MARINE ACCIDENT INVESTIGATION BRANCH
ANNUAL REPORT 2009
Extract from The Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 The sole objective of the investigation of an accident under these Regulations shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.
Marine Accident Investigation Branch Mountbatten House Grosvenor Square Southampton SO15 2JU All reports can also be found on our website: www.maib.gov.uk For all other enquiries: Email:
[email protected] Tel: +44 (0)23 8039 5500 Fax: +44 (0)23 8023 2459
Contents Chief Inspector’s Report
1
Part 1 - Full Investigations and Report Publications
4
Part 2 - Recommendations
9
Background Recommendation response statistics Recommendation methodology Section A - Level 1 Recommendations Section B - Level 2 Recommendations Section C - Level 3 Recommendations Section D - Recommendations to multiple recipients Section E - Withdrawn recommendations Section F - Recommendations brought forward from previous years
11 12 13 14 21 32 43 44 45
Part 3 - Statistics
53
UK vessel accidents involving loss of life UK merchant vessels >= 100gt UK merchant vessels < 100gt UK non-commercial vessels UK fishing vessels Non-UK commercial vessels
54 56 61 62 63 68
Annex - Statistics Coverage
69
Glossary of abbreviations and acronyms
71
C H I E F I N S P E C TO R ’ S R E P O RT
Chief Inspector’s Report There continues to be a significant number of unnecessary accidents at sea, few of which can be attributed to the convenient excuse of “the sea being a hazardous environment”. 1663 marine accidents and incidents were reported to the MAIB in 2009, with many noncommercial casualties still going unreported. It is quite evident from the accidents we investigate that safety standards, supervision, training, inspection and enforcement are routinely well below that expected ashore. Although improvements are taking place, these are normally driven by accident investigations conducted by the MAIB and similar organisations in other countries. Despite its small size and budget, the MAIB is seen as a world leader in the field. With a total staff of just 39, we have had to consider the issues in every one of these 1663 reports; the majority of the 1461 which detailed analysis determined fell within the remit of the MAIB, were then followed up to satisfy ourselves that appropriate actions were taking place to prevent such incidents recurring. In 46 of the cases, it was judged necessary for the MAIB to deploy a team and commence an investigation in order to establish the circumstances and all the causal factors of the incident and thus derive potential recommendations to improve future safety. Twenty of these developed into full investigations leading to major reports being published. This workload is heavy for a small team. It is kept manageable by putting a large amount of effort into selecting which incidents are likely to yield the most important issues for future safety. It is only these that we investigate, and even then fewer than half are judged essential to be taken through from preliminary examination stage to full investigation. This focus of effort allows a “lean and mean” organisation to deliver our legal and our moral obligations in an effective and timely manner. It is a matter of some pride to the MAIB, that representatives of many other countries from around the world come to Southampton to find out how we can do so much for so little. However, there is a danger that the flexibility on which this focussed approach depends may soon be lost. An EU Directive has been passed which requires, from June 2011, that the MAIB must conduct a full investigation into all “very serious accidents”, and to give reasons for any “serious accidents” into which we do not intend to conduct a full investigation. This could in theory double or treble the MAIB’s workload, at a time of considerable resource restraints. We will continue to work with our lawyers and others to ensure that we can meet the intent of the Directive within current resources. 1
M A I B A N N U A L R E P O RT 2 0 0 9
INVESTIGATIONS A wide variety of accidents to merchant vessels were investigated in 2009. Thankfully, the number of fatalities remained low, and the number of injuries to crew has shown a significant reduction. On the negative side, the Belgian and Cypriot administrations have failed to respond to a number of recommendations, despite a crewman being severely injured; and a European manufacturer sees no reason to redesign a windlass motor despite a series of accidents, two of which resulted in crewmen being severely injured when windlass motor casings shattered, spraying shrapnel around the adjacent decks. Thirteen fishermen died in accidents in 2009. This is the second largest total since 2000, and equates to a fatality rate of 102 against a national accident at work rate of less than 11. This rate, which has shown little sign of decreasing over the last 30 years, led to a recommendation being made in May 2010 to the Department for Transport to: “Recognise the consistent and disproportionate rate of fatalities in the UK fishing industry and take urgent action to develop a comprehensive, timely and properly resourced plan to reduce that rate to a level commensurate with other UK occupations”.
RECOMMENDATIONS Of the recommendations issued, 88% have been accepted. A large proportion of those organisations that have not accepted our recommendations are outside the UK. As recommendations may take a long time to complete, it is inevitable that a number have yet to be fully implemented. Our follow-up system continues to monitor progress on these.
FINANCE This Annual Report deals principally with the calendar year of 2009. However, for ease of reference, the figures below are for the 2009/10 financial year, which ended on 31 March 2010; MAIB’s funding from the Department for Transport is provided on this basis, and this complies with the Government’s business planning programme. £ 000s Costs Receipts* Totals
Budget
Outturn
4,272
4,116
100
107
4,172
4,009
* The MAIB gains receipts from investigations carried out on behalf of other administrations, and from the provision of technical services and training conducted on behalf of EMSA and the IMO. 1
Industrial fatality rates are measured per 100,000 worker-years. 2
C H I E F I N S P E C TO R ’ S R E P O RT
CIVIL SERVICE AWARD FOR SCIENCE ENGINEERING AND TECHNOLOGY The MAIB prides itself on its ability to beg, borrow and steal (the last not literally). On a shoestring we have developed a world-leading analysis suite for marine accident investigation. This suite has now been bought by countries as widespread as Norway, the United States and Australia. As a result of this work, our technical team of 2 beat major departments from across Whitehall to win the coveted Civil Service Award for Science Engineering and Technology in 2009.
AND FINALLY... I leave the MAIB in August, after little over 8 years as the Chief Inspector. There have been many challenges. When I joined, I was naïve enough to think that everyone would be on the side of independent investigation, the sole purpose of which was future safety. In fact, few are on our side, as everyone involved in an accident has some form of vested interest, and others often have a particular axe to grind. I have also had to fight to maintain the independence and integrity of the MAIB, and our right to operate free from the growing culture of blame and litigation. That we have continued to operate so successfully in the face of such challenges has reinforced our credibility and is, I believe, an important outcome for safety at sea. I have an amazing team in the MAIB who, despite the gruelling nature of constantly working with death and tragedy, have remained positive and enthused. I wish them and my successor, Steve Clinch, all fortune in continuing this important task.
Stephen Meyer Chief Inspector of Marine Accidents
3
M A I B A N N U A L R E P O RT 2 0 0 9
PART 1 FULL INVESTIGATIONS AND REPORT PUBLICATIONS
4
PART 1: INVESTIGATIONS/PUBLICATIONS
FULL INVESTIGATIONS LIST Full Investigations started in 2009 Date
Name Of Vessel Type Of Vessel
Nationality Size
Nature of Incident
Merchant Vessels 28 Jan Stena Voyager
High speed ro-ro ferry
UK
19 638 gt
Shift of road tanker on vehicle deck causing extensive damage to stern door – Loch Ryan shortly after leaving Stranraer
28 Jan Ville de Mars
Container ship
UK
37 235 gt
Fatal fall involving Chief Officer while descending into ballast tank – Gulf of Oman
25 Feb Vallermosa
Chemical tanker
Italy
25 063 gt
Contact with two vessels discharging cargo – Fawley
23 Mar Stellar Voyager
Oil tanker
Bahamas
58 088 gt
Explosion of windlass motor causing injury to one crewman – Tees Bay
01 Apr Wellservicer
Dive support
UK
9 158 gt
Fatal accident to rigger involving a diving bell cursor – Aberdeen
05 Apr TS Royalist
Sail training vessel UK
83 gt
Grounding – Chapman’s Pool, Dorset
06 May Jo Eik
Chemical tanker
Norway
14 Jun Ijsselstroom
Tug
Netherlands
10 Aug Saetta/Conger
Oil tanker/ Chemical tanker
Greece/ Marshall Islands
58 418 gt/ 44 067 gt
Collision during ship to ship cargo transfer operation – North Sea off Southwold, Suffolk
10 Sep Ever Elite
Container ship
UK
76 067 gt
Fatal accident to AB following collapse of accommodation ladder – San Francisco Bay
16 Sep Maersk Kendal
Container ship
UK
74 642 gt
Grounding – Monggok Sebarok reef in the Singapore Strait
5
12 249 gt
71 gt
Chief Officer and AB overcome by fumes on main deck – Vopak terminal, Teeside Capsize due to girting – Peterhead
M A I B A N N U A L R E P O RT 2 0 0 9 Full investigations list
Full Investigations started in 2009 Date
Name Of Vessel Type Of Vessel
