Mai B Annual Report 2020
Mai B Annual Report 2020
Mai B Annual Report 2020
2020
Marine Accident Recommendations and Statistics
M A R I N E A C C I D E N T I N V E S T I G AT I O N B R A N C H
This publication, excluding any logos, may be reproduced free of charge in any format or medium for research, private study or
for internal circulation within an organisation. This is subject to it being reproduced accurately and not used in a misleading
context. The material must be acknowledged as Crown copyright and the title of the publication specified.
Details of third party copyright material may not be listed in this publication. Details should be sought in the corresponding
accident investigation report or publications@maib.gov.uk contacted for permission to use.
CONTENTS
PART 3: STATISTICS 47
UK vessels: accidents involving loss of life 47
UK merchant vessels >= 100gt 49
UK merchant vessels < 100gt 58
UK Fishing vessels 59
Non-UK commercial vessels 67
FURTHER INFORMATION 75
CHIEF INSPECTOR'S STATEMENT
2019 1 090 22 13
2018 1 227 23 7
The graph below and those on the next page provide an insight into the impact the COVID pandemic had
on the reporting of marine casualties and incidents in 2020. The first lockdown saw a significant reduction
in maritime activity, which was reflected in the dip in reportable accidents from March through to May.
The rate of accident reporting increased later in the year but remained depressed compared against the
5-year average. However, a spike in reports of leisure craft accidents over the summer (June to September)
brought the total number of reportable accidents for the year up to normal levels.
200
160
120
80
40
0
1 2 3 4 5 6 7 8 9 10 11 12
▶1◀
MERCHANT VESSELS >= 100gt UK flag or in UK waters
2020 vessels in casualties & incidents by month reported to MAIB
compared with previous 5 years
120
100
80
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12
100
80
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12
120
100
80
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12
▶2◀
SAFETY ISSUES
In 2020, the MAIB published two investigation reports into the collapse of container stacks on large
container ships1, both of which were transiting the North Pacific Ocean in heavy weather at the time.
Such accidents are challenging to investigate due to the multiple inter-related factors involved and that
critical evidence could be lost overboard during the accident. There have been more accidents involving
large losses of containers since, the most notable being ONE Apus, and more general concerns about large
container vessels were already being raised before Ever Given grounded in the Suez Canal earlier this year.
There is no doubt that accidents involving Ultra Large Container vessels will continue to receive intense
focus, but it is too early to say what common themes might emerge from accident investigations and
whether these could have wider implications for the sector.
On paper, 2020 was a safer year for the UK fishing industry, with only one accident (Joanna C, BM 265)
resulting in fatalities. Regrettably, six commercial fishermen’s lives have been lost already in 2021, meaning
that eight commercial fishermen have lost their lives in the 6 month period November to May. While the
investigations are ongoing, the indications are that five lives were lost as a result of small fishing vessels
capsizing or foundering quickly. The MAIB is currently in the process of recovering the wreck of Nicola Faith
(BS 58), the most recent small fishing vessel to founder, to establish why the vessel sank and its three crew
lost their lives.
The accidents involving leisure and recreational craft that the Branch is investigating are quite varied,
but two themes are worth mentioning. As the tragic accident onboard the motor cruiser Diversion
demonstrated, lives are still being lost due to carbon monoxide poisoning (see Safety Bulletin 2/2020).
There can be many sources of carbon monoxide on a cruising vessel, including the main engines,
generators, heaters and cooking appliances. Whatever the source, the presence of carbon monoxide can be
detected by a reasonably inexpensive alarm, which will provide ample warning that this odourless, highly
toxic gas is present. Owners of craft with enclosed accommodation spaces are strongly advised to fit a
carbon monoxide alarm suitable for use in the marine environment, and to test it regularly.
Two accidents involving Personal Watercraft (PWC) and Rigid Inflatable Boats (RIBs) show how vulnerable
passengers are to injury when these craft collide or hit stationary objects while travelling at high speed.
The collision between a PWC and RIB Rib Tickler, and the RIB Seadogz’s collision with a navigation buoy are
still under investigation, but both accidents resulted in fatalities that could have been avoided had a better
lookout been kept and larger passing distances maintained.
RECOMMENDATIONS
The high level of acceptance of MAIB recommendations in 2020 (>90%) is good news, which validates our
process of involving stakeholders in the formulation of recommendations during the final stages of the
investigation.
A number of outstanding recommendations made to the Maritime and Coastguard Agency seek the
introduction of more stringent stability standards for small commercial fishing vessels. It is hoped that
the long-awaited revision of the Code of Practice for these craft, now due in August 2021, will satisfactorily
address these recommendations and start the process of improving stability standards across this sector of
the UK’s fishing fleet.
1 MAIB Report 2/2020 – CMA CGM G. Washington, and MAIB Report 14/2020 – Ever Smart.
▶3◀
BRANCH ACTIVITY AND DEVELOPMENT
Accident investigation continued throughout the pandemic, but it was far from business as usual. During
parts of the year travel and quarantine restrictions severely curtailed the Branch’s ability to attend accident
sites. This resulted in heavy reliance on remote interviewing and third parties to collect physical evidence.
Like many others, MAIB staff have become adept at remote working, but the constraints of the remote
environment have hindered accident investigation.
Last year saw some staff retire, others take on new responsibilities, and there have been a number of new
joiners. Experience levels in some areas dropped while training was carried out and those new to role
learned the ropes, though this has been hampered by remote working. The combined effect has been an
impact on efficiency and timescales with the result that the average time taken to publish investigation
reports has increased to 16 months. At the time of writing this foreword the training backlog is being
addressed, and a key objective as the pandemic loosens its grip on business will be to reduce the time
taken to deliver investigation reports to normal levels.
On a more positive note: expansion of the Branch’s Technical Team has been completed, broadening the
in-house technical skill set and enhancing capacity for horizon scanning; the Business Support team has
been re-structured; and for the first time in many years the Branch has a full complement of inspectors.
Further, the newly introduced case management system is working well, opening the prospect for data
mining and trend analysis to recommence in earnest.
Finance
The annual report deals principally with the calendar year 2020. However, for ease of reference, the figures
below are for the financial year 2020/21, which ended on 31 March 2021. The MAIB’s funding from the DfT is
provided on this basis, and this complies with the Government’s business planning programme.
▶4◀
STATISTICAL OVERVIEW
400
350
318 accidents
310 accidents
(346 vessels)
(333 vessels)
300
250
200
150
100
55 accidents
(58 vessels)
50
12 accidents
(13 vessels)
0
Very Serious Serious Less Serious Marine Incident
▶5◀
STATISTICAL OVERVIEW
160
140
111 accidents
120 (113 vessels)
100
80
53 accidents
60 (54 vessels)
40
20 0 accidents 4 accidents
(0 vessels) (4 vessels)
0
Very Serious Serious Less Serious Marine Incident
160
140
120
84 accidents
100 (84 vessels)
80
60 34 accidents
40 (34 vessels)
4 accidents 9 accidents
20 (9 vessels)
(4 vessels)
0
Very Serious Serious Less Serious Marine Incident
▶6◀
STATISTICAL OVERVIEW
160
100
80
60 44 accidents
34 accidents (45 vessels)
40 (35 vessels)
7 accidents
20 (7 vessels)
0
Very Serious Serious Less Serious Marine Incident
120
100
80 63 accidents
(67 vessels)
60
40
10 accidents
20 1 accident (10 vessels)
(1 vessel)
0
Very Serious Serious Less Serious Marine Incident
▶7◀
INVESTIGATIONS STARTED IN 2020
Fatal accident to crewman while disembarking the 21m workboat Beinn Na Caillich at Ardintoul Fish Farm, Loch
18 Feb
Alsh on the west coast of Scotland.
