ANNUAL REPORT 2009

MARINE ACCIDENT INVESTIGATION BRANCH

Extract from The Merchant Shipping (Accident Reporting and Investigation) Regulations 2005

The sole objective of the investigation of an accident under these Regulations shall be the prevention of future accidents through the ascertainment of its causes and circumstances.

It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.

Marine Accident Investigation BranchMountbatten HouseGrosvenor SquareSouthampton SO15 2JU

All reports can also be found on our website:www.maib.gov.uk

For all other enquiries:Email: maib@dft.gsi.gov.ukTel: +44 (0)23 8039 5500Fax: +44 (0)23 8023 2459

Contents

Chief Inspector’s Report 1

Part 1 - Full Investigations and Report Publications 4

Part 2 - Recommendations 9Background 11Recommendationresponsestatistics 12Recommendationmethodology 13

SectionA-Level1Recommendations 14SectionB-Level2Recommendations 21SectionC-Level3Recommendations 32SectionD-Recommendationstomultiplerecipients 43SectionE-Withdrawnrecommendations 44SectionF-Recommendationsbroughtforwardfrompreviousyears 45

Part 3 - Statistics 53UKvesselaccidentsinvolvinglossoflife 54UKmerchantvessels>=100gt 56UKmerchantvessels<100gt 61UKnon-commercialvessels 62UKfishingvessels 63Non-UKcommercialvessels 68

Annex - Statistics Coverage 69

Glossary of abbreviations and acronyms 71

1

CHIEFINSPECTOR’SREPORT

Chief Inspector’s ReportTherecontinuestobeasignificantnumberofunnecessaryaccidentsatsea,fewofwhich

canbeattributedtotheconvenientexcuseof“theseabeingahazardousenvironment”.

1663marineaccidentsandincidentswerereportedtotheMAIBin2009,withmanynon-

commercialcasualtiesstillgoingunreported.Itisquiteevidentfromtheaccidentswe

investigatethatsafetystandards,supervision,training,inspectionandenforcementare

routinelywellbelowthatexpectedashore.Althoughimprovementsaretakingplace,

thesearenormallydrivenbyaccidentinvestigationsconductedbytheMAIBandsimilar

organisationsinothercountries.

Despiteitssmallsizeandbudget,theMAIBisseenasaworldleaderinthefield.Withatotal

staffofjust39,wehavehadtoconsidertheissuesineveryoneofthese1663reports;the

majorityofthe1461whichdetailedanalysisdeterminedfellwithintheremitoftheMAIB,were

thenfolloweduptosatisfyourselvesthatappropriateactionsweretakingplacetoprevent

suchincidentsrecurring.In46ofthecases,itwasjudgednecessaryfortheMAIBtodeploy

ateamandcommenceaninvestigationinordertoestablishthecircumstancesandallthe

causalfactorsoftheincidentandthusderivepotentialrecommendationstoimprovefuture

safety.Twentyofthesedevelopedintofullinvestigationsleadingtomajorreportsbeing

published.

Thisworkloadisheavyforasmallteam.Itiskeptmanageablebyputtingalargeamount

ofeffortintoselectingwhichincidentsarelikelytoyieldthemostimportantissuesforfuture

safety.Itisonlythesethatweinvestigate,andeventhenfewerthanhalfarejudgedessential

tobetakenthroughfrompreliminaryexaminationstagetofullinvestigation.Thisfocusof

effortallowsa“leanandmean”organisationtodeliverourlegalandourmoralobligationsin

aneffectiveandtimelymanner.ItisamatterofsomepridetotheMAIB,thatrepresentatives

ofmanyothercountriesfromaroundtheworldcometoSouthamptontofindouthowwecan

dosomuchforsolittle.

However,thereisadangerthattheflexibilityonwhichthisfocussedapproachdependsmay

soonbelost.AnEUDirectivehasbeenpassedwhichrequires,fromJune2011,thatthe

MAIBmustconductafullinvestigationintoall“veryseriousaccidents”,andtogivereasons

forany“seriousaccidents”intowhichwedonotintendtoconductafullinvestigation.This

couldintheorydoubleortrebletheMAIB’sworkload,atatimeofconsiderableresource

restraints.Wewillcontinuetoworkwithourlawyersandotherstoensurethatwecanmeet

theintentoftheDirectivewithincurrentresources.