Nationality
Size
Nature of Incident
Fishing Vessels 12 Feb Maggie Ann
Scallop dredger
UK
23.2 m
Fatal person overboard – Cardigan Bay
20 Jul
Scallop dredger
UK
11.9 m
Capsize resulting in three fatalities – north of the Ardnamurchan peninsula
10 Oct Olivia Jean
Beam trawler
UK
29.9 m
Crush injury during movement of gear – English Channel
06 Nov Korenbloem
Scallop dredger
UK
24.3 m
Fatal person overboard – Dover Strait
11 Nov Osprey III
Stern trawler
UK
9.2 m
Fatal person overboard – East Coast of Scotland
18 Nov Optik
Potter
UK
9.2 m
Fatal person overboard – East Coast of Scotland
20 Dec Etoile des Ondes Potter
UK
14.5 m
Aquila
Collision resulting in sinking and the loss of one crew – English Channel
Small Craft 18 May Sooty
RIB
UK
6.3 m
08 Aug Harwich 2011
Racing powerboat UK
6m
6
High speed grounding resulting on one fatality – Calve Island, near Tobermory, Isle of Mull Collision during race resulting in one fatality – Dover
PART 1: INVESTIGATIONS/PUBLICATIONS
PUBLICATIONS LIST Reports of Full Investigations published in 2009 Vessel Name (Report No)
Vessel Type
Accident Type
Accident Date
Abigail H (15/2009)
Dredger
Flooding and foundering while alongside – Heysham
02 Nov 2008
Antari (7/2009)
General cargo ship
Grounding – near Larne, Northern Ireland
29 Jun 2008
Astral (4/2009)
Product tanker
Grounding – Princessa Shoal, east of Isle of Wight
10 Mar 2008
Eurovoyager (17/2009)
Ro-ro passenger ferry
Major injury to an engine room fitter trapped in watertight door – Dover Strait
03 Nov 2008
HMS Westminster/ Princess Rose (16/2009)
Royal Navy frigate/ Class V passenger vessel
Person overboard during passenger transfer – River Thames, Gravesend Reach
24 Nov 2008
Hurlingham (12/2009)
Class V passenger vessel
Passenger fatality during disembarkation – River Thames, London
17 Aug 2008
Jo Eik (24/2009)
Chemical tanker
Chief Officer and AB overcome by fumes on main deck – Vopak Terminal, Teeside
06 May 2009
Maersk Kithira (9/2009)
Container ship
Fatal injury and serious injury in heavy weather – South China Sea
23 Sep 2008
Maersk Newport (13/2009)
Container ship
Heavy weather damage in English Channel and subsequent fire while alongside in Algeciras, Spain
10 and 15 Nov 2008
Moondance (5/2009)
Ro-ro cargo ship
Electrical blackout and subsequent 29 Jun 2008 grounding – Warrenpoint, Northern Ireland
Norma (3/2009)
Self propelled crane barge
Hazardous diving incident – Dover Strait
21 Jun 2008
Pacific Sun (14/2009)
Cruise ship
Injuries to 77 passengers and crew in heavy weather – Pacific Ocean
30 Jul 2008
Grounding – off Deal, Dover Strait
31 Jan 2008
Grounding and subsequent loss – Cleveleys Beach, Lancashire
31 Jan 2008
Merchant Vessels
Pride of Canterbury Ro-ro passenger ferry (2/2009) Riverdance (18/2009)
Ro-ro cargo ship
7
M A I B A N N U A L R E P O RT 2 0 0 9 Publications list
Vessel Name (Report No)
Vessel Type
Accident Type
Accident Date
TS Royalist (26/2009)
Sail training vessel
Grounding – Chapman’s Pool, Dorset
05 Apr 2009
Saga Rose (1/2009)
Cruise ship
Fatality in ballast tank – Southampton
11 Jun 2008
Scot Isles/ Wadi Halfa (10/2009)
General cargo ship/ Bulk carrier
Collision in the Dover Strait
29 Oct 2008
Stellar Voyager (25/2009)
Oil tanker
Explosion of windlass motor causing injury 23 Mar 2009 to one crewman – Tees Bay
Stena Voyager (21/2009)
High speed ro-ro ferry
Shift of road tanker on vehicle deck 28 Jan 2009 causing extensive damage to stern door – Loch Ryan shortly after leaving Stranraer
Vallermosa (23/2009)
Chemical tanker
Contact with two vessels discharging cargo – Fawley
25 Feb 2009
Ville de Mars (20/2009)
Container ship
Fatal fall involving Chief Officer while descending into ballast tank – Gulf of Oman
28 Jan 2009
Maggie Ann (19/2009)
Scallop dredger
Fatal person overboard – Cardigan Bay
12 Feb 2009
Vision II (8/2009)
Trawler
Fire resulting in 3 fatalities – alongside in Fraserburgh
01 Aug 2008
Celtic Pioneer (11/2009)
RIB
Injury to passenger – Bristol Channel off Cardiff
26 Aug 2008
RIB 6 (6/2009)
RIB
Capsize resulting in one injury – Menai Strait
01 Jul 2008
Sooty (22/2009)
RIB
High speed grounding resulting on one fatality – Calve Island, near Tobermory, Isle of Mull
18 May 2009
Fishing Vessels
Small Craft
8
PA RT 2 : R E C O M M E N D AT I O N S
PART 2 RECOMMENDATIONS
9
M A I B A N N U A L R E P O RT 2 0 0 9
RECOMMENDATIONS Responses to safety recommendations issued by the Marine Accident Investigation Branch. This report is submitted to the Secretary of State for Transport in accordance with The Merchant Shipping (Accident Reporting and Investigation) Regulations 2005, regulation 15(5).
Background Recommendation response statistics Recommendations methodology Section A - Level 1 Recommendations Section B - Level 2 Recommendations Section C - Level 3 Recommendations Section D - Recommendations to multiple recipients Section E - Withdrawn recommendations Section F - Recommendations brought forward from previous years
Page 11 12 13 14 21 32 43 44 45
For details of abbreviations and acronyms used in this Section please refer to the Glossary on page 71.
10
PA RT 2 : R E C O M M E N D AT I O N S
BACKGROUND Recommendations are the prime output of MAIB investigations. They are made to promulgate the lessons from accidents and incidents 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 a preliminary examination (PE) or full investigation the MAIB may make a number of recommendations. These may take the form of a Chief Inspector’s letter following a PE or, in the case of a full investigation, be contained within the published report. Urgent safety recommendations may also be made in Safety Bulletins that can be published at any stage of a PE or full investigation. It is of no consequence whether a recommendation is made as a result of a PE or full investigation, as they are processed in the same manner. Recommendations are made to a variety of addressees who may have been involved in, or have an interest in, the incident or accident. These may range from those organisations which have a wider role in the maritime community such as the Department for Transport (DfT), Maritime and Coastguard Agency (MCA) or an international organisation, through to commercial operators and vessel owners/operators who may have specific issues to address on their vessels. It is required by the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 that the person organisation to whom a recommendation is addressed, consider the recommendation, and reply to the Chief Inspector within 28 days on the plans to implement the recommendation or, if it is not going to be implemented, 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 report to the Secretary of State for Transport fulfils this requirement.
11
M A I B A N N U A L R E P O RT 2 0 0 9
RECOMMENDATION RESPONSE STATISTICS 2009 84 recommendations were issued to 117 addressees in 2009. Each addressee is considered separately for the purposes of these statistics. Of these the percentage total of all 117 recommendations that are either “accepted” or “accepted yet to be implemented” is 88.0%. Throughout the report recommendations are categorised under four broad headings according to the industry sector to which they apply, General Maritime, Commercial Shipping, Fishing Vessels and Leisure Vessels. subtotal Focus % of total General Maritime
30
Commercial Shipping
77
Fishing Vessels
7
Leisure Vessels
3
subtotal
Accepted – Action Implemented
Accepted – Action yet to be Implemented
Partially Accepted
Rejected
No Response Received
11
15
3
-
1
56
11
4
-
6
4
3
-
-
-
3
-
-
-
-
25.6%
65.8%
6.0%
2.6% 117
% of total
74
29
100%
7
63.2%
-
24.8%
7
6.0%
-
6.0%
Details of all these recommendations are at Sections A-C. RECOMMENDATION RESPONSE STATISTICS 2004 to 2008 The following table shows the equivalent status of recommendations issued in 2004 to 2008 as published in the MAIB’s previous Recommendations Annual Reports. Year
Total
Accepted – Action Implemented
Accepted – Action yet to be Implemented
Partially Accepted
Rejected
No Response Received
2008
110
71
31
5
-
3
2007
136
109
23
1
1
2
2006
139
103
30
3
3
-
2005
140
122
14
1
1
2
2004
171
93
52
11
11
4
Of the 150 recommendations accepted – yet to be implemented (at time of publication of relevant annual report): • 76.7% have now been fully implemented • 23.3% remain planned to be implemented. Details of the recommendations still to be implemented are at Section F. 12
PA RT 2 : R E C O M M E N D AT I O N S
RECOMMENDATION METHODOLOGY Sections A-E to this report present the recommendations made throughout 2009, Sections D and E are not included in the statistics. Section F lists the recommendations that are still outstanding accepted – yet to be implemented from previous years. The recommendations have been broken down into three levels, shown in Sections A-C. These are then further divided, as shown below. Emphasis has been given to those recommendations which have been rejected or partially accepted and their entries include the response received by the MAIB, together with an MAIB comment.
Section A
Level 1 Recommendations These have the broadest importance, and may include the requirement for new legislation or changes in policy.
Rejected, Partially accepted, No Response Received Accepted - yet to be implemented Accepted - implemented
Section B
Level 2 Recommendations Addressed to industry bodies and organisations which may call for changes or reinforcement of best practice.
Rejected, Partially accepted, No Response Received Accepted - yet to be implemented Accepted - implemented
Section C
Level 3 Recommendations Those which are addressed to individual owners or companies which are specific to their vessel or company.
