Part 1 - Merchant Vessels

“The sea is selective; slow in recognition of effort and aptitude,

but fast in sinking the unfit”. Felix Riesenberg.
From my point Yet the number of marine casualties at sea
of view it is a continues to give cause for concern. The
particular International Union of Marine Insurance has
privilege to recently published a report which states that
contribute this 2010 will join the worst five vessel loss years
introduction to in the last seventeen years.
the Merchant
Vessels Section of Accidents will happen and this Merchant
the MAIB’s Safety Shipping Section outlines the circumstances
Digest. which led to sixteen incidents. With hindsight
it is perhaps easy to say that many of these
Accidents happen. incidents need never to have occurred. Reality
During my tenure however is not so straightforward.
as the United
Kingdom When being taught to become a diver I was
Secretary of State’s Representative for Salvage introduced to the concept of the “incident pit”.
and Intervention (SOSREP) I was involved in The incident pit is a slang term used by divers.
over seven hundred incidents and the wider It refers to a conceptual pit, the sides of which
SOSREP support team in many more. Some slope gently at first then steeper and steeper
of those involved preventative activity, where until recovery from the pit (or incident) is
a ship appears to be in potentially dangerous impossible. “Falling into the pit” is never
circumstances, many others involved casualty intentional and often commences with a series
salvage and mitigating the impact of accidents of events, each of which alone would not be
whilst acting always, “in the overriding interests serious. However the effect is to put you onto
of the UK”. the downwards slope and additional events can
serve to cause more problems which exacerbate
The MAIB’s role is, of course, that of safety the situation, and steepen the slope until a
at sea. Whilst I was involved with aspects of point of no return is reached. It is often the
incidents as they occurred the MAIB had a fact that many, if not all, of the events may occur
significantly wider brief. From the outset I frequently and, when encountered on their
came into contact with the MAIB Investigation own, often pass unnoticed. An example of this
process and came to know their Inspectorate is outlined in the report “Are They In or Are
well, and I like to think there was mutual They Out?” In “The Lessons” section appears the
respect between us. We would meet on phrase “The chain of events began when . . . . .”.
occasions for discussion of aspects of incidents
from which process I learned that they would Reading through the narratives and lessons
listen to opinions and consider points made I find that across the board, failures in
before coming to their conclusions. After all seamanship and watch-keeping were
they too were involved in the aftermath of significant contributors to the incidents with
incidents and, by publishing the results of inadequate or missing planning and written
investigations, in contributing to the knowledge procedures and key persons being distracted
of the maritime world and furthermore by as joint second. And, perhaps surprisingly,
making recommendations will prevent many in these times, failures in risk assessment
potential incidents in future. Prevention and contribute to at least four of the incidents.
cure. Two of the incidents exemplify topical issues:
weighing containers and over-reliance on
electronic navigational systems.
8 MAIB Safety Digest 2/2011
The MAIB has already pointed out that there The report “How Not To Use ECDIS” and
is a strong case for weighing unaccompanied “What Were They Thinking?” provide examples
lorry trailers before they are loaded for export. of what can go wrong. In the Lessons is the
Similarly there is growing pressure in some statement, “In forthcoming years ECDIS will
quarters for the IMO to establish a legal replace paper charts as the primary means of
requirement that all loaded containers are navigation”. The lesson goes on to point out
weighed at the loading facility before being that proper training is essential if this equipment
stowed aboard a vessel for export. Such legal is to be used effectively and safely. Even on my
requirements are probably years away from own boat I always check the whole of the
being imposed, but there can be little doubt electronic passage plan on the larger magnification
that such a move would be in the interests of screens, where small hazards show up better,
good practice. And not only “loaded” containers and keep a full paper plot during transit.
should be weighed – the incident “Too Much
Up Top” exemplifies the implications of Finally, in “The Lessons” elsewhere, appears the
inadvertently stacking loaded containers following, “Simply checking that an individual
which were supposedly empty. carries the required certification is not sufficient
in an industry where the consequences of poor
Over-reliance on systems such as GNSS and practices can be devastating”. It is a major lesson
ECDIS can be dangerous. In respect of GNSS and a lesson, as are others in this publication,
trials have already established that systems are I believe, espoused by Lord Cullen following
vulnerable to interference from both natural the PIPER ALPHA disaster in July 1988.
(e.g. solar flares) or accidental or deliberate
activities by man (e.g. jamming – where there It is my pleasure to commend the reading
are no restrictions on supply of necessary which follows and the lessons, as they are set
equipment). Trials have indicated that where out, to you. I would be surprised if many
GPS signals are jammed the receiving units people could honestly say they cannot associate
don’t just stop and close down, but they can with some of the events presented.
provide false data which can be dangerously
misleading. What we have to do now is learn . . . . . .

Robin Middleton CBE

Robin Middleton became the Secretary of State’s Representative for Maritime Salvage and
Intervention in October 1999. As the SOSREP he officiated in more than 700 maritime and offshore
incidents and emergencies, five of which involved activation of the UK’s National Contingency Plan.

Mr Middleton’s background includes qualifications and work in law enforcement, commercial

diving, multi-disciplinary organisational management and peacetime emergency response.

He has served the Royal National Lifeboat Institute as a lifeboat crew member and has received the
Institute’s Silver Medal for Bravery. He still serves the RNLI as a member of Council and is a patron
of the Maritime Volunteer Service.

In recognition of his achievements he has received the Lloyds List Lifetime Achievement Award,
been awarded the first Honorary Life Membership of the International Salvage Union, made a
life member of the Tug and Salvage Association, a life Member of UKSPILL, elected to Honorary
Membership of the International Tug and Salvage Union. He was nominated as Personality of
the Year by the British Tug-owners Association in 2007.

Robin Middleton retired from the post of SOSREP at the end of 2007 and now lives in retirement
in the Isle of Man.

