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MARINEA
CCIDENT
INVESTIGATIO
N
BRANCH
ANNUAL
REPORT 2012
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Contents
Chief Inspectors Report 1
Part 1 - Full Investigations and Report Publications 5
Part 2 - Recommendations 11
Background 13
Recommendation response statistics 14
Recommendation methodology and summary tables 15
Section A - 2012 recommendation responses 17
Section B - Recommendations to multiple recipients 38
Section C - Recommendations brought forward from previous years 40
Section D - Changes to previously reported recommendations 52
Part 3 - Statistics 55
UK vessel accidents involving loss of life 57
UK merchant vessels greater than or equal to 100gt 59
UK merchant vessels less than 100gt 64
UK shing vessels 65
Non-UK commercial vessels 70
Annex - Statistics Coverage 71
Glossary of Abbreviations and Acronyms 73
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CHIEF INSPECTORS REPORT
Chief Inspectors Report
2012 has been a year of consolidation for the Branch. New working practices, which
were developed in the wake of the headcount and budget cuts of 2011, have been ne-
tuned and the work of the MAIB continues to receive praise from industry stakeholders.
However, our resilience to further change is much reduced. Staff turnover and sickness,
or other unplanned events, are now less easy to absorb and all MAIB staff are working
under tremendous pressure to deliver valuable, well-structured and intellectually rigorous
investigation reports to tight deadlines. That they continue to do so is testament to the
collective spirit of the Branch and I am indebted to every member of my team for their
commitment, hard work and professionalism.
July 2012 saw the introduction of new regulations: the Merchant Shipping (Accident
Reporting and Investigation) Regulations 2012. The primary purpose of these was to
transpose Directive 2009/18/EC which establishes fundamental principles of marineaccident investigation across the European Union. In particular, the Directive requires
member states to investigate all very serious marine casualties (i.e. accidents that lead to
loss of life, the loss of a vessel or severe pollution) involving commercially operated craft
and shing vessels of 15m or more in length. However, the Branch has been operationally
compliant with the requirements of the Directive since 2011 and therefore the introduction
of new regulations has had a limited impact on our work. That said, during 2012 a new
Branch database has been developed which shares the same taxonomy as the European
Marine Casualty Information Platform (EMCIP). The Directive requires member states to
populate the EMCIP with comprehensive marine casualty data, which is potentially a very
labour intensive task. The new Branch database has the ability to automatically populate the
EMCIP, which will optimise the time spent transferring the data.
One manifestation of a more challenging working environment is that the average time taken
to produce published reports has been increasing slightly from just under 8.5 months in 2011
to 8.6 months in 2012. Some, such as the highly detailed Tombarra reports (MAIB reports
19A & 19B/2012) have taken in excess of 12 months to complete. Looking ahead there is
little prospect of additional resources being available in the medium term and so the Branch
is exploring how digital technology might be used more effectively to promulgate its product
reports and safety lessons to its stakeholders. For example, the MAIB can now be found
on Twitter (please follow us!). In order to improve production times and reduce cost, the use
of password protected soft copies of draft and nal reports is likely to become the norm withmuch less reliance being placed on hard copy print runs. Similarly, work will be progressed
to enable stakeholders comments during consultation periods to be received and processed
electronically.
Thirty investigation reports were published in 2012 compared with 29 in 2011. Two editions
of the Safety Digest were also published. 26 investigations were commenced during the
year compared with 43 in 2011. The decrease in the number of investigations launched
during 2012 reects a more considered approach to deployments in the eld which has been
developed to closely manage the Branch workload. The range of investigations conducted
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MAIB ANNUAL REPORT 2012
during the year has been diverse, ranging from the foundering of small inland waterway craft
through to major collisions between large cargo vessels. A number of issues identied during
MAIB investigations are worthy of note:
A collision between the cargo vessels Seagateand Timor Stream, which occurred
in March 2012, was one of several similar accidents reported to the MAIB whereexperienced seafarers either ignored or did not know the requirements of the COLREGS.
In this case, the investigation quickly identied that the watchkeepers on the two vessels,
both of whom were senior ofcers, did not maintain even the most rudimentary level
of watchkeeping. Of particular concern is the message this behaviour sends to junior
ofcers and how it may inuence the next generation of master mariners. One of the
biggest challenges faced by ship managers is ensuring that company safety management
systems are being adhered to at all times. Part of the solution requires a real commitment
to the safety management system from the highest echelons of management, together
with a concerted effort to instil the companys safety culture within ships senior staff.
Robust audit regimes, preferably conducted during voyages, are useful but only providesnapshots of how ships are being operated. The random scrutiny of voyage data
and other ship-generated records can also help to gauge compliance with company
procedures and provide managers with early warnings should shipboard routines present
a risk to safety when not under the scrutiny of an auditor.
The excessive consumption of alcohol by watchkeepers on commercial vessels is a
persistent problem. This was typied by the collision between the coaster Union Moon
and the passenger ferry Stena Feronia(MAIB Report 26/2012) in which the master, who
was alone on the bridge of Union Moon, was found to be drunk. Alcohol was also an
issue when the feeder container vessel Karin Schepersgrounded off the Cornish coast
(MAIB Report 10/2012.) In both cases the companies concerned operated drug and
alcohol policies that were weak and ineffective.
The small shing vessels Heather Anne, Purbeck Isleand Sarah Jaynewere tragically
lost, partly because they were overloaded. There is currently no requirement for small
(ie
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CHIEF INSPECTORS REPORT
International Maritime Organization. The Branch also works closely with its sister Accident
Investigation Branches, the RAIB and the AAIB to share best practices, but also to identify
synergies and savings where appropriate. We learn as much as we teach during these
exchanges and the Branch becomes stronger from the fresh ideas that this dialogue
generates.RECOMMENDATIONS
54 Recommendations were issued during 2012, of which 94.4% were accepted. This
compares with 93.0% in 2011.
1 recommendation was rejected. This was made to the Department for Transport following
the collision between Morland Sun Clipperon the River Thames (MAIB Report 8/2012
see page 22). One recommendation (to the owner of a shing vessel) has not been
responded to. The MAIB operates a closed loop follow-up process which keeps outstanding
recommendations under constant review.
Of the 214 recommendations that had been accepted, but had not been implementedbetween 2004 and 2011, 87.4% were reported to be fully implemented at the time this report
was published.
STATISTICS
For the third year in succession there were no UK registered ship losses of vessels 100gt.
The number of accidents, as a ratio of the size of the eet, has increased from 76/1000
vessels in 2011 to 92/1000 vessels in 2012. However, this ratio is slightly lower than the
statistical average for the last 10 years (94/1000 vessels).
There were 3 deaths of merchant vessel crew on vessels of 100gt compared to 5 in 2011.
The number of injuries to passengers (50) is at a 10 year low but this may be largely due to
a reduction in the number of large passenger vessels registered in the UK.
Perhaps the most encouraging statistic for 2012 is that the number of shing vessels lost (9
vessels) is at a 10 year low. The main improvement appears to be in the
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MAIB ANNUAL REPORT 2012
FINANCE
The annual report deals principally with the calendar year 2012. However, for ease of
reference, the gures below are for the nancial year 2012/13, which ended on 31 March
2013. The MAIBs funding from the Department for Transport is provided on this basis, and
this complies with the Governments business planning programme.
000s 2012/13 Budget 2012/13 Outturn
Costs Pay 2551 2508
Costs Non Pay 1078 982
Totals 3629 3490
Steve Clinch
Chief Inspector of Marine Accidents
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CHIEF INSPECTORS REPORT
PART 1
FULL INVESTIGATIONS ANDREPORT PUBLICATIONS
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MAIB ANNUAL REPORT 2012
FULL INVESTIGATIONS LIST
Full Investigations started in 2012
Date Name of Vessel Type of Vessel Flag State Size Nature of Incident
Merchant Vessels
16 Jan Dette G Container ship Antigua and
Barbuda
3999 gt Fatal man overboard during cargo
operations while alongside in
Queen Elizabeth Dock, Hull
7 Mar Stena Feronia/
Union Moon
Ro-ro ferry/General
cargo vessel
UK/Cook
Islands
21856
1543
gt
gt
Collision in Belfast Lough, Northern
Ireland
10 Mar Seagate/Timor
Stream
General cargo
vessel/Refrigerated
cargo vessel
UK/Liberia 17590
9307
gt
gt
Collision approximately 25nm north
of the Dominican Republic coast
24 Mar Spring Bok/Gas
Arctic
General cargo
vessel/LPG tanker
Netherlands/
Malta
12113
2985
gt
gt
Collision in English Channel 6nm
south of Dungeness, English
Channel
29 Mar Saga Sapphire Cruise ship Malta 37301 gt Two men overboard while
conducting a lifeboat drill alongside
in Southampton
3 Apr Carrier General cargo
vessel
Antigua and
Barbuda
1587 gt Grounding off the North Wales
coast
10 Jun E.R. Athina Platform supply
ship
Liberia 4488 gt Fatal injury to a crew member while
at anchor off Aberdeen
2 Jul Coastal Isle General cargo
vessel
Antigua and
Barbuda
3125 gt Grounding while on passage off
Greenock
1 Aug Alexander
Tvardovskiy/
UKD Bluen/
Wilson Hawk
General cargo
vessel/Dredger/
General cargo
vessel
Russia/UK/
Barbados
2319
4171
2811
gt
gt
gt
Collision involving three vessels in
Immingham Dock, Lincolnshire
19 Sep Vixen Small inland
waters passenger
vessel
UK 6 m Flooding and foundering on Loch
Lomond. No injuries
2 Oct Wah Shan Bulk carrier Panama 91165 gt Fatal injury to crewman during
mooring operations in Immingham,
Lincolnshire
15 Nov Amber Bulk carrier Malta 10490 gt Contact with moored bargesfollowed by grounding on River
Thames at Gravesend
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Date Name of Vessel Type of Vessel Flag State Size Nature of Incident
21 Nov Windcat 9 Wind farm support
vessel
UK 17.25 m Contact with a buoy off the Norfolk
coast causing damage that led toooding
21 Nov Island Panther Wind farm support
vessel
UK 16.8 m Contact with wind turbine tower
off Norfolk coast causing damage
that led to ooding and some minor
injuries
25 Nov Timberland Bulk carrier UK 13066 gt Fatal man overboard involving two
crewmen in North Sea
5 Dec Arklow Meadow General cargo
vessel
Ireland 9682 gt Escape of toxic cargo fumigant
while discharging at Warrenpoint,Northern Ireland
12 Dec Beaumont General cargo
vessel
UK 2545 gt Grounding near Cabo Negro, north
Spain
Fishing Vessels
Date Name of Vessel Type of Vessel Flag State Size Nature of Incident
13 Jan St Amant Scallop dredger UK 17.8 m Loss of a crewman off the north-
west Wales coast
29 Jan Zenith Trawler UK 21.4 m Fatal man overboard in the Irish
Sea, 29 miles south-east of Kilkeel
11 Apr Onward Trawler UK 21.3m Fire, 60nm off the north coast of
Scotland resulting in the loss of the
vessel. There were no injuries
17 May Purbeck Isle Potter UK 11.6m Vessel lost with all three crew
9nm south of Portland Bill, English
Channel
9 Jul Denarius Trawler UK 22.4m Fire and abandonment in the North
Sea 83nm NNE of Kinnaird Head.
