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VERY SERIOUS MARINE CASUALTY REPORT NO 2/2013 January 2013

Report on the investigation of

the capsize and foundering of the fishing vessel

Heather Anne (FY 126)

resulting in the loss of one crewman

Gerrans Bay, Cornwall

on 20 December 2011

Extract from

The United Kingdom Merchant Shipping

(Accident Reporting and Investigation)

Regulations 2012 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident

Reporting and Investigation) Regulations 2012 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.”

NOTE

This report is not written with litigation in mind and, pursuant to Regulation 14(14) of the

Merchant Shipping (Accident Reporting and Investigation) Regulations 2012, shall be

inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to

attribute or apportion liability or blame.

© Crown copyright, 2013You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned.

All MAIB publications can be found on our website: www.maib.gov.uk

For all enquiries:Marine Accident Investigation BranchMountbatten HouseGrosvenor SquareSouthampton Email: maib@dft.gsi.gov.ukUnited Kingdom Telephone: +44 (0) 23 8039 5500SO15 2JU Fax: +44 (0) 23 8023 2459

CONTENTS

Page

GLOSSARY OF ABBREVIATIONS AND ACRONYMS

SYNOPSIS 1

SECTION 1 - FACTUAL INFORMATION 2

1.1 Particulars of Heather Anne and accident 21.2 Narrative 3

1.2.1 Thefishingtrip 31.2.2 Thecapsize 61.2.3 The rescue 7

1.3 Environment 81.4 Crew 8

1.4.1 Theskipper 81.4.2 The deceased 8

1.5 Vessel 81.5.1 Design 81.5.2 Construction 91.5.3 Modifications 111.5.4 Bilgeequipment 13

1.6 MCAinspections 141.6.1 Rolltest 141.6.2 Exemptionfromstabilityrequirements 141.6.3 Records 15

1.7 Vesseloperation 151.8 Safetyequipment 181.9 Underwatersurveys 18

1.9.1 MAIB 181.9.2 Othersurveys 19

1.10 Wreckrecovery 191.11 Post-recoveryinspection 221.12 ExaminationoftheHRU 221.13 Stabilityassessment 241.14 Stabilityregulations 241.15 MAIBfishingvesselsafetystudy 25

1.15.1 General 251.15.2 Fishingvessellosses 251.15.3 ReviewofMAIBsafetyrecommendations 251.15.4 Studyrecommendations 26

1.16 Researchprojects 271.17 Stabilityguidance 27

1.17.1 Fishingvesselsoflessthan15mLOA 271.17.2 Freeboard 281.17.3 Fishermen’sSafetyGuide 29

1.18 Construction standards 291.19 Stabilitytraining 29

1.20 MarineManagementOrganisation 301.20.1 Background 301.20.2 EFFgrants 301.20.3 Ring-netting 30

1.21 Lifejackets 311.22 Similar recent accidents 32

SECTION 2 - ANALYSIS 33

2.1 Aim 332.2 Vesselstability 332.3 Impactofmodifications 34

2.3.1 Weightgrowth 342.3.2 Free surface effect 342.3.3 Catchsize 34

2.4 Reliabilityofthestabilityassessmentsundertaken 342.4.1 Rolltest 342.4.2 Dynamicassessment 35

2.5 Methodsofassessingsmallfishingvesselstability 352.5.1 Maximumsafeload 352.5.2 Fullstabilityassessment 362.5.3 The Small Commercial Vessel Code Standard and the Small PassengerVesselHeelTest 362.5.4 TheRollPeriodApproximationTest 362.5.5 TheWolfsonGuidanceMethod 362.5.6 Summary 38

2.6 Fishingvesselstabilitystandards 402.7 Fundingconditions 402.8 Survivability 41

2.8.1 Lifejackets 412.8.2 Liferaft 422.8.3 MOB Guardian 42

SECTION 3 - CONCLUSIONS 43

3.1 Safetyissuesdirectlycontributingtotheaccidentwhichhaveresultedin recommendations 433.2 Othersafetyissuesidentifiedduringtheinvestigationalsoleadingto recommendations 433.3 Safetyissuesidentifiedduringtheinvestigationwhichhavebeenaddressed or have not resulted in recommendations 44

SECTION 4 - RECOMMENDATIONS 45

FIGURES

Figure 1 - ExtractofchartBA1267

Figure 2 - ExtractofchartBA154

Figure 3 - Diagramshowingtheringnetoperation

Figure 4 - PhotographofAquarius of Cawsand in 1972 (later re-named Heather Anne)

Figure 5 - Generalarrangement

Figure 6 - Fishroom hatch

Figure 7 - PVCtarpaulin

Figure 8 - Fishroomdischargeoverboard–starboardside

Figures 9 and 10 - Heather AnnereturningtoMevagisseyon19January2011 carrying10.1tonnesofCornishsardines

Figure 11 - Heather Anne’scatch19January2011

Figure 12 - Positionofenginethrottle

Figure 13 - Heather Annebeingrefloated

Figure 14 - Heather Annebeingliftedoutofthewater

Figure 15 - Heather Anne ashore

Figure 16 - Heather Annedamagetoplanking

Figure 17 - RecoveredHRU

Figure 18 - Broken ‘weak link’

Figure 19 - Stabilitynoticeandguidancemark

Figure 20 - Heather Anne withfreeboardguidancemark

TABLES

Table 1 - Heather Anne –landingsofCornishsardinesin2011

Table 2 - Summaryofstabilityassessmentmethods–Heather Anne

ANNEXES

Annex A - Inspectionreport(withaddendum)

Annex B - StabilityAssessment(withselectedappendices)

Annex C - MGN427(F)–StabilityGuidanceforFishingVesselsofunder 15mOverallLength

GLOSSARY OF ABBREVIATIONS AND ACRONYMS

ALB - Allweatherlifeboat

BA - BritishAdmiralty

CIFCA - CornishInshoreFisheriesandConservationAuthority

CPR - Cardiopulmonaryresuscitation

DECC - DepartmentofEnergyandClimateChange

DfT - DepartmentforTransport

EFF - EuropeanFisheriesFund

EPIRB - EmergencyPositionIndicatingRadioBeacon

FISG - FishingIndustrySafetyGroup

GM - MetacentricHeight

GPS - Globalpositioningsystem

GZ - Therightingleverthroughwhichtheforceofbuoyancyacts

HRU - HydrostaticReleaseUnit

ILB - Inshorelifeboat

kg - kilogramme

kW - kilowatt

(L) - Registeredlength

LOA - Lengthoverall

MCA - MaritimeandCoastguardAgency

MFA - MarineandFisheriesAgency

MGN - Marine Guidance Note

MMO - MarineManagementOrganisation

MSN - MerchantShippingNotice

PFD - Personalflotationdevice

PVC - Polyvinylchloride

RN - RoyalNavy

RNAS - RoyalNavalAirStation

RNLI - RoyalNationalLifeboatInstitution

ROV - RemotelyOperatedVehicle

SAR - SearchandRescue

Seafish - SeaFishIndustryAuthority

SIB - StabilityInformationBook

TEZ - TemporaryExclusionZone

UTC - Universal Time, Co-ordinated

VHF - VeryHighFrequency

1975Rules - TheFishingVessels(SafetyProvisions)Rules1975

Times: AlltimesusedinthisreportareUTCunlessotherwisestated

1

SYNOPSIS

Atabout2200on20December2011,theUKregisteredfishingvesselHeather AnnecapsizedandfounderedinGerransBay,Cornwall.Theskipperandhiscrewmanweresoonrecoveredfromthewaterbyanearbyfishingvessel.Neithertheskippernorthecrewmanwaswearingalifejacket;thecrewmanhaddrowned.Therewasnosignificantpollution.

On23February2012,Heather Anne was raised andtowedtoFalmouthforinspection.Astabilityassessmentindicatedthatthevesselhadbeenoperatingwithalowreserveofstability.Heather Anne hadbeensignificantlymodifiedsinceherbuildin1971.Asaconsequence,her displacementhadincreasedbyover50%and,withacatchofanestimated10.5

tonnesonboardatthetimeofcapsize,herfreeboardwasreducedtoonlyafewcentimetres.

AlthoughHeather Annesuccessfullypassedaroll-testfollowingherconversiontoring-nettingin2010,theresultsofthistypeoftestdonotprovideafullassessmentofavessel’sstabilityandcanthereforebemisleading.Currentguidanceonthemethodsthatcanbeusedtoassessthestabilityofsmallfishingvesselsisnotsufficienttoprovidefishermenwiththeinformationneededtounderstandthelimitationsofthevariousoptionsavailable.

Likeotherfishingvesselsof<12mregisteredlength,Heather Annewasnotrequiredtomeetanystatutorystabilitycriteria.However,inresponsetoanumberofprevioussimilar accidents that have resulted in recommendations from the Marine Accident InvestigationBranch,theMaritimeandCoastguardAgencyintendstointroducelegislationby2016whichwillrequiresmallfishingvesselsofunder12mregisteredlengthtocomplywithsimilarstabilitycriteriatothatwhichalreadyexistsforsmallcommercialvessels.Thelegislationwillapplytonewvesselsonly.Newandexistingvesselsof12mandoverwillhavetocomplywiththestabilityrequirementscurrentlyapplicabletofishingvesselsof15mandover.

RecommendationshavebeenmadetotheMaritimeandCoastguardAgency,theMarineManagementOrganisationandtheCornishFishProducersOrganisationwhichseektoimprovethestabilityofsmallfishingvesselsthroughthetimelyprovisionofstabilitycriteriaandthepromulgationofbetterguidanceonthemethodsthatcanbeusedtoassessvesselstabilityonallsmallfishingvessels.

AfurtherrecommendationhasbeenmadetotheMaritimeandCoastguardAgencywhichisdesignedtoprovidesupportforongoingeffortswhichseektoensurefishermenwearpersonalflotationdeviceswhenworkingontheopendeck.ArecommendationhasalsobeenmadetotheownerofHeather Anne which is intendedtoensurethesafeoperationofanyvesselthathemayowninthefuture.

2

SECTION 1- FACTUAL INFORMATION

1.1 PARTICULARS OF HeatHer anne AND ACCIDENTSHIP PARTICULARS

Vessel’s name HeatherAnneFlag UKClassificationsociety NotapplicableFishingnumbers FY126Type Ring-netterRegisteredowner PrivateOwnershipManager(s) NotapplicableConstruction WoodLengthoverall 11.05mRegisteredlength 10.0mGrosstonnage 11.67Minimumsafemanning NotapplicableAuthorisedcargo Fish

VOYAGE PARTICULARS

Portofdeparture Mevagissey,CornwallPort of arrival Mevagissey,CornwallTypeofvoyage FishingCargoinformation Cornish sardinesManning 2

MARINE CASUALTY INFORMATION

Date and time 20December2011atabout2200Typeofmarinecasualtyorincident VerySeriousMarineCasualtyLocationofincident OffNareHead,GerransBay,CornwallPlaceonboard NotapplicableInjuries/fatalities OnefatalityDamage/environmentalimpact Vesselfoundered.NosignificantpollutionShipoperation OnpassageVoyagesegment Mid-waterExternal&internalenvironment Wind:south-westForce6;

SeaState:Slight(1m)Weatherconditions:RainVisibility:ModerateSeawatertemperature:10°CAirtemperature:10°CDarkness

Personsonboard 2

3

1.2 NARRATIVE

1.2.1 Thefishingtrip

Atabout1520on20December2011,thering-netter1 Heather Anne sailed from Mevagissey,Cornwall.Onboardwereherskipperandtwodeckhands,oneofwhomwastheskipper’syoungestsonwhowas16yearsold.TheotherdeckhandwasIanThomas.

Heather AnnesailedtoGerransBay,about14milessouth-westofMevagissey(Figure 1), incompanywithLeonora2. Atabout1700,asdarknessapproached,Heather Anne’sskipperdetected ashoalofCornishsardines(pilchards)bysonarapproximately5cablesofftheshore(Figure 2).Tocatchthefish,adhanbuoywasdroppedandtheringnetwasshotastheskipperturnedthevesseltostarboardandencircledtheshoal.ThetwoendsofthenetwerethendrawntogetherandLeonora was secured to Heather Anne’sportside with 30m of towline.

Thebottomofthenetwasclosedbydrawingthepursewire.Thenetwasthenhauledclosertothevessel’sstarboardsidewhileLeonorapulledonHeather Anne’s portsidetocounterthepullofthenethauler(Figure 3).

