduced to
minimise wind over the deck.
Fire hoses were rigged and directed at the fire
from the nearest accessible position on a
lashing bridge. But these efforts were
The Lessons
1. After a long period of slow speed
operation, the main engine probably
discharged some sparks as the vessel
increased speed. These might have fallen
on the wooden decking of the flat rack,
initially causing the wood to smoulder
and then, with the increasing airflow
over it as speed increased, burst into
flames.
unsuccessful because the water could not

reach the top of the stack, which was 7 tiers
high.
The master decided to alter course and speed
to give a relative wind of 12 knots from
forward to aft. Two water jets, from hoses,
were then played at 45 into the air from the
aft end of the bridge. Although the jets still did
not reach the affected unit, the rain effect was
sufficient to extinguish the fire.
The vessel was able to regain her original
course and speed. An overnight watch was
kept on the area of the fire, but there were no
further problems.
2. Access to fire-affected containers on

large vessels is often difficult. In
particular, access to the upper deck tiers
is a problem, even with the approved
fire-fighting equipment required by
SOLAS. In this case, the master used his
initiative successfully to apply firefighting water to a unit that was at the
extreme operating limit of the equipment
on board.
17
CASE 5
A Tale of Two Lookouts

Narrative
A coastal tanker was enroute to her loading
port around the southern coast of England.
The weather was fine with good visibility, and
moderate traffic conditions were expected.
The master was on the bridge and was busy
with his administrative duties. He left the
watchkeeping officer, who had recently joined
the vessel as an additional OOW on a training
voyage, to navigate the vessel.
Meanwhile, a single-handed fishing vessel had
completed laying her nets and was heading
back into port. On setting the course and
engaging the autopilot the skipper left the
wheelhouse to tidy up the working deck. From
that position, he could not maintain a lookout
because his view was obscured by the
wheelhouse.
The OOW on the tanker was monitoring the

traffic using the two radars, and also by sight.
To do this he was using the 3-minute relative
target trails on the radars, and if he thought
that they indicated a close quarters situation or
collision, he would then acquire the target
with the ARPA so as to monitor it more closely.
All other targets were discarded and not
monitored.
The fishing vessel was initially sighted on the
port bow, and the radar trails indicated that it
would pass about 3 cables astern of the coastal
tanker, so no plot was initiated. Soon after
that, the OOW adjusted the vessels course
(4) to port to allow her to pass clear of a
wreck which lay close by the course line. This
change of course was sufficient to change the
CPA to zero, but he did not look again at the
fishing vessels target (see plot below).
Plot A: Radar as viewed on the tanker
18
CASE 5
Plot B: Radar plot after alteration of course
The skipper of the fishing vessel, who was still

cleaning up, claimed that some sixth sense
made him look up, whereupon he saw his
vessel about to collide with another vessel. He
then just managed to leap to the engine
controls and go full astern. This action did not
The Lessons
1. It is imperative that a lookout be
maintained at all times. Both of these
vessels failed in their obligation to do so.
2. The collision regulations require that
risk of collision should be determined by
all available means. Although in this case
the radar was being used by the tanker,
the OOW was basing his assessments on
scanty information. He was not using the
full capability of the ARPA to assist in
his decision making.
prevent a collision, but it did manage to

reduce the severity of the impact. The fishing
vessel sustained damage to its prow and
gunwale; the tanker a little paint damage to
her hull.
3. When, or preferably before, the OOW

altered course, he should have rechecked
each of the relevant targets to ensure that
he was not altering into danger. The ARPA
facility would have made this task easy.
4. The OOW held the required certificate
of competency to stand the watch, but
his experience as an OOW had been on
fishing vessels, and his perception of
what constituted a safe passing distance
was based on his previous experience.
The master should have been monitoring
the performance of the officer and
instructing him in the required standard.
19
CASE 6
Dont Take Chances in Heavy Seas
Narrative
A 38,000gt vehicle carrier engaged on a regular
liner service between the Aegean and NW
European ports was approaching Lands End
from the English Channel in very heavy
weather. The master, who prudently had
reduced the vessels speed to a minimum off
Lizard Point for several hours when the vessel
was pitching violently in a westerly swell, then
decided that the weather had improved
sufficiently for the vessel to resume its passage
towards the Bristol Channel. Thus, as the
vessel entered the Lands End Traffic
Separation Scheme (TSS) in gale force winds
and very heavy seas, course was altered to
north to round Lands End, which placed the
heavy swell on the beam.
The vessel was carrying a mix of cars, vans and
heavy earth-moving vehicles on its nine decks.
The crew had checked the lashings on all the
various vehicles in the hours leading up to the
vessel rounding Lands End, and extra lashings
were placed on several vehicles, including a 76
tonne excavator unit, which was secured
alongside other vehicles weighing between 30
and 60 tonnes adjacent to the vessels stern
ramp.
When the vessel altered course off Lands End,
it began to roll violently and also continued to
20
pitch heavily, effectively adopting a

corkscrewing motion. After a short time a
lashing on the 76 tonne unit parted, and this
signalled the start of a chain reaction as other
lashings then also started to part. The vehicle
began to slide around the deck, crashing into
and parting the lashings on the adjacent
vehicles. The master was quickly made aware
of the fact that some of the cargo lashings had
parted, but considered he was unable to
reduce the vessels motion as he was in a TSS
and did not think he could alter course.
As the vessel continued to move violently, the
situation on the main deck deteriorated as
there were now 6 cargo units, together
weighing over 200 tonnes, on the move,
colliding with one another and the side of the
ship. The ability of the units to move around the
deck was made worse when the hydraulic tanks
of some of the vehicles were ruptured, causing
the vessels deck to become very slippery.
Once clear of the TSS, the vessel altered
course onto a north easterly heading and the
motion began to improve, but by that time the
damage to both ship and cargo had been
done.
The vessel made port, but was delayed for
several days while the damage to both the
cargo and the hull was assessed and repaired.
CASE 6
The ships cargo
The Lessons
1. The masters decision to resume passage
when the wind remained at gale force
and with a heavy swell still running, was
premature, since the vessel had to turn
beam onto the swell to pass around
Lands End. Whether this decision was
based on the fact that the vessel was on a
liner service, and was already behind
schedule and in danger of missing
another tide at its next port if it did not
resume passage, is not clear, but remains
a possibility.
3. Once the vessel entered the TSS, the

master was adamant that he could not
alter course, even though he was aware
of the extent of the damage being caused
to both the cargo and to his vessel. He
should have considered the safety of his
vessel ahead of the need to keep rigidly
to a particular heading within a TSS.
Rule 2(b) of the Colregs anticipates this
and makes proper allowance for such
circumstances.
2. The master took the decision to resume

passage after many hours on the bridge,
in heavy weather. Mariners must be
aware that their cognitive processes will
be affected by fatigue and that this will
have an adverse impact on their ability to
make clear and rational decisions in such
situations.
21
CASE 7
Bridge Teams Multiple Failures

Lead to Grounding
Narrative
A 25,000 tonne container vessel was
approaching port following a short coastal
passage. The bridge team consisted of the
master, the OOW and the helmsman; the
master had the con of the vessel and the
OOW was plotting the vessels position on a
paper chart using only GPS.
The approach to the port required the vessel
to enter an inlet several miles wide and then
alter course into a bay in which the port was
located.
The passage had been planned to take the
vessel to a suitable position in which the
alteration of course into the bay would take
her clear of a bank, marked by a South
Cardinal buoy, and then into the approaches to
the port. The passage plan did not include any
parallel indexing, clearing bearings or ranges,
22
nor were any no-go areas marked on the

chart for this stage of the passage.
The vessel approached the alter course
position in daylight on a warm, calm day with a
slight haze and with no significant tide. The
engines were on stand-by and speed had been
reduced to approximately 14 knots. The
master, aware that the next alteration of course
would require the vessel to turn to port
through some 40, decided that he would put
the wheel over slightly before the actual
position in order to bring the vessel onto the
new heading. However, he did not advise the
OOW of his intentions.
At the chart console behind the master, the
OOW was in the process of changing charts,
and was transferring the vessels position onto
the new chart when the master called out to
ask him if the vessel was 0.5 mile from the alter
course position. The OOW, presumably not
CASE 7
wishing to point out that he had yet to put a

position on the next chart, replied yes, and
the master accordingly ordered the helmsman
to bring the vessel to port onto the next course.
The OOW plotted the vessels position on the
new chart using the GPS receiver, which he
could see without moving from the chart table.
At no point was the vessel fixed by any other
means, even though both radars, located on
the console at which the master was stationed,
were apparently operating correctly, and the
coast, just a few miles away, provided
identifiable, radar conspicuous targets which
should have permitted visual bearings to be
taken as well as radar ranges. Further, although
the sea bed shoaled steeply just 0.5 mile to
port of the vessels course line, a fact
mentioned in the Admiralty Sailing Directions
for the area as being a potential hazard, the
echo sounder was not running.
When the OOW plotted the vessels position
on the next chart, he realised that they had
altered too soon and that the vessel was, in
fact, still a mile from the alter course position.
Thus, she was proceeding at 14 knots towards
shallow water. The OOW alerted the master to
The Lessons
1. The fundamental requirements of
planning and executing a safe
navigational passage must be clearly and
fully understood and implemented by all
bridge officers. Annexes 24 & 25 of the
MCAs 2002 SOLAS V publication
clearly define the requirements for the
planning and conduct of a safe
navigational passage, the key elements of
which are: Appraising, Planning,
Executing and Monitoring.
2. The annexes refer to the need to consider
all available information when planning
the passage, and of the need to ensure a
the vessels position just as the master

observed visually, and on the starboard bow,
the South Cardinal buoy which he had
expected to be on the vessels port bow on the
heading the vessel was now on.
The master immediately ordered the
helmsman to put the wheel hard to starboard.
She had just started to swing when she
grounded.
The vessel spent 24 hours aground before
being pulled off by salvage tugs. Fortunately,
the bottom in the area was soft mud and the
vessel was found to be undamaged. After a full
divers survey she was able to continue
unconditionally in service.
The crews actions after the grounding were
creditable: they quickly assessed the vessels
watertight integrity and the depth of the water
surrounding her; they informed the coastal
state authority, owners, insurers and Flag State;
they also checked the vessels grounded
position by radar, which revealed that there
was a significant difference between the radar
and the GPS positions. A little late to find this
out!
systematic bridge organisation which