There were no injuries
23 Jul Betty G Beam trawler UK 9.9m Capsize in Lyme Bay while
recovering beam gear. Crew were
safely recovered from liferaft
10 Aug Audacious Trawler UK 27.6m Flooding and sinking in the North
Sea 45nm east of Aberdeen. Crew
abandoned to liferaft and were
safely recovered
Ful l invest igat ions l is t
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MAIB ANNUAL REPORT 2012
Date Name of Vessel Type of Vessel Flag State Size Nature of Incident
1 Sep Chloe T Trawler UK 26.2m Flooding and sinking in the English
Channel, 17nm south of Bolt Head,
Devon. Crew abandoned to liferafts
and were safely recovered
11 Sep Sarah Jayne Trawler UK 14.94m Foundering in the English Channel
off Brixham. Two crew were
rescued but the skipper drowned
PUBLICATIONS LIST
Reports of Full Investigations published in 2012
Vessel Name(Report No)
Vessel Type Accident Type AccidentDate
Merchant Vessels
CSL Thames
(No 2/2012)
Bulk carrier Grounding in the Sound of Mull, West Scotland 9 Aug 11
Clonlee
(No 6/2012)
Feeder container
vessel
Electrical blackout and subsequent grounding on
the River Tyne
16 Mar 11
Blue Note
(No 7/2012)
Dry cargo vessel Derailment of the hatch-lid gantry crane while
alongside in Londonderry, Northern Ireland
22 Jul 11
Sun Clipper/Morl
(No 8/2012)
Passenger vessel/
rigid-hulled
inatable boat
Collision by Blackfriars Road Bridge, River Thames,
London
1 Jun 11
Safer
(No 9/2012)
Cargo vessel Failure of the controllable pitch propeller resulting
in heavy contact with a berthed tug in Immingham
harbour, Lincolnshire
25 Jun 11
Karin Schepers
(No 10/2012)
Container vessel Grounding at Pendeen, Cornwall 3 Aug 11
Dette G
(No 11/2012)
Container vessel Fatal man overboard during cargo operations while
alongside in Queen Elizabeth Dock, Hull
16 Jan 12
Chiefton
(No 12/2012)
Tug Collision, capsize and foundering, with
the loss of one crew member at Greenwich Reach,
River Thames
12 Aug 11
Scot Pioneer
(No 13/2012)
Cargo vessel Fatal injury to a crewman during cargo operations
at Belview Port, Waterford, Republic of Ireland
27 Oct 11
Cameron
(No 14/2012)
Mooring vessel Serious injury to a chief ofcer, Crosby Channel,
Liverpool
21 Nov 11
Ful l invest igat ions l is t
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PART 1: INVESTIGATIONS/PUBLICATIONS
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Vessel Name
(Report No)
Vessel Type Accident Type Accident
Date
Clipper Point
(No 16/2012)
Ro-ro cargo ferry Contact between ferry and two berthed ships at the
Port of Heysham, Lancashire
24 May 11
Pride of Calais
(No 18/2012)
Ro-ro vessel Machinery failure leading to contact with the berth
in Calais, France
22 Oct 11
Tombarra Part A
The weight of the
rescue boat
(No 19A/2012)
Car carrier Fatality to a rescue boat crewman, Royal Portbury
Docks, Bristol
7 Feb 11
Tombarra Part B
The failure of the
fall wire(No 19B/2012)
Car carrier Fatality of a rescue boat crewman, Royal Portbury
Docks, Bristol
7 Feb 11
Tempanos
(No 20/2012)
Container vessel Fatal accident on board the container vessel while
berthed in the Port of Felixstowe, UK
17 Dec 11
Moon Clipper
(No 21/2012)
High-speed
catamaran
Steering control failure and subsequent contact with
Tower Millenium Pier on the River Thames, London
resulting in injuries to 14 passengers and 2 crew
5 Oct 11
Ernest Bevin
(No 22/2012)
Ferry Fatal accident of a crew member on the Woolwich
ferry on the River Thames, London
3 Aug 11
SD Nimble
(No 23/2012)
Tug Accidental discharge of carbon dioxide resulting in
serious injury to a shore-based service engineer at
HM Naval Base Faslane, West Scotland
23 Aug 11
Springbok/Gas
Arctic
(No 24/2012)
Cargo ship/LPG
tanker
Collision in the English Channel 6nm south of
Dungeness
24 Mar 12
Saga Sapphire
(No 25/2012)
Cruise ship Two men overboard while conducting a lifeboat drill
alongside No 106 berth, Southampton
29 Mar 12
Stena Feronia/
Union Moon
(No 26/2012)
RoPax vessel/
cargo vessel
Collision in Belfast Lough, Northern Ireland 7 Mar 12
Norcape
(No 28/2012)
Ro-ro cargo ferry Windlass damage, grounding and accident to
person, Firth of Clyde and Troon Harbour, West
Scotland
26-27
Nov 11
Ful l invest igat ions l is t
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MAIB ANNUAL REPORT 2012
Fishing Vessels
Vessel Name
(Report No)
Vessel Type Accident Type Accident
Date
Vellee
(No 1/2012)
Trawler Flooding and foundering in the Little Minch, West
Scotland6 Aug 11
Golden Promise
(No 3/2012)
Scallop dredger Grounding off the Island of Stroma, North Scotland 7 Sep 11
About Time
(No 5/2012)
Potter Fatal man overboard off Pembrokeshire 14 Jun 11
Starlight Rays
(No 15/2012)
Trawler (working
as guard vessel)
Fatal accident to a crewman 126nm NNE of
Aberdeen
25 Aug 11
Moyuna
(No 17/2012)
Scallop dredger Grounding at the entrance to Ardglass Harbour,
Northern Ireland
21 Nov 11
Onward
(No 27/2012)
Stern trawler Fire on board shing vessel 60nm off the north
coast of Scotland resulting in the loss of the vessel
11 Apr 12
Small Craft
Lion
(No 4/2012)
Reex 38 yacht Fatal man overboard 14.5 miles south of Selsey
Bill, West Sussex
18 Jun 11
Morl/Sun Clipper
(No 8/2012)
See Merchant vessel section for details
Publ icat ions l is t
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PART 2: RECOMMENDATIONS
PART 2
RECOMMENDATIONS
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MAIB ANNUAL REPORT 2012
RECOMMENDATIONSResponses to safety recommendations issued by the Marine Accident Investigation Branch.
This report is submitted to the Secretary of State for Transport in accordance with The Merchant
Shipping (Accident Reporting and Investigation) Regulations 2012, regulation 16(5).
Page
Background 13
Recommendation response statistics 14
Recommendations methodology 15
Section A - 2012 recommendation responses 17
Section B - Recommendations to multiple recipients 38
Section C - Recommendations brought forward from previous years 40
Section D - Changes to previously reported recommendations 52
For details of abbreviations and acronyms used in this section please refer to the glossary on
page 73.
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PART 2: RECOMMENDATIONS
BACKGROUND
Recommendations are a key element of MAIB investigations. They are made to promulgate the
lessons from accidents investigated by the MAIB, with the aim of improving the safety of life at sea
and the avoidance of future accidents. The issue of a recommendation shall in no case create a
presumption of blame or liability.
Following a full investigation the MAIB will, normally, make a number of recommendations.
These will be contained within the published report but will also be addressed to the individuals
or senior executives of organisations concerned, in writing, by the Chief Inspector. Urgent safety
recommendations may also be made in Safety Bulletins that can be published at any stage of an
investigation.
Recommendations are made to a variety of addressees who might have been involved in, or have
an interest in, the accident. These may range from those organisations which have a wider role in
the maritime community such as the Department for Transport (DfT), the Maritime and CoastguardAgency (MCA) or an international organisation, through to commercial operators and vessel
owners/operators who may have specic issues to address on board their vessels.
It is required by the Merchant Shipping (Accident Reporting and Investigation) Regulations
2012 that the person or organisation to whom a recommendation is addressed, consider the
recommendation, and reply to the Chief Inspector within 30 days on the plans to implement the
recommendation or, if it is not going to be implemented, provide an explanation as to why not. The
Regulations also require the Chief Inspector to inform the Secretary of State of those matters
annually, and to make the matters publicly available. This Annual Report to the Secretary of State
for Transport fulls this requirement.
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MAIB ANNUAL REPORT 2012
RECOMMENDATION RESPONSE STATISTICS 2012
54 recommendations were issued in 2012. Of these, the percentage of all recommendations
that are either acceptedor accepted yet to be implemented is 94.4 %.