Grounding of the Bahamas registered general cargo vessel Kaami (9063885) while transiting the Little Minch,
23 Mar
Scotland.
Grounding and flooding of the Gibraltar registered chemical/products tanker Key Bora (9316024) in Kyleakin,
28 Mar
Scotland.
Loss of propulsion, hull damage and flooding of the dredger Shearwater (6822216)2 while towing the barge
09 Apr
Agem One near Cape Wrath, Scotland.
25 May Capsize of the leisure cabin cruiser Norma G in the Camel Estuary, Cornwall, England resulting in one fatality.
Foundering and subsequent loss of a leisure fishing vessel Globetrotter near Fleetwood, England resulting in
31 May
one fatality.
Carbon monoxide poisoning on board motor cruiser Diversion, resulting in two fatalities at the Museum Gardens
4 Dec 20193
quay, River Ouse, York, England.
Grounding of the Isle of Man registered ro-ro freight vessel Arrow (9119414) in restricted visibility while entering
25Jun
Aberdeen Harbour, Scotland.
Fatal injury to a stevedore during cargo operations on the Gibraltar registered general cargo vessel Cimbris
15 Jul
(9281786) in Antwerp, Belgium4.
Fatal injury to crewman following an engine room fire on board the Isle of Man registered LPG tanker Moritz
04 Aug
Schulte (9220794) while alongside in Antwerp, Belgium5.
Fatal injury to a passenger on the RIB Rib Tickler following a collision with a Personal Watercraft near Menai
08 Aug
Bridge, Wales.
▶8◀
INVESTIGATIONS STARTED IN 2020
Date of
occurrence Occurrence details
Capsize and sinking of the UK registered fishing vessel Diamond D (SN100) 20nm north-east of North Shields,
16 Aug
England.
19 Aug Fatal person overboard from the Broads cruiser Diamond Emblem 1 on the River Bure, Great Yarmouth, England.
Fatal injury to a passenger on the RIB Seadogz following a collision with a navigation buoy in the Solent,
22 Aug
England.
Contact by the passenger vessel Waverley (5386954) with the pier on arrival at Brodick, Isle of Arran, Scotland
03 Sep
resulting in passenger injuries and damage to the vessel.
Loss overboard of 33 ISO containers from the container vessel Francisca (9113214) near Duncansby Head,
31 Oct
Scotland.
Collision between the Panamanian cargo vessel Talis (9015424) and the UK registered fishing vessel Achieve (HL
08 Nov
257) off Tynemouth, England, resulting in the subsequent sinking of the fishing vessel.
Capsize and sinking of the UK registered scallop dredger Joanna C (BM 265)6, south of Newhaven, England
21 Nov
resulting in the loss of one life and one crewman missing.
Extensive shock damage, including hull penetration and flooding, to the potting fishing vessel Galwad-Y-Mor
15 Dec
(BRD116) after an external explosion, 19nm north-east of Cromer, Norfolk, England7.
▶9◀
REPORTS AND RECOMENDATIONS
The following pages list the accident investigation reports and safety bulletins published by the MAIB
during 2020. Where the MAIB has issued safety recommendations following an investigation, the current
status of the recommendation and any applicable comments made by the MAIB accompany the entry*.
Recommendations from previous years that remain open are also included on the following pages.
For details of abbreviations, acronyms and terms used in this section please refer to the glossary on page
74.
*Status as of 21 May 2021
Background
Recommendations are a key element of MAIB investigations. They are issued to promulgate the lessons
from accidents investigated by the MAIB, with the aim of improving the safety of life at sea and the
avoidance of future accidents. The issue of a recommendation shall in no case create a presumption of
blame or liability.
Following an investigation the MAIB will, normally, make a number of recommendations. These will be
contained within the published report but will also be addressed in writing to the individuals or senior
executives of organisations concerned. Urgent safety recommendations may also be made in Safety
Bulletins or by letter from the Chief Inspector to the organisations involved, which can be published or
issued at any stage of an investigation.
Recommendations are made to a variety of addressees who might have been involved in, or have an
interest in, the accident. These may range from those organisations that have a wider role in the maritime
community such as the Department for Transport (DfT), the Maritime and Coastguard Agency (MCA) or an
international organisation, through to commercial operators and vessel owners/operators.
It is required by the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 that the
person or organisation to whom a recommendation is addressed, consider the recommendation, and reply
to the Chief Inspector within 30 days on the plans to implement the recommendation or, if it is not going
to be implemented, provide an explanation as to why not. The Regulations also require the Chief Inspector
“to inform the Secretary of State of those matters” annually, and to make the matters publicly available. This
Annual Report to the Secretary of State for Transport fulfils this requirement.
▶ 10 ◀
REPORTS AND RECOMENDATIONS
42 recommendations were issued to 29 addressees in 2020. The percentage of all recommendations that
are either accepted and implemented or accepted yet to be implemented is 92.9%.
Accepted Action
Yet to be Partially No Response
Year Total* Implemented Implemented Accepted Withdrawn Rejected Received
2020 42 30 9 2 0 1 0
The chart below shows the number of recommendations issued under the closed-loop system that remain
open at the time of this publication. There are no outstanding recommendations from 2004-2007,
2010-2012, 2014 and all recommendations made in 2018 are now closed.
0
2019 2017 2016 2015 2013 2009 2008
Regulator Other Gov Dept. Merchant Vessel Industry Fishing Vessel Industry Other
▶ 11 ◀
REPORTS AND RECOMENDATIONS
16 January
CMA CGM G. Washington Serious Marine Casualty 15
No 2/2020
17 January
European Causeway Serious Marine Casualty 16
No 3/2020
6 February
Seatruck Performance Serious Marine Casualty 17
No 4/2020
13 February
Gülnak/Cape Mathilde Serious Marine Casualty 17
No 5/2020
20 February
Red Falcon/Greylag Serious Marine Casualty 18
No 6/2020
19 March
ANL Wyong/King Arthur Serious Marine Casualty 19
No 7/2020
24 June
ZEA Servant Serious Marine Casualty 23
No 11/2020
13 August
Thea II/Svitzer Josephine Serious Marine Casualty 25
No 15/2020
▶ 12 ◀
REPORTS AND RECOMENDATIONS
▶ 13 ◀
REPORTS AND RECOMENDATIONS
8 Rockall Ltd is no longer trading; however, the SafetyFolder is now being managed by Watchful Ltd, and it has undertaken to implement the intent of the
recommendation.
▶ 14 ◀
REPORTS AND RECOMENDATIONS
Safety Issues
▶ Weather routing and parametric rolling
▶ Container securing standards - loose lashings
▶ Reduced structural strength of non-standard containers
▶ Inaccurate container weight declarations and mis-stowed containers
2020/103 Issue direction to its terminal planners to ensure that, where container terminals routinely
weigh containers prior to loading, the cargo plan for those containers is updated to reflect
these weights.
Appropriate action implemented
2020/104 In conjunction with the Health and Safety Executive, promote the involvement of UK container
owners and operators in the Bureau International des Containers, Global Container Database
and the Approved Continuous Examination Programme database.
Appropriate action implemented
2020/105 Amend its rules to require the approved lashing software installed on the onboard loading and
lashing computer to calculate and display maximum roll and pitch angles associated with ship
loading condition and intended passage.
Appropriate action implemented
▶ 15 ◀
REPORTS AND RECOMENDATIONS
2020/106 Review its rules and approval procedure to ensure Container Safety Certifcation data is
accurately reflected within the ship’s loading computer, whatever the type of container.
Compliant with ISO standard or not.