Rejected, Partially accepted, No Response Received Accepted - yet to be implemented Accepted - implemented
Section D
Recommendations to multiple recipients Lists the small number of recommendations that have been addressed to large multiple recipients. As a result, it has not been possible to track responses under the closedloop system. Such multiple addressee recommendations are avoided whenever possible.
Section E
Withdrawn recommendations.
Section F
Recommendations brought forward from previous years. Lists the ongoing outstanding recommendations shown as accepted – yet to be implemented in previous reports.
13
M A I B A N N U A L R E P O RT 2 0 0 9
Section A LEVEL 1 RECOMMENDATIONS
These have the broadest application, and may include the requirement for new legislation or changes in policy. Summary Table Accepted Action yet to be Implemented
Partially Accepted
Rejected
No Response Received
Focus
Total
Accepted Action Implemented
General Maritime
7
2
2
1
-
-
Commercial Shipping
13
6
4
1
-
3
Fishing Vessels
-
-
-
-
-
-
Leisure Vessels
-
-
-
-
-
-
Total
20
8
6
2
-
3
14
Focus
Commercial Shipping
Commercial Shipping
Commercial Shipping
Number
147c
148b
148c
Eurovoyager
Eurovoyager
Eurovoyager
Investigation
No Response Received
15
Cyprus Maritime Administration
Belgium Federal Public Service, Mobility and Transport
Belgium Federal Public Service, Mobility and Transport
Addressed To
The application of SOLAS Regulation 15 to all vessels fitted with watertight doors.
•
The application of SOLAS Regulation 15 to all vessels fitted with watertight doors.
•
No response to date.
Revision of SOLAS Regulation 15 (openings in watertight bulkheads in passenger ships) to reflect the contents of Section 4.3.8 and Section 8 of MSC/Circ.1176 which requires the provision of a local visual indication to indicate when a watertight door is being operated in the remote mode.
•
Present a joint paper to the IMO’s Maritime Safety Committee on:
No response to date.
Revision of SOLAS Regulation 15 (openings in watertight bulkheads in passenger ships) to reflect the contents of Section 4.3.8 and Section 8 of MSC/Circ.1176 which requires the provision of a local visual indication to indicate when a watertight door is being operated in the remote mode.
•
Present a joint paper to the IMO’s Maritime Safety Committee on:
No response to date.
Through representations to the European Commission, take steps to ensure that official guidance provided for inspectors in respect to the application of EU Directive 1999/35/EC is amended to reflect SOLAS requirements regarding the operation of watertight doors at sea.
Recommendation
Responses to recommendations which have not been accepted have been grouped together and presented first. Those which have been accepted are presented secondly and broken down into their vessel type.
Level 1 Recommendations – Breakdown
PA RT 2 : R E C O M M E N D AT I O N S
Abigail H
141
General Maritime
Investigation
Number Focus
Partially Accepted
16 MAIB Comment
The recommendation can best be implemented by introducing a requirement into the Merchant Shipping (Load Line) Regulations, removing the restriction for bilge alarms to be fitted only where engine rooms are unmanned, and adding a requirement for the bilge alarms to be fitted in the cargo hold. This will mirror the requirement of SOLAS for ships of over 500gt. The regulation could also require that the bilge alarm sounds in the accommodation should the central control station not be manned – again, in a similar manner to the requirement for the engineer’s alarm in SOLAS.
MCA Response
MCA comments are noted.
The part of the recommendation to “… be capable of operating when main power supplies are shut down” cannot be made a mandatory requirement under UK law. The recommendation to “… be able to wake sleeping crew in sufficient time for them to react appropriately” again would be very difficult in law. It is concluded that the intent of these parts of the recommendation are better managed by risk assessment and inspection of the vessels as proposed through the response to Recommendation 2009/142.
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.
Recommendation
Maritime and Coastguard Agency (MCA)
Addressed To
M A I B A N N U A L R E P O RT 2 0 0 9
Eurovoyager
148a
Commercial Shipping
Investigation
Number Focus
MAIB Comment
MCA Response
MCA
Addressed To
Recognises the need to apply SOLAS Regulation 15 to all vessels.
•
The MCA’s actions with respect to this recommendation mean that any initiative to realise a revision of SOLAS Regulation 15 rests with the administrations of Belgium and Cyprus. No response to this recommendation has been received from either the Belgium or Cyprus administration.
Recognises the need for change to SOLAS Regulation 15 to reflect contents of MCS/Circ 1176 (see above). However, the MCA is only prepared to support the paper to IMO if presented by the flag state of the vessel concerned.
The application of SOLAS Regulation 15 to all vessels fitted with watertight doors.
• •
Revision of SOLAS Regulation 15 (openings in watertight bulkheads in passenger ships) to reflect the contents of Section 4.3.8 and Section 8 of MSC/Circ.1176 which requires the provision of a local visual indication to indicate when a watertight door is being operated in the remote mode
•
Present a joint paper to the IMO’s Maritime Safety Committee on:
Recommendation
PA RT 2 : R E C O M M E N D AT I O N S
17
Commercial Shipping
115b
18
Commercial Shipping
Commercial Shipping
153a
153b
153
Commercial Shipping
General Maritime
125b
126a
General Maritime
125a
125
Focus
Number
Riverdance
Celtic Pioneer
Celtic Pioneer
Antari
MCA
Department for Transport (DfT)
MCA
Passenger Boat Association
Professional Boatman’s Association
MCA
Investigation Addressed To
Accepted – Yet to be Implemented
Predicted implementation date: December 2010
Conduct an urgent study into stability and operational issues which impinge on the safety of ro-ro vessels operating from UK ports. In particular, the study should identify how the stowage plan should be produced and implemented, how masters can establish the stability of their vessel before sailing, and under varying conditions of service, the securing of trailers, and the securing of cargo within trailers to prevent their movement whilst at sea.
Predicted implementation date: Yet to be advised
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.
Predicted implementation date: Work in progress.
Predicted implementation date: Work in progress.
In consultation with the MCA, continue to work towards the production of an industry approved code of practice for thrill-type boat ride operators, taking into account the safety issues raised in this report and the requirements laid down in the Vibration Regulations.
Predicted implementation date: June 2010
Press the International Maritime Organization for an urgent review of the principles and process used to establish safe manning levels internationally and the use of dedicated lookouts.
Recommendation
M A I B A N N U A L R E P O RT 2 0 0 9
Commercial Shipping
115a
General Maritime
Commercial Shipping
116b
122
Commercial Shipping
116a
116
Moondance
Commercial Shipping
109
Maersk Kithira
Antari
Antari
Investigation
Number Focus
MCA
MCA
DfT
DfT
Bahamas Maritime Authority (BMA)
Addressed To
19
Urge particular caution when assessing the need to go onto the open deck during darkness in view of the difficulties that may be experienced in assessing the magnitude/direction of approaching waves. List control measures that should be adopted when sending personnel onto the open deck in heavy weather.
•
•
The above formal advice should underpin the draft guidance currently being developed and be incorporated into the next revision of the Code of Safe Working Practices for Merchant Seamen.
Provide guidance on the height and frequency of significantly larger waves that may be encountered.
•
Develop and promulgate formal advice to mariners on the specific risks to be considered when assessing the need to go onto the open deck in heavy weather. Such advice should:
To instigate robust, unilateral measures to address the fatigue of bridge watchkeeping officers on vessels in UK waters and to ensure that a dedicated lookout is always posted at night, during restricted visibility and as otherwise required in hazardous navigational situations.
Press for an urgent review of the process and principles of safe manning at the IMO to reflect the critical safety issues of fatigue and the use of dedicated lookouts.
Take urgent action to review the validity of Seatruck Shipholding Limited’s Safety Management Systems to ensure they are sufficiently robust for safe operation of its vessels.
Recommendation
Accepted – Implemented – Recommendation closed by MAIB
PA RT 2 : R E C O M M E N D AT I O N S
Celtic Pioneer
General Maritime
Commercial Shipping
Commercial Shipping
126b
133
147b
Eurovoyager
Hurlingham
Investigation
Number Focus
MCA
MCA
Royal Yachting Association (RYA)
Addressed To
Promote the adoption of procedures that reflect best practice, such as those described in the Code of Practice for Passenger Vessel Operations on the Thames 2009.
•
Through representations to the European Commission, take steps to ensure that official guidance provided for inspectors in respect to the application of EU Directive 1999/35/EC is amended to reflect SOLAS requirements regarding the operation of watertight doors at sea.
Verify compliance with the procedures specified in their DSMC.
•
Improve the targeting of inspections on the operation of Class V vessels (particularly those working during the evening) to:
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.