Throughout the report recommendations are categorised under four broad headings accordingto the industry sector to which they apply: General Maritime, Commercial Shipping, Fishing
Vessels or Leisure Vessels.
Focus Subtotal
Accepted
Action
Implemented
Accepted
Action
yet to be
Implemented
Partially
AcceptedRejected
No Response
Received
Commercial
Shipping36 27 9 - - -
FishingVessels
7 5 - - - 2
Leisure
Vessels3 2 - - 1 -
General
Maritime8 7 1 - - -
Total 54 41 10 - 1 2
Details of all these recommendations are at Sections A-C.
RECOMMENDATION RESPONSE STATISTICS 2004 to 2011
The following table shows the equivalent status of recommendations issued in 2004 to 2011 as
published in the MAIBs previous Recommendations Annual Reports.
Year Total
Accepted
Action
Implemented
Accepted
Action yet to be
Implemented
Partially
AcceptedRejected
No Response
Received
2011 57 33 21 2 - 1
2010 50 36 14 - - -
2009 117 74 29 7 - 7
2008 110 71 31 5 - 3
2007 136 109 23 1 1 2
2006 139 103 30 3 3 -
2005 140 122 14 1 1 2
2004 171 93 52 11 11 4
Of the 214 recommendations listed as accepted yet to be implemented (at time of publication
of relevant annual report): 87.4%have now been fully implemented
12.6%remainplanned to be implemented.
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PART 2: RECOMMENDATIONS
RECOMMENDATION METHODOLOGY
SECTION A - 2012 recommendation responses.
SECTION B - Recommendations to multiple recipients (not included in the statistics).
SECTION C - Recommendations brought forward from previous years.
SECTION D - Changes to previously reported recommendations.
Section A presents all of the recommendations issued in 2012 in ascending numerical order. Each
one is accompanied by the vessel/accident type, level and industry focus of the recommendation.
Where it is appropriate MAIB has included a comment alongside the recommendation narrative.
Section C lists recommendations issued in previous years that remain open; they are presented
in descending numerical order under the year in which they were issued. The actions being taken
to meet these recommendations are ongoing, so each one is accompanied by a target date for
implementation and a comment if needed.
KEY
Levels
The level of the recommendation refers to the type of action required by the recipient. There are
three levels of recommendation:
Level 1 recommendations These have the broadest importance, and may include the
requirement for new legislation or changes in policy.
Level 2 recommendations Addressed to industry bodies and organisations which may call
for changes or reinforcement of best practice.
Level 3 recommendations Those which are addressed to individual owners or companies
which are specic to their vessel or company.
Focus
The focus refers to the sector of industry that the recommendation was applied to:
C (Commercial Shipping) Merchant vessels and small commercial craft.
FV (Fishing Vessel) Registered shing vessels holding a DEFRA shing vessel
licence.
L (Leisure) Recreational vessels, whether operated commercially orprivately owned.
G (General Maritime) Recommendations that have wider application.
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MAIB ANNUAL REPORT 2012
Colour coding
Green : The actions included in these recommendations have been fully accepted by the
recipient, and the changes have been fully implemented.
Yellow : These recommendations have been accepted by the recipient, but the actions neededto close the recommendation are outstanding. Where known, target dates for full
implementation are given.
Red : These recommendations have either been partially accepted or rejected by the
addressee, or no response has yet been received by the MAIB. Partially accepted
and rejected recommendations include comments in the Annual Report and offer the
opportunity to comment to the addressee.
SUMMARY TABLE FOR LEVEL 1, 2 AND 3 RECOMMENDATIONS
Focus Total
Accepted
Action
Implemented
Accepted
Action yet
to be
Implemented
Partially
AcceptedRejected
No Response
Received
Level 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
Commercial
Shipping4 7 25 - 4 23 4 3 2 - - - - - - - - -
Fishing
Vessels0 - 7 1 - 5 - - - - - - - - - - - 2
Leisure
Vessels2 1 - 1 1 - - - - - - - 1 - - - - -
General
Maritime- 2 6 - 1 6 - 1 0 - - - - - - - - -
Total 6 10 38 2 6 34 4 4 2 - - - 1 - - - - 2
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PART 2: RECOMMENDATIONS
Section A
2012 RECOMMENDATION RESPONSES
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MAIB ANNUAL REPORT 2012
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
101
Vellee
Fishingvessel
Flooding&
foundering.
(Report1/2012)
Madeto:Vesselowner
Accepted,fullyimplemented
FV
3
Improvetheplannedmaintenanceandinspec
tionregimesonallvessels
inwhichtheyh
oldaninterest,withparticularfocusontheintegrityofsea
watersystems,hullttingsandidenticationa
ndpreventionofelectrolytic
corrosion.
102
CSLThames
Bulkcarrie
r
Grounding
intheSound
ofMull,WestScotland.
(Report2/2012)
Madeto:AlfaS
hipandCrewManagementGmbH
Withdrawn
C
3
Introducewritteninstructionsandguidanceto
itseetandcarryout
vericationvisitstoitsvesselsasnecessarytoensurethat:
Itsbridgew
atchkeepingofcershaveaclearunderstandingofhow
ECDISsho
uldbeusedonboardthecompanysvessels.
Itsofcersandcrewunderstandthevesselsemergencyprocedures,
andtheneedtoproperlyevaluateroutine
operationsafteranaccidentto
ensurethatanynewrisksareidentiedandmitigatedasappropriate.
MAIBcomment:
TheMAIBhas
withdrawnthisrecommendationasAlfaShipandCrew
Managementnolongermanageanyvesse
ls.
103
Golden
Promise
Fishingvessel
Grounding
ontheIsleof
Stroma,NorthScotland.
(Report3/2012)
Madeto:John
MacAlister(ObanLtd)Ltd
Noresponsereceived
FV
3
Enhancethesafetymanagementofitsvesselsby:
Referringtoandapplyingthebestpracticeguidanceforkeepinga
safenaviga
tionalwatchonshingvessels
promotedinMGN313(F),
includingarrangementsforensuringthe
tnessfordutyofwatchkeepers
andprovisionofaneffectivewatchalarm.
Ensuringallcrewmembershavecompletedallmandatorysafetytraining
courses.
Awaitingupdatefromrecip
ientattimeofpublication
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PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Accidenttype
NarrativeandA
ddressee
Focus
Level
104
Lion
Reex38yacht
Fatalman
overboard.
(Report4/2012)
Madeto:RoyalOceanRacingClub
Accepted,fullyimplemented
L
2
Promulgatethe
followingsafetyissuestoitsrespectivemembershipsandto
theoffshoreracingcommunity:
Theimportanceofnominatingapersonto
takeoverfromtheskipperin
theevento
fhis/herincapacitation.
Theuseof
longandshorttethers/safetylines,asappropriate,toprevent
amanoverboardsituation.
Procedures
indealingwith,andthedifcu
ltiesassociatedwith
recovering
aconsciousandunconsciousmanoverboardwhiletethered
tothevessel.
105
AboutTime
Fishingvessel
Fatalman
overboard.
(Report5/2012)
Madeto:Vesselowner
Accepted,fullyimplemented
FV
3
Refertotheav
ailableindustrybestpracticeguidanceandreviewtherisk
assessmentforAboutTimeandanyothervesselshemayown,toidentify
measurestoim
proveonboardsafetyby:
Identifyingthehazardsposedduringthetransportationofshinggearon
deckande
nsuringtheeffectivesegregationofthecrewfromthegear;
Ensuringth
euseofappropriatefootwearatalltimes;
Evaluating
thehazardsposedbylowbulw
arks;
Appraising
theuseofpersonalotationde
vices(PFDs)andpersonal
locatorbea
cons(PLBs);
Ensuringallcrewhavecompletedthemandatorysafetytrainingcourses.
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MAIB ANNUAL REPORT 2012
Case
Investigation
Vessel/Accidenttype
NarrativeandA
ddressee
Focus
Level
106
Clonlee
Feedercontainervessel
Electricalb
lackoutand
subsequen
tgrounding.
(Report6/2012)
Madeto:North
AtlanticShippingLtd
Accepted,fullyimplemented
C
3
CarryoutacomprehensivereviewofitsSafetyManagementSystem,which
should,asaminimum:
Ensureonb
oardworkingpracticesmakeb
estuseofthecrewresources
available,a
ndcomplywithallappropriate
international,FlagStateand
localmaritimeregulatoryrequirements.
Ensureitsinstructionsandproceduresareachievable,areadhered
toonboard
,andreectthemachineryandcontrolsystemsttedtoits
vessels.
Ensureallitsvesselsareprovidedwithmanufacturersinstruction
manuals,in
thedesignatedworkinglangu
age,forallcriticalequipment
andsystem
sonboard.
Reviewonboardtraining,andtakeapprop
riateactiontoimproveits
crewseme
rgencyresponseperformance.Particularconsideration
shouldbeg
iventopromotingcrewresourcemanagementandimproving
thestandardsofinternalcommunications.
Developarobustprocessformanagingsafety-relatedobservations
madebyexternalbodiesandrecordingan
yrelatedcorrectiveactions
taken.
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PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Accidenttype
NarrativeandA
ddressee
Focus
Level
107
BlueNote
Drycargovessel
Derailmentofthehatch-
lidgantryc
ranewhile
alongside.
(Report7/2012)
Madeto:Reed
erei-MeyeringGmbH
Accepted,fullyimplemented
C
3
Ensurethatcre
wsonitsvesselscomplywith
theintentoftheInternational
SafetyManage
mentCodeandapplicablenationalandinternationallifting
equipmentregulationsby:
Theestablishmentofformal,writtenriska
ssessmentsofshipboard
activities.
Theprovisionofequipmentplannedmaintenanceschedulesand
systemsforrecordingmaintenanceofrep
airs.
Ensuringth
atallrelevantmanufacturersmanualsforoperatingand
maintaining
equipmentareprovidedonbo
arditsvessels.
