Safety Digest 1 1995

8/7/2019 Safety Digest 1 1995

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Su mma ry of Investigations No 1/95

April 1995


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INDEXPage N oIntroduction

1. Eng ine Ro om Fire whilst Alongside 12. Fun dam ental Errors cause Stranding of Small Carg oVessel 33. Attempted Removal of Access Covers causes Injury toCrew Members 5

6781011

4.5.6.7.8.9.

Chlorine Gas Escape from Swimming Pool of Passenger VesselPotential Dan ger of Water Based MudH ow to Plan and Conduct a PassageNew Seam an Injured during Cargo OperationsInjury due t o Incorrect Wiring of D ough R oller Safety G ua rdOccupants; of an Angling Vessel thrown into the Water withoutLife-jackets 12

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10. Un safe System of Work causes Serious Injury t o Fisherm anTwo Crew are Injured during Winch Operations11.

12. Flooding o f An Elderly Wooden Fishing Vessel13. Unsafe P ractice during Hauling

Fishing Vessel Backfloods through its Bilge Pum ping System14.15. Incorrect Operation of Bilge Pu m p leads to Loss of FishingVessel 22

Watertight Bulkhead Saves Fishing Vessel 2316.17.18.19.

Accident to Deck hand when Shooting Pots 24Fatalities d ue to Cordage: not Fit for Use 25

26Failure of Bilge Alarm leads to Loss of a Fishing VesselAppendix A - Investigations Commenced in the Period 01/12/94 -Appendix B - MAIB Priced Publications available from H M S OAppendix C - HMSO Stockists and Distributors Overseas

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INTRODUCTION

This edition of the Summ ary of Investigations marks the start of th e sixthyear of this publication. Including this latest edition we have nowpublished 15 editions which contain over 260 case studies. Som e readersmigh t have copies of every edition, while o the rs possibly will only have th elater ones. However, looking back over the past editions one of the thingswhich is immediately obvious is that little has chang ed over five years. Avery large proportion of the accidents are still due to failures to observethe basic principles of seamanship, and in many cases a lack ofcommonsense. I t would be wrong to think that all accidents could beprevented bu t a very great nu m ber would n ot have occurred if only peo plehad given some thou ght to the job in hand a nd t he likely consequen ces ofwhat could go wrong. Th ere is a lot of truth in t he maxim "To fail to planis to plan to fail".All of us mak e mistakes some time or anoth er and I regret to say we didso when publishing the last summary of investigations - N o 3/94. Casestudy number 5 - "Obstruction at Tidal Berth Causes Pollution" - wasincluded by mistake. T h e investigation into the accident in question hasno t been finalised and the comments are no t strictly valid. W hen th einvestigation has been completed we will include a revised sum mary in afuture edition of Summary of Investigations. W e apologise for anyproblems this may have caused readers.

Chief Inspector of M arine AccidentsApril 1995


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1. ENGINE ROOM FIRE WHILST ALONGSIDENarrativeThis 6,009 gross registered to nnag e refrigerated cargo vessel was undergoing variousvoyage and damage repairs whilst in drydock. Amongst those repairs was therequirement to remove a number of damaged shell bottom plates and floorsunderneath th e engine room.At approximately midnight, the night shift were removing a shell plate by burningalong a shell seam from the und erside of the vessel. T his shell plate formed part ofa double bottom tank, several plates of which had already been removed. As theburner was working on the seam, a loud bang was heard from within the tank rightabove where he was working. The chargehand, who was observing the burningoperation from th e dock bottom, immediately stopped the burning. Seeing flameswithin t he vessel he tried to pu t o ut th e fire with an extinguisher which was at hand .However thick black sm oke rapidly built up and h e decided to leave the dock bottom .Having told on e of his men to ring for the F ire Brigade, the ch argehand together withanother man, rushed on board, each carrying a fire extinguisher. On reaching th eengine room the smoke was so thick that entry was impossible through the engineroom door. Th e ship's staff manag ed to en ter the engine room via the tunn el escapetrunk and attacked the fire initially with fire extinguishers, the n with a fire hose.On ce the fire was out and th e engine room had been cleared of smoke, the seat ofthe fire was found to be centred around two access manholes to the tank beingrepaired. T wo bu rnt o ut plastic containers plus rags were found in the area as wellas a q uantity of oil and w ater.Observations1. Prior to the start of the w ork on this double bottom tank, the tank had beengas freed and a "Safe for Hot Work" certificate issued. A fire watch wasoperative externally bu t did not extend to th e engin e room space imm ediatelyabove the hot work site.2. O n investigation, the fire was found to have started forward of the aft engineroom bulkhead in the imm ediate tank top area above the lub oil tank underrepair. N o dam age was found to either the tank or th e internal pipes and n ointernal debris was foun d.3. T h e two plastic conta iners with their tops cut off had most probably containedslops from the tank cleaning that had been carried o ut prior t o the burningoperation. Rags drenched in oil and w ater together with a variety of charredtins were found in th e imm ediate vicinity of the tank access manhole.