Recommendation M A I B A N N U A L R E P O RT 2 0 0 9
20
PA RT 2 : R E C O M M E N D AT I O N S
SECTION B LEVEL 2 RECOMMENDATIONS
These recommendations are addressed to industry bodies and organisations which may call for changes or reinforcement of best practice. Summary Table Accepted Action yet to be Implemented
Partially Accepted
Rejected
No Response Received
Focus
Total
Accepted Action Implemented
General Maritime
16
4
10
1
-
1
Commercial Shipping
26
20
3
3
-
1
Fishing Vessels
4
1
3
-
-
-
Leisure Vessels
-
-
-
-
-
-
Total
46
25
16
4
-
2
21
Commercial Shipping
Commercial Shipping
149b
149c
22
Focus
Commercial Shipping
Number
140
Partially Accepted
Focus
Number
Stellar Voyager
Investigation
Eurovoyager
Eurovoyager
Investigation
No Response Received
Identify the technical reasons for the catastrophic failure of its windlass motors and determine engineering and design solutions to prevent similar accidents on board vessels fitted with its equipment. Has identified the technical reason for the catastrophic failure of its windlass motor but believes no modification to the design of its equipment is required. In the manufacturer’s opinion the failure was solely due to operator error/bad seamanship. The manufacturer appears to have missed the key point of this recommendation. It is essential that ships’ equipment is designed such that it does not fail in a manner which can cause serious injury or death. In this case the windlass motor casing shattered, spraying shrapnel around the adjacent decks, which severely injured the windlass operator.
TTS Kocks Response
MAIB Comment
Recommendation
No response to date.
Ensure that when inspecting ferries under EU Directive 199/35/EC, Inspectors also take account of EU legislation, such as PUWER, which relate to the health and safety of workers.
No response to date.
Ensure that when inspecting ferries under EU Directive 199/35/EC, Inspectors also take account of EU legislation, such as PUWER, which relate to the health and safety of workers.
Recommendation
TTS Kocks GmbH
Addressed To
Cyprus Maritime Administration
Belgium Federal Public Service, Mobility and Transport
Addressed To
Responses to recommendations which have not been accepted have been grouped together and presented first. Those which have been accepted are presented secondly and broken down into their vessel type.
Level 2 Recommendations – Breakdown
M A I B A N N U A L R E P O RT 2 0 0 9
Commercial Shipping
164b
General Maritime
Commercial Shipping
149a
175
Focus
Number
Vallermosa
Stena Voyager
Eurovoyager
Investigation
23
Tailor Bridge Resource Management training courses, as guided by the output of the UKMPG, BPA and MPA Marine Working Group, to include integration of pilots into the bridge team during pilotage. No further change to syllabus required. Changes to syllabus will be predicated by the outcome of work currently being undertaken by UKMPG, BPA and MPA.
IAMI response MAIB Comment
MAIB is aware that VOSA and the MCA have been working closely together to produce informational literature aimed at ship operators, seafarers, road hauliers and vehicle drivers which highlight the requirements and precautions that need to be observed when transporting articulated lorries and trailers by sea.
MAIB Comment
International Association of Maritime Institutions (IAMI)
VOSA contends that an inspection regime as outlined in the recommendation is outside its current remit and no funding is provided for this purpose.
VOSA Response
The MCA position is noted.
MAIB Comment
Conduct a co-ordinated programme of roadside/dockside inspections of freight vehicles presenting for shipment at UK ports, to identify those vehicles that do not comply with the IMO and MCA guidance on ferry securing arrangements, and take any appropriate actions available to increase levels of awareness and compliance.
MCA’s considered view is that this recommendation has huge implications for ships with watertight doors and that it would not be practical or fully justified under the costs versus benefits to require all watertight doors to comply with EU legislation regarding PUWER. We note the points made in the report and will write to the European Commission to seek a view on the application and impact this will have on enforcing PUWER on watertight door arrangements. The timescale for this can only be that we raise the issue with the EC by November 2009 and cannot predict the further outcome.
MCA Response
Vehicle and Operator Services Agency (VOSA)
Ensure that when inspecting ferries under EU Directive 199/35/EC, Inspectors also take account of EU legislation, such as PUWER, which relate to the health and safety of workers.
Recommendation
MCA
Addressed To
PA RT 2 : R E C O M M E N D AT I O N S
Focus
Fishing Vessel
Fishing Vessel
General Maritime
General Maritime
General Maritime
Number
118
119
127
142
144
24
HMS Westminster/ Princess Rose
Abigail H
Celtic Pioneer
Vision II
Vision II
Investigation
Accepted – Yet to be Implemented
MCA
MCA
RYA
The Seafish Industry Authority
MCA
Addressed To
Predicted implementation date: August 2010
Provide guidance on: • The conduct of passenger transfers between vessels that are underway and making way. • The movement of passengers to and from vessels which are not secured to a quay, including the use of vertical ladders
Predicted implementation date: December 2010
Issue guidance, and through survey and inspection, check that owners conduct a properly structured assessment of risks to crew sleeping on board all vessels less than 500 gross tons that are moored alongside and have been shut down overnight. Where such risks are identified, check that appropriate procedures are in place to mitigate them.
Predicted implementation date: December 2010
Raise the awareness of the dangers of shock and vibration in small highspeed craft through its powerboat training syllabi.
Predicted implementation date: June 2010
Review its survey procedures to ensure that they are effective in checking new build vessels comply with mandated construction standards, specifically that electrical systems are appropriately checked and approved.
Predicted implementation date: December 2010
Broaden the scope of its review of the safety issues associated with crew living on board fishing vessels to include: The impact of security arrangements on emergency access and egress; safe access requirements to and from the vessel.
Recommendation
M A I B A N N U A L R E P O RT 2 0 0 9
25
Commercial Shipping
166
Fishing Vessel
158
Commercial Shipping
Commercial Shipping
147a
165
Focus
Number
Stena Voyager
Stena Voyager
Maggie Ann
Eurovoyager
Investigation
MCA
MCA
MCA
DfT
Addressed To
Ensure emergency drills, plus instruction and guidance on how to conduct risk assessment and improve safety awareness are undertaken to a consistent standard by surveyors and inspectors of fishing vessels throughout the UK. Incorporate guidance into its revision of MGN 265 (F) designed to preclude the need for Scallop fishermen to lean outboard of the bulwark during tipping operations.
•
•
Shipboard procedures include measures to verify that the parking brakes of all vehicles, including semi-trailers, have been applied. Predicted implementation date: May 2010 – Update requested.
•
At the next SMC audit or EU Ferry Directive (1999/35) survey of all UKflagged freight-carrying ro-ro ferries and all foreign-flagged freight-carrying ro-ro ferries operating to UK ports, check the cargo securing arrangements to confirm that: • Onboard practice is in line with the approved cargo securing manual and the procedures detailed in a vessel’s safety management system.
Predicted implementation date: June 2010
Review the cargo securing manuals of all UK flagged HSC carrying freight vehicles to ensure compliance with the numbers of lashing points required in the UK Code of Practice.
Predicted implementation date: April 2015
Expedite its current work on the use of personal flotation devices and personal locator beacons in the UK fishing Industry (MAIB Recommendation 2008/173 refers).
•
As part of its efforts to realise improved safety within the fishing industry:
Predicted implementation date: Yet to be advised
Through representations to the European Commission, take steps to ensure that official guidance provided for inspectors in respect to the application of EU Directive 1999/35/EC is amended to reflect SOLAS requirements regarding the operation of watertight doors at sea.
Recommendation
PA RT 2 : R E C O M M E N D AT I O N S
26
General Maritime
General Maritime
172b
172c
General Maritime
General Maritime
General Maritime
General Maritime
173a
173b
173c
174
173
General Maritime
Focus
172a
172
Number
Vallermosa
Vallermosa
Vallermosa
Investigation
MCA
UKMPA
BPA
UKMPG
UK Maritime Pilots Association (UKMPA)
British Ports Association (BPA)
UK Major Ports Group (UKMPG)
Addressed To
Determine the required level of support provided by bridge teams during acts of pilotage and ensure this expectation is disseminated to vessels arriving at their ports.
•
Predicted implementation date: December 2010
Disseminate to the shipping industry specific detailed information on the expected levels of support which should be provided by bridge teams when a pilot is embarked.
Predicted implementation date: Yet to be advised
Predicted implementation date: Yet to be advised
Predicted implementation date: Yet to be advised
Encourage their members to develop feedback mechanisms for pilots to report on substandard bridge team performance, and take appropriate action as necessary.
Predicted implementation date: Yet to be advised
Predicted implementation date: Yet to be advised
Predicted implementation date: Yet to be advised
Determine the training requirements necessary to ensure pilots can integrate effectively into bridge teams during the performance of their duties. To reinforce the benefits and rationale of integration with bridge teams, such training should make clear the negative impact stress/ overload will have on individuals’ cognitive functions.
•
Task the UKMPG/BPA Marine Pilotage Working Group in consultation with the UKMPA to define their expectations of bridge team/pilot performance, and from this:
Recommendation M A I B A N N U A L R E P O RT 2 0 0 9
Commercial Shipping
Commercial Shipping
103b
104
27
Commercial Shipping
Commercial Shipping
105a
105b
105
Commercial Shipping
Focus
103a
103
Number
Astral
Astral
Astral
Investigation
GlobalMET formally AMETIAP
IAMI
Rederi AB Veritas Tankers
Queen’s Harbour Master Portsmouth
Associated British Ports Southampton
Addressed To
Understand the limitations of their vessel’s anchoring system. Understand the company’s emergency response procedures and are implementing these plans effectively.
• •
Navigation planning for anchoring, including the construction of swinging circles, holding ground and position monitoring while at anchor. The strengths, weaknesses and limitations of vessels’ anchoring systems. Command considerations for safe anchoring, including wind and tide effects, yawing, when to depart an anchorage and actions to take to prevent dragging and to take when dragging is detected.
