Safety Digest: Lessons From Marine Accident Reports

SAFETY DIGEST
Lessons from Marine Accident Reports
1/2022
Featuring introductions by Bob Baker | Pete Dadds | Pip Hare

MARINE ACCIDENT
INVESTIGATION
BRANCH
The Marine Accident Investigation Branch (MAIB)
examines and investigates all types of marine
accidents to or on board UK vessels worldwide, and
other vessels in UK territorial waters.
Located in offices in Southampton, the MAIB is an

independent branch within the Department for
Transport (DfT). The head of the MAIB, the Chief
Inspector of Marine Accidents, reports directly to the
Secretary of State for Transport.
This Safety Digest draws the attention of the marine

community to some of the lessons arising from
investigations into recent accidents and incidents. It
contains information that has been determined up
to the time of issue.
This information is published to inform the

merchant and fishing industries, the recreational
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 If you wish to report an accident or incident
correction if additional evidence becomes available. please call our 24 hour reporting line:
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determine liability. The lessons often extend beyond
The telephone number for general use is: +44 (0)23 8039 5500
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GLOSSARY OF TERMS AND ABBREVIATIONS
CHIEF INSPECTOR’S INTRODUCTION 1

INDEX
M
MERCHANT VESSELS 2
1. Best of intentions, worst of outcomes 4
2. “I didn’t know that... !” 6
3. Stick to the plan 8
F
4. Don’t throw in the towel 10
FISHING VESSELS 38
5. Pitching into trouble 12
17. A handy solution 40
6. A bumper catch of workboats 14
18. Water, water, everywhere 43
7. The stress of catastrophic engine failure 16
19. The price of FAME? 44
8. Washed away 18
20. It came off in my hand 45
9. Belt and braces 20
21. Lookout for anchored vessels 46
10. No going back 22
22. A simple step... into danger 50
11. Fretting failure in gearbox 24
12. The fog of illusion 26
R
13. Making your mark 28
14. Drip, drip, drip, bang 30 RECREATIONAL VESSELS 52

23. Too close, too fast 54
15. On the rocks! 32
24. Don’t swim near moving boats 56
16. One small step for man 34
25. Last orders at the bar 58
INVESTIGATIONS 60
REPORTS 61
SAFETY BULLETINS 64
SAFETY FLYERS 70
GLOSSARY OF TERMS AND CHIEF INSPECTOR’S INTRODUCTION
ABBREVIATIONS Welcome to MAIB’s first Safety Digest of 2022. I would like to start by
thanking Bob Baker, Pete Dadds and Pip Hare for their introductions to the
merchant, fishing and recreational sections of this digest. They each have a
°C ° Celsius wealth of experience in their respective fields, and their introductions are
2/E second engineer very thought-provoking. If nothing else, please read their articles. That said,
I hope you will read much more than that. There is a cautionary tale here for
ABP Associated British Ports everyone, and when you have finished reading the digest please pass it on
AIS automatic identification system so others can benefit too.
ARPA automatic radar plotting aid Bob Baker asks the questions, Why did the officer of the watch switch off
guard alarms on radars/ECDIS? And why is failure of the bridge team and poor
CCTV closed-circuit television communications such a fundamental issue and the most frequent cause of incidents
in coastal/port waters? He goes on to talk about the need for a cultural change
C/O chief officer in the way we embrace safety and in our approach to understanding why
COLREGs Convention on the International Regulations for Preventing Collisions at Sea (1972) accidents happen. I could not agree with him more.
CPP controllable pitch propeller Like Bob, I started bridge watchkeeping in the pre-digital age. Satellite navigation was in its infancy, radars
were unreliable, ARPA did not exist, and the ship’s position was plotted and projected ahead on a paper
DfT Department for Transport chart. In coastal waters, watches were busy, sometimes hectic, and if the watchkeeper did not collect and
ECDIS Electronic Chart Display and Information Systems assimilate the necessary information, they would not know what was happening around them. Compare
this to the modern bridge where all that manual work is being done automatically, and all the watchkeeper
EEBD emergency escape breathing device needs to do is look at the screens (and out of the window!) to see what is going on. Watches have ceased
to be as stimulating and occupying as they were, but the watchkeeper still keeps a 4 or 6-hour stint on the
FAME Fatty Acid Methyl Ester bridge. The frequency of accidents that have occurred when a watchkeeper has decided to keep alert or
IMO International Maritime Organization awake by occupying themselves with their mobile phone, tablet or PC seems to be on the rise, probably
because they are insufficiently engaged by their duties. I would therefore add to Bob’s call for a cultural
kts knots change to safety and say that the role of the human in the digital workplace needs a serious rethink; if we
don’t, it is us that will be asleep at the wheel.
LOTO lock-out/tag-out
MGN Marine Guidance Note Few people have the courage to tell a “When I…” story as powerful as Pete Dadds’ account of his capsize, and
I am grateful that he shared his experience with us. The first thing that stands out for me is the old saying,
nm nautical mile “Never turn your back on the sea”, because it always has the capacity to be unpredictable. The second is that
Pete and his crew were wearing PFDs and so were able both to survive the initial shock of immersion in
OOW officer of the watch cold water and stay afloat long enough to be rescued. I think the message about wearing PFDs when on
PEC Pilotage Exemption Certificate the working deck is slowly getting around. However, too many of MAIB’s customers were unfortunately not
wearing a PFD when they entered the water, with often tragic results. Pete’s story shows that it is possible to
PFD personal flotation device survive going over the side, but to do so you need to be wearing a PFD.
RIB rigid inflatable boat Pip Hare writes about the risks of being a single-handed round the world sailor, about mitigating the
foreseeable risks in advance, and being ready to change her plans in the face of changing circumstances. At
RNLI Royal National Lifeboat Institution
MAIB we often talk about safety margins, and how easily these are eroded. Going a bit fast in poor visibility,
RoPax roll-on/roll-off passenger ferry rushing a maintenance task, loading more catch than is safe, staying out for one more haul in deteriorating
weather, show-boating (in all its forms); it is all too easy to erode the safety margins. A few years ago, the
ro-ro roll-on/roll-off Royal Yachting Association ran a campaign entitled Know Your Limits and the detail is still available on its
VHF very high frequency website:
VTS vessel traffic services https://www.rya.org.uk/knowledge/safety/know-your-limits

Whatever your means of getting afloat, it is worth a read.
Andrew Moll
Chief Inspector of Marine Accidents
MAIB Safety Digest 1/2022 | 1

MERCHANT VESSELS
I am now well into patience. The marine industry has traditionally the same attitude and training, while needed, operations, particularly for pilots and port
my 47th year in the been built around command and control rather must be appropriate. Changing culture seems authorities. Pilot ladder deficiencies top our
marine industry. than a structure that encourages the watch to be one of the most difficult things to achieve, Port of London incident report statistics by a
When I went to officer to question the master or pilot; “I was just yet it is the subject most frequently raised considerable margin. After a long campaign
sea there were trying to get the job done” is a fateful phrase that and discussed in training courses, seminars, involving all elements of the industry, we are
very few electronic I have heard many a time. companies’ strategies, etc. The word culture and starting to see a gradual improvement in the
navigational examples of poor safety or professional culture condition and rigging of pilot ladders, but focus
aids available, Until improvements are made in these softer even feature heavily in our day-to-day life and cannot be lost in ensuring this vital piece of
technology was skills, we will struggle to understand why it is frequently mentioned in mainstream news equipment is correctly rigged. Asking a pilot to
limited and the individuals take the decisions that ultimately reports into incidents and failings. step from a moving boat onto a rope ladder and
processes and lead to incidents and accidents. I am sure the climb up the side of a ship demands the highest
procedures we use MAIB has the statistics, but how many incident It seems obvious and simple when discussed; standards of safety, without compromise.
today, such as risk investigations attributed the cause either fully or however, it is not, and to make that step change
assessment, passage plan, bridge team, ISM, etc., substantially to human error rather than delving to improve safety everyone in the marine We are all human and we all make mistakes.
had yet to be developed. I have therefore had deeper into the underlying contributory factors industry must embrace new thinking. Acknowledging this and asking, “Why?” will
the benefit and privilege of seeing the maritime that influenced the incident? Do investigators hopefully contribute to the provision of a safer
or companies take the time to establish and Finally, it is good to see the MAIB include the work environment.
industry improve, develop and expand safety
explore why an individual decided not to follow serious issue of pilot ladders in this edition of
training, culture and systems. I have also seen
the procedures, conduct a risk assessment or the Safety Digest. This is a critical part of our
the advent of smaller crews, quicker turnaround
in port and ever-increasing use of technology and follow their training? Why did the officer of the
sophisticated systems. watch switch off guard alarms on radars/ECDIS?
And why is failure of the bridge team and poor
The human interface and what can be described communications such a fundamental issue and
as human and organisational contributory factors the most frequent cause of incidents in
constantly feature in incident reports, not just coastal/port waters?
the MAIB’s but all of our own. In an industry
that continues to introduce new procedures, I do think we are all sometimes guilty of
processes, safety systems and technology, we still taking action after an incident that focuses
seem to fail when it comes to understanding the on producing another procedure rather than
human element. evaluating why the existing procedures or
training, which are probably perfectly fit for
purpose, were not followed. To understand
Everyone should be why these issues occur, the cultural approach to
aware of their cultural investigations and the actions stemming from
the recommendations need to become more
as well as technical open, collaborative and cooperative. If we can BOB BAKER | Chief Harbour Master, Port of London Authority
competence be less defensive and more open when being
investigated, we may learn more as to why Bob became the Port of London Authority (PLA) chief harbour master in May 2016. He is responsible
It is therefore vitally important, and even more individuals act the way they do. Unfortunately, for all operational and navigational matters, including vessel traffic management, pilotage, harbour
so now as the concept of alternative fuels, in a society where liability, compensation and services and port security. He sits on the PLA board and is a member of the authorities Licensing
autonomous vessels and artificial intelligence are litigation appear to be the priority, these become Committee. Bob joined the PLA from Forth Ports, where he was chief harbour master and a director of
coming over the horizon, that our ship personnel, major barriers to establishing this. Forth Estuary Towage from 2001. Bob’s seagoing career lasted from 1975 to 1991, mainly sailing on bulk
carriers that traded worldwide. Following his sea career Bob worked as a superintendent in Africa for a
VTS officers, pilots, tug crews, harbour masters,
As with everything safety-related, if we are number of years, primarily overseeing the discharge and distribution of aid cargoes. Returning to the
etc., are properly trained and experienced
going to shift the cultural dial it is everyone’s UK, he worked at the Port of Tilbury, latterly as general manager of conventional cargo operations and
enough to meet the challenges of this fast-
responsibility to willingly participate. Yes, harbour master.
evolving industry. Everyone should be aware of
their cultural as well as technical competence, companies and management have to create the Bob chairs the UK Major Ports Group (UKMPG)/British Ports Association (BPA) Marine Pilot Group
developing and improving on skills such as right environment for this more collaborative and sits on the Department for Transport’s steering group for the Port Marine Safety Code. A Master
collaborative communication, empathy and approach, but everyone involved needs to adopt Mariner, Bob also holds an MBA from Henley Management College.
2 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 3

1 1
Best of intentions, worst of outcomes
cargo vessel | flooding
A small dry cargo vessel was in harbour and its indicated as shut on the ballast control panel. The block the strainer lid flew off and
engineers were investigating why ballasting 2/E then went to the engine room and manually seawater began flooding into
operations were taking longer than normal. shut the isolation valve between the strainer and the engine room. The engineers
Their plan was to clean the ballast system’s the pump (Figure 1). tried unsuccessfully to replace the
seawater strainer and then check the ballast lid, then decided to evacuate the
pump’s condition. With the chief engineer present, the 2/E loosened engine room and raise the alarm.
the strainer lid’s retaining bolts and tried to lever
To isolate the strainer, the second engineer (2/E) the lid off with a screwdriver, but it would not In the engine room, the water
went to the ballast control panel and shut the budge. The engineers then rigged a chain block level rose over the bottom plates
automatic butterfly hull valve between the hull to the strainer lid, having completely removed until the seawater pressure
inlet and the strainer (Figure 1). The hull valve all the bolts. As the weight came onto the chain equalised and the vessel settled
with the engine room partly
flooded (Figure 2). The vessel was
For illustrative purposes only: not to scale made watertight after a diver
fitted an external patch over
Sea Engine room the hull valve. Thereafter, the
Lifting eye contaminated water was pumped
Strainer box lid
out to road tankers for disposal
and the vessel was dry docked for
Test plug repairs.
Gasket
After the accident, a technical
Strainer lid bolts investigation identified that the
Manual gate valve
automatic butterfly hull valve
was defective, and had remained
Actuator partially open when indicated as
shut on the ballast control panel.
To pump This investigation also found that
the strainer was clean but that a
Automatic butterfly valve Strainer box ballast pump defect had caused
the slow ballasting operations.
The company has provided a
Perforated strainer revised safe system of work for
strainer cleaning. Figure 2: The flooded engine room
Figure 1: Ballast water valve and strainer arrangements
The Lessons
1. Procedure → The strainer lid was fitted with a test plug (Figure 1), provided to make sure the system was 2. Check → Given that the hull valve indicated shut on the ballast control panel, it was reasonable of the
not still under pressure before the lid was removed. However, the engineers involved in this accident neither engineers to assume this was correct. However, where there is doubt or, for instance, when reducing a system
followed an approved procedure for the strainer clean nor opened the test plug and so were unaware of to single valve isolation to sea, it is good practice to visually inspect the valve’s mechanical position indicator
the faulty hull valve that meant the system was still open to sea pressure. Additionally, when they tried to as well as checking its remote indication. A further precaution is to loosen the nuts, then use wedges to crack
remove the lid with a screwdriver, the absence of any leakage underpinned their assessment that the system the lid open; if water floods out, the retaining nuts can be retightened to seal the strainer lid.
was isolated.

