Safety Digest - 1-2004 PDF

MARINE ACCIDENT
INVESTIGATION BRANCH
SAFETY
DIGEST
Lessons from Marine
Accident Reports
1/2004
is an
INVESTOR IN PEOPLE
MARINE ACCIDENT INVESTIGATION BRANCH
SAFETY DIGEST
Lessons from Marine Accident Reports
No 1/2004
is an
INVESTOR IN PEOPLE
Department for Transport

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Bressenden Place
London SW1E 5DU
Telephone 020 7944 3000
Web site: www.dft.gov.uk
Crown copyright 2004
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acknowledged as Crown copyright and the title of the publication specified.
Further copies of this report are available from:

MAIB
1st Floor
Carlton House
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SO15 2DZ
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February 2004
MARINE ACCIDENT
INVESTIGATION BRANCH
The Marine Accident Investigation Branch (MAIB) is an independent part of the Department for
Transport, the Chief Inspector of Marine Accidents being responsible directly to the Secretary of
State for Transport. The offices of the Branch are located at Carlton House, Carlton Place,
Southampton, SO15 2DZ.
This Safety Digest draws the attention of the marine community to some of the lessons arising from
investigations into recent accidents and incidents. It contains facts which have been determined up
to the time of issue.
This information is published to inform the shipping and fishing industries, the pleasure craft
community and the public of the general circumstances of marine accidents and to draw out the
lessons to be learned. The sole purpose of the Safety Digest is to prevent similar accidents happening
again. The content must necessarily be regarded as tentative and subject to alteration or correction if
additional evidence becomes available. The articles do not assign fault or blame nor do they
determine liability. The lessons often extend beyond the events of the incidents themselves to ensure
the maximum value can be achieved.
Extracts can be published without specific permission providing the source is duly acknowledged.
The Editor, Jan Hawes, welcomes any comments or suggestions regarding this issue.
The Safety Digest and other MAIB publications can be obtained by applying to the MAIB.
If you wish to report an accident or incident

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

The Branch fax number is 023 8023 2459.
The e-mail address is maib@dft.gov.uk
Summaries (pre 1997), and Safety Digests are available on the Internet:
www.maib.gov.uk
Crown copyright 2004
MARINE ACCIDENT INVESTIGATION BRANCH
The role of the MAIB is to contribute to safety at sea by determining the causes and
circumstances of marine accidents, and working with others to reduce the likelihood of such
causes and circumstances recurring in the future.
Extract from
The Merchant Shipping
(Accident Reporting and Investigation)
Regulations 1999
The fundamental purpose of investigating an accident under these Regulations is to determine its
circumstances and the causes with the aim of improving the safety of life at sea and the avoidance of
accidents in the future. It is not the purpose to apportion liability, nor, except so far as is necessary to
achieve the fundamental purpose, to apportion blame.
INDEX
GLOSSARY OF TERMS AND ABBREVIATIONS
INTRODUCTION
PART 1 MERCHANT VESSELS
1. Hands-on Training yes but Dont Lose Control!
10
2. Spontaneous Lowering of a Lifeboat
12
3. Low Pressure Not Low Risk
13
4. A Stopper That Didnt Stop
14
5. Late Changeover Leads to Grounding
15
6. If There is no Risk Assessment, Do Your Own
17
7. Out of Control
18
8. Unplanned Trip up the River
19
9. Tug Trauma
21
10. Ouch!
24
11. Quick Response to Vehicle Fire on Ro-Ro Ferry
26
12. What a Foul Up!
27
13. Who Put That There?
29
14. It Has Been Drained, But is it Dry?
31
15. Beware of Berths that Dry Out
33
16. Stay A Leading Light Use Them!
35
PART 2 FISHING VESSELS
37
17. Modifications Result in Loss of Stability, Vessel and a Life
38
18. Overloaded, Overdue, Over..
40
19. Too Much On Top
42
20. Quick Action Saves Fishing Boat and Crew
44
21. Winch Problem Leads to Capsize
45
22. Dodgy Alarm, So No Warning
47
23. A Fatal Override
48
PART 3 LEISURE CRAFT
49
24. Catamaran Capsize in Solent
50
25. Out of Sight, Out of Mind
52
26. Early Warning Headaches
54
27. Lookout! What Lookout?
55
MAIB NOTICEBOARD
56
APPENDICES
Appendix A Preliminary examinations and investigations started in the
period 01/11/2003 to 29/02/2004
57
Appendix B Reports issued in 2003
58
Appendix C Reports issued in 2004
60
Glossary of Terms and Abbreviations

AB
CO2
Able Seaman
CPP
Controllable Pitch Propeller
EPIRB
Emergency Position Indicating Radio Beacon
GT
Gross tons
Mayday
Spoken distress signal
Ro-Ro
Roll on roll off
RYA
Royal Yachting Association
VHF
Very High Frequency
VLCC
Very Large Crude Carrier
Carbon Dioxide
Introduction
Welcome to the first Safety Digest of 2004.
Regular readers will notice a couple of changes in
style; not only have we introduced colour, to try
to make the articles more readable, but we have
also, for the first time, asked non-MAIB people
to write the introductions to the three sections.
As part of our move to persuade the maritime
community to become more involved in our
work, you will find introductions written by wellknown and respected members of the
commercial, fishing and leisure industries.
Although the style might have changed, the
substance remains the same. Here are 27
accidents or incidents, all very different, reported
in (I hope) a straightforward manner, so that we
can all learn the lessons from the misfortunes of
others. Please take the time to consider them all.
For anyone operating a vessel commercially
merchant ship, fishing boat or leisure craft
there is a legal duty to report accidents. If you are
in doubt about the requirements, give us a ring,
or report it anyway we would far rather have
over-reporting than under-reporting. If you
believe accidents are being suppressed, rather
than reported, tell us (we have a legal duty to
protect our sources), or report it to the
confidential reporting system CHIRP.
MAIB Safety Digest 1/2004
For those who go to sea for pleasure, there is no

legal requirement to report accidents. However,
we would encourage you to report
accidents/incidents anyway. We have recently
tracked down an unidentified ship that collided
with a yacht and, in Case 27 of this edition, we
describe how we followed up a near-miss incident
in the English Channel, reported to us by a
yachtsman. If you dont report things, we do not
know the scale of the problem, and we cannot
try to improve matters. Do your bit for safety
report accidents/incidents.
Finally, I would like to draw readers attention to
the MAIB Noticeboard on page 56. This
replicates an important Safety Bulletin published
as a result of an accident that occurred on 30
January 2004, which had the potential to be
lethal. Although it happened on board a fishing
vessel, all mariners should take heed.
Stephen Meyer
Chief Inspector of Marine Accidents
April 2004
Part 1 Merchant Vessels

They tell us of something lacking. A lack of
planning, risk assessment, maintenance, training,
competence, pre-work briefings (called tool box
talks in the offshore industry), challenge,
management of change, accountability,
equipment, and so on and so on. Quite a list!
Quite an indictment!
I like a good read, and I always look forward to

the thump of the MAIB Safety Digest landing on
the doormat. And it is a good read. Draw the
curtains, make up the fire and settle into a
favourite armchair. Here are exciting tales of
adventure on the high seas, groundings, fire on
board, storm at sea and others. When you read it
from cover to cover you get a whiff of Joseph
Conrad in these tales.
But these tales are not fiction. These are not the
outpourings of the fevered imagination of the
Chief Inspector, Stephen Meyer, and his crew.
No imagination could have invented better
stories than these. This is cold, stark, mean
reality that is laid out before us. Lurking in these
pages are not the heroes and villains of fiction.
These are real, honest, decent people. Real
people who are getting hurt. Real people who are
getting killed. They could be our colleagues; for
some they are. When this sailor returns home,
adoring mothers, wives and children will not see
a happy smiling face. Perhaps they may never see
his face again. More than one life can be
wrecked in these adventures.
So these pages are not for entertainment; they
are for learning. And just like those collected
stories of fiction there are recurring themes,
themes we have seen before on these pages and
elsewhere. But unlike Conrad, these are not of
murder, greed, desire or revenge; these are much
more mundane and straightforward. These are
themes of inadequacy. They are about not
coming up to scratch, not cutting the mustard.
And why do these accidents always seem to

happen without warning? Well isnt that what an
accident does? But, hold on! Are they without
warning? Are not the warning signs there? They
just have to be looked for, hunted down,
observed, identified and dealt with. Then we will
see them for what they are, these same themes.
If one were to choose just a few themes to
concentrate on, which should they be? If I were
to choose they would be:
Planning no work should be considered
without a plan. For the complicated and
unusual tasks a proper one must be made in
advance, but for routine work it can be as
simple as tool box talks with all those to be
involved just before the work starts. What is
the job, what resources are needed, what
procedures exist, who will do what, etc?
Risk assessment a meaningful and thorough
risk assessment is essential to highlight the
hazards and risks and the actions to take to
lessen them. It will also show up the strengths
and weaknesses in training, equipment etc.
The risk assessment should be a living
document, visited frequently and always
aligned with the plan.
Management of change widely used in the
oil and gas industry, this allows you to deal
with unplanned events or changes, which
occur during the work. Being alert to changes
in weather, timing, berthing, equipment, etc.
and revisiting the plan and risk assessment
when they occur.
Challenge all those carrying out work must

continually question the work in hand and if
they are unhappy, even that slight unease in
the gut, then they should stop the job and
challenge the process.
So lets keep Joseph Conrad firmly on the
bookshelf and make sure all the characters of
OUR stories come home safe and sound. Lets
make sure they come home to their families
without harm. Stop and take time to think how
we can achieve this because, make no mistake, it
can be achieved. Ask some simple questions such
as:
How can I perform this task without injury to
myself?
And lets keep this admirable Safety Digest off the

bookshelf and well thumbed in the mess-rooms
and canteens of our workplaces. Do you have
enough copies and do you send them out to all
your ships? Discuss the stories on board and in
the office. Take a copy to the next safety
meeting.
Ask another simple question. Can this happen to
us? When reading these accounts we can all
recognise the familiar themes. Take action before
an event happens and you or your colleagues
become the main character in the next story the
Chief Inspector will write for the entertainment
of others.
Safe sailing.
How can I perform this task without injury to

others?
David Blencowe
David Blencowe is Area General Manager of Maersk Supply Service in the UK, based in Aberdeen. He is a
master mariner who has served in passenger ships, cross channel ferries and as master of offshore vessels. He
has a deep interest in safety of ships crews and is a member of the steering group on the offshore industrys
Marine Safety Forum.
CASE 1
Hands-on Training yes but