MAIB Safety Digest 2/2011 9

 CASE 1
No Brakes
Narrative visor was penetrated by the linkspan arm
(Figure 1) and the forefoot and forepeak buckled
As a ro-ro passenger ferry approached a link- on impact with the concrete ramp (Figure 2).
span, she did not slow down as expected. The Control of the starboard CPP system was lost
master further reduced the pitch on the two because a linkage had failed, leaving the pitch
controllable pitch propellers (CPP) from the stuck on full ahead (Figure 3). An identical
control panel on the port bridge wing, but failure had occurred on the starboard CPP
soon noticed that the pitch indicator for the system several months earlier when the system
starboard propeller was still at full ahead. was being tested alongside. On that occasion,
the broken linkage was replaced but the
The master ordered the chief officer to take cause of its failure was not investigated. The
control of the propulsion in the wheelhouse replacement linkage was taken from onboard
and to put the pitch on both propellers to full spares but was longer than the original
astern. This was done quickly, but the vessel’s component and had to be adjusted after fitting.
speed remained at about 10 knots and the Unfortunately, the adjustment of the linkage
vessel’s bow sheered towards an adjacent pier. caused it to come into contact with other
As the bow glanced off the pier, the starboard components when the engine was overloaded,
anchor was let go and the starboard engine which ultimately led to its eventual failure
was stopped. Seconds later, the ferry hit the during the ferry’s passage.
linkspan and was severely damaged. The bow

Figure 1: Penetration in bow visor

10 MAIB Safety Digest 2/2011

 CASE 1

Figure 2: Buckling of the stern and forepeak

Figure 3: Failed linkage from CPP

MAIB Safety Digest 2/2011 11

 CASE 1

The Lessons 3. When a CPP system fails, the default

position for the pitch varies between full
1. Mechanical and electrical failures are not ahead and full astern. In this case, the pitch
always readily apparent. Therefore, the failed to full ahead. Consequently, although
testing of propulsion and steering controls full astern was ordered, this only increased
prior to port entry and after changing the power ahead on the starboard propeller.
control positions is crucial.
4. Ships’ engineers often pride themselves
2. Machinery breakdowns have a knack of on fixing machinery when it goes wrong.
occurring when least expected. When they However, a role that is equally important,
happen close to dangers, accidents can is finding out why the machinery or
frequently only be prevented by rapid equipment failed in the first place. This
diagnoses and response. In this respect, goes a long way in preventing a similar
breakdown drills not only improve system breakdown occurring in the future.
knowledge among bridge teams, but they If required, technical advice can be sought
also help to prepare for the unexpected. from shore superintendents, manufacturers
and class.

12 MAIB Safety Digest 2/2011

 CASE 2
More Thought Less Speed
Narrative The master used considerable lateral thrust
to try and align his vessel with the linkspan.
During a busy bank holiday weekend, an However, this reduced the stern power
incoming ro-ro passenger ferry operating in available and the ferry struck protective
sheltered waters was unable to berth because fendering adjacent to the linkspan at a speed
her linkspan was occupied by a sister vessel. of about 4.5 knots (Figure 1). As a result, two
The ferry, which was already 25 minutes behind passengers were slightly shaken and the
schedule, had to wait nearly 20 minutes before vessel’s stern ramp was damaged (Figure 2).
the berth was clear and the master could
commence a stern-first approach. No speed indication was available on the
bridge wings because the GPS display was only
Powered by three Voith Schneider units, the available in the wheelhouse; the vessel was
ferry quickly accelerated to 8.4 knots under the not fitted with a speed log because of the
control of the master on the starboard bridge underwater turbulence created by the propulsion
wing. The OOW was on the port bridge wing system. The master had been on duty for about
monitoring the vessel’s proximity to adjacent 9 hours and was scheduled to be relieved on
berths. As the ferry was north of the position arrival.
from which the approach to the berth was
usually started, the master tried to rejoin the
usual track. However, the combination of the
vessel’s speed, which was faster than usual,
and her angle of approach, resulted in the ferry
slightly over-shooting the usual approach track
by several meters.

Figure 1: Damage caused to mounting Damage caused to fendering

MAIB Safety Digest 2/2011 13

 CASE 2

Figure 2: Damage sustained to stern ramp

The Lessons 2. Speed is critical to every berthing. It

impacts on vessels’ handling characteristics,
1. When plying between the same places, turning circles, stopping distances, leeway,
ferry crews inevitably become very familiar the effectiveness of bow thrusters, and the
with the approaches to the berths used. use of tugs. The margin between too fast
This is largely beneficial, but care must be and too slow is often delicately balanced
exercised to carefully consider and plan and needs to be carefully judged and
each arrival, particularly when responding monitored. An unnecessarily fast approach
to changes to the ‘normal’ routine that may might save seconds, but also risks there
occur at short notice. It is important not being less time and water available to react
to let familiarity lead to complacency, when things don’t go as intended.
particularly at the end of a long day.

14 MAIB Safety Digest 2/2011

 CASE 3
Unguarded Machinery and Lone Work -
a Fatal Combination
Narrative Although the emergency services were quickly
on scene, the wiper had already died of severe
During self-discharging operations of a cargo head injuries.
of slag, the wiper called the cargo control room
on his personal radio set to report that he was The wiper had not been required to carry
on watch in the conveyor belt tunnels, which out any maintenance work on watch and no
were beneath the cargo holds. mechanical faults were found in the self-
discharging machinery.
About 45 minutes later, the chief officer went
down to the tunnels to carry out routine The reason for the wiper becoming caught
rounds of the self-discharging system. When he in the system is unknown. There were no
reached the after end of the port side conveyor witnesses.
belt, he found the wiper’s body between the
conveyor belt roller and a supporting beam.
The chief officer activated the emergency
conveyor belt stop system and called for help.

The conveyor belt system

MAIB Safety Digest 2/2011 15

 CASE 3

The Lessons 3. There were no risk assessments on board

the vessel. A proper risk assessment of the
1. The machinery at the end of the conveyor area could have identified control measures
belt system was guarded by only a waist- such as enhanced guarding or CCTV
high hand rail. Therefore, it was easy for a coverage, which existed in other areas of
crew member to intentionally or the conveyor belt system, and extension of
unintentionally bypass the rail and come the safety stop arrangements.
into contact with the moving belt or end
roller. There was no safety stop in the 4. The wiper had been given only verbal
immediate area. instructions on his duties during cargo
discharge operations. There was no written
Ship owners have an obligation under The job description for this work. A more
Merchant Shipping and Fishing Vessels defined job description might have deterred
(Provision and Use of Work Equipment) him from carrying out any extraneous work
Regulations 2006 to ensure that every that could have placed him in danger.
dangerous part of the ship’s work equipment
is provided with guards or protection
devices. These are to prevent access to
danger zones or to halt movements of
dangerous parts before the danger zones
are reached.

2. The wiper worked alone during his 6-hour

watch. His only contact with the cargo
control room was to call the officers there
on his personal radio set if he wished to go
to the mess. There were no procedures in
place to regularly check on a lone worker.
This is contrary to the Code of Safe
Working Practices for Merchant Seamen,
which gives advice on communications
for personnel entering and working alone
in unmanned machinery spaces.