2 2
“I didn’t know that... !”
passenger ferry | grounding
In the early hours of a stormy winter’s day, a roll-on/roll-off passenger ferry (RoPax), which was laid up Unfortunately, the pilot was unaware that, due to the shaft generator arrangement, the load had to
for the festive period, broke free from its moorings in winds gusting up to 55 knots (kts) (Figure 1). The be taken off the bow thrusters before the propellers could be clutched in. The master stopped the
master had anticipated storm force, off-berth winds but was confident in the mooring arrangement. bow thrusters, but the pilot was not told, and the bow started to drift downwind toward another ferry
The engines were on immediate standby, and a good lookout was being maintained, so by the time berthed nearby.
the master had been called and arrived on the bridge the steering and propulsion plants had been
brought online. Noticing what was happening, the pilot asked the master to apply more thrust to be told that it was not
possible while the engines were being clutched in (Figure 3). Concerned that the bow would contact
Unfortunately, the master was unable to regain control of the vessel and to prevent damage to the this moored vessel, the pilot ordered the tugs to stop pulling the stern round and shortly afterwards,
propellers the engines were declutched as the vessel’s stern grounded on a soft mud bank. The bow was with astern momentum already in place, the RoPax made light contact with the moored hotel ship as it
held close to the berth by the linkspan structure (Figure 2). drifted downwind (Figure 4).
A pilot boarded shortly afterwards and a plan was discussed and agreed with the master. With two tugs With all engines and thrusters available soon after the light contact, and with the assistance of the tugs,
made fast on the starboard quarter, the RoPax’s stern was pulled free of the mud bank. Tugs and the bow the ferry was berthed without further incident.
thruster were used to manoeuvre it clear of a hotel ship moored astern of their position before the pilot
asked for the engines to be clutched in. A dive survey and damage assessment concluded that the RoPax had suffered minor damage.
Moored hotel ship RoPax’s stern makes light contact

Berthed ferry
Wind Moored RoPax
Wind
Wind
Wind
RoPax’s bulbous bow on linkspan structure
Figure 1: RoPax alongside before the moorings parted Figure 2: RoPax’s stern aground on a mud bank Figure 3: The point where the pilot was told that the bow Figure 4: Light contact was made with the hotel ship
thrusters were unavailable
The Lessons
1. Margin of safety → The master considered his mooring plan sufficient and had taken steps to increase 2. Communicate → Although the RoPax was aground when the pilot boarded, it was safe and there
the readiness of the vessel should engines be needed. However, the almost simultaneous failure of the stern was time to conduct a full exchange with the master and agree a plan of action. Despite this, and having
lines meant there was not enough time to get the propulsion plant online before the stern ran aground. previously completed movements on the vessel, the pilot was unaware that the bow thrusters would
The day before, the duty tug had offered to push up against the ferry overnight due to the forecast winds. be unavailable while the engines were clutched in. Without this critical piece of information, he had an
It cannot be established why the RoPax’s master did not accept this offer, but this incident would have incomplete mental model of how the manoeuvre would unfold. A well-considered pilot card should act as
been largely mitigated had the tug been in place. Calculating the strength of a mooring plan based on the a prompt for the master to share critical information such as this when a pilot joins the bridge team. In this
nominal breaking strains of the ropes is fraught with danger, and a healthy safety margin should always be case, the consequences were fortunately minor.
employed.

3 3
Stick to the plan
workboat | contact
The crew of a 7m workboat were tasked with their patrol from the offshore side of the jetty. assess the damage. Once at the pontoon, the
patrolling an oil terminal overnight, which However, in an attempt to finish it quickly, the coxswain was taken to the facility’s medical
included checking pipelines for signs of leakage, coxswain took the workboat under the access centre for a drugs and alcohol test, which proved
monitoring terminal infrastructure and general roads (Figure 1). The vessel safely passed under negative.
security of moored vessels. the first two access roads in a westerly direction,
but when passing under the third it was pushed The patrol boat returned to its base when an
At 1830, the two crew joined the vessel. With a bodily to starboard by a wave and the port bow escort was available and was taken out of the
strong south-westerly wind (24 to 37kts), and a made heavy contact with a pile. water the following morning. Subsequent surveys
strong outgoing tide causing wind against tide revealed significant damage to the bow, with
conditions, the sea had a steep chop and the crew The deckhand briefly lost his footing but was delamination of the glass-reinforced plastic as far
knew that they were in for an uncomfortable otherwise uninjured. He then proceeded inside back as 2m from the bow (Figure 2). The boat was
night. They conducted a short informal dynamic the boat to check on the coxswain, who was also out of action for several weeks for repairs.
risk assessment but did not make notes. unhurt. Damage was found at the bow and a
small amount of water was entering the boat.
In fair conditions it was usual to conduct the Bilge pumps were sufficient to stem the ingress
patrol passing inside of the berths (Figure 1) while the coxswain informed the company and
but, with the high sea state during the previous drove the boat to a nearby pontoon to further
midnight patrol, they decided to conduct
Vessel strikes pile
Figure 2: Damage to bow and deck delamination
Figure 1: Workboat patrol route Normal route Route on night of accident
The Lessons
1. Margin of safety → Due to the prevailing conditions, the crew had already decided to conduct the 2. Guide → With the weather assessed by the crew as marginal for the relatively small vessel, a larger more
patrol on the outboard side of the main jetty. However, to speed it up the coxswain took the boat under the capable boat, which was available, might have been a better choice. Incorporating a matrix into operational
roadway access to the terminal berths. At night, the waves and pilings were more difficult to see, and in instructions, which matches suitable conditions for tasks against available assets, can assist crew to plan
marginal conditions it would have been prudent to stay on the offshore side of the terminal throughout the essential tasks in marginal conditions when there is limited onsite supervision.
patrol. This might have lengthened the patrol but would have increased the margin of safety and minimised
the risk to boat and crew.

4 4
Don’t throw in the towel
survey vessel | fire
A survey vessel crew member was settling back

into his cabin after a period of leave. Shortly
after turning up the temperature on the cabin
thermostat he noticed a faint burning smell and
reported it to the duty engineer.
After a brief discussion and check of the cabin,

the crew member and duty engineer decided
that the smell probably originated from someone
vaping on an outside deck. The crew member left
the cabin for a little while, but when he returned
he noticed smoke coming out of a ventilation
duct. He raised the alarm and shut the cabin
door as he left. The ship’s emergency response
team mustered and entered the cabin once the
electrical supply and ventilation system was
isolated. They discovered a fire in the ventilation
duct and tackled it with a water fire extinguisher.
The emergency response team removed the cabin
ceiling panels and confirmed that the fire was out Figure 1: The ventilation duct post-fire
(Figure 1). The company reported that a similar incident
had occurred on the same ship approximately
The shipping company conducted an internal eight years before, the details of which were
investigation and found that a passenger had shared fleetwide. Safety signs were installed in
previously used the cabin and stuffed a towel the cabins, providing occupants with guidance
into the ventilation duct to prevent a cold air on how to immediately report defects. The vessel
draught (Figure 2). The towel caught fire when was recently sold and no known cabin ventilation
the ventilation duct’s automatic heating element system modifications have been undertaken.
turned itself on.
Figure 2: The towel that was stuffed into the ventilation duct
The Lessons
1. Observe → Fairly innocuous actions can lead to potentially dangerous scenarios. Ship’s crew are reminded 3. Action → Good emergency preparedness and swift action by the emergency response team prevented
to be vigilant for ad hoc alterations to cabin fixtures and fittings. this becoming a major incident; well-trained crews are good news.
2. Revise → It is important to learn lessons from previous incidents and take action to improve safety. In this
case, had a simple modification to the cabin ventilation duct been made after the previous incident it might
have prevented the passenger from placing a towel in the duct and inadvertently causing a fire.

5 Figure: The tanker and the barge in contact just after collision
5
Pitching into trouble
tanker | collision
A chemical/product tanker was approaching obstructions. Meanwhile, the bridge and engine
its berth; weather conditions were fine, a pilot room teams attempted to regain control in
was on board, and the master was controlling backup and local modes but were unable to do so.
the vessel. The vessel had a single shaft with
a controllable pitch propeller (CPP) and a bow None of the crew’s actions were successful in
thruster. regaining CPP control, so the master activated
the bridge main engine emergency stop and both
In the final stages of the approach, the master anchors were dropped as the speed reduced.
set the CPP control from ‘20 ahead’ to ‘20 astern’ Despite these actions, the tanker eventually came
to reduce speed; the bow thruster was also in to rest when it collided with a barge moored in
use. The vessel did not seem to be responding the river (see figure). There was no significant
to the CPP, so the master selected ‘40 astern’; damage to either vessel.
however, the vessel then appeared to increase
speed. The master decided to abort the berthing
and managed to steer the vessel safely back into
the river, avoiding the berth and some adjacent
The Lessons
1. Maintain → A post-accident technical investigation found that a CPP hydraulic control valve had 2. Teamwork → Faced with a loss of control in a confined navigational environment, the crew, aided by the
malfunctioned, resulting in a loss of system pressure and consequent loss of propeller pitch control. The pilot, worked as a team to try to bring the situation under control. The early decision to abort the berthing
defect was determined to be excessive wear and tear on the valve. However, the investigation also identified and steer clear of danger unquestionably avoided a more severe outcome. Dropping the anchor when still
that, although probably not contributing to the loss of control, some ‘non-approved’ spare parts were found making headway can be hazardous but, given the lack of time and space, almost certainly contributed to
in use on the system. It is important that manufacturer-approved spare parts are used, particularly in critical minimising the consequences of this accident.
systems such as propulsion and steering.

6 6
A bumper catch of workboats
workboats and cargo vessel | collision
For illustrative purposes only: not to scale

It was the early hours of the A small general cargo vessel was heading east the situation, WB1’s port propeller shaft became
morning and dark, but visibility was on passage in the same area and had observed a fouled by the emergency towline (Figure 2). Once
WB1 good and the weather conditions vessel ahead by AIS and visual observation. The the tow had been re-established and everyone
fine. A large workboat (WB1) was cargo vessel’s officer of the watch (OOW) did not safely accounted for, the coastguard agreed that
on a coastal passage, heading alter course and intended passing close by the the vessels could continue their passages.
north and towing two smaller, contact.
Figure 1: Schematic of tow and (inset) post-collision situation
100m towline unmanned, catamaran workboats

(WB2 and WB3) (Figure 1). The tow WB1’s crew were increasingly
was set up with 100m of towline concerned about the situation and
between WB1 and WB2, then 80m used a searchlight to try and attract the
of towline between WB2 and WB3. cargo vessel OOW’s attention. WB1’s
WB2
An emergency towline was also crew also tried hailing the cargo vessel
Cargo vessel
being streamed astern of WB3 and by very high frequency (VHF) radio;
all three workboats were correctly this warning came too late and the
80m towline cargo vessel passed between WB2 and
lit as a ‘tug and tow’, restricted in
their ability to manoeuvre and WB3, severing the towline and casting
therefore unable to keep out of the WB3 adrift (Figure 1, inset).
WB3 way of another vessel. However,
Realising what had happened the
defects meant that only WB3 was
cargo vessel was stopped, then both
transmitting on the automatic
WB1’s skipper and the cargo vessel’s
Emergency towline identification system (AIS).
OOW called the coastguard to report
the incident. When trying to recover
WB1
WB2
Figure 2: The emergency towline caught in WB1’s propeller
WB1’s port propeller

fouled by the
emergency towline
WB3
The Lessons
2. Risk → The cargo vessel’s OOW had observed an AIS contact ahead. AIS is useful to assist the OOW with
1. Observe → The International Regulations for Preventing Collisions at Sea (COLREGs) require a constant situational awareness, although should not be relied upon as the primary means of collision avoidance.
cycle of keeping a good lookout, assessing the situation and taking action to avoid collision when judged In this instance, close scrutiny of the combined radar, visual and AIS information could potentially have
necessary. As the cargo vessel was approaching the tow, the OOW identified that there was a vessel ahead; indicated that more than one vessel was ahead. Under these circumstances, or where there is uncertainty,
however, inadequate action was taken to properly assess the situation. The primary means of assessing reducing speed would allow more time to accurately assess the situation.
collision risk is visual and radar information and sufficient evidence should have been available to the cargo
vessel’s OOW to see that action was necessary (as the ‘give-way’ vessel) to pass at a safe distance. 3. Action → As the situation developed, WB1’s skipper used a searchlight and VHF radio to alert the cargo
vessel’s OOW. However, these actions came too late to be effective. In any collision situation, it is incumbent
upon both vessels taking steps to avoid collision. This includes the ‘stand-on’ vessel taking evasive action
where it is judged the ‘give-way’ vessel’s actions alone will be insufficient to avoid collision.