Theintrodu
ctionofarequirementforspec
ictrainingandacompetence
checkforth
osecrewmembersinvolvedin
theoperationofgantrycranes
tofulltherequirementforfamiliarisationtraining.
108
BlueNote
DryCargo
vessel
Derailmentofthehatch-
lidgantryc
ranewhile
alongside.
(Report7/2012)
Madeto:Marin
erShipsEquipment
Accepted,fullyimplemented
C
3
Reviseitsgantrycranedesignto:
Provideafacilityforthecrewtosafelyandefcientlycheckthatthe
hooksarefullyengagedintothehatch-lidssidesockets.
Notwithstandingactionsalreadytaken,provideclearindicationwhenthe
hooksarenotengagedtowarnoperators
nottocarryonlifting(suchas
bypainting
theendsofthehooksinahighlyvisiblecolour,orbyother
means).
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PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
110
Morl/
SunClipper
Rigid-hulle
dinatable
boatandp
assenger
vessel
Collision.
(Report8/2012)
Madeto:PortofLondonAuthority
Accepted,fullyimplemented
L
1
TakeactiontofurtherenhancethesafenavigationofallvesselsontheRiver
Thames,takingintoaccounttheincreasedac
tivityexpectedontheriverin
2012,by:
Introducing
asquicklyaspossibleamand
atoryspeedlimitontheareas
oftheRiverThameswheresuchlimitshavebeendeterminedtobe
necessarybyriskassessment.
Exploringa
ndimplementingfurthermeansofeffectivelypromulgating
localregula
tionsandnavigationalandsafetyadvicetotherecreational
usersoftheRiverThames,particularlythosewhoarenotmembersof,
orafliated
to,theriversestablishedclubsandassociations.
111
Safer
Cargovessel
Failureofthe
controllablepitch
propeller.
(Report9/2012)
Madeto:DeBockMaritiemB.V.
Accepted,fullyimplemented
C
3
ReviewSafer
ssafetymanagementsysteminorderto:
Improvesh
ipsofcersinductionproceduresandtrainingforthemain
propulsion
systemanditsmanoeuvringco
ntrols.
Ensureafu
llrangeofaheadandasternp
itchtestsarecarriedoutprior
toportdepartureandarrival.
Clarifyanchoringandanchorreadinessprocedures.
Requireshipscrewtocarryoutperiodicd
rillstopractisethecorrect
responsetopropulsionsystemfailures.
Regularlytestthearrangementsprovided
fortheoperationofpropulsion
systemsin
anemergency.
112
Safer
Cargovessel
Failureofthe
controllablepitch
propeller.
(Report9/2012)
Madeto:MAN
DieselandTurboSE
Accepted,fullyimplemented
C
3
Enhancetheappearanceandlabellingofthe
backupcontrolbuttonon
Alphatronic2000PropulsionControlSystems
sothatduringanemergency
itsfunctionism
orereadilyapparent.
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MAIB ANNUAL REPORT 2012
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
113
Safer
Cargovessel
Failureofthe
controllablepitch
propeller.
(Report9/2012)
Madeto:BureauVeritas
Accepted,yettobeimplemented
C
3
Makeasubmis
siontoIACStointroduceauniedrequirementfor
controllablepitchpropellersystemstobesubjectedtoafullrangeoftestsin
bothaheadandasterndirectionsduringthec
ommissioningtrialsofnewand
existingsystem
s.
Targetdatefo
rcompletion-notgiven
114
Karin
Schepers
Containervessel
Grounding
atPendeen,
Cornwall.
(Report10
/2012)
Madeto:MCA
Accepted,fullyimplemented
G
2
Provideoperationalguidancetocoastguardo
fcersontheuseofpowersof
directiontopre
ventavesselfromleavingUK
watersincircumstanceswhere
thepowersdelegatedtotheSOSREPhaven
otbeeninvoked.
115
Karin
Schepers
Containervessel
Grounding
atPendeen,
Cornwall.
(Report10
/2012)
Madeto:MCA
Accepted,yettobeimplemented
G
2
Assessthedesirabilityof,and,whereappropriate,developoperational
guidelinesforu
singAutomaticIdenticationS
ystems(AIS)datatomonitor
marinetrafcm
ovements.Specialconsiderationshouldbegivento
usingAISdata
tomonitormarinetrafcmovementinareasofhightrafc
concentrations,includingtrafcseparationschemes,wherethereislimited
ornoradarcov
erage.
Targetdatefo
rcompletion-June2015
116
Chiefton
Tug
Collision,c
apsizeand
foundering
withtheloss
ofone
crewmember.
(Report12
/2012)
Madeto:MCA
Accepted,yettobeimplemented
C
2
Advisecertifyin
gauthoritiestoensuretheirsu
rveychecklistsreectthe
contentofSub-section25.2.2oftheSmallCo
mmercialVesselandPilot
BoatCode,by
includingarequirementtochecktheefcientoperationofthe
emergencyreleasesystemfromalloperating
positions.
Targetcomple
tiondate-December2013
Awaitingupdatefromrecip
ientattimeofpublication
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PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
117
Chiefton
Tug
Collision,c
apsizeand
foundering
withtheloss
ofone
crewmember.
(Report12
/2012)
Madeto:MCA
Accepted,yettobeimplemented
C
2
Provideadditio
nalguidancerelatingtothefollowingelementsofcombined
push/pulltowageoperations:
Tugselectiontoensurethatbollardpullis
appropriatefortheintended
operation.
Theimportanceofeffectivecommunicatio
nstoensurecontroloftowing
operations
atallstages.
Theassess
mentandadjustmentoftowle
ngthtoavoidtheriskof
overrunand,specically,includetheseelementsintheUnderpinning
Knowledge
syllabiofthedraftMarineGuidanceNote-Towage
Endorseme
nts.
Targetcomple
tiondate-August2013
118
Chiefton
Tug
Collision,c
apsizeand
foundering
withtheloss
ofone
crewmember.
(Report12
/2012)
Madeto:BTA,
NWA,BPA,UKMPG
Accepted,fullyimplemented
C
2
PromulgateMA
IBsSafetyFlyeratAnnexJto
theirmembership.
119
Chiefton
Tug
Collision,c
apsizeand
foundering
withtheloss
ofone
crewmember.
(Report12
/2012)
Madeto:PalmerMarineServicesLtd
Accepted,fullyimplemented
C
3
ReviewitsprocedurestoensurecompliancewiththePLAsCodeofPractice
forCraftTowag
eOperationsontheThames2
011andtheMCAsSmall
CommercialVe
sselandPilotBoatCodeinrespectto:
Towinghoo
ktesting,maintenanceandrecordkeeping
Useoflifejackets
Maintaining
watertightintegrity
Conductof
riskassessments.
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MAIB ANNUAL REPORT 2012
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
120
StarlightRays
Fishingvessel
Fatalaccid
entto
crewman.
(Report15
/2012)
Madeto:Owne
r/skipperofvessel
Accepted,fullyimplemented
FV
3
Improvethestandardofoccupationalsafetya
ndprotectionforcrewworking
ontheirvessel
by:
Ensuringth
attheuseonboardofanypor
tableengine-drivenpumpsis
inaccordan
cewiththeguidanceprovided
bytheMCA.
Educatingandsupervisingcrewtopreven
tthemfromusingdangerous
workingpra
ctices.
121
Cameron
Mooringve
ssel
Seriousinjuryto
crewman.
Report14/2012)
Madeto:BriggsMarineContractorsLtd
Accepted,fullyimplemented
C
3
Introducemeasurestoimprovethesafetyofdeckoperationsconductedon
boarditsvesse
ls,byensuringthat:
Alltasksar
eappropriatelyplannedandbr
iefed.
Supervisingofcersandratingsmaintainanobjectiveoverviewofthe
workbeing
undertaken.
Risksassociatedwithliftingoperationsareidentied,assessed,and
haveappro
priatecontrolmeasuresinplac
e,and
Allcrewarefamiliarwith,andadhereto,a
pplicableregulationsand
guidance.
122
ClipperPoint
Ro-rocarg
ovessel
Contactbe
tweenferry
andtwobe
rthedships.
(Report16
/2012)
Madeto:SeatruckFerriesLtd
Accepted,fullyimplemented
C
3
Workwithothe
rstakeholdersinthePortofHeysham,anddevelopand
implementaprogrammetoensurethattheirb
ridgeteamsareproperly
trainedandsupportedtoenablethemtoimprovetheirperformancetoavoid
onepersonse
rrorleadingtoanaccident.
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PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
123
ClipperPoint
Ro-rocarg
ovessel
Contactbe
tweenferry
andtwobe
rthedships.
(Report16
/2012)
Madeto:HeyshamPortLtd
Accepted,fullyimplemented
G
3
ReviewtheimplementationofthePortMarine
SafetyCodeinthePortof
Heyshamtoen
surethat:
Itsriskassessmentisanaccurateassess
mentoftheportsrisks.
Communicationbetweentheportsmanagersandtheportsusersis
effectivean
dproactive.
Arisk-base
dprocedure,thatrequiresferryoperatorstodemonstrate
howthepo
tentialhazardsfromvesselsth
atroutinelyusetheportcanbe
controlled,
isestablished.
Theprovisionoftowageservicesisappro
priate.
124
ClipperPoint
Ro-rocarg
ovessel
Contactbe
tweenferry
andtwobe
rthedships.
(Report16
/2012)
Madeto:MCA
Accepted,fullyimplemented
G
3
Liaisecloselyw
ithHeyshamPortLimitedtoa
greeascheduletoconduct
aPortMarineSafetyCodehealthcheckassoonasispracticable
during2013,to
assessandprovideadviceon
PMSCcompliance,once
currentmeasuresbeingtakenbytheportauthoritytoenhanceitssafety
managementp
rocedureshavebeenimpleme
nted.
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MAIB ANNUAL REPORT 2012
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
125
Moyuna
Fishingvessel
Grounding
atthe
entrancetoArdglass
harbour,Northern
Ireland.