16 MAIB Safety Digest 2/2011

 CASE 4
Lulled Into a False Sense of Security
Narrative The vessel’s owners and DPA were aware of the
conditions and asked the master if he planned
A 1300 tonne, 40 year old cargo vessel was on to delay the voyage, and shelter. However,
a regular voyage carrying 1250 tonnes of logs the master, although having reduced speed to
between two NW European ports in winter. about 4 knots because of the weather, assessed
About 250 tonnes of the logs were stowed on that an unexpected lull would enable the vessel
deck. The logs were 5.5 metres long and rested to make the tide as planned at her destination.
on wood bearers to prevent them sliding on the
wet deck. They were held in place by webbing The master pressed on, but when the vessel’s
lashings and 2 metre high, 90mm² uprights heading was altered away from the lee, she
fitted into sockets welded at the hatch coamings encountered increasingly severe conditions.
at 2.5 metre intervals. The vessel began to pound into the heavy
seas and a large wave broke over her deck.
Due to a deep depression producing severe
gales, the vessel remained within the lee of The force of the wave overloaded the lashings
the land for most of her voyage. However, the in the fore and middle sections of the logs on
location of her destination port meant that she deck, and the lashings parted. This allowed the
would have to eventually transit more exposed logs to move to starboard (Figure 1) and overload
waters. the uprights, which bent 90° (Figure 2). About
100 tonnes of loose logs fell overboard.

Figure 1: The timber shift

MAIB Safety Digest 2/2011 17

 CASE 4

Figure 2: Uprights bent 90o

The Lessons 3. Log cargoes can take time to settle, and their
lashings need to be tensioned regularly. This
1. It is no coincidence that nearly all timber is not always possible in rough seas and it is
cargo shifts and losses overboard occur worth noting that, no matter how strong or
during bad weather. In such conditions, effective lashings might seem, they are no
a timber deck cargo is vulnerable to match for imprudent ship-handling in heavy
movement when hit with great force by weather.
considerable amounts of water. The water
can get between the timber, and pounding 4. The use of hog wires between the cargo and
and rolling can generate tremendous loading linking the uprights make log stows more
on the cargo and its lashings. secure by sharing the load with the uprights
and the lashings.
2. In cases where severe weather and sea
conditions are unavoidable, masters should
be conscious of the need to reduce speed and/
or alter course at an early stage in order to
minimise the forces imposed on the cargo,
structure and lashings.

18 MAIB Safety Digest 2/2011

 CASE 5
How Not to Use ECDIS
Narrative ECDIS display to a 1:50000 scale and saw from
the charted depth of water that the vessel was
A 4000 tonne dry cargo ship was on passage aground. This was confirmed after switching
in the North Sea. The visibility was good and on the echo sounder. A green, starboard mark
the sea was calm. The OOW was alone on the was also seen off the port bow.
bridge and was monitoring the vessel’s position
in relation to the voyage plan using an ECDIS. By now, the master had arrived on the bridge
The autopilot was selected and for much of with the chief officer and put the propeller
his watch the OOW worked on paperwork in pitch to full astern. The vessel refloated
anticipation of a forthcoming vessel audit. without difficulty and there was no damage.
No action was taken to save the VDR data.
The voyage plan had been input to the ECDIS
by the vessel’s chief officer and had been The amended voyage plan had taken the
amended the previous evening to shorten vessel across a charted area of shallow water.
the route and save time. At 1550, course was The vessel’s officers had not been trained in
altered to 331 to follow the intended plan. the use of ECDIS and no procedures on the
About 25 minutes later, the master, who was system’s use were included in the vessel’s SMS.
in his cabin, felt a change in the vessel’s They were therefore ignorant of many of
vibrations. He called the OOW and instructed the system requirements and features, and
him to check the depth of water. The OOW operated the system in a very basic and
looked at the ECDIS display and reported to inherently dangerous manner. In-built safe-
the master that there was no cause for concern. guards in the vessel’s ECDIS were not utilised
and system warnings were not acted upon. In
However, the vibrations increased and the addition, the planner’s check of the route plan
vessel quickly lost speed. The OOW now was only cursory and was not cross-checked
realised that something was wrong and put the by the master.
propeller pitch to zero. He then changed the

The Lessons vessel’s position by different means.

The use of ECDIS does not diminish the
1. In forthcoming years, ECDIS will replace importance of keeping a good lookout.
paper charts as the primary means of
navigation on many vessels. It goes without 3. The principles and requirements of passage
saying that deck officers need to be properly planning on ECDIS are no different than
trained in the use of this equipment if it is when using a paper chart, and a master’s
to be used effectively and safely. responsibility to cross-check the work of
his officers still remains.
2. The prime responsibility of an OOW is
the immediate safety of his ship. This 4. VDRs have been fitted on many ships for
responsibility cannot be met when he is a number of years, yet many masters are
distracted by secondary duties. ECDIS is still not certain when VDR data needs to
potentially a very accurate and effective be saved. Where doubt exists, it is better to
navigation and bridge watchkeeping aid, save the VDR data and not use it, rather
but it is no more than just that: an aid. than to lose information that might help to
When using ECDIS, OOWs still need to prevent similar accidents from occurring in
keep their wits about them, identifying the future.
navigational marks and cross-checking a

MAIB Safety Digest 2/2011 19

 CASE 6
Corrosion – a Penetrating Issue
Narrative A ventilation fan was removed to enable an
internal inspection of the duct. Water could
A cruise ship was expected to encounter severe be seen seeping into the ship, apparently
weather during the first few days of her next from under a large rust flake at the ship’s side.
voyage, and appropriate precautions were taken: Assessing that disturbing the rust flake might
storm shutters were closed, crew and passengers cause the plate to fail, a blanking piece was
were briefed, and warning notices were posted manufactured and attached to the duct in place
on doors opening onto the upper deck. of the fan as a temporary containment measure.
Previous ultrasound surveys of the area when
The ship left port in the early evening and, the vessel was last in dry dock had not identified
once clear of land, started to experience any significant diminution of the steel.
significantly stronger winds than were originally
forecast, prompting the master to adjust the On arrival at the ship’s next port of call, an
passage plan so as to take advantage of the underwater survey was carried out and ultra-
lee of an off-lying island. Beam winds reached sound measurements of the shell plate were
90 knots and it was necessary to offset the taken in way of the ventilation duct. The shell
ship’s heading by 30º to maintain the revised plate thickness was measured as 3mm, and
planned track. Once clear of the island, the seas further scraping of the corrosion on the ship’s
increased and the ship sustained damage to a side around the area of leakage increased the
number of external and internal fittings. rate of water ingress both above and below the
original site.
In the engine room, water was observed to
be coming from a ventilation duct. The duct
was of rectangular construction, and used two
adjacent transverse frames and the ship’s side
plating to form three sides, with the duct
completed by the fitting of a plate over the
two frames.