7 7
The stress of catastrophic engine failure
cargo vessel | machinery
The main engines of a roll-on/roll-off (ro-ro) housing. The ship’s operator was aware of this Some months later while
cargo vessel were regularly maintained by an instruction but had no oversight of how the on passage, a sudden and
engineering contractor. Over the years the contractor completed the work. increasingly loud sound
contractor had slowly taken over the work emanated from the main
from the engine manufacturer to reduce The contractor, having undertaken similar work engine. The duty engineer
costs. The contractor was approved to work on different manufacturers’ engines, considered recognised that something
on the large diesel main engines on board the that the other manufacturers had a simpler and serious was occurring and
ship and undertook their work in accordance easier approach to the connecting rod bearing took cover as the main engine
with the ship’s planned maintenance system. replacement. The contractor chose to remove catastrophically failed. Major
Although they had access to most of the engine the bearing shell with a disc cutter and use a gas internal engine components
manufacturer’s maintenance instructions, cutting torch to heat up the bearing housing to were thrown out through
they did not have the detailed information to slide the shell into position. In doing so, they the crankcase and a large fire
perform the work on the engine connecting rod introduced notches and heat marks into the engulfed the engine room
bearings. Nevertheless, their own instructions bearing housing (Figure 1). (Figure 2). The duty engineer
were similar. was fortunate to escape through
the thick black smoke that
The engine manufacturer advised that the enveloped the engine room
replacement of a connecting rod bearing should as he struggled out of the
be undertaken at one of their specialist centres compartment via the secondary
due to the difficult machining and reinstallation escape route, without the use of
process; because of its interference fit in the Figure 2: Post-failure engine component debris in sump
an emergency escape breathing
bearing housing, this involved cutting the device (EEBD).
bearing shell axially to a fine tolerance to enable
it to collapse and then using liquid nitrogen Once the vent flaps had been closed and the duty engine room could be re-entered as it was unclear
to contract the new shell for installation in the engineer accounted for, the engine room was whether all the carbon dioxide bottles assigned
flooded with carbon dioxide, which extinguished to the main engine room had been discharged.
the fire. However, it was some days before the
Figure 1: Bearing housing notches

from disc cutter
The Lessons
3. Equipment → The duty engineer was lucky to escape from the smoke-filled engine room. While the
1. Qualified → It is not unusual for contractors to undertake major maintenance work on board a ship; ship had the correct number of emergency escape breathing apparatus as required when the ship was
however, it is imperative that they can provide assurance that they have the skills and equipment to meet constructed, it did not have to comply with a 2003 International Maritime Organization (IMO) circular that
the original equipment manufacturer’s expectations of how it should be done. Operators and managers required one EEBD to be positioned on each deck or platform level near the secondary means of escape.
must endeavour to maintain a level of oversight that ensures work is completed to a satisfactory standard. Ship managers and operators should consider increasing and improving EEBD distribution to maximise the
likelihood of escape from a smoke-filled space.
2. Maintain → Whereas components were overengineered and could withstand poor treatment in the past,
this is not always the case for modern, technically advanced machinery. Engine components, particularly 4. Signage → The carbon dioxide fixed firefighting system was activated and successfully extinguished the
on modern engines, are designed to maximise the power output while keeping component mass and size fire. However, it was unclear in the bottle room which gas bottles discharged to which space and therefore
to a minimum. The components are thus highly stressed and their correct maintenance is critical. What impossible to confirm that all bottles had been discharged. This led to delays in gaining entry to the
may seem an innocuous cut or heat mark from using inappropriate tools can have serious consequences space, which in some circumstances could be critical. Such a problem can be avoided with clear labelling
when the component is heavily loaded or operating at high revolutions. This type of damage affects the and a means of checking that the necessary bottles have been discharged, as outlined in MGN 389 (M+F),
component metallurgy and introduces stress raisers, which can lead to fatigue failure. Operating Instructions and Signage for Fixed Gas Fire-Extinguishing Systems.

8 8
Washed away
passenger ferry | risk assessment
A high-speed passenger ferry was berthed at still a few passengers at the pier, so the crewman
a pier, embarking passengers via a shoreside lowered the gangway back down onto the deck
gangway that rested on the deck at the ferry’s for them to embark.
stern embarkation point. The ferry was made
fast aft with a stern line and a spring. A similar As the final passengers were stepping on board,
ferry was berthed at the same pier in a stern-to- the second ferry propelled ahead. The second
stern configuration. ferry’s propeller wash caused the stern to swing
out and the gangway fell off the embarkation
After the last passenger embarked, the crew point. The passenger on the gangway at the time
member at the aft embarkation point raised the stumbled (Figure 2) and could have fallen into the
gangway and let go the stern line in preparation sea; the crewman realised what was happening
for departure (Figure 1). At the same time, the and grabbed the passenger, preventing this.
master informed the crewman that there were
Figure 2: The stumbling passenger as the gangway fell off the ferry’s embarkation point
Second ferry’s propeller wash
Passenger ferry Second ferry
Gangway
Pier
Figure 1: Shore gangway raised, and the stern line cast off
Figure 3: The effect of the second ferry’s propeller wash, with no stern line attached
The Lessons
1. Observe → It was unsafe to embark more passengers after the stern line had been released. The ferry 2. Procedure → The company issued a fleet circular because of this accident, reminding its crews of the
was not properly made fast and became vulnerable to the effect of the second ferry’s propeller wash (Figure importance of all mooring lines being in place whenever the gangway is lowered.
3). Communication between the bridge and the mooring deck is key to ensuring that crew know and
understand the full situation, particularly where such evolutions can be very repetitive. It is also important
for bridge teams to monitor the embarkation point closed-circuit television (CCTV), if provided, to maintain
a good awareness of passenger movements.

9 9
Belt and braces
cargo vessel | accident to person
Two engineers on board a moored cargo vessel One of the engineers was making some final
were performing routine planned maintenance adjustments to the compressor’s drive belt when
to a deck air compressor (Figure 1). The the compressor automatically started, trapping
engineers met in the machinery control room, his hand between the pulley and the belt and
prepared a risk assessment for the work, and severing part of his index finger (Figure 2). After
isolated the power to the compressor in line hospital treatment, the engineer returned to the
with the company’s lock-out/tag-out (LOTO) vessel.
procedures. After completing the maintenance,
but before replacing the v-belt guards, the The company conducted an internal investigation
engineers switched the power back on to test and issued a safety bulletin that reminded ship’s
the compressor. staff of its LOTO procedures and the importance
of risk assessments.
Figure 1: Deck air compressor belt Figure 2: Severed finger at the time of the accident (top) and after hospital treatment (bottom)
The Lessons
2. Risk → If it is necessary to test or adjust equipment without safety guards in place, as in this case, the risks
1. Hazard → Risk assessments are best conducted on site so that all potential hazards, such as automatic associated with the task should be identified and mitigated in the risk assessment.
starting of equipment, can be identified. The benefits of reviewing generic risk assessments and
undertaking dynamic risk assessments cannot be underestimated. 3. Procedure → LOTO procedures must remain in place until all maintenance tasks are completed. If
adjustments are required to systems after a test run, then a second LOTO procedure should be instigated.

10 10
No going back
passenger transfer vessel | contact
A passenger transfer vessel was approaching

a wind farm turbine with three crew and three
windfarm technicians on board. It was the
first trip of the day and weather conditions
were favourable with good visibility, a light
breeze and gentle sea. The vessel propulsion
system’s landing mode gave the skipper precise
manoeuvring control when approaching wind
turbines to embark or disembark passengers.
As the vessel approached the turbine’s landing

platform, the skipper reduced speed and
selected the landing mode in preparation for
the technicians’ transfer. The skipper moved
the propulsion control lever to astern to further
reduce speed. However, the vessel did not
Figure 3: Water ingress damage
respond as expected and so he increased the lever (unrelated to the propulsion control loss)
fully astern. This had no effect and the transfer
vessel made heavy contact with the landing
platform.
The impact caused a bow indentation (Figure 1)

and buckling damage to the hull plating (Figure Figure 2: Deformed internal frames
2). One of the technicians was injured when he
was thrown against the table in front of his seat;
he was treated by ambulance paramedics when Figure 1: Indentation damage to the passenger
transfer vessel’s bow area
the vessel returned to harbour.
The Lessons
2. Communicate → It is important to keep passengers informed if things are going wrong. Although this
1. Risk → A post-accident technical analysis identified that the loss of propulsion control resulted from accident was hard to prevent, post-event CCTV analysis indicated that there was about 10 seconds between
a seizure of the mechanical arm controlling propeller pitch. This occurred because the installation the skipper realising that control was lost and the impact. This is a very short timeframe in which to deliver
arrangement resulted in excessive wear, with a consequent risk of the pitch control arm locking when in an emergency response; however, taking any opportunity to warn passengers and call for them to ‘brace’
use; something that the manufacturer was able to replicate in post-accident trials. Although not the cause would potentially reduce the risk of injury.
of the accident, technical analysis found excessive water ingress in an electrical terminal box (Figure 3) on
the propulsion control system. It was further established that the water ingress was caused by previous 3. Maintain → Take care with maintenance and repairs. The residual water that drained away during the
maintenance to an adjacent seawater cooler, when residual water had been allowed to drain over the seawater cooler maintenance should have been prevented from flowing over electrical components. Taking
electrical control box. Since the accident, the company has taken action to improve the installation time to protect other equipment from damage during maintenance tasks will prevent damage and future
arrangements of the propeller pitch control system and relocated the seawater cooler. breakdowns.
4. Check → Always check the propulsion manoeuvring control response. The vessel was on its first trip of
the day out to the wind farm. At the end of the passage, and before the precise manoeuvring, a full function
check of all propulsion modes, including ‘testing the brakes’ by going astern, may have detected the problem
in advance of the heavy contact.

11 11
Fretting failure in gearbox
live fish carrier | machinery
It was a poor night with high winds and rough An inspection the following day found that Shaft shown in highlighted
seas when a live fish carrier lost propulsion due the main input shaft (see figure) along the top box. Arrow shows where shaft
to a gearbox failure. Without propulsion, the half of the gearbox had failed. The damaged sheared at flange/shaft transition
vessel lay beam on to the sea and began to roll parts were dismantled and dispatched to the
heavily, making life extremely uncomfortable gearbox manufacturer who established that the
for the four crew on board. The vessel was less most likely cause of failure was fretting (micro
than 2 nautical miles (nm) from land and was movement) between the gearwheel and shaft, Prime mover
being blown quickly onshore by the prevailing which introduced a crack to the area and resulted
wind. The master of the stricken vessel raised a in failure. Examination revealed that the failure
VHF distress transmission. Fortunately, another occurred where the shaft transitioned to the
fish carrier heard the distress call and was near flange for the gearwheel.
enough to get a towline onto the drifting vessel
before it grounded on the rocky shoreline. A The vessel was out of service for nearly a month
little later, a lifeboat and emergency towing while a new shaft was fabricated and fitted.
vessel arrived and accompanied both vessels to
a safe harbour.
Propeller
Figure: Gearbox damage and (inset) broken shaft
The Lessons
1. Maintain → The vessel had a history of propeller fouling and minor groundings. The controllable pitch 2. Check → Since its delivery in 1996, the manufacturer had not serviced or inspected the vessel’s gearbox.
propeller had developed a malfunction, during which the response was erratic and jerky. Routine inspections and regular gearbox oil analysis were not conducted.
□ Intermittent problems with propulsion should not be left unattended. Defective propulsion could □ The gearbox is a complex item of machinery. It needs routine inspection and frequent monitoring
lead to navigational accidents if vessel control is erratic, especially in shallow and busy waterways. to ensure that incipient failures are detected early and corrective actions taken. Regular gearbox
oil analysis can be used to detect particles, and therefore provide an early indication of excessive or
□ Events that stress the propeller can cause significant loading on the driving gear, resulting in relative uneven wear on the components.
movement between gearwheel and shaft. Failure is almost inevitable when a crack develops.

12 12
The fog of illusion
freight ferry | grounding
Navigating in fog can mean that emerging 225° and, as the ferry returned close to track,
situations are difficult to understand and, further adjusted the ferry’s heading to 234°.
sometimes, stop.
Once the ferry was in the channel, the PEC holder
A ro-ro freight ferry was inbound to its reduced its speed to 6.5kts. The ferry’s heading
destination port on a summer morning. The was altered to 245° and the ferry then moved to
weather was fine and the seas slight, although the north of track. Neither the bridge team nor
there were numerous fog patches in the area. The the PEC holder, who was observing the ferry’s
bridge team comprised the master, OOW and movement by radar, immediately noticed the
a Pilotage Exemption Certificate (PEC) holder. change of track. The ferry had moved to the edge
The PEC holder had the con and was using the of the navigable water before the master and PEC
radar to navigate; he was also steering the ferry holder saw the northern breakwater and realised
himself. the danger.
It was two days after spring tides and entry The PEC holder applied port helm to counteract
into the port was planned for the middle of the the tidal stream. With 30° port helm, the ferry
ebb tide. The tidal stream was predicted to set rapidly returned to track before crossing to the
across the harbour entrance to the north-west south. After about 15 seconds, the PEC holder
at about 0.8kts, reducing in the confines of the realised that the ferry’s bow was approaching the
breakwaters. southern limit of the channel and applied full
starboard helm. The manoeuvre was too late and
As the ferry approached the breakwaters of the could not prevent the ferry from grounding on
port at a speed of 10kts, the visibility reduced the rocks that lay at the edge of the channel.
to about 150 metres. The master asked the PEC
holder if he was happy to continue and the PEC The ferry was eventually refloated with the
holder confirmed that he was. assistance of a harbour tug, but not before Figure: Damage to the port side of the hull
suffering substantial damage to the port side of
The planned track into harbour was 237° but the the hull (see figure), port propeller and rudder.
ferry was making good a 253° course over the There was no pollution and nobody sustained
ground. The PEC holder altered the heading to injuries.
The Lessons
3. Plan → Restricted visibility is a game changer. Bridge teams should always plan for the unexpected and a
1. Teamwork → Bridge teams play an essential part in maintaining ship, crew and cargo safety. To be well-placed abort position can prevent a ship from being placed in potential danger. It is usual for companies
effective, a bridge team must have a shared mental model of the task in hand and each member of the to require bridge manning to be increased in poor visibility. This is so that tasks can be shared and no-one
team must be clear about their duties. When the task includes pilotage, the pilot or PEC holder must be becomes overloaded.
incorporated into the bridge team and the plan discussed in detail.
2. Procedure → Navigational equipment continues to develop and advancements bring greater capability
for improving the bridge team’s awareness of progress and navigational hazards in proximity of the ship.
However, this equipment can only improve safety if used correctly.