provides close and continuous monitoring
of the vessels position ensuring, as far as
possible, that different methods of
determining the position are used to
check against errors in any one system.
3. Navigators should use all available means
to check the position of their vessel, but
they must regularly verify the accuracy
of positions displayed by electronic
position fixing systems by reference to
visual bearings and transits whenever
available.
4. This was a classic example of people on a
bridge not working as a team.
23
CASE 8
Same Old Story
Narrative
A 79-metre general cargo vessel was on
passage through UK waters in the early hours
of a winters morning. Conditions were good,
with winds of around force 4, generally from
the west, and good visibility.
A cargo of 1900 tonnes of ferro silicon was
embarked, a product used in the steelmaking
process, which can emit flammable and toxic
gases when exposed to moisture. Also on
board were the 7 crew; although the vessels
Safe Manning Certificate required a crew of 6,
she had an additional AB/rigger on board to
assist with the 30-year old vessels
maintenance. Only the master and chief officer
took navigational watches, working a 6 on, 6
off shift pattern, with the chief officer also
responsible for overseeing cargo operations in
port.
The vessels passage plan required the transit
of a channel, and at 0235 the chief officer, who
was on watch alone on the bridge, made the
course alteration for the passage through this
stretch of water. The passage speed was 8
knots.
The vessel was on autopilot, and the chief
officer made some minor adjustments to try to
keep her on track. Both doors were closed on
the bridge, making it extremely stuffy, and at
around 0300 the chief officer fell asleep in the
24
chair. The vessel immediately began to drift

north of the track, set by the tidal stream,
although still on a constant heading. No watch
alarm was fitted on the bridge and the chief
officer didnt wake up until 0432 when the
vessel heavily impacted the rocky western side
of a small uninhabited island at a speed over
the ground of 9.8 knots, assisted now by the
start of the flood tide.
Initial attempts to free the vessel by going
astern were unsuccessful, and the master who,
like the rest of the crew had been woken by
the impact, contacted the coastguard, using
VHF (but not DSC) to inform them of the
incident.
Two harbour tugs and the local lifeboat were
immediately deployed to the scene. However,
they were unable to provide immediate
assistance because of the swell and shallow
waters. The vessel refloated at around 0650 on
the rising tide and the two tugs were then able
to tow her to a nearby port where she was
boomed off alongside.
Diver surveys confirmed extensive bottom
damage to the vessel, with penetration to all
double bottom tanks forward of the engine
room, including a central fuel tank containing
10 tonnes of marine gas oil. Fortunately there
was only limited pollution and the holds
remained intact throughout. No injuries were
sustained.
CASE 8
The Lessons
1. Unfortunately this is still an all too
common story for the MAIB, with
cumulative fatigue and lone
watchkeeping contributing to a serious
accident, the consequences of which
could have been even worse given the
hazardous cargo on board. The master
commented that he had chosen not to
use the ABs for watchkeeping, and
preferred to reserve them for
maintenance day work, which he
considered more important given the age
of the vessel. The STCW Code requires
that, during the hours of darkness, there
is an additional person on the bridge with
the sole purpose of keeping a lookout,
and it is probable that had this been
adhered to, this accident would have
been avoided.
2. It is clear, too, that owners must take
some responsibility for the effective
utilisation of crew, to ensure safe
watchkeeping levels. A Port State
Control inspection of this vessel several
months before the grounding had
identified from the logbook that the ABs
were not being used as night lookouts.
The owners subsequently issued a NonConformity notice to prohibit this
practice, yet it had been allowed to
continue on the vessel, unchecked.
Further, the vessels ISM Manual did not
stipulate the requirement for a lookout,
and no watch alarm had been fitted.
Perhaps a stricter audit regime, and a

more emphatic safety culture, would
have ensured that AB lookouts were
being used to prevent a scenario exactly
such as this.
3. The chief officer had been working a 6
on, 6 off routine for around 312 months.
The cumulative effects of these watches,
exacerbated by the cargo work during the
vessels regular port visits, were a recipe
for fatigue. If ever you do feel the first
signs of sleep approaching, think about
what simple measures you could take to
try to minimise the chance of an
unplanned nap catching you out. None
the less, the most effective solution to
fighting fatigue is sufficient and
appropriately organised manning. In
hindsight, perhaps an additional mate to
reduce the watchkeeping burden would
have been a more sound investment than
another AB on this vessel.
4. Finally, although not significant this time,
it must be emphasised that it is always
better to use DSC to initially report an
incident. A vessels position and the time
are automatically included in distress and
urgency alerts if a DSC radio set is
interfaced with the GPS, and even if it
isnt, the position can still be manually
input. A digital alert is generally more
likely to reach a maritime rescue centre
than a VHF voice transmission, and it
also frees up Channel 16 for use during
the emergency.
25
CASE 9
Never Mind the Waypoint Mind

the Ship
Damage to the starboard side of the ship
Narrative
A small coaster was following a route south
west bound in the English Channel. It was dark
and the OOW was navigating by GPS, using the
cross-track error function to monitor the ships
position relative to the planned track and to
make appropriate course adjustments to reach
the next waypoint. He saw an overtaking ship
astern and slightly to starboard. Both of her
sidelights were visible and her masthead lights
were nearly in line, though open, indicating
that the other ship would pass down the
starboard side. The OOW monitored the other
ships approach, and identified her from the
AIS.
When the overtaking ship was about 7 cables
astern, the OOW tried to call her by VHF radio.
Receiving no response he switched on the
accommodation floodlights to make his ship
more visible. There was still no action from the
overtaking ship, and so, in a further attempt to
attract attention, he switched on his
searchlight and directed it at the other ship.
26
Again he called by VHF radio, with no

response.
With the other ship now fewer than 4 cables
astern, the OOW altered course by 10 to port.
However, after 2 or 3 minutes, with both
sidelights of the other ship still visible, he
altered back to his original course to take his
stern away from the overtaking ships bow.
When the overtaking ship was less than a cable
away, the OOW called by VHF radio, again with
no response, and then sounded a long blast on
the ships whistle. The other ship, which was
now about 50m on the starboard beam, then
altered course to starboard, causing her port
quarter to collide with the coasters starboard
side.
The OOW stopped the engines, switched on
the deck lights and mustered the crew to
check for damage. After identifying minor
damage only, and exchanging relevant
information, both ships resumed their
respective voyages.
CASE 9
The Lessons
1. The overtaking ship failed to take early
and substantial action to keep well clear,
and the coasters OOW failed to take
effective avoiding action when he became
concerned that the overtaking ship was
not taking appropriate action. WHY?
Because both were more intent on
keeping to their respective planned
tracks, regardless of the fact that, given
their position in a traffic separation
scheme, both tracks were likely to lead
to the same waypoint. Navigation by the
sole use of the GPS means that the
OOW loses spatial awareness, and
without reference to a chart is uncertain
as to how much safe water there is on
either side of the planned track and,
hence, how much sea room is available in
which to manoeuvre for the purpose of
collision avoidance. The OOW needs to
maintain an overall appraisal of the
situation and be prepared to modify the
planned track to meet the demands of
collision avoidance.
2. The OOWs action in illuminating his
own ship and in directing his searchlight
towards the overtaking ship to attract
attention was appropriate. However, he
should have also sounded at least five
short and rapid blasts on the whistle and
supplemented this with a light signal of
at least five short and rapid flashes as
soon as he became doubtful that the

overtaking ship was taking appropriate
action to keep clear.
3. Identification of another ship, by AIS,
provides no guarantee that subsequent
use of VHF radio for collision avoidance
will be successful. There is still the
possibility of a misunderstanding due to
language difficulties and, of course, of
action being chosen that may not comply
with the COLREGS and may lead to the
collision the VHF radio call was
intended to prevent.
4. The OOWs action in temporarily
altering course by 10 to port was
neither large enough, nor was it
sufficiently sustained to be readily
apparent to the overtaking ship. What
was needed was positive action, made in
ample time, and with due regard to the
observance of good seamanship.
Although a stand-on ship is required to
keep her course and speed, and may take
action as soon as it becomes apparent
that the ship required to keep out of the
way is not taking appropriate action, she
MUST take action when collision cannot
be avoided by the action of the give-way
ship alone. By the time the overtaking
ship was abeam and altering her course
to starboard, the point by which a
collision could then be avoided by her
action alone had already passed.
27
CASE 10
Contain Containers
Remaining containers being lifted by crane after collapsing on deck
Narrative
A general cargo/container vessel was on
passage in heavy weather with a full deck load
of containers. The vessel was pitching heavily
in force 9 conditions with the wind and waves
about 30 on her port bow. During a period of
particularly heavy pitching, the vessel shed 20
containers from the deck into the sea; other
containers toppled from their stowed position
onto the hatches.
The containers were required to be fastened to
the deck using securing devices known as
twistlocks. However, it was later found that a
28
number of twistlocks for retaining the lost

containers were in the open position during
the passage. The vessel had a large mixture of
both left and right-handed manual twistlocks;
this mixture of securing devices made it very
difficult to establish if inboard twistlocks were
in an open or shut position, not only before
sailing but also before discharging.
Additionally, the stowage of the containers, on
this occasion, was such that heavier
containers were stowed on top of lighter
ones, which created toppling effects in the
stack and induced severe leverage on the
deck fittings.
CASE 10
The Lessons
1. Over a period of time, the vessel had
acquired a mix of left and right-handed
twistlocks. When damaged units were
put ashore for repair they would be
replaced with exchange units;
unfortunately these were not always of
the same orientation as the originals. A
ships crew should check exchange units
and refuse to accept anything other than
same handed locking devices. Only by
maintaining a strict operating regime will
deck crew (and stevedores) be able to tell
at a glance whether these items are
open or closed.
2. Highlighting the locking levers on

twistlocks with fluorescent paint would
greatly assist personnel in identifying
operational mode.
3. Stowing heavy containers above lighter
ones will have an effect on local stack
stability and put unnecessary strains on
securing devices and deck fittings. Before
loading containers check and double
check that the stowage plan conforms to
industry best practice, with no heavies
over lights.
29
CASE 11
Hatch Hazards
Narrative 1
A bulk carrier had completed discharging
cargo alongside and the final hatch cover was
to be closed. Two ABs were sweeping out
cargo residue from the trackways between the
side-rolling hatch covers and the cargo-hold
coaming when the bosun decided to remove
the securing pins in anticipation of closing the
hatches. He removed 3 of the 4 pins, but the
4th was stuck. He therefore applied hydraulic
power and moved the hatch cover slightly to
release the pin. He then instructed one of the
ABs to remove the 4th pin, which he did. Once
the final pin was clear, the bosun proceeded to
close the hatch. As he did so, the other AB,
who was still in the trackway, was crushed
between the hatch and the coaming (see
figure). He sustained fatal crush injuries.
The accident was caused by a casual attitude to
safety on board and a failure to appreciate the
dangers involved. Not only did the bosun fail
to check that all personnel were clear of the
hatch before closing it, but also he removed