Appropriate action implemented
Safety Issues
▶ Vehicles not adequately secured for anticipated wind and sea conditions
▶ Freight vehicle drivers allowed to remain in their cabs on the vehicle decks during passage
▶ Decision to sail and ship handling in heavy seas
2020/107 Amend its SMS to provide specific guidance on the lashing of cargo in heavy weather to all
vessels in its fleet, to ensure that it meets industry best practice and the guidance provided in
the MCA’s Code of Practice – Roll-on/Roll-of Ships – Stowage and Securing of Vehicles.
Appropriate action planned: 31 December 2021
MAIB Comment: The full implementation of the intent of this recommendation has been delayed
due to the impact of COVID-19 restrictions. As an interim measure enhanced heavy weather lashing
arrangements have been put in place onboard each vessel.
▶ 16 ◀
REPORTS AND RECOMENDATIONS
Safety Issues
▶ The effects of under keel clearance and squat were not
considered before departure
▶ The lack of support from the bridge team meant that the
ferry’s master was a single point of failure
▶ The bridge team did not fully utilise the electronic navigation
aids available, which led to a loss of situational awareness
2020/108 Take further measures to enhance the safe navigation of its vessels by optimising its use of
electronic navigation systems to provide real time positional information, and enhancing its
Bridge Resource Management training.
Appropriate action planned: No date given
Safety Issues
▶ Loss of steerage - no direct cause identified
▶ Crucial manoeuvring information was not recorded on the
vessel's VDR
▶ 17 ◀
REPORTS AND RECOMENDATIONS
Safety Issues
▶ Ineffective bridge resource management
▶ Insufficient helmsman practice steering into Cowes
▶ Lack of assessed practice navigating by instruments alone
▶ Master became cognitively overloaded due to high situational
stress
2020/110 Conduct regular assessment of ship-handling capabilities of masters and C/Os, not limited
solely to normal operational routines of berthing and unberthing, including pilotage by
instruments alone.
Appropriate action implemented
2020/111 Review the method of determining the orientation of the vessel displayed on the ship’s
electronic chart system, to ensure that the system is not solely reliant on the operation of a
toggle switch, and that there is a method of positive confirmation of the orientation displayed
at each manoeuvring console.
Appropriate action implemented
2020/112 Review its risk assessment for collision between a commercial vessel and raft of yachts
moored at Shepards Wharf Marina, to provide more clarity on mitigating measures that can be
controlled by Cowes Harbour Commission.
Appropriate action implemented
2020/113 Produce a comprehensive risk assessment of the risk of a collision between a commercial
vessel and raft of yachts moored at Cowes Yacht Haven Marina, detailing the mitigating
measures that can be controlled by Cowes Yacht Haven.
Appropriate action implemented
▶ 18 ◀
REPORTS AND RECOMENDATIONS
Safety Issues
▶ Lack of awareness of hazards associated with condensed aerosol
firefighting systems
▶ Control of contractors
▶ Installation standards - system isolation and safe systems of work
▶ Emergency preparedness - no rescue plan
2020/S114 Issue a safety alert to the owner/operators of vessels fitted with its systems and its network
of marine installation/maintenance engineers highlighting the circumstances of this accident
and advising them of appropriate measures to take to reduce the risk of exposure to fire
suppressant particles.
Appropriate action implemented
Safety Issues
▶ Risk of collision was underestimated
▶ VHF and AIS information was distracting and unhelpful
▶ Lack of intervention by VTS
▶ King Arthur was not proceeding at a safe speed in thick fog
2020/115 Conduct a review of vessel traffic services in the vicinity of Algeciras designed to enhance the
coordination between the authorities involved in order to improve the deconfliction of traffic.
Such a review should consider establishing:
• a dedicated holding area or anchorage for waiting vessels, and;
• a traffic organisation service for vessels in the approaches to Algeciras.
Rejected - closed
MAIB comment: It is disappointing that this recommendation has not been accepted, particularly given
the levels of engagement during the investigation process. Spain’s Standing Commission for Maritime
Accident and Incident Investigations did not agree with some aspects of the investigation and did not
approve the whole investigation report. As a result, the Spanish Ministry of Development could not
consider this recommendation.
▶ 19 ◀
REPORTS AND RECOMENDATIONS
2020/116 Propose to the International Maritime Organization that the navigation status information
in the automatic identification system be reviewed to ensure that a vessel’s status can be
accurately described, including vessels underway but not making way.
Appropriate action planned: 30 August 2021
Safety Issues
▶ Inadequate passage planning
▶ An effective lookout was not maintained and an unmanned bridge meant that navigational hazards
were not recognised
▶ The route monitoring function of the vessel's electronic navigational equipment was not fully utilised
2020/117 Take steps to ensure that any vessel it may own in the future is navigated safely, paying
attention to:
• Requirements for rest detailed in MSN 1884 (F).
• Guidance on keeping a safe navigational watch detailed in MGN 313 (F).
• The coverage and updating of electronic charts.
Partially accepted - closed
MAIB comment: Blue Pesca Ltd does not currently own or operate any fishing vessels, but has
undertaken to fully implement Recommendation 2020/117 when it recommences fishing activities.
▶ 20 ◀
REPORTS AND RECOMENDATIONS
Safety Issues
▶ Hazardous and uncontrolled self-mooring operation
▶ Operational procedures not followed
▶ Age and agility of person conducting the task not properly considered
▶ Work as done versus work as imaged not identified during internal audit
2020/118 Amend the Code of Safe Working Practices for Seafarers to include guidance for the safe
completion of mooring operations including, specifcally, the circumstances when it is
permissible for crew to carry out self-mooring operations.
Appropriate action implemented
2020/119 Review its audit programme to ensure a common approach to safety and adherence to
operational procedures across the UK Dredging fleet.
Appropriate action implemented
▶ 21 ◀
REPORTS AND RECOMENDATIONS
Safety Issues
▶ The movement of pedestrians and vehicles over the stern ramp was
not monitored or controlled
▶ The use of mobile phones in a working environment was a distraction
▶ The risk of distraction when using mobile phones in working areas on
board ships not adequately addressed by industry bodies
▶ The way work was conducted on board Seatruck Progress did not
always match onboard procedures
№ Recommendation(s) to: Maritime and Coastguard Agency and Isle of Man Ship Registry
2020/120 Issue guidance on the potential distractions caused by the use of mobile telephones on working
decks and other workspaces on board ships.
MCA - Appropriate action implemented
2020/121 Incorporate guidance on the potential distractions caused by the use of mobile telephones on
working decks and other workspaces on board ships into the Code of Safe Working Practices for
Merchant Seafarers.
Appropriate action implemented
2020/122 Highlight to the ferry industry the lessons to be learned from this accident, through its Health
and Safety Sub-Committee and Ferry and Cruise Panel, taking into account, inter alia:
• The importance of segregating vehicular and pedestrian movements across a vessel’s
ramps, particularly when there is only one means of access.
• The importance of co-ordinating vessel-based and shore-based safety management
systems to pedestrian safety.
• The difficulties created by ports and terminals adopting differing work practices.
• The potential hazard of distraction caused by mobile phone use.
Appropriate action implemented
▶ 22 ◀
REPORTS AND RECOMENDATIONS
2020/123 Continue to strive to improve the safety of its crews, considering, inter alia:
• The requirements of the Code of Safe Working Practices for Merchant Seafarers,
particularly regarding the segregation of pedestrians and vehicles on a ferry’s stern ramp
where a protected pedestrian walkway cannot be provided.
• The findings of the recent safety climate survey report and its suggestions to improve
procedural compliance and crew attitudes towards safety.
• The importance and benefts of continuing to monitor the safety climate among its
workforce.