(Report17
/2012)
Madeto:Vesselowner
Accepted,fullyimplemented
FV
3
Takethefollow
ingactionstoimprovenavigationalpracticesonboard
Moyuna:
Ensureskippersandcrewarefamiliarwithandfollowtheguidance
containedinMGN313(F)(KeepingaSaf
eNavigationalWatchon
FishingVessels).
Ensurethe
vesselisadequatelyequipped
withnavigationchartsand
portinformation.
Encourage
skipperstoundertakevoluntarytraininginlinewithMGN411
(M+F)tore
freshnavigationalskills.
ReinforcethecorrectuseoftheDSCVHF
radioalerttoensuredistress
messagesarereceivedbytheCoastguard.
126
Moyuna
Fishingvessel
Grounding
atthe
entrancetoArdglass
harbour,Northern
Ireland.
(Report17
/2012)
Madeto:NIFHA
Accepted,fullyimplemented
FV
3
InconjunctionwiththeCommissionersofIrishLights,completeitsintended
reviewofnavig
ationalaidsinArdglassHarbour,toensuretheyare:
Effectiveandreliable.
Wellpublicisedtolocalharbourusers.
127
Prideof
Calais
Ro-rovess
el
Machinery
failure.
(Report18
/2012)
Madeto:P&O
FerriesHoldingsLtd
Accepted,fullyimplemented
C
3
Takestepstoimprovetheeffectivenessofits
crewswhendealingwith
mechanicalem
ergencies,takingintoaccount
theneedtodrillmachinery
breakdownsas
realisticallyaspossible,andtheimportanceoftechnical
emergencysitu
ationcheckcardsbeingaccurate,fullyconsideredand
veried.
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29
PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
128
Tombarra
(partA)
Carcarrier
Fatalityofrescueboat
crewman.
(Report19
a/2012)
Madeto:MCA
Accepted,yettobeimplemented
C
1
SubmittoIMO
proposalsfortheLSACodeto:
Reectare
quirementforasystemapproachtodavitandwinch
installationswiththeaimofeliminatingthe
possibilityofanycomponent
beingoverstressedtothepointoffailure.
Providecla
ricationonthettinganduse
ofsafetydevicesondavitand
winchsyste
ms,usingagoal-basedapproachtotheirapplication.
Targetcomple
tiondate-Notgiven
129
Tombarra
(partA)
Carcarrier
Fatalityofrescueboat
crewman.
(Report19
a/2012)
Madeto:MCA
Accepted,yettobeimplemented
C
1
SubmittotheIMOaproposaltomandateam
aximumheightofthedavit
headusedinconjunctionwithrescueboatsandsurvivalcraftttedonboard
bothcargoand
passengerships,basedupon:
Recognitionoftheseveredifcultiesfacedbythecrewsofhigh-sided
vesselssuchasTombarrawhenattemptin
gtolaunchrescueboatsina
seaway.
Theincreasedhazardstowhichthecrewsofrescueboatsandsurvival
craftareex
posedwhenoperatingatheigh
t.
Theaction
takenbyWilhelmsenLinesCa
rCarriersLtdtochangethe
designofitsfuturevesselstolowerthehe
ightoftherescueboatdavit
head(Figu
re14ofinvestigationreport)
.
Themaxim
umheightofdavitheadsused
inconjunctionwithsurvival
craftalread
yrecommendedforpassengervesselsinSOLASIII/24;and,
Theguidan
ceprovidedinMSCCirc1094
regardingtheheightofdavit
headsused
forfastrescueboatsonboardpassengerships.
Targetcomple
tiondate-notgiven
Follow-upletterwrittentoChiefExecutiveofMaritimeandCoastguardAgency
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MAIB ANNUAL REPORT 2012
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
130
Tombarra
(partA)
Carcarrier
Fatalityofrescueboat
crewman.
(Report19
A/2012)
Madeto:ILAMA
Accepted,fullyimplemented
C
2
Reviewitsdesignsofdavitandwinchinstallationstoensurethatthe
possibilityofanycomponentbeingover-stressedtothepointoffailureis
eliminatedbyfullyconsideringkeyfactors,pa
rticularlythewinchcapability
understallconditionsandsinglepointfailures
.
131
Tombarra
(partA)
Carcarrier
Fatalityofrescueboat
crewman.
(Report19
A/2012)
Madeto:ILAMA
Accepted,fullyimplemented
C
2
Ensurethatthe
type,numberandpositioning
ofsafetydevicesusedon
winchanddavitinstallationsiscriticallyasses
sed,takingintoaccount:
Manufacturersguidance
Themarine
environment
Systemdesign,and
Theconsequencesofmalfunction.
132
Tombarra
(partA)
Carcarrier
Fatalityofrescueboat
crewman.
(Report19
A/2012)
Madeto:UmoeSchat-HardingAS
Accepted,fullyimplemented
C
3
WorkwiththeownersofvesselsttedwiththeSA1.5/1.75davits/W50RS
winch/15/20kW
electricmotorcombinations,toensurethatthefallwireor
anypartofthe
davitstructurecannotbeoverloadedtothepointoffailure.
133
Tombarra
(partA)
Carcarrier
Fatalityofrescueboat
crewman.
(Report19
A/2012)
Madeto:UmoeSchat-HardingAS
Accepted,fullyimplemented
C
3
Reviewandrevise:
Thesuitabilityanduseofproximityswitch
esasnalstopdeviceson
man-lifting
equipmentsuchasdavits.
Itsinternal
qualityassurancesystemstoe
nsurethatallequipmentit
suppliesto
vesselscomplieswiththeconditionsoftheequipments
certication
.
Itsdavitandwinchoperatingmanualsino
rdertomakecleartheneed
toceaseho
istingbeforethedavitarmrea
chesthedavitproximity
switch,and
thattherequirementsforther
eplacementcomponentsis
unambiguo
us.
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PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
134
Tombarra
(partB)
Carcarrier
Fatalityofrescueboat
crewman.
(Report19
B/2012
Madeto:MCA
Accepted,yettobeimplemented
C
1
SubmittotheIMOproposalstoamendtheLS
ACodedesignedto:
Ensureany
waterenteringfoam-lledbuo
yancychamberswithinthe
enclosedhullsofrescueboatsandlifeboa
tscanbeeasilyremoved.
Requirethe
actualweightoftherescueboatorlifeboatsuppliedtothe
vessel,rath
erthanitsprototype,tobepro
videdinitscertication.
Targetcomp
letiondate-notgiven
135
Tombarra
(partB)
Carcarrier
Fatalityofrescueboat
crewman.
(Report19
B/2012)
Madeto:MCA
Accepted,yettobeimplemented
C
1
SubmittotheIMOproposalstoamendMSC.1/Circ.1206/Rev.1designed
torequirethea
nnualweighingofrescueboatsandlifeboatswhichuse
buoyancyfoam
withininternalspaces,assoo
nasispracticable.
Targetcomple
tiondate-notgiven
136
Tombarra
(partB)
Carcarrier
Fatalityofrescueboat
crewman.
(Report19
B/2012)
Madeto:ILAMA
Accepted,fullyimplemented
C
2
Promulgateguidancetoitsmembers,onthepotentialthatanincreaseinthe
weightofarescueboatorlifeboatcouldadve
rselyaffectitsstructureand
performance,a
ndcouldresultinover-loading
thehostvesselsdavits.Such
guidanceshouldemphasisethat:
Itisbestpr
acticetoweighrescueboatsandlifeboatstocheckforweight
growthduringannualservicing;
Whereare
scueboatorlifeboatisfoundtobeoverweightthencorrective
actionmustbetaken;
Drainageo
fwaterfromfoam-lledbuoyan
cyspacesisextremelydifcult
unlessspecicallyprovidedforinthedesignoftherescueboator
lifeboat;
Theinterna
lqualitycontrolstandardsrequ
iredbySOLASandtheMED,
andstricta
dherencetofoamsuppliersinstructions,areessentialto
ensurethatbuoyancyfoamisproducedto
therequiredlevelofquality.
Follow-upletterwrittentoChiefExecutiveofMaritimeandCoastguardAgency
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MAIB ANNUAL REPORT 2012
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
137
Tempanos
Containervessel
Fatalityfromfallinto
cargohold.
(Report20
/2012)
Madeto:South
ernShipManagementCo.S.A
Accepted,fullyimplemented
C
3
Improvethestandardofoccupationalsafetya
ndprotectionforcrewworking
onitsvesselsduringcontainercargooperatio
nsbyupdatingtherisk
assessmentso
nallitsmanagedvesselstoensurethattheriskofwalking
closetopartlyopenholdsisidentied,andco
ntrolmeasuresareputin
placetopreventpersonnelfromfallingintoho
lds.
138
Tempanos
Containervessel
Fatalityfromfallinto
cargohold.
(Report20
/2012)
Madeto:Hutch
isonPortsUK
Accepted,fullyimplemented
G
3
Ensureitscontainerterminalstaffconductsafetymeetingswithcrewsof
visitingcontain
ervesselsbeforethecommencementofcargooperations.
139
Moonclipper
Highspeedcatamaran
Steeringcontrolfailure.
(Report21
/2012)
Madeto:Collin
sRiverEnterprisesLtd
Accepted,fullyimplemented
C
3
Carryoutarev
iewofthecurrentcrewresourcesandcriticalsystem
congurationsonboarditsRiverRunner150
craft,inordertoensurethat:
Thecrewa
resufcientlyresourcedtoope
ratethevesselssafelyandto
dealwithallreasonablyforeseeableemer
gencyscenarios.
Allreasona
blypracticabletechnicaloption
shavebeenconsideredin
ordertominimisethelevelofrelianceplacedontheoperatortoprevent
enginestalls.
Thecurrentsteeringcontrolsystemcong
uration,andanyfuture
proposedc
hanges,fullymeetallappropriatetechnicalstandards.