the securing pins and applied hydraulic power
while the ABs were in a vulnerable position.
However, the ABs were willing to continue
working in a vulnerable position once
hydraulic power had been applied, indicating
that poor practices had been the norm for
some time.
Narrative 2
A bulk carrier was in the process of discharging
a cargo of soya beans from number 5 hold. The
second officer and two ABs were on deck. It
had been raining, so the side opening hatch
covers were closed but not secured. The rain
abated, so the second officer climbed on to the
hatch covers and removed the central bolt. He
asked the AB at the hatch controls which hatch
he wanted to open first, to which the response
was, starboard. The second officer gave the
order to open the hatch, while he stood on the
port hatch cover.
Indication of the casualtys position
30
CASE 11
He stayed on the hatch cover while he

assessed if it was likely to rain again. He then
moved to the forward end of the port hatch
cover to climb down. The AB at the hatch
controls was at the aft end of the hatch and
was not able to see the second officer climbing
down. As the second officer placed his left foot
on the hatch cover runner, the AB started to
open the port hatch, even though he had
The Lessons
1. When regularly operating hatch covers,
it is easy to become complacent about the
hazards, and for bad practice to creep in,
especially if there are time pressures to
get the ship to sea. Review the
procedures on your vessel to ensure that
measures exist to ensure personnel are
clear of the danger areas before hatch
cover securing pins or locks are released
and power applied.
received no instruction to do so. The hatch

roller ran over the second officers left foot as
he climbed down, crushing his toes. He was
wearing safety boots at the time.
The second officer was evacuated to hospital
where, sadly, all the toes on his left foot had to
be amputated and a skin graft applied.
2. Ensure there are clear communications

and that all involved know what is going
to happen. Making assumptions that
personnel are clear is dangerous; positive
checks must be made before moving
hatch covers.
31
CASE 12
Blocked Sea Suction Prevents

Engine Room Flood
Narrative
A small ro-ro ferry was used to operate a daytime only service.
Once the ferry was tied up for the night, the local crew secured her
and left for home.
It had become normal practice for the engineers to leave the ships
side valves open. This was to expedite preparations for sea, which
were carried out early each morning. The crew did not consider
this to be an issue because there had never been a flood as a result
of this routine. Little did the crew realise how close they came to a
disaster.
During early morning, routine, pre-sailing checks the engineer was
stunned by what he discovered. He found that the starboard main
engine bilge eductor system valve, which was out of sight, behind
the engine, had completely sheared off from the sea water suction
pipe. It was very fortunate that the pipe was completely blocked by
a plug of corrosion products which prevented the engine room
being completely open to the sea.
On investigation it was found that the pipe between the valve and
the ships side was so badly corroded that the engine vibration had
finally caused it to part (figure).
Vessels eductor system valve
32
CASE 12
The Lessons
It is not very often that the by-products of
corrosion save the day. However, had it not
been for the extensive corrosion blocking the
pipe, the engine room would have suffered
severe flooding damage when the pipe parted,
and would have been out of service for a
long time. Had the bilge ejection system been
checked periodically, the blockage, and
therefore the corrosion, would probably have
been spotted and attended to.
General guidance on the prevention of
flooding can be found at MGN 165(F)
Fishing Vessels Risk of Flooding.
Although directed towards the fishing
industry, the MGN nevertheless provides
examples of best practice.
1. It is always good engineering practice to

close ship side valves whenever possible
and so reduce the expensive risk of backflooding from sea. This also applies to
non-return valves because debris often
accumulates in the valve body,
preventing the non-return action.
2. Have you a procedure for checking the
functionality of systems that are not in
regular use? In this case, the bilge
ejection system would have been
ineffective and could not have been used
to pump out bilge water in an emergency.
3. Do not forget to survey pipe systems that
are not in regular use they will be
subject to the risk of corrosion and pipe
wall thinning, leading to eventual
perforation and flooding.
The following lessons can be drawn from

this near miss incident:
33
CASE 13
I See No Ships
Converted fishing vessel shortly before sinking
Narrative
A 2137gt chemical tanker, fully loaded by
volume with a cargo of Cyclo Hexane UN 1145,
departed from a north east coast port. Once
the pilot had disembarked and the vessel was
in open water, the master handed over the
watch to the chief officer. It was dark, and a
lookout was present on the bridge.
A 13.28m converted fishing vessel, now a
commercially coded pleasure yacht, had
departed from an east coast harbour with the
skipper and two crew members on board. The
planned passage took the vessel 37 miles
north, to its home port. The skipper had
obtained a weather forecast from the
coastguard prior to the late afternoon
departure. The forecast was for a north
westerly wind veering to the north, force 4 to
5, sea state slight. The predominant swell was
also northerly, the prevailing direction on this
stretch of coastline.
At about 2140, the OOW on the chemical
tanker observed a red side light and a single
34
masthead light of another vessel about 20 off

the starboard bow, at a range of approximately
4 miles. The OOW knew that he had to make a
planned 21 alteration of course to starboard
10 minutes later and, because the ARPA radars
would not acquire the contact, he decided that
the planned alteration would also suffice as a
collision avoidance manoeuvre. There had
been no successful attempt to determine
whether a risk of collision existed, and what
the effect of the planned manoeuvre would be.
Once steady on the new course, and still
observing the red sidelight of the other vessel,
the OOW assessed by eye that its closest point of
approach was about 0.5 mile down the port side.
While the OOW attempted to acquire the contact
on the X and S band ARPA displays, the pleasure
yacht made a 20 alteration of course to port. By
the time the OOW looked up, a green sidelight
was showing on the port side of the chemical
tanker, and collision was assessed as imminent.
The OOW engaged hand steering, applied
maximum starboard rudder, and sounded a long
blast on the ships whistle. The pleasure yacht
struck the chemical tanker amidships.
CASE 13
After leaving port, the pleasure yacht had

headed into the wind and swell. Ship motion
took its toll on the crew, who took turns to
steer by hand and maintain a lookout. The
ships position was monitored by GPS
waypoint navigation and the helmsman
maintained a distance of 1.5 to 2 miles off the
coast using the radar range marker. Although
the skipper was on watch prior to the incident,
he could not recall seeing a vessel ahead,
either visually or on the radar prior to altering
course. He consequently altered 20 to port to
The Lessons
1. The chemical tanker did not properly
establish whether a risk of collision
existed. The OOW had two options
available to him:
To take a series of compass bearings, or
Acquire the contact on ARPA and
assess the results.
Once he had properly determined
whether a risk of collision existed, an
appropriate and measured response could
have been taken.
2. Both the OOW and the lookout on the
chemical tanker identified the lights of
the pleasure yacht. As the situation
changed, neither kept the other informed
of developments. The lookout could have
told the OOW that the aspect and colour
of the lights had changed, and he could
pass through the waypoint, and on to the final

destination only 4 miles away. Shortly
afterwards, the collision with the chemical
tanker occurred.
The chemical tanker stood by the stricken
yacht, which transmitted a GMDSS distress
signal. The yacht was taking on water. As a
precautionary measure, the crew inflated a
liferaft, but in the event were safely rescued by
the local lifeboat. The vessel foundered about
2 hours after the initial collision.
also have been tasked to try and acquire

the contact on the S band radar display.
Further, in the absence of any
information, the OOW could have
adopted hand steering earlier until the
situation clarified.
The key figures employed on the bridge
are often referred to as the bridge team.
In this case, the absence of team work
was evident.
3. The skipper of the pleasure yacht did not
identify the presence of the chemical
tanker until the collision occurred. The
lookout and radar watch were clearly
ineffective due, in part, to the crew
suffering from sea sickness. Before
setting sail on a small vessel, consider the
experience of the crew, the prevailing
weather and sea conditions, and the
possibility of the crew (including the
skipper!) becoming disabled due to
sickness.
35
CASE 14
Unsecured Electrical Fan Causes

Cabin Fire
Narrative
An oil tanker was carrying out a replenishment
of a smaller tanker while underway. The
weather conditions were good and it was a
calm, warm and pleasant day.
One of the ABs decided to take advantage of
the warm weather and take a dip in the
swimming pool. As he exited his cabin, he
decided to leave his electric, oscillating fan
running on a table, on slow speed, to keep his
cabin cool.
About 20 minutes later the AB returned to his
cabin. As he opened the door he was
immediately confronted by dense smoke. He
noticed that the fan had fallen to the deck. The
plastic fan motor casing was badly burnt (Figure
1) and this had caused the carpet to catch fire
(Figure 2). The AB immediately unplugged the
fan and fought the fire using a foam
extinguisher located in the adjacent alleyway.
In the meantime, the ships fire detection

system alarm sounded. The fire party were
called and quickly made their way to the cabin
area. On arrival, they found that the fire had
already been extinguished by the AB.
There are two possible explanations for the
cause of the fire:
The fan developed an electrical fault while
on the table, and this caused the plastic
casing to ignite. Once the casing had burnt
through, the metal fan dropped, toppled to
the deck and ignited the carpet.
The oscillations of the unsecured fan
caused it to move across the table and fall
to the deck. Once on the carpet, the fan
blades could not rotate because the front
guard was missing, and this caused the fan
motor to overload and overheat. This, in
turn, led to the casing igniting and then the
carpet.
Figure 1
36
CASE 14
Figure 2
The ships managers were conscious of the fire

risk posed by electrical equipment, so
operated a policy of recording all of its portable
and individuals private electrical equipment.
The equipment listed on the register was
periodically tested and results recorded.
The Lessons
Although the AB did not raise the alarm, he
did respond quickly and instinctively to the
fire situation. He was aware of the need to
isolate the fan from the electrical supply
before tackling the fire with the foam
extinguisher. His calm and prompt action
certainly prevented the fire from spreading
and the risk it would have posed to the crew.
this accident:
1. If it is not possible to isolate electrical
equipment, it is far safer to use a CO2
rather than a foam extinguisher to fight
an electrical fire.
2. Do not forget the importance of the loud
vocal alarm when discovering a fire. The
loud shout of Fire, Fire, Fire focuses
people on the emergency situation.
The subsequent ships investigation found that

the ABs fan was not on the register, although
while its history was unknown, it did have an
electrical test sticker on it, dated 2 years
previously.
3. It is good practice to record and

periodically test the ships portable and
individuals private electrical equipment.
Do not forget to update the register
when crew join and leave the ship.
4. Equipment with the potential to cause
fire or injury should be secured to
prevent unintended movement. In this
case, the fan could have been secured to
the table, another work surface or a
shelf.
5. Do ensure that rotating machinery is
guarded to prevent injury. Although the
fan was a small piece of equipment, the
missing front guard should have been
replaced. It is all too easy to
inadvertently place a hand or finger
among the rotating blades.
37
CASE 15
Pretty But Dangerous