Oncethenetwasalongside,Heather Anne’sdeckhandsstartedtoscoopthefishoutofthenetusingabrailer 3. Anestimated20tonnesoffishwereinsidethenet.Thefishwereputintothefishroom,andinto12orangefishbinsthatwerestackedondeck.Thefishroomwasfilleduntilthefishwereapproximately30cmbelowthefishroomdeckhead.

Within an hour, Heather Anne wasfullyloadedwithacatchestimatedbytheskippertobebetween8and9tonnes.Theequivalentofbetweentwoandthreebinsoffishwas then loaded on to Leonora.However, alargequantityoffishremainedinthenetsotheskippercalledLauren Kate,anotherMevagissey-basedring-netter,byVeryHighFrequency(VHF)radioandinformedherskipperthathehada“super catch” whichhewasabletoshare.Lauren Kate leftherfishinggroundsinSt.AustellBayandmadeforGerransBayincompanywithhertowboat,Venus. Meanwhile, an anchorwasdroppedfromHeather Anne’sportquarter tohelpkeepthevesselinposition.

Lauren Kate and Venus arrivedinGerransBayatabout2100.By2140,Lauren Kate’screwhadbrailedonboardbetween3and4tonnesoffishfromHeather Anne’s net, much of which was transferred to Venus. In the meantime, the son of Heather Anne’sskipperhadtransferredtoLeonora, which then started to head towardsMevagissey.Venus followed soon after.

1 Ring-nettingissimilartopurse-seiningandusesabottomweightedwallofnettoencircleadenseschoolofpelagicfish.Thetwoendsofthenetarebroughttogetherandthepursewireisdrawnintoclosethebottomofthenet.Thenetisthenhauled,bringingthefishtothesurfacealongsidethevessel.

2 Fishingvesselsthathavebeenconvertedtoring-netfishingusuallyuseasecondvesselasatowingvessel.Priortothenetbeinghauledin,thetowingvesselisattachedtothefishingvesselbyatowlineonthesideoppositetothenet.Thetowingvesselisthenusedtocounterthepullingeffectofthefishingvessel’snethaulerandsopreventtheringnetfrombeingoverrun.

3 Abrailerisahand-heldnetusedtotransferfishfromaseineorringnet.

4

Figu

re 1

:ExtractofchartBA1267

ReproducedfromAdm

iraltyChartBA1267bypermissionoftheControllerofH

MSOandtheUKHydrographicOffice

5

Figure 2:ExtractofchartBA154

ReproducedfromAdmiraltyChartBA154bypermissionoftheControllerofHMSOandtheUKHydrographicOffice

6

1.2.2 Thecapsize

When Heather Anne’snetwasemptyitwashauledonboardandstowed.Thevessel’sanchorropewaspassedacrosstoLauren Kate for her crew to recover the anchorusingawinch.

Heather Anne’sskippersetaheadingontheautopilottotakethevesselsouthofNareHeadtowardsMevagissey(Figures 1 and 2).Healsoadjustedthethrottlelevertoincreasethevessel’sspeedtoabout7knotsandsecuredtheleverwithapieceofropetopreventitfromvibratingoutofposition.

Heather Anne

Leonora

Dhan buoy

Ring net Purse wire

Figure 3:Diagramshowingtheringnetoperation

7

TheskipperremainedinthewheelhousewhileIanThomastidiedthedeckandfishinggearforward.Thevesselwasdeepinthewaterandtrimmedbythebow.Theskippernoticedthatshewassheeringexcessivelywiththeautopilotengaged,sohechangedtohand-steering.Largeamountsofhelmwerethenrequiredinordertokeepthevesselonherintendedcourse.

Thevesselwasrollinggentlyandtheequivalentofseveralbucketfulsofwatercameontothedeckthroughtheshutteredfreeingportsinthevessel’sbulwarks.Theskipperputthedecklightsonandopenedtheshutteronthefreeingportsitedoutside the wheelhouse door to allow the water on the deck to run over the side.

Soonafter,theskipperbecameconcernedatthewaythevesselwashandling.Hemovedthethrottleleverbackandslowedtheengine.However,duringarolltostarboard,Heather Annecontinuedtorolluntilcapsizingandcork-screwingunderthewater.TheskipperandIansoonsurfaced,buttheywerenotwearinglifejacketsandtheskipperhadtohelpIantostayafloat.

1.2.3 The rescue

As soon as Lauren Kate’s crew had recovered Heather Anne’s anchor, Lauren Kate alsostartedtoreturntoMevagissey.ThevesselwasaboutonequarterofamilebehindHeather Anne whenherskippernoticedHeather Anne’s white stern and deck lightsdisappear,andthevessel’sradartargetceasedtodisplayontheradarscreen.

Lauren Kate’sskipperimmediatelyincreasedspeed.AshisvesselnearedHeather Anne’slastknownposition,theskippersawaglowunderthewater.Hethensawand heard Heather Anne’sskipper,withIan,ontheseasurface.Life-ringswerethrowntowardsthemenand,assoonasthevesselwascloseenough,oneofLauren Kate’screwreachedoverthevessel’ssideandgrabbedIan.However,hewasunabletolifthimonboardduetothevessel’sfreeboard.

Lauren Kate’slandingderrickwasquicklymadereadyandwasusedtowinch,firstIan,andthenHeather Anne’sskipper onboard.Ianshowednosignsoflifesocardiopulmonaryresuscitation(CPR)wasstarted.At2210,Lauren Kate’sskipper broadcasta“Mayday”callviaVHFradioChannel16.The“Mayday”wasreceivedbyBrixhamCoastguard,whichtaskedtheFalmouthallweatherandinshorelifeboats(ALBandILB)andaRoyalNavy(RN)rescuehelicopter,R193,fromRoyalNavalAirStation(RNAS)Culdrosetoassist.

Atabout2245,IanwastransferredtotheILBandthentotheALB.HewasthenwinchedonboardR193andflowntoMalpasnearTrurowherehewasmetbyanambulanceandtakentotheRoyalCornwallHospital.Ianwasdeclareddeceasedashortwhilelater.Thesubsequentpostmortemexaminationconcludedthathehaddrowned.

On22December2011,theMaritimeandCoastguardagency(MCA)establishedaTemporaryExclusionZone(TEZ)coveringaradiusof200maroundthewreckposition(Figure 2).

8

1.3 ENVIRONMENT

Duringtheearlyeveningof20December2011,thewindinGerransBaywaswest-south-westbetweenBeaufortforce2and3,andtheseawascalm.Thewindincreasedduringtheeveningand,bythetimeoftheaccident,wassouth-westerlyforce6andtheseawas1mhigh.Theweatherwasovercastwithrain.Theairandseawatertemperatureswerebothabout10°C.

1.4 CREw

1.4.1 Theskipper

Heather Anne’sskipperwas42yearsoldandhadbeenafishermansinceleavingschoolin1985.TheskipperhadworkedwithIanThomasonboardthefishingvessel Trevosebetween1985and1995,andhadpurchasedHeather Anne from hisfatherin1995.HehadcompletedthefollowingmandatorySeaFishIndustryAuthority(Seafish)courses:

• First-aid:February1999,May2002andJuly2006;

• Fire-fighting:September2004;

• Seasurvival:November1984;and,

• Safetyawareness:April2002.

TheskipperhadalsoattendedaSeafishintermediatestabilityawarenesscourseinJuly2006(seeparagraph1.19)anda2-dayengineroomwatchkeepingcourseinMay2011.

1.4.2 The deceased

IanThomaswas50yearsoldandhadworkedasafishermaninthesouthwestofEnglandforabout35years,including4yearsasaskipper.HehadworkedasadeckhandonboardHeather Anneona‘share’basis4 since 2002.

IanhadcompletedallofthemandatorySeafishtrainingcourses,exceptseasurvival.HehadalsoattendedtheSeafishintermediatestabilityawarenesscoursewith Heather Anne’sskipperinJuly2006.Ianwasnotastrongswimmer.

1.5 VESSEL

1.5.1 Design

Heather Annewasoriginallydesignedasanetterand,althoughnotspecified,herloadingcapacitywasexpectedtobeabout5tonnes;4tonnesstowedinthefishroomand1tonnestowedonthedeck.Shewasbuiltin1971byGPercyMitchell&Sons,inPortMellon,CornwallandwasoriginallynamedAquarius of Cawsand (Figure 4).

4 Asharefishermanissomeonewhogetsallorpartoftheirpaybysharingtheprofitsorgrossearningsofthefishingboat.

9

1.5.2 Construction

Heather Annewasconstructedofoakframesandlarchhullanddeckplankingattachedwithironfastenings.Herlengthoverall(LOA)was11.05m,andherregisteredlength(L)was10m.AgeneralarrangementofthevesselisshownatFigure 5.

Thevessel’sinternalspaces(fishroom,forepeak,engineroom,andaccommodation) wereseparatedbynon-watertightbulkheads.Accesstothefishroomwasviaahatchontheforedeck(Figure 6) coveredby a reinforced fibreglasscoatedplywoodcoverwhichwassecuredbytwohinged‘dog’clips.Accesstotheaccommodationandengineroomwasviathefibreglasswheelhouse.Aslidingdoorwasfittedonthestarboardsideofthewheelhousewhichledtothedeck.Anetstowageareawassitedaftofthewheelhouse.

Fourfreeingportsweresitedonthemaindeck,twooneachside.Thefreeingportscouldbeclosedusingwoodenverticalshutters.Thefreeingportswerenotwatertightwhentheshutterswereclosed.

ThevesselwasfittedwithaLeylandThornycroft164kWdieselengine,whichhadbeeninsitusincebuild.

Figure 4:PhotographofAquarius of Cawsand in 1972 (later re-named Heather Anne)

10

Figure 5:Generalarrangement

Figure 6: Fishroom hatch

11

1.5.3 Modifications

Sincebuild,Heather Annehadchangedownershipseveraltimesandhadbeenextensivelymodified.Since1995,themodificationshadincluded:

• ThereplacementofthesteelA-framewithanaluminiumwhalebackandmast.

• Thereplacementoftheaftwoodenmastwithanaluminiummast.

• Thefittingofarefrigerationplantcomprisingamainengine-drivencompressorandacondenserintheengineroom,andrefrigerantcoolingpipesinthefishroomdeckhead.

• Thereplacementoftwofueltankswithfourfueltanks(twoportandtwostarboard)providinganequivalenttotalcapacityofabout2000litres.Thetankswerecross-connectedandthefillingpointswereunderneathremovableplatesonthedeck.

• In 2009 and 2010, Heather Annewasoperatedwithapolyvinylchloride(PVC)tarpaulinwithweldedseams(Figure 7) fittedinsidethefishroomtoformacentral‘tank’.Thetarpaulinwasheldinplacebylongitudinalpoundboardsonbothsides.The‘tarpaulintank’,whichhadacapacityofabout3.4m³,wasfittedtosimplifythestowageandremovalofcatchwithinthefishholdwhenring-netting.The‘tank’alsohelpedtopreventthebilgepipeworkandpumpsbecomingblockedbytoughbutflexiblefishscalesthatresultedfromthebrailingprocess.

Figure 7:PVCtarpaulin

12

InApril2010,Heather Anne’sskipperappliedfor,andobtained,aEuropeanFisheriesFund(EFF)granttosupportachangeinfishingmethodtoring-netting5. TheEFFgrantwasapprovedon16July2010andwasmanagedanddisbursedbytheMarineManagementOrganisation(MMO).

During2010,theconversionworkwasundertakenbyCTomsandSonLtd,inPolruan,Cornwall.Thestructuralworkincludedthefittingof:

• Analuminiumringnetderrickfittedontheforward‘A’frame

• Amainlandingderrick,completewithhydrauliclandingwinchandcontrols

• Analuminiumgantryaftofthewheelhousetotakethenewmizzenmastandsail, and a net hauler

• Analuminiumsolidbulwarkandassociatedstanchionsontopofthebulwarkrail,includingacut-outsectionandheavypipeforshootingthenet.

Theringnetgear,whichweighedapproximately1.3tonneswhendry,wassuppliedbyspecialistfishingequipmentmanufacturersandincluded:

• A208mringnetwithamaximumfishingdepthof46metresmadefromblacknylon20mmfullmeshnetting.

• 260mofleadgroundline(weighing1kgpermetre)

• Headlinefloats–fourboxesof144floatpieces(total576)

• Mainheadline–220mof8mmrope

• Floatline–220mof12mmrope

• Mainsoleline–260mof8mmrope

• Ringnetdrawingrope(pursewire)–220mof14mmsteel-corerope.