Theinformation,guidanceandFMEAcon
tainedinthecraftoperating
manualsfu
llyreectthevesselscurrentm
achinerycongurations.
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PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
140
Moonclipper
Highspeedcatamaran
Steeringcontrolfailure.
(Report21
/2012)
Madeto:MCA
Accepted,fullyimplemented
C
3
AssesstheactionstakenbyCollinsRiverEnterprisesLtdasaresultofthe
safetyissuesidentiedinthereportincluding,specically:
Seekingreassurancethatthecompanys
steeringcontrolsystem
changesha
vebeensubjectedtoanappro
priatetechnicalreview
process.
Verifyingth
atthemanningandcompetencylevelsonboardThames
ClippersRiverRunner150vesselsareappropriate.
141
SDNimble
Tug
Accidental
dischargeof
carbondioxideresulting
inseriousinjury.
(Report23
/2012)
Madeto:Lloyd
sRegister
Accepted,yettobeimplemented
C
2
ProposetoIAC
SthatURZ17beamendedto
reecttheimportanceof
servicesupplie
rsproceduresbeingsufcientlyrobusttoensurethatsafe
systemsofworkareagreedandimplemented
withshipscrewspriorto
commencingw
orkonboardvessels.
Targetcomple
tiondate-notgiven
142
SDNimble
Tug
Accidental
dischargeof
carbondioxideresulting
inseriousinjury.
(Report23
/2012)
Madeto:Ocea
nEngineering(Fire)Ltd
Accepted,fullyimplemented
C
3
Takestepstoimprovethemonitoringandsafetyofitsserviceengineers,
andtheadoptionofsafesystemsofwork,tak
ingintoaccountthelessonsto
belearnedfrom
thisaccident,particularly:
Theavailab
ilityofsysteminformation
ThestorageofCO2cylindersbelowdecks
Vesselmov
ementsandactivities
Therequire
mentsofURZ17.
143
ErnestBevin
Ferry
Fatalaccid
entofacrew
member.
(Report22
/2012)
Madeto:Serco
LimitedMarineServices
Accepted,fullyimplemented
C
3
Evaluatethesuitabilityofitsworkboatsforretrievingunconsciouspersons
fromthewater
andensuretheyareappropria
telyequippedforsuch
eventualities.
Awaitingupdatefromrecip
ientattimeofpublication
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MAIB ANNUAL REPORT 2012
Case
Investigation
Vessel/Accidenttype
Narrativean
dAddressee
Focus
Level
144
Springbok
andGas
Arctic
Cargovesseland
LPGtanke
r
Collision.
(Report24
/2012)
Madeto:Seatr
adeGroningenB.V
Accepted,fullyimplemented
C
3
Reviewvessel
manningandwatchroutinesto
ensurethatitsmastersand
ofcersareabletotakesufcienthoursofres
twhenmakingfrequentport
calls.
145
Springbok
andGas
Arctic
Cargovesseland
LPGtanke
r
Collision.
(Report24
/2012)
Madeto:Seatr
adeGroningenB.V
Accepted,fullyimplemented
C
3
Conductareviewofitssafetymanagementsystemandassociatedcontrols
toensurethefollowing:
Accesstot
hebridgeandsourcesofdistra
ctionareproperlymanaged
duringperiodsofpilotageandincreasedh
azard.
OOWsare
cognisantofandtakeappropriateactiontomitigatethe
hazardsof
visualblindsectorsonthebrid
ge.
Bridgeteam
sunderstandtheimportance
andrigorouslyapplythe
companyrequirementsfornavigatinginre
ducedvisibility,withparticular
emphasiso
n:
Provisionofanadditionallookout
Safes
peed
Useoffogsignals
Thecompa
nysrequirementsforalcoholtestingfollowinganaccident
arestrictlyadheredto.
146
Saga
Sapphire
Cruiseship
Twomeno
verboard
whilecond
uctinga
lifeboatdrill.
(Report25
/2012)
Madeto:Acrom
asShippingLtd
Accepted,yettobeimplemented
C
3
Seekformalap
provalfromtheMaltaAdministrationandtheappropriate
classicationsocietyinrespectto:
Theuseof
theweldedbarmodication,ttedtothetenderliftingplates,
asmeanso
fsecuringthebowsingtacklerope.
Theuseof
thejacklinesafetyharnesstether,securingarrangements
currentlyin
useonSagaRubystenders.
Targetcomple
tiondate-July2013
Awaitingupdatefromrecip
ientattimeofpublication
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PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
147
Saga
Sapphire
Cruiseship
Twomeno
verboard
whilecond
uctinga
lifeboatdrill.
(Report25
/2012)
Madeto:AcromasShippingLtd
Accepted,fullyimplemented
C
3
Reviewtheoperatinginstructionsforthebowsingandtricingarrangements
ttedaspartofthelaunchingsystemforallte
ndersandlifeboatsacrossthe
Sagaeet,toe
nsuretheyareconsistentand
accordwithbestpractice.
148
Saga
Sapphire
Cruiseship
Twomeno
verboard
whilecond
uctinga
lifeboatdrill.
(Report25
/2012)
Madeto:Acrom
asShippingLtd
Accepted,fullyimplemented
C
3
Reviewthefollowingprojectmanagementandship-relatedproceduresfor
bringingavess
elintoservice:
Integration
ofthekeytrainingrequirementsintotheprojectmanagement
plan,inpar
ticularfortrainingthatisequipment-dependent.
Timelyesta
blishmentoftheshipssafetymanagementorganisationwith
respecttoriskassessments,recordingan
d,whereappropriate,tests/
inspectionofpersonalprotectiveequipme
nt.
Manageme
nt,reportinglinesandcommunicationarrangements
fortraining
duringnon-operational(ret/do
cking),transitionaland
operationalphasestoensurethat:
Allcrewreceivetrainingappropriatetotheirtasks.
Aneffectiveandconsistentleveloftrainingoversightismaintained.
149
StenaFeronia
andUnion
Moon
RoPaxves
seland
cargovess
el.
Collision.
(Report26
/2012)
Madeto:North
ernMarineManagementLtd
Accepted,fullyimplemented
C
3
AmenditsSMS
tomakecleartherolesandresponsibilitiesofthebridge
teamwhencon
ductingpilotagewithaPECholderwhoisnotpartofthe
normalshipsc
omplementandisperforminganactofpilotage.
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MAIB ANNUAL REPORT 2012
Case
Investigation
Vessel/Accidenttype
Narrativeand
Addressee
Focus
Level
150
Onward
Fishingvessel
Fireresultingintheloss
ofthevess
el.
(Report27
/2012)
Madeto:Mithc
owieFishingCompanyLimited
Noresponsereceived
FV
3
Ensurethatthe
crewsonboardanyvesselsitmayowninthefuturearefully
preparedtoeffectivelydealwithemergencys
ituations,takingintoaccount,
interalia:
Therequire
menttoconductperiodicemergencydrillsandthe
importance
ofemergencydrillstoavesse
lssafety.
Theneedforallearlywarningdevicessuchasredetectionsystems
andbilgea
larmstobeproperlymaintainedandtested,andthatcrews
fullyunders
tandtheiroperation.
Theneedforcrewstohaveagoodknowledgeofallonboardsafety-
relatedsystemsandequipment,andthatroutinesafetyprecautions
suchasthe
closingofredoorsaretaken
atalltimes.
151
Norcape
Ro-rocarg
oferry
Windlassd
amage,
grounding
andaccident
toperson,
West
Scotland.
(Report28
/2012)
Madeto:AssociatedBritishPorts
Accepted,fullyimplemented
G
3
Undertakeafo
rmalreviewoftheneedforcom
pulsorypilotageinTroon.
152
Norcape
Ro-rocarg
oferry
Windlassd
amage,
grounding
andaccident
toperson,
West
Scotland.
(Report28
/2012)
Madeto:AssociatedBritishPorts
Accepted,fullyimplemented
G
3
ReviewtheformalsafetyassessmentformarineoperationsinTroon
harbourtoensurethat:
Towageguidelinesaredevelopedinconju
nctionwithportusers.
Itsanemom
eterisplacedinanoptimumlocationtoprovideaccurate,
reliablewin
dinformationwhichisaccepte
dbyportusersasabasisfor
itscontrolm
easures.
Portusersareawareofanylocallyagreedsoundsignals,whichshould
besuchtha
ttheycannotbeconfusedwith
thoserequiredtobeusedby
theColregs
.
Awaitingupdatefromrecip
ientattimeofpublication
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PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Accidenttype
NarrativeandA
ddressee
Focus
Level
153
Norcape
Ro-rocarg
oferry
Windlassd
amage,
grounding
andaccident
toperson,
West
Scotland.
(Report28
/2012)
Madeto:MCA
Accepted,fullyimplemented
G
3
LiaisewithAss
ociatedBritishPortsandarrangeaPortMarineSafetyCode
healthcheck
visittoTroononcompletionof
theharbourauthoritysformal
safetyassessm
entfortheport(see2012/152
).
154
Norcape
Ro-rocarg
oferry
Windlassd
amage,
grounding
andaccident
toperson,
West
Scotland.
(Report28
/2012)
Madeto:P&O
Ferries
Accepted,fullyimplemented
C
3
Inrelationtopassageplanning,monitoringan
dmanoeuvring:
Reviewthe
weatheradviceavailableforit
sportsofcall,andprovide
guidanceto
itsmastersonthemostappro
priatesourcestouse.
Remindits
bridgeteamsofthevalueofusingpassageplanabort
positionsasformaltriggersforvalidatingthedecisiontoenterport.
Reviewthe
provisionofinformationtomanoeuvringconsolestoensure
thatofcersmanoeuvringtheirvesselsareabletoretainfullsituational
awareness.
155
Norcape
Ro-rocarg
oferry
Windlassd
amage,
grounding
andaccident
toperson,
West
Scotland.