Dont Lose Control!
Narrative
A ferry was leaving port in daylight. The bridge
was manned, as normal, by the master, the chief
officer and a helmsman. However, instead of the
master handling the controls, the chief officer, as
part of his training, was manoeuvring the vessel
under the guidance of the master. The chief
officer had only recently joined the vessel,
having served a number of years as a pilot in a
different geographical location.
The ferry, which was fitted with a Becker rudder,
was required to conduct a port turn to exit the
harbour between two breakwaters. After
manoeuvring from her berth, she proceeded at
slow speed so as to keep sufficiently clear astern
of another departing ferry.
After the other ferry had cleared the harbour, the
chief officer, from his position at the port bridge
wing control position, ordered about 40 port
10
helm. He moved the pitch controls of both

propellers to 40% and then, on the masters
instruction, to 60% ahead. The vessel started
swinging, but her rate of turn was slower than
expected. The chief officer then applied full bow
thrust to port and, on the masters suggestion,
applied astern pitch to the port propeller.
As the vessel was completing the turn, the chief
officer applied 60% ahead pitch to both
propellers with the helm amidships. At this
point, the master walked to the starboard bridge
wing and noted that the vessel was moving
towards the breakwater on that side, due, partly,
to the tidal flow. He then ordered hard to
starboard helm and bow thrust to starboard in an
attempt to prevent contact with the breakwater
knuckle. Although the ferry started swinging to
starboard, the manoeuvre failed to prevent her
starboard side from striking the knuckle. The
master then took control and manoeuvred the
vessel back alongside.
CASE 1
The Lessons
1. The manoeuvre did not proceed as
expected. A successful outcome depends
on adequate planning, execution and
monitoring, and an ability to recover a
situation should things go wrong. In this
case, the chief officer was following a
manoeuvring plan which, although
normally achievable, was inappropriate
given the circumstances on the day.
The ferrys exit from the harbour was
delayed, resulting in her creeping ahead
to a position from which she was unable
to complete her normal turn safely, given
the prevailing cross-tidal flow. This was
because of her slow speed and close
proximity to the breakwater at the start
of the turn.
2. The chief officer had received no
specific guidance as to how to
manoeuvre the vessel out of the harbour.
He had observed previous departing
manoeuvres and did not feel it necessary
to receive a specific briefing on this
occasion. Equally, the master considered
it unnecessary to brief the chief officer
since he was aware that he had handled
the vessel before and was an experienced
pilot, albeit in a different geographical
location.
Although the manoeuvre was

inappropriate, the master failed to
intervene in sufficient time to prevent
the accident. This was due to his
misplaced confidence in the chief
officers ability, and the fact that his
position on the bridge caused him to
adopt an abnormal overall perspective.
In other words, he was not in an
appropriate position or mind-set to
monitor the chief officers actions
effectively.
Hands-on experience is an essential
element of training, but the risks should
be carefully evaluated, and the level of
supervision should be sufficient to
ensure that the master is able to restore
control immediately should things go
wrong.
3. The effect of a Becker rudder can be
significantly different to that of a
conventional rudder. Notably, the
application of large angles of helm can
reduce a vessels forward motion. This,
together with the tidal flow, contributed
to the slower than expected rate of turn
on this occasion. It is essential that
operators are made fully aware of this
effect before being required to
manoeuvre a vessel in confined waters,
particularly if they are unfamiliar with
high lift rudder systems.
11
CASE 2
Spontaneous Lowering of a
Lifeboat
The unusual direction of load on the aft
suspension hook damaged the boats stern, but
there were no injuries.
A later examination showed that the remote
release wire of the winch had not been set up
correctly, and had prevented its brake from being
fully applied. Reports from the crew also
indicated that there had been earlier incidents
where lifeboat winch brakes had not been
applied properly because of problems with
remote release wires.
Narrative
During a stay in port, a cruise vessel lowered
several of her lifeboats to the water for crew
training and engine testing. On completion, the
boats were hoisted to their stowed position and
their gripes secured.
Shortly afterwards, two seamen noticed that one
of the boats was not in its properly stowed
position, and released its gripes to re-position it.
However, before they were able to complete this
task, a senior officer instructed them to carry out
another job.
Shortly after this, the lifeboat with the released
gripes began to move very slowly from the
stowed position because its winch was paying
out.
The Lessons
1. It would have been sensible for the
senior officer to ask what the ratings
were doing to the lifeboat before he
diverted them to another task. He would
then have been aware that there was a
problem with this lifeboat.
2. The vessels safety management system
failed to take account of earlier reports
of similar winch brake release wire
problems to identify a safety-related issue
that required attention.
3. Care and attention needs to be taken to
ensure that remote operating wires for
winch brakes are properly adjusted.
Efforts to insert harbour pins, and apply the

winchs brake, failed to arrest the boats motion.
Realising that the boat could safely continue
lowering, and enter the water, crew entered the
boat to release the combined tricing/bowsing
gear. They were unable to do this properly and,
fearing for their safety, they climbed from the
boat.
The boat continued to slowly lower, until the
tricing/bowsing gear at the forward end pulled
free. Further lowering then caused the boats
bows to continue until they reached the water,
with the boat hanging by the stern (see figure).
12
CASE 3
Low Pressure Not Low Risk
Stairs to
lower level
Generator top
Narrative
A ro-ro ferry with over 400 passengers on board
was on an overnight passage. The watchkeeping
engineer was alone in the machinery spaces
when the automatic fire alarm activated.
When he investigated, the engineer found fire
around the top of a diesel generator. He rang the
engineers fire alarm and attempted to tackle the
fire using several portable extinguishers.
These efforts were only partly successful.
However, he found time to start another
generator, transfer the load and stop the affected
generator. He then tried to isolate the fuel supply
to this generator by going to the lower level of
the engine room. Although he was well aware of
the location of the fuel shut-off valve, he was
unable to find it. Realising he was in a dangerous
situation, he left the engine room.
By this stage, all other engineers had arrived to
assist, and the vessels full emergency procedures
came into play to effectively tackle the fire using
the CO2 smothering system.
Later examination of the generator found that a
low pressure fuel line had failed because it was
not properly secured. This had allowed heated
fuel and vapour to escape where it was ignited,

probably by the engines hot exhaust manifold.
The Lessons
1. The engineer was becoming seriously
affected by smoke inhalation by the time
he attempted to shut off the fuel supply
to the generator. This caused his senses
to be so impaired that he was unable to
find the shut-off valve; an item with
which he was very familiar.
2. It was most fortunate that the engineer
left the engine room at that stage, rather
than making further efforts to locate the
fuel shut-off; further delay might
literally have been fatal.
3. This incident is the latest in a series of
fires caused by leakage from engine low
pressure fuel lines. It again highlights the
importance of paying as much attention
to the condition of low pressure fuel
lines as is normally given to high
pressure systems, which are typically
seen as those posing the greater risk to
safety.
13
CASE 4
A Stopper That Didnt Stop

Narrative
The Lessons
A vessel was being warped along a quay. It was

daylight and the weather was fine. A team
comprising an officer and three seamen was
tending the aft moorings.
1. The sternline was a multiplait synthetic

rope. The stopper, which was a
singleplait synthetic rope, failed to stop
the sternline slipping under tension
while it was being transferred from the
warping drum to the bitts.
A sternline was led from a roller fairlead, through

a set of bitts, around a pedestal fairlead and on to
a warping drum. The officer was operating the
winch. On heaving the sternline tight, one of
the seamen used a stopper to secure the rope in
readiness for it to be turned up on the bitts. The
officer then reversed the warping drum, and a
second seaman began removing the slack rope
from the pedestal fairlead. While doing so, the
rope suddenly slipped through the stopper, thus
tightening, striking the second seaman and
causing him abdominal injuries.
If a stopper is to function effectively, it is

essential that it is applied correctly. The
Code of Safe Working Practices for
Merchant Seamen recommends the
West Country method (double and
reverse stoppering), which requires two
rope tails.
Ensure you have the right equipment to
do the job, and that those who are
required to use it are properly trained to
do so.
2. The casualty removed the rope from the
pedestal fairlead in the expectation that
the stopper would do its job. Both he,
and the officer in charge, failed to take
account of the possibility of the stopper
failing. Had they done so, they could
have ensured that he approached the
rope from the opposite direction, causing
it to move away from him when it came
under load.
Mooring operations, no matter how
routine they become, carry risks. By
thinking ahead, and planning for the
unexpected, many of those risks can be
avoided. Think on your feet and youll
stay on them!
14
CASE 5
Late Changeover Leads to Grounding
Narrative
A UK ferry was entering a Netherlands port in
good weather. The main engine control
changeover from sea to manoeuvring mode was
later than usual, and the engine control room
phoned the bridge to inform them that there
would be a delay in starting the bow thrusters.
The master decided to continue heading for the
berth at reduced speed, and to berth without bow
thrusters by walking out the starboard anchor.
Five minutes later, one of the main engines
stopped, followed three minutes later by the
other engines. The starboard anchor was dropped
and the vessel stopped. However, she was pushed
by the wind and tide into the mud on the
shoreline.
In this vessel, when the changeover of main

engine control from sea to manoeuvring mode is
initiated, the engine management system
automatically synchronises another alternator
with the switchboard. On this occasion, the
automatic process failed, and the system locked
up; preventing it from being reset. The lack of
capacity on the switchboard made the use of bow
thrusters impossible. Also, when the master
reduced speed, the main engine cooling system
could not respond. Hence, the main engines
overheated and shut down one by one.
The changeover from sea to manoeuvring mode
was carried out at the end of passage, rather than
before, as required in the standing orders. This
meant that the subsequent faults could not be
corrected in time to prevent the main engines
shutting down.
After restarting two of her main engines, within

ten minutes the vessel was able to continue and
to berth successfully, aided by one bow thruster
and two tugs. She sustained no damage.
15
CASE 5
The Lessons
1. Given sufficient time to rectify the fault,
this grounding would not have occurred.
The guidance given by masters and chief
engineers standing orders is the result of
accumulated knowledge and experience.
It should not, therefore, be ignored.
3. Control systems on modern vessels are

becoming ever more sophisticated.
However, they can and still do fail.
It is essential that control systems are
designed to facilitate manual override at
any time in the event of a failure, and
that ships staff are practised in manually
overriding these control systems quickly
and efficiently when necessary.
2. It is essential that the master is fully

briefed by the engine control room, when
problems affecting the safe navigation of
the vessel are encountered. Had this
master been informed of the full extent
of the problems, which led to the bow
thrusters being unavailable, he would
have been able to take appropriate action
to ensure the vessels safety. As it was,
he was only aware that there was a
problem with the bow thrusters.
16
CASE 6
If There is no Risk Assessment,