Duringtheconversion,severalplanksontheturnofthebilgeinwayofthefishroomonthestarboardside,whichhadbeencoveredbyaprotectiverubbersheet,werediscoveredtobesufferingfromwoodworm.Theseplankswerereplaced,andthenewplanksweresecuredwithgalvanisednailswhichhadanexpectedlifespanof15years.

InNovember2011,Heather Anne’sskipperreplacedthetarpaulintankinthefishroomwithanotherPVCtarpaulinwithacapacityof5.02m3.Asthereplacementtankextendedtotheportandstarboardsidesofthefishroom,itsfittingrequiredtheremovalofthepoundboards.Thereplacedtarpaulinwasmovedtotheforepeakandwasusedasaballasttank.

5 Inthesouth-westofEngland,Newlyn,MevagisseyandLooearecommonlyrecognisedasthemainring-nettingports.ThesuccessoftheNewlynring-netters,includingtheintroductionofpurpose-builtvessels,promptedotherfishermenalongthecoasttomovetothismethodoffishing.FourMevagissey-basedfishingvesselshavebeenconvertedtoring-nettingwiththeaidofanEFFgrant.

13

1.5.4 Bilgeequipment

Three4000litre/hourelectricpumps,twoofwhichoperatedintandem,werefittedbelowthedeckinthefishroom.Thepumpsoperatingintandemdischargedthrougha75mmdiameterstrengthenedrubberhose,thatpassedthroughthedeckviaasteeldeckfittingandoverboardthroughthestarboardbulwark(Figure 8) via a brassnon-returnvalve.

Figu

re 8

:Fishroomdischargeoverboard-starboardside

Discharge

Non

-ret

urn

valv

e

14

Thethirdpumpdischargedoverboardontheportsidebelowmaindecklevelviaa30mmdiameterrubberhose.Thedischargehoseontheportsidewasnotfittedwitha non-return valve.

Anelectricandahand-operatedbilgepumpwerefittedintheengineroom.Abilgealarmfloatswitchwasfittedonaframeattheforwardendoftheengineroomabout30cmabovethekeel.Thisalarmwastestedonanoccasionalbasis.

Thebilgealarmpanelwassitedinthewheelhouse.Whenactivateditemittedaloudaudiblealarmwhichcouldbemutedbyatoggleswitch.

1.6 MCA INSPECTIONS

1.6.1 Rolltest

InJuly2010,theMMOadvisedtheMCAoftheEFFgrantmadeinrespecttothe conversion of Heather Anne. TheMCAdidnotobjecttotheconversionbutrequestedthataconditionofthegrantshouldbethatthevesselwasinspectedoncompletionofthework.

TheMCAinspectedHeather Anneon29September2010.Theattendingsurveyorraisedconcernsovertheextentoftheworkundertakenandthepotentialeffectthismighthaveonthevessel’sstability.Asaresult,Heather Anne’s skipperwasinformedthatthevessel’sstabilityandtheheightsofthestarboardbulwarkandthefishroomhatchcoamingwererequiredtobeassessedbeforethevesselcouldresumefishing.

On9November2010,anMCAsurveyorconductedaroll-testonHeather Anne inMevagisseyharbourinherdepartport6 condition. Three rolls were conducted, comprisingfiveoscillationseach,givingameanrollperiodofjustover3.8seconds.

Themetacentricheight7 (GM) for Heather Anneindicatedbytherollperiodwas0.761m,whichwas0.071mgreaterthanthecalculatedminimumGMrequiredof0.69m.TheattendingsurveyorconsideredthecalculatedGMtobeacceptable,butheadvisedtheskipperthatheshouldnotcarrytoomuchfishondeck.

1.6.2 Exemptionfromstabilityrequirements

OncompletionofHeather Anne’srolltestinNovember2010,herskipperwasprovidedwithwrittenguidance,whichwasattachedtotherolltestresults.Theguidanceconfirmedthevessel’sexemptionfromtheFishingVessel(SafetyProvisions)Rules1975,(1975Rules)andalsoincluded:

It is important to appreciate that by virtue of meeting the criterion in only one loading condition does not ensure immunity against capsizing or absolve the skipper from his responsibilities. It is assumed that adequate stability will be maintained throughout the whole voyage cycle. This will only be valid if best practices with regard to operation of the vessel, use of consumables and stowage of catch are followed.

6 DepartPortcondition:fuelandwatertanksfull;netsandwiresonboard;1.5tonnesofice;100kgoffishboxes.7 Metacentricheight(GM)isameasureoftheinitialstaticstabilityofavessel.AlargerGMindicatesagreaterresistancetocapsize,andashorterrollperiod.

15

In order to ensure that adequate stability is maintained throughout the voyage cycle you are advised that:

Fish landed on deck should be stowed below as soon as possible. Fish hold and deck area should be suitably divided by boards to prevent shifting of fish/ice.

Cargoes of bulk fish that can move freely MUST NOT BE CARRIED.

Good seamanship should be exercised having regard to the influence on the vessel’s stability of beam winds, following seas and trapped water on deck (Freeing ports should be closed only as necessary during fishing).

1.6.3 Records

Fishingvessels<15mLOAarenotsubjecttoMCAsurveyandtheMCAdoesnotholdsurveyrecordsforthemunlessavesselhasbeensubjecttoanincidentrequiringitsintervention.Consequently,theMCAdidnotmaintainasurveyfileon Heather Anneuntilitsinspectionofthevesselfollowingherconversiontoring-nettingin2010.

1.7 VESSEL OPERATION

Between 1995 and 2010, Heather Anne’sskipper hadprimarilyfishedusingwrecknettinganddriftnettechniquestocatchpressurestocks8upto60milesfromland.FollowingHeather Anne’s conversiontoring-nettingin2010,theskipperalsotargetednon-pressurestocks,suchasCornishsardines,alongthecoast.Heather Anne’sskipperhadnopreviousexperienceofring-netting,andhadsoughtandobtainedadviceontheuseofthistechniquefromacrewmanworkingonboardaNewlyn-basedring-netter.DetailsofthequantitiesoffishlandedbyHeather Anne in 2011 are shown in Table 1.

Date No.ofbinslanded

Landed weight(kg)

Average kg/bin

5/1/2011 19 7453 394

9/1/2011 2 750 375

12/1/2011 19 7500 405

17/1/2011 25 10075 406

19/1/2011 25 10100 411

21/11/2011 5 1770 370

23/11/2011 19 7220 368

2/12/2011 23 8106 352

6/12/2011 22 8505 400

7/12/2011 n/a 6638 n/a

11/12/2011 n/a 1580 n/a

19/12/2011 17 n/a n/a

Table 1: Heather Anne –LandingsofCornishsardinesin2011

8 Somefishspeciesinparticularareas(stocks),forwhichtheUKshareofquotaisconsideredinsufficienttoallowunrestrictedfishing,aredesignatedas‘pressurestocks’.Otherstockssubjecttoquotaandlicensingaredesignatedas‘non-pressurestocks’.Allfishingvessels>10mrequirealicencetofishfor‘pressure’and‘non-pressure’stocks.

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Figures, 9, 10 and 11 show Heather Anne returningtoMevagisseyfromafishingtripon19January2011with10.1tonnesofCornishsardinesonboard.Thevesselcarried12bins(7binsonthedeckwith4binsontopand1binonthefishhatch)(Figure 11).Eachbinwas1.15mwide,0.96mdeepand0.6mhigh,andcouldholdapproximately450kgoffish.Several,smallerbluebinswerealsocarried.Itwasnotuncommon for Heather Anne’sfreeboardtoreducebybetween70cmand80cmwhencarryingagoodcatch.

Whenthevesselwasun-ladenitwasherskipper’susualpracticetofillthetarpaulintankintheforepeakwithabout0.5tonneofwatertotrimthevesselbyherheadandimprovethevisibilityahead.Thetankwasdrainedwhenfishingcommencedbyloweringonecornerandallowingthewatertodrainintothefishroom.Thewaterwasthenpumpedoverboard.

Whenwreckordrift-netting,thevesselhadalsocarriedintheregionof10tonnesoffishonboard,splitbetweenthefishroomandinbinsondeck.However,whenwreckordriftnetting,thetarpaulintankwasremovedfromthefishroomandcentrelinepoundboardswerere-fitted.

Copyrightreserved.

Noreproductionpermissable.

Figure 9: Heather AnnereturningtoMevagisseyon19January2011,carrying10.1tonnes of Cornish sardines

[Publicationpursuanttosection259(2)oftheMerchantShippingAct1995-Permissionwitheldbycopyrightholder]

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Figure 10: Heather AnnereturningtoMevagisseyon19January2011,carrying10.1tonnesof Cornish sardines

[Publicationpursuanttosection259(2)oftheMerchantShippingAct1995-Permissionwitheldbycopyrightholder]

Copyrightreserved.

Noreproductionpermissable.

Figure 11: Heather Anne’scatch19January2011[Publicationpursuanttosection259(2)oftheMerchantShippingAct1995-Permissionwitheldbycopyrightholder]

Copyrightreserved.

Noreproductionpermissable.

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1.8 SAFETY EqUIPMENT

ThesafetyequipmentcarriedonboardHeather Anne included:

• Onefour-manMLLifeguard‘Forties’canister-typeinflatableliferaftstowedonawoodenframeonthewheelhouseroof.Theliferaft,whichwasownedbytheskipper,wasmanufacturedinSeptember2003andhadaserviceintervalof3years.IthadbeeninspectedandservicedbyauthorisedserviceagentsinMarch2007andon9August2010.Thelastservicetestandsurveyreportindicatedtheliferaftwasingoodcondition.Followingtheservice,theliferafthadbeenconnectedtothewheelhouseroofbyIanThomasusingaHammarH20Rhydrostaticreleaseunit(HRU).Thelengthoftheliferaft’spainterwas7m.

• Sevenauto-inflate175kNlifejackets,andfoursolidbuoyancylifejackets.NeithertheskippernorhiscrewworelifejacketswhenworkingonboardHeather Anne.

• ARoyalNationalLifeboatInstitution(RNLI)‘MOBGuardian’manoverboardalertsystemwithfourpersonalweardevices9.ThesystemwasfittedonboardHeather Anne severalweeksbeforetheaccidenttoreplaceanemergencypositionindicatorradiobeacon(EPIRB),thebatteriesofwhichwereoutofdate.TheMOBGuardianwasintendedtobeusedwhenthevesselwasoperatedsingle-handed.Ithadonlybeenusedbytheskipper’syoungestson.

1.9 UNDERwATER SURVEYS

1.9.1 MAIB

On11January2012,anunderwaterinspectionofHeather Anne was conducted on behalfoftheMAIBtoconfirmherlocationandtoassesshercondition.Thewreckwasfoundtoberestingonherkeelonamixofsandandshaleatadepthof24m.Nostructuraldamagewasdetected.

InspectionofHeather Anneidentified:

• Thewreckwasonanorth-eastheadingandwaslistingtostarboardatanangleofabout20°

• Therudderwashard-overtostarboard

• Thethrottlepositionindicatedthattheenginehadbeenontick-overatthetime of the accident (Figure 12)

• The liferaft was not on the wheelhouse roof

• Thenon-returnvalveinthefishroombilgesystemwhichdischargedoverboardthroughthevessel’sstarboardsidewasjammedopen

9 Thepersonaldevicesmaintainradiocontactwithanonboardbaseunituntiltheradiosignalisbrokenwhenthewearerfallsinthewater.Thebreakingofradiocontacttriggersthetransmissionofanemergencysignalwhichisintendedtoalertthesearchandrescueservices.TheonboardbasestationalsotransmitshourlymessagesviasatellitetotheRNLIoperationcentre.AmissedreportwillautomaticallybedetectedbythesystemandtheRNLIwillattempttocontactthevessel.Ifcontactcannotbemadeandthevesselisassessedtobeatsea,thevessel’slastknownpositionispassedtothecoastguardtoenableasearchandrescueoperationtocommence.

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• Thefishroomhatchwasmissingandasubstantialquantityoffishremainedwithin the hold.

AfurtherunderwaterinspectionwasconductedonbehalfoftheMAIBon15February2012,whichidentifiedthattheshutteronthestarboardaftfreeingportwasclosedandthattheliferaftpainterwasnotonthewheelhouseroof.