(Report28
/2012)
Madeto:P&O
Ferries
Accepted,fullyimplemented
C
3
Carefullyreviewitsemergencyresponsearra
ngementstoensureall
feasiblerecove
ryoptionsareproactivelyevaluatedsoastoprovideits
shipsstaffand
incidentmanagementresponseteamswiththedataneeded
totakeinforme
ddecisions.
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MAIB ANNUAL REPORT 2012
SECTION B
RECOMMENDATIONS TO MULTIPLE RECIPIENTSLists the small number of recommendations that have been addressed to
multiple recipients. As a result, it has not been possible to track responses
under the closed-loop system. Such multiple addressee recommendations are
now being avoided wherever possible, so as to make the closed-loop system
as effective as possible.
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PART 2: RECOMMENDATIONS
2011
Case
Investigation
Vessel/Accidenttype
NarrativeandA
ddressee
Focus
Level
2011/152
QueenMary2
Passenger
ship
Catastroph
icfailure
ofacapacitorinthe
aftharmoniclter
rooma
pproaching
Barcelona.
(Report28/2011)
Madeto:Lloyds
Register
Acc
epted,yettobeimplemented
C
2
Reviewandclarifyitsrulesontheinstallationofxedwater-basedlocal
applicationre-ghtingsystemsincompartmen
tscontaininghighvoltage
systemsand,thr
oughIACS,proposetheappro
priateamendmentsto
incorporatethisguidanceintheFSSCode
Targetdateforcompletion-workisongoing
2011/144
Commodore
Clipper
Ro-ropass
engerferry
Fireonmainvehicle
deckwhile
onpassage
toPortsmo
uth.
(Report24/2011)
Madeto:Baham
asMaritimeAuthority
Acc
epted,yettobeimplemented
C
1
Developajointp
aperwiththeMaritimeandCoastguardAgencyfor
submissiontotheIMOtoconsiderarequirementforallvessels,whose
principalmeansofaccessisviaasingleramptoavehicle,specialcategory
orro-rospace,toassesshowanalternativeme
ansofpedestrianaccessto
shorecouldbeimprovedinanemergency.
Targetdateforcompletion-notgiven.Previoustargetdate:November
2012
2011/143
Commodore
Clipper
Ro-ropass
engerferry
Fireonmainvehicle
deckwhile
onpassage
toPortsmo
uth.
(Report24/2011)
Madeto:Baham
asMaritimeAuthority
Acc
epted,yettobeimplemented
C
2
MakeasubmissiontotheIMOtoconsiderarequirementforallexistingro-
ropassengervesselstobettedwith,orhavereadyaccessto,meansof
determiningtheeffectofdamageorentrainedw
aterfromre-ghtingonthe
vesselsstability.
Targetcompletiondate-notgiven
Awaitingupdatefromrecipientattimeofpublication
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42
MAIB ANNUAL REPORT 2012
Case
Investigation
Vessel/Accidenttype
NarrativeandAddressee
Focus
Level
2011/134
SapphireII
andSilver
Chord
Fishingve
ssels
Collisionresulting
inthefoundering
ofSapphireIIoff
Stornoway,Scotland.
(Report21/2011)
Madeto:MCA
Ac
cepted,yettobeimplemented
FV
2
Ensureitssurveyorsverifyduringsurveyand/orinspectionthattheeld
ofvisibilityfrom
shingvesselwheelhousesco
mplieswiththecriterialaid
downinMGN3
14(F)and,wherenecessary,o
wnersaredirectedtotake
actiontoensurethatadequatevisibilityisafforded.
Targetcompletiondate-August2013
2011/126
JackAbryII
Fishingve
ssels
GroundingontheIsle
ofRum.
(Report14/2011)
Madeto:Scape
cheSA
Ac
cepted,yettobeimplemented
FV
3
Enhancethesa
fetymanagementofitsvesselsby:
Providingspecicoperationalinstructionsandguidancewithrespectto:
themanage
mentofhoursofworkandrest,takingintoaccounttravelling
timewhenc
hangingcrew;watchkeepingb
estpractice,including
passagepla
nningandtheappropriateuse
ofnavigationalequipment,
watchalarm
sandlookouts;andthecondu
ctandfrequencyofdrills.
Increasingonboardoversighttoensureco
mpliancewithitsinstructions
andguidance,riskassessments,andstatu
toryregulations.
Targetcompletiondate-notavailable,workinprogress
2011/121
PrincesClub
WaterSports
Parkfatal
accident
Inatable
bananaboat
Fatalaccidentat
PrincesC
lubWater
SportsPa
rkin
Bedfont,M
iddlesex.
(Report11/2011)
Madeto:MCA
Ac
cepted,yettobeimplemented
G
2
Takeappropriateactiontoimprovethesafetyoftowedinatableridesby:
Considering
theBritishWaterSkiandWak
eboardClubDriversAward
asastanda
rdforcommerciallyoperatingb
oatstowinginatables,
andincludin
gitinthelistofsuitablealternativequalicationstothe
Boatmaster
sLicence
Atitsnextreview,amendingtheInlandWatersSmallPassengerBoat
Code,Annex5,sothattheguidanceisrelevanttotheboatsoperating
oninlandwatersandnotjustbeachcraft.
Targetcompletiondate-December2015
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PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Accidenttype
NarrativeandAddressee
Focus
Level
2011/120
PrincesClub
WaterSports
Parkfatal
accident
Inatable
bananaboat
Fatalaccidentat
PrincesC
lubWater
SportsPa
rkin
Bedfont,M
iddlesex.
(Report11/2011)
Madeto:HSE
Ac
cepted,yettobeimplemented
G
2
Includeoversightoftheactivityofridingontow
edinatablesintothe
arrangementsthatarecurrentlybeingconside
redtoreplacetheAdventure
ActivitiesLicensingAuthority.
Targetcompletiondate-Workisongoing
2011/111
Yeoman
Bontrup
Bulkcarrier
Fireande
xplosion
onboard
Yeoman
Bontrupa
tGlensanda
Quarry,LochLinnhe,
westernS
cotland.
(Report5/2011)
Madeto:MCA
Ac
cepted,yettobeimplemented
C
2
Improveitsexis
tingguidanceonthestowageofshipsusechemicals.
Targetcompletiondate-August2013
2011/109
Yeoman
Bontrup
Bulkcarrier
Fireande
xplosion
onboard
Yeoman
Bontrupa
tGlensanda
Quarry,LochLinnhe,
westernS
cotland.
(Report5/2011)
Madeto:Baham
asMaritimeAuthority
Ac
cepted,yettobeimplemented
C
1
TheBahamasM
aritimeAuthority,supportedbytheMCA,isrecommended
tosubmitpropo
salstotheIMO:forself-unload
ingvesselsto:
Reviewand
improveredetection,contain
mentandextinguishing
standardsforcargo-handlingareas.
Developsta
ndardsforconveyorbeltrere
sistanceproperties.
Targetcompletiondate-notavailable
2011/101
DeltaRIB
RIB
Injurytop
assenger
ontheRiv
erThames,
London.
(Report1/2011)
Madeto:MCA
Ac
cepted,yettobeimplemented
G
2
TheMCAisrec
ommendedtoprioritiseandresourcetherevisionofMGN
280toensuretheupdatedCodeofPracticefo
rSmallCommercialVessels
ispublishedas
soonaspossible
Targetcompletiondate-March2014
Awaitingupdatefromrecipientattimeofpublication
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MAIB ANNUAL REPORT 2012
Case
Investigation
Vessel/Accidenttype
NarrativeandA
ddressee
Focus
Level
2010/123
OliviaJean
Fishingvessel
Injurytos
herman
17nmSSE
ofBeachy
HeadintheEnglish
Channel.
(Report10
/2010)
Madeto:MCA
Acc
epted,yettobeimplemented
FV
2
Considerthendingsofthisinvestigationwhen
assistingtheDepartmentfor
Transporttoadd
ressMAIBrecommendation2010/112,includingtheneedto
improveshingvesselstandardsandoccupationalsafetyby:
Reviewingth
eapplicationofLOLER,PUWER,riskassessmentand
workingtime
regulationsonboardshingvesselstoensurethattheyare
suitableforthetaskofimprovingsafetyand
reducingaccidents.
Providingcle
arandrobustguidancetoitss
urveyorsandtheshing
industryatla
rge.
Ensuringaccuraterecordsaremaintainedsuchthatsurveyorsare
providedwiththeinformationrequiredtosu
rveyshingvessels
effectively.
Improvingits
recordingofaccidentsonvesselsSIASrecordstoidentify
trendsanda
ctuponthem.
Targetcompletiondate-August2013
2010/120
BroArthur
Oilandchemical
tanker
Fatalityofashore
workerinN
o.2cargo
tankwhile
alongside
atCargillT
erminal,
Hamburg.
(Report9/2010)
Madeto:ICS
Acc
epted,yettobeimplemented
C
3
Includeguidanceonthefollowingintherespec
tiveInternationalChamberof
Shippingpublica
tionsduringtheirnextperiodic
review:
TSGC-man
agementofcontractorsandsu
b-contractorswithemphasis
onthemaste
rsandotherofcersandcrew
membersrelatedhealth
andsafetyre
sponsibilities.
TSGCandISGOTT-theneedfortheprovisionoflightweight,portable
casualtyrecoveryequipmentsuitableforre
coveryfromdeepcargo
tanksandforthecrewtobefullytrainedin
itsuse.
Targetcompletiondate-December2014
2010
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PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Accidenttype
NarrativeandA
ddressee
Focus
Level
2010/119
BroArthur
Oilandchemical
tanker
Fatalityofashore
workerinN
o.2cargo
tankwhile
alongside
atCargillT
erminal,
Hamburg.
(Report9/2010)
Madeto:MCA
Acc
epted,yettobeimplemented
C
2
Provideaddition
alguidanceonthefollowing:
Managemen
tofcontractorsandsub-contra
ctorswithemphasisonthe
mastersand
otherofcersandcrewmembersrelatedhealthandsafety
responsibilities.