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4. Most probably the fire was ignited by sparks from the burning operationshooting through the man hole and dropping onto e i ther oil soaked rags or thefluid in th e open top containers.Comment

1. It is important th at a f ire watch and fire patrols cover not only the im med iatearea w here h ot work is taking place, but also those areas adjacent.2. The cause of the fire was bad housekeeping on the pa r t of the personsemployed to carry o ut t he tank cleaning. All waste material a nd fluids shouldhave been removed from the area and all f luids placed in sealed containers oncompletion of the shift. Th ese and o ther precautions are identif ied in C hap ters2 and 13 of the "Code of Safe Working Practices for Merchant Seamen".Similar guidance will be fo und in the HSE App roved C od e of Practice relatingto Safety in Docks and the Docks Regulations 1988.

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2. FUNDAMENTAL ERRORS CAUSE STRANDING OF SMALL CARGOVESSELNarrativeA general/bulk car go ship of 794 gross registered tons left W hitstable shortly aftermidnight boun d for Le Havre. She was in ballast with a maximum d raug ht of 2.45metres. H er speed in this condition was 8 knots. O n clearing the ha rbour the Mastertook the first watch. After abou t two hours the M ate took over the watch, at whichtime the vessel was about to alter course off North Foreland Lighthouse. Th e newcourse to make good was 151 (T) which would take the ship between Gull andGoodwin buoys an d clear 0.5 n m N E of the Goodwin Knoll Bank (see ch art extract).Th e wind a t the t ime of the alteration of course was NE'ly 5 and the spring t ide wasebbing giving a predicted set of 035 (T) x 1.5 knots.It was the Mate's intention to navigate by pilotage techniques, steering gyro coursesbetween visual sightings and rad ar de tections of th e buoys en route. T h e radar wasset on the 6 mile range. T he vessel was also equipped with a Phillips AP Navigatorwhich worked from the D ecca system. Visibility from the wh eelhou se was restricteddue to spray and the vessel was rolling heavily.Th e Ma te allowed a total of -6 o n the course of 151 (T) for the resultant effectsof wind and tide. T he course steered was not noted in the ship's deck log. T he firstbuoy should have been sighted within 20 minutes after the alteration of course.How ever, the M ate did not see this buoy or any of the other buoys expected visuallyor on th e radar, neither did h e attem pt to use any othe r method to establish the ship'sposition. T he M ate allowed this situation to continue for an ho ur until eventually hefelt the ship run aground.The vessel had stranded on the Goodwin Sands and was "high and dry" by thefollowing low tide. T he vessel was eventually refloated o n the next rising tide. Th er ewas n o damage: to the ship, no injury to personnel and n o pollution resulted from th eaccident.Observations1. The Mate had a 1st Mate's (FG) Certificate, 20 years experience in theLimited Eu ropean Tr ad e and, in all likelihood, had been using visual estimatedpositions from buoys and lights as the main or sole basis for navigation formany of those years. He qualified in 1966 and ha d no t und erta ken any formaltraining or updating since that time.2. T h e choice of course to pass within 0.5 mile to the North of the GoodwinKnoll Bank in stron g NE'ly w inds was im pru den t especially when consideringthe restricted visibility from the wheelhouse under those conditions.3. Th e Master left n o written or verbal "night orders' ' before he left the bridge.Although this may no t have contributed directly to th e incident it is consideredindicative of the general relaxed approach to formal bridge and navigationalprocedures.

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4. The Master decided that, due to a heavy workload on the previous day, n owatch rating would be required on the bridge.5 . In th e 24 hours prior to the s tranding the Mate had been able to s leep for anaggregate of about 7 hours over three different periods.Comment1. This incident shows how imp ortant the fundam ental rules for good navigationalwatchkeeping practice ar e and how, if good simple procedures ar e in place,potentially hazardous incidents can b e avoided. For example:

- A second person on the bridge would have helped in sighting andidentifying navigational marks . Sch edule 1 of the M erchant Shipping(Certification and Watchkeeping) Regulations 1982 refers.- Night O rde rs may have highlighted the particular dan gers to beexpected and thus ensured a greater degree of vigilance. (MerchantShipping Notice N o M. 1102).- Positively fixing th e ship's position by any m ean s which were availableand preferably by m ore than o ne of those m ean s or, if fo r any reasonthis was not possible, estimated positions plotted on th e chart, wouldhave indicated the potential for grounding. (M erchan t Shipping NoticeN o M.854 para 21 and M erchant Shipping Notice N o M.1102 para 20).- Calling the Master when a navigational mark is not seen by theexpected tim e or w hen having difficulty in fixing the ship's position, isa prudent and sensible practice which should have been followed onthis occasion. (M erchan t Shipping Notice No M.1102 para 24).- Passage planning with proper consideration of the forecasted wind an dtidal streams would have highlighted the potential hazard t hat th echoice of course provided. (M erchan t Shipping Notice No M.854).

Ensuring that the officer of th e watch was properly rested beforecorning on watch would have helped en sure fitness for duty. Schedu le1 of the Merchant Shipping (Certif ication and Watchkeeping)Regu lations 1982 refers.T he provision of any one of these proced ures would have greatly reduced t helikelihood of stranding. T he fact tha t non e of these procedures were in placema de the event almost inevitable.

2. In addition, in connection with the poor standard of navigational watchke epingshown, Merchan t Shipping Notice N o M.1328 draws attention to t he "SmallVessels' Navigation and Radar Training Courses" which are ru n by nauticalcolleges.