•
• •
Encourage your members providing training to deck officers, to conduct a full review of the study programmes delivered to ensure that deck officers gain effective instruction on:
Are provided with, and are familiar with, correct and clear anchoring procedures.
•
Review your SMS instructions and enhance your auditing procedures to ensure that masters and ships’ officers:
Provide guidance to your VTSOs on the language and terminology used, particularly to non English speakers, in communicating with ships’ masters and officers to minimise the possibility of misunderstanding or confusion and, where appropriate, to issue masters with clear instructions.
Recommendation
Accepted – Implemented – Recommendation closed by MAIB
PA RT 2 : R E C O M M E N D AT I O N S
28
Commercial Shipping
129
Commercial Shipping
107
Fishing Vessel
Commercial Shipping
106d
120
Commercial Shipping
106c
Commercial Shipping
Commercial Shipping
106b
108
Commercial Shipping
Focus
106a
106
Number
Celtic Pioneer
Vision II
Norma
Norma
Norma
Investigation
Develop generic checklists where appropriate. Ensure such guidance is widely promulgated within the shipping and commercial diving industries.
• •
Review your quality management system to ensure that the electrical system of new vessels fully complies with the relevant sections of the Sea Fish Industry Authority construction standards, and equipment is suitable for its intended purpose and is installed in accordance with manufacturers’ fitting instructions.
Highlight to your membership the need to identify key shipboard operations integral to a vessel’s intended and potential employment and to ensure appropriate associated procedures have been developed whenever conducting ISM Code audits as recognised organisations on behalf of flag states.
Through your membership promulgate the guidance for diving operations conducted from, or within close proximity to, merchant vessels as soon as this has been developed by the Maritime and Coastguard Agency, the Health and Safety Executive, International Marine Contractors Association and Association of Diving Contractors.
Consolidate the guidance available for diving operations conducted from, or within close proximity to merchant vessels.
•
Under the lead of the Maritime and Coastguard Agency:
Recommendation
Bay Island Voyages Review your risk assessments and operating procedures taking into consideration the safety issues identified in this report, and ensure that all such procedures are followed.
Macduff Shipyards Ltd
International Association of Classification Societies Ltd. (IACS)
International Chamber of Shipping (ICS)
Association of Diving Contractors
International Marine Contractors Association
Health and Safety Executive (HSE)
MCA
Addressed To M A I B A N N U A L R E P O RT 2 0 0 9
Focus
Commercial Shipping
General Maritime
Commercial Shipping
Commercial Shipping
General Maritime
Number
134
135
138
139a
152
29
Celtica Hav
Pacific Sun
Pacific Sun
Hurlingham
Hurlingham
Investigation
Perth and Kinross Council
Cruise Lines International Association (CLIA)
Princess Cruises
London River Services (LRS)
MCA
Addressed To
Require all vessels using LRS piers to adhere to the Code of Practice for Passenger Vessel Operations on the Thames 2009.
•
Use the Princess Cruises’ standard for securing furnishings and equipment in passenger vessels (once completed) as a basis for developing a guide on industry best practice. Disseminate the safety issues, actions taken and lessons learnt following this accident to your members. Ensure that the recently increased minimum under keel clearance required by vessels passing over the Shell NGL pipeline is strictly adhered to, and that the risks associated with any proposed dredging in the vicinity of the pipeline are fully assessed in consultation with key stakeholders.
•
•
•
•
•
Review the role of active stabilisers in ensuring passenger safety. The review should include system redundancy, planned maintenance, and the need to fit suitable alarms to warn of system degradation or failure. Carry out a fleet-wide assessment of the risk of injury from moving furnishings and objects following large angles of heel. This should include the calculation of the forces involved and identify suitable means of securing objects both routinely, and for heavy weather. Develop a standard for securing furnishings and equipment in public spaces, particularly in muster stations and their access routes. Develop your heavy weather guidance and instructions to include actions to reduce the risk of injury.
Ensure the lighting and marking arrangements of the pier edges make a distinct contrast with the surrounding water in all ambient light conditions.
•
•
Clarify where the responsibility for passenger safety lies, and ensure that adequate control measures are in place to ensure passenger safety, particularly in emergency situations.
•
Assess the risks associated with the movement and control of passengers on your piers at night, to:
Issue improved information to operators of Class III – VI (A) Domestic Passenger ships to guide them on the measures they should take to comply effectively with the Domestic Passenger Ships Safety Management Code.
Recommendation
PA RT 2 : R E C O M M E N D AT I O N S
Commercial Shipping
154b
Commercial Shipping
Commercial Shipping
Commercial Shipping
Commercial Shipping
General Maritime
155a
155b
156
164a
177
155
Commercial Shipping
Focus
154a
154
Number
Stellar Voyager
Stena Voyager
Riverdance
Riverdance
Riverdance
Investigation
American Bureau of Shipping
MCA
ICS
BMA
MCA
Freight Transport Association
The Road Haulage Association
Addressed To
30
Promulgate the findings of its investigation to the classification society and users of the equipment. Where appropriate, take corrective design measures to prevent catastrophic failure in the future.
• •
Whenever catastrophic failure of class approved equipment occurs, it shall be a condition of continued approval that IACS members require the relevant manufacturer to: • Conduct a detailed investigation into the causes of the failure.
Propose to the International Association of Classification Societies that: • IACS Unified Requirement - A for mooring and anchoring equipment is revised to include measures to prevent the catastrophic failure of windlass hydraulic motors through over-pressurisation and over-speed and thereby remove the potential to cause injury to persons.
Conduct a co-ordinated programme of roadside/dockside inspections of freight vehicles presenting for shipment at UK ports, to identify those vehicles that do not comply with the IMO and MCA guidance on ferry securing arrangements, and take any appropriate actions available to increase levels of awareness and compliance.
Review existing guidance to owners on “Emergency Preparedness” and promote careful consideration of the merits of using Emergency Response Services.
Ensure proper and effective methods exist to promulgate and disseminate safety information produced by IMO, and other relevant organisations, to ship operators.
Provide guidance to shippers on the additional securing of cargo onto trailers intended for shipping by sea to withstand the dynamic forces that may be experienced.
Recommendation M A I B A N N U A L R E P O RT 2 0 0 9
PA RT 2 : R E C O M M E N D AT I O N S
SECTION C LEVEL 3 RECOMMENDATIONS
These are addressed to individual organisations, owners or companies that are specific to their area, vessel or company. They have no direct impact on the shipping industry as a whole, although the lessons are promulgated through the individual investigation reports, through media coverage of the report and through the MAIB’s Safety Digests. Summary Table Focus
Total
Accepted Action Implemented
Accepted Action yet to be implemented
Partially Accepted
Rejected
No Response Received
General Maritime
9
5
3
1
-
-
Commercial Shipping
36
30
4
-
-
2
Fishing Vessels
3
3
-
-
-
-
Leisure Vessels
3
3
-
-
-
-
Total
51
41
7
1
-
2
31
Focus
Commercial Shipping
Commercial Shipping
Number
131
132
Addressed To
Maersk Newport Servyman del Estrechio S.L.
Maersk Newport Servyman del Estrechio S.L.
Investigation
No Response Received
A nominated safety watchman is always readily available and that a replacement is allocated during his/her absence.
•
32
Separating “in use” gas bottles from those in the storage area where this is feasible. Ensuring that no flammable materials, including clothing, are left in the vicinity of oxygen/acetylene bottles.
• • No response to date.
Carrying out leak tests on newly assembled oxy/acetylene connections.
•
Adopt industry best practice by:
No response to date.
Workers are equipped with a VHF radio to communicate with each other and the crew in an emergency.
•
Review hot work procedures to ensure that:
Recommendation
Responses to recommendations which have not been accepted have been grouped together and presented first. Those which have been accepted are presented secondly and broken down into their vessel type.
Level 3 Recommendations – Breakdown
M A I B A N N U A L R E P O RT 2 0 0 9
Focus
General Maritime
Number
179
Partially Accepted
Stellar Voyager
Investigation
MAIB Comment
TTS Kocks Response
TTS Kocks GmbH
Addressed To
Is supplying an instruction plate providing operating guidance which will be fixed at a location clearly visible to the operator on the anchor winch.
•
The additional operational guidance provided by the manufacturer is welcome however it is disappointing to note there appears to be no intention to improve the quality/content of technical instruction manuals to facilitate better/correct routine maintenance of the equipment.
Is sending operational instructions to operators of vessels equipped with hydraulic driven windlasses supplied by TTS Kocks/F.R.Kocks GmbH.
•
Ensure comprehensive technical and operational instructions are provided for all the components of its windlass machinery, including those supplied from other manufacturers.
Recommendation
PA RT 2 : R E C O M M E N D AT I O N S
33
34
Commercial Shipping
161
Commercial Shipping
137
Commercial Shipping
General Maritime
128b
150
General Maritime
Focus
128a
128
Number
MCA
Ship manager: CMA-CGM Group
Ville de Mars
Thames Cruises Ltd
Institute of Licensing
Local Authorities Coordinators of Regulatory Services (LACORS)
Addressed To
Eurovoyager
Hurlingham
Celtic Pioneer
Investigation
Accepted – Yet to be Implemented
Access points are positioned appropriately to minimise the risk of a passenger falling overboard while embarking or disembarking, and that gangways are used where necessary.
