Napoli Investigation “close to completion”

February 5, 2008

The MAIB investigation into the structural failure of MSC Napoli on 18 January 2007 in the English Channel is nearing completion.

Says MAIB: “The investigation has been complex and has required in-depth research in several areas including the vessel’s structure and container vessel operation. It is currently our aim to publish the final report in April 2008.”

MAC understands that the investigation included a computer-based simulation costing some 8m euro.


When an FRB is just a drop in the Ocean

February 5, 2008

MAIB has completed its preliminary investigation into the fall of an FRB from the Viking Discovery in December 2007:

The crew of Viking Discovery were carrying out a regular launching drill of the Fast Rescue Craft (FRC), when it dropped approximately 30 feet into the water, injuring the boat’s three crew. Weather conditions were good at the time, with little wind and a slight swell. The three injured men were taken ashore by helicopter, where one man was found to have broken the bones in both feet, requiring reconstructive surgery. Injuries to the other two men were slight.

The ship was new, and during previous drills carried out on board the crew had noticed that the steel ring at the end of the fall, used to attach the boat for lifting, was at the same height as the boat coxswain’s head when the quick release hook was released. To overcome the danger of the coxswain or other crewmen being hit by the ring, a tripping rope was attached to the ring so that it could be pulled up to deck level once the boat was released.

The davit in use was a “Caley” type, and the fall led through a docking head to the boat. In the boat, the lifting hook equipment included a cruciform arrangement, designed to mate with the docking head on the davit to securely hold the boat in position as the davit was topped and lowered. With the boat in the stowed position, the tripping rope led through the docking head and cruciform arrangement.

The onboard standard procedure was to cock the release hook with the boat still docked in the davit, and then begin lowering. The boat would then enter the water, the hook would release, and the ring would be pulled clear. However, on this occasion the tripping rope had jammed between the cruciform arrangement and the jaws of the docking head. The hook was cocked for off-load release, and lowering commenced. The jam in the docking head stopped the boat from moving immediately, reducing tension in the fall. This tension reduction was sensed by the hook, and it consequently released. The only support for the boat was now the rope jam, which then released and the boat fell.

Action taken:

  • On the day of the accident, the owner published a safety alert advising that when launching boats, the hook should not be cocked until the boat is approximately 1m from the water.
  • The hook manufacturer intends to amend its operating instructions to the effect that the hook should be cocked only when the boat is close to the water.
  • The Chief Inspector of Marine Accidents has written to the owner of Viking Discovery to endorse this practice of not cocking the release hook until the boat is close to the water, and strongly advising a reassessment of other options for keeping the lifting ring clear of the boat when the hook is released. He has also written to the hook manufacturer to endorse the change intended to be made to its standard operating instructions and to encourage this practice to be passed to other manufacturers.

Pilot/VTS assisted Collision – Too Many Gentlemen On The Bridge

January 29, 2008

The UK’s Maritime Accident Investigation Branch has released its full report on the collision between the Audacity and the Leonis in the approaches to the River Humber in April 2007. There was a pilot aboard the Audacity and there was a VTS in operation.  It’s well worth a read.

Among the observations were: ” Effectively, no-one held the con on the bridge of Audacity because both the master and pilot had deferred to the other, there was no discussion or questioning of the intentions of Leonis, and at a critical time they involved themselves with tasks that were inappropriate given the impending close quarters situation.”

Polite deference may be a virtue, but not necessarily in bad visibility.

Also worrying is: “The bridge on Audacity was insufficiently manned in the circumstances and conditions. It did not comply with company requirements or HES instructions to pilots, however no additional resources were requested by the pilot.”

VTS operators made similar errors to the ones made by ships bridge teams that consistently appear in reports on incidents involving vessels with a pilot aboard: “VTS operators did not consider they were able to give advice and guidance to vessels with pilots on board. It was considered that the pilot would know what he was doing and that the operator did not need to be further involved once a pilot was on board.”

Pilots are, indeed, highly trained and extremely knowledgeable but not infallible.

As the American P&I Club video, Stranger On The Bridge advises, “Be more alert, not less, when there is a pilot aboard”.

Passing Gas with a Whispa

December 28, 2007

The UK’s MAIB has released the results of its investigation into the collision between the yacht Whispa and the LPG carrier Gas Monarch. The report comes in the wake of the clearing of manslaughter charges against a ship’s officer for the deaths of three yachtsmen following that boat’s collision with a large vessel.

The Liquefied Petroleum Gas (LPG) carrier, Gas Monarch, collided with the sailing yacht, Whispa, in dense fog 6 miles ESE of Lowestoft on the evening of 16 April 2007. There were no physical injuries on either vessel. There was no damage to Gas Monarch and initial structural damage to Whispa was relatively minor. However, the damage to the yacht worsened due to progressive flooding as she was towed to Lowestoft by a lifeboat.