Appropriate action implemented
Safety issues
▶ Working under a suspended load or in the load's fall zone
▶ No task specific risk assessment or lifting plan
▶ Inappropriate storage area for loose lifting gear
▶ Ineffective inspection regime for lifting gear
Safety issues
▶ Hazards associated with crossing the river sand bar
▶ Local environmental conditions - unexpected wave heights
▶ The crew did nor wear PFDs
▶ 23 ◀
REPORTS AND RECOMENDATIONS
Safety Issues
▶ Insufficient situational awareness to support safety-critical
decision making on board a Royal Navy submarine
▶ Passage planning had identified the hazard for the submarine of
operating near busy shipping lanes; however, the action taken to
keep clear was ineffective
2020/124 Deliver an independent review of the actions taken following this and previous similar events,
to provide assurance that such actions have been effective in reducing the risk of collision
between dived RN submarines and surface vessels to as low as reasonably practicable.
Appropriate action implemented
Safety Issues
▶ Weather routing in heavy seas - bow slamming and hull vibration
▶ The containers were not stowed or secured in accordance with the
guidance contained in the ship’s cargo securing manual
▶ The lashing rod locking arrangements were not used, which increased the
risk of loosening
▶ Verified Gross Mass irregularities in 36% of the stow
2020/125 Highlight to its ships’ masters the increased risk of cargo damage when ships experience hull
slamming and stern shuddering during heavy weather.
Appropriate action implemented
2020/126 Introduce a programme for lashing equipment inspections when the ship is not in service.
Appropriate action implemented
▶ 24 ◀
REPORTS AND RECOMENDATIONS
2020/127 Take action to ensure its shore planners are fully trained in the use of its ship loading computers
and that they understand the importance of checking the permissible load limits for containers
and lashing systems.
Appropriate action implemented
Safety Issues
▶ Insufficient anchor cable and second anchor not used
▶ Tug did not have adequate navigational plan when it left the
channel
▶ Vessel manager’s emergency response organisation was
ineffective
▶ Valuable intervention by SOSRep initiated successful
salvage of stranded vessel
2020/128 Review the company’s emergency response organisation and procedures with the aim of
improving decision making and the clarity of advice provided to its vessels.
Appropriate action implemented
▶ 25 ◀
REPORTS AND RECOMENDATIONS
Safety issues
▶ Cold water shock and cold water incapacitation
▶ The casualty was not wearing a Personal Flotation Device or carrying a Personal Locator Beacon
In view of fishing industry initiatives and the recommendations made in the MAIB’s report into the
fatal man overboard from the single-handed fishing boat Sea Mist9, no recommendations have been
made as a result of this investigation.
Safety Issues
▶ The boat's diesel-fulled cabin heater was not correctly
installed, inspected or regularly serviced by a suitably
competent person
▶ The exhaust silencer was not designed for marine use
and the exhaust system leaked
▶ A carbon monoxide detector was not fitted
This bulletin was issued to raise awareness of the importance of installing carbon monoxide (CO)
alarms on boats with enclosed accommodation spaces and no recommendations were made.
9 Recommendation details are on page 37 and the full report can be download from our website: https://www.gov.uk/maib-reports/man-overboard-
from-single-handed-creel-boat-sea-mist-with-loss-of-1-life
▶ 26 ◀
REPORTS AND RECOMENDATIONS
Safety Issues
▶ Fall prevention requirements for open deck access routes
▶ Transfer of helm and propulsion control and control position indication
▶ Boat hirer competence checks and boat handover familiarisation instruction
MAIB comment: Bullet points 1, 3 and 4 have been accepted and passed onto the Higher Boat Code
Working Group for action. Bullet 2 has been rejected but has been passed onto the Boat Safety Scheme
for their consideration by the Association of Inland Navigation Authorities.
▶ 27 ◀
REPORTS AND RECOMENDATIONS
Safety Issues
▶ Unplanned boating activity - both boats were operating at speed and carrying out uncoordinated
manoeuvres in the same stretch of the river
▶ An effective lookout was not maintained on either vessel
▶ No national standards for fire service boat operations when not involved in flood rescue work
№ Recommendation(s) to: Mid and West Wales Fire and Rescue Service
2020/130 Undertake a review of the crewing and staff qualification requirements for boats within
MWWFRS to determine appropriate levels for familiarisation, training and emergency
operations status and include the requirement within revised procedures and guidance.
Appropriate action implemented
2020/131 Introduce a method of recording time spent as helmsman of its boats and implement a
minimum number of hours required as helmsman to maintain competency.
Appropriate action implemented
2020/132 Include reference to its boats within the internal audit and inspection report process.
Appropriate action implemented
2020/133 Consult with the Maritime and Coastguard Agency and the UK Harbour Master’s Association
to introduce a standard code for the operation of all fire and rescue service craft when in
categorised or non-categorised waters.
Appropriate action planned: 30 November 2021
▶ 28 ◀
REPORTS AND RECOMENDATIONS
Safety Issues
▶ Unsafe crane operations
▶ Established safe practices were not being followed on deck
▶ Enforcement of drug and alcohol policies ineffective
▶ Slow reporting of accident to MAIB
2020/134 Take action to improve the safety culture on its vessels. In particular, to take steps to ensure
all crew on its vessels understand and adhere to agreed and established safe systems of work,
aligned to the company’s safety management system, and that all accidents are reported
appropriately.
Appropriate action implemented
2020/135 Investigate improvements to gantry crane warning systems, including pre-movement warning
or automatic stop systems.
Appropriate action implemented
▶ 29 ◀
REPORTS AND RECOMENDATIONS
Safety Issues
▶ Over shoulder, pre-manoeuvre checks were not being carried out
▶ Supervision of inexperienced helmsman
▶ Operation of watercraft in close proximity to each other and wave jumping
2020/136 Review and amend its Personal Watercraft and Start Powerboating handbooks to provide
guidance on:
• The importance and conduct of the over-the-shoulder pre-manoeuvre check;
• How to safely operate in company with other craft, with particular focus on
communication and safe distances;
• The oversight of inexperienced/untrained helms in an informal setting;
• Crossing waves and wakes, with particular focus on control of personal watercraft and safe
distances from vessels creating wake, and:
• Disseminate to their members a summary of the safety messages from this accident prior
to the start of the 2021 boating season.
Consideration should also be given to including the above topics in the relevant training course
syllabi.
Appropriate action planned: 31 August 2021
▶ 30 ◀
REPORTS AND RECOMENDATIONS
Safety Issues
▶ Enclosed space working without safety precautions
▶ Unsafe lone working in an enclosed space
▶ Insufficient risk assessment or method statements for
maintenance work on board
▶ Inadequate refrigeration plant maintenance resulting in
loss of containment of ozone depleting gas
2020/137 Implement measures for the safe conduct of enclosed space operations on board fishing
vessels, specifically:
• Amend the Merchant Shipping (Entry into Dangerous Spaces) Regulations, 1988, or any
subsequent regulations for potentially hazardous spaces, to include fishing vessels.
Consideration should also be given to aligning UK regulations and guidance with the IMO
terminology for enclosed spaces.
• Update fishing vessel codes of practice and surveyor’s checklists to reflect enclosed space
safety and operations, specifically including atmosphere monitoring and crew preparation
for emergencies.
Appropriate action planned: 31 March 2022
2020/138 Review Letters of Delegation to its Recognised Organisations in order to ensure clarity of
understanding with regard to responsibility for survey of machinery items.
Appropriate action planned: 31 December 2021
2020/139 Implement an onboard safety management system in accordance with the MCA’s Fishing
Safety Management Code, specifically ensuring that safe systems of work are in place for all
operations.
Appropriate action planned: 29 May 2021
2020/140 Encourage its members to maintain onboard safety management systems in accordance with
the MCA's Fishing Safety Management Code.
Appropriate action implemented
▶ 31 ◀
REPORTS AND RECOMENDATIONS
Safety Issues
▶ Entrapment of crew under upturned hull
▶ Self-righting retractable keel was not secured in place.
▶ Inadequate guidance for the securing of the retractable keel.