13 13
Making your mark
bulk carrier | contact
A small, coastal bulk carrier was heading upriver to swing the vessel to port through 180° and
towards its intended berth. It was early morning berth starboard side to the quay (Figure 1). As
and there was a moderate breeze on the port a matter of routine, the master had set a radar
quarter and the last of the flood tide (Figure 1); range marker 20m offset from the bow as a safety
visibility was good but in darkness. reference to avoid contact with the quay during
the turn.
The master, second mate, lookout and a pilot
had been on the bridge for the passage upriver. The pilot thought the speed was slightly high just
In the approach to the berth the second mate before the turn began, but did not raise concern.
and the lookout went to the forward mooring The master was controlling the vessel and started
station, leaving the master and pilot to conduct the turn using port rudder, slow astern and full
the berthing manoeuvre. The master’s plan was bow thruster to port.
For illustrative purposes only: not to scale After swinging almost 90°,
the second mate radioed the
bridge, warning that the bow
Bow makes
contact was passing too close to the
quay; however, this came too
Vessel making way late for the master to take
effective avoiding action
Intended and the vessel’s bow made
berthing
position heavy contact. The bow was
scraped and dented and the
impact left a paint mark on
the quay wall, although it
was undamaged (Figure 2).
Wind Tidal stream
Figure 1: Vessel’s track, including environmental effects Figure 2: Damage to vessel and (inset) paint mark on the quay
The Lessons
1. Plan → Passage plans are ‘berth-to-berth’ for a reason: to ensure that there is a careful plan for every phase 3. Action → The forward mooring station did not provide regular updates on the distance to the quay. A
and that it is properly executed. In this case, neither the wind and tidal stream effects nor the optimum single report was made, which came too late to take avoiding action. To avoid misunderstanding, early and
speeds were considered in the berthing plan. A safer course of action might have been to reduce speed regular reports on closest points of approach and actual distances should be clearly communicated.
earlier and then use the wind and tidal stream to aid a turn at rest, with little or no headway.
4. Monitor → Use of a radar range marker was a reasonable safety barrier to aid the turn; however, it
2. Communicate → Pre-arrival briefings that incorporate the pilot are significant milestones in delivering needed to be monitored. The master directed his attention to handling the vessel and other crew members,
a shared mental model. Such briefings should include the forecasted and actual weather conditions, who could have assisted him, had left the bridge and gone to their mooring stations. Good bridge team
planned speeds, and expected safe passing distances of navigational hazards. Only then can navigational management can help to alleviate these situations by making sure everyone knows their role and that
decisions or deviations from the plan be challenged. The master should encourage all crew and the pilot to navigation aids are effectively monitored for signs of danger.
speak up where there is uncertainly; such challenge should then be acted upon or the reason given for why it
is not.

14 14
Drip, drip, drip, bang
naval auxiliary vessel | machinery
A naval auxiliary vessel was in harbour

undergoing a maintenance period. The
purser, who was working in her cabin, heard
a loud bang followed by the noise of the
lifeboat davit deploying on the adjacent
upper deck.
The alarm was raised and the chief officer,

bosun and other duty personnel attended
the scene. The lifeboat davit was found to
have partially deployed (see figure) but with
no control input. It was apparent that the
loud bang occurred when the lifeboat’s gripe
pins sheared. After ensuring that the lifeboat
was safely held on its wire falls, the bosun
used the pendant operating controller (see
figure) to return the davit and lifeboat to the Normal stowage for controller
stowed position.
Figure: The partially deployed davit and lifeboat

Controller
The Lessons
1. Hazard → A post-accident technical investigation established that the incident happened because of 2. Maintain → Checks on electrical equipment, especially when permanently stored on the upper deck,
water ingress to the pendant operating controller, causing an electrical short that activated the ‘dead ship’ need to be rigorous and any risk of water ingress eliminated. The pendant controllers were stowed on the
launch system. The water ingress into the electric pendant controller occurred because its cable gland and davit arm when not in use, exposed to the environment with the consequent risk of degradation. Although
grommet had deteriorated over time, allowing water to pass along the cable into the controller’s housing. not specifically mentioned in the maintenance instructions, such controllers should be examined for wear
The davits and lifeboats had recently passed a statutory inspection with no defects or operating failures and tear as part of safety and maintenance routines.
reported. The davits were also subject to regular weekly and monthly onboard maintenance checks by the
crew. However, similar deterioration of the other pendant controller on board was also found.

15 15
On the rocks!
cargo vessel | grounding
A general cargo vessel being navigated using The crew were mustered but, after an initial
an Electronic Chart Display and Information assessment of the damage, the movement of the
System (ECDIS) was sailing through coastal vessel on the rocks became so violent that they
waters on a dark night with a large following had to lie on the deck of the bridge. The master
sea. The chief officer (C/O) received a call from a informed the local coastguard that he intended to
local fishing vessel to warn him he was heading abandon ship and within 3 hours the entire crew
into shoal waters, which he acknowledged by had been safely evacuated by helicopter.
replying that he was about to alter course. He
then instigated a slight alternation to starboard The vessel was successfully refloated by
as per the passage plan. Moments later the salvors after temporary repairs but declared a
vessel came to a juddering stop as it grounded constructive total loss and subsequently towed to
on a well-charted and marked shoal (Figure 1). a scrapping facility.
Route line
Waypoint
Grounding position
Figure 1: The general cargo vessel aground on the shoal

Figure 2: The passage plan took the vessel directly over the shoal
The Lessons
1. Plan → The ship’s master prepared the voyage plan within approximately one and a half hours while conflicts with charted data, whether selected or not, that fall within the cross-track limit of each leg defined
alongside in the previous port. Information had been insufficiently appraised before the master started in the voyage planning process. The master did not use this tool and so an important safety barrier was
plotting courses on the vessel’s ECDIS and so an IMO recommended route, which would have taken the ignored; in circumventing the checking process, the master became a single point of failure.
vessel safely past the shoal that the ship grounded on, was missed. It is essential that information is fully
assessed before plotting a route, and that enough time is allocated for the critical task of voyage planning. 3. Observe → Although the C/O followed the master’s planned route, he ineffectively monitored the vessel’s
safe progress along the planned track and conducted a planned course alteration that took the vessel onto
2. Check → The manning on the vessel did not allow time for the C/O to conduct the voyage plan in line the charted shoal (Figure 2), despite acknowledging a warning from a local fishing vessel. The ECDIS look
with the safety management system and so the master completed it, which inadvertently led to no second ahead alarms had been deactivated and so the crossing of a safety contour and proximity to an isolated
check of the plan. The officer conducting the voyage plan should undertake a full check of the route on danger, although charted, did not generate a warning. The C/O and his lookout also failed to see that the
appropriately-scaled electronic navigation chart cells before, in most cases, passing it to the master for vessel was heading to the north of a south cardinal mark, which should immediately have caused concern. It
verification. To supplement the visual checks, all ECDIS have a route check function, which will highlight any is vital that bridge teams use all available tools to monitor the safe passage of their ship.

16 16
One small step for man
pilot ladders
A review of the 200 plus pilot ladder incidents failures were a consequence of the side ropes’ The pilot ladder should be safely rigged. deck area, and adequate ladder and deck lighting
reported to the MAIB in 2021, several of poor condition, which a routine visual inspection Reported incidents include inappropriate rigging at night. Pilot embarkation and disembarkation
which involved failures during pilot use, has would almost certainly have detected. If the arrangements such as the use of shackles or must be overseen by a suitably qualified crew
highlighted some key safety messages: side ropes are frayed, or in any way degraded, ladders attached to guardrails. Pilot ladders member, with available communication to the
do not use the ladder. Pilot ladders should be should be secured to deck strong points by a rope bridge. When not in use, the pilot ladder needs to
The pilot ladder should be in good condition less than 30 months old; the year of assembly or stopper lashed to the ladder’s side ropes. When be covered to avoid exposure to contaminants or
and regularly inspected. Many reported reassembly can be found on the identification rigged, the steps should be horizontal, clean, in other elements that may cause rope degradation
instances involved frayed or damaged side ropes, plate usually located on the lower spreader good condition and evenly spaced. There should and failure.
particularly at the lower end (Figures 1 and 2). (Figure 3). be a maximum of two replacement steps.
Post-incident reports have identified that the Further guidance is available in the Pilot Boarding
Other considerations include the availability of Arrangements – Best Practice poster (Figure 4)
communication and lifesaving appliances at the produced by Associated British Ports with the
access point, an obstruction-free surrounding cooperation of other industry bodies.
If the side ropes are

frayed, or in any way The year of assembly or reassembly can
degraded, do not use be found on the identification plate
the ladder
Ladder identification plate
Figure 1: Example of an elderly ladder with its side ropes

(inset) in an unsatisfactory condition
Figure 3: Failed pilot ladder, showing ladder identification plate location
Figure 2: Example of a failed pilot

ladder side rope

Arrangement
Requirements Requirements 16
16 Requirements
against the steps.
– Best Practice – Best Practice

– Best Practice
Vessels are expected to meet the requirements of the regulations as laid out
in SOLAS Chapter 5 Regulation 23 and IMO Resolution A.1045 (27). Vessels are expected to meet the requirements of the regulations as laid out
When not in use, the pilot ladder needs to be covered Vessels are expected to meet the requirements of the regulations as laid out in SOLAS Chapter 5 Regulation 23 and IMO Resolution A.1045 (27).
inFailure
SOLAS toChapter
provide 5compliant boarding
Regulation 23 and arrangements
IMO Resolutionmay result
A.1045 in your ship
(27).
being delayed or having pilotage cancelled with associated cost implications. Failure to provide compliant boarding arrangements may result in your ship
to avoid exposure to contaminants or other elements Failure to provide compliant boarding arrangements may result in your ship
being delayed or having pilotage cancelled with associated cost implications.
being delayed or having pilotage cancelled with associated cost implications.
Securing
Pilot
Pilot Ladders should not be Pilot Ladder should be secured
Trap Door Arrangements

Securing
Side ropes should be secured to secured around handrails which at deck level to a strong point
Securing Winch Reel

are not designed to be load
Securing Trap
WinchDoor
Reel Arrangements
deck strong points via rope stoppers
Ladders
bearing or certified for that use.
Pilot
arrangements
which are lashed to the side ropes
Securing Winch Reel

Pilot Pilot
shouldshould
Pilot Ladders not be not be Ladder should be secured
Pilot
using a ‘rolling hitch’ which leads so Pilot Ladders Pilotshould
Pilot Ladder be secured
Pilot
Pilot Ladders should not be
arrangements
Pilot Ladder should be secured secured around handrails which
should be secured at deck
to alevel to point
a strong point
arrangements
that the lashing seizes when weight is Side ropes to secured around handrails which The pilot ladder should
levelshould bepoint
Pilot
secured around handrails which Side ropes secured to at deck level strong
Side ropes should be secured to
Pilot
at deck to a strong should
are not be to be load
not designed
deck strong Pilotare
Ladders Pilot Ladder should be secured
points points viastoppers
rope stoppers
Ladders
applied to the ladder deck strong via rope not designed to be load extend above the lower
Ladders
deck strong points via rope stoppers are not designed to be load
Ladders
ropes should beside bearing or certified for that use.
secured around handrails which
use. at deck level to a strong point
Boarding
Sidewhich are lashed secured
to the to ropes
side bearingThe
or certified forwinch should
thatreel The platform
pilot ladder should
to the height of
Boarding
which are lashed to the side ropes bearing or certified for that use. which are lashed to the ropes Pilot Ladder
Side ropes should not be deck strongapoints viahitch’
rope stoppers are not designed to be load
Ladders
using a ‘rolling hitch’ which leads so using using
a ‘rolling‘rolling
hitch’ which whichso
leads leads so not be relied upon to support the pilot
bearing or certified for that use.
extend
the above
handrail theandlowerremain
andshould
Boarding
secured to the deck by shackles. which are
that lashed to
the lashing the side
seizes ropes
when weight is The Pilotwhen
ladder Ladder
thewinch reel should
pilot ladder is in use. platform
TheinPilot to the height
Ladder
alignment winch of
with reel
that the lashing seizes when weight is that the alashing seizeswhich
when weight
so is
As weight comes onto the ladder using ‘rolling hitch’
applied
leads not be relied upon to support the pilot nothandrail
the be and
relied remain
upon
against the ships side.to support the pilot
applied to the ladder applied to the to the ladder
ladder
that the lashing seizes when weight is
the shackles are likely to jam The Pilot Ladder should be in alignment
ladder when the with and
pilot ladder is in use.
Arrangement
ladder when the pilot ladder is in use.
secured
Arrangement
applied to the ladder against the ships side.
Side ropes should not be
against the steps. Side Side
ropesropes
should shouldnot be not be to a strong point, independent of the
Arrangement
secured to the deck by shackles. The Pilot
winch Ladder should be secured
reel. The Pilot Ladder should be secured
secured
securedSide thetodeck
toropes the deck
should by shackles.
not
by shackles.be to a strong point, independent of the
As weight comes onto the ladder to a strong point, independent of the
As weight to comes onto the ladder
Mechanical
As weight comes
secured theonto
deckthebyladder
shackles. winch reel. winch reel.
the shackles are likely to jam
Requirements
the shackles are onto
likely toladder
jam
Requirements
As weight
the shackles comes
are likely the
to jam
against the steps.
Mechanical Mechanical
Requirements
Securing of
thethe
against
against shackles are likely to jam
the steps.
steps.
Access
against the steps.
Securing of Access
Securing
Pilot Ladder to Deckof
–– Best
Best Practice
Practice
Pilot Ladder
– Best Practice
Winch Reel
Winch Reel
to Deck
Pilot Ladder
A mechanical device or locking pin Winch
should be Reel
Means
should be
Means provided
to ensure safe, convenient, and
provided
unobstructed passage for any
should be utilised to lock
A mechanical device or locking pin
person embarking on or
powered winch reels to prevent the unobstructed passage for any
should be utilised to lock A mechanical device
disembarking from,orthe
locking
ship.pin
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should be utilised to lock
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in in
SOLAS in SOLAS
Chapter Chapter 523
5 Regulation Regulation
andand
IMO 23 and IMO Resolution
Resolution A.1045 A.1045 (27).
(27). winch reel from being accidentally powered winch reels to prevent the
SOLAS Chapter 5 Regulation 23 IMO Resolution A.1045 (27). failure or human error.
operated as a result of mechanical winch reel from being accidentally
Failure to provide compliant boarding arrangements may result in your ship failure or human error. operated as a result of mechanical
Failure
Failureto to
provide compliant
provide compliantboarding arrangements
boarding arrangements maymay
result in your
result shipship
in cost
your failure or human error.
being delayed or having pilotage cancelled with associated implications.
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Trap Door Arrangements Accommodation Ladders and RetrievalLines