1.9.2 Othersurveys

On11January2012,theDevonandCornwallPolicedivingteamrecoveredthevessel’schartplotter,theglobalpositioningsystem(GPS)receiverandthefishfinderfromthewheelhouse.TheHRUwasalsoremovedfromthewheelhouseroof.

Atthesametimeasthepolicediveteamwereonsite,theCornishInshoreFisheriesandConservationAuthority(CIFCA)10conductedasurveyofthewreckusingaremotelyoperatedvehicle(ROV).TheROVconfirmedtheconditionofthehullandalsoshowedthatthevessel’sbowwasgentlybumpingupanddownontheseabedinthebenignseaconditions.TheseabedintheimmediatevicinityofthewreckwassearchedbutHeather Anne’s liferaft was not found.

1.10 wRECk RECOVERY

On23February2012,Heather Anne wasliftedtothesurfaceusingairbags(Figure 13).Thevesselwasthentowedtoshallowerwatertoenablethehullconditiontobeverified.Thefollowingday,Heather Anne wastowedtoQueensJetty,A&PFalmouth,whereliftingstropswereplacedunderthehull.

10 CIFCAwasestablishedon1April2011asaresultoftheMarineandCoastalAccessAct2009,andisresponsibleformarinefisheriesandenvironmentalmanagementoftheCornishinshorewatersandestuaries.

Figure 12:Positionofenginethrottle

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Thevesselwasthenliftedoutofthewaterbyashorecrane(Figure 14). Water entrappedwithinthehullwasthenpumpedoutbeforethevesselwasloweredandchocked (Figure 15).

Figure 13: Heather Annebeingrefloated

NareHead

Figure 14: Heather Annebeingliftedoutofthewater

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Closeexaminationfoundthatalocalisedareaofplankingonthestarboardsideturnofthebilgeintheareaofthefishroomwasdamaged(Figure 16).Thedamagedareawascoincidentwithanareaofthehullthathadrestedontheseabedandthepositionofaliftingstropusedduringthevessel’srecovery.

Figure 15: Heather Anne ashore

Figure 16: Heather Anne-damagetoplanking

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1.11 POST-RECOVERY INSPECTION

Heather Anne wasinspectedbetween27Februaryand15March2012byanindependentmarinesurveyoronbehalfoftheMAIB.Thesurveyor’sinspectionreport(withaddendum)(Annex A) included:

From our general examination of the hull we found the planking, away from the damage, and hull equipment in reasonable order for the age and type of vessel.

The hull damages found were all on the starboard side just forward of amidships where we understand the vessel had been sitting on the bottom. There were no hull damages on the port side in this area.

The timbers in way of the damages were all in reasonable condition with no sign of any rot. The 10th timber out from the keel appeared to have been renewed recently in a different wood from the original hull. There appeared to have been some refastening carried out fairly recently in way of the damaged area but this was not as extensive as it could have been with several planks having not been refastened over quite some considerable length. The two sprung planks, 5 & 7, were examples of this.

With the very poor state of the fastenings in the general area around the missing sections of planking the damage could have occurred when the vessel was lying on the bottom and may have been moving slightly.

Whilst we were unable to fully examine the skin fittings they all appeared to be in place and intact, in view of other findings with the hull etc, we do not consider hull penetrations or skin fittings to have contributed to the vessels sinking in any way.

We consider the freeing port arrangements on the vessel to be adequate providing the shutter boards which were noted were not kept in place.

From the position of the switch on the bilge alarm panel it is more than likely that the bilge alarm was in the mute position.

1.12 EXAMINATION OF THE HRU

ExaminationoftheliferaftHRUfollowingitsretrievalbytheDevonandCornwallPolice (Figure 17) identifiedthatthedevicehadoperated.AhologramontheHRUindicatedthatithadbeenfittedafter24February2009butthedatetabsshowingitsrequiredreplacementdatehadnotbeenremoved.The‘inservice’lifeoftheHRUwasamaximumof2years.

TheremainsoftheHRUlowerthimblewhichincorporatedthe‘weaklink’wasfoundonthestarboardsideofthewheelhouseroof.The‘weaklink’appearedtohavebrokenasintended(Figure 18).

Anidenticalropethimbleandpadeyewasattachedtotheroofontheportsideofthewheelhouseroof.NoremainsofthestrapwhichheldtheliferaftinplaceandwhichshouldhavebeenconnectedtotheHRU,werefound.

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Figure 17:RecoveredHRU

Figure 18: Broken ‘weak link’

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1.13 STABILITY ASSESSMENT

To assess Heather Anne’sstabilitywhenshecapsized,acomputermodelofthehullwasdeveloped.Anincliningexperimentwasalsoconductedon18March2012 to determinethevessel’slightshipweightandhercentreofgravity.

Thevesselwasassessedinvariousstandardconditions,representativeofavoyageprofile,againstthe1975Rules.Thevessel’sstabilitywasalsoassessedintheestimatedlossconditionandtheconditionon19January2011whenshelanded10.1tonnesoffish.Theassessmentreport(Annex B)isconsideredtoprovideanaccurate indication of Heather Anne’sstabilityinthevariousconditions.However,giventheapproximationandestimationnecessaryinsuchananalysis,theresultingnumericalvaluescontainedintheconditiondataarenotabsolute.

1.14 STABILITY REGULATIONS

The1975Rulesintroducedawiderangeofsafetystandards,includingtherequirementforstabilitycriteriaforallvesselsof12m(L)andover.The1975RulesweresupersededbyTheFishingVessels(CodeofPracticefortheSafetyofSmallFishingVessels)Regulations2001andTheFishingVessels(Safetyof15-24MetreVessels)Regulations2002.Asaresult,therequirementforstabilitycriteriatobemetwaslimitedtovesselsof15mLOAorlonger.TheCodeofPracticefortheSafetyofSmallFishingvesselswaspromulgatedinMSN1756(F),whichwaspublishedinMarch2001.Thestabilityrequirementsforvessels>15mLOAwaspromulgatedinMSN1770(F)TheFishingVesselsCodeofSafeWorkingPracticefortheConstructionandUseof15MetreLengthOverall(LOA)tolessthan24metreregisteredlength(L)FishingVessels.

In2007,MSN1756(F)wassupersededbyMSN1813(F)TheFishingVesselsCodeofPracticefortheSafetyofSmallFishingVessels.MSN1813(F)wasissuedtoincreasethesafetyoffishingvesselsinforeseeableoperatingconditions,andthe survival of the crew in the event of an accident. The revised Code of Practice requirednewfishingvessels(whoseconstructionstartedafterApril2001)ofbetween7mLOAand15mLOAtocomplywiththeconstructionandoutfitstandardsissuedbySeafish.Italsorecommendedthatvesselsofbetween12m(L)andlessthan15mLOAcomplywiththe1975Rulesanditssubsequentamendments.

In addition, MSN 1813 (F) states:

It is recommended that vessels of between 12m registered length (L) and less than 15 metres length overall (LOA) continue to comply with the stability requirements contained in Section 16 and 74 of the Fishing Vessel (Safety Provisions) Rules 1975, and its subsequent amendments. Vessel owners are also advised to comply with the requirements contained in Annex 4 of this Code and MGN 281 (Fishing Vessel Freeboard and Stability Information Booklet).

It is recommended that stability information should be checked and the continuing validity certified at intervals not exceeding five years by a MCA or MCA approved surveyor. When changing, repositioning or adding equipment, e.g. fishing gear, winches, or shelters advice should be sought from MCA on the effect this could have on the stability of the vessel.

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When a vessel changes its mode of fishing, in addition to having a stability check, the MCA will review any exemptions that may have previously been applied associated with the original fishing method(s). The MCA, through the Fishing Industry Safety Group and its Small Fishing Vessel Code Sub-Group is currently developing legislation that will reintroduce these stability requirements.

1.15 MAIB FISHING VESSEL SAFETY STUDY

1.15.1 General

InNovember2008,MAIBpublishedits‘Analysis of UK Fishing Vessel Safety 1992 to 2006’.Thestudyanalysedall256deathsofcommercialfishermenoperatingonUK-registeredfishingvesselsthathadoccurredduringtheperiod,withaviewtoidentifyingcausalandcontributingfactors,drawingconclusions,andmakingrecommendations.Allsectorsoftheindustrywerecontactedandaskedtocontribute,andthereportwasbaseduponaconsensusofviewsfromacrosstheindustry.

1.15.2 Fishing vessel losses

Theanalysisidentified:

• The majority of vessel losses (52%) were due to flooding/foundering, and most of these involved vessels with lengths <12m. 13% of losses were due to groundings, whilst capsize/listing caused 12% of vessels to be lost.

• Just under 40% (99) of all fatalities between 1992 and 2006 were due to flooding/foundering, capsize/listing or missing vessels.

• 63 of these (25% of all fatalities) involved <12m vessels:

• Stability issues were identified in many of these accidents, with 18 fatalities attributed to vessels with low freeboard, 9 caused by inadequate stability and 8 due to vessel modifications.

• <12m vessels are not required to carry emergency positioning indicating radio beacons (EPIRB), and only 1 of the vessels had one fitted; problems with this EPIRB however, led to a delay in starting the search and rescue, and 3 crew died.

• 34 of the 63 fishermen killed in these accidents were known not to have been wearing PFDs, and it is considered likely that neither were many of the other 29 deceased.

1.15.3ReviewofMAIBsafetyrecommendations

TheanalysisalsohighlightedanumberofrecommendationsmadetotheMCArelatedtofishingvesselstability.Itincluded:

Following the investigation into the capsize of Charisma in 200211, probably due to undetected flooding combined with a heavy deck load of bagged mussels, MAIB recommended that:

11 www.maib.gov.uk/publications/investigation_reports/2002/charisma__ob588_.cfm

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“MCA, in consultation with the fishing industry, develop and promulgate guidance for the loading of fishing vessels under 15m LOA”.

The MCA commissioned two research projects, RP559 and RP560, which were to develop a simplified method of assessing stability on <12m vessels, without the need for expensive inclining tests and stability books, and to produce a simplified stability notice for use on >12m vessels. The projects were completed in May 2006, but despite the efforts of the MCA and Seafish it has not proved possible to identify any vessels to participate in the validation of the results.

The Amber and Kirsteen Anne investigations12, although resulting in separate reports, effectively made three parallel recommendations regarding small fishing vessel stability. Two of these recommendations revisited the areas of devising a simple method of assessing stability and of enhanced stability awareness among the operators of small fishing vessels, and were considered to be addressed by the actions above. A further recommendation was also made to the MCA to:

“Conduct a formal safety assessment of the introduction of a mandatory stability requirement for existing fishing vessels under 15m”.

This was rejected, although the MCA agreed to conduct a risk and cost-benefit assessment into whether a stability standard for <15m vessels would materially affect the accident rate. In confirming this intention to MAIB, MCA noted that even if a mandatory stability standard on small fishing vessels was proven to significantly enhance stability, it would be almost impossible to implement such a measure given the large number of vessels in the <15m fleet’.

1.15.4Studyrecommendations

Recommendation2008/178madetotheMCAincluded,interalia:

• Work towards progressively aligning the requirements of the Small Fishing Vessel Code, with the higher safety standards applicable under the Workboat Code.

Inresponsetothisrecommendation,theMCAincludedinitsbusinessplanfor2012to2016amilestonetobecompletedbyApril2016to:

Develop and issue alternative small fishing vessel standards based on the Small Commercial and Pilot Boat Code

Recommendation2008/173,alsomadetotheMCA,included:

• Introduce a requirement for under 15m vessels to carry EPIRBs.

12 www.maib.gov.uk/publications/investigation_reports/2003/amber.cfmand

www.maib.gov.uk/publications/investigation_reports/2003/kirsteen_anne.cfm

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1.16 RESEARCH PROjECTS

TheresearchprojectscommissionedbytheMCAaimedatdevelopingguidancefortheloadingoffishingvesselsunder15m(L)wereundertakenbytheUniversityofSouthampton’sWolfsonUnitforMarineTechnologyandIndustrialAerodynamics.

TheexecutivesummaryofphaseIIoftheprojects Loading Guidance for Fishing Vessels Less than 12m Registered Length (ReportNo.1903/2),whichwaspassedtotheMCAinMay2006,included:

The remit of this study was to develop effective methods of assessing the stability of fishing vessels, which do not unduly disadvantage the existing fleet. Based on this assessment, to provide clear guidance on loading, freeboard and operation, in a simplified format for ease of understanding and use by fishermen, which will enhance safety.