Predicted implementation date: December 2010
With the help of human factors experts, conduct a study to try and identify ways of developing a positive safety culture and reducing complacency on board your ships, and to share the results of this study with others via the MCA's Human Element Advisory Group.
Predicted implementation date: November 2010
Explore potential means of improving the safe use of powered watertight doors, through industry bodies such as the National Occupational Health and Safety Committee, taking into account ship crews' apparent reluctance to observe existing guidelines, current technology and the need to keep watertight doors closed at sea.
Predicted implementation date: Work in progress
•
Review the passenger access arrangements on all its vessels to ensure that: • Passengers are protected in the event that a mooring line or other part of the mooring system fails.
Predicted implementation date: To be advised as the code of practice is not yet available.
Predicted implementation date: To be advised as the code of practice is not yet available.
When available, promulgate the approved code of practice for thrill-type boat operators, and strongly encourage local authorities within the United Kingdom to require operators to adhere to the code as a condition of licensing.
Recommendation
M A I B A N N U A L R E P O RT 2 0 0 9
Focus
General Maritime
Commercial Shipping
Number
178
183
Jo Eik
Stellar Voyager
Investigation
ICS
Oil Companies International Marine Forum (OCIMF)
Addressed To
35
That the cargo specific MSDS is promulgated to receivers (terminal or transhipment ships/barges) either directly from the ship or via the ship operator or agent so that risk control measures are based on accurate information. That areas of the deck which fall into the IMO’s definition of an Enclosed Space are identified, and that appropriate control measures are in place following risk assessment.
•
•
Predicted implementation date: December 2012
Emphasise the need for the cargo specific MSDS to be held on board as supplied by the shipper.
•
Include the following safety issues identified in this report in the next periodic review and amendment of the Tanker Safety Guide Chemicals:
Predicted implementation date: September 2010
At the next revision of its publication ‘Anchoring Systems and Procedures for Large Tankers’ include guidance on weighing anchor, highlighting the lessons from this accident and stressing the importance of minimising the tension on the anchor chain when ‘heaving in’ on the windlass.
Recommendation
PA RT 2 : R E C O M M E N D AT I O N S
Commercial Shipping
101b
Commercial Shipping
Commercial Shipping
Commercial Shipping
Commercial Shipping
Leisure Vessel
Leisure Vessel
102a
102b
110
111
112
113
102
Commercial Shipping
36
RIB 6
RIB 6
Moondance
Moondance
Astral
Pride of Canterbury
101
101a
Investigation
Number Focus
Plas Menai Centre
Plas Menai Centre
Seatruck Ferries Shipholding Ltd
Seatruck Ferries Shipholding Ltd
The Nautical Institute
ICS
ICS
Interferry
Addressed To
Operating areas, limitations and personal flotation requirements, Restrictions to operations dependent on seating availability, Considerations for 'journeying' and similar activities, Procedures for amending/changing authorised activities; and Emergency response procedures.
Review your communications strategies and procure equipment as necessary, to ensure that all centre activities are effectively supported by appropriate means of communication at all times.
• • • • •
Review your risk assessments and thereafter amend your staff handbook to provide staff with further guidance and instruction on:
Undertake a review of the onboard risk assessment procedures to ensure your vessels comply with Seatruck Ferries Shipholding Limited's policy.
Provide guidance to suitably trained internal ISM auditors on the scope of their responsibilities, including assessment of crew knowledge, departmental management and inter-departmental communications.
Circulate the MAIB's Safety Flyer on anchoring procedures to all your members.
Promulgate to ship owners/managers the MAIB Safety Flyer describing this accident and the principal lessons to be learned from it.
Recommendation
Accepted – Implemented – Recommendation closed by MAIB
M A I B A N N U A L R E P O RT 2 0 0 9
Fishing Vessel
121
37
Commercial Shipping
Commercial Shipping
Commercial Shipping
Commercial Shipping
124a
124b
124c
124d
124
Commercial Shipping
Commercial shipping
117
123
RIB 6
Leisure Vessel
114
Scot Isles/Wadi Halfa
Maersk Kithira
Vision II
Antari
Investigation
Number Focus
International Federation of Shipmasters’ Associations
The Nautical Institute
UK Chamber of Shipping
ICS
Maersk Ship Management
MB Vision LLP
Briese Schiffahrts GMBH & Co.
RYA
Addressed To
Promulgate to your respective members the MAIB Safety Flyer accompanying this report to highlight the dangers of complacency in bridge watchkeeping officers and the importance of establishing an effective bridge team capable of maintaining a proper lookout, using all available means, at all times.
Amend your safety management system to include: • Additional heavy weather checklist measures to ensure watertight integrity.
Develop work instructions for crews tasked with connecting its vessels to, and disconnecting shore power. The instructions should include, inter alia: Identification of those breakers considered safe to switch off; Highlight the dangers of isolating any emergency system; Electrical schematic diagrams.
Review and amend your safety management system to ensure your internal auditing policies verify the following: • Compliance with hours of rest regulations • Effective passage planning in accordance with SOLAS Chapter V, Regulation 34 • Understanding of the requirements for notifying coastal states • The appropriate use of lookouts and watch alarms at sea.
Promulgate to your centre principals, trainers and instructors the lessons from this accident, and emphasise that safety of life remains an essential requirement during all activities, which becomes of paramount importance as soon as the activity ceases to follow the briefed plan.
Recommendation
PA RT 2 : R E C O M M E N D AT I O N S
130
Commercial Shipping
Number Focus
Maersk Newport
Investigation A.P. Møller Maersk
Addressed To Casualty Committee composition is appropriate to the specific circumstances. Compliance with the accident reporting requirements for United Kingdom registered vessels. Effective and inclusive communications between shore management, contractors and ship's staff. All identified safety related deficiencies are sufficiently assessed for fleet wide notification. Ship's staff, regardless of management involvement, maintains oversight of contractors and that the hot work Permit to Work procedures, as specified in the Global Ship Management System, are strictly complied with. Foreign language work approvals are translated for compliance purposes. Global Ship Management System includes detailed instructions for the preservation of Voyage Data Recorder information for accident investigation purposes.
• • • • •
• •
Review and amend your current procedures to ensure:
Recommendation M A I B A N N U A L R E P O RT 2 0 0 9
38
39
Commercial Shipping
General Maritime
143
Commercial Shipping
139b
136
Number Focus
Abigail H
Pacific Sun
Hurlingham
Investigation
Wyre Marine Services
Passenger Ship Association (PSA)
Thames Cruises Ltd
Addressed To
Introduce procedures to ensure that marine crews are not distracted by commercial activities, including responsibility for the bar, which could detract from the performance of their primary duties.
•
Improve existing procedures to keep the level of oily waste in the bilges of your vessels to a minimum and introduce routine inspections of pipework and internal surfaces of hull plating to identify vulnerable areas and give the maximum warning of potential failures.
Disseminate the safety issues, actions taken and lessons learnt following this accident to their members.
Provide masters with clear guidance on the conduct of operations and, specifically, the requirement to ensure the wheelhouse is manned at all times when the vessel’s engine is in gear.
•
•
Introduce employment procedures to ensure, as far as possible, that crew are working in accordance with the regulations for hours of work and rest.
•
Use the Princess Cruises’ standard for securing furnishings and equipment in passenger vessels (once completed) as a basis for developing a guide on industry best practice.
Conduct effective emergency training drills to practice responding to the range of hazards identified in your risk assessments of vessel operations.
•
•
Implement a system to record accidents and near misses, identify the lessons to be learned, and review and update your risk assessments and emergency procedures.
•
Review and amend your safety management system, as necessary, to comply with the Code of Practice for Passenger Vessel Operations on the Thames 2009 and, specifically, to:
Recommendation
PA RT 2 : R E C O M M E N D AT I O N S
General Maritime
Commercial Shipping
146
151
Commercial Shipping
Commercial Shipping
Fishing Vessel
Fishing Vessel
Commercial Shipping
157a
157b
159
160
162
157
General Maritime
145
Number Focus
40
Ville de Mars
Maggie Ann
Maggie Ann
Riverdance
Eurovoyager
HMS Westminster/ Princess Rose
HMS Westminster/ Princess Rose
Investigation
CMA-CGM Group
The Scallop Association
AGR Fishing Company
Interferry
ICS
Transeuropa Shipping Lines Ltd
City Cruises Plc
City Cruises Plc
Addressed To
Ensuring that the skipper conducts regular emergency drills. Implementing a robust inspection and maintenance regime for all working equipment.
• •
Review and improve your internal audit procedures such that follow up action taken to address non conformity is properly documented and verified.
Endorse and promulgate through its membership the fishing accident flyer published by the MAIB which highlights the safety lessons learned from this tragic accident.
Modifying working procedures as necessary to preclude the need for crew to lean outboard of the bulwark during tipping operations.
•
Improve the safe operation of your vessel by:
Promulgate to ship owners/managers the MAIB Safety Flyer describing this accident and the principal lessons learned from it.
Adopt measures, including the review of VDR data, to ensure that your procedures for the operation of watertight doors are strictly observed.