Ventilation duct with cover removed showing the leak in the vessel’s hull

20 MAIB Safety Digest 2/2011

 CASE 6

The Lessons 3. Classification society rules detail the areas

that require thickness measurement during
1. Using the gap between the frames as a class renewal survey. All suspect areas are
ventilation duct was an efficient use of required to be measured; as the ship ages,
space. The duct, however, was designed the scope of the required measurement
and built in such a way that it was increases. However, it is possible for the
impossible to inspect the steelwork inside. measuring transducer to be inadvertently
Even if the duct had been coated internally placed on only thicker parts of the structure.
before being closed up, condensation would This will give a false impression of the
have regularly formed in it which, over overall state of the plate and smaller areas
time, would have broken down the coating of extensive corrosion may not be identified.
and led to corrosion. The fitting of removable It is therefore essential to conduct a visual
inspection plates at each deck would have inspection in addition to ultrasound
readily enabled the duct to be inspected thickness measuring, particularly in the
internally and for preventative maintenance case of this type of ventilation duct and
to be carried out. other areas of similar construction.

2. When considering modifications to existing

structures ships’ staff, shore managers
and, when appropriate, class surveyors,
should consider carefully any potential
unintended consequences that may adversely
impact on the operation or fabric condition
of the vessel.

MAIB Safety Digest 2/2011 21

 CASE 7
Too Little Too Late
Narrative Over the next 2 minutes the master discussed
the diesel generator with the chief engineer,
A ro-ro cargo ferry was on a southerly heading agreed passing intentions with an outbound
when entering a river port at night in good vessel via VHF radio, and advised the forward
visibility. The master held a pilotage exemption and aft mooring parties of the need to minimise
certificate for the port and was very familiar the use of electrical power.
with the channel, which he had navigated
regularly for over 4 years. During this time, the wind and tidal stream set
the ferry out of the main channel. When the
Accompanying the master on the bridge were master realised that the next port hand mark,
the chief engineer, an OOW and a helmsman. a light-float, was now on the starboard bow,
There was no passage plan drawn on the chart he used both helm and engines to try and
and the bridge team had not been briefed on manoeuvre the vessel towards the main channel.
the arrival. The tidal stream was flooding at However, this action was taken too late and
between 3 and 4 knots, and a 20 knot wind was the 50 tonne lightship struck the vessel’s port
acting on the vessel’s starboard beam. side. The buoy’s superstructure was damaged
(figure) and its mooring chain was severed by
In preparation for entering a lock, the master the ferry’s propeller blade.
manoeuvred the vessel to the eastern side of
the channel; he also stopped the vessel’s The ferry immediately anchored in the main
engines. He was then told that the diesel channel but was later towed to her berth by
alternator supplying the bow thruster had two harbour tugs. The buoy was recovered 5
shut down due to low lubricating oil pressure. miles upriver.

Damage sustained to the lightship’s superstructure

22 MAIB Safety Digest 2/2011

 CASE 7

The Lessons 3. In pilotage waters, concentration and

teamwork are essential if distractions such
1. Many vessels routinely trade between the as machinery breakdowns are to be prevented
same ports. Although this enables bridge from jeopardising a vessel’s safe navigation.
teams to become familiar with the ports’ Responsibilities must be clearly defined to
navigational and procedural requirements, ensure that whoever has the con is not
such familiarity does not replace the need distracted, particularly when navigating
for detailed passage planning. This allows close to dangers at night where distances
the potential effects of differing environmental can be difficult to judge, and where the
conditions to be identified, and provides effects of strong tidal streams might not
the master with an accurate picture of the be readily apparent.
safe water available. In this case, because
the passage had not been planned, position
monitoring relied on staying between the
buoys and the master was unaware that
there was sufficient water for the ferry to
leave the light-float to starboard.

2. Briefings given to bridge teams prior to

port entry and departure are extremely
useful in ensuring that all key personnel are
aware of the intended plan; they also provide
a prompt for the effects of factors such as
strong tidal streams, winds and other vessel
movements to be fully considered.

MAIB Safety Digest 2/2011 23

 CASE 8

It Only Takes One Slip For a Fatal Fall

Narrative Although the supercargo was also concerned
about their demeanour he opted to reassess
It was a cold morning with temperatures the situation at the time they were needed to
dipping to freezing, and there was intermittent “sweep” No 1 CPO cargo tank, the first tank
snow as a chemical tanker berthed alongside to be discharged.
to discharge its last parcels of cargo before a
routine docking. This was also the master’s last The atmosphere of No 1 CPO cargo tank was
trip before retirement – unfortunately he was tested correctly for oxygen levels, but the
to remember the day for all the wrong reasons. equipment used to test for other gases only
reached half-way down the tank.
A cargo of crude palm oil (CPO) and stearin,
which is a derivative of CPO, had been loaded Despite this flawed and potentially dangerous
in the Far East for discharge in Europe. While procedure, a “Permit to Enter” was issued.
the crew had wide-ranging chemical experience, The “sweepers”, who did not have their own
most had not dealt with these cargoes before safety checklist and were ill equipped, entered
which, in their solidified state were very waxy the tank. They wore deep tread footwear and
and made surfaces extremely slippery. Because plastic-faced gloves, but they did not have
of this inexperience, a supercargo had been hard hats, personal gas monitors, safety
contracted to advise on cargo operations to glasses, emergency breathing apparatus or
ensure the maximum cargo could be discharged. communications equipment. The supercargo
To achieve this, “sweepers” were used to push noticed that one of the “sweepers”, who
the remains of the cargo into the cargo pump was the subsequent 57 year old casualty,
suction well. needed help to descend the angled ladders.
Nevertheless, the “sweeping” task was
Cargo operations proceeded well, and during completed efficiently. During late evening a
the afternoon the chief officer carried out a third “sweeper” joined the team to “sweep”
“sweeping” risk assessment. However, this was No 2 stearin cargo tank. Once again no safety
superficial. There was no consideration given briefing or “tool box” talk was given. The risk
for the use of a safety harness or fall arrestor assessment and atmosphere testing having
despite the extreme slipperiness of the cargoes been completed in the same manner as for No
and the advice in the ship’s safety management 1 cargo tank, the “sweepers” entered the tank,
system regarding their use in large spaces. still ill equipped. Once again the casualty needed
help to go down the ladders, but because of
Soon afterwards, the first two unkempt and the success with No 1 cargo tank the operation
noisy “sweepers” arrived on board. They were was not aborted. About 30 minutes later the
met by the chief officer and supercargo, who supercargo indicated he was satisfied that the
both noticed the smell of alcohol. The super- maximum cargo had been discharged, and
cargo gave them a short brief on the “sweeping” signalled for the “sweepers” to leave the tank
task and, although their English was poor they (Figure 1).
indicated they understood. No safety briefing
or other information was passed on by the The first “sweeper” left the tank and noticed
ship’s officers. As they waited to be called, that the casualty was approaching the top
a number of the crew noticed the “sweepers’” resting platform with the other “sweeper”
unusual, noisy behaviour, which included behind him. Very soon afterwards, at least
“playfighting”, but this went unreported. one loud thump was heard and the remaining
“sweeper” emerged from the tank shouting that