Thereportproposedamethodofgeneratingsimplifiedstabilityguidancethroughcolour-coded‘SafetyZones’withfreeboardguidancemarkslinkedtorecommendedmaximumseastates.Fordeckedvesselswithnostabilitydata,onlythevessel’sLOAandbreadtharerequiredtocalculatethefreeboardguidancemarksandthecorrespondingzones.Thesafetyzonesweredefinedas:

Green: “Safe” in all but extreme sea states

Amber: “Low level of safety” and should be restricted to low sea states

Red: “Unsafe, and danger of capsize” unless restricted to calm conditions and with extreme caution

Thereportrecommended:

That guidance freeboard marks be placed on fishing vessels for which the guidance information is based on freeboard alone. These will enable the fishermen to relate the guidance information to his vessel directly. [sic]

1.17 STABILITY GUIDANCE

1.17.1 Fishingvesselsoflessthan15mLOA

InDecember2010,theMCApublishedMGN427(F)–StabilityGuidanceforFishingVesselsofunder15mOverallLength(Annex C).TheMGNstatedthatfullstabilityrequirementsforthe12m(L)to15mLOAfishingvesselsweretobereintroducedinthenearfuturebutthattherewasnointentiontointroducecompulsorystabilityrequirementsforvesselsunder12m(L).

The MGN states:

A number of factors can affect a vessel’s stability, for example its length and breadth, the freeboard, the centre of gravity of the ship and equipment, distribution of weights such as in the fish hold, on deck, in hoppers, in nets, fuel, water and stores etc. Research has shown the importance and effect on stability of maintaining adequate freeboard. The weathertight deck, hatches and doors should be kept closed and decks should be kept clear of water and other moveable weights. While a vessel may appear very ‘stiff’ because of her large

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beam, if the freeboard is small there may be little reserve of stability when the vessel heels or is in large waves due to the dangers of downflooding. Also a vessel which appears very sea-kindly and comfortable with a slow roll period can actually be potentially unsafe in terms of stability. Keeping water off the deck by closing scuppers or freeing ports may seem sensible and safe, but does have the opposite effect if a wave comes onboard and causes instability because of the trapped water and its free surface effect. It is also vital that a catch is not stored on deck, it should be stored as low as possible in the vessel as soon as is practicable.

MGN427(F)highlightsfivemethodsofassessingafishingvessel’sstability:

• FullStabilityMethod.Appliestoallvessels>12m(L)andrequiresstabilitydatatobeformulatedfromanincliningexperimentandcalculation.

• SmallCommercialVesselCodeStandard(heeltest).Appliestovesselscarryinglessthan1tonneofcargoandrequiresaheeltestresultinginaheelanglelessthan7ºandsufficientfreeboard.

• SmallPassengerVesselHeelTest.AnalternativetotheSmallCommercialVesselCodeheelteststandardwhichalsorequiresaresultingheelanglelessthan7ºandspecifiedminimumfreeboard,butwhichcanbeusedforvesselscarrying>1tonneofcargo.

• Rollperiodapproximation-asimpleoperationalcomparativemethodtodeterminewhetheravesselisstiffortender.Iftherollperiodinsecondsislessthanavessel’sbeaminmetres,thevesselisconsideredtobestiff.Iftherollperiodinsecondsisgreaterthanthevessel’sbeam,thevesselisconsideredtobetender.

• WolfsonGuidance(seeparagraph1.16).

Thedetailsoftherequirementsofeachofthemethodsareprovidedinannexestothe MGN.

The MGN also states that a notice entitled Simple Efforts for Maintaining Stability or similarshouldbepostedinaprominentpositiononboardafishingvessel,andthatskippersandcrewshouldattendtheSeafish1-dayStabilityAwarenesscourse.

1.17.2 Freeboard

MSN 975 – Freeboard of fishing vesselswaspublishedin1981andprovidedadviceonfreeboardandstability,including:

It has been observed that many vessels engaged primarily in bulk fishing are frequently loaded such that the reserves of stability or freeboard remaining may be small to counter any adverse effects of sea or wind with consequent danger to crew on deck or to the vessel itself.

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Maintenance of adequate freeboard in all parts of the vessel is an important feature of safe operation. When a vessel designed for a particular mode of fishing is altered to suit an entirely different method with new arrangements and rates of stowage, the stability and freeboard must be verified and assessed for compliance with Rule 15(1).

Vessels to be employed in bulk fishing can be particularly vulnerable to the effects of small reserves of stability, trim and freeboard. Safe limits of loading should be made available to skippers in a readily understandable form.

MSN975didnotapplytofishingvessels<12m(L).

1.17.3 Fishermen’sSafetyGuide

TheMCApublicationFishermen’s Safety Guide – A guide to Safe Working Practices and emergency procedures for fishermen providesadviceonawiderangeofoperatingpracticesonboardfishingvessels.Asectiononstabilityexplainstheeffectsofavessel’scentreofgravity,loosewaterorfishondeck,loadingandunloading,andfreeboard.

1.18 CONSTRUCTION STANDARDS

NewvesselsarerequiredtocomplywithSeafishconstructionstandardsinordertobeeligibletoregisterasaUKfishingvessel.Forvessels<15mthestandardsspecifythatstabilityfornewvesselsshouldbeproperlyassessedbyapersonhavingappropriatequalifications.Thestandardsalsohighlightthatfullstabilityassessmentsarerequiredforfishingvesselsbetween12m(L)and15mLOAandrecommendthatcurrentstabilityrequirementsarealsoappliedtovesselsofbetween10mLOAto12m(L).

RevisedSeafishconstructionstandardsforvessels<15m(L)werepublishedinSeptember2012,andwereeffectivefrom1January2013.Thestandardsincludeanewrequirementthatdeckedvesselswithacontinuouswatertightweatherdeckhaveaminimumfreeboardfromthedesignwaterlineofnotlessthan300mm.Vesselswithafreeboardlessthan300mmaretobelimitedintheirareaofoperationto20milesfromasafehavenandinfavourableweatherconditions.

1.19 STABILITY TRAINING

Seafishprovidesbothmandatoryandvoluntarytrainingforfishermen.Thenon-mandatory1dayintermediatestabilityawarenesscoursewasintroducedinApril2006incloseconjunctionwiththeMCAandhasbeencompletedbynearly4500fishermen.Thecourseusedaseriesofvisualanimationsandaspeciallydesignedmodelboattoexplainkeyaspectsofstabilityandtoprovideskipperswithagreaterunderstandingoftheissuesinvolved.

Themodelboatfeaturesaninterchangeablestructuretosimulatearangeofdifferentfishingvesseltypesand,inconjunctionwithawatertankandavarietyofweights,arangeofoperatingconditionscanbetestedtoreflectthedangersofadditionaltopweight,free-surfaceeffect,catchondecketc.

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Thecoursesyllabuscoverskeyareasaffectingstabilityincluding,buoyancy,centreofgravity,metacentre,vesselequilibrium,effectonthemovementofweights,freesurfaceeffect,rollperiodsandgeneralstabilityguidanceincludingweight‘creep’orgrowth.

Tofurtherimpressuponthefishermentheimportanceoftheseareas,specificMAIBaccidentinvestigationsarehighlighted.Anendofcourseassessmentrequiresapassmarkof60%.

1.20 MARINE MANAGEMENT ORGANISATION

1.20.1 Background

TheMMOwasestablishedandgivenpowersundertheMarineandCoastalAccessAct2009tocontributetosustainabledevelopmentinthemarinearea,withrespecttoplanning,regulatingandlicensing.

TheMMOincorporatestheworkoftheMarineandFisheriesAgency(MFA)including,since1April2010,responsibilityfortheadministrationoftheEuropeanFisheriesFund(EFF).ItalsoundertakesspecificfunctionspreviouslyassociatedwiththeDepartmentofEnergyandClimateChange(DECC)andtheDepartmentforTransport(DfT).

Withinitsrangeofresponsibilities,theMMOalsomanagestheEnglishfishingfleetcapacity(approximately22%ofthetotalUKfleet)andEnglishfisheries’quotas.WithfundingfromtheEFF,theMMOisabletoassistfishermenthrough,forexample,diversificationintootherfishstocks,purchaseofnon-mandatorysafetyequipment,updateofequipmenttobecomemoreproductive,andimprovementofcrewfacilities.

1.20.2EFFgrants

TheEFFgrantschemecommencedinSeptember2008andwasadministeredbytheMFApriortoApril2010.Thegeneralconditionsforreceivingagrantincluded:

The beneficiary agrees] to meet any legal obligations imposed under EU and UK law, statutory instrument or bye-law, to obtain any necessary consents, rights and way leaves, give any necessary notices and meet any specific rules, regulations and/or standards that may be relevant to the project.

From5July2010,theMMOhasinformedtheMCAofthegrantsawardedforvesselmodifications,regardlessofwhetherornotthemodificationsaffectvesselstability.Inaddition,aspartoftheprojectapplicationprocess,MMOcoastalofficerscommentonthesuitabilityoftheproposedprojectsandinspecttheworksaftercompletiontoensuretheymeetthetermsofthegrant.

1.20.3Ring-netting

Between18February2010and17August2011,sixapplicationsforfundingtowardring-netconversionsormodificationswerereceivedbytheMFAorlatterlytheMMO.FiveoftheserelatedtoMevagisseybasedfishingboats,includingHeather Anne, andoneforaNewlynbasedvessel.Oneofthesix,notrelatingtoafullconversion,wasdeclined.Thegrantswereintendedto:

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• Improveselectivitywithvirtuallynounwantedby-catchordiscards

• Diversifyawayfrompressurestocks

• Reducesteamingtofishinggroundsresultinginlessfuelconsumption.

1.21 LIFEjACkETS

In2000,initsinvestigationreportintothecapsizeofDonna M 13 the MAIB recommendedthattheFishingIndustrySafetyGroup(FISG):

Raise an agenda item on the compulsory wearing of lifejackets for fishermen when working on deck, and to seek the views of fishermen’s representatives on this subject.

The MAIB’s ‘Analysis of UK Fshing Vessel Safety 1992 to 2006’ (paragraph1.15) recommended that the MCA:

Review international safety initiatives and transfer best practice to the UK fishing industry with particular reference to the use of PFDs and Personal Locator Beacons.

Arecommendationwaslatermadein2009totheMCAfollowingthedeathofacrewmanfromthefishingvesselMaggie Anne 14 to:

Expedite its current work on the use of personal flotation devices and personal locator beacons in the UK fishing industry.

In2010,afterreviewingtheseandprevioussimilarrecommendations,theMCAconcludedthatthecompulsorywearingofpersonalflotationdevices(PFDs)ontheworkingdeckoffishingvesselswouldhaveapositiveeffectonsafetyanddramaticallyreducethenumberoffatalities.ThisissuehassincebeenastandingagendaitemattheFISGmeetingsatwhichtheMCAhastakenintoaccountfishingindustryconcerns.GettingfishermentowearPFDsisnowakeypartoftheMCA’sfishingvesselsafetyproject,anditsbusinessplanfor2011-2015included:

Put arrangements in place to require fishermen to wear Personal Flotation Devices (PFDs) by December 2012.

TheMCAhassincewideneditsfocusonPFDstoincludesafetylinesasanadditionoralternativetoPFDs.Aftercloseconsultationwiththefishingindustry,andtoenablethecontinuedprovisionofPFDswiththeassistanceofEFFgrant,theFISGhasalsodecidedtoprioritiseitseffortstoengendaculturechangeinfishermensothatPFDsarewornvoluntarilyinappropriatecircumstances,suchaswhenworkingontheupperdeckatsea.TheMCAintendstoimplementthemandatorywearingofPFDsifitbecomesclearthatthisnon-regulatoryapproachisnotworking.

13 www.maib.gov.uk/publications/investigation_reports/2000/donna_m.cfm14 www.maib.gov.uk/publications/investigation_reports/2009/maggie_ann.cfm

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1.22 SIMILAR RECENT ACCIDENTS

From 2007 until the loss of Heather AnneinDecember2011,20UKregisteredfishingvesselsof<12m(L)havecapsized15.Theseresultedfrom:fishinggearbeingcaughtonanunderwaterobstruction(10),flooding(5),heavyweather(4)orunevenweightdistribution(1).Theseaccidentsincluded:

• On10November2008,thefishingvesselLouisa16hadbeenrakingtheseabedfor“whiteweed”offShoeburyNesswhentheweatherdeteriorated,withwindsgustinguptoForce8androughseas.Asthevesselheadedbackintohermooringshewaslostabout1.2nmoffSouthendPier.Nodistresssignalwasreceived,andtheowner,whowastheonlypersononboard,losthislife.