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3. ATTEMPTED REMOVAL O F ACCESS COVERS CAUSES INJURY TOCREW MEMBERSNarrativeTwo incidents occurred on sep arate vessels, which resulted in injury to crew m embe rs.They both involved the attemp ted removal of inspection or access covers to tanks.In on e case a Chief Officer slackened an ullage port dog during the loading of a smalltanke r whilst venting of the P/V valves could clearly be heard. T he pressure within thetank caused the ullage lid to blow open and eject the flame gauze into the ChiefOfficer's face.T he second case involved th e removal of the secur ing nuts of an access cover to abulk carrier's ballast suction well which had b een isolated f or several mo nths. Intern alpressure had accumulated in this well, probably du e to t he leaking of compressed airfrom the rem ote contents gauging system. T he crewmen remo ved all the securingnuts on th e cover and then, in o rder to free the cover from its joint, struck it with aham mer. T he cover freed suddenly and was projected upw ards by the air p ressurewithin the well, breaking the hammer which struck and injured the crewman's ribs.ObservationsThese two cases provide a clear dem onstration of the large quantities of energy whichmay be present in gases at even modest pressure; energy which may suddenly bereleased o nce the gases are free to escape to atm osphere.Comment

Gu idanc e on the testing of enclosed spaces and systems for pressure, befo re securingbolts of covers or joints a re fully removed, is con tained in th e "Code of Safe W orkingPractices for M erchant Seamen".

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4. CHLORINE GAS ESCAPE FROM SWIMMING POOL OF PASSENGERVESSELNarrativeTh e swimming pool are a of a passenger vessel was reopened to passengers after beingclosed ove rnight. The norm al backflushing procedu res we re followed d uring whicha quan tity of chlorine gas escaped into the pool area affecting the pool a t tend ant andsom e passengers. Imm ediate medical attention was available and all affected person squickly reco vered.Observations1. For the purpose of maintaining hygienic conditions the w ater in th e swimmingpool was regularly dosed with sodium hypochlorite; this was the source of th echlorine gas.2. Th e management and crewing of the vessel had changed shortly before this

incident suggesting that th e crew w ere unfam iliar with th e idiosyncrasies of thepools pumping, filtration and chemical dosing systems.Comment1. The vessels managers have taken steps to ensure that passengers areprevented from entering the pool area when pumping or chemical dosingopera tions are likely to cause a release of chlorine.2. Modifications were ma de to the chemical dosing system to ensure thoroughmixing, so preventing the accumulation of pockets of chemicals.3. Also, tests for chlorine conten t of the water are to be performed on a routinebasis with clear reporting procedures of the results. Du ring these tests thesystem will be s hut down an d the a rea cle ared of personnel.

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5. POTENTIAL, DANGER OF WATER BASED MUDNarrativeAn offshore supply vessel back loaded a cargo of water based mud from a mobiledrilling rig. T he cargo was loaded into tanks a nd circulated during t he return passageto port. W hen alongside, the tank hatches were opened and discharge of t he mudcommenced.After approximately o ne hou r, a representative of th e consignee boarded the vesseland noted t he M ate leaning over the hatch coaming of a tank th at was being drained.He advised the Mate: not to d o so because th e cargo was contam inated and was liableto give off hydrogen sulphide gas at a concen tration level of 5 ppm.Observations1. T he cargo was not manifested and th e vessel had received n o documentationstating that the water based m ud was contam inated.2. It was norm al practice to have the tank hatches open d uring discharge in orderto b e able to readily monitor th e quantity of cargo remaining in t he tanks.Comment1. Although water based mud is not classed as a hazardous cargo, it cansometimes be contaminated with hydrogen sulphide gas.2. T he short an d long term exposure concentration limits for hydrogen sulphidegas are 15 ppm and 10 ppm respectively.3. Although the concentration of gas was apparently below th e above limits, th evessel should have been provided with form al written docum entation specifyingthat the mud was contaminated and would give off hydrogen sulphide gas ata concentration of 5 ppm. A safety da ta sh eet for th e gas should have alsobeen supplied.4. Unless there is a clear justification for not doing so, all bulk liquid cargoesshould be loaded, carried and discharged under closed conditions.

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6. HOW NOT TO PLAN AND CONDUCT A PASSAGENarrativeA 2,333 gross registered tonn age s tern trawler/fish factory vessel was aw aiting ord ersand anchored to seaward of the island of Bressay, Shetland at position A. H erMaster received orders to move his vessel to ano ther position, B, a bo ut thre e milesto the north-west in the northern approaches to Lerwick Har bou r (se e chart extract).It was a fine day with a slight sea and good visibility.It was the Master's intention to take his vessel past th e northern tip of Bressay, steera westerly course for abo ut two miles and the n turn to th e north towards position B,leaving Th e B rethren rocks to starboard. He proposed to d o this by visual pilotage.The Second and Third Officers were with the Master on the bridge, the SecondOfficer monitoring the radar and the Third Officer on the wheel.O n passing Score Hea d, th e M aster saw an island on the port bow and conned thevessel to pass it to port a t a distance of about half a mile. A little later, the Seco ndOfficer fixed the position from the radar and marked it on the chart .As the vessel approached G ree n Holm, t he M aster asked t he Second Officer how farthey would pass from "the island". On being told two or three cables", h e orderedan alteration of course to starboard to increase the passing distance. Shortlyafterwards the ech o sound er showed rapidly decreasing depths and a fur ther turn tostarboard was ma de. T he vessel then grounded heavily o n Nive Baa rocks.Observations1. The Master had taken Green Holm to be Holm of Beosetter. The Second