Narrative
What started out as a routine onboard activity
on a fine and sunny day ended in a painful
experience for a seasoned bosun.
The vessel had to shift to another berth across
the river to complete loading operations. The
bosun was assisted by two other seamen at the
aft mooring station who were told to let go the
starboard stern and spring lines and heave
them in. The bosun then proceeded to the
port stern line, which was made fast to the
capstan with five turns and backed up with
additional turns around the bits. He removed
the turns from the bits and then three turns
from around the capstan. It was his intention
to surge the rope while heaving so that just
enough slack was given for the linesman on
the quay to cast off, and the rope could then be
retrieved smartly to keep the propellers clear.
The Lessons
1. The winch or capstan drum/rope contact
area should never be painted, because in
addition to causing excess friction it can
damage the mooring ropes. It might be
pretty, but it is also dangerous.
38
After signalling to the linesman to keep his

hands clear, the bosun set the capstan to haul
with his left hand and attempted to surge the
mooring rope using his other hand. The
capstan initially tightened the mooring rope,
causing tension to be put on it. It then
unexpectedly surged, sharply jerking the
bosuns right wrist.
Subsequent investigation of the incident
revealed that the capstan had been painted
about 4 days prior to the incident, and that
paint applied to the drum/rope contact area
had not fully cured. This paint caused the
mooring rope to stick on the drum when the
capstan was operated, causing it to come
under tension instead of slacking off.
The bosun was sent ashore for medical
attention and was lucky to escape major
injuries.
2. Making mooring ropes fast on drum ends

on capstans is contrary to good mooring
practices and was, in this case, also
contrary to company procedures.
3. Mooring ropes should not be surged on
moving capstans or winch drums. The
machinery should be stopped, and then
the rope surged, if necessary.
CASE 16
Hurry Aground
Narrative
A 154m bulk carrier was leaving a port. The
master, who held a PEC for the port, the chief
mate, helmsman and cadet were on the bridge.
The ship was ready to leave some 20 minutes
ahead of the scheduled sailing time, and the
master decided to leave. The mooring gang
was already in attendance so permission to sail
was obtained from the VTS service for the
port, moorings were let go and the ship left
her berth.
The bridge team on the bulk carrier was
informed by VTS that there was a ship inbound
to the port and that a small barge was also in
the approach channel. Some time later, the
inbound ship was heard communicating with
the barge on VHF radio, telling her to keep to
the south of the channel and out of the way of
the traffic. As the bulk carrier approached the
final bend in the channel before the sea reach,

speed was reduced and course altered to allow
the inbound ship to clear the bend. Once the
inbound ship was clear, the bulk carrier again
increased speed and altered course to regain
her original track.
As the bulk carrier came round the bend in the
river, she was confronted by the barge which
was apparently in the centre of the channel. The
master of the bulk carrier decided that his only
course of action was to alter hard-to-port to
clear the barge. This he managed to do, but the
alteration resulted in the bulk carrier leaving
the navigable channel and running aground.
The vessel was refloated on the next high tide,
without tug assistance, and continued to her
next port, where an underwater survey
confirmed that, luckily, no damage had been
sustained.
Barge
Outbound ship
Inbound ship
Figure 1: Shore based radar plot
39
CASE 16
Outbound ship
Barge having reversed
Inbound ship
Figure 2: Shore based radar plot
40
CASE 16
The Lessons
1. The master of the bulk carrier was not
fully aware of where other ships using
the navigable channel were, even though
he had been monitoring the VTS
broadcasts. He had monitored VHF
communications which had warned the
barge to remain south of the channel and
clear of traffic, and yet did not appear to
recognise that the barge would be
encountered shortly after rounding the
bend in the channel. Had he done so, he
would have been better placed to make
an informed decision when considering
his options for avoiding a collision.
2. The master of the barge was fully aware
of the presence of outbound vessels that
were constrained by their draught and
could only navigate in the marked
channel. Notwithstanding this fact, he
chose to navigate the barge along the
south side of the channel (i.e. the port
side of the channel for inbound vessels)
even though this was likely to risk a
close encounter with outbound traffic.

While there was sufficient depth of
water either side of the marked channel
for the barge to safely navigate in, the
master was of the opinion that there was
also sufficient room within the channel
for any outbound vessel to safely pass
the barge.
3. When the master on the bulk carrier
finally realised the barge lay directly
ahead, there was very little time to assess
the situation. The initial action taken
had the desired effect of missing the
barge, but resulted in the grounding. Had
there been more time to assess the
situation, it is probable that by
continuing the turn to starboard the bulk
carrier would have still avoided a
collision with the barge but remain in the
navigable channel.
4. Had the master utilized those on the
bridge as a bridge team, it is likely that
the danger would have been recognised
earlier, and the accident avoided.
41
Part 2 Fishing Vessels

It gives me great
pleasure to provide
this introduction to
the fishing vessels
section of the MAIB
Safety Digest 3/2007.
I have been involved
with safety since the
inception of the
National Federation
of Fishermens
Organisations in 1977, when the government
of the day adopted the Holland Martin Report
on The Safety of Fishing Vessels, which
included deep sea trawlers and inshore vessels
of 40 feet and over. The fishing industry and
the government department worked very hard
to bridge the gap between large company
owned vessels and skipper owned vessels to
implement the new safety rules. Problems
arose. Fishermen viewed the department with
suspicion, suspecting they were being
manipulated out of business. Surveyors were
not familiar with the great variety of fishing
vessels and their working practices. The
majority of the fishing vessels were of wooden
construction, the surveyors were more used to
large steel vessels. Consistency was a difficulty;
one surveyor could interpret the rules
differently to another. However, problems
were eventually resolved, standards of fishing
vessel safety improved over the years, until
today all fishing vessels are subject to code
inspections and surveys.
The make up of the fishing fleets has altered
dramatically since the early days of the Fishing
Industry Safety Group. In 2005, from a total of
6341 UK registered commercial fishing vessels,
over 85% were under 16.5 metres registered
length and over 98% of the fleet had engine
42
power less than 750 kilowatts. Consequently

most fishermen are required only to undertake
a mandatory basic training in Survival, Fire
Fighting, First Aid and Safety Awareness. It is
only when a vessel is over 16.5 metres that
skippers tickets and engineering certificates
are required. However, the mandatory courses
do raise the fishermans awareness of the
dangers of his work, and the vast majority of
fishermen are diligent in all aspects of their
fishing operations. Fishermen are by nature
very independent, and although they have
often resented what they see as interference
in their way of life, they are now accepting of
the necessity of compliance with fishing vessel
safety regulations.
Making the fishing industry a safer occupation
is essential, and training and education can
make a significant contribution. Attending
training courses other than the mandatory
ones can sometimes be costly and
inconvenient for the self employed fisherman,
and if there is a charge for the training this is a
disincentive. Nevertheless, the short courses,
i.e. watchkeeping, radar, engineering, enable
fishermen to build up their knowledge and
skills. FIFG funding has been available, but
unfortunately the funding programme is
drawing to a close. The fishing industry should
be on a par with the merchant service which
has funding available year on year.
The Sea Fish Industry Authority provides the
UK fishing industry with a network of Group
Training Associations, and together with the
three training centres, Banff and Buchan
College, The Mallaig Marine Training Centre
and the Whitby and District Fishing Industry
Training School, training at port level is readily
available. Courses include a 5-day watchkeeping
course and a 1-day stability awareness course.
The Marine Accident Investigation Branch, in

its role of safety at sea, investigates incidents
and makes recommendations. The MAIB
teases out the root causes of the incidents and
raises fishermens awareness of the
consequences of neglect, fatigue or even
carelessness.
the loss of life which can occur. I would urge

fishermen to continue to read the Safety
Digest, to continue to learn from the reports,
and to commend the Digest to their fishing
colleagues.
Safe fishing!
The six fishing industry reports in this issue of

MAIBs Safety Digest detail some of the
dangers of trawling and potting and, tragically,
GH Traves, MBE
George Traves began his career at sea working as a wireless operator on deep sea trawlers operating out of
Hull and Grimsby. For over 40 years he has worked as a skipper/owner of fishing vessels and was awarded
an MBE in 1990 for his services to fishing. George was a founder member of the National Federation of
Fishermens Organisation, was Chairman between 1987 and 1989 and President between 1989 and 1991
representing the organisation on FISG and SFIA training. He is a MAFF appointee to the North Eastern Sea
Fisheries Committee (Chairman) and is Chairman of the Association of Sea Fisheries Committees.
43
CASE 17
Too Much Up Top!
Photograph showing the vessels point of suspension for the dog rope and cod end
Narrative
A 10m GRP trawler was 3 hours into a tow
when she slowed down. It was felt that a trawl
door had possibly fallen on its back, but when
attempts to rectify this showed no increase in
the vessels speed, it left the crew with little
option other than to haul the gear.
As the trawl wires were hove in, it became
apparent that there was an abnormal weight
in, or on, the gear. Because of the strain on the
winch, it took some time to ease the doors up
to the gallows but, eventually, they were
retrieved, secured alongside and unfastened
from the trawl warps. The sweeps were
transferred from the warp ends onto the net
drum, and as the net built up on the drum the
hydraulic relief valve started to lift, radically
reducing the speed of hauling. In an attempt
to take the strain off the net drum the dog
44
rope, which led to the cod end, was taken up

over the Gilson gantry and onto the winch
drum ends. The crew were still unable to
establish the cause of the weight in the net
although it was not unusual for boulders to
become caught in the cod end in this
particular region.
By systematically hauling on the dog rope and
winding slack netting onto the drum, recovery
of the net continued. Until then, the boat had
been idling at dead slow ahead before the
wind. To further take strain off the gear, the
skipper put the vessel into neutral. The vessel
then started to fall off the wind and, as this
happened, the weight of the net suspended
from the high gantry affected the vessels
transverse stability, resulting in a dramatic list.
This was apparent only when starboard deck
edge immersion occurred and water was
building up on deck.
CASE 17
Recognising their perilous situation, the crew