• On26November2008,thefishingvesselGeorgie Fisher17wasdredgingformusselsinTheWash,andhadloadedabout14tonnesofmusselswhenshewasbeachedtowaitforthenexttide.WhenGeorgie Fisher returned to the musselbedsandresumeddredgingshewasheadingintoshallowerwaterwhenthestarboarddredgecamefast.Thevesselquicklyheeledtostarboard,takingwaterontothedeck.Despitetheskipper’sefforts,hewasunabletofreethedredgeorcorrecttheheel;downfloodingoccurredintotheengineroom,viathevents,andthevesselcapsizedtostarboard.Thevessel’sthreecrewwererescuedbyanearbyvessel.FollowingthisaccidenttheChiefInspectorof Marine Accidents wrote to Georgie Fisher’s ownerrecommendingthatthevessel’sengineroomventsbemodifiedtoincreasethelevelatwhichdownfloodingoccurs,andthatanincliningtestbeconductedonthevesseltoassessitsstabilityanddetermineitssafeoperatinglimits.HealsowrotetotheChiefExecutiveoftheMCAhighlightingthatbothGeorgie Fisher and Ellie May representfurtherexamplesofthefounderingorcapsizeofsmallfishingvessels,identifiedasanareaofconcerninMAIB’sNovember2008reportAnalysis of UK Fishing Vessel Safety 1992 to 2006.

• Atabout1540UTCon20July2009thefishingvesselAquila18, with a crew of four,capsizedwhiledredgingforscallopstotheeastoftheIsleofMuck,offthewestcoastofScotland.Threeofhercrewlosttheirlivesintheaccident;nonewerewearinglifejackets.Aquila wastrawlingwhenherstarboardtrawlwarpbecamesnaggedontheseabed.Sheyawedandheeledtostarboardinfollowingseas.Theskipperputtheengineoutofgear,buthadnotimetotakefurtheractionbeforethevesselcapsizedaslargewavesbrokeoverherstarboardside.Atthetimeofherbuild,Aquila metthestabilitystandardforlargerfishingvessels,therebeingnostandardforvessels<12m(L).However,analysisundertakenbytheMAIBfoundthat,duetoanincreaseinherdisplacementtonnage,atthetimeoftheaccidentshenolongermetthisstandard.Followingtheaccident,Seafishagreedto includeinitsstabilityawarenesscoursetheimportanceofensuringthatavessel’sstabilityisassessedbyacompetentpersonwhenmodificationsoradditionsaremade.

15Excludescapsizesthatoccurredasaresultofbeaching.

16 www.maib.gov.uk/publications/completed_preliminary_examinations/completed_preliminary_examinations_2009/louisa. cfm

17 www.maib.gov.uk/publications/completed_preliminary_examinations/completed_preliminary_examinations_2008/georgie_fisher.cfm

18 www.maib.gov.uk/publications/investigation_reports/2010/aquila.cfm

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SECTION 2 - ANALYSIS

2.1 AIM

Thepurposeoftheanalysisistodeterminethecontributorycausesandcircumstancesoftheaccidentasabasisformakingrecommendationstopreventsimilaraccidentsoccurringinthefuture.

2.2 VESSEL STABILITY

Thestabilityassessmentreport(Annex B) shows that Heather Annewasoperatingwithaverylowreserveofstabilitybeforehercapsize.Thedifficultiesexperiencedwhensteering,thevessel’sslowrateofrollfromsidetoside,andtheingressofwaterthroughtheclosedfreeingports,wereallsymptomsofherperilouscondition.

Withanestimatedcargoof10.5tonnesoffishandentrainedseawater,thevessel’sfreeboardwasabout131mm19fromdecklevelandthecorrespondingrightingleverswereverylowindeed(seeAnnexB,Diagram6).OnceHeather Anne’s finalrolltostarboardreachedanangleintheregionof13°,capsizewasinevitable.

ThereisnodoubtthatHeather Anne hadbeenatanincreasedriskofcapsizesinceherconversiontoring-nettingin2010.Indeed,whenthevesselwasloadedwith10.1tonnesoffishon19January2011(Figures 9, 10 and 11 and Table 1)herstabilityconditionwasonlymarginallybetterthanon20December2011(Table 4 in Annex B).Itispossiblethatcapsizewasonlyavoidedonthatoccasionduetobetterseaconditionsandthefactthatthelargertarpaulinhadnotyetbeenfittedinthefishroom.

Asitwouldhavetakenonlyaverysmallchangeinthevessel’sconditionduringHeather Anne’sreturnpassagetoMevagisseyon20December2011,tocausehertocapsize,thefinaleventthattriggeredhertotallossofstabilityisdifficulttodetermine.However,itwasalmostcertainlyduetooneoracombinationofseveralfactors,including:thefreesurfaceeffect20ofthefishandentrainedseawaterinsidethefishroomandtheseawaterondeck;theheelingduetotheuseofhighanglesofrudderortheincreasingseastate;andthemovementofweightsonthedecksuchasfishboxesorthevessel’screw.

Giventhattheplanksinwayofthedamagedareaonthevessel’sstarboardside(Figure 16)hadbeenreplacedin2010,andtheprobabilitythatthedamagewascausedbythevessel’smovementontheseabed(Annex A) orbyaliftingstropwhen the vessel was raised (Figures 13 and 14),itisunlikelythatthecapsizewasinitiatedbyfloodingresultingfromasprungplankinthisarea.Inaddition,asthedischargesoverboardwererelativelyhighonthevessel’sside(Figure 8), it wouldnothavebeenpossibleforseawatertoenterthehullviathispipeworkduringpassage,evenwiththevessel’sverylowfreeboard.Nonetheless,hadthevesselstartedtofloodforwhateverreason,theskipperwouldnothavebeenalertedbecausethebilgealarmwasmuted.Inanyevent,thetimeavailabletotakeanyactionwouldhavebeenminimalduetothevessel’slowfreeboardandlowreserveofstability.

19 The131mmminimumfreeboardidentifiedatAnnexBwasmeasuredonthelowsideofthevesselwiththevesselheeledatanangleof1.76°.Therefore,thefreeboardwouldhavebeenmarginallygreaterontheoppositeside.

20 Inapartlyfilledtankorhold,thecontentswillshiftwiththemovementofavessel.This‘freesurfaceeffect’increasesthedangerofcapsize.

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2.3 IMPACT OF MODIFICATIONS

2.3.1 Weightgrowth

ThecomparisonofFigures 4 and Figure 15clearlyshowsthatsincebuildin1971,Heather Anne hadbeenextensivelymodified.Suchchangesaddedsignificantweightontheupperandlowerdecks.Asaresult,whenthevesselwasinclinedinMarch2012,herlightshipdisplacementhadincreasedfromanestimated15.7tonnesatbuildto23.9tonnes,anincreaseofover50%.

Importantramificationsofthevessel’sincreaseddisplacementwerethathercentreofgravitywasraisedandherfreeboardwaslowered.Consequently,althoughthevesselinherloadedconditionatbuildwaslikelytohavemetthelaterstabilityrequirementsintroducedinthe1975Rules(whichwerenotobligatoryforthevessel),itisclearthatthevessel’sin-servicemodificationsreducedherreserveofstabilitytothepointwherethevesselnolongercompliedwiththestabilityrequirementsofthe1975Rulesinanyseagoingcondition(Table 3 in Annex B).

2.3.2 Freesurfaceeffect

Thefittingofatarpaulin‘tank’inthefishroomwasaseeminglyminoraddition.However,whenthecapacityofthetarpaulinwasincreasedfrom3.4m3 to 5.02m3 inNovember2011,althoughthiswasanincreaseof48%involume,alongwiththeremovalofthelongitudinalpoundboardsitincreasedthetank’sfreesurfacemomentby240%(Table 1 in Annex B).

Theupperedgesofthetarpaulintankdidnotabutthedeckhead,soitcouldnotbepressedfullwithoutfishoverflowingitsedges.Therefore,evenwitha‘full’tankoncompletionoffishingon20December2011,theupperlevelofthemixtureoffishandresidualseawaterwithinthetarpaulinwas30cmbelowthemaindeck.Consequently,theestimated4.7tonnesofcargowasfreetomovefromsidetosidetosomedegree,providingafreesurfacemomentasthevesselrolled.Inevitably,suchmovementandcorrespondingshiftinweightwouldhaveexacerbatedHeather Anne’sfinalroll,whichultimatelyledto capsize.

2.3.3 Catchsize

When Heather Anne wasbuilt,themaximumweightofhercatchwasexpectedtobeabout5tonnes(4tonnesinthefishroomandtheremainderonthedeck).Thevessel’sconversiontoring-nettingundoubtedlyincreasedthelikelihoodoffrequentlycarryingmuchlargerquantities.Thecatchonboardwhenshecapsizedwasestimatedinthestabilityassessment(Annex B)tobeabout10.5tonnes,whichwasmorethantwicetheweightoriginallyenvisagedbyherdesigner.TheweightofthefishandentrainedseawaterincreasedHeather Anne’sdisplacementtoabout38.5tonnesandreducedherfreeboarduntilitwasonlyafewcentimetres.

2.4 RELIABILITY OF THE STABILITY ASSESSMENTS UNDERTAkEN

2.4.1 Rolltest

AfterbeinginformedbytheMMOthatHeather Anne hadbeenconverted toring-netfishing,theMCAsurveyor’sconcernoverthevessel’sstabilitywaswarranted.However,inNovember2010arolltestwastheonlyviablemeansavailabletothe

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surveyortoassessHeather Anne’sstability.Afullstabilityassessmentwouldhavebeenrelativelyexpensiveandthesurveyorconsidereditwouldbedifficulttojustify.Theuseofarolltestonthisoccasionwasthereforeunderstandable.However,Heather Anne’scapsize only13monthsaftertherolltestisseriouscauseforconcernandhighlightsthatavessel’sstabilityshouldnotbeassessedbyarolltestalone.

Inthiscase,therolltestprovidedanapproximationofHeather Anne’s GMinonlyher‘departportcondition’;itdidnotaccuratelyreflectthevessel’s‘fullyloadedcondition’.Crucially,therolltestdidnotsufficientlytakeaccountoftheadverseeffectsonthevessel’sstabilitycausedbyherincreaseddisplacementandreducedfreeboardsincebuild.Consequently,whilethemeasuredGMwasgreaterthantheminimumcalculatedGMrequiredbythe1975Rules,byitselftheGMdidnotprovideameaningfuloraccuratemeasurementofHeather Anne’sstability,nordiditprovidetheskipperwithguidanceastohowmuchcatchhisvesselcouldcarry.Theresultsof Heather Anne’srolltestwerethereforemisleadingtoboththeMCAandthevessel’sskipper.

2.4.2 Dynamicassessment

As Heather Anne was<12m(L),thevesseldidnothavetomeetanyspecificstabilitycriteriaand,likemanysimilarsizedfishingvessels,itwaslefttoherskippertoensure that his vessel remainedfitforpurposeinthisrespect.However,thevesselhadpassedtherolltestfollowingherconversionandhadsubsequentlycarriedlargecatchesdividedbetweenthefishroomandonthedeck.Insuchcircumstances,itispossiblethattheskipperhadgainedafalseimpressionofhisvessel’scapabilities.

Onthenightofthecapsize,Heather Anne’sskipperrealisedthathewouldnotbeabletobrailonboardthefullcontentsofhisnet.However,whenLauren Kate arrived tosharehiscatch,hewasunawarethathisvesselhadalreadybeenloadedtothepointwherehersafetywasinjeopardy.

Theskipperwasanexperiencedfishermanwhohadcompletedtraininginstabilityawareness,butitisalsoclearfromhisuseofthetarpaulintankthatheeitherdidnotfullyunderstandordidnotfollowtheloadingguidanceprovidedalongwiththeresultsoftherolltest(paragraph1.6.2).Healsodidnotrecognisethedangersignsofseawaterenteringthedeckeventhoughthefreeingportswereclosed,thedifficultiesinmaintaininghisintendedheading,orbythevesselrollingslowly.Itwasnotuntilmomentsbeforecapsizethatherealisedthatsomethingwaswrong.Bythen,itwastoolateforanyeffectivepreventativeactiontobetaken.