2

MAIBANNUALREPORT2009

INVESTIGATIONSAwidevarietyofaccidentstomerchantvesselswereinvestigatedin2009.Thankfully,the

numberoffatalitiesremainedlow,andthenumberofinjuriestocrewhasshownasignificant

reduction.Onthenegativeside,theBelgianandCypriotadministrationshavefailedto

respondtoanumberofrecommendations,despiteacrewmanbeingseverelyinjured;and

aEuropeanmanufacturerseesnoreasontoredesignawindlassmotordespiteaseriesof

accidents,twoofwhichresultedincrewmenbeingseverelyinjuredwhenwindlassmotor

casingsshattered,sprayingshrapnelaroundtheadjacentdecks.

Thirteenfishermendiedinaccidentsin2009.Thisisthesecondlargesttotalsince2000,and

equatestoafatalityrateof102againstanationalaccidentatworkrateoflessthan11.This

rate,whichhasshownlittlesignofdecreasingoverthelast30years,ledtoarecommendation

beingmadeinMay2010totheDepartmentforTransportto:

“RecognisetheconsistentanddisproportionaterateoffatalitiesintheUKfishing

industryandtakeurgentactiontodevelopacomprehensive,timelyandproperly

resourcedplantoreducethatratetoalevelcommensuratewithotherUKoccupations”.

RECOMMENDATIONSOftherecommendationsissued,88%havebeenaccepted.Alargeproportionofthose

organisationsthathavenotacceptedourrecommendationsareoutsidetheUK.

Asrecommendationsmaytakealongtimetocomplete,itisinevitablethatanumberhaveyet

tobefullyimplemented.Ourfollow-upsystemcontinuestomonitorprogressonthese.

FINANCEThisAnnualReportdealsprincipallywiththecalendaryearof2009.However,foreaseof

reference,thefiguresbelowareforthe2009/10financialyear,whichendedon31March

2010;MAIB’sfundingfromtheDepartmentforTransportisprovidedonthisbasis,andthis

complieswiththeGovernment’sbusinessplanningprogramme.

£ 000s Budget OutturnCosts 4,272 4,116Receipts* 100 107Totals 4,172 4,009

*TheMAIBgainsreceiptsfrominvestigationscarriedoutonbehalfofotheradministrations,andfromtheprovisionoftechnicalservicesandtrainingconductedonbehalfofEMSAandtheIMO.

1 Industrialfatalityratesaremeasuredper100,000worker-years.

3

CHIEFINSPECTOR’SREPORT

CIVIL SERVICE AWARD FOR SCIENCE ENGINEERING AND TECHNOLOGY

TheMAIBpridesitselfonitsabilitytobeg,borrowandsteal(thelastnotliterally).On

ashoestringwehavedevelopedaworld-leadinganalysissuiteformarineaccident

investigation.ThissuitehasnowbeenboughtbycountriesaswidespreadasNorway,the

UnitedStatesandAustralia.Asaresultofthiswork,ourtechnicalteamof2beatmajor

departmentsfromacrossWhitehalltowinthecovetedCivilServiceAwardforScience

EngineeringandTechnologyin2009.

AND FINALLY...

IleavetheMAIBinAugust,afterlittleover8yearsastheChiefInspector.Therehave

beenmanychallenges.WhenIjoined,Iwasnaïveenoughtothinkthateveryonewould

beonthesideofindependentinvestigation,thesolepurposeofwhichwasfuturesafety.

Infact,fewareonourside,aseveryoneinvolvedinanaccidenthassomeformofvested

interest,andothersoftenhaveaparticularaxetogrind.Ihavealsohadtofighttomaintain

theindependenceandintegrityoftheMAIB,andourrighttooperatefreefromthegrowing

cultureofblameandlitigation.Thatwehavecontinuedtooperatesosuccessfullyinthe

faceofsuchchallengeshasreinforcedourcredibilityandis,Ibelieve,animportantoutcome

forsafetyatsea.IhaveanamazingteamintheMAIBwho,despitethegruellingnatureof

constantlyworkingwithdeathandtragedy,haveremainedpositiveandenthused.Iwish

themandmysuccessor,SteveClinch,allfortuneincontinuingthisimportanttask.