Officer assumed, from the position he plotted, that the Master intended topass between Green Holm and Nive Baa. So far as he was concerned, thevessel was very close to what he took to be the inten ded track. Fo r thisreason, the Second Officer did not see it necessary to draw the Master'sattention to his plotted position.2. T he vessel was refloated on the following tide b ut the re was extensive bottomdamag e, fortunately without pollution. Although the Master had decidedwhich route he intended to take, h e had not revealed his plan to th e SecondOfficer.Comment1. This accident would probably not have happened if, before starting thepassage, the M aster had laid off his intende d track on the char t and shown itto the Second Officer.

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2. T h e Master sh ould then have given explicit instructions to th e Second Officeras to w hat h e expected him to d o during the passage. Fo r example, to monitorth e position a t frequ ent intervals an d notify him if th e vessel was no t keepingto the planned track. Merchan t Shipping Notice N o M.854 includes acomprehensive guide to the planning an d conduct of passages. T he followingcomments in the preamble to the Notice are re levant to this accident:"Accidents happen because o ne person mak es th e sort of mistake t o which allhuman beings are prone in a situation where th ere is n o navigational regimeconstantly in use which might en able th e mistake to be detected before anaccide nt occurs".

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7. NEW SEAMAN INJURED DURING CARGO OPERATIONSNarrativeA Ro-Rocargo vessel was engaged in loading operatio ns while along side in port. Atrailer was reversed into the corner of the vehicle deck, leaving a small clearancebetween th e rear of the trailer an d a side frame. T he trailer was then raised in orderto position a supporting trestle un dernea th it . D uring this operation, the trailer rolledbackwards and trapped the leg of a seaman , who had moved into a position betweenthe trailer and the fram e, in readiness to comm ence lashing.Observations1.2 .

T he seam an had just joined th e vessel.The management company has indicated th t al l new seamen are to beinstructed to k eep well clear of trailers until authorised by a com petent personto move in and commence lashing.

Comment1. As th e seam an was new to th e vessel, he should have been properly supervised.2. Section 4.6.13 of the "Code of Safe Working Practices for Me rchant S eamen' 'highlights th e im portance of informing a new crew member as soon as possibleafter he boards, of the occupational safety arrangements an d of the particularhazard s associated with th e vessel. It also advises that o lder ha nds should b ereminded of the need to maintain a high level of safety consciousness an d tose t a good example to the less experienced crew member.3. Section 2.14 of the Roll-on/Roll-off S hips - "Stowage and S ecuring of Vehicles

- Code of Practice'' advises tha t no at tempt should be m ade to secure a vehicleuntil it is parked, the brakes, where applicable, have been applied and theengin e has been switched off.

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8. INJURY DUE TO INCORRECT WIRING OF DOUGH ROLLER SAFETYGUARDNarrat iveA cook was using a powered dough roller to prepare some pastry in the galley.T he m achine consisted of a pow ered horizontal belt runn ing between two rollers. Athird roller was situa ted over this belt ai: mid length; this roller could b e adjusted sothat th e gap between t he belt a nd roller suited the required thickness of the dough.T he do ugh could be rolled o ut by placing it on the belt an d starting th e belt drive sothat th e dough was forced between the belt an d th e third roller. B elt direction wouldthen be reversed and operation repeated with a smaller clearance between the beltand t he roller until th e desired dough thickness was achieved.Control of the direction of belts movement was altered by way of a guard attachedto a directional switch. This guard was also designed to preven t the operators hand sfrom being trapped between the belt and roller. Thus, in operation it was intendedthat th e converging belt/roller was covered by the g uard and the diverging belt/rollerarea was unguarded. The tendency for objects to be dragged in between belt androller should thus have been prevented.This type of op eration was being performed by th e cook when his hand w as draggedbetween the roller an d the belt .Inspection of the machine immediately established that the combined switch/guardopera ted incorrectly. It was wired in such a way as to requ ire th e guard t o cover theoutlet from the roller/belt rather than the inlet area. Th e machine had b een w ired inthis fashion when it was installed in the ship several years previously. Correctoperation was swiftly restored by rewiring the switch.Observations1. Clearly no proper assessment had be en m ade of th e safety requireme nts of thismachine and the persons using it.2. Further, no functional tests had been performed during any electrical safetychecks on th e m achine.CommentTh e operator of this machine, o r his supervisor, should have had the m anufacturersoperating instructions available to him. Without such information the op erato r mayhave had insufficient knowledge to operate the machine safely and to recognisedefects in its operation.