2.5 METHODS OF ASSESSING SMALL FISHING VESSEL STABILITY

2.5.1 Maximumsafeload

Heather Anne’scapsizecouldhavebeenavoidedhadherskipperknownthemaximumloadhisvesselwascapableofcarryingsafely.However,determiningthemaximumsafeloadoffishingvessels<12m(L)isproblematic. ThefivemethodsofassessingthestabilityofsmallfishingvesselsdetailedinMGN427(F)(Annex C and paragraph1.17.1)varyconsiderablyintheirapproach,complexity,cost,andthemarginsofsafetytheyafford.Moreover,despiteMGN427(F)emphasisingtheimportanceofmaintaininganadequatefreeboard,notallofthemethodssuggestedintheMGNprovideanyindicationofavessel’smaximumloading.

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2.5.2 Fullstabilityassessment

Thefullstabilitymethodisbyfarthemostcomprehensiveandaccuratemethodfromwhichavessel’smaximumloadcanbederived.However,thismethodrequiresahullcomputermodeltobeconstructed,anincliningexperiment,andastabilityinformationbook(SIB)tobeproduced.NewfishingvesselsarebuilttotheSeafishconstructionstandardsandsometimeshavestabilityanalysescompletedaspartoftheirdesign.However,theretrospectiveuseofthismethodwouldbeproblematicasmanyexistingsmallfishingvesselshaveinherentlylowreservesofstability,andmanyfishermendonotconsidertheexpenseisjustified.

In the case of Heather Anne,theminimumfreeboardextrapolatedfromthestabilityrequirementsforfishingvessels>15mLOA(MSN1770(F))was256mm(Table 3 in Annex B).

2.5.3 TheSmallCommercialVesselCodeStandardandtheSmallPassengerVesselHeelTest

ThemethodsadaptedfromtheSmallCommercialVesselCodeandtheSmallPassengerVesselCodeHeelTestrequireavesseltoheeltoanangleoflessthan7ºwhenaprescribedloadisplacedonthevessel’ssides.Theyalsoprovideaminimumfreeboardwhichisinterpolatedfromavessel’slengthandwhichthereforeenablesskipperstoderiveasafeloadinglimit.

However,theSmallCommercialVesselCodeStandardislimitedtovesselscarryinglessthan1tonneofcargo,soitcanonlybeappliedtothesmallestfishingvessels;itcouldnothavebeenappliedtoHeather Anne.TheSmallPassengerVesselCodemethodpermitsgreatercargocapacity,andthereforecouldhavebeenappliedtoHeather Anne.

UsingthemethodsadaptedfromtheSmallCommercialVesselCodeStandardandtheSmallPassengerVesselCodeHeelTest,theminimumrequiredfreeboardforHeather Anne wouldhavebeen430mmand515mmrespectively.

2.5.4 TheRollPeriodApproximationTest

Thesimplest,butbyfartheleastinformativemethodofassessingstabilityistherollperiodapproximation,butthisonlycategorisesavesselasstiffortender,whichiswhollyinsufficientforavessel’ssafeoperation.Furthermore,rollperiodislinkedtoinertia,whichwillvarywidelybetweenvesselsdependingontheirupperdeckequipmentandunderwaterappendagessuchasbilgekeelsandskegs.Therefore,theresultsofarollperiodapproximationtestmightbemisleading.

2.5.5 TheWolfsonGuidanceMethod

TheWolfsonGuidancemethodcalculatesthepositionofafreeboardguidancemarkonavessel’shullbasedonavessel’slengthandbeam.Themarkisthenintendedtobeusedbyavessel’sskipperinconjunctionwithastabilitynoticewhichlinksthefreeboardmarktotheseastatetoindicatealevelofsafetyina‘trafficlight’format.AcompletedstabilitynoticeforHeather Anne is shown at (Figure 19) and the freeboardguidancemark,whichwasputonthevesselafterherrecovery,isshownat Figure 20.

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Figure 19:Stabilitynoticeandguidancemark

MAIB NOTE

EquatestoRedzone

EquatestoAmberzone

EquatestoGreenzone

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2.5.6 Summary

ItisevidentfromthereviewoftheassessmentmethodssuggestedinMGN427(F)thatthenotefailstoprovidemeaningfulpracticalguidancetoownersandskippersregardingtheassessmentofsmallfishingvesselstability.Moreover,itslackofclaritythroughinclusionofextractsfromthesourcestandardsandtheresultinginclusionofirrelevantreferencesinsomeareasisconfusing.

Table 2 summarisestheapplicationofthefivemethodssuggestedinMGN427(F)withregardtoHeather Anne. TheproposedminimumfreeboardfortheSeafishconstructionstandardsfornewvessels<15mLOAisalsoincludedforcomparison.As Heather Anne’sfreeboardwasonlyabout131mmwhenshecapsized,itwassignificantlylessthantheminimumfreeboardsderivedfromthestabilityassessmentssuggested(whereapplicable).

Figure 20: Heather Annewithfreeboardguidancemark

Wolfson mark

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Method Minimum Freeboard Comments

Fullstability 256mm

Maximumloadmustbeusedtoderive a vessel’s SIBExtrapolatedfromthe requirementsofMSN1770(F)(Table 3 in Annex B)

Approximate RollPeriod Notdefined

Onlyprovidesguidanceonwhether a vessel is stiff or tender

Small Commercial Vessel Code Standard

430mm In association with a heel test andonlyforvesselscarryingless than 1 tonne

SmallPassenger VesselCodeHeel Test

515mmIn association with heel test for vesselscarryingmorethan1tonne

Wolfson Guidance Mark

250mm(amber/red)510mm(green/amber)

Usedinconjunctionwithastabilitynoticeandlinkedtosea state

ProposedSeafish Construction Standard 300mm Onlyrequiredifoperating

>20nmfromsafehaven

Table 2: Summaryofstabilityassessmentmethods–Heather Anne

However,inthecaseofHeather Anne, the Small Commercial Code Standard could nothavebeenapplied,therollapproximationmethodwouldhavebeenoflittlevalue,andtheminimumfreeboardrequiredbytheSmallPassengerVesselCodeHeelTest(515mm) and the Small Commercial Code Standard (430mm) would have reduced thecargowhichshe couldhavecarriedtotheextentthatthevesselwouldpossiblyhavebeeneconomicallyunviableasaringnetter.Onlytheapproximateminimumfreeboardextrapolatedfromtherequirementsforlargerfishingvessels(256mm),andtheminimumfreeboardderivedfromtheWolfsonGuidancemethod(250mm),appeartobecredible.

Thelackofstabilityrequirementsforvessels<12m(L)makestheneedtoprovideclearguidancewhichisrelevanttotheoperationofthesevesselscompelling.Suchguidanceshouldtakeaccountof,interalia:

• Thelimitationsofthealternativestoafullstabilityassessment.

• Thesuitabilityofthealternativestabilityassessmentsforsmallfishingvessels.

• Thatavessel’svulnerabilitytocapsizeisnotnecessarilyrelatedtoherGM,andthatalargeGMdoesnotguaranteethatavesselhasasufficientrightinglever.

• Theimportanceofvesselshavingbothafreeboardmarkandamaximumloadcalculation.

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• Theimpactofvesselmodifications.

• Owners’andskippers’awarenessofstabilityconsiderations.

TheWolfsonGuidancemethodpotentiallyprovidesapracticalandinexpensivewayforfishingvesselskipperstogaugetheloadingoftheirvesselsinvaryingseaconditions.Unfortunately,asthemethodhasyettobefullyvalidatedduetothelackoffishingvesselsthatwerewillingtoparticipateinitstrialsin2006,itisviewedwithscepticismwithinsomequartersofthefishingindustry.Givenitspotentialusefulnessincontributingtosmallfishingvesselsafety,itisimportantthatthepracticalityandaccuracyofthemethodistestedassoonaspossible.

2.6 FISHING VESSEL STABILITY STANDARDS

Thecontinuinglossofsmallfishingvesselsandtheircrewsthroughcapsize(paragraph1.22)remainsaseriouscauseforconcern.Itisapparentfromtheseaccidentsthatsmallfishingvesselsthatoperatewithlowreservesofstability,oftenasaresultofmodificationorloading,haveareducedlikelihoodofrecoveryfollowingunforeseeneventssuchastheirfishinggearbeingcaughtonanunderwaterobstruction,worseningseaconditions,orflooding.

Thestabilityrequirementsforsmallfishingvesselscontainedinthe1975RulesanddevelopedthroughtothesubsequentCodesofPractice,donotincludeanyrequirementsforfishingvesselsof<12m(L).Althoughtheproposedminimumfreeboardrequirementsforvessels<15mrequiredbytheSeafishconstructionstandards(paragraph1.18andTable2)shouldhelpimprovethesafetyofnewsmallfishingvessels,thecurrentexemptionofexistingfishingvessels<12m(L)fromanystabilitycriteriaisunjustified,particularlyconsideringtheiraccidentrateandthehazardsassociatedwithfishingcomparedtoothersmallcommercialvesselactivities.

AlthoughtheMCAstatedanintentinMGN427(F)in2010nottointroducestabilitycriteriaforfishingvessels<12m(L),theinclusionofamilestoneinits2012to2016businessplantodevelopalternativesmallfishingvesselstandardsbasedonothercommercialcodes,isachangeindirectionwhichshouldimprovethesafetyofallsmallfishingvesselsinthelongerterm.

Tobefullyeffective,anystabilityrequirementswhicharedevelopedforfishingvesselsof<12m(L)mustensurethatallnewvesselsandvesselswhichhavebeensubstantiallymodifiedaresubjecttoappropriatestabilityassessments.Otherexistingvesselsmusthaveaminimumfreeboardmarkedontheirhull,otherwiseskipperswillhavenomeansofaccuratelydeterminingthemaximumsafeload.

2.7 FUNDING CONDITIONS

TheadverseeffectsthatbulkfishingcanhaveonfishingvesselstabilityarewelldescribedinMSN975.AlthoughtheMSNisaimedatlargerfishingvessels,Heather Anne’sweightgrowthandincreaseddisplacementfollowingherconversiontoring-nettingin2010,togetherwiththesizeofhercatchon20December2011whichledtohereventualcapsize,showthatsuchdangersapplyequallytosmallerfishingvessels.

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FollowingHeather Anne’sconversiontoring-nettingin2010,notonlywasthevessel’sstabilityconsiderablyreduced,butthevesselwasalsolikelytocatchandcarrylargequantitiesoffish.WhentheMMOinformedtheMCAaboutHeather Anne’sintendedconversion,theMCAimmediatelyrecognisedthepotentialadverseimpacttheconversionworkcouldhavehadonthevessel’sstability.UnfortunatelytherolltestthatwasconductedfailedtoconfirmtheMCA’sconcerns.Thereisnodoubtthathadafullstabilityassessmentbeenundertaken,theviabilityofoperatingHeather Anne asaring-netterwouldhavemeritedcriticalreview.

Furthermore,althoughtheMMObestowedresponsibilitiesonthebeneficiariesofEFFgrantstomaintaincompliancewithallapplicableregulations,Heather Anne’s capsize andthedeathofIanThomasshowthatsuchasystemisflawedwherenoregulationexists.ThesafetyoffishingvesselswhichareconvertedorsubstantiallymodifiedwiththesupportofanEFFgrantwouldbebetterprotectediftheMMOandtheMCAworkedmorecloselytogethertoensurethatthevesselsconcernedmaintainsufficientreservesofstability.Inmanycasesthiswouldonlybepossiblethroughafullstabilityassessment.Therefore,giventherelativelyhighcostsinvolved,thelinkingoftheprovisionofsuchassessmentstothefundingorgrantconditionsisworthyofexploration.

2.8 SURVIVABILITY

2.8.1 Lifejackets

Suddenlyenteringseawateratatemperatureofabout10°C,Ianwaslikelytohaveexperiencedshocktosomedegreewhenfirstimmersed.Suchashockcancauseapersontogaspandinhalewater.However,despitenotbeingastrongswimmer,Ianwasabletosurface.AlthoughtheskipperthentriedtosupporthimuntilLauren Kate arrived,itwouldhavebeenextremelydifficultfortheskippertokeepIan’smouthclearofthewater.Neitherofthemenwaswearingalifejacket,anditwouldhavebeendifficultforeventhebestofswimmerstocopeintheseaandwindconditionsexperienced.GiventherelativelysmalllengthoftimeIanspentinthewater,thereislittledoubtthathischancesofsurvivalwouldhavebeendramaticallyincreasedifhehadbeenwearingoneofthelifejacketscarriedonboardHeather Anne.