Retrieval Lines
Trap Door Arrangements Accommodation
Combination Ladders and
Arrangements Deck Lines
Retrieval
Deck
Combination
Trap Arrangements
Door Arrangements Accommodation Ladders and Tongues
Retrieval lines can be dangerous to both pilots and pilot launches. Retrieval lines
Accommodation Ladders andand

Ladders Tongues
Retrieval lines
pose a trip can be
hazard dangerous
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climbing bothifpilots and
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lowlaunches.
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the launch. The
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Combination Arrangements
line should
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when climbing and the
if strung too low may andfoul
leadthe launch. The
Door Arrangements
attached above last spreader forward.
The pilot ladder should line should be attached above the last spreader and lead forward.
Winch Reel Combination Arrangements

Wincharrangements
Reel Combination Arrangements
extend above the lower pose a trip hazard when climbing and if strung too low may foul the launch. The
The pilot ladder should The lower platform of the accommodation
line should be attached
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be a minimum in 5m
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The lower platform should
sea level. There is also a risk of pilot ladders
winch reel. There is also a risk of pilot ladders
The Pilot Ladder should be secured against the ships side. be a minimum of 5m above sea level. which are secured in this way
which are secured in this way
shouldofbe becoming detached from deck
Mechanical
to The Pilotpoint,
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tongues or hooks when in use.
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Winch Reel
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to ensure safe, convenient, and step should
step should
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person embarking on or unobstructed passage for any
should be
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disembarking from, the ship. person embarking on or
powered winch reels to prevent the should be
Means disembarking provided
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should be utilised to lock disembarking from, the ship.
powered winch reels to prevent the
operated as a result of mechanical
disembarking from, the ship.
Figure 4: ABP’s poster promoting best practice for the rigging of pilot boarding arrangements
failure or human error.
operated as a result of mechanical
failure or human error.
Retrieval Lines
Deck Issues with defective or non-compliant pilot boarding arrangements is
DeckTongues Deck a topic which the UK port marine and pilotage industry, including the
Issues with defective or non-compliant pilot boarding arrangements is Issues with defective or non-compliant pilot boarding arrangements is
Tongues
below organisations, have been working hard to highlight.
Tongues
a topic which the UK port marine and pilotage industry, including the
Retrieval Lines
pose a trip hazard when climbing and if strung too low may foul the launch. The a topic which the UK port marine and pilotage industry, including the
line should be attached above the last spreader and lead forward. below organisations, have been working hard to highlight.
below organisations,
We hope youhave willbeen working hard to highlight.
Retrieval Lines
be able to use this poster
DecktoWeraise
Deck Tongues should not
to raise awareness and compliment onboard IssuesWewith
hope you will
defective be able to usepilot
or non-compliant this poster arrangements is
boarding
be used to secure a Pilot ladder.
Deck
hope you will be able to use this poster
Deck Tongues should not education and training.
Tonguesawareness
Retrieval lines can
should
be dangerous to both pilots and pilot launches. Retrieval lines
not and if strung too low may foul the launch. The
Suspending pilot ladders from to raise
a topic whichawareness
the UK portand compliment
marine onboard
and pilotage industry, including the
Deck
poseTongues
a trip hazard when climbing be used to secure a Pilot ladder.
and compliment onboard Issues with defectiveand
or non-compliant pilot boarding arrangements is
be deck
36
tongues
|be
MAIB
or hooks imposes
Safety Digest 1/2022 education
below organisations, have training.
been working hard to highlight. MAIB Safety Digest 1/2022 | 37
line should be
Tongues
used
Retrievalto secure
lines a
canPilot ladder.
dangerous to both pilots andand
pilot launches.
forward.Retrieval lines Suspending pilot ladders from
Suspending
pose a trip pilot
attached
loads
ladders
hazard from
when
above
on the ladders
climbing
the lastthey
which spreader lead
and iftostrung too low may foul the launch. The
education and training.
deck tongues or hooks imposes a topic which the UK port marine and pilotage industry, including the
are not normally designed
deck should
tongues
line be imposes
or hooks attached above the last spreader and lead forward.
withstand.
loads on the ladders which they below organisations, have been working hard to highlight.
FISHING VESSELS
I suppose we can removed the backline from the pot hauler so we I saw him bob up from under the bow and climb clothing. After 4 hours, a passing yacht saw us
all look back on our were not attached to the seabed, while I went onto the upturned hull and we locked eyes for in between the swells and called the coastguard
past and think of into the wheelhouse to get the mending kit for a few seconds. Another swell rolled through who in turn paged Mudeford RNLI – the station
a few ‘close calls’ the pot on the gunnel. As I headed back to the but nothing like the one that hit us, and I swam I helm. The lifeboat crew were told we were
or incidents that pot, I noticed that it was being pulled over the over to the boat and climbed out of the water. I a sailing dinghy, so they had more than one
have occurred side of the boat as the bow lifted rapidly on a remember asking him if he was okay and then surprise when they turned up to find us instead!
while fishing. Some larger than usual swell, and I can only describe whether I was; he said I was bleeding. I was so
probably stand what I saw out of my forward windows as like full of adrenaline that I was unaware I had split I have replayed the event many times, both
out more than something from a Hollywood movie. my head open and was covered in blood. The in my head and in my sleep, and asked myself
others. I guess I next 4 hours were spent trying to stay on the what I could have done differently to change the
can say that I carry bottom of the boat, which was now the top. outcome.
a few ‘I owe you’ The noise was like The flood tide eased and the ebb started to
The boat was in very good condition, well looked
cards. I have been nothing we had ever push us back to where we went over, on top of
after with all the safety kit on board, and our
overboard twice, once with a rope around my leg Christchurch Ledge.
while shooting pots away on a crabber. On that heard before training certificates were up to date. Martin had
The wind was up, the swell was up, we were been working with me for 15 years and between
occasion, I chose to take a chance and jump over
On the horizon, coming towards us about half very cold and we now faced the possibility that, us we had 50 years’ experience of fishing that bit
the side with the pot before I lost my leg; luckily,
a mile in the distance, a large unbreaking black although we had survived the original upending, of water.
I managed to get my foot out of my boot and
make it to the surface. I was not wearing a PFD wall now obscured the views of the land 7 miles we were both doubtful of going back through it
The MAIB read the files regarding the incident,
and could not tell if I was swimming up or down on the other side of the bay. I shouted to Martin as there was now a wall of breaking seas of wind
but their conclusion was the same as mine: it
in the darkness but, as I broke the surface, I saw that we were shooting away “NOW!” as I put the over tide.
was a rogue wave – we could not have predicted
the boat facing me in the water, waiting to pick boat hard to starboard and increased the power
The bottom of the hull was only just out of the it or known it was going to happen. The boat,
me up. to my port engine, which was already in gear
water by a few inches, but it was enough for us equipment, paperwork, etc. were all in order,
going up the tide. I ran outside and threw two
to hang on. It had snowed in the previous weeks we had the forecasts, we had a plan – there was
My closest ‘scrape’ was a few years ago when pots over the starboard side to give me slack to
and so the temperature was cold and we were nothing we could have done to prevent it.
potting on Christchurch Ledge. The forecast was get the back rope into my pot ramp between my
SW 4-5, decreasing 3, with a 1.2m swell. The outboards and, as I was stood at the stern, the feeling the effects of that as well as being in wet
wind had already gone through by the time we wave ran on us. The noise was like nothing we
left port so all we had to contend with was a had ever heard before; I have seen a few waves
hard spring flood and a 4ft swell. We aimed to over the years, but this one was as far as the eye
haul just 100 pots and be back to meet the lorry could see inshore and out and breaking. The bow
at 1000, so a nice short day, or at least that was dropped vertically and 10ft of water was above us
the plan. Unfortunately for myself and Martin, – I was falling headfirst into the bow when I was
everything was literally about to go sideways! knocked out.
We hauled the first few strings of pots and were

catching above average numbers of good-sized What on earth would I PETE DADDS | Fisherman (skipper/owner) and volunteer helm at Mudeford RNLI
lobsters. The sun shone and the wind had gone
completely, leaving a glassy sea with a 3ft swell
tell his wife and kids? It was inevitable that Pete would grow up to work on boats, having spent his early childhood in and
around the boatyard where his dad was a foreman. When he was 13 years old, his brother took him
set coming through every few minutes – a lovely fishing and he was literally hooked, spending every spare moment of his teenage years either fishing
morning. At 0845, with one string left to haul, a The boat was upside down when I came to, on the beach or out on a boat. During school holidays and weekends he would earn his pocket money
nearby fisherman radioed to say he was going directly facing me and 15 metres away. As I helping out on the mackerel boat trips. When Pete left school, he enrolled on the Seafish Youth
home and that I was now the only boat there. I floated in the water supported by my PFD and Training Scheme where he worked on a variety of boats and built up the knowledge and experience
went out on deck to tell Martin that we would trying to take in what had happened it suddenly that eventually allowed him to buy his own boats, the latest of which is a 6.9m Cheetah catamaran that
finish hauling this string and head back in earlier dawned on me that there was no sign of Martin! he has owned and worked for the past 17 years.
than planned. The next pot came on board with My fish boxes and life rings had floated free but I In 1993, Pete joined Mudeford RNLI at a time when most lifeboat crews consisted of fishermen and is
a repair needed, just as a set of swells started to could not see my crew: What on earth would I tell proud to still be there as helm and their lifeboat trainer/assessor. He is also vice chairman of both the
roll through. Martin was on the winch and he his wife and kids? Mudeford and District Fishermen’s Association and the South Coast Fishermen’s Council.

17 17
A handy solution
stern trawler | accident to person
On board a large stern trawler, a crew member’s The vessel was fitted with three 15cm diameter security measure, a further stern line was in the crew member operating the hydraulic controls.
hand was crushed when it became trapped pins on each side of the boat. Hydraulically process of being put out, with the intention that His hand was then caught between the pin and
between a hydraulically operated trawl wire operated, they rose out of the deck and located the vessel end would be looped over one of the the deckhead (Figure 2).
guide pin and the deckhead at the stern of the into sockets in the deckhead (Figure 1). large diameter trawl guide pins in the transom to
vessel. The crewman needed surgery on his secure it. The company that owned the fishing vessel
damaged hand and fortunately made a full The crew had just completed moving their completed an accident investigation and a review
recovery. vessel to another berth within the port and had The injured man had rested his hand on the top of its risk assessments. Among the mitigating
secured its mooring ropes. As an additional of the pin just before it was raised by another measures identified, it undertook to paint
warning marks both on the top and bottom of
For illustrative purposes only: not to scale each pin so that the red warning paint on
the bottom appeared when the pin was
raised (Figure 3).
Trawl wire guide pins
Figure 1: Hydraulic trawl wire guide pins at stern of vessel Figure 2: Top of guide pin and deckhead socket
The Lessons
2. Hazard → In this case, the crew member absentmindedly placed his hand into a dangerous location.
1. Check → Working on any vessel is hazardous, particularly if there is moving machinery in the vicinity. If The company has taken steps to visually highlight the danger zone to remind workers of potential hazards.
machinery can be started or be caused to move remotely, then the machinery operator must check that the Emphasising hazards or hazardous areas around a vessel is a simple, cheap and effective means of reducing
workspace is clear before doing so. risks and can become part of onboard training. Getting crew to identify hazards and then to highlight them
can be an effective means of safety management engagement on board any vessel.

17 Figure 3: Guide pins with warning paint on the top and at the base
18
Water, water, everywhere
fishing vessel | fire
A large ocean-going squid fishing vessel was

moored alongside in a ship repair facility,
undergoing scheduled maintenance. Most of
the crew had gone on leave and the ship had
been left in the shipyard’s care. A welder was
carrying out repairs in one of the ship’s insulated
cargo holds and inadvertently set fire to some
insulation. Fortunately, he escaped from the
hold and managed to raise the alarm. Figure : The fishing vessel
As the fire intensified, it quickly spread to Post-accident investigations identified that no

adjacent holds and the ship’s accommodation. fire watch was maintained to help the shipyard
The local fire service fought the fire, assisted by a welder and no hand-held fire extinguishers were
harbour tug equipped with firefighting capability. available where he was working.
The firefighters and tug deluged the vessel
with water (see figure), which began to flood its Several months later the vessel was refloated,
hull. Because its crew were unable to start the but the fire and flood damage resulted in it
ship’s equipment and pump out the water, the being declared an insurance total loss and it was
ship became increasingly unstable as the hull scrapped.
continued to fill and it eventually capsized and
partially sank on the berth.
The Lessons
1. Risk → Hot work is always hazardous and a hot work permit should be in place before work begins. Risk reduction
measures should include maintaining a fire watch in and near the hot work site and ensuring first response
firefighting equipment is close to hand.
2. Procedure → When placing a vessel into a shipyard facility, its management and crew should check that safe
operating procedures are in place for the planned tasks; this includes ensuring availability of staff sufficiently
conversant with ship’s systems to be able to deal with most emergency situations.
3. Equipment → Vessel instability due to large volumes of water is an additional hazard when fighting fires on
board ships. To prevent this, make sure there are available means to remove water from decks and compartments.