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9. OCCUPANTS O F AN ANGLING VESSEL THROWN INTO TH E WATERWITHOUT LIFE-JACKETSNarrativeAn 8.3 m etr e glass reinforced plastic moto r vessel left harbour w ith eight anglers andthe Skipper on board early one October morning. The wind was NW 3 but a m oderatesea was runn ing and visibility was good. T h e vessel anch ored approximately 1 mileoffshore for th e anglers to fish. Later on when the anchor was being retrieved, theancho r rope fouled th e propeller, causing th e vessels stern to swing into th e sea.Working throu gh a trunk in the deck over the propeller the Skipper managed to cutthe an chor rop e away. Wh en h e had finished this h e felt tha t th e vessel was floatingdeeper in the water and was somewhat down by the stern. The engine cover wasremoved and a large amount of water was found to be present in the bilges. Theelectric bilge pump was started and th e manu al bilge pump pu t into operation. Flareswere set off and while th e Skipper was broadcasting a MayDay to the Coastguard thebo at went down steeply by the stern, temporarily trapping him in the wheelhou se.The flares were seen by a pilot cutter and by a small pleasure boat and these twoboats rescued everyone from the water. All survivors were taken by ambulance tohospital a nd later discharged.Observations1. Th e cause of the initial flooding has never been identified, but it is thoughtlikely tha t the stern gland may have been dam aged by the fouled anch or rope.2. D ue to t he suddenness with which th e vessel sank all the persons on board

were thrown i nto th e water without life-jackets.3. It is very fortu nate that th ere were boa ts nearby t o render assistance within 10to 15minutes of the survivors entering the water. With the sea temperature a tabout 10 C, unconsciousness amongst som e of the survivors could have be enexpected after about 30 minutes in th e water and deaths from hypothermiamay have followed after a furth er 30 minutes.4. There was no bilge alarm fitted and the electrical bilge pump had to beswitched on from inside the wheelhouse, as it did not operate automaticallyfrom a float switch. The boat was already low in the water before it wasrealised th at it was flooding, which left little time either t o stem the floodingand save the boat or to aban don it in an organised manner.5. T h e boat w as not carrying a liferaft. Fortunately all survived, but it might havebeen a different story if help had not bee n immediately to hand.

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10. UNSAFE SYSTEM O F WORK CAUSES SERIOUS INJURY TOFISHERMANNarrativeA deckhand was seriously injured whilst working in the enclosed factory deck onboard a stern freez er trawler. He fell through an o pen hatch into the fish hold. Priorto his accident, the deckhan d was alternating between two working positions. O n eposition was located on a closed section of th e forward fish hold access hatches, th eother was o n a closed section of the after fish hold access hatches, which remainedopen during the processes of freezing, boxing and stowing the fish. These accesshatches had a coaming height of 0.27 m etre an d were no t fenced nor guarded in anyway.T he accident occurred when the deckhand, moving from t he after working positionto th e forward one, was stepping up on to the closed access hatch cover, across thecorner of the open sect ion. His fo ot slipped and he fell sideways and backwardsthrough th e op en hatch in to the fish hold, falling a distance of about 4 metres. Hesustained injuries to his head and fractures to his ribs and vertebrae. A t the time ofthe accident th e weather was fine and th e sea calm with little or n o motion o n th evessel.Observat ions1. Th e immediate cause of this accident is obvious, th e deckh and slipped whilstattem pting to access his working position close to a n unfenced/unguarded ope nhatch. However the underlying and fundam ental cause of this accident an d ofmany others tha t occur on fishing vessels, was th e failu re of the m anagementashore to see that the Skipper and M ate on board devised and enforced a safe

system of work, as part of their wider responsibility to ens ure tha t th e vesselwas operated in a safe and proper manner.2. Th ere are H ealth and Safety regulations relating to th e fencing of hatches onfishing vessels, but these do no t apply to a fishing vessel a t sea.3. The system of work for this deckhand did not take account of the seriousdanger to his safety posed by the unfenced open hatch to the fish hold.Although the re were no applicable regulations requiring th e fencing of theseaccess hatches, the danger they posed when open was obvious and thecircumstances of this accident were easily foreseeable.4. The investigation of working practices on the factory deck revealed otherequally obvious dangers for which the system of work took n o account . Theaccident to this deckhand should have alerted the management and theSkipper to the weaknesses in their systems of work a nd stimulated a thoroughreview. Some consideration was given to fencing the hatches but this wasrejected for various reasons. T he result was that other deckhands, whosubsequently performed the task of th e injured man , were subjected to exactlythe same degree of danger as had caused this accident. T he vessel waseventually taken out of service by t he operators, for com mercial reasons.

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Comment1. It is recognised that fishing is a dangerous occupation and that in respect ofmany of the dangers to which fishermen are exposed, much depen ds on th ecare and vigilance of th e individual if accidents ar e to be avoided. How everthis does not excuse management, Skippers and Mates who ignore obviousdangers in their working practices, where those dangers could have been

substantially reduced with a l i tt le more tho ught and care.2. As pa r t of the legal duty to operate vessels in a safe and proper manner,management and Skippers have a responsibility to devise and enforce safesystems of work on board t heir vessels. This require s a rational assessmen t ofthe risks of injury an d a positive approach to finding ways to reduce such risks.If this is not d on e th e safety of fishermen will depen d entirely upon their ownvigilance and care, in which case inexperience, loss of concentration and/or'contributory negligence' will eventually take its toll, as dem onstrate d by thisavoidable accident.3. Section 31 of the M erchan t Shipping Act 1988 places a duty on th e owner totake all reasonable steps to ensu re that th e vessel is operated in a safe manner .Section 27 of th e M erchan t Shipping Act 1970, as substituted by Section 32 ofth e 1988 Act, im poses a duty on the Skipper (or any person employed onboard ) 'to preserve any person on board from death o r serious injury'. Failu reto discharge any of these d uties is a criminal offence.4. Th e Depar tment of Tra nsp ort publication 'Fisherm en an d Safety' is a guide tosafe working practices for fishermen. It includes advice abou t working ne arhatches. This booklet is free of charge and can be obta ined f rom the M arineSafety Agency in S outham pton or from any M SA District Marin e Office.