▶ Inadequate risk assessments and ineffective safety audit processes
2020/141 Seek an authoritative external review of its safety management system, once its internal review
and updating process is complete.
Appropriate action implemented
2020/142 Consider offering RYA Sailability centres the benefit of voluntary participation in external audits
of their safety management systems, undertaken by its cadre of trained RTC inspectors.
Appropriate action implemented
▶ 32 ◀
REPORTS AND RECOMENDATIONS
31 January 2019
Unnamed Rowing Boat (throw bag rescue line) 35
No 2/2019
30 May 2019
Nancy Glen (TT100) 35
No 6/2019
20 June 2019
CV30 36
No 7/2019
1 August 2019
Kuzma Minin 36
No 11/2019
15 November 2019
Sea Mist (BF918) 37
No 14/2019
5 December 2019
Millgarth 37
No 15/2019
15 March 2018
Saga Sky/Stema Barge II 38
No 3/2018
18 October 2018
CMA CGM Centaurus 38
No 17/2018
12 April 2017
CV21 39
No 7/2017
18 May 2017
Osprey/Osprey II 39
No 10/2017
15 June 2017
Zarga 40
No 13/2017
2 November 2017
Typhoon Clipper/Alison 40
No 24/2017
7 December 2017
Nortrader 41
No 26/2017
7 July 2016
JMT (M99) 41
No 15/2016
▶ 33 ◀
REPORTS AND RECOMENDATIONS
29 April 2015
Cheeki Rafiki 42
No 8/2015
10 December 2015
Stella Maris (HL705) 42
No 29/2015
2 May 2013
Purbeck Isle (PH 104) 43
No 7/2013
13 June 2013
Sarah Jayne (BM 249) 44
No 13/2013
20 June 2013
Vixen 44
No 16/2013
21 May 2009
Celtic Pioneer 45
No 11/2009
1 July 2009
Abigail H 45
No 15/2009
28 November 2008
Fishing Vessel Safety Study 1992 to 2006 46
FV Safety Study
▶ 34 ◀
REPORTS AND RECOMENDATIONS
2019/105 Develop an appropriate standard for public rescue equipment ensuring that the topic of throw
bags and their rescue lines is addressed as a priority.
Appropriate action planned: No date given
MAIB comment: Implementation delayed due to the impact of COVID-19 restrictions, British Standards
Institution still to provide revised date.
2019/109 Include in its new legislation addressing the stability of existing fishing vessels of under 15m,
a requirement to undertake both a freeboard check and stability check, which should be
recorded and repeated at intervals not exceeding 5 years.
Provide guidance on the conduct of 5-yearly stability checks to ensure the results can be
effectively compared to determine whether the vessel’s stability has altered.
Align the text of MSN 1871 (F), The Code of Practice for the Safety of Small Fishing Vessels of
less than 15m Length Overall, to mirror Statutory Instruments 2017 No. 943 Merchant Shipping,
The Fishing Vessel (Codes of Practice) Regulations 2017. This amendment should be in respect
of vessel owners’ obligation to notify the MCA of any proposal to alter or modify a vessel’s
structure, remove or reposition engines or machinery or change the mode of fishing.
Include in its new legislation introducing stability criteria for all new and substantially modified
vessels, a requirement for this to be validated by a 5-yearly lightship check.
Partially accepted - action planned: 31 August 2021
▶ 35 ◀
REPORTS AND RECOMENDATIONS
2019/110 Review and amend ISO 12401 and ISO 15085 at the earliest opportunity in light of lessons
learned from this accident to:
• Ensure the danger of snagging of tether hooks is highlighted and suitable precautions are
taken for terminating jackstays.
• Clarify that the ISO 12401 standard test assumes that the tether is loaded longitudinally
and that the hook must be free to rotate to align with the load, and lateral loading of the
hook must be avoided.
• Clarify what force should be applied during an accidental hook opening test.
• Consider including a requirement for a tether overload indicator.
Appropriate action planned: 31 December 2023
2019/111 Raise awareness of the dangers of laterally loading safety tether hooks, including consideration
of suitable amendments to World Sailing’s Offshore Special Regulations.
2019/117 Take steps to ensure that its vessels are adequately resourced to operate safely and in
accordance with international conventions, taking into account the potential consequences
of vessels having insufficient fuel and oils, and the statutory requirement to maintain P&I
insurance.
Withdrawn
MAIB comment: JSC Murmansk Shipping Company was declared bankrupt in October 2020 and is no
longer trading.
▶ 36 ◀
REPORTS AND RECOMENDATIONS
2019/119 Evaluate and, as appropriate, revise the safety guidance for single-handed fishermen provided
by the MCA and Seafish to ensure that it remains fit for purpose and readily available to
fishermen.
Appropriate action implemented
2019/120 Take action to improve the promulgation of the available safety guidance and safety lessons to
single-handed fishermen.
Appropriate action implemented
2019/124 Ensure that a thorough assessment of site-specifc risks, leading to an agreed procedure, is
completed for all locations where tugs provide their services. Where shared risks are identifed,
work jointly with the tug owners and operators to achieve this.
Appropriate action implemented
▶ 37 ◀
REPORTS AND RECOMENDATIONS
2018/104 Commission a study to review the full range of emergency response assets available in the
Dover Strait area, including a reassessment of the need for a dedicated emergency towing
capability.
2018/127 Review and improve its management of pilotage and berthing operations in respect of large
container ship movements within the port of Jebel Ali, with particular regard to the following:
• Development of approved pilotage and manoeuvring plans, including optimum use of tugs
and ensuring ships do not commit to the buoyed channel until completion of a detailed
and effective master/pilot information exchange.
• Provision of approved pilotage and manoeuvring plans to a visiting ship as soon as
practicable prior to the pilot boarding.
• Provision of Bridge Resource Management training specifically tailored to meet the needs
of pilots.
• Removal of Key Performance Indicators that potentially create inappropriate performance
bias towards efficiency against safety.
MAIB comment: Most of the actions recommended were accepted and have been implemented;
however, DP World UAE Region considered it impractical to provide pilotage and manoeuvring plans to
visiting ships prior to pilots boarding.
▶ 38 ◀
REPORTS AND RECOMENDATIONS
MAIB comment: Implementation project delayed due to impact of COVID-19 restrictions and Brexit
workloads.
2017/115 Include in its forthcoming Recreational Craft Code with respect to commercially operated
passenger carrying RIBs:
• A requirement for the certificated maximum number of passengers to be limited to the
number of suitable seats designated for passengers.
• Guidance on its interpretation of "suitable" with respect to passenger seating.
• A requirement for passengers not to be seated on a RIB’s inflatable tubes unless otherwise
authorised by the Certifying Authority and endorsed on the RIB’s compliance certificate
with specified conditions to be met for a particular activity.
▶ 39 ◀
REPORTS AND RECOMENDATIONS
2017/117 Review and enhance its guidance and instructions for the monitoring, maintenance and discard
of HMSF mooring ropes, and bring this to the attention of its customers. The revised guidance
should emphasise the importance of:
• Deck fitting and rope D:d ratios.
• Applying appropriate safety factors for given applications.
• Understanding the causes of kinking and the potential impact of axial compression fatigue
on the working life of HMSF rope.
• Rope fibre examination and testing as part of the assessment of fibre fatigue degradation
and discard.
▶ 40 ◀
REPORTS AND RECOMENDATIONS
2017/154 Update The Merchant Shipping (Carriage of Cargoes) Regulations 1999 with appropriate
references to the IMSBC Code.
2016/130 Include in its intended new legislation introducing stability criteria for all new and significantly
modified decked fishing vessels of under 15m in length a requirement for the stability of new
open decked vessels, and all existing vessels of under 15m to be marked using the Wolfson
Method or assessed by use of another acceptable method.