19 20
The price of FAME? It came off in my hand
beam trawler | machinery trawler | man overboard
A 15m beam trawler suffered engine failure During the early hours of the morning, before
while fishing and had to be towed back to port daylight, the two crew on board a 10 metre
by a Royal National Lifeboat Institution (RNLI) trawler (see figure) were preparing for their
lifeboat. Nobody on board was injured and there second haul of the night. The weather was fine
was no external damage to the vessel. with a slight swell as the skipper and crewman,
neither of whom was wearing a personal
A service engineer’s investigation found that the flotation device (PFD), made their way onto
engine failure was caused by clogged engine fuel the deck. The boat was underway, steering by
filters, serious damage to the engine fuel system autopilot as the nets were hauled to the surface.
and contamination within the fuel tank, which Figure: Fuel filter clogged with diesel bugs The skipper was working the winch while the Figure: The trawler
resulted in extensive engine repairs and complete crewman waited for the net to be positioned so The skipper witnessed the crewman’s fall and
fuel system cleaning. that he could release the catch from the cod end quickly threw a lifebuoy into the sea before
into the reception hopper on the shelter deck. making his way down from the shelter deck
The trawler’s fuel supplier had recently started □ FAME and the associated water provide However, as the cod end was raised it became and into the wheelhouse. He was able to turn
to provide fuel containing Fatty Acid Methyl an ideal culture for microbial biological caught on the lip of the hopper so the crewman the boat and steer back to the area where the
Ester (FAME), commonly known as biodiesel. contamination, more commonly known as climbed up onto the net drum to pull it into the deckhand had gone overboard before stopping
DfT’s Renewable Transport Fuel Obligation diesel bug (see figure);
correct position. and calling out to him. The skipper was happy to
required that certain non-road mobile machinery
□ Diesel bug can cause expensive fuel system see the crewman only a few feet away, the unseen
vehicles burned FAME fuels; this regulation problems, resulting in blocked filters, When the crewman pulled on the netting to
applied to some inland waterway vessels, but lifebuoy floating a short distance from him.
damaged fuel pumps and injectors, a reposition the net, the section he was pulling
not to seagoing vessels. However, some suppliers contaminated fuel tank and, ultimately, The skipper threw a mooring rope towards the
suddenly broke and came away in his hand. The
mistakenly believed it was mandatory to supply engine failure. Modern common fuel rail crewman who was able to grasp it and be pulled
crewman lost his balance and fell from the net
seagoing vessels such as pleasure yachts and engines may be especially sensitive to this alongside. With difficulty, the skipper helped him
problem due to high operating fuel pressures drum to the deck below; landing upright on
fishing boats with a marine gas oil fuel that back on board.
and temperatures and large fuel return flow his feet he almost sat on the bulwark, but his
contained up to 7% FAME. back to tank; momentum carried him backwards over the
bulwark and into the sea.
FAME-based marine fuels present certain □ FAME can be corrosive to rubber and copper
challenges to safe engine operation: and lead to fuel system damage such as
leaking seals;
The Lessons
□ FAME is hygroscopic so tends to attract □ FAME fuels tend to oxidise quickly and should
the moisture often found in marine
environments;
not be stored for long periods. 1. Risk → Ultimately, it is better not to go into the water in the first place. In this case, the crewman was working in
a position where he was pulling towards the side of the boat and any failure would almost inevitably lead to him
going overboard. A moment to consider the risk of any activity, especially when something changes, is a moment
well spent.
The Lessons
2. Cold water shock → The sea temperature that night was about 11°C. Falling into water below 15°C can kill
1. Communicate → Suppliers should inform their customers that their fuel contains FAME. a healthy person in minutes. The initial gasp due to the shock of the cold water on your skin may result in water
entering your lungs, followed by hyperventilation and a dramatic increase in heart rate and blood pressure, which
2. Maintain → Fuel suppliers who choose to supply FAME to seagoing vessels should make sure moisture does can lead to cardiac arrest. If you are fortunate enough to survive the cold shock period, your body will soon begin to
not accumulate in their shore tanks and that the fuel is regularly tested for bugs. react to the cold and you will be unable to swim, climb a ladder or keep hold of a rope. In this case, the skipper was
extremely lucky that he found the crewman quickly and was able to assist his recovery. The outcome could have
3. Check → Vessel owners should check FAME fuel compatibility with the engine manufacturer. been very different if the skipper had been unable to locate the crewman or help recover him back on board.
4. Procedure → Vessels choosing to burn FAME fuel may require additional fuel filtration. 3. Equipment → Wearing a PFD when working on the open deck is strongly recommended and is also common
sense. Wearing a PFD increases your chances of survival and gives your rescuers more time and a better chance of
5. Action → FAME suppliers and users should use fuel stocks quickly to reduce the risk of oxidisation. locating you. Put simply, a PFD can save your life if you end up in the water.

21 21
Lookout for anchored vessels
fishing vessel and yacht | collision
Departing harbour around midnight, two It soon became evident that the fishing vessel The tow into harbour was uneventful and the
fishing vessels set off to deploy several fixed had hit a yacht anchored in the bay. The yacht’s yacht was placed on a slipway to assess the
nets. The standard routine was to leave the nets crew came on deck to see what had happened. damage. The split in the yacht’s side was larger
in place for about 3 hours before recovering Discovering a split in the port side of their yacht, than first appreciated and the water ingress had
them, at around sunrise, and then head back which was now taking on water, the yacht crew caused some internal damage, but there were no
into port. agreed to be towed into the nearest harbour. injuries. The fishing vessel was undamaged.
The anchor rope was released and the yacht’s
Having shot away their first net, one of the two crew donned lifejackets and started bailing
fishing vessels started to sort out their second the flood water out of their vessel. The partner
net on the aft deck. The net had become tangled fishing vessel arrived to check on the situation
so the skipper went aft to deal with it, leaving and its skipper remarked that his fishing vessel
his crewman in the wheelhouse. The vessel was had earlier passed near the same spot; he had
steaming along at around 3kts when there was a been travelling at 6kts and had not noticed the Position of the black ball day shape, indicating the yacht is at anchor
loud bang. anchored yacht.
Anchor light visible but obscured by presence of background lights
Yacht listing to port, with split in sidenot obvious as mainly below thewaterline
Figure 1: The anchored yacht post-accident againstbackground lights from the shore Figure 2: The anchored yacht listing to port, with (inset) the unorthodox anchor
light visible
The Lessons
1. Observe → The COLREGs are clear about the need to maintain an effective lookout by sight and hearing as 2. Action → The yacht was 6.7m in length and anchored close to shore. The yacht was equipped with a radar
well as by all available means appropriate. The fishing vessel was fitted with a modern radar and AIS, though reflector and had made some efforts to be visible at a reasonable range (Figure 2), but was not transmitting
the AIS had not been switched on. The fishing vessels were operating close to shore and the presence of on AIS. When at anchor and without a watch on deck it is prudent to make yourself as visible as possible
background lights made seeing the anchored yacht more difficult (Figure 1). The fishing vessel crew were not to other vessels in the vicinity. AIS can improve the visibility of small vessels and yachts to others operating
varying the radar range scale and had not obtained early warning of the risk of collision. nearby; however, a well-placed all-round anchor light with visibility of at least 2nm should be the minimum
action taken to maximise an anchored yacht’s chances of being seen.

21 Figure 3 Preparing the tow
21
3. Prepare → The fishing vessel crew realised that their bulbous bow would likely have damaged the yacht
below the waterline and quickly offered to tow the yacht into harbour (Figure 3). This decision reduced the risk
to life posed by the significant damage to the yacht’s port side. Emergencies rarely occur at a convenient time; it
pays to know where lifejackets are stowed, the location of leak repair equipment, that the bilge pump works and
is effective, and how to contact the local coastguard.
Bulbous bow on fishing vessel evident, hence the split below the waterline

22 22
A simple step... into danger
workboat | fatal accident
It was mid-afternoon and the fish farm ladder, but while the workboat was still moving
technicians, who had been on the water since slowly ahead, the team leader stepped through
about 0800, were cold, tired, and hungry. the gate (see figure) and onto the ladder. Before
The site team leader, who had missed the the workboat’s skipper could react, the team
opportunity to have lunch, asked one of the fish leader’s torso was crushed between the bulwark
farm’s workboat skippers for a lift to a moored gate and the barge ladder fender.
barge where he would be able to eat his lunch in
the warmth of the control cabin. The seriously injured team leader shouted in pain
as the workboat drifted away. A worker on the
The short passage to the barge was uneventful barge rushed to assist and took hold of the team
and the workboat skipper and team leader, leader’s PFD collar to prevent him falling from
who had often worked together, chatted on the the ladder. The team leader could not feel his legs
vessel’s bridge. They did not specifically discuss and shortly afterwards slipped out of his jacket
the transfer from the workboat to the barge, and PFD and fell into the water. He surfaced
which was regarded as routine. During the final seconds later, floating on his back but apparently
approach to the barge, the team leader made his unconscious.
way onto the deck in preparation for the transfer.
Despite being quickly recovered onto the
The sea conditions were slight as the workboat workboat, and the valiant efforts of the workboat
approached the barge and its skipper began crew, farm technicians and emergency services,
positioning the vessel. The team leader, wearing the team leader could not be resuscitated.
a PFD with unfastened crotch straps, stood ready
by the open bulwark gate. As the workboat’s
bulwark gate came level with the barge access
Figure: Reconstruction of the team leader stepping through the bulwark gate
The Lessons
1. Plan → The transfer of the team leader from the workboat to the barge was unplanned. Transfers to the 3. Equipment → There is usually no warning that you will need personal protective equipment. While it is
barge were usually made by a small rigid inflatable boat (RIB), not the larger workboats. Planning ensures sometimes hot or uncomfortable to wear, it is designed to save lives or minimise injury. Always make sure
that all involved, regardless of their experience, are aware of what is expected of them and what to expect of PFDs are fitted properly and securely, and with the crotch straps fastened, so that the wearer’s head remains
others. above water if they fall overboard.
2. Qualified → On board operations should always be directly supervised or delegated by the vessel’s 4. Procedure → Bulwark gates should be kept closed unless in use as an open gate poses an unnecessary
skipper to ensure that at least one person has a safety overview. It is easy to assume that experienced people hazard. On this occasion, keeping the gate closed until the workboat was in position and it was safe to
know what they are doing, but the team leader was primarily involved in small boat operations and was transfer would have avoided this accident.
unaware that he was taking a risk by stepping off the slowly moving workboat.

RECREATIONAL VESSELS
I have made my serious job, and we will not please everyone all help us as sailors to learn and develop and speed limit, not drinking alcohol, reading up
life and my career of the time. In the first article the flip side of one remind us of the basic but fundamental safety about their local area – then the outcomes may
on the water. To stunt to entertain some guests was a tragic loss cornerstones, which can often be overlooked have been different. If nothing else, this might
me being afloat of life, while the mixing of alcohol and boating when complacency or outside factors pull our pull us up short the next time we seek to cut a
represents ultimate in the second article also led to tragedy for a attentions elsewhere. corner.
freedom; to learn, novice crew; pushing a friend into the water
to challenge myself, was a foolish prank that resulted in far-reaching It is not just a lack of risk awareness that leads Going afloat gives so much to so many people.
to be self-reliant and lifelong consequences for many people. us into danger. As this digest demonstrates, it Boating is an incredible activity and I would
and to explore our The third article reminds us that heading out is often small and seemingly innocuous actions never want to dissuade anyone from giving it a
incredible planet. to sea without knowledge and experience can that can get us into the most trouble. When go. I use this digest to ‘keep me straight’ and it
But navigating quickly leave a crew out of control, reiterating the faced with a big and obvious risk I tend to act reminds me who I should be on the water and
a vessel on any importance of both carrying and knowing how to appropriately, perhaps in my case because I of my responsibility to keep myself and those
body of water use a valid means of calling for help. am scared, but like everyone else I am also around me safe.
carries an element of risk and the articles in this human and do not always stick to the rules
when conditions appear easy. One thing is clear
section demonstrate the tragic consequences It is not just a lack of through reading these articles: if each crew had
of both underestimating and disregarding the
hazards. As a single-handed round the world risk awareness that stuck to a set of safety rules – remaining in the
yachtswoman I myself may be considered a risk- leads us into danger
taker, and I would accept that label. However,
whenever I go afloat I am aware of the risks that I
take, I look them head-on, I mitigate them to the No day on the water should end in a fatality and
best of my ability and I am always ready to alter fortunately most do not. We are recreational
my plans with changing circumstances. water users and whatever we seek to find out
there, be it challenge, excitement, relaxation or
The three articles that follow are hard to read but escape, none of us should ever set off without
contain important lessons for us all to remember. fully understanding what could go wrong and
Our primary role as a skipper is to manage the how we would deal with it. Despite shining a
safety of our vessel and crew, which can be a spotlight on distressing events, these articles
PIP HARE | British yachtswoman, journalist and sailing coach

Pip’s professional sailing career spans 30 years. She has sailed most of the world’s oceans but only
found the opportunity to break into solo sailing 10 years ago, when she entered the OSTAR race from
Plymouth, UK, to Newport, USA. Since completing that race, Pip has worked her way through the
international ranks of ocean racing, competing in all of the major classes.
Pip has relied on grit and determination throughout, both in the sailing and to drive her own training,
race campaign and fundraising. She has built a solo racing career on her resolve to realise her dream –
and refusal to take ‘no’ for an answer.
Pip’s passion and drive is evident every time she gets on a boat and her achievements match her
enthusiasm: in 2020, with a tiny budget and a support team made up of volunteers, she qualified for a
place on the start line of the world’s toughest yacht race.
In June 2020, Medallia joined Pip as title sponsor for the Vendée Globe campaign, allowing her to
acquire a boat and recruit a small team to take on the world in November 2020.
Pip emerged as the skipper who smashed expectations and pushed her old boat to a performance
few thought possible. With one Vendée Globe complete, Pip is now well on her way to the next solo
circumnavigation in 2024.