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11. TWO CREW ARE INJURED DURING WINCH OPERATIONSNarrativeA 15.6 me tre, w ooden, sh elter decked, stern trawler ha d just stopped fishing to haulthe gear . The weather and sea were calm. Th ere were fou r in the crew: th e Skipperwas in th e wheelhouse, the winchman was operating the winch inside the sh elter andthe two deckhands were aft by the gallows.Using the winch, the warps were hauled through a block on each of th e gallows. Asthe nylon towing pennants, which were still attached to the warps, approached th eblocks the d eckh ands called to t he winchman to stop hauling.Unfortunately, the w inchman did no t hear the comm ands to stop hauling and bothdeckhands were caught between the towing pe nnants and the gallows. Th e deckhandat the port gallows was able to duck out from under the towing pennant but hereceived a cut above his eye in the process. T he deckhand at the starboard gallowswas no t a s fortunate: he was pinned against the gallows by the towing pe nna nt beforethe winch was stopped a nd suffered a broken collar bone, cracked ribs and bruisingto the chest .T he casualties we re evacua ted by helicopter to hospital.Observations1. It is clearly a poor layout design which results in the winchman having arestricted view of the aft gallows.2. Th e deckhands had approached th e gallows to unhook the towing pennants

without taking the precaution of waiting to see the w arp stop, and by doing sohad placed themselves in a d ange rous position.3. Both casualties suggested that similar accident could be avoided by "standingwell out of the way until the towing penna nts have been brought up to th eblocks".4. This accident could very easily have resulted in fatalities.Comment

1. Th e factors relat ing to this accident are well covered by th e recent Mercha ntShipping Notice No M.1561 "Dangers from W inches, Machinery an d FishingGear". The following relevant advice is contained in that notice:- DO keep w ell clear of all running gear.- DO .....maintain a reliable communication system between th e wheelhouse,- DO NOT stand .... in a bight or within t he line of leads of a wire.winch control positions and th e working deck.

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2. A hands-free intercom/tannoy system w ould improve com munications betweenthe winch operator and crew working on the aft deck.3. An emergency stop button for the winch located on the a ft deck might haveprevented this accident.

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12. FLOODING OF AN ELDERLY WOODEN FISHING VESSELNarrativeA 50 year old w ooden fishing vessel with a crew of five was operating ab ou t 40milesfrom land. The sea was moderate and the wind was decreasing to force 5 - 6. T h eflooding started in the fish hold area but as there were no watertight bulkheadsbetween this space and t he en gine room both spaces flooded to a depth of about ametre. The vessels bilge strum boxes choked which resulted in the bilge pumpingsystem being ineffective. T he Coastguard was alerted, and a rescue h elicopter tooka portable pum p to th e flooded vessel. The pumping operation was successful and sh ewas escorted safely into harbour.Observations1. On checking the records, this was the third incident of flooding to this vesselwithin fo ur years.2. It was considered by m ore pru den t f ishermen that th e Skipper of this elderlyfishing vessel was operating her a t too high a speed in these conditions.3. Th e cause of flooding was loss of caulking from between the hull planking inway of th e fish hold.Comment1. T h e Skipper sho uld have reme mb ered tha t his first responsibility is the safetyof his crew.2. Operators of elderly wooden vessels may consider the carriage of a portableself-contained diesel driven pu mp to b e a useful back-up.3. Because so many of this type of vessel are lost, serious consideration shouldbe given to making the bulkhead between the fish hold and engine room aswatertight as possible.4. T h e Dos and Donts which may help to prevent fishing vessels being lostthrough flooding are se t out in M erchant Shipping Notice N o M .1327.