Provide training for your masters employed in conducting passenger transfers between vessels making way through the water. The training should be tailored to take account of the characteristics of specific vessels and should be incorporated into the training schedule contained within your company's safety management system.
Carry out a comprehensive risk assessment on vessels you use to conduct passenger transfers when making way. The assessment should examine all aspects of the transfer operation and lead to the development of robust procedures, guidance and appropriate manning levels for this type of operation.
Recommendation M A I B A N N U A L R E P O RT 2 0 0 9
General Maritime
General Maritime
176
Commercial Shipping
169
171
Commercial Shipping
168
Leisure Vessels
Commercial Shipping
167
170
Commercial Shipping
163
Number Focus
41
TS Royalist
TS Royalist
Sooty
Velox
Stena Voyager
Stena Voyager
Stolt Petrel
Investigation
The Association of Sail Training Organisations (ASTO)
The Marine Society and Sea Cadets
Un-named private boat owner
Faversham Ships Ltd
Turner’s (Soham) Ltd
Stena Line Ltd
Stolt Tankers B.V.
Addressed To
A proper and effective lookout is maintained at all times. Passage is conducted at a safe speed. Position is monitored. The person in charge has not consumed alcohol in excess of the limit currently prescribed for drivers of road vehicles.
• • • •
Promulgate the safety lessons learned from the accident by distributing the MAIB Flyer on its investigation to the ASTO membership.
Develop a structured system for the selection and audit of relief masters.
A proper passage plan is produced before departure.
•
Examine their departure procedures and methods of navigation when operating leisure craft, with a view to ensuring that:
Ensure that your company's Safety Management System captures all safety significant activities carried out on board company vessels, and that the associated equipment is effectively operated, maintained and inspected by competent personnel.
Ensure all its freight vehicles intended for shipment by ferry are fitted with ferry securing rings in accordance with the guidance given in the ISO 9367 standards.
Seek assurance through operational trials/inspections that, following the implementation of its safety manager’s recommendations, the crews on board its HSS 1500 vessels are able to stow and secure all vehicles in accordance with the cargo securing manual prior to leaving the berth within the scheduled turnaround times.
Review the controllable pitch control systems on board your vessels to ensure that the risks of systems failure are identified, and the potential effects of their failure mitigated.
Recommendation
PA RT 2 : R E C O M M E N D AT I O N S
Commercial Shipping
181
Commercial Shipping
Commercial Shipping
Commercial Shipping
Commercial Shipping
182a
182b
182c
184
182
Commercial Shipping
180
Number Focus
Jo Eik
Jo Eik
Jo Eik
Jo Eik
Investigation
42 Intertek OCA
Federation of Inspection Agencies
Tank Storage Association
ICS
Jo Tankers AS
Jo Tankers AS
Addressed To
Cargo checklists are completed diligently; tank washing defects are identified and corrective action taken to maintain the principle of "closed operations" as far as is practicable. Crews use the respiratory protection in accordance with its QMS instructions. Terminal emergency procedures are clearly promulgated and that key personnel, in addition to the chief officer, are familiar with them.
•
• •
Review its procedures for accessing cargo specific MSDSs to ensure that cargo surveyors are equipped with the appropriate PPE respiratory protection.
Promulgate via your membership the MAIB's Safety Flyer which highlights the circumstances and lessons to learn from this investigation.
Pre-arrival conferences are conducted as close to the arrival at the loading/discharge port as possible.
•
Implement management control measures to verify:
Provide Butterworth hatch closing arrangements to reduce cargo vapour discharge when using tank portable washing equipment.
Recommendation M A I B A N N U A L R E P O RT 2 0 0 9
PA RT 2 : R E C O M M E N D AT I O N S
SECTION D RECOMMENDATIONS TO MULTIPLE RECIPIENTS Lists the small number of recommendations that have been addressed to large multiple recipients. As a result, it has not been possible to track responses under the closed-loop system. Such multiple addressee recommendations are now being avoided wherever possible, so as to make the closed-loop system as effective as possible.
No recommendations were addressed to multiple recipients in 2009
43
M A I B A N N U A L R E P O RT 2 0 0 9
SECTION E WITHDRAWN RECOMMENDATIONS
No recommendations were withdrawn during 2009
44
PA RT 2 : R E C O M M E N D AT I O N S
SECTION F RECOMMENDATIONS BROUGHT FORWARD FROM PREVIOUS YEARS Lists the ongoing outstanding recommendations shown as accepted – yet to be implemented in previous reports.
45
Fishing Vessel
Commercial Shipping
2008/ 186
2008/ 148
Commercial Shipping
2008/ 188a
Number Focus
Shark/Royalist
CFL Performer
CFL Performer
MCA
MCA
IAMI
Investigation Addressed To
Accepted – Yet to be Implemented
Recommendations are listed by year/number.
46
The need to ensure that all crew understand key safety information and can communicate effectively with each other during an emergency. The requirement to maintain and regularly test fire detection and emergency equipment.
• •
Predicted implementation date: March 2010 – Update requested
The conduct and proper recording of mandatory emergency drills and the importance of crew familiarisation training.
•
Review and expand the content and application of MGN 336(F) - Overseas Management, to include management of all UK, 24 metre in length and over fishing vessels, and the following additional management issues:
Predicted implementation date: June 2010
Continue to strongly support the expeditious adoption of current proposals for the formal inclusion of an ECDIS competence and its mandatory assessment in the STCW Code and, in doing so, to press for an urgent review of the IMO model course syllabus for ECDIS training to ensure it remains fit for purpose and that successful completion of the course is determined by examination and practical assessment.
Predicted implementation date: May 2009 – update requested.
Encourage its members providing training in ECDIS to align this as closely as possible with the IMO model course and to determine the successful completion of such training through practical assessment and examination.
Recommendation
RECOMMENDATIONS BROUGHT FORWARD FROM PREVIOUS YEARS M A I B A N N U A L R E P O RT 2 0 0 9
Fishing Vessel
Leisure Vessel
Leisure Vessel
2008/ 147
2008/ 140
2008/ 139
Number Focus
47
Last Call
Last Call
Shark/Royalist
BIS
Department for Business, Innovation and Skills (BIS)
MCA
Investigation Addressed To
Check officers hold appropriate CoC and CEC qualifications and crews have completed mandatory safety training courses. Establish auditable procedures to ensure that the rectification of defects identified during survey are verified within prescribed timescales. Carry out emergency drills during survey/inspection and to confirm that mandatory emergency drills are conducted and properly recorded.
• • •
Predicted implementation date: Not given
In conjunction with HMRC, seek to develop procedures whereby HMRC can notify local authorities of the import of recreational leisure craft into the Community market. This is to enable local authorities to conduct such checks as they deem necessary to ensure that individuals and companies importing such craft comply with the Recreational Craft Directive and that non CE marked craft undergo a postconstruction assessment.
Predicted implementation date: Not given
Seek a review, through the Recreational Craft Sectoral Group and the European Commission, of guidance provided to manufacturers of recreational craft and Notified Bodies, to ensure that, when significant improvements to safety are mandated, such standards are applied to all new craft including new “series production” craft sold in the UK.
Predicted implementation date: April 2010 – Update requested
Alert owners to Intermediate Surveys in the same manner as for Renewal Surveys and, in consultation with Defra, establish administrative procedures that will lead to fishing vessel licence suspension in the event of noncompliance.
•
Amend its survey and inspection procedures for 24 metre in length and over fishing vessels, to include measures to:
Recommendation
PA RT 2 : R E C O M M E N D AT I O N S
48
General Maritime
2008/ 118
Commercial Shipping
2008/ 128
Fishing Vessel
Commercial Shipping
2008/ 130
2008/ 124
General Maritime
2008/ 137
Number Focus
8m Rigid Raider
Blithe Spirit/ Lady Hamilton of Helford
MSC Napoli
MSC Napoli
Viking Islay
Director of Reserve Forces and Cadets
MCA
IACS
IACS
MCA
Investigation Addressed To
Predicted implementation date: December 2010
Put in place measures to ensure that approval for cadet forces to conduct an activity outside the usual syllabus is subject to its inclusion in an advance training plan submitted through the chain of command, and that approval is given only after compliance with pertinent policies and procedures has been determined.
Predicted implementation date: April 2010 – Update requested
Ensure candidates’ understanding of the additional risks posed by the operation of the higher speeds associated with non displacement fishing vessels is fully tested when developing the syllabus for the = 100gt UK merchant vessels < 100gt UK non-commercial vessels UK fishing vessels Non-UK commercial vessels
Page 54 56 61 62 63 68
For details of reporting requirements and terms used in this section please see Annex Statistics Coverage on page 69.