Appropriate action planned: 31 August 2021
2016/131 Require skippers of under 16.5m fishing vessels to complete stability awareness training.
▶ 41 ◀
REPORTS AND RECOMENDATIONS
2015/117 Co-operate with certifying authorities, manufacturers and repairers with the aim of developing
best practice industry-wide guidance on the inspection and repair of yachts where a GRP matrix
and hull have been bonded together.
Appropriate action planned: No date given
MAIB comment: A stakeholder group has been established and it has been set a target date of December
2021 to deliver a draft framework of the guidance.
2015/120 Include in the SCV Code a requirement that vessels operating commercially under ISAF11 OSR
should undergo a full inspection to the extent otherwise required for vessels complying with
the SCV Code.
Appropriate action planned: 30 March 2022
2015/165 Introduce intact stability criteria for all new and significantly modified decked fishing vessels of
under 15m in length.
Appropriate action planned: 31 August 2021
▶ 42 ◀
REPORTS AND RECOMENDATIONS
2015/171 Work together to ensure European Commission funded modifications are fully reviewed for
their impact on vessel stability and safety by agreeing the remit of such reviews and setting
realistic target times to enable such co-operation.
MCA:Appropriate action implemented
2013/204 Align its hull survey requirements for fishing vessels of <15m length overall with those applied
to workboats under the Harmonised Small Commercial Vessels Code.
Appropriate action planned: 31 August 2021
▶ 43 ◀
REPORTS AND RECOMENDATIONS
2013/213 As part of its intended development of new standards for small fishing vessels, review and
include additional design and operational requirements as necessary to ensure that a vessel
engaged in bulk fishing remains seaworthy throughout its intended loading procedure. Specific
hazards that should be addressed include:
• The increased risk of capsize from swamping if freeing ports are closed.
• The risk of downflooding if flush deck scuttles and fish hold hatch covers are opened at
sea.
Appropriate action planned: 31 August 2021
MAIB comment: A proposed licensing regime for boat hirers was developed by Stirling, Argyll & Bute
and West Dumbartonshire Councils in 2014 that, if approved, was intended to be applied consistently by
the three local authorities. It is disappointing that Stirling Council has yet to introduce a boat licensing
system for inland waters falling under the Council’s area of responsibility, particularly given that Argyll
& Bute and West Dunbartonshire Councils have fully implemented the intent of the recommendations
made in the Vixen report.
▶ 44 ◀
REPORTS AND RECOMENDATIONS
2009/126 Review and revise the deck manning and qualification requirements of the harmonised SCV
Code taking into account the speed of craft and the type of activity intended in addition to the
distance from shore and environmental conditions.
Appropriate action planned: 30 March 2022
MAIB comment: The implementation of this recommendation was delayed due to a change in strategy
for the regulation of small commercial vessels: the first draft SI is currently being processed.
2009/141 Introduce a mandatory requirement, for all vessels greater than 24m length and less than 500
gross tons, for the fitting of bilge alarms in engine rooms and other substantial compartments
that could threaten the vessel’s buoyancy and stability if flooded. These, and any other
emergency alarms, should sound in all accommodation spaces when the central control station
is unmanned. In addition to functioning in the vessel’s normal operational modes, alarms
should be capable of operating when main power supplies are shut down, and be able to wake
sleeping crew in sufficient time for them to react appropriately.
Appropriate action planned: 30 June 2021
▶ 45 ◀
REPORTS AND RECOMENDATIONS
2008/173 In developing its plan to address the unacceptably high fatality rate in the fishing industry,
identified in its study of statistics for the years 1996 to 2005, in addition to delivering the actions
outlined at 6.2, the MCA is recommended to consider the findings of this safety study, and in
particular to:
• Clarify the requirement for risk assessments to include risks which imperil the vessel such
as: environmental hazards; condition of the vessel; stability etc.
• Work towards progressively aligning the requirements of the Small Fishing Vessel Code,
with the higher safety standards applicable under the Workboat Code.
• Clarify the requirements of The Merchant Shipping and Fishing Vessels (Health and Safety
at Work) Regulations 1997 to ensure that they apply in respect of all fishermen on board
fishing vessels, irrespective of their contractual status.
• Ensure that the current mandatory training requirements for fishermen are strictly
applied.
• Introduce a requirement for under 15m vessels to carry EPIRBs.
• Review international safety initiatives and transfer best practice to the UK fishing industry
with particular reference to the use of PFDs and Personal Locator Beacons.
• Conduct research on the apparent improvement in safety in other hazardous industry
sectors, such as agriculture, construction and offshore, with the objective of identifying
and transferring best safety practice from those industries to the fishing industry.
▶ 46 ◀
UK VESSELS: ACCIDENTS INVOLVING LOSS OF LIFE
PART 3: STATISTICS
For details of reporting requirements and terms used in this section please see the annex - Statistics
Coverage on page 68 and the glossary on page 74.
Fish farm Loch Alsh, Scottish Fatal accident to a fish farm worker while transiting
18 Feb Beinn Na Caillich
workboat Highlands between a vessel and a barge.
High speed A high speed passenger craft hit a buoy, resulting in
22 Aug Seadogz The Solent, England
passenger craft one fatality.
River Bure, Great Fatal person overboard from inland waterway
19 Aug Diamond Emblem 1 Motor cruiser
Yarmouth, England cruiser.
Inflatable
A fatal incident in which a crew member fell
28 Aug Unknown dinghy used in Dee Estuary, Wales
overboard after dinghy grounded on a sandbank.
cockling
Great Yarmouth, A passenger onboard a river cruiser fell overboard
15 Sep Acapulco Motorboat
England and was fatally injured by the propeller.
Fishing vessels
Off the coast of Capsized and sank with three crew on board. One
21 Nov Joanna C (BM 265) Fishing vessel Beachy Head, crew member was found alive, but two certified
England deceased.
▶ 47 ◀
UK VESSELS: ACCIDENTS INVOLVING LOSS OF LIFE
▶ 48 ◀
UK MERCHANT VESSELS >= 100gt
There were no losses of UK merchant vessels >= 100gt reported to the MAIB in 2020
2011 - 1 521 -
2012 - 1 450 -
2013 - 1 392 -
2014 - 1 361 -
2015 - 1 385 -
2016 - 1 365 -
2017 - 1 356 -
2018 - 1 332 -
2019 - 929 -
2020 - 1 242 -
▶ 49 ◀
UK MERCHANT VESSELS >= 100gt
Collision - 3 3 7 - 13
Contact - - 5 1 - 6
Fire/explosion 1 - 1 3 - 5
Flooding/foundering - 1 - - - 1
Grounding - 7 1 10 1 19
Machinery 1 3 5 5 - 14
Total 2 14 15 26 1 5813
2011 185 5
2012 186 3
2013 134 1
2014 142 -
2015 141 2
2016 133 2
2017 153 -
2018 114 -
2019 105 3
2020 78 -
▶ 50 ◀
UK MERCHANT VESSELS >= 100gt
Number
Rank/specialism of crew
Chief mate 1
Officer, deck 1
Officer, engineering 3
Rating 1
Total 78
Rating: 1
Chart 6
▶ 51 ◀
UK MERCHANT VESSELS >= 100gt
Provision room 1
Total 78
Restaurant/bar 1
Stairway/ladders 8
Theatre 1
Other 5
Unknown: 1
Over side: 1
Accommodation: 31
Ship - other: 34
Engine department: 8
Chart 7
▶ 52 ◀
UK MERCHANT VESSELS >= 100gt
Table 8: Deaths and injuries of merchant vessel crew by part of body injured
Number
Part of body injured of crew
42.3%
2.6%
Head
Whole body and
Eye(s) 1 multiple sites
10.3% Back
MV
Upper limbs
Wrist 9
Back 29.5%
Back, including spine and vertebrae
8
in the back Lower limbs
Lower limbs
Toe(s) 1
Foot 4
Ankle 9
Note: Percentages may not add up to 100% due to rounding
Leg, including knee 8
Chart 8
Lower extremities, other parts not
1
mentioned above
Total 78
▶ 53 ◀
UK MERCHANT VESSELS >= 100gt
Number
Deviation* of crew
Pushing, pulling 2
Body movement under or with physical
stress (generally leading to an internal Putting down, bending down 1
injury)