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13. UNSAFE PRACTICE DURING HAULINGNarrativeTwo separate incidents resulted in hand and wrist injuries to f ishermen engaged inhauling operations. Both of the vessels concerned are about 20 metre s registeredlength and u sed fo r stern trawling from a n aft gallows.Th e general practice on such vessels is as follows:During hauling operations two crew members are stationed at the gallows, one ateither side and ano ther is positioned a t th e forward winch. The two trawl warps aresimultaneously heav ed on their respective sides via an upper gallows block then alower gallows block to the winch. After th e trawl doo rs are secured to th e gallows, th ewinch is used t o heave the bridles. E ach bridle consists of a single sweep, leading fro mthe trawl door to a swivel connection, and a double sweep, leading from the swivelconnection to the m outh of th e trawl net.On th e two vessels concerned th e single sweep is normally heaved on board until theswivel connection reache s a position betw een th e upper gallows block a nd th e stern.Hauling is then stopped and any appare nt twists in the dou ble sweep are removed byman ually turning th e swivel after which hauling is resumed. However, th ere is atendency for the do uble sweep to twist as it passes through th e lead block system tothe winch. In ord er to prev ent th e twists travelling back along th e doub le sweep andso closing the mou th of the net, any twists which appeared at t he roller of the uppergallows block ar e removed by manually separating th e two parts of th e double sweepas they pass over the stern towards t he block.In each of the two cases, on e of the two fishermen who were engaged to remove th etwists inadvertently delayed the removal of his hand , which resulted in it becomingtrapped between the two parts of th e double sweep and being drawn in to the block.Fortunately, in both cases the winch ope rator h ad a clear view of the fisherman andwas able t o prevent furth er injury by stopping an d then reversing the winch.Obse rvat ions1. Th e pract ice of untwisting the double sweep while it was in the process ofbeing heaved on board was common on both vessels.2. In th e first case, the fisherman was very experienced in the hauling operation

and put the cause of his accident down to a lapse of concentration. In thesecond case, th e fishermen was very inexperienced and was not being properlysupervised.

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Comment1. T he practice of manually separating the two parts of the double sweep whileit is in t he process of being heaved on board is unsafe. T he alternatives to thispractice would b e to sto p hauling before attempting to untwist the ropes or toaccept the consequences of twisted ropes, eg increased rope wear andrestriction of the net mouth .2. In both cases, only the prompt action of the winch op erator prevented whatcould have been a much m ore serious outcome.3. Appropriate advice on safe working practice s with winches is provided in the"Fishermen an d Safety" booklet a nd in M ercha nt Shipping Notice N o M.1561.

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14. FISHING VESSEL BACK FLOODS THROUGH ITS BILGE PUMPINGSYSTEMNarrativeA 23 met re s teel fishing vessel with fou r perso ns on board was 25 miles out to sea.T he wind was force 5 and freshening and a 2 metre swell was running. A t 0400 hoursthe engine room bilge a larm sounded an d water was found to be up to th e tail shaft.T he engine driven bilge pum p was started bu t th e water level continued to rise. Wh enit had flooded over the engine room floor plates th e pum p was stopped and the bilgeand sea valves closed. After this was don e the level of flood water stopped rising.T he vessel was pumped dry using th e manu al bilge pump and she was escorted backto po rt by th e local lifeboat.Observations1. After the vessel returned to port the bilge system was inspected. T he engine

room bilge valve shared a chest with the deck wash sea valve. It wasestablished that the valve lid of the engine room bilge suction valve haddisintegrated and fallen into the bilge suction pipe. Th is had cau sed a partialblockage of the suction pipe, thus preventing the bilge from being properlypumped out.2. It was th e practice on this vessel to m aintain slightly ope n th e s ea suction valveon the deck wash pum p valve chest, even when trying to pum p bilges. Thus,water from within this chest was able to bypass the damaged bilge valve lid,and into the engine room bilge, both when using the deck wash system andwhen pumping bilges.CommentVessels have been lost du e to back flooding through th e bilge pum ping system. In thiscase the Skipper acted correctly and saved his vessel by stopping the pump andclosing all sea valves. Merchant Shipping Notice No M.1327 advises fishermen to"close all sea valves (a nd o ther valves controlling th e inlet an d o utlet of water throughthe hull) when the cause of the flooding is not known o r canno t be controlled".

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15. I N CO RRE CT OPERATION O F BILGE PUMP LEADS TO LOSS O FFISHING VESSELNarrativeA steel hulled fishing vessel of 21.4 m etres length was operating a s a pair trawler inthe No rth S ea with a crew of six .D u e to mechanical difficulties this vessel, and itspa rtne r vessel, decided to head fo r port in order to obtain spares. Afte r several hourssteamin g th e Skipper noticed tha t the vessel was rath er low in the water. Inspectionestablished tha t substantial amou nts of water were in both the eng ine room and fishhold. Attempts to use th e bilge system to pum p o ut the vessel proved ineffective andthe Skipper decided that the vessel should be abandoned. All of the crew safelytransferred to the partn er vessel with the aid of a liferaft.The flooded vessel sank several hours later.Observat ions1. T he normal practice employed for pumping bilges on this vessel includedkeeping the sea suction to the bilge pumps partly open. The object of thispractice was to prime th e pumps and to ensure the pumps did not run dry.2. It is com mo n practice on man y fishing vessels to allow bilge pumps to b e leftrunning without close supervision. Maintaining an open sea suction is amethod of preventing the pumps from overheating if and when the bilgesbecome dry.3. In this incident the sea suction was left partly open while attempting to pumpou t th e vessel.Comment1. Clear advice on the proper use of bilge systems is contained in MerchantShipping Notice N o M.1327. In particular it advises th at th e sea suction on abilge pum p should be closed after the pum p is primed and running.2. Keeping the sea suction open to a bilge pump, when attempting to clear bilges,must reduce th e rate at which water is removed from the bilges; of the totalquantity of water being pumped some is coming from the sea and som e fromthe bilges. In a f looding emergency it is essential to pum p a t the m aximum

possible rate from th e bilges. This can only be do ne if no water is being drawnfrom th e sea; the sea suction must therefore be closed.