launched their liferaft as the boat rolled over,
giving no time to transmit a distress or don
lifejackets. As the vessel lay capsized, the two
crewmen untied the liferaft painter before
getting into the raft; they were unaware that
there was a knife inside the raft specifically for
cutting the painter. Fortunately, the vessels
EPIRB floated free as the vessel sank, and its
transmissions alerted SAR services to a
possible emergency.
The Lessons
1. Small trawlers seldom have the ability, or
stability, to handle excessive weights. In
these situations serious consideration
should be given to jettisoning the gear
and obtaining help from a larger, more
able vessel to retrieve it later.
2. The danger of lifting/hauling from high
points cannot be ignored on any vessel.
Weights suspended from heights
seriously compromise stability, as do fish
in hoppers above deck level. Operators
should take all necessary steps to reduce
top weight as much as possible and keep
the vessel in a stable condition.
3. When trawling on hard or stony ground
operators should give consideration to
fitting their nets with stone traps and flip
up ropes. These provide both safety and
economic benefits by reducing the
chances of boulders finding their way
into the cod end. Information on these
can be obtained from the SFIA (Sea Fish
Industry Authority).
Once in the raft, the two men dried it out and

checked the equipment. Although no potential
rescuers were in the area, the skipper let off
one of their three red pinpoint flares to see if
they worked. An hour later, the crew were
rescued by a passing container ship whose
watchkeeper spotted their second pinpoint
flare.
The survivors were transferred to an RNLI
lifeboat and returned to shore, uninjured.
4. The crew had not undertaken the

mandatory Sea Survival course. Had
they done so, they would not have
jeopardised their survival by trying to
untie the painter while in the water.
Instead, they would have known that a
knife was available on board the raft for
this specific purpose. This same course
also trains participants on the
appropriate use of location aids such as
pinpoint flares; these are held in the
hand and can only be seen within the
visible horizon. Using them when no
potential rescuer is to hand is a waste of
valuable resources
5. Vessels of this size are not required by
regulation to carry either liferafts or
EPIRBs. Undoubtedly these items saved
this crews lives; all owners, regardless of
their vessels size, should give serious
consideration to carrying such
equipment, which in many cases is
provided free of charge under
Government funded initiatives.
45
CASE 18
Not Dressed For The Job
Photograph demonstrating the vessels lifting area and height of rails
Narrative
An injured fisherman was being airlifted in gale
force conditions by a SAR helicopter when it
became necessary for the helicopter crew to
guillotine the winch wire because the casualty
was being dragged violently towards the boats
rail. This resulted in the fisherman striking the
rail hard and going overboard, in darkness,
without a lifejacket. Fortunately the man was
wearing a flotation suit and, because he was
conscious, he was able to float face-up with the
aid of the suit.
The SAR helicopter had no secondary winch
46
on board and was therefore unable to retrieve

the casualty from the sea. It was, however, able
to lower a flotation aid on the end of a spare
highline to the casualty and pinpoint his
position for the fishing vessel. The fishing
vessel skipper skilfully manoeuvred the boat
alongside the casualty to enable his colleagues
to recover him on board.
The fishing vessels crew administered first-aid
treatment to the casualty while they steamed
ashore at full speed. Once in the lee of the
land, the casualty was transferred to an allweather lifeboat and then onwards to hospital
by waiting ambulance.
CASE 18
The Lessons
1. Helicopter rescue is fraught with danger.
This case clearly illustrates the
importance of wearing both a lifejacket
and a flotation suit (or immersion suit)
during helicopter transfers. Although a
flotation suit will provide protection
from the cold, and will keep the wearer
afloat, there is no guarantee that it will
also float the wearer face-up. A
lifejacket will turn the person onto their
back and ensure the nose and mouth are
above the water even if they are
unconscious.
2. The skipper manoeuvred his vessel
skilfully alongside the casualty and gave
him a slight lee as he was dragged from
the sea by two of his crewmates hanging
out over the bulwarks. The crew were
wearing neither flotation suits nor
lifejackets, simply because they did not
expect the airlift to go wrong. The
skipper could quite easily have ended up
with more men to rescue and, without
being suitably dressed they would have

had little chance of survival. Always be
prepared for the unexpected, and do all
that is possible to minimise risks; a preemptive risk assessment and crew
discussion on MOB recovery, before it is
ever needed, will help prepare the crew
for the day it happens.
3. This vessel carried mandatory type
approved lifejackets which, although
ideal for abandonment, are impossible to
wear on a regular basis and would have
been extremely cumbersome during this
rescue. Daily wear self-inflating
lifejackets are already in use on many
fishing vessels as an addition to the
abandonment type. These have been
proven as suitable for regular wear and
are ideal for deck crew during most
operations. Fishing vessel operators
should give serious thought to obtaining
and promoting daily wear lifejackets,
thus maximising the protection afforded
to their crewmen when the unexpected
happens.
47
CASE 19
Shrimp Boiler Lights up the

Engine Room
Boiler copper
Flame
Fuel
pump
Corrugated air supply pipe
Fuel
Fuel
regulator isolating
valve
valve
Figure 1
Narrative
The skipper and 2 crew of a 9.9 metre beam
trawler had just completed an uneventful
passage to nearby shrimp fishing grounds. The
weather was pleasant, and after shooting away
the gear the crew relaxed in the wheelhouse,
looking forward to the days fishing.
Meanwhile, the skipper lit the diesel-fuelled
shrimp boiler, located on the main deck, just
forward of the wheelhouse. The purpose of
doing this was to bring the water up to
temperature ready for the first haul.
It was a very basic boiler: an electrically driven
blower supplied air through a flexible, plastic
corrugated hose, and a small pump delivered
the diesel fuel (Figure 1). Both the blower and
fuel pump were located in the engine room
and were switched on from the wheelhouse by
48
two identical switches fitted within a common

electrical box.
The boiler was so basic that operating
instructions were considered unnecessary.
Once the water had boiled, the skipper
thought that he had switched off the fuel
pump, leaving the air blower running to allow
any unburned fuel to burn off, and to purge
the boiler furnace.
The boat continued its towing course as
normal but normality was about to end!
Five minutes later, the skipper noticed a
flickering light on deck, in the vicinity of the
boiler. He raised the alarm, grabbed a fire
extinguisher from the wheelhouse and made
CASE 19
Figure 2: Shrimp boiler after the fire, with melted air supply pipe
his way forward to attack the fire with one of

the crew carrying the deck wash hose. The fire
was quickly extinguished, but it had melted
the boilers plastic corrugated air supply pipe
(Figure 2).
Aware that the air supply pipe led from the
engine room, the skipper opened the engine
room hatch located in the wheelhouse. Once
in the engine room, he assessed that the seat
of the fire was in the vicinity of the blower, so
he discharged the remains of his extinguisher
in that direction. The smoke by that time was
black and very thick and acrid, forcing him to
retreat.
Back in the wheelhouse, the skipper closed
the engine room hatch and instructed the
crew to haul in the fishing gear and don
their lifejackets. Unfortunately, only two of
the three lifejackets could be found because

one was hidden under the large amount of
surplus equipment on board. Soon after
calling the coastguard, the skipper
attempted to stop the engine using the
remote fuel pump stop in the wheelhouse.
But this was unsuccessful because the fuel
pump linkage had broken. The engine
continued to run, at idling speed.
A short time later, the local RNLI lifeboat
arrived on scene and the crew transferred
from the vessel. The trawler was towed back to
port and was met by the emergency services.
The Fire and Rescue Service extinguished a
small carbonaceous fire in the engine room.
Meanwhile, the skipper was transferred to
hospital for treatment following smoke
inhalation. He was released a short time later.
49
CASE 19
The Lessons
On investigation, it was found that the small
bore ventilation air pipes to the engine room
were completely blocked by rust flakes. This
meant that the air supply for the engine had
to come either through the engine room
hatch which was shut tight or back
through the boiler air blower pipe work.
3. Fully investigate systems that are not

operating correctly in this case the
engine had been running rough for
some time and this would have been due
to air supply starvation.
In attempting to shut down the boiler, it is

probable that the skipper inadvertently
switched off the air blower. This caused the
engine to draw air through the blower
system, and the boiler flame to be drawn
into, and ignite, the plastic section of pipe
work. The flames from the burning plastic
would have been drawn into the engine
room, through the blower. Electrical cable
insulation then caught fire, dropped onto
foam and plastic materials left on the floor
plates, and caused these to ignite also.
4. Although the boiler was of a basic

design, it caused a potentially serious fire
because it was most likely not shut down
correctly; a risk assessment should have
identified the need for safe operating
instructions and clearly identified
operating switches.

this accident:
6. Remove unnecessary gear: it can cause

blockage to pumping systems, become a
fire hazard, prevent access to safety
equipment, and can impede escape in the
event of an emergency.
1. Do not neglect maintenance of less

obvious systems such as engine room
ventilation. Out of sight should not
mean out of mind!
50
2. Engine remote shut-down systems need

to be maintained and tested on a regular
basis.
5. Where there is a risk of incorrect start

up or shut-down sequences, consider
fitting interlocks to prevent
maloperation.
CASE 20
Spot the Difference
Narrative
Do you notice any differences between the
two photographs? Concentrate on the ramp
at the centre of the vessels stern and imagine
lines of pots being shot out through this
opening. This is a common way of laying a line
of pots and involves them being carefully
stowed on deck, with the associated ropes, in
such a manner that they are free to pass
through the stern opening, without assistance
from the crew, once the process has
commenced.
You will, by now, have realised that the two
photographs are in fact the same, but please
read on, as two similar accidents occurred
within days of one another, in different parts of
the country. However, although they had the
same cause, the accidents had tragically
different outcomes.
The Lessons
1. When risk assessing any operation at
sea, consider the question What if a
person does something they shouldnt?
If you cannot ensure their safety at all
times, which on the deck of a fishing
vessel is unlikely, then you must
consider the last resort the provision of
suitable Personal Protective Equipment:
in this case a lifejacket and suitable
clothing, to make the operation as safe as
reasonably practicable.
The two boats were both laying fishing pots in

strong winds. In both accidents a crew
members foot became caught in the pot ropes
as they paid out, and they were pulled over the
stern of their vessel. Tragically, one of the men
lost his life; happily the other was rescued and,
after being airlifted to hospital, made a full
recovery.
The man who lost his life was a young
fisherman with a few years experience; the
man who was rescued had been fishing for
over 50 years. Neither of the men was wearing
a lifejacket.
The operation on both boats had been risk
assessed to ensure that the crew remained well
clear of the rope as it paid out, and both men
were trained and experienced in this type of
fishing. However, in each case, the fishermen
became trapped in the rope and were quickly
dragged over the side and into the sea.
2. The wearing of a lifejacket when

working on deck should be considered
an essential safety control measure. It is
noteworthy that, after 50 years as a
fisherman, the survivors first priority
was to purchase a suitable lifejacket
before he returned to sea. He now
intends to wear this at all appropriate
times in the future. He learnt his lesson
the hard way you now have the
opportunity to learn yours from his
lucky escape and from the tragic death of
a young fisherman.
51
CASE 21
Trim For Safety,