Treading badly, twisting leg or ankle, slipping without falling 3
Other 3
Other 1
Other 1
Total 78
▶ 54 ◀
UK MERCHANT VESSELS >= 100gt
2019 2020
0 5 10 15 20 25 30 35 40
30
Body movement without physical stress
13
8
Loss of control
7
35
Slipping, stumbling and falling
38
0
Other
1
▶ 55 ◀
UK MERCHANT VESSELS >= 100gt
Table 10: Deaths and injuries of merchant vessel crew by type of injury
Number
Main injury of crew
Multiple injuries 1
Unknown or unspecified 2
Total 78
▶ 56 ◀
UK MERCHANT VESSELS >= 100gt
2011 109 1
2012 50 -
2013 46 -
2014 56 1
2015 55 1
2016 51 1
2017 26 -
2018 81 -
2019 107 -
2020 25 -
Number of
Main injury passengers
Closed fractures 23
Bone fractures
Open fractures 1
Total 25
15 From 2012 to 2019 this table excludes injuries/fatalities that were not in connection with the operation of a ship.
▶ 57 ◀
UK MERCHANT VESSELS < 100gt
Table 14: Merchant vessels < 100gt by nature of casualty and vessel category
Passenger ship
Total
Capsizing/listing - - - - - 2 - 2
Collision 1 1 - - 2 1 5 10
Contact - 2 2 - - 2 5 11
Fire/explosion - 1 - - - 1 4 6
Flooding/foundering 1 - 6 - - - 1 8
Grounding 1 - 12 5 - 9 7 34
Machinery - 4 9 3 2 2 6 26
Deaths - - 3 - - - 2 5
Injuries 4 2 12 6 6 3 8 41
▶ 58 ◀
UK FISHING VESSELS
There were 5 443 UK registered fishing vessels at the end of 2020. During 2020, 165 casualties to vessels
involving these vessels were reported to the MAIB. Figures in the following tables show casualties to vessels
and injuries to crew involving UK registered vessels that were reported to the MAIB in 2020.
8 fishing vessels were reported lost (0.15% of the total fleet) and there were 2 fatalities to crew.
▶ 59 ◀
UK FISHING VESSELS
Under 15m loa 15m loa to <24m reg 24m reg and over Total lost UK registered % lost
Incident rate
Number of per 1 000 vessels at risk
vessels involved (to one decimal place17)
Capsizing/listing 3 0.6
Collision 10 1.8
Contact 3 0.6
Fire/explosion 8 1.5
Flooding/foundering 9 1.7
Grounding 15 2.8
16 From 2012 to 2019 this table excludes injuries/fatalities that were not in connection with the operation of a ship.
17 Rates may not add up due to rounding.
▶ 60 ◀
UK FISHING VESSELS
Table 18: Fishing vessels in casualties — by nature of casualty and by length range
Number of vessels involved Incident rate per 1 000 vessels at risk (to one decimal place18)
Capsizing/listing 2 0.4
Collision 4 0.8
Contact 2 0.4
Fire/explosion 5 1.0
Flooding/foundering 4 0.8
Grounding 12 2.5
Machinery 83 17.0
Capsizing/listing 1 2.3
Collision 5 11.4
Contact 1 2.3
Fire/explosion 2 4.6
Flooding/foundering 4 9.2
Grounding 3 6.9
Machinery 30 68.6
Collision 1 7.8
Fire/explosion 1 7.8
Flooding/foundering 1 7.8
Machinery 4 31.0
▶ 61 ◀
UK FISHING VESSELS
Table 19: Deaths and injuries to fishing vessel crew by type of injury
Number
Main injury of crew
"Drowning and non-fatal
Drowning and asphyxiation 2
submersions"
Closed fractures 6
Bone fractures
Open fractures 1
Effects of temperature
Effects of reduced temperature 1
extremes, light and radiation
Total 38
Traumatic amputations: 6
Poisonings and
infections: 2
Effects of
temperature
extremes, light
and radiation: 1
Bone fractures: 7
Dislocations, sprains
and strains: 2
Concussions and
internal injuries: 12
Chart 10
▶ 62 ◀
UK FISHING VESSELS
Table 20: Deaths and injuries to fishing vessel crew by part of body injured
Number
Part of body injured of crew
Head 7.9%
Finger(s) 10
Torso and
organs FV 2.6%
Other
Hand 1
Wrist 1
Lower limbs
Ankle 1
Note: Percentages may not add up to 100% due to rounding
Other
Chart 11
Not specified 1
Total 38
▶ 63 ◀
UK FISHING VESSELS
Number
Deviation* of crew
Pushing, pulling 3
Body movement under or with physical
stress (generally leading to an internal Twisting, turning 1
injury)
Other 2
Of animal20 1
No information 1
Total 38
▶ 64 ◀
UK FISHING VESSELS
2019 2020
0 2 4 6 8 10 12 14
12
Body movement without physical stress
8
8
Loss of control
9
11
Slipping, stumbling and falling
11
1
Other
0
0
No information
1
▶ 65 ◀
UK FISHING VESSELS
Table 22: Deaths and injuries to fishing vessel crew by vessel length (of which, deaths shown
in brackets) 2011-202021
70
60
Number of fishing vessel crew
8
50
6
40
8
2
9 6 5
30 4 7
5
20
10
0
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Chart 13
21 From 2012 this table excludes injuries/fatalities that were not in connection with the operation of a ship.
▶ 66 ◀
NON-UK COMMERCIAL VESSELS
There were no losses of non-UK vessels in UK waters reported to the MAIB 2020.
Table 24: All non-UK commercial vessels in UK waters — by vessel type and by nature of
casualty
Collision 11 6 1 5 - - 23
Contact 7 - 2 - - - 9
Fire/explosion 2 - 2 - - - 4
Grounding 12 2 1 1 2 - 18
Machinery 12 2 3 3 4 - 24
Deaths - - - - - - -
Injuries 6 5 7 4 5 1 28
▶ 67 ◀
ANNEXES, GLOSSARY AND FURTHER INFORMATION
22 https://www.gov.uk/government/organisations/marine-accident-investigation-branch/about#regulations-and-guidance
▶ 68 ◀
ANNEXES, GLOSSARY AND FURTHER INFORMATION
Marine Casualty23
An event or sequence of events that has resulted in any of the following and has occurred directly by or in
connection with the operation of a ship:
• the death of, or serious injury to, a person;
• the loss of a person from a ship;
• the loss, presumed loss or abandonment of a ship;
• material damage to a ship;
• the stranding or disabling of a ship, or the involvement of a ship in a collision;
• material damage to marine infrastructure external of a ship, that could seriously endanger the safety
of the ship, another ship or any individual;
• pollution, or the potential for such pollution to the environment caused by damage to a ship or ships.
A Marine Casualty does not include a deliberate act or omission, with the intention to cause harm to the
safety of a ship, an individual or the environment.
Each Marine Casualty is categorised as ONE of the following:
Very Serious Marine Casualty (VSMC)
Marine Casualty which involves total loss of the ship, loss of life, or severe pollution.
Serious Marine Casualty (SMC)
Marine Casualty where an event results in one of:
• immobilisation of main engines, extensive accommodation damage, severe structural damage, such
as penetration of the hull underwater, etc., rendering the ship unfit to proceed;
• pollution;
• a breakdown necessitating towage or shore assistance.