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17. ACCIDENT TO DECKHAND WHEN SHOOTING POTSNarrativeA 10 m etre po tter was operating in calm seas. At t he time of th e accident pots werebeing sho t away. Th e deckhand was aft lif ting the pots o nto th e gunwale and lettingthem go as th e rope became taut . Th e wind was l ight and the sea ca lm.Several pots in th e curren t str ing had bee n passed over th e side. T he d eckhand washolding the next pot in the sequ ence on the gunwale. Unfortunately it fell off onto theaf t deck. When the rope to this pot becam e taut the pot was l if ted a nd jammedbetween the bulwark and the fish hold hatch coaming and the deckhands leg wastrapped between th e pot an d the fish hold hatch cover.T he S kipper cut him fre e and had him airlifted to hospital. His leg was crushed butn o bones were broken.Observat ions1. T he deck hand appea red to have a well thought ou t system for organising thepots an d ropework to minimise th e risks involved in shooting. How ever, as thiscase unfortunately shows, shooting pots is a hazardous operation requiringtotal concentration on the pa r t of the opera tor.2. One means by which the operation can be made safer is to contain the potropes by pound boards to a chann el down th e side of th e vessel. By this me ansthe crew a re completely separated from th e pot ropes.CommentIf th e ropes had been contained by poun d boards which formed a c hann el down theside of the vessel, it is unlikely that this accident would have occurred as the potwould have been prevented from falling back inboard by the pound boards.

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18. FATALITIES DUE TO CORDAGE NOT FIT FOR USENarrativeCase No 1A 60 me tre stern trawler while a t sea in calm conditions was hauling her n et when itwas discovered tha t the n et was entangled around the cod end rope. To untangle thenet th e cod end rope was s toppered off to a post at the t ransom and t he winch wasslackened off. Seven of the crew took abo ut 15 minutes to c lear the net , but beforeal l of them h ad left the working area a loud bang was heard. T he cod end rope andnet ran freely over the aft en d und er th e weight of the net in the water. O ne of thecrew mem bers received a fatal blow o n t he head from a joining shackle in th e cod en drope.Case No 2A 23 m etre fishing vessel was alongside the pier discharging he r nets a shore p rior t obeing slipped for a refit. All six crew were employed in the project. Pa rt of t he ne twas ashore and to lay out the remainder, a hauling rope was fixed using leadingblocks. After re-positioning the blocks for a second pull, a block secured to ahandrail broke free, striking and killing a fisherman employed under the YouthTraining Scheme.Observations1. The cause of both tragic accidents was the failure of ropes. In the firstincident the stopper rope broke and in the second incident it was the ropesecuring the block to the handrail.2. In both cases the quality of the rope selected for taking heavy loads wasinadequate.3. In the second incident, unfortunately the casualty was standing within thebight.Comment1. Som e guidance on the ca re of ropes can b e found in section 15.4 of the "Codeof Safe Working Practices for Merchant Seamen".2. A decision on whether a rope is, or is not, f it for further use m ust be based onits condition and if any defects have been observed during an examination.The examination should only be undertaken by someone who knows whatdefects to look fo r and how to look for them.3. It is strongly recommended that a length of rope which has been foun d to bedefective should be cut into short unusable lengths to prevent any possibility

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19. FAILURE OF B ILGE ALARM LEADS TO LOSS OF A FISHING VESSELNarrativeA 23 metre steel fishing vessel was operating in the North Sea with a crew of five.After shooting the gea r the crew remained o n deck for about one an d a half hoursgutting an d stowing the fish. Having completed this work t he crew placed th eir wetclothes in th e engine room, then ma de tea or went to bed. Th e Skipper remained onduty in the wheelhouse. Ab out an hour after the crew had turned in he noticed thevessels lights flickering. O n going into the en gine room to investigate he found wa terto a level above th e floor plates.After the crew w ere alerted and the Coastguard contacted for assistance, at temptswere made to pump out the engine room using the vessels own pumps but thisproved futile. T he Skipper decided to abandon the vessel due to the depth of thefloodwater and the nature of the vessels rolling. All five men took to one of thevessels liferafts and the vessel capsized approximately five minutes later. T he crewwere safely recovered by a Coastguard helicopter about an hour later.Observations1. N o signs of flooding were observed by th e crewmen w hen they placed the ir wetclothes in the engine room to dry, abo ut an h our be fore th e discovery of th eflooding. It is therefore concluded that the rate of flooding must have beenrapid.2. A lthou gh th e vessel was equip ped with a high level bilge alarm , it failed tooperate during this incident.3. N o clear cause of the flooding has been established but, due to the impliedrate of flooding it is speculated that part of the engine cooling water systemfailed.Comment1. Whatever the true cause of the engine room flooding, a fully operationa l bilgealarm would have given the crew a very much earlier indication of flooding,possibly giving them time to identify, and even to rectify its cause.2. T h e advisability of testing bilge alarms regularly and having their audible

function switched on is covered in Merchant Shipping Notice No M.1327,together with other sensible advice on action in the event of flooding.

Safety Digest 1 1995

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Transcript of Safety Digest 1 1995