Do Your Own
Narrative
It was standard practice on board a small UK
tanker to rig a gangway from the poop deck. This
was secured at the top by looping chains through
roller fairleads, and securing them outboard with
bottle screws about 1m down each side of the
gangway.
When removing the gangway, shore riggers on
the quay would steady the lower end, while a
shore crane lifted the gangway slightly to take
the tension off the securing chains. A seaman
then stepped on to the gangway and released the
bottle screws, allowing the chains to be removed.
The procedure had been done many times.
No risk assessment on this procedure had been

carried out, and the seaman tasked with releasing
the chains was not using a safety harness. He
wasnt even wearing a lifejacket.
Once the chains were released, the gangway was
not secured to the vessel in any way. In this
condition, it was supported by a shore crane, and
was merely resting on the poop of the vessel.
Any movement in the vessel could have led to
both it, and the seaman, dropping free and into
the water or on to the quay.
On this occasion, while the seaman was facing

the vessel and undoing the bottle screws, the
shore riggers left the lower end of the gangway.
This allowed it to tilt and sway, nearly causing
him to fall off. It is thought that the riggers left
to assist in letting go another adjacent vessel
which was leaving the quay at the time.
The Lessons
1. If you are asked to do something which
you feel is unsafe, question it! The
procedure followed to release the
gangway was incredibly dangerous. The
fact that it had been done on many
occasions without incident was no reason
for anyone on board to have felt content
that it was safe.
2. A risk assessment, as described in the
Code of Safe Working Practices for
Merchant Seamen(Chapter 1) must be
completed, to cover the risks arising
from all work activities on board. Such a
risk assessment would have highlighted
the many dangers associated with this
procedure.
3. When working aloft or outboard, as in

this case, a number of safety precautions
must be taken. These are also described
in the Code of Safe Working Practices for
Merchant Seamen (15.2).
4. Using shore facilities and personnel to
assist in ships procedures other than
those for which they are specifically
employed, is dangerous. They are not
trained in shipboard operations, and are
not part of a vessels safety management
system.
17
CASE 7
Out of Control
Narrative
A vessels lifeboat, davits, and associated
launching/recovery equipment had been
overhauled, and the lifeboat was returned to the
vessel by lorry.
The lifeboat was positioned under the davits, and
two crewmen climbed into it to connect the hoist
wire of a mobile crane. The mobile crane lifted
the lifeboat and suspended it below the davit
heads while the crewmen attached the falls. They
disconnected the crane hoist wire, and stayed in
the lifeboat while the crane jib was lowered. The
davits took the weight of the lifeboat.
The Lessons
1. Would you climb into a suspended
lifeboat knowing that the davits, lifeboat
suspension hooks, and winch had all
been repaired but had not been loadtested properly?
2. Was this the only way to re-attach a lifeboat
to the falls? The falls could have been
lowered to the lifeboat and reconnected by
the crewmen. They could then have left the
lifeboat before hoisting began.
3. Does your vessel hold maintenance
information for the lifeboat and its
associated equipment? If it does not, you
should raise the matter in your next
safety meeting, since it is a requirement
to carry instructions for onboard
maintenance and repair work.
4. Is the person performing the
maintenance on your lifeboat competent
and experienced? They should not be
working on it if they are not.
5. If you are sent to perform a task on
board, do not assume that someone else
has considered all the hazards involved.
THINK about those hazards. Can a
hazard be avoided, or the risk be reduced
as far as possible? If not, speak up!
18
The maintenance work on the davit winch had

been performed without the aid of the winch
manufacturers data. Although untested, it was
then used to hoist the lifeboat until the limit
switch shut off the power.
Suddenly and unexpectedly, the winch began
to run out and, despite efforts to apply the
winch brake, the lifeboat continued to
plummet. It struck the edge of the quay and
plunged into the water with the two men still
on board.
The two crewmen were slightly injured and the
lifeboat suffered moderate impact damage.
This accident provides further evidence of

the hazards in operating and maintaining
lifeboats and their launching systems.
The MAIB Safety Study 1/2001 : Review
of Lifeboat and Launching Systems
Accidents (visit our website at
www.maib.gov.uk for further information),
points out that in the 10 years covering the
review, 12 seafarers died and 87 were
injured while training on, or testing,
lifeboats and launching systems.
Further examination of these accidents
found winches to be the most frequently
recorded source. Although no fatalities have
been recorded, some had the potential to
cause serious accidents.
Common faults occur in several winch types
which employ one way clutches, brakes and
switches. Often they do not operate as
intended, usually owing to shortcomings in
their maintenance, repair or adjustment.
As winches are often regarded as simple
items of machinery, and are readily
maintained by ships staff or engineering
contractors, their importance may not be
fully respected. As such, major overhauls
may be carried out without the knowledge,
experience or correct equipment that a
specialist contractor can provide.
CASE 8
Unplanned Trip up the River
Windlass after catastrophic failure
Narrative
A 2,240gt general cargo ship carrying packaged
timber was berthed on a river wharf starboard
side to, pointing downriver, during equinoctial
spring tides. She was secured by 2 26.5cm
(10.5") circumference head ropes and a 19cm
(7.5") spring forward; similar sized ropes were
used aft. Soon after the onset of the flood tide,
the tension on the forward ropes increased and
the bow was set slowly off the wharf.
As the chief officer made his way to the
forecastle to see what was happening, the fore
spring parted. The starboard anchor was quickly
let go using about 10m of chain cable, but this
failed to check the movement of the bow
towards the middle of the river. This caused the
port head rope to be lost overboard after being
pulled through the bollards upon which it had
been turned up. This left just a single mooring
rope forward, which also started to slip through
its bollards until it was secured by its eye. The

port anchor was then let go using a similar
amount of cable as before, but when applying
the brake, the windlass catastrophically failed
(see figure), and its shaft containing the winch
drums and associated fittings was wrenched from
the deck and pulled forward over the hawse
pipes.
Assisted by two able seamen, the chief officer
managed to secure the anchor cables using
chain cargo lashings. He then ordered the area
to be cleared because of the strain on the
remaining head rope. As the chief officer was
moving aft, however, the head rope parted and
struck him on the leg, which luckily was not
broken.
By that time, the master and engineer had been
alerted to the situation and had gone to the
bridge and engine room respectively. The
engine and bow thruster had been started and,
19
CASE 8
with the aft mooring lines having also parted,

the master tried to manoeuvre the ship ahead
using full rudder. This, however, was
unsuccessful because the ship was now aground
along some of her length. With the ship lying
across the river, and the flood tide gaining
momentum, the ship started to list. The list
increased to over 30 within 30 minutes and
caused some of the deck cargo, which had been
unsecured in preparation for discharging, to fall
overboard.
The Lessons
1. The selection of the sizes and types of
berthing ropes used on board ships is
largely a matter of commonsense and
good practice. A small coaster using
ropes usually associated with VLCCs
might appear to give a large safety
margin, but if the ropes cannot be
effectively secured, are stronger than the
deck fittings, or are too heavy to be
handled by the crew available, they might
prove to be a liability. It is in everyones
interest to ensure that mooring lines are
fit for purpose. Are yours?
2. It is basic seamanship to ensure that
mooring ropes are secured by a sufficient
number of turns around the bollards, and
that they are married. The potential
consequences of failing to adhere to
these well tried and tested practices can
be disastrous.
3. Environmental conditions vary from day
to day, from port to port, and from berth
to berth; they must never be taken for
granted. The need to keep a close eye on
the tidal and weather conditions is
20
Soon after, the ship refloated on the rising tide

and, although her list reduced considerably, the
master was unable to use the main engine to
control the ships movement because of an
apparent problem with the CPP control system.
The failure of the windlass also meant that more
anchor cable could not be paid out.
Consequently, the ship drifted helplessly up the
river and collided with three ships moored
alongside, before her anchors finally held and tug
assistance arrived.
particularly important in areas with

strong tidal streams and large tidal
ranges, where it is also prudent to seek
local advice. It is better to think ahead,
and take precautions such as putting out
additional mooring lines, or having the
engine on stand-by during critical
periods, than it is to try and respond to
lines parting in the middle of the night,
or with many of the crew ashore. Such
measures might be inconvenient and
unpopular at the time, but they might
also save the day.
4. Catastrophic failures of deck fittings and
equipment are uncommon, but do
happen. Therefore, to assume that a
winch or windlass is trustworthy,
because it looks solid and has stood the
test of time, is fraught with danger.
Dont be complacent when working in
the vicinity of any load-bearing
equipment you will always come off
second best.
5. It is worth remembering that most
machinery on ships is designed to operate
up to an angle of 22.5. Little can be
relied upon thereafter.
CASE 9
Tug Trauma
Narrative
When a refrigerated cargo ship, carrying empty
pallets, arrived at a pilot pick-up point, the port
control advised that the pilot would have to
board just inside the harbour because of the
strong gale conditions. Shortly after, port control
confirmed that the pilot was on his way and told
the vessel you can take it very easy.
By the time the pilot boarded, the vessel had

continued into the harbour and was only 4.5
cables from her berth. She had slowed further
and had lost steerage. The pilot hurried to the
bridge and, with the assistance of one of two tugs
in attendance, turned the ship beam-on to the
wind in readiness for berthing.
As the vessel entered the harbour, the mooring

teams closed up and made ready to come
alongside starboard side to. About 60m of 23cm
(9") polypropylene rope was taken from its
working drum and flaked out in readiness for use
as a spring (Figure 1).
During this manoeuvre, the pilot advised the

master that tugs would be secured forward and aft
using ships lines. The master immediately passed
this information to the mooring teams, and the
forward spring was quickly re-configured so that
it could be used by the tug. From its drum, it was
led between the bitts on the starboard side
(Figure 2).
The master had anticipated that a tug would

need to be secured aft for mooring, and had
briefed the aft team accordingly. As the ship was
fitted with a powerful bow thruster, the master
did not anticipate having to secure a tug forward.
Indeed, it was exceptional to secure a tug forward
in any port.
As soon as the tow line was secured to the tugs

hook, the tugs skipper manoeuvred ahead
because there was a danger of the tow line (of
which between 30m and 50m had paid out very
quickly) fouling the tugs propellers. The tug
opened from the vessels port bow, until the bight
was clear of the water. At about the same time,
Polypropylene rope flaked out for use as a spring

21
CASE 9
Rope led between the bitts on the starboard side
while the cargo ship was also being manoeuvred

astern and set by the wind, the officer in charge
forward ordered an AB to secure the tow line.
However, as the AB moved towards the bitts, the
tow line suddenly became very tight. It then
jumped over the lip at the top of the forward bitt,
and struck the AB on the upper front of the
body, causing him to be thrown 2m across the
deck.
22
The AB was conscious but had difficulty

breathing.
The officer in charge informed the bridge
immediately, and requested medical assistance
from ashore. The AB was taken to hospital,
where he died soon after from internal injuries.
CASE 9
The Lessons
1. Ropes and wires are a constant source of
danger for personnel working on deck,
and cause numerous deaths and injuries
each year. Many accidents of this nature
could be avoided if basic precautions are
taken, such as not standing in the danger
zone of a rope under tension, and not
standing in a bight. Such precautions,
however, are sometimes more easily said
than done, particularly when ropes and
wires come under tension without
warning, or the danger zone caused by a
rope under tension is not readily
apparent. In such circumstances,
teamwork is critical; several pairs of eyes
are more likely to spot the dangers than
just one. Therefore, when working on
deck, look after number one, but also
keep a weather eye on others. It could
save a life.
2. Sufficient time for preparation and
briefing is beneficial when conducting
routine tasks on deck; it is essential
when undertaking something out of the
ordinary. Ensuring that everyone
concerned, regardless of their experience
and knowledge, is made aware of what is
to be done, how it is to be achieved, what
equipment is to be used, and the safety
precautions to be taken, is a valuable
insurance policy; one which usually
yields high dividends.
3. When working with tugs, particularly