In2000,theMAIBmadeitsfirstrecommendationaboutthecompulsorywearingoflifejacketsbyfishermenworkingondeck.Intheinterveningyears,therehasbeenasuccessionofdiscussions,educationprogrammesandresearchprojects,yetfishermencontinuetodrownwhomightotherwisehavelivedhadtheybeenwearingaPFDwhentheyenteredthewater.TheMCA’sinitiativetointroducearequirementforfishermentowearPFDswhenworkingontheopendeckbyDecember2012wasapositivestepforward.However,thedecisiontodelaythisimplementationdatetoallowEuropeanFisheriesFundgrantstobeusedtopurchasePFDshasmerits:forexample,theScottishFishingFederationhasappliedforfundingtoequipallScottishfishermenwithapersonalPFDtowearontheworkingdeck,anditisunderstoodthattheotherUKfishingfederationshavesimilarinitiativesplanned.Nonetheless,simplyprovidingfishermenwithPFDsisnotenough.MAIBinvestigationshavefrequentlydiscoveredthatPFDsforusewhileworkingareavailableonboardfishingvessels,yettheywerenotbeingwornwhentheaccidentoccurred.ThecultureoftheindustrythereforeneedstochangetomakewearingaPFDamatterofroutinewhenworkingondeck.

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ThatlifelinesarebeingconsideredaviablealternativetoPFDsonsmallfishingvesselsisalsoasourceofconcern.Lifelinesareusefulforhelpingpreventanindividualfrombeingwashedoverboardinheavyweather,thoughtherearecurrentlynoequipmentstandardsfortheiruseonfishingvessels.Moreover,thewearingoflifelinesonboardsmallerfishingvesselwhichmightcapsizeorfounderwithlittlewarningispotentiallydangerous.SincethelossofHeather Anne,fiveUKfishermenhavelosttheirliveswhileworkingonsmallfishingvesselsduetotheirvesseleitherrapidlycapsizingorrapidlyfoundering.Asitwas,theseindividualshadnotimeinwhichtocollectanddontheir‘abandonship’lifejacketsbuthadtheybeenattachedtotheirvesselbyalifeline,theirchancesofsurvivalwouldhavebeenreducedevenfurther.

Therearemanyreasonswhyfishermenmightsuddenlyfindthemselvesinthewater,includingunsafeworkingpracticesondeck;poorstability,overloadingandsnaggingleadingtovesselcapsize;andinternalfloodingresultinginfoundering,tonameafew.Allthesesafetyissuesarebeingaddressed,buttheirresolutionislikelytotakeyears.Inthemeantimelives,suchasthatofIanThomas,canbesavedbyfishermenwearingaPFDwhenworkingondeck.TheMCAshouldthereforedefinethesafetyimprovementitseeks,andthetimebywhichitistobeachieved,andifthenecessaryprogressisnotevidentthenmoveswiftlytointroducemandatorywearingoflifejacketsonsmallfishingvessels.

2.8.2 Liferaft

IanThomas’schancesofsurvivalwouldalsohavebeenincreasedhadHeather Anne’s liferaft floatedtothesurfaceandinflatedclosetothemeninthewater.Therefore,theliferaft’sdisappearanceisofseriousconcern.Theliferaftwasindateforserviceandwasreportedtohavebeeningoodcondition.Inaddition,boththeHRUandthe‘weaklink’appeartohaveoperatedcorrectly.Astheliferafthasnotbeenfound,itisimpossibletodeterminewhyitdidnotfunctionasexpected.Itcanonlybeassumedthattheliferaftinflatedsufficientlyforitsbuoyancyforcetobreakthe‘weaklink’butthatitonlypartiallyinflated,floatedawayandtheneventuallysank.

2.8.3 MOB Guardian

FollowingHeather Anne’scapsize,itwasfortunatethatLauren Kate wasnearbyandthatherskipperquicklyrealisedthatHeather Anne wasintroublewhenhesawherlightsandradartargetdisappear.Otherwise,itishighlylikelythatthealarmwouldhavebeenraisedonlywhenHeather Anne didnotreturntoMevagisseyasexpected.Hadthatbeenthecase,theresultanttimedelaywouldhavemeantthatHeather Anne’sskippermightalsohaveperished.

Heather Anne wasfittedwithanMOBGuardianinlieuofanEPIRB,butthesystemwasnotswitchedon(seeparagraph1.8).However,althoughwhenanMOBGuardiansystemisoperatingitprovidesimmediatenotificationashoreintheeventofamanoverboard,itdoesnotprovideimmediatenotificationinthecaseofthelossofavessel.Therefore,evenifthesystemonboardHeather Anne hadbeenswitchedon,thelossofcommunicationwiththesystem’sshorestationfollowingcapsizewouldnothavepromptedasearchandrescueasquicklyasanEPIRB.

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SECTION 3 - CONCLUSIONS

3.1 SAFETY ISSUES DIRECTLY CONTRIBUTING TO THE ACCIDENT wHICH HAVE RESULTED IN RECOMMENDATIONS

1.  Heather Annewasoperatingwithaverylowreserveofstabilityanditwouldhavetakenonlyaverysmallchangeinthevessel’sconditiontocausehertocapsize,[2.2]

2. Sincebuildin1971,Heather Anne hadbeenextensivelymodified.Themodificationshadsignificantlyincreasedherdisplacement,raisedhercentreofgravityandreducedherfreeboard.[2.3.1]

3. Therollwhichultimatelyledtothevessel’scapsizewouldhavebeenexacerbatedbythefreesurfaceeffectofthefishandentrainedwatercontainedinaPVCtankfittedinthefishroom.[2.3.2]

4.  Heather Anne wascarryinganestimated10.5tonnesoffish(includingentrainedwater)splitbetweenherfishroomandthedeck.Thiswasovertwicetheweightofcatchenvisagedbyherdesigner.[2.3.3]

5.  Heather Anne’scapsizeonly13monthsaftersuccessfullypassingarolltesthighlightsthatcautionneedstobetakenwhenavessel’sstabilityisassessedbyarolltestalone.Theresultsoftherolltestweremisleading.[2.4.1]

6. Theskipperdidnotappreciatethedangersoffittingthetarpaulintankinthefishroom.Hewasalsounawareofthevessel’sperilousconditionuntilmomentsbeforeshecapsized.Bythen,itwastoolateforanyeffectiveactiontobetaken.[2.4.2]

7. Otherthanhispreviousexperienceonboard,theskipperhadnoinformationorindicationofthemaximumloadHeather Anne wasabletosafelycarry.[2.5]

8. Thedeceasedwouldhavehadagreaterchanceofsurvivalhadhebeenwearingalifejacket.TheMCAshouldnowspecifywhatbehaviouralchangeitrequiresand,ifthisisnotdelivered,moverapidlytomandatethewearingofPFDswhileworkingonthedecksoffishingvessels.[2.8.1]

3.2 OTHER SAFETY ISSUES IDENTIFIED DURING THE INVESTIGATION ALSO LEADING TO RECOMMENDATIONS

1. ThelimitationsofthestabilityassessmentmethodssuggestedinMGN427(F)makethenoteoflittlepracticalusetofishermen.Thereisacompellingneedtoprovidestabilitycriteriaforfishingvessels<12m(L),whicharerelevanttotheirsize,constructionandoperation.[2.5]

2. TheWolfsonGuidancemarkispotentiallyaveryusefultooltohelpfishingvesselskippersdecideontheloadingoftheirvesselsinvaryingseaconditions.Unfortunately,itsaccuracyhasnotyetbeenvalidated.[2.5]

3. Thecurrentexemptionofexistingfishingvessels<12m(L)fromanystabilitycriteriaisunjustified,particularlyconsideringtheiraccidentrateandthehazardsassociatedwithfishingcomparedtoothersmallcommercialvesselactivities.[2.6]

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4. ThesafetyoffishingvesselswhicharesubstantiallymodifiedwiththesupportofanEFFgrantwouldbebetterassurediftheagenciesinvolvedworkedtogethertoensurethatthevesselsconcernedmaintainedsufficientreservesofstability,possiblythroughthelinkingofstabilityassessmentstothegrantconditions.[2.7]

5. It was fortunate that Lauren Kate wasnearby.Otherwise,itishighlylikelythatHeather Anne’sskipperwouldhavealsoperished.[2.8.3]

6. ThevesselwasnotfittedwithanEPIRB.[2.8.3]

3.3 SAFETY ISSUES IDENTIFIED DURING THE INVESTIGATION wHICH HAVE BEEN ADDRESSED OR HAVE NOT RESULTED IN RECOMMENDATIONS

1. Astheliferafthasnotbeenfound,itisimpossibletodeterminewhyitdidnotfunctionasexpected.Itisassumedthattheliferaftinflatedsufficientlyforitsbuoyancyforcetobreakthe‘weaklink’butthatitonlypartiallyinflated,floatedawayandtheneventuallysank.[2.8.2]

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SECTION 4 - RECOMMENDATIONS

TheMaritimeandCoastguardAgencyis recommended to:

2013/106 ReviseMGN427(F)inordertoprovideclearerandmorecomprehensive guidancetosurveyorsandfishermenonthemethodsavailabletoassess smallfishingvesselstability,takingintoaccount,interalia:

• Thelimitationsofthealternativestoafullstabilityassessment.

• Thesuitabilityofthealternativestabilityassessmentsforsmallfishingvessels.

• Avessel’sstabilityisdependentonseveralfactorsincludingheruprightGM,freeboardandhullform.

• Theneedforskipperstobeawareofthemaximumloadingoftheirvesselsandthebenefitsofafreeboardmark.

• Theimpactofvesselmodifications.

• Owners’andskippers’awarenessofstabilityconsiderationswhilefishing.

2013/107 Expediteitsdevelopmentandpromulgationofalternativesmallfishingvessel stabilitystandards,whichwillensurethatallnewfishingvesselsunder15m (L)aresubjecttoappropriatestabilityassessments,andwhichwilleventually beincludedinthestandardsbasedontheSmallCommercialVesselandPilot BoatCodescheduledforintroductionin2016.

2013/108 Specifytheimprovementinsafetyculture/behaviouralchangethatitis seekingwithrespecttothevoluntarywearingofpersonalflotationdevicesby individualsworkingonthedecksoffishingvessels,andthetimescalewithin whichitistobeachieved;

 and

Makearrangementstorapidlyintroducethecompulsorywearingofpersonalflotationdevicesontheworkingdecksoffishingvesselsifthesoughtafterchangesarenotdelivered.

TheMaritimeandCoastguardAgencyand theMarineManagementOrganisationare recommended to:

2013/109 Worktogethertolinkthefundingprovidedformodificationstosmallfishing vesselswithafullassessmentoftheimpactsuchmodificationswill haveonsuchvessels’stability,particularlywheretheproposedmodifications willsubstantiallyalterthemethodoffishingtobeundertaken.

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TheMaritimeandCoastguardAgency,theMarineManagementOrganisationand the CornishFishProducersOrganisationare recommended to:

2013/110 Worktogethertoarrangetrialsofthe‘Wolfson’markonboardaselection ofCornishfishingvesselsunder15m(L)inordertogathersufficientdatato enabletheMCAtoprovideclearevidenceonthemarks’practicality,accuracy and usefulness.

TheownerofHeather anneatthetimeoftheaccidentis recommended to:

2013/111 Takestepstoensurethatanyvesselhemayowninthefutureisoperated safely,takingintoaccounttheneedto:

• Accuratelydeterminethevessel’smaximumsafeloadingandbeguidedaccordinglywithregardtothesizeofcatchthatmaybetakenonboard.

• Re-apprisehimselfoftheguidanceavailabletofishermenregardingstability,particularlywithregardtothestowageofcargoandfreesurface effect.

• Carefullyconsidertheimpactonavessel’sstabilitybeforemakinganymodifications.

• CarryanEPIRBinordertoenableaswiftresponsebyshoreauthoritiesintheeventofvessellossorabandonment.

• Ensurethatallpersonsworkingonavessel’sopendeckwearPFDswhile at sea.

• Ensurethatallcrewhavecompletedtheirmandatorysafetytrainingcourses.

MarineAccidentInvestigationBranchJanuary2013

Safetyrecommendationsshallinnocasecreateapresumptionofblameorliability

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