24 MAIB Safety Digest 2/2011

 CASE 8
his colleague had fallen. The casualty was found
at the bottom of the tank directly in line with
the top resting platform and vertical ladder to
the main deck. He was removed from the tank
by the local emergency services. They declined
the use of the ship’s own casualty recovery
equipment because of its unsuitability.

Figure 2: An aerial view of the vertical ladder

Figure 1: Cargo hold Figure 3: The crewman’s heavily contaminated glove

The post mortem toxicology report identified It was also found that the mandatory bi-
that the casualty’s blood contained a cocktail monthly dangerous space casualty recovery
of prescription and illegal drugs, which would drills had not been practised for a considerable
have caused severe impairment. All the evidence time and none had been planned for the
suggests that he fell from the vertical ladder forthcoming year.
(Figure 2) and passed over the top resting
platform’s upper guardrail. His heavily cargo-
contaminated gloves (Figure 3) could easily
have caused him to lose his hand grip on the
slippery surface of the ladder rungs. This was
further exacerbated by his impaired physical
condition.

MAIB Safety Digest 2/2011 25

 CASE 8

The Lessons 3. Risk assessments need to be thorough if

they are to be of use in identifying the
1. While there is a clear responsibility for a appropriate level of control measures.
worker to take reasonable care of his own Marine Guidance Note, MGN 410,
health and safety, The Merchant Shipping The Merchant Shipping and Fishing Vessels
and Fishing Vessels (Health and Safety (Health and Safety at Work) (Work at
at Work) Regulations 1997 also requires Height) Regulations 2010 identifies that
the Company to “co-ordinate arrangements work at height may also include “working
for the protection of all workers and the in or entering or exiting deep tanks …”.
prevention of risks to their health and Due consideration should be given to the
safety”. Safety management systems should use of safety harnesses or fall arrestors.
provide guidance regarding the control and
management of contractors to assist the 4. The risk assessment and “Permit to Enter”
master to discharge his responsibilities was based on incorrect atmosphere readings
effectively. because the equipment was unsuitable.
Crew should be equipped with the correct
2. A number of those on board had concerns sampling equipment and be fully trained in
about the casualty’s behaviour and ability its use and interpretation of results obtained.
to negotiate the tank ladders, but these
were not acted upon. If there is any doubt 5. Had this accident happened while at sea,
about a person’s physical or professional the casualty would have been put at further
ability to carry out work - whether they risk. This is because the crew had not been
are crew or contractors - they should be suitably trained in rescue techniques, and
confronted and, if necessary, the task the rescue equipment was unsuitable for
should be aborted. the task in that it took 18 minutes to rig.
Lightweight rapid deployment tripods and
quadpods are commercially available and
should be considered.

26 MAIB Safety Digest 2/2011

 CASE 9

Too Much Up Top

Narrative Approximately 5 hours after arriving alongside,
containers in the aftermost bay toppled to port.
A container feeder vessel was operating between Eighteen were lost overboard and a number of
three north European ports; each call always those that remained in the bay suffered damage.
involving a complete discharge and loading
of cargo. On arrival at the vessel’s home port It was later found that the top containers in seven
an unlashing gang immediately boarded and out of nine stacks, which had been declared
released the lower lashing bars and twist locks as empty on the loading plan, each contained
that connected the bottom two containers cargo of up to 30 tonnes weight. With the top
in each stack stowed on deck. It was normal four containers in each stack still connected
for the upper four containers of each stack to by twist locks, these single units were very top
remain connected by twist locks as a single heavy and liable to topple easily when exposed
unit, until such time that their bay was to be to a suitable trigger.
unloaded.

Two shore cranes worked the ship, both initially

discharging and eventually one loading as the
other carried on the discharge. The second
officer monitored operations from the deck and
occasionally carried out ballasting operations as
and when the ship developed a list.

Container twist locks

MAIB Safety Digest 2/2011 27

 CASE 9

The Lessons 2. Despite trading between three ports that

had significantly different salinity levels,
1. The load plan was inaccurate because the it was found that the deck officers on board
container line’s cargo planning department were using the same dock water density for
generated its load plans using the weights all calculations. In an industry where
declared by the shipper when initially discrepancies between actual and declared
booking container slots on the ship. If the weights is not uncommon, the pre-sailing
shipper updated the line at a later date, with comparison between calculated and observed
accurate weights, the software system was draughts and trim is a key indication to the
not configured to update the planning master that the actual load is significantly
department. This has since been addressed. different from the load plan.
Until containers are individually weighed
before being loaded on to a ship, the very
least that container lines can do is to ensure
that their planning departments have the
most accurate data held by the company.

28 MAIB Safety Digest 2/2011

 CASE 10

What Were They Thinking?

Narrative course to starboard to give way to the three
crossing vessels. His plan was to pass astern
Shortly after entering a busy traffic separation of all the vessels before coming back on the
scheme (TSS), the master of a large container planned track.
vessel arrived on the bridge to assist the bridge
team during the vessel’s transit. The waters On clearing what the master thought to be
were congested, and as the traffic density the first of the three vessels referred to, he was
increased, the master took the con and the contacted by VTS, who advised him again to
OOW switched roles to provide support to the slow down. He acknowledged by confirming
master. that he had reduced speed and planned to pass
around the stern of the next two vessels.
As the vessel approached a precautionary area
at 21 knots, Vessel Traffic Services (VTS) advised VTS, however, responded by informing him
the vessel to exercise caution as three outbound that the second of the two vessels, which was
vessels were ahead and intending to cross the now almost right ahead, was not outbound.
TSS (Figure 1). This was acknowledged by the OOW and,

Figure 1: AIS plot of vessel

The master, who had already started to slow despite a subsequent warning from VTS that
down the vessel from full sea speed to full the vessel was heading towards shallow water,
ahead manoeuvring on the ‘load’ programme, the master continued on his collision avoidance
set the telegraph to half ahead and altered course.