Gas Monarch was proceeding at full speed, in fog, when her master left the bridge in the hands of his third officer (3/O) and an able bodied seaman (AB), contrary to his own standing orders. The 3/O had been on watch for about 1hour 40 minutes when Whispa appeared out of the fog on a crossing course at very short range. Evasive action by both craft was unsuccessful and the vessels collided.

Prior to the collision, the 3/O on Gas Monarch had detected Whispa by radar and had calculated that the contact would pass clear to starboard. Gas Monarch lost Whispa’s radar contact at a distance of just under 3 miles, but carried on at full speed with no sound signals in the dense fog.

Whispa was motoring on her auxiliary engine with her skipper on watch and his crew member resting below. The yacht skipper had detected Gas Monarch by radar and monitored the target track close to his radar heading marker, for several miles. Whispa’s skipper had limited knowledge of his radar’s capabilities or limitations; without plotting, calculating a closest point of approach (CPA), or establishing Gas Monarch’s speed he concluded that the vessels were on a collision course. Whispa made a bold alteration to starboard when the vessels were just over a mile apart (and closing at fully 18 knots) but this action, instead of moving Whispa clear of Gas Monarch, brought the two vessels onto a collision path.

Gas Monarch’s bow struck Whispa’s port transom and rudder, slewing the yacht round to port and pushing her clear, which allowed the vessels to pass without further contact.

The 3/O on Gas Monarch was in a state of shock as a result of the incident and did not slow the ship. Hearing Whispa’s distress call stimulated him into calling the master, who rushed to the bridge, immediately stopped the ship, and identified Gas Monarch to the coastguard. Gas Monarch stood by Whispa until the yacht was taken in tow by the lifeboat.

The MAIB investigation identified a number of contributing factors to the accident, including:

• A failure by both vessels to abide by collision avoidance regulations
• Deteriorated performance and accuracy of both vessels’ radars
• Lack of experience by Gas Monarch’s third officer, compounded by lack of support from the master
• Inappropriate use of radar equipment by both vessels.

As a result of the accident, the managers of Gas Monarch have:
• Serviced and replaced magnetrons in both radars
• Implemented bridge team refresher training
• Reviewed and intensified its fleet audit procedures
• Recommended to her owners the replacement of electronic radar plotting aids with Automatic Radar Plotting Aids (ARPA)
• Accelerated S-VDR installation throughout its fleet.

As a result of the accident, Whispa’s owner has:
• Installed AIS “B” to improve detection by ships monitoring the system
• Installed a GMDSS DSC VHF radio
• Installed additional bilge pumps and bilge warning alarms.

In addition, the Oil Companies International Marine Forum (OCIMF) has:
• Added a Radar Performance Monitor guidance note to its Vessel Inspection Questionnaires
• Proposed amendments to its Tanker Management Self Assessment tool to reflect that all vessels should be fitted with ARPA as best practice.

Recommendations have been made to the Maritime and Coastguard Agency (MCA) and Comité International Radio-Maritime1 (CIRM) regarding small commercial vessel training requirements and radar training.

Enclose Space Entry – Complacency Cannot Be Allowed To Grow

December 7, 2007

Commenting on the recent meeting of the Maritime Accident Investigators International Forum in Beijing, Stephen Meyer, Chief Inspector of Marine Accidents for the UK’s MAIB writes in the latest Safety Digest, released this month,

“Please read these cases and then consider, if accident investigators from around the world all see these same issues time and again in accidents, how confident are you that you/your ship/your company are getting them right?

The other key concern we all shared was the apparent growth in the number of accidents involving entry into enclosed/confined spaces. Although there are no examples in this Safety Digest, MAIB is currently dealing with three such cases, two of them fatal, and many other countries at MAIIF reported similar. Please look again at your systems and re-brief your crews on the importance of correct ventilation and entry procedures. This is a critical area, where complacency cannot be allowed to grow.”

Enclosed space entry accidents are a hot button for MAC. They’re covered specifically in two episodes (The Case Of The Silent Assassin and the Case Of The Electric Assassin – due for broadcast 7th December) as well as the related Case Of The Lethal Lampshade – all available on the podcasts page.

Sadly, such cases often involve multiple casualties: the seafarer who was first effected followed by the would-be rescuer/s.

Of the incidents we’ve looked at to date one theme seems to be consistent: ship’s officers who think they’re smarter than the people who wrote the enclosed space safe entry procedures and set poor safety standards that they pass on those those under their command. Poor monitoring of safety procedures by the ship’s management and an almost total lack of competency assessment compound the problem.