when securing or releasing, good
communication between pilots, masters,
mooring teams and tugs is essential.
Without it, co-ordinating the actions of
the ship and the tug becomes extremely
difficult. Everyone needs to be kept in
the picture.
4. When using VHF radio, although
expressions such as take it very easy
might be understood by most people,
they are open to interpretation,
particularly when english is not the
recipients first language. Such phrases
are, therefore, best avoided whenever
possible. Precise instructions might need
a little more thought, but they reduce the
potential for confusion, and possible
embarrassment.
5. When experiencing rough and
uncomfortable conditions at sea, the lure
of an alongside berth can be difficult for
a master to resist. Berthing in extreme
conditions, however, can be risky and is
seldom easy. It therefore requires careful
consideration. Although staying at sea
might be unpopular, occasionally it can
be the safer option.
23
CASE 10
Ouch!
Narrative
A surveyor requested a demonstration of a rescue
boat being launched from a 70m vessel while in
port.
To lift the boat from its chocks, the motor
controls were operated, but there was no
movement of the winch. The second engineer was
called to investigate and, with a view to raising
the boat by hand, the manual winding or crank
handle was inserted on to the winch brake shaft.
A crewman began to turn the handle to raise the
boat. Meanwhile, another crewman depressed the
hoist button on the winchs remote control box.
This started the winchs motor, which, in turn,
rotated the crank handle. The crewman turning
the crank handle was struck by it, before it flew
from its shaft into the sea. His arm was broken.
An investigation found the safety cut-off switch,
which should have isolated the power supply to
the winchs motor with the crank handle in

place, was defective. An external indication of
the defect, was the switchs operating lever being
able to rotate about 330, rather than the 60
quoted by the manufacturer (see figures).
This excessive movement allowed the internal
cam to move the switchs contacts from the
closed, to the open, and then to the closed
position. This final closed position allowed the
winch motor to be started with the crank handle
in place. However, with the movement limited
to 60 the switch would have moved just from
closed to open, as intended.
Further examination found that the switchs
operating cam had been modified several years
previously. This modification allowed the
excessive movement.
As an interim measure, a substantial external
stop was welded to the winchs body to prevent
unwanted movement of the switch lever.
Interlock switch lever
Correct position of interlock switch lever

24
CASE 10
The Lessons
1. Using replacement or modified
components that are not to
manufacturers specification can have
consequences that are not always easy to
predict. Particularly on safety-related
equipment, it is always prudent to use
manufacturers replacement parts.
3. Changes in operational procedures were

also made, by requiring the winchs
remote control box to be unplugged
whenever the crank handle was in place.
2. Having recognised the dangers of the

switch levers excessive movement, the
owners and crew sensibly made
immediate efforts to make the system
safe, by fitting an external stop.
330 rotation of interlock switch lever
Incorrect position of interlock switch lever
25
CASE 11
Quick Response to Vehicle Fire on

Ro-Ro Ferry
Narrative
A ro-ro passenger ferry was in the process of
loading vehicles on to her main vehicle deck.
Towards the end of the loading period, the deck
crew directed a lorry to the starboard side
amidships.
When the driver of the lorry switched off the
ignition, after having parked in the designated
position, a small electrical fire started in the
vehicle cab. He quickly informed the deck crew.
The response from the deck crew was immediate.
The Lessons
This case is one in which the crew put their
meticulously practised procedures into place,
which led to a successful outcome. The
lessons are therefore positives ones:
1. Incidents such as this one can happen at
any time where vehicles of unknown
condition are loaded onto a ro-ro vessel.
It is, therefore, imperative that crew are
vigilant at all times, and make regular
inspections of car decks, both before and
during sailing, so that a small fire is not
allowed to escalate into a larger one.
A CO2 extinguisher was used initially, followed

by a fire hose, to quench the fire and cool the
surrounding area. The master assessed the
situation, and decided the fire brigade need not
be called. He also ensured that the passengers
were kept fully informed throughout.
When the fire had been extinguished, a small
shunter truck was sent on board to tow the firedamaged lorry ashore.
The driver of the lorry suffered minor smoke
inhalation. The ferry eventually sailed 10
minutes late.
Keeping passengers informed about what

is happening, as was done during this
incident, will have the added benefit of
eliciting a much more helpful response
from them in the event of evacuation.
3. The ultimate decision as to whether the
fire brigade should be called to tackle a
fire lies with the master. Remember, the
fire brigade would rather arrive at the
scene of a fire, and find it already
extinguished, than deal with a far more
serious incident caused by hesitation
on the part of the crew in seeking their
help.
2. Any fire on board a passenger ferry can

lead to panic and confusion among
passengers if the crew do not respond
effectively and professionally. By
demonstrating their training in dealing
with such an emergency, these crew
members were able to reassure the
passengers, maintain calm and prevent
the outbreak of panic.
26
CASE 12
What a Foul Up!

Narrative
A totally enclosed lifeboat was boarded by its
crew and a number of others for a practice drill.
All were on board with their seat belts secured.
Once everyone was ready, the coxn pulled on
the winch brakes remote release wire. The
davits arms began to swing out and the
automatic gripes released.
The process continued without a hitch until the
davit arms were fully swung out and the boat
began to lower. The boat started to lean in
towards the ship, its stern continuing to lower
and its bows not moving. As lowering continued,
the rotation increased until the boat was almost
on its beam-ends and with its stern hanging
down. At this stage the aft lower block came free
from the suspension hook. Operation of the

brake stopped, with the boat hanging from the
forward suspension hook.
Some of those in the boat slipped involuntarily
from their seat belts. Various pieces of gear broke
free and tumbled about the boats interior. There
were a number of minor injuries.
The aft suspension hook was re-engaged and the
lifeboat was safely lowered to the water. There
was serious damage to the davits arms, and the
unit was taken out of service.
An investigation concluded that the ring on the
released end of the forward gripe, instead of
safely sliding over the lifeboats canopy during
lowering, had fouled on the gripe bobbin
attached to the lifeboat (see figure).
Gripe bobbin
27
CASE 12
The Lessons
1. This incident could have had much more
serious consequences. It shows that even
well maintained systems can suffer the
most unexpected problems.
3. If the gripe wire end rings are large

enough to fit over an attachment on the
lifeboats exterior, be sure that eventually
it will happen, and probably during
launching. Consider changing the rings
dimensions or attachments so that
fouling is impossible.
2. During practice launchings, it is prudent

to have a person on deck who can ensure
that all is running freely, and who is able
to halt the operation in the event of
problems.
28
CASE 13
Who Put That There?

Narrative
Immediately after a ro-ro ferry, with 54
passengers and 40 crew on board, entered the
approach channel of a port she routinely visited,
she grounded at a speed of 8 knots. The ferrys
draught was 5.8m, the charted maintained depth
of the channel was 6m, and the height of tide
was 1.42m. The approach channel was prone to

silting, and a warning to this effect was shown on
the appropriate Admiralty chart.
Fortunately, because the bottom was soft silt,
nobody was injured and the ship was undamaged.
She was refloated about 2 hours later on the
rising tide.
29
CASE 13
The Lessons
1. When a channel of maintained depth is
shown on a chart, it is probably not
unfair to assume that most mariners
consider the depth shown to be reliable.
Unfortunately, this is not always the
case. Some areas are particularly prone
to silting at varying rates depending on
tidal and weather conditions. This can
make it very difficult for port authorities
to maintain channels to the depths
advertised, and their failure to do so can
spoil a masters day, particularly if no
warning is given. Dont take maintained
depths in channels, or at alongside
berths, for granted; make sure you have
the latest information from the port or
harbour authority. Where doubt exists,
at least proceed with caution.
30
2. Echo sounders appear to be used less and

less, possibly due in part to the improved
accuracy and reliability of both charts
and navigation systems in recent years.
When in restricted waters, however,
particularly where survey information is
old or scant, or where the nature of the
seabed is known to change, it is
foolhardy to ignore them. Take the
opportunity to compare actual against
expected depths. It costs nothing, and
might prevent your aspirations becoming
high and dry.
3. Warnings, cautions, and notes on
navigational charts are there for a
reason. Dont ignore them!
CASE 14
It Has Been Drained, But is it Dry?
Narrative
A 3,500 tonne ro-ro cargo vessel was on passage
in restricted waters to carry out sea trials
following her main engine being converted to
run on gas oil. About 4 hours after leaving her
berth, the fire detection system in the
wheelhouse indicated there was a fire in the
engine room.
The engine room was manned, and the chief
engineer reported to the master within 5 minutes
of the alarm sounding, that there was a fire in the
economiser and that it was being attacked with
hand-held extinguishers. The general alarm was
sounded and the crew were mustered. It became
apparent that the fire could not be controlled by
hand-held extinguishers, and the master and
chief engineer decided to use the CO2 fixed firefighting system. With the masters permission,
the chief engineer stopped the main engine and
the vessel grounded lightly on the mud-lined
shore.
Twenty five minutes after the initial alarm, the

crew were all accounted for and the engine room
was battened down ready for CO2 flooding. The
first charge of CO2 was released and the fire
brigade was called. Boundary cooling was
established, and 10 minutes later, two of the fire
officers boarded the vessel. A second charge of
CO2 was released as a precautionary measure.
Ninety minutes after the first release of CO2, and
on the fire brigades advice, the engine room was
opened up to allow ventilation of the space. A
fire party in breathing apparatus entered the
engine room after a further 40 minutes. They
reported that the fire had been successfully
extinguished, and 412 hours after the initial
alarm, the fire brigade confirmed that the engine
room was safe to enter without breathing
apparatus.
The vessel was towed back to her berth, where
the cause of the fire was investigated. Since she
had been converted to run on gas oil, there was
31
CASE 14
no longer any need to heat the fuel. This led to

the thermal oil waste heat unit being drained
and isolated, as it was no longer needed. The
manufacturers stated that it was safe to operate
with the unit drained and opened to atmosphere.
This was done by removing the oil inlet and
outlet headers at the bottom of the unit.
The Lessons
1. When taking equipment out of service, it
is essential that all possible dangers are
identified and eliminated. Had it been
known that the tubes were coiled, it
would have been clear that oil residues
were likely. The unit could then have
been flushed through. An assumption
that the unit was fully drained led to a
serious fire.
However, the horizontal tubes took the form of

coils, so some thermal oil remained in the unit.
When the exhaust gasses heated it sufficiently,
this oil ignited.
3. The assistance of the fire brigade was

useful and very welcome. Not only were
they able to give the master good advice,
they also assisted with specialist
equipment and in ensuring that the fire
was fully extinguished.
2. The fire was tackled quickly and

effectively. The decision to use CO2 was
taken early enough to ensure the best
possible outcome. As a result, there were
no injuries and the damage was minor
and local to the seat of the fire.
32
CASE 15
Beware of Berths that Dry Out
Narrative
A 58m length general cargo vessel entered a port
on the north coast of France to load a cargo of
stone. The vessel had used the port on many
occasions in the past without problems. There
was a high tidal range at the port, and the berth
dried out at low water. Normally, the sandy
bottom was level, but a westerly gale had blown
into the harbour, which had caused sand to build
up at the ends of the berth.
A substantial amount of cargo had been loaded
by the time the vessel took the bottom, with the
tide still falling. She broke her back. The double