Stephen MeyerChief Inspector of Marine Accidents

4

MAIBANNUALREPORT2009

PART 1FULL INVESTIGATIONS AND

REPORT PUBLICATIONS

PART1: INVESTIGATIONS/PUBLICATIONS

5

FULL INVESTIGATIONS LIST

Full Investigations started in 2009

Date Name Of Vessel Type Of Vessel Nationality Size Nature of Incident

Merchant Vessels

28Jan Stena Voyager Highspeedro-roferry

UK 19638 gt Shiftofroadtankeronvehicledeckcausingextensivedamagetosterndoor–LochRyanshortlyafterleavingStranraer

28Jan Ville de Mars Containership UK 37235 gt FatalfallinvolvingChiefOfficerwhiledescendingintoballasttank–GulfofOman

25Feb Vallermosa Chemicaltanker Italy 25063 gt Contactwithtwovesselsdischargingcargo–Fawley

23Mar Stellar Voyager Oiltanker Bahamas 58088 gt Explosionofwindlassmotorcausinginjurytoonecrewman–TeesBay

01Apr Wellservicer Divesupport UK 9158 gt Fatalaccidenttoriggerinvolvingadivingbellcursor–Aberdeen

05Apr TS Royalist Sailtrainingvessel UK 83 gt Grounding–Chapman’sPool,Dorset

06May Jo Eik Chemicaltanker Norway 12249 gt ChiefOfficerandABovercomebyfumesonmaindeck–Vopakterminal,Teeside

14Jun Ijsselstroom Tug Netherlands 71 gt Capsizeduetogirting–Peterhead

10Aug Saetta/Conger Oiltanker/Chemicaltanker

Greece/MarshallIslands

5841844067

gt/gt

Collisionduringshiptoshipcargotransferoperation–NorthSeaoffSouthwold,Suffolk

10Sep Ever Elite Containership UK 76067 gt FatalaccidenttoABfollowingcollapseofaccommodationladder–SanFranciscoBay

16Sep Maersk Kendal Containership UK 74642 gt Grounding–MonggokSebarokreefintheSingaporeStrait

6

MAIBANNUALREPORT2009

Full Investigations started in 2009Date Name Of Vessel Type Of Vessel Nationality Size Nature of Incident

Fishing Vessels

12Feb Maggie Ann Scallopdredger UK 23.2 m Fatalpersonoverboard–CardiganBay

20Jul Aquila Scallopdredger UK 11.9 m Capsizeresultinginthreefatalities–northoftheArdnamurchanpeninsula

10Oct Olivia Jean Beamtrawler UK 29.9 m Crushinjuryduringmovementofgear–EnglishChannel

06Nov Korenbloem Scallopdredger UK 24.3 m Fatalpersonoverboard–DoverStrait

11Nov Osprey III Sterntrawler UK 9.2 m Fatalpersonoverboard–EastCoastofScotland

18Nov Optik Potter UK 9.2 m Fatalpersonoverboard–EastCoastofScotland

20Dec Etoile des Ondes Potter UK 14.5 m Collisionresultinginsinkingandthelossofonecrew–EnglishChannel

Small Craft

18May Sooty RIB UK 6.3 m Highspeedgroundingresultingononefatality–CalveIsland,nearTobermory,IsleofMull

08Aug Harwich 2011 Racingpowerboat UK 6 m Collisionduringraceresultinginonefatality–Dover

Ful l invest igat ions l is t

PART1: INVESTIGATIONS/PUBLICATIONS

7

PUBLICATIONS LISTReports of Full Investigations published in 2009Vessel Name(Report No) Vessel Type Accident Type Accident Date

Merchant Vessels

Abigail H (15/2009)

Dredger Floodingandfounderingwhilealongside–Heysham

02Nov2008

Antari (7/2009)

Generalcargoship Grounding–nearLarne,NorthernIreland 29Jun2008

Astral (4/2009)

Producttanker Grounding–PrincessaShoal,eastofIsleofWight

10Mar2008

Eurovoyager (17/2009)