53
M A I B A N N U A L R E P O RT 2 0 0 9
UK vessel accidents involving loss of life
Date
Name of Vessel
Type of Vessel Location
Merchant Vessels 100gt and over 28 Jan Ville de Mars Container ship 2 Feb 1 Apr 25 Jul
Gulf of Oman
Pride of Dover Ro-ro passenger Dover ferry Wellservicer Dive support Aberdeen vessel Hyundai Tokyo Container ship Bering Sea
Accident
Deaths
Table 1 - UK Vessel Accidents involving Loss of Life
Fall involving Chief Officer while descending into ballast tank Passenger overboard
1
Accident to rigger involving a diving bell cursor Person overboard
1
1
1
10 Sep Ever Elite
Container ship
San Francisco Bay
Accident to AB following collapse of accommodation ladder
1
19 Nov Ever Smile
Container ship
Taipei Harbour
Person overboard during mooring operation
1
3 Dec
Cargo barge
Marchwood, Southampton
Carbon monoxide poisoning
1
Person overboard Person overboard while alongside in harbour Person overboard while alongside in harbour Person overboard
1 1
Drowning after falling into water while accessing vessel Capsize
1
Person overboard Person overboard Person overboard
1 1 1
Person overboard
1
Collision followed by sinking
1
Goole Star
Fishing Vessels 12 Feb Maggie Ann 18 Feb Mercurius
Scallop dredger Cardigan Bay Scallop dredger Milford Haven
6 Apr
Contest
Stern trawler
Mallaig
25 Apr
Ryanwood
Pair trawler
7 Jun
Ajax
Stern trawler
North Sea, East Coast of Scotland Fraserburgh
20 Jul
Aquila
Scallop dredger North of the Ardnamurchan peninsula Potter NW of Orkney Scallop dredger Dover Strait Stern trawler East Coast of Scotland Potter East Coast of Scotland Potter English Channel
9 Oct Noronya 6 Nov Korenbloem 11 Nov Osprey III 18 Nov Optik 20 Dec Etoile des Ondes
54
1 1
3
PA RT 3 : S TAT I S T I C S
Date
Name of Vessel
Type of Vessel Location
Pleasure Craft (Non-Commercial) 28 Feb Jensa Angling boat River Crouch, Essex 21 Mar Open dinghy Loch Awe, Scotland 1 May Kayak River Tay, Scotland 2 May Ben Brack Star Motor Cruiser Upper Lough Erne, Northern Ireland 18 May Sooty RIB Calve Island, near Tobermory, Isle of Mull 22 May Cobra Narrowboat Pewsey, Kennet and Avon Canal 22 Jun Nine Moons Motor yacht Corsica 27 Jun -
Kayak
12 Jul
Sailing dinghy
30 Jul
Laser Stratos 132 Harry
31 Jul
Stella Maris
1 Aug
-
Lunan Bay, Montrose Keilder Water
Narrowboat
Varney’s Lock, Oxford Canal 8m open power Near Capri, boat Mediterranean Rowing boat River Dart
Harwich 2011 Racing powerboat 23 Aug Canoe
Accident
Deaths
UK vessel accidents involving loss of life
Person overboard
1
Drownings following presumed foundering Drowning while kayaking
4
Person overboard
1
High speed grounding
1
Fire
1
Grounding resulting in accident to person Drowning while kayaking in surf
1
Capsize followed by entrapment in rigging Injuries sustained after falling into lock
2
Collision
2
Drowning following capsize
1
1
1
1
8 Aug
Dover
Collision during race
1
Drowning following capsize
2
21 Nov -
Kayak
Loch Maree, Scotland River Dart
Drowning while kayaking
1
1 Dec
Inflatable dinghy Christchurch Bay Motor yacht River Dart
Person overboard
1
Person overboard
1
-
13 Dec Edward
See definitions in Annex Not all accidents involving pleasure craft (as defined in Annex) and recreational craft hired on a bareboat basis are required to be reported to the MAIB. While we would encourage all such accidents/incidents to be reported, we do not consider this to be a definitive or comprehensive register of waterborne fatal accidents
55
M A I B A N N U A L R E P O RT 2 0 0 9
UK merchant vessels >= 100gt Table 2 - Merchant Vessel Total Losses 2009
*
Date
Name of Vessel
Type of Vessel
Age
20 Mar
Humber Star
Product Tanker
40
gt 274
LOA Metres 45
Nature of Accident Foundering
* Constructive total loss
Table 3 – Merchant Vessel Losses: 1997-2009
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Number Lost
UK Fleet Size
gt Lost
1 1 1 1 1 2 6 5 2 1
1 055 1 072 1 035 1 050 1 047 1 210 1 343 1 406 1 443 1 480 1 518 1 578 1 564
869 3 476 12 778 11 217 671 832 1 579 54 304 645 274
Table 4 - Merchant Vessels in Accidents: 1997-2009
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Vessels
UK fleet size
Accidents/1 000 vessels
237 217 160 139 134 129 145 145 197 129 116 135 125
1 055 1 072 1 035 1 050 1 047 1 210 1 343 1 406 1 443 1 480 1 518 1 578 1 564
225 202 155 132 128 107 108 103 137 87 76 86 80
See definitions in Annex
56
PA RT 3 : S TAT I S T I C S UK merchant vessels >= 100gt
Table 5 - Merchant Vessels in Accidents by Nature of Accident and Vessel Category Dry Passenger cargo
Passenger Tanker/ cargo combination carrier
Other commercial Total
Cargo Handling Failure Collision Contact Fire/Explosion Flooding/Foundering Grounding Heavy Weather Hull Failure Machinery Failure Person Overboard Pollution
1 10 13 1 7 1 2 8 3 -
1 5 9 2 6 2 7 3 1
1 2 -
3 3 1 2 1 1 1
1 6 5 1 1 3 1 7 3 -
3 24 31 2 4 18 4 2 25 10 2
Total
46
36
3
12
28
125
Table 6 - Merchant Vessels in Accidents by Nature of Accident: 1997-2009 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Capsize/Listing 1 1 2 1 2 Cargo Handling Failure 2 2 1 8 1 1 3 1 1 2 1 4 3 Collision 30 23 10 25 16 18 12 16 38 25 14 21 24 Contact 24 23 18 14 13 25 37 28 33 20 30 27 31 Escape of Harmful 15 27 15 4 11 4 2 1 2 1 Substance Fire/Explosion Flooding/Foundering Grounding Heavy Weather Machinery Failure Person Overboard Other
Total
26 4 21 2 50 15 48
24 3 20 4 55 8 28
19 3 16 2 48 11 16
18 2 7 5 50 5 1
21 3 18 1 39 10 -
26 1 14 4 28 10 2
22 3 13 3 41 8 3
24 3 15 4 42 5 1
22 6 26 1 51 13 3
7 4 21 6 30 11 2
7 2 11 4 36 7 -
12 4 26 4 23 11 2
2 4 18 4 25 10 4
237 217 160 139 134 129 145 145 197 129 116 135 125
57
M A I B A N N U A L R E P O RT 2 0 0 9 UK merchant vessels >= 100gt
Table 7 - Deaths and Injuries of MV Crew and Other Workers by Place Where Accommodation space - crew Accommodation space - passengers Cargo or other tank space Engine room External stairway/ladder/gangway External working deck/shelter Galley Hotel service areas Internal stairway/ladder Mooring deck Navigation/communication control space Overside/aloft Ro-ro vehicle deck/ramp Ship’s boat Store space Workshop Other external deck Other internal deck/space Other machinery space Other
Number of people 25 4 4 18 8 29 12 14 13 13 3 3 7 6 3 2 14 10 4 11
Total
203
Table 8 - Deaths and Injuries of MV Crew and Other Workers by Rank Rank/specialism Master/Skipper Chief Engineer Officer, Deck Officer, Electrical Officer, Engineering Rating Rating, Deck Rating, Engineering Rating, General purpose Other Crew Worker (Non-Crew)
Number of people 1 4 19 2 17 7 62 17 15 54 5
Total
203
58
PA RT 3 : S TAT I S T I C S UK merchant vessels >= 100gt
Table 9 - Deaths and Injuries of Merchant Vessel MV Crew and Other Workers by Injury Main injury Amputation of hand/fingers/toe
Number of people 5
Bruising
22
Burns/shock (electrical) Burns/scalds (non electrical) Chemical poisoning/burns from contact or inhalation Concussion/unconsciousness due to head injury Crush injury Cuts/wound/lacerations Death - confirmed Death - presumed Dislocations Eye injuries Fracture - of the skull/spine/pelvis/major bone in arm or leg Fracture - other Strains - other strains/sprains/torn muscles/ligaments Strains - strained back Other
2 3 1 9 14 22 4 2 11 3 27 24 33 14 7
Total
203
Table 10 - Deaths and Injuries to Merchant Vessel Crew: 1997-2009 Crew Injured 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 * 2009
Of which resulted in death
327 330 288 300 296 302 288 307 246 231 242 225 203
5 2 4 3 3 5 3 4 2 3 12 5 6
* 2009 and subsequent years: Include workers on board vessels who are not crew members
59
M A I B A N N U A L R E P O RT 2 0 0 9 UK merchant vessels >= 100gt
Table 11 - Deaths and Injuries to Passengers by Injury Main injury Bruising Concussion/unconsciousness due to head injury Crush injury Cuts/wound/lacerations Death - confirmed Dislocations Fracture - of the skull/spine/pelvis/major bone in arm or leg Fracture - other Strains - other strains/sprains/torn muscles/ligaments Unknown
Number of people 17 2 2 7 1 9 39 35 2 2
Total
116
Table 12 - Deaths and Injuries to Passengers: 1997-2009 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Number of injuries
Of which resulting in death
94 120 80 137 138 134 186 146 109 114 106 170 116
2 1 1 1 1 1 2 1
60
PA RT 3 : S TAT I S T I C S
UK merchant vessels