bottom was unaffected, but the deck plating
crumpled around amidships when the hull sagged
on the uneven surface. The ships sides were
crumpled in a V shape, with a deformation of
about 200mm at the deck edge, tapering down to
nothing at the double bottom.
The cargo was discharged, and when she floated
she straightened out. Although the ship was
damaged, it was considered safe for her to sail to
a port of repair. This was reached without
incident.
33
CASE 15
The Lessons
1. Using berths that dry out can be safe,
but the hull must not be overloaded. In
the case of a flat-bottomed vessel, the
master should satisfy himself that the
surface of the ground at the berth is
fairly level, before heavy cargo is taken
on board. This check is not so important
with soft mud, but it could be crucial if
the bottom is hard sand, as was the case
with this accident.
34
2. When a vessel uses a port regularly it is

easy to assume that everything will be
fine. If the bottom is hard sand, dont
make this assumption. If the flatness of a
berth is in doubt, it should be allowed to
dry out, and an inspection should be
carried out before a vessel uses it to load
heavy cargo.
CASE 16
Stay A Leading Light Use Them!
Narrative
Early the next morning, after a smaller vessel had

entered the port without difficulty, the harbour
authority considered that the conditions had
moderated sufficiently to also allow the tanker to
enter. The wind at the time was onshore between
25 to 30 knots, with a moderate swell and a flood
tide. It was dark.
was advised by the pilot embarked in a cutter,

that in view of the conditions, he would board at
the harbour entrance rather than the normal
embarkation point in the vicinity of the fairway
buoy. He was also instructed to manoeuvre well
south of the fairway buoy before making an
approach. The tanker, however, initially passed
to the north of the fairway buoy, and about 15
minutes later, was still about 0.5 cable north of
the intended track of 236, indicated by leading
lights. At this point, the master altered course
about 25 to port, to bring the ship further south.
Although the tanker then crossed the intended
track, course was not adjusted back to starboard,
and shortly after, the tanker grounded just inside
the harbour entrance.
After weighing anchor, the master, who was

accompanied on the bridge by an AB helmsman,
She was later refloated on the rising tide, and

there was no pollution.
On arrival at her port of discharge, an oil tanker

carrying about 3000 tonnes of gas oil was advised
that the conditions were too severe to allow her
to enter. The tankers master, who had recently
joined the ship and had never previously visited
the port, decided to anchor in its approaches.
35
CASE 16
The Lessons
1. Entering a port for the first time,
without a pilot and in adverse conditions,
while feasible, carries additional risks. If
in doubt, dont do it. Nobody will thank
you for trying, but getting it wrong.
Equally, it would be prudent for harbour
authorities to determine the masters
experience before inviting him to enter
what would normally be areas of
compulsory pilotage.
2. Ignoring navigational advice given by
port authorities can be perilous.
Sometimes, such advice might seem
irrelevant or unnecessary, but it is
usually based on experience and the
knowledge of local conditions; unless
there are sound safety reasons for not
doing so, such advice is best adhered to.
3. It is important that bridge organisation
and manning is adjusted to meet the
changing navigational situation. Passage
through restricted waters, particularly
without the assistance of a pilot, is
usually very demanding and requires a
masters unerring concentration. With
the presence of numerous distractions on
a modern bridge, this can only really be
achieved if there are enough people
available to share the load. Good bridge
management is an essential requirement
to keep any ship safe. Is yours up to
scratch?
4. When operating in restricted waters, in
adverse weather or strong tidal streams,
the importance of the use of headmarks,
36
transits, leading lights, and radar parallel

indices, should not be underestimated.
When applied correctly, these methods
can provide a real-time indication of
position relative to planned track, give a
rapid assessment of the set and leeway
induced by the prevailing conditions, and
allow the ship to be navigated with great
accuracy. Successful application,
however, requires the methods in use to
be continuously monitored, crosschecked, and practised. Sadly, however,
with the advent of electronic charts, and
the reliance on pilots, there is a tendency
for bridge watchkeepers to dispense with
leading lights and other visual pilotage
techniques. Such skills are not purely the
gift of pilots, so dont let them fade away.
5. Running a transit ahead, like most
things, takes practice, and when left to
their own devices, inexperienced officers
are usually only on track when they
cross it!
Nothing can replace practical experience,
but a few tips when running a transit are
worthy of mention:
A quicker assessment of tidal set and
leeway is usually achieved by getting
on track early;
Take care not to overshoot; and
Beware of the fact that the sensitivity
of transits, which is a function of the
distance between the two marks,
relative to your range from them,
varies considerably.
Part 2 Fishing Vessels

sometimes occur over a period of time whereby
the vessel has been constructed for one particular
fishing pattern, and has changed to another.
Other effects on stability can be the overloading
of fishing gear on deck, along with the unwanted
fastener/boulder which may occur at any time
whilst fishing.
Having been asked to write this introduction to

the fishing vessel section of the Safety Digest, it
strikes me that many fishermen are unaware of
the role that the MAIB carries out. The MAIB
investigates accidents which occur in our
industry, and produces a report of the accident so
that we, as fishermen, may learn lessons to
reduce the possibility of this occurring again in
the future.
In this issue of the Safety Digest, you will read
about a number of accidents and incidents which
have occurred to all types of fishing vessels. In a
number of cases here, a key area is stability.
Stability is difficult for most of us to understand,
but in some of the cases you are about to read,
what becomes clear is that stability has been
greatly affected by modifications. These changes
So what is stability in fishing vessels? Stability is

the ability of your vessel to right itself to the
upright position after it has been forced over by
an external force. But if modifications are made
to the vessel, these changes can severely restrict
the vessels ability to come to the upright
position, and can, in extreme cases, cause the
vessel to overturn.
So what can we, as fishermen, do to ensure the
stability of our vessels? We need to ask advice
from a suitably qualified person before we make
any modifications to our vessels, no matter how
small that change may be. We need to be aware
of the capabilities of our vessels, and be prepared
for the unexpected. Remember, stability cannot
be measured, it needs to be calculated.
Take care when fishing, return home safely.
George Geddes
An experienced seine net and trawl skipper, who is also a representative of the Scottish Fishermens
Federation. George is currently a part-time instructor for the basic fishermens safety courses, and has recently
completed a diploma in Safety and Risk Management. He is skipper/owner of a 21m twin rig trawler working
out of north east Scotland.
37
CASE 17
Modifications Result in Loss of

Stability, Vessel and a Life
Narrative
A 10-metre vessel was single-handedly trawling
for prawns. It was dark, and the weather was fine
and clear with light winds.
While hauling, it became apparent that a heavy
object had entered the net. The skipper tried to
clear it by hauling on the dog rope, but this
parted under load. He then wound as much of
the net as he could on to the net drum and
started to tow the heavy object towards port,
where he intended to get help to remove it.
During the tow, the skipper established radio
contact with the coastguard, but
communications were suddenly lost. A search for
the missing vessel was initiated.
38
The vessel was subsequently found on the

seabed. The skippers body was recovered from
the wheelhouse, and the vessel was later raised
and inclined to establish her stability at the time
of her loss. The heavy object was found to be a
large rock.
The inclining experiment, and its subsequent
analysis, indicated that her inherent stability had
been poor. The vessel had been modified
extensively: the gunwale had been raised and a
shelter and net drum had been fitted, all of
which reduced her inherent stability. The result
was that it would have taken little to capsize her
so suddenly that the skipper did not even have a
chance to get out of the wheelhouse.
CASE 17
The Lessons
1. Without a stability standard, adequate
stability awareness, and knowledge of the
loading limits of their particular vessel,
skippers of fishing vessels under 15
metres in length are severely hampered
in their ability to judge when it is safe to
lift, tow or carry heavy loads.
Knowledge of a vessels stability and her
loading limits is, therefore, an essential
control measure aimed at reducing the
risk of capsize. To this end, skippers
should take advantage of the one-day
safety awareness course offered by
Seafish, and seek professional advice,
particularly following any significant
modifications.
2. The Code of Practice for the Safety of

Small Fishing Vessels does not stipulate
any stability requirements for fishing
vessels under 15 metres in length.
However, it does require the fitting of a
bilge alarm, which provides early
warning of flooding, and ensures those
on board have time to react. This vessel
did not have a bilge alarm. Therefore,
her skipper would not have been
automatically alerted to any ingress of
water which would have affected the
vessels freeboard and stability.
39
CASE 18
Overloaded, Overdue, Over..

Narrative
A 6.5m creel boat failed to return to port as
planned. A search began, and she was found
partly submerged several hours later. The vessel
was recovered, but there was no sign of her crew
of two. It was concluded that the vessel was lost
because of poor stability caused by material
alterations, overloading and water ingress.
During the creel boats 25 years in service,
substantial modifications had been made to her.
In particular: the raising of gunwales, the fitting
of a deck (which was not watertight),
enlargement of the wheelhouse, the addition of
an hydraulic pot-hauler and the fitting of ballast.
All would have significantly changed her

stability characteristics. The insertion of freeing
ports above a non-watertight deck would also
have increased the probability of water
accumulating in the bilge.
The vessel had recently changed ownership, and
the previous operators maximum load on deck
was sixty creels. At the time of her loss, she was
carrying ninety.
The vessel was not fitted with a bilge alarm, and
her electrical bilge pump was defective.
Lifejackets were found in the vessel, but a liferaft
was not carried.
Estimated loading condition after recovery
40
CASE 18
The Lessons
1. Most vessels are modified over the
course of their time in service so that
they keep pace with technology, are more
efficient and comfortable, or as a result
of a change in the type of fishing
conducted. Consequently, some vessels
have grown considerably since build.
However, any structural modifications
have the potential to adversely affect a
vessels stability, which might not be
obvious. So before making any
significant alterations, such as adding a
winch, extending a wheelhouse, fitting a
deck and freeing ports, and adjusting
ballast, it is always wise to seek the
advice of a qualified person.
2. The overloading of small fishing vessels
is an ever-present danger, and almost
total reliance is placed on skippers
experience and knowledge of their boats
to guard against it. However, after a
change of ownership, in most cases a
new skipper will not be familiar with
how a vessel handles. It is therefore
important, when buying a second-hand
boat, that its maximum loading and
limiting conditions be included among

the information passed on from its
previous operators. Without this, a
skippers assessment is reliant on trial
and error. Unfortunately, some crews
dont get a second chance when such
assessments are misjudged.
3. In a decked vessel, the easiest way to
ensure that an accumulation of water in
the bilge does not pass unnoticed, is to fit
a high level alarm. Physical checks of the
bilge can tend to fall towards the bottom
of the priority list when fishing, and
even when automatic bilge pumps are
working, they might mask, or not cope
with, a serious ingress.
4. There will not always be time to grab
and don a lifejacket when things go pearshaped. Think about wearing them at all
times when on deck, particularly when
conditions are marginal.
5. Just because a vessel is not required to
carry a liferaft, does not mean that her
crew will never need one. If there is
room to carry one, do so. Its not the
regulators lives which are at risk.
41
CASE 19
Too Much On Top