Be pro-active. Always assume an enclosed space is dangerous, because it is, know the rules about safe entry and stick to them.

MAIB Mulls Sleepy Single Watchkeeper Aground On Sanda

November 29, 2007

The UK’s Maritime Accident Investigation Branch has issued its preliminary report on the grounding of the 1,409 gross tonnes general cargo ship Fingal on 7th September 2007. Needless to say the words “fallen asleep” and “on watch alone” occur in the same paragraph.

We’ve commented before on fatigue and singlewatchkeeping in The Case Of The Cozy Captain (Podcast here, transcript here).

The MAIB Preliminary report says:

“The general cargo ship Fingal was carrying a cargo of timber, when she grounded on Sanda Island, south of the Mull of Kintyre, whilst on passage from Campbeltown to Londonderry. There were calm conditions and good visibility. The master had been on watch alone and had fallen asleep after making a course alteration, some 20 minutes before the grounding. The grounding occurred close to high tide and the vessel developed a list of about 14 degrees to port as the tide fell. Four of the crew were evacuated by lifeboat, as a safety precaution. No injuries or pollution occurred at the time of the grounding.

The crew returned the following morning when the vessel was refloated with tug assistance and proceeded to Troon, where a diver’s examination revealed bottom damage to the forward part of the vessel. Whilst alongside in Troon a minor overboard discharge of gas oil occurred during ballasting operations, resulting from a split between a gas oil bunker tank and an adjacent ballast tank, caused by the grounding.”

Action taken:

The Preliminary Examination revealed a number of safety issues including: manning levels; hours of work and rest; bridge lookout and audit of procedures. After reviewing the actions put in place by the vessel’s managers, following the accident, the Deputy Chief Inspector considered no further recommendations were necessary.

Enclosed Space – Two Lucky People – The MAIB PE For Panguric II

November 20, 2007

Panurgic II

Category Merchant
Vessel name Panurgic II
Manager: Privately owned
Type: Hopper/Dredger
Built: 1950
Construction: Steel
Length overall: 34.74m
Gross tonnage: 139.9
Date & Time 14 October 2007, 1420 (UTC+1)
Location of incident: Flixborough Wharf, River Trent
Incident Type: Accident to person
Persons onboard: 3 crew
Injuries/fatalities: 2 crew injured
Damage/pollution: Vessel holed prior to accident – no pollution


On 14 October 2007 the hopper/dredger Panurgic II was dredging at Flixborough Wharf on the River Trent, when water was observed entering her accommodation space.

The skipper started the bilge pump for that space and manoeuvred the vessel onto a mud bank at the end of the berth to ensure she was safe. The crew then placed a portable, petrol driven, pump into the accommodation space, which was located below the main deck of the vessel.

With both pumps coping with the ingress of water, the skipper manoeuvred the vessel off the mud bank and positioned her alongside the wharf. He then left the vessel to purchase repair materials from a nearby store. Two crew members remained on board to oversee the continuing pumping operation.

While the skipper was ashore, the vessel took the bottom and trimmed by the head as the tide ebbed. This resulted in water flowing forward from the accommodation space into an adjacent confined space.

At this point the pumps in the accommodation space lost suction and the two crew members decided to move the portable, petrol driven, pump into the adjacent confined space. They attempted to gain suction with the pump positioned on deck, but this proved unsuccessful, so they lowered the pump into the space and then entered the compartment to place the suction hose in the water. This proved successful and with the pump working well both men left the space.

Some time later the pump lost suction and one of the crew members went into the space to investigate. His colleague then joined him in the space and together they managed to regain suction on the pump.

However, the first crewman to enter the space then reported feeling dizzy and was making for the ladder when he collapsed and lost consciousness. The second man then stopped the pump and left the space to get a rope to pull his colleague out.

Fortunately, the skipper and another man returned to the vessel at this time and were able to quickly extract the unconscious crew member from the space. They applied first aid and summoned an ambulance. The crew member regained consciousness as the ambulance arrived.

Both crew members were taken to hospital. They were found to be suffering the effects of carbon monoxide poisoning and spent some time in hospital before recovering fully.

A hole in the vessel’s bottom was eventually located and plugged. The vessel then proceeded to dry dock for permanent repairs.

Action taken:

The Chief Inspector of Marine Accidents has written to the owner of Panurgic II commending him on the actions he took to ensure the vessel’s safety after the hull was breached and in giving prompt first aid to the injured crewman. The Chief Inspector also stressed the importance of undertaking risk assessments for on board operations to help in ensuring that they are conducted in a safe manner, referring to the operational guidance contained in the Code of Safe Working Practices for Merchant Seamen.

The owner has scrapped the petrol driven pump and replaced it with a diesel pump capable of obtaining suction from the deck.