Not For Catching Fish
Narrative
A 20m trawler was returning to port after 6
days of poor fishing, during which time she
had used all the fuel in her forward tanks and
most of her fresh water from the tank in her
forepeak. Due to the poor fishing experienced
over the 6 days, there was little weight in the
forward fish room to counteract the effect of a
stern trim which had developed as fuel and
water were consumed. Additionally, in normal
operating conditions, the vessel had very little
freeboard aft, and had been granted a 20% aft
freeboard reduction due to her age. The
induced stern trim and very low freeboard
meant that the vessels aft deck was almost
constantly awash as she rolled in the force 6
seas with the wind on her starboard bow.
The skipper became aware of a starboard list
developing, so went to investigate. The cause
of the list was traced to an obsolete fuel tank in
52
the vessels transom, which was gradually

filling with seawater (it was a requirement of
the vessels stability criteria that the aft fuel
tanks remained void at all times). The skipper
was not unduly alarmed as he knew the water
was contained within the tank. Furthermore,
he had encountered water in the tank several
months previously due to a crack in the deck;
on that occasion the vessel made shore safely,
whereupon the water was drained from the
tank, pumped overboard and the deck
repaired.
As the list increased, the skipper attempted to
drain the water from the tank into the steering
flat and pump it overboard. Unfortunately, the
main bilge pump failed to function, possibly
due to it drawing air through a perforated
suction pipe, or debris in the valve chest. An
emergency electrical submersible pump was
rigged to pump the water, but unfortunately
this burned out soon after being started,
CASE 21
leaving the skipper with no option but to stop

draining water from the tank and call the
coastguard for assistance.
The vessel continued steaming ashore,
awaiting the arrival of a salvage pump from the
SAR services, trimming even further by the
stern and listing more to starboard until the aft
deck became totally submerged to the extent
that the bulwark rail was dipping in the sea.
Unfortunately, the vessels engine room vents,
positioned on the starboard side of an aft
facing bulkhead, were open.
By the time the skipper realised this additional
danger, it was too late to put a man onto the
exposed deck to close the vent flaps. As the
vessel trimmed further by the stern, and listed
to starboard, seawater found its way into these
vents and drained down below decks.
The wind decreased and the sea state

improved as the vessel got closer to shore.
Consequently the vessel stopped rolling and
remained listed on her starboard side, and this
alerted the skipper to the angle of loll
developing. Aware of the worsening situation,
the skipper ensured all his crew were in
lifejackets and instructed them to prepare a
liferaft. He stopped the vessel, which
immediately settled on her side, allowing the
crew to step into the liferaft, taking with them
their EPIRB and portable VHF radio. Within
minutes of abandoning, the crew were
winched to safety by a SAR helicopter, which
had been summoned earlier by the
coastguards. Soon afterwards, the vessel sank
by the stern.
53
CASE 21
The Lessons
1. The skipper preferred to use fuel from
the forward tanks before the aft tanks
and thus keep the vessel trimmed by the
stern to improve towing capability. This
was contrary to the vessels stability
criteria, which required the aft tanks to
be used first to maintain adequate
freeboard aft. On the day in question,
this was further aggravated by poor
fishing and lack of weight in the fish
room to compensate for the stern trim.
Once the aft void started to fill with
water, the vessels stability was totally
compromised, leading to further stern
trim and list.
It is essential that operators give due
credence to stability criteria at all times
and trim their vessels to maintain
optimum vessel safety (not optimum fish
catching potential). The SFIA offers a 1day Intermediate Fishing Vessel Stability
Awareness Course, which is currently
offered free of charge by Group Training
Associations throughout the UK. All
fishermen should take advantage of this
highly recommended course, which gives
sound practical advice and hands on
interaction on stability matters.
2. Having successfully overcome a similar
incident previously, the skipper might
not have appreciated the danger his
vessel was in. However, the conditions
were not exactly the same: the trim was
different, due to fuel consumption and
loading in the fish room; the void tank
might not have been completely full of
water; the weather conditions were
different, causing the vessel to roll
continuously with water over her decks.
54
So many variables at sea mean that

situations are seldom exactly the same
it is essential to be alert for subtle
changes that can make a big difference.
3. In view of the previous flooding
incident, where the vessel made shore
safely, the skipper was not initially
concerned about locating the source of
ingress. By the time it became apparent
that a serious situation had developed, it
was too late to put crew on the deck to
search for a cause and possibly prevent
further ingress. Even the most
insignificant damage should be
investigated as soon as possible to
prevent situations developing into
emergencies.
4. The open vent flaps allowed water to
find its way below decks and
subsequently sink the vessel. Seafarers
should be acutely aware of the dangers
of downflooding through openings, at all
times, and take all due precautions
where there is a possibility of this
happening. Had the vents been closed
early on during this emergency, it would
have prevented further ingress, and
allowed the crew a good margin of safety
until the SAR salvage pump arrived.
5. The crew abandoned safely with the
presence of mind to wear lifejackets and
to take their EPIRB and portable VHF
radio into the liferaft. Although on this
occasion they were rescued swiftly,
things could have been very different if
it had been dark or out of immediate
reach of SAR services. By using
available survival equipment, this crew
greatly enhanced their chances of a safe
rescue.
CASE 22
Two Sides of the Same Coin

For a collision to occur, both vessels must have applied the COLREGS incorrectly.
In this incident, the story is viewed from both sides.
Heads:
Narrative
A fishing vessel returned to port to land a
catch and to allow the skipper to attend a
doctors appointment. The usual mate had not
sailed with the boat on its last trip, but was to
take over as skipper on the next voyage.
asleep. The watch alarm was on and working,

but it could be reset without the crewman
having to leave the chair (see Figure 1). The
crewman described the watch alarm as a
snooze alarm, and used it as such to rouse
himself sufficiently to check the course before
returning to his slumbers.
Having landed the catch, collected new fish

boxes and loaded more ice and fuel, the
fishing vessel left the port at about 2300. It was
the new skippers intention to take the watch
until they reached the fishing grounds.
However, one of the crewmen insisted that it
was his turn to take the watch, so the skipper
turned in. The time was about 0200.
At about 0425, the crew of the fishing vessel

were woken by the impact of their vessel with
a much larger vessel. They all hurried to the
bridge and then, under the skippers direction,
checked the vessel for damage. The only
visible damage was a dent to the starboard
bow (see Figure 2). and some damage to the
cladding in the cabin.
The crewman had received 5 hours sleep the

previous morning, and had not slept for the 24
hours before that. He was very tired, and
sitting in the wheelhouse chair he soon fell
There were no injuries or pollution, and after

contacting the other vessel, and confirming
names and ports of registry, they returned to
port.
Watch alarm
cancel button
Figure 1: Vessels watch alarm cancel button, next to the crewman on watch
55
CASE 22
Figure 2: The damage to the tankers side
The Lessons
1. The watchkeeper was very tired, and
used the watch alarm in the same way as
he would use a clock snooze alarm. The
positioning of the reset button so close
to his chair meant that he did not have
to move from his chair to cancel the

alarm.
2. The skipper was not tired, having only
just joined the boat. It would have been
prudent for him to have remained on
watch, and to allow his severely fatigued
crew member to sleep.
Tails:
Narrative
A 57,000gt tanker was approaching the coast at
slow speed with the intention of anchoring at
0600. At 0352 the OOW noted a small contact
on his radar at 6 miles and about 30 on his
port bow. He acquired the target with the
ARPA, and the initial tracking information
showed the target to have a CPA of 1 mile to
port. Checking through the binoculars, the
OOW could see the lights of a small power
driven vessel showing a green sidelight,
making him the stand-on vessel in this
situation.
It was about this time that the relieving OOW
arrived on the bridge and the watch handover
commenced. This included information
concerning the small vessel, including the
initial ARPA data giving a CPA of 1 mile to port.
Once the handover was completed, and the
56
off-going OOW had left the bridge, the new

OOW checked the radar again and noted that
the small contact was now at 2 miles and had a
much reduced CPA. The time was 0415.
Concerned that the give way vessel was still
standing on, the OOW started to try and attract
the other vessels attention using the Aldis
lamp. When this had no effect, he sounded five
short blasts on the ships whistle, and shortly
afterwards started to alter course to starboard.
The whistle signal woke the master, who
arrived on the bridge to find the fishing vessel
alongside his starboard side but moving clear,
and his own ship swinging to starboard.
Ordering port helm to stop the swing, contact
was made with the small vessel via the VHF
radio. It was established that there were no
injuries or pollution, and the vessel continued
to her anchorage.
CASE 22
The Lessons
1. The small vessel was first noticed just
before watch handover, and the initial
ARPA data noted. The OOW then
concentrated on handing over the watch,
and the collision risk was not determined
again for approximately 20 minutes. By
this time the approaching vessel was at 2
miles, allowing little time to assess the
situation and to take avoiding action.
The handover of the watch took
precedence over the collision situation,
and the approach of the other vessel was
not monitored.
2. The initial CPA data is displayed after 1
minute of tracking. The most accurate
data is not available until the target has
been tracked for a full 3 minutes. In this
case, the OOW made his assessment of
the situation based on the initial
information, i.e. on scanty radar
information. Had the handover included
continually checking the latest ARPA
data of the approaching vessel, more
time would have been available to
properly assess the situation and take
effective action.
3. In this case, a lookout was on the bridge,

but took no part in the action. A lookout
is no use if he is not briefed and used as
an important part of the bridge team. In
this case, he could have played an
important role in monitoring this closing
contact while the OOWs were handing
over. OOWs must use their bridge teams
effectively if they are to remain safe.
4. When a large stand-on vessel is
approached by a substantially smaller
give-way vessel there is a point at which
a decision must be made that an
alteration of course is required. Often,
an alteration is needed at a greater
distance than the smaller vessel
considers necessary. The OOW is left
with a choice of standing on assuming
that the smaller give-way vessel is going
to alter course or taking avoiding
action, which may not, in fact, be
necessary due to the small vessels
imminent alteration. Following the rules
and taking early and substantial action
to keep well clear removes this
dilemma.
57
Part 3 Leisure Craft