Narrative
The owner/skipper of a 10-metre steel fishing
vessel operated her for several years as a prawn
trawler. He then decided to convert her to cockle
dredging for operations in local rivers and a large
estuary.
For this conversion, he removed the trawl winch
and fitted a large diesel-driven water pump, a
suction pump, a powered riddle and an A frame
for handling the gear. The two pumps were
mounted on deck, and the riddle on the port
bulwark. These three items were of substantial
weight. Some extra ballast was added in an effort
to compensate for this topweight.
The vessel was operated with few problems for a
couple of months by the skipper and one
crewman.
On this occasion, the skipper agreed that a third
person could join him for a day. The day went
well, with a substantial catch of cockles. These
were stowed in large bags, each holding an
estimated one tonne. Two bags were stowed in
the fish hold, three on deck and one on the fish
hatch forward of the wheelhouse.
The skipper decided this was their limit, and
hauled the dredging gear on board. The boat was
in a narrow part of a river, and the skipper
needed to turn her, to return to their landing
quay.
As he knocked the boat out of gear, to begin a
three-point turn in the narrow river, the boat
began to heel to port. This heeling continued.
The three men realised something was amiss, and
managed to jump into the water before the boat
completely capsized.
Fortunately, all three men managed to kick off
their boots etc and swim to the shore. One
managed to walk to a nearby house, where the
emergency services were called. None suffered
any serious injury.
42
The Lessons
1. The weight of cockle bags on deck was
substantial for a boat of this size. This
topweight, coupled with the unknown
effects of the modifications made to the
boat, generated a condition where she
had no reserves of stability. For boats of
this size, which are not required to
comply with any formal stability
standards, it is vital that owners and
skippers take great care when modifying
and loading them, so that they retain
some reserve of stability.
2. Fortunately, all three men were able to
make their way to the bank of the river.
In less friendly conditions they might
have been less fortunate. Permanent
wear buoyancy, that is comfortable to
wear while working, can provide vital
support in such circumstances. All
fishermen should consider wearing such
aids.
CASE 19
Diesel-driven pump
A frame
Pump
43
CASE 20
Quick Action Saves Fishing Boat

and Crew
Narrative
The skipper of a 22-metre fishing vessel was
reading in his bunk at about 2130, when he
noticed a strong smell of burning plastic. He
quickly left his cabin and checked the engine
room. Although the engine room was clear of
smoke, there was a light smoky haze in the
accommodation.
On carefully opening the galley door, the skipper
saw that the area was full of smoke. He shut the
door immediately, and raised the alarm by
shouting for all the crew to get up and bring their
lifejackets to the bridge. He told the cook to shut
off the power to the cooker, and then went up to
the wheelhouse. Once there, he again raised the
alarm over the tannoy, and was met on the
bridge by the rest of the crew. Not all had
brought their lifejackets.
Having told the crew that there was a fire in the
galley, he called the coastguard on Channel 16.
The coastguard put out a Mayday distress call.
The Lessons
This incident shows how a difficult situation
can be brought under control by clear
thinking and quick action.
1. By opening the galley door carefully, and
only a little, the skipper prevented the
fire from spreading, and ensured his own
safety.
The smoke by that time was very heavy, and the

cook shut the hatch down from the wheelhouse
and checked that the entry to the forward shelter
was shut.
An offshore stand-by vessel in the vicinity
reacted to the Mayday and sent its fast rescue
boat to the fishing boat, with 4 lifejackets and a
breathing apparatus set. The stand-by vessel then
came in close, and trained its fire monitors on to
the hotspot on the lower accommodation.
The fire was brought under control, and the
fishing vessel was able to return to port under her
own power, having first evacuated three of the
five crew members as a precaution.
Investigation showed that the fire had been
started by a survival suit coming into contact
with a black heater in the drying room when
the vessel had started rolling, about 30 minutes
before the fire was noticed. This spread through a
bulkhead to the galley area.
3. Ensuring that all available hatches and

openings were closed, contained the fire
long enough for it to be brought under
control.
4. The unguarded black heater has since
been fitted with a guard six inches all
around it, and the bulkhead to the galley
has been replaced by a steel one. Think
about where you dry wet clothing.
2. Immediately raising the alarm and

instructing all the crew to muster on the
bridge allowed further action to be taken
once all the crew were accounted for.
44
CASE 21
Winch Problem Leads to Capsize
Narrative
A large vessel was fishing to the west of
Scotland. The wind was north-west force 3, there
was a heavy swell, the visibility was moderate to
poor in rain, and it was dark. A crew of six was
on board.
In the late evening, the port fishing gear became
snagged on an underwater obstruction. While
trying to pull it free, the winches stopped. This
effectively anchored the vessel to the seabed in
the heavy swell, which caused her to take a large
list to port. Because she was rolling either side of
the port list, the port engine intakes went below
the waterline. This, in turn, caused the engine
room to flood. Between 5 and 10 minutes later,
the vessel capsized to port.
After the winches stopped, all six hydraulic
pumps that powered them were restarted, but
before the load could be taken off the port winch,
the system failed again. The computer-controlled
winch system on the vessel was very complex. It
has not been possible to identify clearly the
reason why the winches stopped. However, had
the emergency start been used, it is possible that
the load on the port winch could have been
released. Also, it was not necessary to re-start all
six hydraulic pumps. Starting one of them that

supplied the port winch might have been
sufficient to release the load. However, there was
very little time to consider the options, because
the capsize and foundering were very rapid.
The brakes were set up so that they came on
automatically when the winches stopped. The
winch control system could have been
configured so that the brakes stayed off. Had the
safety brake been enabled, and worked as
intended, it might have saved the vessel.
The engine intakes were low on the port side.
Although this arrangement met the requirements
of the regulations, these intakes should have
been positioned higher up and/or further inboard
to avoid the risk of downflooding.
Events happened so quickly that the crew did
not have time to radio for help before they
abandoned their vessel. Five of them successfully
boarded the liferaft; tragically one man was lost.
The five survivors were wet and very cold; it was
crucial that they were rescued without delay. The
EPIRB saved the day; the coastguard were able to
pinpoint the accident, and immediately
dispatched a helicopter which rescued the
survivors.
45
CASE 21
Winch control panel
The Lessons
1. If your vessel is fitted with a complicated
winch control system, be sure that you
would know what to do if faced with this
sort of emergency. If a safety brake
feature is fitted, it should be enabled.
2. If your vessel is fitted with vulnerable
engine intakes, be aware of the risk of
downflooding. Such intakes should
ideally be moved further up and/or
further inboard.
46
3. The liferaft and EPIRB almost certainly

saved five lives:
Without the liferaft, the five men
would have found themselves in rough
seas and darkness. Their survival time
would have been severely limited.
The EPIRB alerted the coastguard and
enabled the recovery to be initiated.
In cases like this, the value of such safety
equipment is clearly demonstrated.
CASE 22
Dodgy Alarm, So No Warning

Narrative
A 9.9 metre length wooden stern trawler was
operating with a crew of two. She left her home
port in the early morning and, after steaming for
about five hours, shot her gear. The weather
conditions were very good.
After towing for about 1 2 hours, the skipper,
suspecting a problem with the gear, decided to
haul it in. The gear was hauled on board and the
cod end emptied on to the deck. The skippers
suspicion was unfounded; the gear was in good
order and was shot again.
1
After gutting and boxing the small amount of

fish caught, the crewman asked the skipper to
turn on the deck wash water. The skipper did
this by switching on the electromagnetic clutch
of the deck wash pump from the wheelhouse
console.
When the crewman reported there was no water
coming from the deck wash hose, the skipper
opened the engine room hatch in the
wheelhouse to investigate. He immediately saw
water halfway up the engine. This surprised him,
as there had been no sound from the bilge alarm,
The Lessons
1. The boat was fitted with a bilge alarm,
but the last occasion the skipper had
heard it sound was about a year before
this accident. A routine for testing the
alarm, before departure and during
normal working conditions, would have
allowed any defect to be detected and
remedied as soon as it developed. Had
the bilge alarm sounded early in this
accident, it might have given the skipper
time to take corrective action, such as
closing seacocks.
2. This boat was not required to carry a
liferaft by the code of practice governing
all the electrics were still working, and during his

last look into the engine room, about three hours
earlier, he had seen no problem.
Inspection of the fish room confirmed that the
flooding was widespread and serious.
After telling his crewman to remove his leggings
and boots, and to fetch the lifejackets, the
skipper called a nearby fishing vessel on the VHF
radio, asking for assistance. The two men then
launched and inflated their liferaft, and the
crewman climbed on board. In the meantime,
the skipper had broadcast a Mayday. The
floodwater on their boat had reached deck level.
Before any further assistance was required, the
nearby fishing boat came alongside and took
both the skipper and his crewman on board.
Not long after evacuating their boat, the two
men watched it sink.
This was a well-maintained boat, and there was
no obvious cause for the flooding. However,
there is some suspicion that there was a failure of
a flexible hose in the engines seawater cooling
system.
its operation. However, the skipper

prudently carried one on board, and had
it serviced annually. It worked during
this accident and, had the nearby fishing
vessel been a little slower in coming to
assist, could have proved vital to the
survival of the two men.
3. Although the cause of the flooding has
not been established, because of their age,
some suspicion has fallen on the flexible
hoses fitted to the engines seawater
cooling system. Flexible hoses have a
limited life span and, where their use is
unavoidable, best practice is to inspect
them regularly, together with any worm
drive clips used to secure their ends.
47
CASE 23
A Fatal Override
Narrative
An 11-metre prawn trawler was normally
operated by her skipper and a deckhand.
However, on this occasion, the skipper was
unable to employ anybody as a deckhand so
decided to sail single-handed.
He hauled the gear until the doors were hung

from the gantry. He then attached the bridle to
the net drum, and began hauling to bring the net
in. However, he latched the spring-loaded lever
of the drum control into the haul position,
using a bent wire hook, so he could stand aft of
the drum to guide the net on to it.
The vessels layout was conventional: a fishing

winch amidships, just aft of the forward
wheelhouse, and a net drum mounted on a stern
gantry. The winch and net drum were
hydraulically-powered from an engine-driven
pump.
For some reason, he put his hand on to a swivel

shackle on the bridle as it came on to the net
drum; probably to lay the shackle flat. But his
gloved hand became caught in the shackle and,
as he was out of reach of the control lever, he
was unable to stop the drum.
The control levers for the winch and net drum

were both self-centring, so whenever they were
released, each returned to the stop or safe
position.
He was dragged around with the moving drum

until he was covered by a number of turns of the
bridle. The force in the bridle fatally crushed
him.
The skipper left his home port early in the

morning and sailed for about an hour until he
shot the gear. It was probably at the end of his
first tow that he ran into trouble.
Meanwhile, the vessel was still steaming under

control of the autopilot. She slowly sailed on her
pre-set course for several hours until she
grounded on a headland. There she was found,
with her engine still running and with the dead
skipper horribly wrapped around the net drum.
The Lessons
1. A fishing vessel of this size is required to
operate under The Fishing Vessels Code
of Practice for the Safety of Small Fishing
Vessels Under 12 Metres in Length. This
Code requires that a risk assessment be
performed on the operations carried out
on board. In this case, no risk assessment
had been done. Ideally, a risk assessment
should have identified the unsuitability
of this vessel for single-handed operation
as a trawler.
48
2. A risk assessment should also have

shown that the self-centring control
levers of the net drum and the winch
were critical safety devices, and essential
to the safety of those on board.
Overriding these safety features
completely removes a vital control
measure, makes a nonsense of any risk
assessment performed, and places crew in
serious danger.
Part 3 Leisure Craft