MAIB Safety Digest 2/2011 29

 CASE 10
On clearing the last vessel, the master then insufficient to prevent the vessel from running
initiated a turn to port, but this action was aground on a charted reef at 14 knots (Figure 2).

Figure 2: Vessel aground on the reef

The Lessons 3. The master and OOW misinterpreted the

information received from VTS with respect
The bridge team collectively made a series to which three vessels it had referred to,
of errors, which they failed to recognise. and became irritated by its frequent
Had they done so, this would have prevented interventions. This resulted in important
the grounding: information from VTS being missed.

1. Although the engine telegraph had been set 4. The vessel’s position was being monitored
from full ahead manoeuvring to half ahead, by the bridge team on ECDIS. However,
this had no effect on the engine speed as they did not utilise the equipment to its full
the reduction in engine speed was governed potential. Doing so, would have alerted them
by the automatic ‘load down’ programme, to the impending danger and the vessel’s fast
which had to be overridden for any reduction rate of approach towards the reef.
to take immediate effect.
5. The combination of an early and substantial
2. The master’s assessment of the situation reduction of speed, together with an
and decision to alter course to starboard appropriate alteration of course, would
were based on his observation of true have safely cleared all vessels. Rule 8 (c)
vectors and relative trails of the radar targets; of the COLREGS advocates an alteration
the bridge team made no attempt to utilise of course alone as the most effective collision
the ‘trial manoeuvre’ function. avoidance action - but only when a vessel
has sufficient sea room; a point not fully
appreciated in this case.

30 MAIB Safety Digest 2/2011

 CASE 11

Are They In Or Are They Out?

Narrative As the vessel approached the berth, the master
and OOW moved to the starboard bridge wing
While a ro-ro passenger ferry was making her controls and the second officer went to the
usual passage she began to roll noticeably. The port bridge wing. The second officer told the
OOW, who was part way through a compass Information Office to call the passengers down
error calculation, requested clearance from the to the vehicle decks, and then he left the bridge
engine control room to deploy the stabiliser to open the bow doors. When the bow was
fins. Permission was granted and the fins were about 4 metres off the pads, and the vessel was
extended, after which the OOW returned to his 1 metre off forward and 3.5m off aft, the master
calculations. He forgot to place the “Fins Out” bent down to shade the bridge wing console
sign on the engine controls, which was the from the bright sunshine. He then saw that the
normal practice to heighten awareness and to stabiliser fin indicator light was showing that
supplement the control panel indicator light. the fins were still extended. As he ran to the
centre console to house the fins, the master
As the vessel approached her destination, the instructed the OOW to thrust the vessel off
master went to the bridge and agreed that the the berth. The port fin housed normally; the
OOW would keep the con and berth the vessel starboard fin did not.
under his close supervision. The second officer
arrived on the bridge to complete the pre-arrival The vessel moored port side alongside another
checklist, and had a conversation with the ro-ro berth and discharged her cargo. It was
master. Some minutes later, the second engineer later found that the starboard stabiliser operating
called the second officer and told him that ram was deformed and the fin protruded from
the engine room was ready for entry into port the vessel’s side by 1.5m.
and that the fins were out. The second officer
entered this into the pre-arrival checklist, but
he mistakenly recorded that the fins were in,
and then resumed his conversation with the
master. The OOW gave a briefing to the bridge
team, and the second officer announced that
the pre-arrival checklist was complete, which
the master acknowledged.

MAIB Safety Digest 2/2011 31

 CASE 11

The Lessons 4. Despite being aware that the fins were out,
and having a CCTV monitor in the engine
1. A chain of errors began when the OOW control room showing the vessel’s position,
extended the stabiliser fins while he was the engineers on watch were distracted with
distracted with another task. This led him other tasks and did not warn the bridge
to forget to display the “Fins Out” sign on team that the fins were still out as the vessel
the engine controls, to tell the master that approached the berth.
they were out on approach to the port, and
to mention their status when he conducted 5. Effective bridge resource management
the bridge team port entry briefing. should eliminate the risk that an error on
the part of one person could result in a
2. The second officer was also distracted by dangerous situation. Without an alarm to
his conversation with the master, and indicate that the fins were out as the vessel
missed the second engineer’s statement that approached the berth, reliance was placed
the fins were out. This error went undetected on team management procedures to identify
because reliance was placed on the “Fins and address the impending danger. In this
Out” sign being displayed, even though the case, all members of the bridge and engine
indicator light on the control room panel room teams had become distracted with
was illuminated to indicate that the fins other tasks to the extent that the OOW’s
were out. error in leaving the fins out remained
undetected until it was too late.
3. As the master allowed the OOW to keep
the con to the berth, he did not specifically
enquire as to the status of the fins. Instead,
he relied on the OOW’s briefing and the
second officer’s pre-arrival checklist to
confirm that all was ready for arrival.
He also entered into a conversation with
the second officer, which would have
impaired his general oversight and
supervision.

32 MAIB Safety Digest 2/2011

 CASE 12

Testing Times
Narrative Eventually, a wire fall securing clamp broke as it
approached a davit sheave, causing the boat to
A cargo vessel was conducting a rescue boat drop into the water with the two crew members
drill while alongside in port. The boat, which still inside.
was crewed by the chief officer and an AB, was
lowered to the water and taken for a short trip
in the harbour. It was then manoeuvred back
alongside the vessel in preparation for recovery.

The AB secured the lifting hook, and the second

officer, who was operating the recovery davit
on the vessel, then pushed the winch “start”
button to raise the boat. As the boat neared its
stowage position, the second officer released
the “start” button. However, the winch
continued to operate. The davit limit switch
then operated, but this also failed to stop the
winch.

The Lessons 2. A single point failure was able to override

the limit switch electrical relay. Although
Investigation found that a winch motor electrical the “emergency stop” was available as a last
relay had become stuck, causing both the “start” resort, the limit switch was designed to
and limit switch electrical relays to be over- prevent equipment overload by stopping
ridden. The “emergency stop” button had not the operation with the rescue boat at, or
been activated. close to, its stowage position. Built-in
redundancy can itself help to improve safety.
1. Electrical failures can happen. It is therefore In this case, a second winch motor electrical
essential that adequate safety measures relay was subsequently fitted in series with
are in place when they do. In this case, a the first, requiring both relays to become
functional “emergency stop” was available seized for the same problem to arise in the
to electrically isolate the winch motor. future.
However, it was neither tested before the
recovery operation nor activated when
things started to go wrong. Crew members
need to be familiar with the safety features
provided and have the confidence to use
them when required. Such knowledge is
maintained through regular testing during
emergency drills and before operational use.