Ro-ropassengerferry Majorinjurytoanengineroomfittertrappedinwatertightdoor–DoverStrait

03Nov2008

HMS Westminster/Princess Rose (16/2009)

RoyalNavyfrigate/ClassVpassengervessel

Personoverboardduringpassengertransfer–RiverThames,GravesendReach

24Nov2008

Hurlingham (12/2009)

ClassVpassengervessel

Passengerfatalityduringdisembarkation–RiverThames,London

17Aug2008

Jo Eik (24/2009)

Chemicaltanker ChiefOfficerandABovercomebyfumesonmaindeck–VopakTerminal,Teeside

06May2009

Maersk Kithira (9/2009)

Containership Fatalinjuryandseriousinjuryinheavyweather–SouthChinaSea

23Sep2008

Maersk Newport (13/2009)

Containership HeavyweatherdamageinEnglishChannelandsubsequentfirewhilealongsideinAlgeciras,Spain

10and15Nov2008

Moondance (5/2009)

Ro-rocargoship Electricalblackoutandsubsequentgrounding–Warrenpoint,NorthernIreland

29Jun2008

Norma (3/2009)

Selfpropelledcranebarge

Hazardousdivingincident–DoverStrait 21Jun2008

Pacific Sun (14/2009)

Cruiseship Injuriesto77passengersandcrewinheavyweather–PacificOcean

30Jul2008

Pride of Canterbury (2/2009)

Ro-ropassengerferry Grounding–offDeal,DoverStrait 31Jan2008

Riverdance (18/2009)

Ro-rocargoship Groundingandsubsequentloss–CleveleysBeach,Lancashire

31Jan2008

8

MAIBANNUALREPORT2009

Vessel Name(Report No) Vessel Type Accident Type Accident Date

TSRoyalist(26/2009)

Sailtrainingvessel Grounding–Chapman’sPool,Dorset 05Apr2009

Saga Rose (1/2009)

Cruiseship Fatalityinballasttank–Southampton 11Jun2008

Scot Isles/ Wadi Halfa (10/2009)

Generalcargoship/Bulkcarrier

CollisionintheDoverStrait 29Oct2008

Stellar Voyager (25/2009)

Oiltanker Explosionofwindlassmotorcausinginjurytoonecrewman–TeesBay

23Mar2009

Stena Voyager (21/2009)

Highspeedro-roferry

Shiftofroadtankeronvehicledeckcausingextensivedamagetosterndoor–LochRyanshortlyafterleavingStranraer

28Jan2009

Vallermosa (23/2009)

Chemicaltanker Contactwithtwovesselsdischargingcargo–Fawley

25Feb2009

Ville de Mars (20/2009)

Containership FatalfallinvolvingChiefOfficerwhiledescendingintoballasttank–GulfofOman

28Jan2009

Fishing Vessels

Maggie Ann (19/2009)

Scallopdredger Fatalpersonoverboard–CardiganBay 12Feb2009

Vision II (8/2009)

Trawler Fireresultingin3fatalities–alongsideinFraserburgh

01Aug2008

Small Craft

Celtic Pioneer (11/2009)

RIB Injurytopassenger–BristolChanneloffCardiff

26Aug2008

RIB6(6/2009)

RIB Capsizeresultinginoneinjury–MenaiStrait

01Jul2008

Sooty(22/2009)

RIB Highspeedgroundingresultingononefatality–CalveIsland,nearTobermory,IsleofMull

18May2009

Publ icat ions l is t

9

PART2:RECOMMENDATIONS

PART 2RECOMMENDATIONS

10

MAIBANNUALREPORT2009

RECOMMENDATIONSResponsestosafetyrecommendationsissuedbytheMarineAccidentInvestigationBranch.

ThisreportissubmittedtotheSecretaryofStateforTransportinaccordancewithTheMerchantShipping(AccidentReportingandInvestigation)Regulations2005,regulation15(5).

PageBackground 11Recommendation response statistics 12Recommendations methodology 13

SectionA-Level1Recommendations 14SectionB-Level2Recommendations 21SectionC-Level3Recommendations 32SectionD-Recommendationstomultiplerecipients 43SectionE-Withdrawnrecommendations 44SectionF-Recommendationsbroughtforwardfrompreviousyears 45

FordetailsofabbreviationsandacronymsusedinthisSectionpleaserefertotheGlossaryonpage71.