Theneedfortheprovisionoflightweight,portablecasualtyrecovery
equipmentsuitableforrecoveryfromdeepcargotanks,andforthecrew
tobefullytra
inedinitsuse.
Targetcompletiondate-December2013
2010/112
Korenbloem/
OspreyIII/
Optik
Fishingvessels
Fatalman
overboard
accidents.
(Report6/2010)
Madeto:DfT
Acc
epted,yettobeimplemented
FV
1
Recognisethec
onsistentanddisproportionate
rateoffatalitiesintheUK
shingindustryandtakeurgentactiontodevelopacomprehensive,timely
andproperlyres
ourcedplantoreducethatrate
toalevelcommensurate
withotherUKoc
cupations.
Targetcompletiondate-workisongoing;theMCAhasdevelopedan
overallstrategy
forimprovingsafetyintheshingindustry,whichis
awaitingminist
erialapproval
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MAIB ANNUAL REPORT 2012
2009
Case
Investigation
Vessel/Ac
cidenttype
NarrativeandA
ddressee
Focus
Level
2009/183
JoEik
Chemicaltanker
Twocrewcasualties
fromreleaseofcargo
vapours.
(Report24
/2009)
Madeto:ICS
Accepted,yettobeimplemented
C
3
Includethefollowingsafetyissuesidentiedin
thisreportinthenext
periodicreviewandamendmentoftheTankerSafetyGuideChemicals:
Emphasisetheneedforthecargo-specic
MSDStobeheldonboardas
suppliedbytheshipper.
ThatthecargospecicMSDSispromulgatedtoreceivers(terminalor
transhipmen
tships/barges)eitherdirectlyfromtheshiporviatheship
operatororagentsothatriskcontrolmeasuresarebasedonaccurate
information.
Thatareaso
fthedeckwhichfallintotheIM
OsdenitionofanEnclosed
Spaceareid
entied,andthatappropriatec
ontrolmeasuresareinplace
followingriskassessment.
Targetcomplet
iondate-publicationexpect
ed2013/2014
2009/141
AbigailH
Grabhopp
erdredger
Floodinga
nd
foundering
,Portof
Heysham.
(Report15
/2009)
Madeto:MCA
Accepted,yettobeimplemented
G
1
Introduceaman
datoryrequirement,forallvesselsgreaterthan24m
lengthandlessthan500grosstonnes,forthe
ttingofbilgealarmsin
engineroomsandothersubstantialcompartmentsthatcouldthreaten
thevesselsbuo
yancyandstabilityifooded.T
hese,andanyother
emergencyalarmsshouldsoundinallaccomm
odationspaceswhenthe
centralcontrols
tationisunmanned.Inaddition
tofunctioninginthevessels
normaloperationalmodes,alarmsshouldbecapableofoperatingwhen
mainpowersup
pliesareshutdown,andbeab
letowakesleepingcrewin
sufcienttimefo
rthemtoreactappropriately.
Targetcomplet
iondate-September2014
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PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Ac
cidenttype
NarrativeandA
ddressee
Focus
Level
2009/128a
CelticPioneer
RIB
Injurytoa
passenger
onboardtheRIB
CelticPion
eer,inthe
BristolChannel.
(Report11
/2009)
Madeto:LACORS
Accepted,yettobeimplemented
G
3
Whenavailable,promulgatetheapprovedcodeofpracticeforthrill-type
boatoperators,andstronglyencouragelocala
uthoritieswithintheUnited
Kingdomtorequireoperatorstoadheretothecodeasaconditionof
licensing.
Targetcomplet
iondate-willpromulgatewh
ennewcodeofpracticeis
available(2009
/126a)
2009/128b
Madeto:InstituteofLicensing
Accepted,yettobeimplemented
G
3
Whenavailable,promulgatetheapprovedcodeofpracticeforthrill-type
boatoperators,andstronglyencouragelocala
uthoritieswithintheUnited
Kingdomtorequireoperatorstoadheretothecodeasaconditionof
licensing.
Targetcomplet
iondate-willpromulgatewh
ennewcodeofpracticeis
available(2009
/126a)
2009/126a
CelticPioneer
RIB
Injurytoa
passenger
onboardtheRIB
CelticPion
eer,inthe
BristolChannel.
(Report11
/2009)
Madeto:MCA
Accepted,yettobeimplemented
G
1
Reviewandrevisethedeckmanningandqualicationrequirementsofthe
harmonisedSCVCodetakingintoaccountthe
speedofcraftandthetype
ofactivityintend
edinadditiontothedistancefromshoreandenvironmental
conditions.
Targetcomplet
iondate-April2014
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MAIB ANNUAL REPORT 2012
Case
Investigation
Vessel/Accidenttype
NarrativeandA
ddressee
Focus
Level
2008/177a
Fishingvessel
safetystudy
Fishingvessel
Madeto:MCA
Acc
epted,yettobeimplemented
FV
1
Reviewthecurrentrequirementsforsafetytrainingwithparticularreference
totrainingasses
smentandrefreshertraining.
Targetcompletiondate-May2015
2008/175a
Fishingvessel
safetystudy
Fishingvessel
Madeto:DfT
Acc
epted,yettobeimplemented
FV
1
Workcloselytog
etherandwiththeshingindustrysafetyrepresentatives,
toensurepragm
aticsafetyconcernsareintegratedintoconservationpolicy
measures.
Targetcomplet
iondate-Takenforwardasp
artofnew
shingvessel
strategy,expec
tedby2015
2008/174a
Fishingvessel
safetystudy
Fishingvessel
Madeto:DfT
Acc
epted,yettobeimplemented
FV
1
Agreethecoherentresourcedplanforreducing
thefatalityrateintheshing
industry(seeRe
commendation2008/173).
Targetcompletiondate-April2015
2008/174b
Madeto:MCA
Acc
epted,yettobeimplemented
FV
1
Agreethecoherentresourcedplanforreducing
thefatalityrateintheshing
industry(seeRe
commendation2008/173).
Targetcompletiondate-April2015
2008
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PART 2: RECOMMENDATIONS
Case
Investigation
Vessel/Ac
cidenttype
NarrativeandA
ddressee
Focus
Level
2008/173
Fishingvessel
safetystudy
Fishingvessel
Madeto:MCA
Accepted,yettobeimplemented
FV
1
Indevelopingits
plantoaddresstheunacceptablyhighfatalityratein
theshingindus
try,identiedinitsstudyofsta
tisticsfortheyears1996
to2005,inadditiontodeliveringtheactionsou
tlinedat6.2,theMCAis
recommendedtoconsiderthendingsofthiss
afetystudy,andinparticular
to: Clarifythere
quirementforriskassessmentstoincluderiskswhich
imperilthev
esselsuchas:environmentalh
azards,conditionofthe
vessel,stabilityetc.
Worktoward
sprogressivelyaligningtherequirementsoftheSmall
FishingVesselCode,withthehighersafety
standardsapplicableunder
theWorkboa
tCode.
Clarifythere
quirementsofTheMerchantS
hippingandFishingVessels
(Healthand
SafetyatWork)Regulations1997toensurethattheyapply
inrespectofallshermenonboardshing
vessels,irrespectiveoftheir
contractualstatus.
Ensurethat
thecurrentmandatorytraining
requirementsforshermen
arestrictlya
pplied.
Introducearequirementforunder15mves
selstocarryEPIRBs.
Reviewinternationalsafetyinitiativesandtransferbestpracticetothe
UKshingin
dustrywithparticularreferencetotheuseofPFDsand
PersonalLocatorBeacons.
Conductres
earchontheapparentimprove
mentinsafetyinother
hazardousindustrysectors,suchasagricu
lture,constructionand
offshore,withtheobjectiveofidentifyingan
dtransferringbestsafety
practicefrom
thoseindustriestotheshing
industry.
Targetcomplet
iondate-April2016
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Case
Investigation
Vessel/Ac
cidenttype
NarrativeandA
ddressee
Focus
Level
2008/130
MSCNapoli
Container
ship
Structuralfailure
whileintheEnglish
Channel.
(Report9/2008)
Madeto:IACS
Accepted,yettobeimplemented
C
2
Researchandreviewthetechnologicalaidsav
ailablewhichwouldassist
masterstomeasurehullstressesinportandatsea.
Targetcomplet
iondate-December2014
2008/128
MSCNapoli
Container
ship
Structuralfailure
whileintheEnglish
Channel.
(Report9/2008)
Madeto:IACS
Accepted,yettobeimplemented
C
1
ReviewthecontentsofURS11(LongitudinalS
trengthStandard)toensure:
Hullgirders
trengthandbucklingchecksar
ecarriedoutatallcritical
sectionsalongtheentirelengthofthehull.
Anevaluatio
nofthesuitabilityofcurrentURS11designwavebending
momentcriteriaforvesselswithlowblockcoefcientisundertaken.
Membersoc
ietiesusecommonmethodologieswhencomplyingwiththe
requirementsofthisrule.
Targetdatefor
completion-December2014
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PART 2: RECOMMENDATIONS
2007
Case
Investigation
Vessel/Ac
cidenttype
NarrativeandA
ddressee
Focus
Level
2007/144
Thunder
Generalcargovessel
Grounding
atthe
approache
stothe
DeeEstua
ry.
(Report12
/2007)
Madeto:DfT
Accepted,yettobeimplemented
C
1
Inconsideringd
ecisionsontheHarbourRevisionOrderssubmittedbythe
EnvironmentAg
encyandMostynDocksLimite
d,takeintoaccounttheneed
toclarifythesta
tusoftheMostynOuterChann
el,suchthattheresponsible
authorityhasthenecessarypowerstoensurethesafetyofnavigationinthe
channel.
Targetcompletiondate-July2013
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MAIB ANNUAL REPORT 2012
SECTION D
CHANGES TO PREVIOUSLY REPORTED RECOMMENDATIONS
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PART 2: RECOMMENDATIONS
Case
Investigation