The Royal Ocean
Racing Club (RORC)
was founded 80
years ago to
promote offshore
racing and the
development of
offshore racing
yachts. In that time,
we have seen massive developments in the
sport related to the design of racing yachts, the
materials from which they are built and the
standards and intensity to which they are
sailed. At the outset, there were no safety
regulations whatsoever! Now, there are
comprehensive international regulations, the
Offshore Special Regulations (OSR) published
by the International Sailing Federation (ISAF),
used on an international basis consistently by
the great majority of clubs organising offshore
races.
The OSR have been developed over the years
from experience (sometimes but rarely bitter)
from all around the world. As well as the
RORC, input also comes from experienced
yachtsmen, designers, race organisers and
others with specific knowledge and expertise.
Importantly the MAIBs reports and similar
reports from other national accident
investigation bodies and, increasingly,
International Standards also make significant
contributions. Conversely, the OSR were used
as a basis for many of the ISOs developed in
support of recreational craft safety e.g. ISO
15085 Man overboard prevention and
recovery, closely mirrors the OSR as does ISO
9650 1 dealing with offshore liferafts.
Safety is not an issue which can be dealt with
58
once. It is no good setting a set of regulations

in stone. Developments in design, novel
materials, technology, etc all influence safety.
Safety regulations therefore need continuous
review and updating. In the UK, contribution
to OSR is through the Royal Yachting
Association (RYA) largely based on
submissions from the RORCs own Special
Regulations Committee. This in turn receives
input from industry, from the RORCs
Technical Committee and others with specialist
knowledge and experience.
Safety is however far more than just standards
for the construction, fitout and equipping of
yachts. It is much more an attitude of mind.
The best, most comprehensive, most
rigorously enforced standards are useless if
individual boats pay lip service only. Or if,
despite properly equipped yachts, their crews
have no experience or knowledge of what to
do in an emergency or how to use the safety
equipment carried. Training and education are
thus of equal, or perhaps even greater,
importance. These two areas have probably
seen the most development in the last few
years.
This is of course all developed for and related
to racing. There is however no reason
whatsoever why cruising yachtsmen should
not use the Offshore Special Regulations as the
basis for their own safety standards. They are
encouraged to do so. The Regulations are
freely available and are published by both ISAF
and the RORC through their respective
websites. The RYA also publishes them
together with a comprehensive guide to safety
offshore.
But does all of this work? Is offshore racing

generally safe? Do we learn from accidents and
incidents? I think it does, that it is and that we
do. OSR are up to date; they do reflect modern
developments; they do incorporate changes
reflecting actual events at sea. Yachtsmen in
this context are open and communicative. So
when something happens, or somebody
comes across a good idea, it does get passed

into the system, and if on review is thought to
be generally applicable, it will get enshrined in
the regulations. But anything that can be done
to improve this process is to be applauded.
And that very definitely includes the work of
the MAIB.
Mike Urwin
Royal Ocean Racing Club Technical Director
Mike Urwin started sailing dinghies in the 1960s on the Thames and has progressed through small one
design keelboats to offshore racing including races such as the Fastnet Race. With a degree in mechanical
engineering, the early part of his career was spent carrying out research into hovercraft, flight simulators,
wave energy and wind energy. He has worked for the RORC for 14 years, initially as Technical Manager,
carrying responsibility for rating rules managed by the club, for advice to the club on safety related matters,
and the development of safety standards applied to boats competing in the clubs races. He is also an ISAF
International Judge and has officiated at races all around the world. He sits on various RORC and RYA
Committees, and also the ISO working party responsible for ISO 12217-2, the International Standard on
the stability and buoyancy of sailing boats.
59
CASE 23
Relaxing Canal Trip Ends in

Tragedy
Narrative
Two elderly couples and an elderly gentleman
hired a 20m narrowboat for a 1-week holiday.
They were all experienced at canal boating,
and although the single gentleman was
partially paralysed on his right-hand side, he
was still very able to helm a canal boat using
his left hand. When he was on the helm,
another member of the crew would operate
the throttle.
The party loaded their stores on to the hired
canal boat and then completed the safety
handover with a member of the boat yard staff.
The brief did not include any mention of
manoverboard action, or the use of the lifering, which was stored amidships on top of the
canal boat, and the party declined lifejackets
when offered. The boat had a semi-traditional
stern, which had no rail around the transom.
Two days into the holiday, the party were
heading downstream in a meandering section
of a river, which was flowing relatively quickly
due to recent rain. The weather was windy
with frequent heavy showers. The partially

paralysed gentleman was steering, standing on
the right side, helming with his left hand. One
of the ladies was sitting down operating the
throttle as needed.
The boat entered a particularly sharp righthand turn, and it became apparent that they
were not going to get round in one go. Astern
thrust was applied, but at the same time the
wind caught the bow and the boat gently
bumped into the left-hand bank of the river.
The stern, pushed by the current, edged closer
to the right-hand bank. At some point, the
gentleman on the tiller lost his footing and fell
off the right-hand side of the boat, into the
river, and drifted downstream. There was a cry
of man overboard, and the lady who had
been down below dived into the river to help.
She swam to the casualty and attempted to
keep his head above water. Meanwhile,
another gentleman climbed on top of the canal
boat to deploy the life-ring. The lanyard for the
life-ring was wrapped around it like a yo-yo.
Unfortunately, the life-ring lanyard didnt
unravel as it was thrown, resulting in the life-
Aft section of the narowboat
60
CASE 23
Demonstrating use of the life-ring
ring dropping into the water beside the boat.

The lanyard was pulled back in, and fully
unravelled, before a second attempt at a throw
was made. The throw did not reach the pair in
the water, the lady having now managed to
raise the casualtys head above water.
The gentleman on top of the canal boat then
untied the life-ring lanyard from its securing
point on the boat, and took the life-ring on to
the left-hand riverbank so that he could get
into a better position to throw it again. Two
farmers, who happened to be in a nearby field,
then helped in the rescue, throwing the life-
The Lessons
1. Make sure you have a manoverboard
procedure and that you know how to use
the safety equipment on your hire boat.
Throwing the life-ring correctly might
have ensured vital seconds were saved
while those in the water were trying to
remain afloat. It was very lucky, in this
case, that the rescuer who dived in did
not also perish.
ring and pulling the two people out of the

water. The emergency services were called and
CPR was administered to the elderly
gentleman.
The accident site was quite remote, so
paramedics arrived sometime later. The
gentleman was flown to hospital by helicopter,
where he was pronounced dead. After hospital
checks, the other four members were released
shortly afterwards, with only the lady who
entered the water having suffering mild
hypothermia.
party. Diving into a river to assist a weak

or non swimmer can put you at great
risk.
3. Ensure you hire a canal boat that is
suitable for your party. For example, you
may wish to consider:
a cruiser stern, which includes a rail
around the stern
easier access steps into cabin
2. Lifejackets, although often seen as

unnecessary on a canal boat, are really
essential if there are any non-swimmers
or physically impaired members in your
other child-friendly safety features if

travelling with children.
61
CASE 24
Lookout Above and

Below the Water
Dive vessel displaying the Alpha flag and the American Territories flag
Narrative
A 30 foot (9.1m) yacht was returning to the UK
at the end of a charter period, heading for a
breakwater entrance.
Eight divers from a diving vessel positioned
between the yacht and the breakwater
entrance had begun diving operations.
Weather conditions were good, the wind
northerly at 15 knots and visibility excellent.
The yacht was on a north easterly heading and
making good a speed of about 7 knots. It was
close hauled and intended to pass to the north
of a fishing boat that the skipper and his crew
had already identified.
Similarly, the diving vessel had identified the
yacht and assessed that it was heading for the
western breakwater entrance, and continued
monitoring diving operations; the skipper had
probably underestimated the speed made
good by the yacht.
The diving vessel was displaying clearly and
conspicuously the international code flag
Alpha, drawing attention to the fact that it was
engaged in diving operations and that vessels
62
were to keep well clear and pass at slow speed.

As a precautionary measure, the dive vessel
was also displaying the American Territories
flag, orange with a white diagonal stripe, which
had the same meaning as flag Alpha. Both flags
were 1m2 and were hoisted 2.5 metres above
deck level.
As the yacht approached, the divers released
two orange inflatable delayed surface marker
buoys, which indicated that they were
returning to the surface. Although the marker
buoys were shielded by the sails, the skipper
had identified two orange markers and
assumed that they were lobster pot marker
buoys. His intention was to clear them, all be it
at close range.
At no point prior to the incident had the
skipper positively identified the flags displayed
by the diving vessel. As a result, the yacht
passed over the top of the divers as they
surfaced, blissfully unaware of the diving
operations beneath them. Attempts by the
Coastguard and the dive vessel to contact the
yacht by VHF radio failed. Thankfully on this
occasion there were no injuries sustained by
any of the diving party.
CASE 24
The Lessons
1. A proper lookout must be maintained by
all vessels at all times. Remember that a
proper lookout means not only
identifying the presence of another
vessel, but also checking whether that
vessel is displaying lights, shapes or flag
signals that indicate it is engaged in
special operations.
2. Once the lookout has identified a shape
or flag, the skipper and the crew must be
familiar with its meaning. Specifically,
crews should actively familiarise

themselves with the International Code
of Signals.
3. Maintaining a good VHF listening watch
should be a standard part of every
vessels watchkeeping arrangements.
Owners spend significant sums of money
to purchase the latest hi-tec radio
equipment; unless the radio is turned on
and set to the correct frequencies, with
the volume control properly adjusted, it
is of little use to anyone.
63
CASE 25
How Safe is Your Safety Boat?
Stern view of the safety boat
Narrative
Two young boys were undertaking some
sailing training on a privately-owned Hobie Cat
dinghy in sheltered waters. Although they had
both previously sailed monohull dinghies
together, it was their first time in a Hobie Cat.
They therefore spent the morning with a
sailing coach, who helped them familiarise
themselves with the dinghy and then
accompanied them in a rigid inflatable (RIB)
safety boat from a nearby sail training centre
while they got used to the catamarans
characteristics.
The boys continued to sail the dinghy into the
afternoon. Although the coach had by now
64
been dropped off ashore, the safety boat, with

two qualified Royal Yachting Association (RYA)
safety boat handlers on board, continued to
keep station about 50 metres ahead of them.
All was well until the helm of the safety boat
noticed that one of the boys was in the water,
with the dinghy still upright.
As the safety boat manoeuvred close, it was
evident that the boy helming the dinghy was
struggling to recover the other boy, whose
trapeze harness was catching on the lip of the
dinghys starboard hull.
Given their ongoing difficulties, the crew of
the safety boat decided to help. The helmsman
placed the engine in neutral and the crewman
CASE 25
began to move across the boat to assist.