Learning by personal experience is probably the
best way of retaining knowledge and skills.
However, no sensible recreational skipper would
deliberately put either themself, or their boat, at
risk in order to learn what actions to take when
either life or their boat is in danger.
This unique contribution that the Safety Digest
makes to avoiding mishaps and accidents, is that
we can all learn from the properly documented
and analysed experiences of others.
Not all incidents can be avoided; using the sea
and inland waters always has a certain element of
risk attached to it. Indeed, it is the proper
management of those risks that attracts many
people to both the freedoms and responsibilities
associated with all forms of boating.
The RYA believes that a lifelong commitment to
learning and, when necessary, training, should be
an integral part of every skippers mindset. Safety
at sea is not just a list of equipment on a properly
maintained vessel. It is a golden thread linking
all aspects of maintaining, equipping and, most
of all, skippering a small boat.
The value judgments that a good skipper or crew
apply to passage planning, navigation or
seamanship can be critical in ensuring a safe
passage. Complacency, particularly that borne
out of an over familiarity with a particular boat
or venue, can become an infectious attitude that
eventually leads to sloppy practices and
accidents.
The lack of awareness of the needs and

requirements of other water users is a constant
reoccurring theme in these reports. It is every
skippers responsibility to be familiar with the key
provisions of the collision regulations,
particularly those associated with large
commercial vessels.
All recreational boat skippers need to assess
whether their boat and equipment is appropriate
for the planned voyage, use their judgment and
skill in managing their boat and crew to best
effect, and plan to be self reliant and resourceful
if the unexpected does happen.
Rod Carr, RYA Chief Executive

Rod Carr has been Chief Executive of the RYA since December 2000. Among his many sailing achievements,
he was Crew Boss for the Admirals Cup campaign in 1981 on board Yeoman, he coached the Olympic team
for the Los Angeles games in 1984, the Seoul and Barcelona Olympics in 1988 and 1992 before being
appointed overall team manager for the Savannah games in 1996. He was appointed RYA Racing Manager
in 1997.
49
CASE 24
Catamaran Capsize in Solent
Narrative
A catamaran was being sailed by her new owners
who had taken delivery from Portsmouth. The
skipper and three crew were experienced and
were wearing suitable clothing for a blustery
April evening. The boat was equipped with VHF
radio and a good selection of emergency
equipment, although no EPIRB was carried.
50
It was getting dark, and with the wind blowing

20 to 25 knots from SSW, the crew were sailing
under a double-reefed mainsail and reefed
headsail. They tacked on to starboard and soon
afterwards an unusual wave pattern hit the
weather hull, reported to be travelling against
the direction of the wind and swell. It lifted the
hull so far that the boat lost stability and
capsized.
CASE 24
The catamaran inverted almost immediately,

leaving the crew to find safety on the upturned
hulls. Because the capsize had happened so
quickly, there had been no time to retrieve the
grab-bag containing flares and other equipment.
The VHF was now out of action, as well as being
inaccessible, and the mobile telephones were
down below.
Skipper and crew had no option but to huddle
together for warmth, and hope for a rescue.
The Lessons
1. The importance of correct clothing for
the conditions cannot be over
emphasised. All four members of the
crew were wearing thermal
underclothing, midlayer garments, as
well as heavy weather jackets and high
trousers. They were also wearing
lifejackets and harnesses. Despite low sea
and air temperatures, all four survived
eleven hours on the upturned hulls
relatively unscathed.
Luckily, they were less than a mile offshore from

Stansore Point in the Solent, but it was now
completely dark.
It was not until about 0700 the following day, as
it grew light, that their distress signals (raised
and lowered arms) were spotted from the shore
and the alarm was raised. All four were taken off
by the inshore lifeboat, and taken to hospital
suffering from mild hypothermia. Fortunately, all
made complete recoveries.
3. An EPIRB mounted in the cockpit

would have raised the alarm within
minutes of the capsize, and would have
spared the crew a long, cold and
extremely uncertain night.
4. The skipper told the MAIB that he was
grateful that they had all eaten a good
meal before departure, and had stayed
away from alcohol. He also highlighted
the importance of keeping morale high
and believing in the rescue.
2. Locate the grab-bag somewhere so that it

can be reached if the boat becomes
inverted. This is obviously particularly
important with a multi-hull, which, once
inverted, will stay inverted.
51
CASE 25
Out of Sight, Out of Mind
Narrative
A family hired a 13 metre-long wooden motor
cruising boat for a weeks holiday on the Norfolk
Broads. The boat had nine berths and a
displacement of about 8 tonnes.
The family sailed downstream on the ebb tide
and approached a closed swing bridge. Because
they were towing a dinghy with a mast too high
to pass under the bridge, three long blasts, the
signal required for the bridge to be opened, were
given. However, on closer approach, it was
obvious that the bridge was not going to open in
time. The person in control of the boat had to
decide quickly whether to let go the dinghy or to
go alongside the jetty adjacent to the bridge. He
chose the latter. On approaching the jetty at
some speed, one of the familys young sons
jumped ashore holding a rope, which had been
made fast to a metal cleat attached to the deck of
the boat, and put a few turns around a wooden
bollard on the jetty. The intention was to use the
rope to swing the boats head into the ebb tide
before making her fast alongside. The young man
was bent down near the bollard as the tension
came on to the rope. The momentum of the
boat, enhanced by the tidal current, came to bear
on the metal cleat which broke free of the deck
and flew back along the line of the rope. The
cleat struck him in the face with great force. He
suffered severe injuries.
52
An inspection of the metal cleat found that the

two mild steel holding-down bolts were severely
corroded. One of them had failed some time
before the accident, the other one had failed
because it could not take the force of the rope
under tension.
The boat owner had no set maintenance
programme for his boats, and did not look at
fittings on a regular basis. The last time the bolts
had been inspected and replaced was 8 years
before the accident.
View from under sheared bolts before removal
CASE 25
View from above
Above view of adjacent cleat (incident cleat would have looked exactly like this)
The Lessons
1. Boat owners should ensure regular
servicing procedures for all equipment on
board are in place. That includes
standing equipment, integral parts of
which cannot be seen without
dismantling. In a salty atmosphere, mild
steel bolts should be visually inspected
annually and, if necessary, replaced every
two years. Better still, stainless steel
bolts should be fitted.
2. When berthing a boat, it is preferable to

turn her to stem the stream before
manoeuvring alongside, as she will then
be under easy control due to the braking
effect of the current.
3. Always be aware of the hazards involved
in berthing, especially from ropes and
wires coming under tension, and the
need to maintain a safe distance from
them.
53
CASE 26
Early Warning Headaches

Narrative
Four members of a family were on their 15 tonne,
twin screw motor yacht for a winter holiday. She
was berthed at a marina. It was cold, so they
turned on the oil-fired cabin heater during one
evening.
While the family was having an evening meal,
two of them complained of feeling unwell. It was
suspected that they were suffering from the early
stages of flu and they went to bed with headaches
and sore throats. The cabin heating was turned
off overnight, and all felt fine the next morning.
The Lessons
1. A simple carbon monoxide detector in
the cabin could have given an early
warning of the problem.
The following evening, the heating system was

again used. This time, all four members of the
family began to feel unwell. It was at this stage
that suspicion fell on the heating system.
These suspicions were confirmed when a
professional examination showed that there were
various defects which allowed exhaust gases from
the heater to be drawn into the cabin.
It is most fortunate that nobody suffered
anything worse than a headache. Fatalities from
carbon monoxide poisoning could so easily have
resulted.
3. Because of the dangers that may be

caused by poor or defective installations,
it is always prudent to use qualified and
experienced personnel to install and
routinely check these systems to ensure
safe operation.
2. In the absence of a detector, complaints

of headaches or sore throats from
anybody on board should be taken
seriously when any gas or oil-fired cabin
heater is in use. It is better to turn off
the heater, and shiver, than to suffer
fatalities.
54
CASE 27
Lookout! What Lookout?

Narrative
A yacht, under sail, was crossing the English
Channel, which is a busy waterway requiring
increased levels of vigilance regardless of the
prevailing weather conditions. It was daylight,
and the weather was fine with good visibility.
A cargo ship was seen approaching from the
starboard side, and a series of compass bearings
was taken, which confirmed a risk of collision.
The Lessons
Sadly, this is not an uncommon story.
It should never be assumed that a ship will
automatically keep out of the way of a vessel
under sail. In this case, the yachtsmen
correctly took a series of compass bearings to
ascertain if a risk of collision existed. They
then continued to monitor the situation, and
took appropriate action to avoid a collision
when it became apparent that the ship did
not intend to do so.
Following this incident, the MAIB held
discussions with the merchant vessels
company. As a result of these discussions,
the ships master will ensure that, while
transiting the area in the future, VHF radio
controls are correctly set, watches are
doubled, and an additional lookout is posted
forward.
As the ship closed, the yachtsmen became

concerned and called the ship on VHF radio
Channels 16 and 13, without response. No
avoiding action was taken by the ship, and the
yacht finally hove to, resulting in the ship
passing ahead at a range of about 0.25 mile.
Those on the ship were unaware of the incident.
This article re-emphasises the importance of

notifying the MAIB of incidents and
accidents. Only by receiving notification, can
the MAIB take action by suggesting
improvements to safety and passing the
lessons on to others. Our role is to
encourage discussion, which, by increasing
awareness, hopefully then reduces the risk of
a recurrence.
We do take note of incidents which are
reported to us.
And we do endeavour to implement and
follow up any recommendations to emerge
as a result.
But we need your help to do this.
55
MAIB NOTICEBOARD
MAIB SAFETY BULLETIN 1/2004
Near lethal use of CO2 onboard fishing vessel

30 January 2004
Background
At 2300 on 29 January 2004, a twin rig 23.92 metre
trawler sailed to her fishing grounds.
fuel oil, hydraulic oil and ventilation systems from the

space. They must also have a good understanding of
the operation of fixed CO2 fire extinguishing systems.
In particular:
The vessel had been towing her twin rig gear for about
3 hours when the skipper saw smoke coming from the
outlet of the engine room exhaust ventilator. He went to
the engine room immediately, where he discovered a fire.
The skipper attempted to isolate the fuel systems, but
without success. He then transmitted a "Mayday". About
30 minutes into the incident, he tried to operate the fixed
CO2 system. However, this failed because the system
had been badly maintained, and the crews knowledge
of the operating procedures was, at best, superficial. At
about this time, smoke from the engine room began to
reduce, and the skipper was under the impression that
CO2 had been successfully discharged. A short time
later, he, together with the ships engineer, entered the
engine room to see if the fire had been extinguished.
In this case, the fire died out without the use of the CO2.
However, the outcome could have been very different,
and this case highlights the need for effective
maintenance and testing, and knowledge of how to use
the system.
Even more importantly, the skipper and ships engineer
were unaware of the potentially lethal dangers they faced
when they re-entered the compartment. Had the CO2
system been successfully discharged, the engine room
would still have contained dangerous levels of CO2 at
this time, and it is highly likely that the decision to enter
could have resulted in the death of both men.
1.
Whenever it has been necessary to release CO2 into

the engine room to extinguish a fire, ventilation of
the space should not be resumed until it has been
confirmed that the fire is out and the space has
sufficiently cooled to prevent re-ignition.
2.
Thereafter, entry into a space that has contained