MAIB Safety Digest 2/2011 33

 CASE 13

Assumptions and Interaction Strike Again

Narrative this action was ineffective as the cargo vessel
was now so close to the ro-ro vessel that
A 2,800gt cargo vessel collided with a 58,000gt hydrodynamic interaction occurred between
ro-ro vessel as it was overtaking the larger vessel the two vessels. The cargo vessel took a sheer
in the confines of a buoyed channel when they to port and collided with the ro-ro vessel’s
were departing from a major port. Local pilots starboard quarter.
were embarked on both vessels at the time.
The cargo vessel’s engine was stopped, but
The ro-ro vessel had recently entered the she remained pinned against the ro-ro vessel
channel from a lock, and was steadily increasing for several minutes. The ro-ro vessel’s bridge
speed as the cargo vessel approached her team had been unaware of the close proximity
from the starboard quarter. The cargo vessel’s of the other vessel until the collision occurred
pilot assumed the ro-ro vessel would quickly as both vessels had been monitoring different
increase speed and pull ahead, and initially was VHF channels.
not concerned as the distance between the two
vessels continued to decrease. The cargo vessel’s engine was then put astern
and she slid aft, along the ro-ro vessel’s hull,
However, the cargo vessel continued to until she came clear of the larger vessel. Both
overtake the other vessel, and with shallow vessels suffered minor damage as a result of
water to starboard it reduced speed in an the collision, but were able to continue on
attempt to prevent a collision. Unfortunately their respective passages.

The Lessons the two vessels due to the reduced pressure

between the underwater portion of the hulls.
1. The cargo vessel was overtaking the ro-ro Mariners should familiarise themselves with
vessel and was thus the give way vessel. MGN 199 (M) Dangers of interaction in
However, the pilot of the cargo vessel order to be alert to the situations when
assumed that the ro-ro vessel would quickly hydrodynamic interaction may occur.
pull ahead, but by the time it was realised
that this was not happening, it was too late 3. The bridge personnel were not functioning
to avoid a collision. The pilot of the cargo as a team on either vessel. They had been
vessel made an assumption, based on scanty monitoring different VHF channels and
information, that the ro-ro vessel was those on the ro-ro vessel were not aware
increasing speed. He should have ensured of the cargo vessel until after the collision.
that this was the case before coming so close It is essential that every member of the
to the other vessel that a collision was bridge team remains vigilant and fully
unavoidable. involved in monitoring the execution of
the passage, and that a good all round
2. Hydrodynamic interaction occurred between lookout is maintained when the vessel is
the two vessels when the cargo vessel drew in pilotage waters as well as when she is
level with the ro-ro’s starboard quarter. at sea.
There was a strong attractive force between

34 MAIB Safety Digest 2/2011

 CASE 14

A Lack of Planning Gets the Master

Carried Away
Narrative this momentum and turn the vessel through
approximately 225º before heading to the
Two large bulk carriers collided in an anchorage north, out of the anchorage and towards the
when one was set down on to the other (still pilot boarding position. This took the bulk
anchored) vessel by a strong spring tidal stream carrier towards the anchored vessel lying
while weighing anchor and manoeuvring to approximately 1½ miles astern of her original
pick up a pilot. Both vessels suffered extensive position. The master ordered the wheel hard
damage, requiring them to be taken out of to port and put the engine to dead slow ahead.
service for repairs.
For the next 25 minutes, during which time
The first bulk carrier had arrived at the port 4 the ship was undertaking this slow turn to port,
days earlier and had anchored while she waited very little information was exchanged between
for the berth to become available. The master the bridge team concerning the safe navigation
was advised on the afternoon before the accident of the vessel. The chief officer of the anchored
that the ship would berth on the next morning’s vessel had been monitoring the bulk carrier’s
high water. Despite the company’s SMS manoeuvre and became concerned that she
providing an in depth series of checklists for was getting set on to his own ship. He contacted
passage planning (all of which were ticked off the bulk carrier by VHF to warn of this and then
as having been completed), the strong flood called his master to the bridge.
tidal streams in the area had not been identified.
The bridge team began to discuss the current,
Prior to weighing anchor the chief mate had and over the next 7 minutes the master gradually
started to test the gear, and when the master increased his vessel’s engine speed through
arrived on the bridge he finished off the slow ahead, half ahead and full ahead to the
pre-departure checks. Neither referred to a maximum available. However, the master’s
checklist, both of them considering the vessel efforts were too late, and the bulk carrier collided
to be neither departing nor arriving, but with the anchored vessel, causing structural
effectively shifting ship within a harbour. When damage above the waterline to both vessels and
the mate went forward to haul the anchor, the the anchored vessel to part its cable just below
bridge team consisted of the master, the third the hawse pipe. Both vessels assessed damage,
mate and a helmsman. A pre-departure briefing ensured the safety of their crew and checked
was not held and therefore the tidal streams that there was no risk of pollution before safely
were not discussed. re-anchoring. Guidance for this on board the
vessel that was manoeuvring was not easily
As the vessel got underway, the bow payed accessible in the SMS, and the master did not
off to port. The master decided to carry on refer to it.

MAIB Safety Digest 2/2011 35

 CASE 14
Ship A

Ship B - at anchor

Tidal stream - 3 knots Pilot position

Turning circle in still waters

Actual turning circle under influence of tidal stream and wind

Wind F4/5

1.3 miles

Plan showing intended and actual track of ship A

The Lessons funded. Typical ways of achieving this goal

include conducting internal audits at sea
1. The modern seafarer often bemoans the rather than when the vessel is alongside,
number of checklists that have to be or listening to VDR recordings of arrivals
completed beforeand
Plan showing intended carrying out
actual track theA most
of ship or departures selected at random.
simple of tasks. However, this accident
demonstrates very well the importance of Operators and owners need to recognise
referring to such an aide-mémoire properly, that they have a responsibility to monitor
rather than simply “ticking the boxes”. the working practices of the men and women
On this occasion two of those boxes that that work on their vessels. Simply checking
were ticked included an assessment of the that an individual carries the required
tides and currents, and the holding of a certification is not sufficient in an industry
navigational brief. where the consequences of poor practices
can be devastating.
For the operator’s part, they should provide
checklists that are simple, not over exhaustive 3. Provided there is sufficient sea room, it is
and are readily available if needed in an safer, and better seamanship, to pass astern
emergency situation. The reason why one of a ship at anchor. Passing close ahead of
of the masters did not refer to a post-collision a ship at anchor is potentially perilous, but
decision support checklist or aide-mémoire if it is unavoidable, the effects of the tidal
was because it consisted of 2½ pages of stream, wind and a ship’s manoeuvrability
text, embedded somewhere in several hundred need to be taken into account.
pages of the SMS.
4. Demonstrating a good anchor watch, the
2. Although deck officers on the bulk carrier chief officer of the anchored vessel ensured
which was underway had successfully that, when the accident happened, the alarm
completed a bridge team management was raised quickly and the crew were able
course, there was evidence that this training to assess damage, start engines and re-anchor
was not put into practice. Operators should without undue delay. While at anchor,
make every effort to ensure that their the OOW should remember that he is not
officers and crew are carrying out best relieved of his responsibilities for the safety
practice as instructed during the various of the vessel just because it is not underway.
training courses they might well have