However, as he did so, he slipped and
inadvertently grabbed hold of the throttle to
prevent his fall. This forced the engine into
gear. Although he immediately pulled the kill
cord, the stern of the RIB momentarily slewed
to port before the engine stopped, and the
propeller struck the boys left leg, causing
serious injuries.
The Lessons
1. This accident highlights the dangers
posed by unprotected rotating propellers.
Had a propeller guard been fitted to the
safety boat, the terrible injuries would
probably have been prevented. Such
guards can lead to reduced acceleration,
speed and manoeuvrability of the boat;
however, the benefits of a safely guarded
propeller have to be given consideration
compared to the boats potential loss in
performance. It is suggested that the
requirement for a propeller guard will
depend on the exact role and particular
operational conditions that a safety boat
is likely to encounter.
2. The throttle on this particular RIB was
in a relatively exposed position, which
made it vulnerable to unintentional
operation, as so tragically demonstrated
here. Extra caution must be taken when
moving around the area where exposed
throttles are situated, particularly when
The safety boat crewman immediately called

for an ambulance using his mobile phone, and
the injured boy was recovered to the safety
boat and taken back to the sailing centre. The
boy was subsequently transferred to a local
hospital, where his left leg had to be
amputated above the knee.
people are nearby in the water.

Consideration should also be given to
the fitting of guards or rails around such
throttles to reduce the risk of accidental
operation.
3. If you are in a safety boat which is
attempting to recover a person from the
water, try to turn the boats bow towards
the person. This will shield them from
the propeller as much as possible. When
conditions allow, ideally the engine
should be shut down when approaching
somebody in the water. This will remove
the chance of its inadvertent operation.
4. Although both of the boys were familiar
with general manoverboard drills, they
had not practised these in this particular
design of dinghy. Had they done so, they
would probably have been aware of the
problem with the harness and the lip of
the hull, and found a way of overcoming
it.
65
APPENDIX A
Preliminary examinations started in the period 01/07/07 31/10/07
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.
Date of
Incident
Name of Vessel
Vessel Type
Flag
15/07/07
Kinghorn RNLI
RNLI lifeboat
UK
Acc. to person
28/07/07
Barlovento 2
Yacht
Unknown
Hull failure
Time Flies
Pleasure craft
(non-commercial)
UK
Hull failure
31/07/07
Size (gt)
Incident Type
Velazquez
Container
UK
7519.00
Smit Collingwood
Tug
UK
281
04/08/07
5m angling boat
Angling
UK
05/08/07
Stena Britannica
Ro-ro vehicle/passenger ferry
UK
55050.00
Hazardous incident
**/08/07
Ellie May
Fishing vessel
UK
7.23
Foundering (1 fatality)
08/08/07
MSC Columbia
Container
UK
51931.00
Acc. to person
(1 fatality)
11/08/07
Barbary Partridge
Small commercial motor

vessel
UK
20/08/07
Smit Cymyran
Survey/research
UK
105.00
Grounding
22/08/07
Buccaneer Elan 33
Small commercial sailing

vessel
UK
1.50
Acc. to person
(1 fatality)
03/09/07
Apollo
Fishing vessel stern trawler
UK
246.00
Acc. to person
(1 fatality)
07/09/07
Fingal
General cargo single deck
Netherlands,
Antilles & Aruba
1409.00
Grounding
2/10/07
Shayne
Angling vessel
UK
Unk
Flooding/
Foundering
(2 fatalities)
14/10/07
Panurgic II
Workboat
UK
Unk
Acc to person
18/10/07
Unnamed powerboat
Powerboat
UK
Unk
Capsize
21/10/07
Nordsee
General Cargo
Antigua & Barbuda 2579 grt
Contact
23/10/07
Luvly Jubbly
tug
Honduras
144 grt
Machinery failure
Longsands
Crane barge
Unk
Unk
Machinery failure
Monika
General Cargo
Antigua & Barbuda 1768 grt
30/10/07
Acc. to person
Acc. to person
(2 fatalities)
Flooding
Acc to person
(1 fatality)
Investigations started in the period 01/07/07 31/10/07

Date of
Incident
Name of Vessel
Vessel Type
Flag
Size (gt)
Incident Type
10/07/07
Pacific Star
Cruise ship
UK
35144
Heavy weather
damage
28/07/07
HD1
Bahamas
2357
Contact
28/07/07
Lady Candida
Megayacht
UK
143
Fire/explosion
03/08/07
8m rigid raider
Other (non-commercial)
UK
07/08/07
Dublin Viking
UK
21856
Acc. to person
(1 fatality)
23/09/07
Viking Islay
Offshore supply
UK
928.00
Acc. to person
(3 fatalities)
03/10/07
Lady Hamilton of Helford
FV
UK
6.73 grt
Collision
Blithe Spirit
FV
UK
0.85 grt
Flourish
FV
UK
40.11 grt
Nautica
General Cargo
St Vincent &
Grenadines
1587 grt
11/10/07
66
Capsize/listing
Collision
APPENDIX B
Reports issued in 2007

Annabella collapse of cargo containers
while in the Baltic Sea on 26 February 2007
Published 13 September
Aqua-boy grounding, Sound of Mull on 11
November 2006
Published 4 July
Arctic Ocean and Maritime Lady
collision between Arctic Ocean and Maritime
Lady, the capsize of Maritime Lady, and
contact with wreck of Maritime Lady by Sunny
Blossom, and its subsequent grounding in the
Elbe River on 5 December 2005
Published 1 February
Brothers grounding of vessel with the loss
of two lives off Eilean Trodday on 1 June 2006
Published 31 January
Calypso engine room fire on board the
passenger cruise vessel 16 miles south of
Beachy Head on 6 May 2006
Published 19 April
Danielle major injuries sustained by a
deckhand 17 miles south-south-east of
Falmouth on 6 June 2006
Published 29 March
Ennerdale major LPG leak from the gas
carrier while alongside Fawley Marine Terminal
on 17 October 2006
Published 25 May
FR8 Venture loss of two lives, plus one
seriously injured person on board the
Singaporean registered tanker close to the
west pilot station to Scapa Flow in the Orkney
Islands on 11 November 2006
Published 18 July
Haitian sloop capsize of an un-named
Haitian sloop with the loss of at least 60 lives
while under tow by Turks and Caicos police
launch Sea Quest 1nm south-east of
Providenciales, Turks and Caicos Islands on 4
May 2007
Published 1 August
Harvest Caroline grounding, Tanera More,

Summer Isles, north west coast of Scotland on
31 October 2006
Published 22 June
Hilli starboard boiler explosion resulting in
one fatal and one serious injury on board the
liquid natural gas tanker, Hilli, Grand Bahama
shipyard, Freeport, Grand Bahama on 10
October 2003
Published 27 March
Hooligan V report on the investigation of
the fuel failure, capsize, and loss of one crew
member from the Max Fun 35 yacht 10 miles
south of Prawle Point on 3 February 2007
Published 14 August
Maersk Doha investigation of the
machinery breakdown and subsequent fire,
Chesapeake Bay, off Norfolk, Virginia, USA 2
October 2006
Published 6 July
Lindy Lou fire on board the canal boat at
Lyme View Mariner, Adlington, Cheshire,
resulting in 1 fatality on 20 January 2007
Published 3 October
Maersk Dover/Apollonia/Maersk
Vancouver close-quarters situation between
the ro-ro passenger ferry Maersk Dover, the
tanker Apollonia and the container vessel
Maersk Vancouver in the Dover Strait on 17
October 2006
Published 17 May
Meridian loss of the fishing vessel and her
four crew 160nm due east of Aberdeen on 26
October 2006
Octopus/Harald grounding of the jack-up
barge Octopus towed by the tug Harald,
Stronsay Firth, Orkney Islands, 8 September
2006
Published 14 August
67
APPENDIX B
Ouzo loss of the sailing yacht and her three

crew, south of the Isle of Wight during the
night of 20/21 August 2006
Published 12 April
Sea Express and Alaska Rainbow
collision on the River Mersey on 3 February
2007
Sian Elizabeth injury to a member of the
crew, 3 miles north of Kings Lynn on 14
September 2006
Published 12 March
Skagern/Samskip Courier collision,
Humber Estuary, on 7 June 2006
Published 4 April
Thomson Celebration fatal accident to
person, at anchor in St Peter Port, Guernsey,
Channel Islands on 26 September
Published 4 June
Thunder grounding at the approaches to
the Dee Estuary on 10 August 2006
Published 12 June
68

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MARINE ACCIDENT

MARINE ACCIDENT INVESTIGATION BRANCH

Department for Transport

Further copies of this report are available from:

If you wish to report an accident or incident

The telephone number for general use is 023 8039 5500.

Crown copyright 2007

MARINE ACCIDENT INVESTIGATION BRANCH

PART 1: MERCHANT VESSELS

No Easy Withdrawals From This Bank

Odd Ship, Odd Handling

A Bridge Too Far

Rain, But No Rainbow

A Tale of Two Lookouts

Dont Take Chances in Heavy Seas

Bridge Teams Multiple Failures Lead to Grounding

Same Old Story

Never Mind the Waypoint Mind the Ship

10. Contain Containers

11. Hatch Hazards

12. Blocked Sea Suction Prevents Engine Room Flood

13. I See No Ships

14. Unsecured Electrical Fan Causes Cabin Fire

15. Pretty But Dangerous

16. Hurry Aground

PART 2: FISHING VESSELS

17. Too Much Up Top!

18. Not Dressed for the Job

19. Shrimp Boiler Lights up the Engine Room

20. Spot the Difference

21. Trim For Safety, Not For Catching Fish

22. Two Sides of the Same Coin

PART 3: LEISURE CRAFT

23. Relaxing Canal Trip Ends in Tragedy

24. Lookout Above and Below the Water

25. How Safe is Your Safety Boat?

Reports issued in 2007

Glossary of Terms and Abbreviations

Automatic Radar Plotting Aid

0.1 nautical mile

Closest Point of Approach

Digital Selective Calling

Emergency Position Indicating Radio Beacon

Fast Rescue Craft

Global Maritime Distress and Safety System

Global Positioning System

Glass Reinforced Plastic

International Sailing Federation

International Safety Management Code

Marine Guidance Note

Officer of the Watch

Offshore Special Regulations

Pilotage Exemption Certificate

Rigid Inflatable Boat

Royal National Lifeboat Institution

Royal Ocean Sailing Club

Royal Yachting Association