23 23
Too close, too fast
motor yachts | fatal collision
Two large commercially operated motor yachts

(A and B) had been rafted up at an anchorage so
that the guests, who all knew each other, could
party together. Towards the end of the day, the
crew of yacht A asked their guests to return on
board so they could start heading back to their
marina berth for the evening.
Once everyone was on board yacht A, the skipper

went to the bridge and started the engines. On
deck, the mate lifted the anchor and then stowed
fenders once underway. Yacht A’s skipper opened
away in preparation for a close pass by the still
anchored yacht B, so the friends could wave
goodbye to each other.
During the close pass manoeuvre yacht A’s

skipper lost control and collided with yacht B’s
bow (see figure), fatally injuring the crewman
who was on the foredeck.
Figure: The damage to yacht B’s bow
The Lessons
1. Risk → Yacht A’s skipper intended to end a great day for the guests by delivering an exciting close 2. Procedure → At the time of the collision, yacht A was proceeding at over six times the local speed limit
pass manoeuvre. However, this was undertaken at short notice without a plan and the decision was for the anchorage. In the constrained limits of harbours and anchorages, speed limits are an important safety
heavily influenced by the guests’ desire to wave goodbye. The loss of control occurred due to a series barrier, intended to allow plenty of time for vessels to respond to developing situations. On this occasion,
of hydrodynamic effects, which would have been difficult to foresee and resulted in making yacht A yacht A’s high speed and yacht B’s proximity left no margin for error, with tragic consequences.
momentarily difficult to steer. Although guests’ wishes can be taken into consideration, professional crews of
commercially operated motor yachts must stay in control of their vessels and operate them safely.

24 24
Don’t swim near moving boats
inland waterways motor cruiser | fatal accident
Seven friends hired a motor cruiser (see figure) for a short break and planned to spend a relaxing designed for swimming from and so other members of the group helped those in the water to get out. To
few days cruising around an inland waterway area, celebrating a member of the group’s birthday. On keep them clear of the propeller, the swimmers were recovered from the side of the boat.
arrival at the boatyard, the skipper was quickly briefed on how to operate the onboard systems but
opted not to have a boat handling demonstration as he had previous boating experience. It was a one- After a change of driver, and with several of the group drinking alcohol, another person was pushed into
to-one briefing due to COVID-19 restrictions. the water. As before, the motor cruiser was stopped and reversed towards the swimmer, who made for its
stern. From the helm position, the driver could not see the swimmer behind him and was unaware of the
The group took their luggage on board and set off, cruising for a while before tying up for the night. They swimmer’s proximity; despite shouts from those on deck to get clear of the stern, the swimmer did not
left early the next morning, intending to reach their next overnight destination, a large town, by early react and was overrun by the boat, suffering a severe laceration to his left leg from the propeller.
afternoon. They stopped mid-morning for breakfast and then continued down river, stopping in the late
morning for a drink at a pub. The motor cruiser was stopped and two of the group got into the water to assist the casualty. Unable
to get him back on board, they dragged him to the bank and started first aid, including applying a
Underway again by midday, and with beautiful sunny weather, the friends started pushing each other tourniquet to his heavily bleeding leg. The emergency services were called and an ambulance and then
into the river as the boat motored along. Each time the person in the water was recovered back on air ambulance attended. The casualty was taken to hospital, but had lost a great deal of blood and
board, the boat had to be stopped and reversed. The motor cruiser had no boarding ladder and was not tragically could not be saved.
Figure: Inland waterways motor cruiser
The Lessons
1. Hazard → Whether intended, accidental or because of horseplay, entering the water close to a boat that 2. Risk → Everyone on board had been drinking alcohol during the morning, which they regarded as part
is underway can be dangerous. In hot conditions a swim might seem appealing, but a rotating propeller of the fun of being on holiday and unwinding. However, boats can be dangerous, with the capability to
presents significant hazards and should be avoided. Additionally, the local authority did not recommend cause harm to occupants and other water users. It is sensible to avoid alcohol consumption until the boat
swimming from boats in this area and, in this case, the motor cruiser did not have a boarding ladder. is moored securely. Alcohol can also affect your ability to swim and, if you do fall in, reduce your chances of
survival.
3. Equipment → Hire companies always supply lifejackets and advise that these are worn on exposed
decks. If you do fall in, a lifejacket will support you and keep your airways clear of the water until help arrives.
An unworn lifejacket is of no use.

25 25
Last orders at the bar
rigid inflatable boat | flooding
It was late afternoon on a beautiful summer’s help, and was able to respond quickly and rescue
day, but the sea was choppy and there was the three distressed youths. Shortly afterwards, a
a strong breeze. Three young adults were local lifeboat arrived at the scene and recovered
returning from an enjoyable day trip to a local the sinking RIB.
island in their 6m RIB, which was handling
the choppy water easily. As they approached The youngsters were unaware of a safety notice
their destination the sea suddenly and without published by the local harbour authority, which
warning turned very rough with steeper, warned mariners of the hazards presented by
confused waves. The crew could not understand a sandbar at the entrance to the harbour. The
why the sea conditions had unexpectedly safety notice highlighted that the tidal streams
changed, but the coxswain responded and could be as high as 6kts in the harbour entrance
reduced the RIB’s speed. during spring ebb tides and specified there was
an 8kts speed limit; mariners were also advised
Despite the coxswain’s actions, the RIB to exercise caution when crossing the sandbar.
encountered a series of short and steep waves Further harbour authority guidance indicated
that struck the boat heavily, one after the other. that the sandbar area was unsuitable for
These heavy blows caused a fibreglass step inexperienced mariners, even in relatively light
fitted to the buoyancy tube at the forward end to winds. It also stated that serious consideration
partially detach, allowing water into the tube (see should be given to not crossing the sandbar in
figure). The RIB quickly lost most of its buoyancy very strong winds.
and started sinking.
With the water level in the RIB rising and its

crew beginning to panic, the coxswain had the
presence of mind to use the boat’s VHF radio
and called for help on channel 16. Fortunately,
a passing vessel was close by, heard the call for
Figure: Detachment of fibreglass step from the buoyancy tube
The Lessons
2. Aware → This accident was not the first time boaters have been caught out by a sandbar and will not be
1. Hazard → Boating is a fun activity, but a day on the water is not without risk. Each area will have its own the last. By their nature, sandbars cause the water depth to become shallow very quickly, shortening and
hazards, which are liable to change quickly. Harbour authorities can issue Notices to Mariners that alert steepening any sea swell into large plunging waves, and can seemingly appear from nowhere, catching
harbour users to local dangers. These notices are often posted near harbour offices or access points. Always boaters unaware. Make sure you know where sandbars are and in what weather and tidal conditions it is safe
read and understand the safety advice for the waters that you wish to use. to cross them.
3. Margin of safety → RIBs are often constructed from several materials that vary in properties. For
example, fibreglass is rigid and will not flex at the same rate as the rubber tubes on which they are fitted. In
this case, the sudden flexing of the RIB’s rubber resulted in detachment of the fibreglass fixture. Know your
vessel’s design and sea condition limitations and take care not to exceed them.

INVESTIGATIONS REPORTS
started during the period 1 September 2021 to 28 February 2022 issued in 2021 and 2022
2021
Date Occurrence
19 September 2021 Auxiliary engine room fire on board Finnmaster, a Finland registered ro-ro cargo Minx / Vision Arrow
vessel, while departing Hull, England. Collision between a motor yacht and an anchored motor Grounding of a ro-ro freight ferry in the approach
yacht at Île Sainte-Marguerite, near Cannes, France on channel of Aberdeen Harbour, Scotland on 25 June
11 October 2021 Poisoning of a shore worker due to inhalation of phosphine gas being used as a
25 May 2019, with loss of 1 life. 2020.
cargo fumigant on board Thorco Angela, a Marshall Islands registered general 1/2021 Published 28 January 2021 8/2021 Published 2 July 2021
cargo vessel, in Liverpool, England.
16 October 2021 Capsize of Goodway, a single-handed creel boat, with the loss overboard and Finlandia Seaways Stolt Groenland
presumed death of its crew member near Cairnbulg in north-east Scotland. Catastrophic main engine failure resulting in an engine Cargo tank explosion and fire on board a chemical
room fire and injury to the third engineer on board a tanker in Ulsan, Republic of Korea on 28 September
cargo vessel, 11 miles east of Lowestoft, England on 2019.
25 October 2021 Grounding of Chem Alya, a Liberian registered chemical/products tanker in the
16 April 2018. 9/2021 Published 20 July 2021
Needles Channel, west of the Isle of Wight, England.
2/2021 Published 25 February 2021
Globetrotter
30 October 2021 Multiple fatalities during a stand-up paddleboard activity on the River Cleddau, Ocean Quest Foundering of a wooden hulled motorboat off the coast
near Haverfordwest, Wales. Flooding and foundering of a fishing trawler 70 miles of Fleetwood, England on 31 May 2020, with loss of 1 life.
north-east of Fraserburgh on 18 August 2019. 10/2021 Published 6 August 2021
24 November 2021 The presumed sinking of a migrant boat while attempting to cross the English 3/2021 Published 9 April 2021
Channel. The exact circumstances and the number of persons or vessels involved Shearwater / Agem One
has not been determined. However, evidence indicates that at least 27 migrants Diversion Immobilisation and flooding of a dredger following
either drowned or died of hypothermia. Carbon monoxide poisoning on board a motor cruiser repeated collisions with an unnmanned barge on
at the Museum Gardens quay on the River Ouse, York, 9 April 2020.
Our investigation will focus on the emergency response to the accident. If it is
England on 4 December 2019, with loss of 2 lives. 11/2021 Published 9 September 2021
determined that none of the events leading up to the fatalities occurred in UK
waters, the investigation will cease. 4/2021 Published 15 April 2021
Cimbris
13 December 2021 Collision between the UK registered general cargo vessel Scot Carrier and the Olivia Jean Crush incident on general a cargo vessel in Antwerp,
Danish registered construction vessel Karin Høj off the coast of southern Sweden, Crush incident on board a scallop dredger north-east of Belgium on 14 July 2020, with loss of 1 life.
resulting in 2 fatalities. Aberdeen, Scotland on 28 June 2019, with loss of 1 life. 12/2021 Published 22 September 2021
5/2021 Published 12 May 2021
12 January 2022 Double fatality on board Emma Louise, a motor cruiser berthed at Hamble, Norma G
England. Seadogz Capsize of a motor cruiser in the Camel Estuary, near
Collision between a high-speed passenger craft and a Padstow, Cornwall, England on 25 May 2020, with loss of
navigation buoy on Southampton Water, England on 22 1 life.
Correct up to 28 February 2022. Go to www.gov.uk/maib for the very latest MAIB news August 2020, with loss of 1 life. 13/2021 Published 14 October 2021
Interim Published 20 May 2021
Talis/Achieve
Beinn Na Caillich Collision between a prawn trawler and a general cargo
Crush incident involving a fish farm worker during vessel, resulting in sinking of trawler off Tynemouth,
transfer from a workboat to a feed barge in Ardintoul, England on 8 November 2020.
Glenshiel, Scotland on 18 February 2020, with loss of 14/2021 Published 3 December 2021
1 life.
6/2021 Published 26 May 2021 Key Bora
Grounding of a chemical tanker in the approaches to
Kaami Kyleakin Pier, Isle of Skye, Scotland on 28 March 2020.
Grounding of a general cargo vessel on Sgeir Graidach, 15/2021 Published 16 December 2021
the Little Minch, Scotland on 23 March 2020.
7/2021 Published 3 June 2021

2022
Stolt Groenland
Galwad-Y-Mor Rib Tickler/personal watercraft
Subsea explosion resulting in crew injuries and damage Collision between a RIB and a personal watercraft on the
to a fishing vessel off Cromer, Norfolk, England on Menai Strait, Wales on 8 August 2020, with 1 loss of life.
15 December 2020. 3/2022 Published 17 February 2022
1/2022 Published 20 January 2022
Diamond D
Flooding, capsize and foundering of a prawn trawler
20 nautical miles north-east of Tynemouth, England on
16 August 2020.
2/2022 Published 9 February 2022
Shearwater/Agem One
Correct up to 28 February 2022. Go to www.gov.uk/maib for the very latest MAIB news
Stolt Groenland
Achieve / Talis

SAFETY BULLETINS
issued during the period 1 September 2021 to 28 February 2022
MAIB SAFETY BULLETIN 2/2021