36 MAIB Safety Digest 2/2011

 CASE 15
Mind the Gap!
Narrative At about 0345, a few vehicles were loaded for
the return journey. A short time later a lady
A car and foot passenger ferry arrived alongside arrived at the ferry terminal clearly in some
her dedicated berth during the early hours of distress following an altercation with the person
the morning. The weather was very poor with driving her there. She had a number of bags
driving rain and winds gusting force 7-8, and the and a small, wheeled suitcase with her.
visibility wasn’t helped because some of the lights
at the terminal had developed a fault, causing As she made her way towards the ferry ramp
them to go off and come on intermittently. she kept her head down against the driving
rain. Unfortunately, instead of moving towards
The ramp was lowered onto the 2 cm proud, the yellow painted footpath on the ramp, the
stiff rubber cushioning of the linkspan. Although lady veered off towards the right. She believes
there was a large gap between the outboard she might have tripped on the linkspan rubber
edges of the ramp lifting mechanism and the cushioning before stumbling between the ramp
linkspan wall, it had never been the practice and the linkspan wall (Figure 2) and then falling
to fit a barrier; after all, no one could possibly into the cold water.
walk into the gap and fall overboard - especially
as the walkway was identified with bright yellow Luckily the second mate had seen what happened
paint (Figure 1). Or could they? and immediately threw a lifebuoy into the water,
which the lady managed to grab and hold on
The ferry was fully secured to the linkspan. to. She was pulled to the side of the linkspan
The vehicles were driven off the ramp and the and the ferry’s crew and shore staff hauled her,
foot passengers followed, guided by the yellow uninjured, from the water.
painted walkway.

Figure 1: The walkway onto the vessel The position where the passenger fell

MAIB Safety Digest 2/2011 37

 CASE 15
The Lessons 3. Consider eliminating or at least reducing
tripping hazards – the consequences, as this
The yellow painted foot passenger walkway case shows, can be potentially severe.
clearly indicated the safe route to be taken by
foot passengers when leaving the ferry. Because 4. While the indicated pathway may well
the risk area (the gap between the ramp and appear to be satisfactory, a person walking
the linkspan wall) was behind disembarking onto a ferry, fully laden and with his (her)
passengers, the risk of falling into the water head down in inclement weather will have
was negligible. The gap, however, presented a a different perspective. Do check to see if
risk to embarking passengers, and this risk had the pathway is sufficiently indicated to
not been recognised. Therefore no risk control avoid confusion both on the ferry and the
measures had been put in place, such as a linkspan access/egress routes.
hinged barrier or other closing arrangement.
5. There is no clear evidence that the
1. Ensure that risk assessments are reviewed intermittent lighting contributed to this
regularly and that control measures are put accident. However, defects affecting lighting
in place to help prevent accidents such as should be addressed as soon as possible so
this one. A simple hinged gate, closing off that passengers can identify and avoid any
the gap between the ramp and the linkspan tripping hazards.
wall, could easily have prevented this
accident.

2. Just because an accident has not happened

in a particular area doesn’t mean that one
will not occur in the future. Do think of
all eventualities: if there is a way to fall
through a gap, someone is bound to find it!

38 MAIB Safety Digest 2/2011

 CASE 16

A Lucky Escape
Narrative The raising of the ‘A’ frame was a fairly slow
process, but after about 45 minutes it was upright
The ‘A’ frame on board a 25 year old floating (Figure 1). This was a critical phase of the rigging
sheerleg was being rigged by her crew while operation where the weight of the ‘A’ frame
the vessel lay alongside. The rigging, which had transferred from the heaving to the luffing
never been risk assessed and for which there winches.
were no operational procedures, was controlled
from the wheelhouse by the master. With the At this point, the vessel’s commercial agent
mate keeping a watchful eye on deck, the master boarded. The master stopped both sets of
started to lift the ‘A’ frame into position using winches and gave the agent the information
separate heaving and luffing winches; heaving he required. The rigging operation was then
in on one set of winches and slacking back on resumed. However, a lack of co-ordination
the other. The rigging equipment was not fitted in the use of the hoisting and luffing winches
with alarms or interlocks to warn or prevent caused the crane’s deck pad eye fittings (Figure 2)
elements of the equipment becoming overloaded, to become overloaded. As a result, the deck
and there were no signs or labels by the winch pad eyes failed and the 80 tonne ‘A’ frame fell
controls to show the directions of heave and backwards onto the wheelhouse and the main
slack. deck. Although substantial damage to the deck
and wheelhouse resulted (Figure 3), thankfully
no one was injured.

Figure 1: The A-frame in the upright position

MAIB Safety Digest 2/2011 39

 CASE 16

Figure 2: Damaged deck eye pad fittings

Figure 3: Damage to the wheelhouse and main deck

40 MAIB Safety Digest 2/2011

 CASE 16

The Lessons 3. All lifting equipment should be periodically

tested and examined regardless of what it
1. Where tasks require a high degree of skill is used for. Many seafarers are aware of the
and/or co-ordination, it is essential that requirements in this respect for appliances
operators are protected from unnecessary used in cargo work, but few seem to be
distractions, regardless of their experience aware of the requirements for other lifting
or proficiency. In this case, the arrival equipment.
of the agent at a critical point of the rigging
operation broke the master’s concentration
and caused him to lose his place in the
sequence of events.

2. It is important that all key shipboard

operations are identified and properly
assessed. Appropriate procedures must then
be developed and followed, which reduce
the potential for human error, taking into
account factors such as the provision of
physical and electronic safety measures
and alarms, manning requirements, and
control of access.

MAIB Safety Digest 2/2011 41