CO2 should only be attempted by personnel using
breathing apparatus. If breathing apparatus is not
carried on board, and it really is impossible to wait
for assistance from ashore, entry should only be
attempted when the space has been thoroughly
ventilated with clean air, and all residues of CO2
have been removed. It is strongly recommended
that this should include the need to obtain expert
advice from ashore before any attempt at re-entry is
made.
Additionally, all fishing vessel skippers and crews are

recommended to:
1.
Ensure remote controls for fuel oil and hydraulic

pumps, quick closing fuel oil valves and closing
devices for ventilators, emergency stops for
ventilation fans and CO2 fixed fire-fighting systems
are tested regularly and maintained in good order.
2.
Ensure clear instructions for operating CO2

extinguishing systems are displayed near the
distribution control valves and near the gas
cylinders.
3.
Ensure audible alarms for warning personnel within

the engine room, that the CO2 fire extinguishing
system is about to be operated, are regularly tested
and maintained in working order.
Safety Recommendations
Skippers and crews are reminded that the Regulations
require that all crew onboard UK registered fishing
vessels have completed the compulsory one day "Fire
Prevention and Fire-Fighting" training course. This
course can be arranged by contacting SEAFISH on
01482 327 837.
In the event of a fire in the engine room, skippers and
crews should ensure that they are fully conversant with
the operation of the remote controls for the isolation of
56
APPENDIX A
Preliminary examinations started in the period 01/11/03 29/02/04

A preliminary examination identifies the causes and circumstances of an accident to see if it meets the criteria required to
warrant an investigation, which will culminate in a publicly available report.
Date of
Accident
Name of Vessel
Type of Vessel
Flag
Size
Type of Accident
29/11/03
La Belle Trois
Fishing vessel
UK
15.59
Fire
14/07/03
Lord Nelson
Commercial sail
training vessel
UK
368
Hazardous inc.
07/12/03
Onward Star
Fishing vessel
UK
39.53
Acc. to person
08/12/03
Dart 9
Ro-ro cargo
Bermuda
22748
Acc. to person
08/12/03
Nora
Dry cargo vessel
Estonian
2351
Acc. to person
Capsize/Listing
27/12/03
Unnamed speedboat
Pleasure craft
UK
28/12/03
Reliance
Yacht
UK
Missing vessel
04/01/04
Telesis
Fishing vessel
UK
20.05
Hazardous inc.
04/01/04
Amenity
Tanker
UK
1453
Hazardous inc.
05/01/04
Ann Marie
Fishing vessel
UK
5.02
Flooding
07/01/04
Roseanne
Sven Dede
Fishing vessel
Dry cargo
UK
Antigua Barbuda
9.94
3815
Hazardous inc.
Hazardous inc.
22/01/04
Sea Riss
Dry Cargo
Netherlands
1595
Fire
31/01/04
Adamant
Crewboat, twin-hull
UK
134
Collision
02/02/04
Aalskere
Fishing vessel
UK
242
Acc. to person
13/02/04
Transcend
Fishing vessel
UK
48.86
Fire
25/2/04
Tian Tong Feng
Bulk carrier
Hong Kong
39042
Grounding
Investigations started in the period 01/11/03 29/02/04

Date of
Accident
Name of Vessel
Type of Vessel
Flag
Size
Type of Accident
01/11/03
Donald Redford
Dredger
UK
681
Contact
03/12/03
H.C. Katia
Passenger ferry
UK
186
Contact
29/01/04
Scot Venture
Dry Cargo
UK
2594
Hazardous inc.
30/01/04
Elegance
Fishing vessel
UK
357.00
Fire
57
APPENDIX B
Reports issued in 2003

Amber loss of fishing vessel in the Firth of
Forth on 6 January 2003 with the loss of one life
Published 23 October
Arco Adur investigation of a fatal accident on
the River Medway on 25 February 2003
Published 25 September
Ash/Dutch Aquamarine collision between mv
Ash and mv Dutch Aquamarine in the SW lane of
the Dover Strait TSS, with the loss of one life,
on 9 October 2001
Published 20 March
Bro Axel/Noordhinder near miss between Bro
Axel and Noordhinder, and the subsequent
grounding of Bro Axel at Milford Haven on
5 December 2002
Published 16 September
Claymore investigation of the entanglement in
moorings, St Margarets Hope, on 11 March 2003
Published 3 October
Diamant/Northern Merchant collision
between vessels 3 miles SE of Dover on 6 January
2002
Published 4 April
Flamingo capsize of fishing vessel east of
Harwich on 7 July 2002
Published 12 June
Jambo grounding and loss of the Cypriotregistered general cargo ship off Summer Islands,
West Coast of Scotland on 29 June 2003
Published 17 December
Kirsteen Anne loss of vessel at Firth of Lorn
on 31 December 2002 with the loss of her two
crew
Published 31 July
Kodima cargo shift, abandonment and
grounding in the English Channel on 1 February
2002
Published 21 January
58
Marbella collision between UK-registered

fishing vessel and offshore platform in the Rough
Gas Field about 25 miles south-east of
Flamborough Head on 8 May 2002
Published 26 April 2003
Maria H vessel striking the Keadby railway
bridge on 29 May 2002
Published 28 March
Nedlloyd Vespucci/Wahkuna collision
between container ship and yacht in the English
Channel on 28 May 2003
Published 19 December
Norsea fire in the aft engine room of ro-ro ferry
on 2 September 2002
Published 30 June
Nottingham Princess investigation of
Nottingham Princess striking Trent Bridge,
Nottingham, on 15 November 2002
Published 22 August
Ocean Star failure of a warp block on board
the UK registered fishing vessel north of the
Shetland Islands, resulting in one fatality on
26 November 2001
Published 13 May
Osprey fatal accident to a man overboard from
the fishing vessel in Lochinver Harbour on
20 April 2002
Published 3 February
P&OSL Aquitaine investigation of a fatal
accident during a vertical chute evacuation drill
from the UK registered ro-ro ferry P&OSL
Aquitaine, in Dover Harbour, on 9 October 2002
Published 25 July
Portsmouth Express wash wave incident off
East Cowes on 18 July 2002
Published 3 June
Pride of Bath investigation of a barbecue fire
in the galley of Pride of Bath on the River Avon,
Bath on 20 July 2002
APPENDIX B
Pride of Portsmouth collision between Pride of

Portsmouth and HMS St Albans, Portsmouth
Harbour on 27 October 2002
Published 5 August
Solway Harvester summary report on

investigation of the capsize and sinking 11 miles
east of the Isle of Man on 11 January 2000, with
the loss of seven lives
Published 13 June
Pride of Provence contact between the vessel

and The Southern Breakwater, Dover Harbour
eastern entrance, on 18 April 2003
Published 13 November
Stena Explorer fire on board HSS Stena

Explorer entering Holyhead, 20 September 2001
Pride of the Dart grounding of the class VI

passenger vessel on Mew Stone rocks near the
entrance to the River Dart on 28 June 2002
Published 30 April
Tullaghmurry Lass sinking of fishing vessel

Tullaghmurry Lass, with loss of three lives, in the
Irish Sea on 14 February 2002
QE2 flooding of aft engine room of passenger

cruise ship QE2 on 21/22 May 2002
Published 31 March
Annual Report 2002 Published June 2003
QE2 escape of steam and hot water on board

QE2 in mid-Atlantic, resulting in one fatality on
23 June 2002
Published 8 July
Safety Digest 2/2003 Published August 2003
Radiant capsize and foundering about 45 miles

north-west of the Isle of Lewis, with the loss of
one life on 10 April 2002
Safety Digest 1/2003 Published April 2003
Safety Digest 3/2003 Published December 2003

Timber Deck Cargo Study Published August
2003
A full list of all publications available from the
MAIB can be found on our website at
www.maib.gov.uk
59
APPENDIX C
Reports issued in 2004

Breakaway 5 investigation of the capsize of
the hire boat, on the Norfolk Broads, resulting in
one fatality, 19 July 2003
Trident VI investigation of grounding of the

inter-island passenger vessel off Herm Island,
near Guernsey, in the Channel Islands,
23 August 2003
Elhanan T investigation of the flooding and

foundering of the fishing vessel east-north-east of
Fraserburgh, 14 August 2003
Published 4 March
60

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MARINE ACCIDENT

MARINE ACCIDENT INVESTIGATION BRANCH

Department for Transport

Further copies of this report are available from:

If you wish to report an accident or incident

The telephone number for general use is 023 8039 5500.

Crown copyright 2004

MARINE ACCIDENT INVESTIGATION BRANCH

PART 1 MERCHANT VESSELS

1. Hands-on Training yes but Dont Lose Control!

2. Spontaneous Lowering of a Lifeboat

3. Low Pressure Not Low Risk

4. A Stopper That Didnt Stop

5. Late Changeover Leads to Grounding

6. If There is no Risk Assessment, Do Your Own

8. Unplanned Trip up the River

11. Quick Response to Vehicle Fire on Ro-Ro Ferry

12. What a Foul Up!

13. Who Put That There?

14. It Has Been Drained, But is it Dry?

15. Beware of Berths that Dry Out

16. Stay A Leading Light Use Them!

PART 2 FISHING VESSELS

17. Modifications Result in Loss of Stability, Vessel and a Life

18. Overloaded, Overdue, Over..

19. Too Much On Top

20. Quick Action Saves Fishing Boat and Crew

21. Winch Problem Leads to Capsize

22. Dodgy Alarm, So No Warning

23. A Fatal Override

PART 3 LEISURE CRAFT

24. Catamaran Capsize in Solent

25. Out of Sight, Out of Mind

26. Early Warning Headaches

27. Lookout! What Lookout?

Appendix B Reports issued in 2003

Appendix C Reports issued in 2004

Glossary of Terms and Abbreviations

Controllable Pitch Propeller

Emergency Position Indicating Radio Beacon

Spoken distress signal

Roll on roll off

Royal Yachting Association

Very High Frequency

Very Large Crude Carrier

MAIB Safety Digest 1/2004

For those who go to sea for pleasure, there is no

Part 1 Merchant Vessels

I like a good read, and I always look forward to

And why do these accidents always seem to

MAIB Safety Digest 1/2004

Challenge all those carrying out work must

And lets keep this admirable Safety Digest off the

How can I perform this task without injury to

Hands-on Training yes but

helm. He moved the pitch controls of both

MAIB Safety Digest 1/2004

Although the manoeuvre was

Efforts to insert harbour pins, and apply the