This document, containing safety lessons, has been produced for marine safety purposes only,
M A R I N E A C C I D E N T I N V E S T I G AT I O N B R A N C H
SAFETY BULLETIN based on information available to date.
The Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 provides
for the Chief Inspector of Marine Accidents to make recommendations at any time during an
investigation if, in his opinion, it is necessary or desirable to do so.
SB2/2021 NOVEMBER 2021
The Marine Accident Investigation Branch is carrying out an investigation into the fatal crushing
of a crewman on the upper vehicle deck of the roll-on roll-off ferry Clipper Pennant.
Extracts from
The United Kingdom
Merchant Shipping The MAIB will publish a full report on completion of the investigation.
(Accident Reporting and
Investigation) Regulations
2012 Regulation 5:
“The sole objective of a safety
Fatal crushing injury of a crewman
investigation into an accident
under these Regulations
shall be the prevention of
on the upper vehicle deck of the roll-on roll-off ferry
future accidents through the
ascertainment of its causes
and circumstances. It shall
Clipper Pennant Andrew Moll
not be the purpose of such
Chief Inspector of Marine Accidents
an investigation to determine
liability nor, except so far in Liverpool, England
as is necessary to achieve
its objective, to apportion
blame.” on 20 July 2021
Regulation 16(1):
“The Chief Inspector
may at any time make
recommendations as to how
future accidents may be
prevented.”
Press Enquiries:
+44 (0)1932 440015
Out of hours:
+44 (0)300 7777878
NOTE
Public Enquiries: This bulletin is not written with litigation in mind and, pursuant to Regulation 14(14) of the Merchant
+44 (0)300 330 3000
Shipping (Accident Reporting and Investigation) Regulations 2012, shall not be admissible in any judicial
NOTE
This bulletin is not written with
proceedings whose purpose, or one of whose purposes, is to apportion liability or blame.
litigation in mind and, pursuant to
Regulation 14(14) of the Merchant
Shipping (Accident Reporting
and Investigation) Regulations
2012, shall be inadmissible in
any judicial proceedings whose
purpose, or one of whose
purposes is to attribute or
apportion liability or blame.
© Crown copyright, 2021

See http://www.
nationalarchives.gov.uk/doc/
open-government-licence for Clipper Pennant
details.
All bulletins can be found on

our website:
https://www.gov.uk/maib
For all enquiries:

This bulletin is also available on our website: www.gov.uk/maib
Email: [email protected]
Tel: +44 (0)23 8039 5500
Press Enquiries: 01932 440015 Out of hours: 0300 7777878
Public Enquiries: 0300 330 3000

BACKGROUND
At about 1400 on 20 July 2021, the bosun of the roll-on roll-off cargo ferry Clipper Pennant
suffered fatal crushing injuries during cargo loading operations.
Clipper Pennant was in Liverpool and the bosun was working on the upper vehicle deck,
marshalling1 tractor unit drivers who were loading semi-trailers. Two other crew members were
Figure 1: Reconstruction of the semi-trailer parking arrangement, with inset view of the space (post-accident)
on the upper vehicle deck, assisting the bosun by locating the resting trestles and lashing the
semi-trailers once in position.
The accident occurred after the bosun had directed a tractor unit driver to push a semi-trailer into
its stowage location, between a semi-trailer that had already been lashed and the bulkhead at
the port forward end of the upper vehicle deck (Figures 1 and 2). As the semi-trailer was being
manoeuvred, the bosun had positioned himself between the moving semi-trailer and the vessel’s
structure, resulting in the crushing accident.
GUIDANCE
The Maritime and Coastguard Agency’s Code of Safe Working Practices for Merchant Seafarers
(COSWP) provides guidance for safe operations on vehicle decks and Section 27.6.3 states that:
● Personnel directing vehicles should keep out of the way of moving vehicles, particularly
those that are reversing, by standing to the side, and where possible should remain within
the driver’s line of sight.
● Extra care should be taken at the ‘ends’ of the deck where vehicles may converge from both
sides of the ship.
● Safe systems of work should be provided in order to ensure that all vehicle movements are
directed by a competent person.
Clipper Pennant’s Deck Safety and Procedures Guide included instructions for deck crew, which
stated that ‘during the loading of trailers, crewmembers must not stand behind the trailer. Never
walk behind a moving vehicle or position yourself outside the sight of the tug driver’.
INITIAL FINDINGS
All aspects of this accident are under investigation by the MAIB and a full report explaining the
causes and circumstances will be published in due course. Nevertheless, it is apparent from
the initial evidence collected that there is an extreme risk of crushing injuries in stowage spaces
adjacent to the vessel’s structure, with limited areas to remain clear or escape.
1
The marshaller, also referred to as the banksman, was responsible for supervising, controlling and directing
vehicle movements, using hand, whistle or radio signals with tractor unit drivers and other crew members.
1 2

ACTIONS TAKEN
Use of the port forward cargo stowage spaces has been temporarily suspended by the vessel’s
operator, pending futher investigation and assessment.
SAFETY LESSON
Bosun
Where tractor units are being used to push semi-trailers, safety procedures must be in place to
ensure that deck crew are not standing in the vehicle’s path.
Ship's Operators of vessels with roll-on roll-off vehicle decks are advised to:
structure
● Review their cargo handling procedures to identify the hazards associated with stowage
spaces where there may be limited areas for escape.
● Conduct a specific risk assessment for all such spaces. These spaces should then be
marked and, unless appropriate mitigating measures can be put in place, not used.
● Ensure that onboard safety procedures and crew safety briefings reflect the guidance in
COSWP Section 27.6.3.
Issued November 2021
Parked semi-trailers
Semi-trailer
Tractor unit
Figure 2: Graphic showing plan view of the semi-trailer’s approach to the parking
space
3 4

SAFETY FLYERS
issued during the period 1 September 2021 to 28 February 2022
Talis was on passage between Blyth and the Netherlands on a south-easterly course at 8 knots.
The bridge was manned by the chief officer and an able seaman as lookout. During the passage,
the chief officer worked at the chart table and ship’s computer.
Achieve was less than a mile away when Talis’s chief officer spotted a target on the radar about 30º
on the port bow. With the able seaman he looked out from the port side of the bridge and suddenly
SAFETY FLYER TO THE FISHING INDUSTRY spotted Achieve very close; he could see there was no-one in the wheelhouse. He sounded the
whistle then altered course to starboard, but it was too late to prevent the collision
Collision between fishing vessel Achieve (HL257) and general cargo ship
Talis, resulting in the sinking of Achieve off Tynemouth, England,
Safety lessons
on 8 November 2020
1. Keeping a proper lookout is fundamental to safe navigation. In fog, different methods are
Image courtesy of RNLI (Tynemouth) Image courtesy of Paul Gowen (shipspotting.com) required, which are usually focused on the radar and, if fitted, Automatic Identification System
(AIS). A proper lookout was not being kept on either vessel, and prior to the collision the skipper
of Achieve was not in the wheelhouse.
2. Achieve was not fitted with either a radar reflector or AIS, both of which would have made the
fishing boat more visible. However, once Talis’s watchkeeper had seen Achieve on the radar, he
lost valuable time assessing the contact rather than taking early action to avoid the collision.
3. Neither vessel was sounding fog signals. With the use of radar and AIS it is tempting to assume
that vessels will detect each other long before a fog signal is heard. However, when all else
fails, hearing a fog signal can give a valuable warning of danger
Narrative
On 8 November 2020, the 9m wooden prawn trawler Achieve collided with the 82m general cargo
ship Talis in fog. Achieve was severely damaged and sank while being towed to port.
Achieve had completed fishing and was heading back to Tynemouth to land its catch. It was on
a south-westerly course at 5 knots. The skipper was in the wheelhouse and spent some time
familarising himself with a new radar, which he had fitted two days previously. The deckhand was
working in the aft shelter deck, sorting the catch. At some point, the skipper went aft to check on
the deckhand’s progress with boxing the prawns. This flyer and the MAIB’s investigation report are posted on our website: www.gov.uk/maib
Reproduced from Admiralty Chart 156 by permission of HMSO and the UK Hydrographic Office
Blyth For all enquiries:

Marine Accident Investigation Branch
First Floor, Spring Place
105 Commercial Road Email: [email protected]
Southampton Tel: +44 (0)23 8039 5500
SO15 1GH
Publication date: December 2021
Talisʼs track
Extract from The United Kingdom Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 – Regulation 5:
“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012
Achieveʼs track shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an such
investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”
NOTE
This safety flyer is not written with litigation in mind and, pursuant to Regulation 14(14) of the Merchant Shipping (Accident Reporting and
Investigation) Regulations 2012, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to attribute
or apportion liability or blame.
Tynemouth
© Crown copyright, 2021
You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must
re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of
the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright
holders concerned.
Chart showing tracks of Talis and Achieve

Safety lessons
1. To undertake fishing operations safely, the vessel was normally operated by three crew. The
change of plan, from undertaking a delivery voyage only to then trawl for fish, meant that
there was nobody available to man the wheelhouse while the other crew were working on
deck, or to check for damage after the trawl doors hit the hull. The change of plan introduced
additional risks that were normally mitigated by the provision of a third crewman. Any change
SAFETY FLYER TO THE FISHING INDUSTRY of agreed plans or deviation from a standard operation should involve a brief step back and a
reassessment of the risks. Had this been done, the decision to fish with reduced crew might not
Flooding, capsize and foundering of the trawler Diamond D (SN100) have been taken, and the vessel might not have been lost.
north-east of Tynemouth, England, on 16 August 2020
2. All unattended spaces should be regularly checked. Had the internal spaces or the wheelhouse
been checked periodically, the crew might have noticed the flooding, or the sounding of the
bilge alarms warning of the flooding. Additional pumping capacity could then have been brought
into action to control the volume of water flooding on board.
3. Neither of the crew was wearing a PFD while working on deck. During the abandonment, the
skipper ended up in the water without a PFD and was lucky not to have succumbed to the
debilitating effects of immersion in the cold seawater. Because he was not wearing a lifejacket,
had he not been quickly pulled out of the water into the liferaft it is possible that he would have
drowned. If you do fall or jump into the water, wearing a lifejacket improves your chance of
survival because it keeps you afloat.
4. The crew’s activation of the EPIRB led directly to their timely rescue. This highlights the
importance of being familiar with how to use the emergency equipment on board your vessel.
This flyer and the MAIB’s investigation report are posted on our website: www.gov.uk/maib
For all enquiries:

Marine Accident Investigation Branch
Diamond D First Floor, Spring Place
105 Commercial Road
Southampton Email: [email protected]
Narrative SO15 1GH Tel: +44 (0)23 8039 5500
At about 1500 on 16 August 2020, the wooden-hulled 15.67m fishing vessel Diamond D capsized Publication date: February 2022
and sank after suffering hull damage and subsequent water ingress while trying to uncross its
towing wires.
Diamond D was on a relocation voyage when the two crew decided to undertake a trawl before Extract from The United Kingdom Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 – Regulation 5:
arrival into the River Tyne. While fishing, they picked up a heavy object in the net and accidentally “The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012
crossed the towing wires. The crew spent several hours working on deck, attempting to uncross shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an such
the towing wires, haul the net on board and free the heavy object. During this process the trawl investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”
doors were heard hitting the hull several times; it is likely that this caused hull planks or caulking NOTE
to become dislodged. Despite working on deck for a prolonged period neither crewman wore a This safety flyer is not written with litigation in mind and, pursuant to Regulation 14(14) of the Merchant Shipping (Accident Reporting and
Investigation) Regulations 2012, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to attribute
personal flotation device (PFD). The wheelhouse was left unattended and the bilge alarms, which or apportion liability or blame.
would have alerted the crew to the flooding, were not noticed until it was too late to take remedial © Crown copyright, 2022
action. The crew grabbed lifejackets and the vessel’s Emergency Position Indicating Radio Beacon You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must
(EPIRB), launched the liferaft and managed to abandon the vessel as it capsized. The EPIRB re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of
provided the rescue services with an accurate location and, about 1 hour later, they were rescued the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright
holders concerned.
unharmed.

Safety Digest: Lessons From Marine Accident Reports

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Safety Digest: Lessons From Marine Accident Reports

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SAFETY DIGEST

Lessons from Marine Accident Reports

Featuring introductions by Bob Baker | Pete Dadds | Pip Hare

Located in offices in Southampton, the MAIB is an

This Safety Digest draws the attention of the marine

This information is published to inform the

The editor, Clare Hughes, welcomes any comments

▶ By email to [email protected]; © Crown copyright 2022

CHIEF INSPECTOR’S INTRODUCTION 1

2. “I didn’t know that... !” 6

3. Stick to the plan 8

12. The fog of illusion 26

14. Drip, drip, drip, bang 30 RECREATIONAL VESSELS 52

VTS vessel traffic services https://www.rya.org.uk/knowledge/safety/know-your-limits

MAIB Safety Digest 1/2022 | 1

2 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 3

4 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 5

Moored hotel ship RoPax’s stern makes light contact

Wind Moored RoPax

6 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 7

Vessel strikes pile

Figure 2: Damage to bow and deck delamination

Figure 1: Workboat patrol route Normal route Route on night of accident

8 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 9

A survey vessel crew member was settling back

After a brief discussion and check of the cabin,

10 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 11

12 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 13

For illustrative purposes only: not to scale

100m towline unmanned, catamaran workboats

Figure 2: The emergency towline caught in WB1’s propeller

WB1’s port propeller

14 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 15

Figure 1: Bearing housing notches

16 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 17

For illustrative purposes only: not to scale

Second ferry’s propeller wash

Passenger ferry Second ferry

18 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 19

20 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 21

A passenger transfer vessel was approaching

As the vessel approached the turbine’s landing

The impact caused a bow indentation (Figure 1)

22 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 23

Figure: Gearbox damage and (inset) broken shaft

24 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 25

26 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 27

Wind Tidal stream

28 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 29

A naval auxiliary vessel was in harbour

The alarm was raised and the chief officer,

Figure: The partially deployed davit and lifeboat

30 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 31

Figure 1: The general cargo vessel aground on the shoal

32 | MAIB Safety Digest 1/2022 MAIB Safety Digest 1/2022 | 33

If the side ropes are

Ladder identification plate

Figure 1: Example of an elderly ladder with its side ropes

Figure 3: Failed pilot ladder, showing ladder identification plate location