11

PART2:RECOMMENDATIONS

BACKGROUND

RecommendationsaretheprimeoutputofMAIBinvestigations.TheyaremadetopromulgatethelessonsfromaccidentsandincidentsinvestigatedbytheMAIB,withtheaimofimprovingthesafetyoflifeatseaandtheavoidanceoffutureaccidents.Theissueofarecommendationshallinnocasecreateapresumptionofblameorliability.

Followingapreliminaryexamination(PE)orfullinvestigationtheMAIBmaymakeanumberofrecommendations.ThesemaytaketheformofaChiefInspector’sletterfollowingaPEor,inthecaseofafullinvestigation,becontainedwithinthepublishedreport.UrgentsafetyrecommendationsmayalsobemadeinSafetyBulletinsthatcanbepublishedatanystageofaPEorfullinvestigation.ItisofnoconsequencewhetherarecommendationismadeasaresultofaPEorfullinvestigation,astheyareprocessedinthesamemanner.

Recommendationsaremadetoavarietyofaddresseeswhomayhavebeeninvolvedin,orhaveaninterestin,theincidentoraccident.ThesemayrangefromthoseorganisationswhichhaveawiderroleinthemaritimecommunitysuchastheDepartmentforTransport(DfT),MaritimeandCoastguardAgency(MCA)oraninternationalorganisation,throughtocommercialoperatorsandvesselowners/operatorswhomayhavespecificissuestoaddressontheirvessels.

ItisrequiredbytheMerchantShipping(AccidentReportingandInvestigation)Regulations2005thatthepersonorganisationtowhomarecommendationisaddressed,considertherecommendation,andreplytotheChiefInspectorwithin28daysontheplanstoimplementtherecommendationor,ifitisnotgoingtobeimplemented,anexplanationastowhynot.TheRegulationsalsorequiretheChiefInspector“toinformtheSecretaryofStateofthosematters”annually,andtomakethematterspubliclyavailable.ThisreporttotheSecretaryofStateforTransportfulfilsthisrequirement.

12

MAIBANNUALREPORT2009

RECOMMENDATION RESPONSE STATISTICS 200984recommendationswereissuedto117addresseesin2009.Eachaddresseeisconsideredseparatelyforthepurposesofthesestatistics.Ofthesethepercentagetotalofall117recommendationsthatareeither“accepted”or“acceptedyettobeimplemented”is88.0%.

Throughoutthereportrecommendationsarecategorisedunderfourbroadheadingsaccordingtotheindustrysectortowhichtheyapply,GeneralMaritime,CommercialShipping,FishingVesselsandLeisureVessels.

Focus

subtotal

%oftotal

Accepted – Action

Implemented

Accepted –Action

yet to be Implemented

Partially Accepted Rejected

No Response Received

General Maritime

30

25.6%

11 15 3 - 1

Commercial Shipping

77

65.8%

56 11 4 - 6

Fishing Vessels

7

6.0%

4 3 - - -

Leisure Vessels

3

2.6%

3 - - - -

subtotal

% of total

117

100%

74

63.2%

29

24.8%

7

6.0%

-

-

7

6.0%

DetailsofalltheserecommendationsareatSectionsA-C.

RECOMMENDATION RESPONSE STATISTICS 2004 to 2008Thefollowingtableshowstheequivalentstatusofrecommendationsissuedin2004to2008aspublishedintheMAIB’spreviousRecommendationsAnnualReports.

Year TotalAccepted – Action

Implemented

Accepted – Action yet to be

Implemented

Partially Accepted Rejected No Response

Received

2008 110 71 31 5 - 3

2007 136 109 23 1 1 2

2006 139 103 30 3 3 -

2005 140 122 14 1 1 2

2004 171 93 52 11 11 4

Ofthe150recommendationsaccepted – yet to be implemented (attimeofpublicationofrelevantannualreport):• 76.7%havenowbeenfully implemented

• 23.3%remainplanned to be implemented.