Less Serious Marine Casualty (LSMC)
This term is used by MAIB to describe any Marine Casualty that does not qualify as a VSMC or a SMC.
Marine Incident (MI)
A Marine Incident is an event or sequence of events other than those listed above which has occurred
directly in connection with the operation of a ship that endangered, or if not corrected would endanger
the safety of a ship, its occupants or any other person or the environment (e.g. close quarters situations
are Marine Incidents).
Accident
Under current Regulations6 Accident means any Marine Casualty or Marine Incident. In historic data,
Accident had a specific meaning, broadly equivalent to (but not identical to) Marine Casualty.
Operation of a ship
To qualify as a Marine Casualty an event/injury etc must be in connection with the operation of the ship
on which it occurs. MAIB’s interpretation of this includes any “normal” activities which take place on
board the vessel (e.g. a chef who cuts himself while preparing food is considered in connection with the
operation of the ship).
23 http://www.legislation.gov.uk/uksi/2012/1743/regulation/3/made
▶ 69 ◀
ANNEXES, GLOSSARY AND FURTHER INFORMATION
Collisions/Contacts – Until 2012 the UK defined a collision as a vessel making contact with another vessel
that was subject to the collision regulations, after 2012 a collision is any contact between two vessels, i.e.
Until 2012
Collision - vessel hits another vessel that is underway, floating freely or is anchored.
Contact - vessel hits an object that is not subject to the collision regulations e.g. buoy, post, dock, floating
logs, containers etc. Also another ship if it is tied up alongside. In order to qualify as the equivalent of a
Marine Casualty the contact must have resulted in damage.
From 2013
Collision - a casualty caused by ships striking or being struck by another ship, regardless of whether the
ships are underway, anchored or moored.
This type of casualty event does not include ships striking underwater wrecks. The collision can be with
other ship or with multiple ships or ship not underway.
Contact - a casualty caused by ships striking or being struck by an external object. The objects can be:
floating object (cargo, ice, other or unknown); fixed object, but not the sea bottom; or flying object.
Injury - The EU requires injuries to be reported if they are “3 day” injuries. This is described in more detail
in section 4.2 of the European Statistics on Accidents at Work (ESAW) Summary methodology24 (Note that in
this context the term “Accident” means an injury.)
“Accidents at work with more than three calendar days’ absence from work. Only full calendar days of
absence from work have to be considered, excluding the day of the accident. Consequently, ‘more than
three calendar days’ means ‘at least four calendar days’, which implies that only if the victim resumes
work on the fifth (or subsequent) working day after the date on which the accident occurred should the
incident be included.”
UK injury data also includes “serious” injuries. In addition to “3 day” injuries these are:
• any fracture, other than to a finger, thumb or toe;
• any loss of a limb or part of a limb;
• dislocation of the shoulder, hip, knee or spine;
• loss of sight, whether temporary or permanent;
• penetrating injury to the eye;
• any other injury -
◦ leading to hypothermia or unconsciousness,
◦ requires resuscitation, or
◦ requiring admittance to a hospital or other medical facility as an inpatient for more than 24 hours;
In the IMO Casualty Investigation Code25 (section 2.18) Serious injury means an injury which is sustained
by a person in a casualty resulting in incapacitation for more than 72 hours commencing within seven days
from the date of injury.
Due to the special working conditions of seafarers, injuries to seafarers while off-duty are considered to be
occupational accidents in MAIB Annual Reports26.
24 http://ec.europa.eu/eurostat/en/web/products-manuals-and-guidelines/-/KS-RA-12-102
25 https://wwwcdn.imo.org/localresources/en/OurWork/MSAS/Documents/Res.MSC.255(84)CasualtyIinvestigationCode.pdf (page 9, 2.18)
26 http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:91:0::NO::P91_SECTION:MLC_A4 (Article II 1.(f) & Standard A4.3)
▶ 70 ◀
ANNEXES, GLOSSARY AND FURTHER INFORMATION
Persons overboard
Until 2012
Any fall overboard from a ship or ship's boat was the equivalent of a Marine Casualty.
From 2013
Any fall overboard from a ship or ship's boat (that does not result in injury or fatality) is a Marine Incident.
▶ 71 ◀
ANNEXES, GLOSSARY AND FURTHER INFORMATION
Vessel Types included in MAIB Annual Report statistics from 2013 to date
1. MAIB use definitions in line with those used by EMSA and IMO. EXCEPT that the data presented in the
MAIB Annual Reports includes certain vessel types that are outside the scope of EU Directive 2009/18/
EC28 (the Directive).
2. Vessel types outside the scope of the Directive that are INCLUDED in MAIB Annual Report statistics:
• Fishing vessels of under 15 metres;
• Government owned vessels used on government service (except Royal Navy vessels);
• Inland waterway vessels operating in inland waters;
• Ships not propelled by mechanical means;
• Wooden ships of primitive build;
• Commercial recreational craft with fewer than 13 persons on board.
3. Vessel types outside the scope of the Directive that are EXCLUDED from MAIB Annual Reports:
• Royal Navy vessels;
• Fixed offshore drilling units.
4. Vessel Types (potentially) inside the scope of the Directive that are EXCLUDED from MAIB Annual Report
statistics:
• Recreational craft | Personal watercraft;
• Recreational craft | Sailing surfboards;
• Ships permanently moored which have no master or crew.
5. One “vessel” type, offshore drilling rigs, are inside the scope of the Directive, but usually outside
the scope of MAIB. For UK-flagged installations, broadly, if an accident occurs while the installation
is in transit MAIB investigate and record details, otherwise the Health and Safety Executive (HSE) is
responsible for investigating and recording details. More information can be found on pages 40 to 41 of
the Operational Working Agreement between MAIB, MCA & HSE29.
6. Until 2012 the MAIB considered SAR craft to be non-commercial. From 2013 onwards they are
considered commercial.
28 http://emsa.europa.eu/emsa-documents/legislative-texts/72-legislative-texts/28-directive-200918ec.html
29 Refer to pages 11 and 12 of the Operational Working Agreement between HSE, MCA and MAIB:
http://www.hse.gov.uk/aboutus/howwework/framework/mou/owa-hse-mac-maib.pdf
▶ 72 ◀
ANNEXES, GLOSSARY AND FURTHER INFORMATION
Vessel categories used in MAIB Annual Report statistics from 2013 to date
Commercial recreational
May be a subset of either of the above two entries. Those over 100gt may be, for instance, a tall ship or
luxury yacht. Those under 100gt may be a chartered yacht or a rented dinghy.
UK fishing vessels
Commercial Fishing Vessels Registered with the UK Maritime and Coastguard Agency’s Registry of Shipping
and Seamen. Note that this category includes under 15 metre fishing vessels that are specifically excluded
from the scope of the Directive.
Passenger
In addition to seagoing passenger vessels this category also includes inland waterway vessels operating on
inland waters.
Service ship
Includes, but not limited to, dredgers, offshore industry related vessels, tugs and SAR craft.
Recreational craft
Recreational craft may be commercial or non-commercial. In the statistics section of each Annual Report
only “Table 1: Loss of life…” includes non-commercial recreational craft.
▶ 73 ◀
ANNEXES, GLOSSARY AND FURTHER INFORMATION
▶ 74 ◀
ANNEXES, GLOSSARY AND FURTHER INFORMATION
Terms
FURTHER INFORMATION
Marine Accident Investigation Branch
First Floor, Spring Place
105 Commercial Road
Southampton
SO15 1GH
Email
maib@dft.gov.uk
Online resources
www.gov.uk/maib https://twitter.com/maibgovuk
www.facebook.com/maib.gov www.youtube.com/user/maibgovuk
www.linkedin.com/company/marine-accident-investigation-branch
▶ 75 ◀
MAIB Annual Report