DetailsoftherecommendationsstilltobeimplementedareatSectionF.

13

PART2:RECOMMENDATIONS

RECOMMENDATION METHODOLOGY

SectionsA-Etothisreportpresenttherecommendationsmadethroughout2009,SectionsDandEarenotincludedinthestatistics.SectionFliststherecommendationsthatarestilloutstandingaccepted – yet to be implementedfrompreviousyears.

Therecommendationshavebeenbrokendownintothreelevels,showninSectionsA-C.Thesearethenfurtherdivided,asshownbelow.Emphasishasbeengiventothoserecommendationswhichhavebeenrejected orpartially acceptedandtheirentriesincludetheresponsereceivedbytheMAIB,togetherwithanMAIBcomment.

SectionA

Level 1 Recommendations Thesehavethebroadestimportance,andmayincludetherequirementfornewlegislationorchangesinpolicy.

Rejected, Partially accepted, No Response Received

Accepted-yettobeimplemented

Accepted-implemented

SectionB

Level 2 Recommendations Addressedtoindustrybodiesandorganisationswhichmaycallforchangesorreinforcementofbestpractice.

Rejected, Partially accepted, No Response Received

Accepted-yettobeimplemented

Accepted-implemented

SectionC

Level 3 Recommendations Thosewhichareaddressedtoindividualownersorcompanieswhicharespecifictotheirvesselorcompany.

Rejected, Partially accepted, No Response Received

Accepted-yettobeimplemented

Accepted-implemented

SectionD

Recommendations to multiple recipientsListsthesmallnumberofrecommendationsthathavebeenaddressedtolargemultiplerecipients.Asaresult,ithasnotbeenpossibletotrackresponsesundertheclosed-loopsystem.Suchmultipleaddresseerecommendationsareavoidedwheneverpossible.

SectionE Withdrawn recommendations.

SectionF

Recommendations brought forward from previous years.Liststheongoingoutstandingrecommendationsshownasaccepted – yet to be implemented inpreviousreports.

14

MAIBANNUALREPORT2009

Section A

LEVEL 1 RECOMMENDATIONSThesehavethebroadestapplication,andmayincludetherequirementfornewlegislationorchangesinpolicy.

Summary Table

Focus TotalAccepted

Action Implemented

Accepted Action yet

to be Implemented

PartiallyAccepted Rejected

No Response Received

General Maritime 7 2 2 1 - -

Commercial Shipping 13 6 4 1 - 3

Fishing Vessels - - - - - -

Leisure Vessels - - - - - -

Total 20 8 6 2 - 3

15

PART2:RECOMMENDATIONSLe

vel 1

Rec

omm

enda

tions

– B

reak

dow

n

Responsestorecommendationswhichhave

not b

een

acce

ptedhavebeengroupedtogetherandpresentedfirst.

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tedarepresentedsecondlyandbrokendownintotheirvesseltype.

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Res

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ion

Add

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mercial

Shipping

Eur

ovoy

ager

Belgium

Federal

PublicService,

Mobilityand

Transport

ThroughrepresentationstotheEuropeanCom

mission,takestepstoensure

thatofficialguidanceprovidedforinspectorsinrespecttotheapplicationofEU

Directive1999/35/ECisamendedtoreflectSOLA

Srequirementsregardingthe

operationofwatertightdoorsatsea.

No

resp

onse

to d

ate.

148b

Com

mercial

Shipping

Eur

ovoy

ager

Belgium

Federal

PublicService,

Mobilityand

Transport

PresentajointpapertotheIMO’sMaritimeSafetyCom

mitteeon:

•RevisionofSOLA

SRegulation15(openingsinwatertightbulkheadsin

passengerships)toreflectthecontentsofS

ection4.3.8andSection

8ofMSC/Circ.1176whichrequirestheprovisionofalocalvisual

indicationtoindicatewhenawatertightdoorisbeingoperatedinthe

remotemode.

•TheapplicationofSOLA

SRegulation15toallvesselsfittedwith

watertightdoors.

No

resp

onse

to d

ate.

148c

Com

mercial

Shipping

Eur

ovoy

ager

CyprusMaritime

Adm

inistration

PresentajointpapertotheIMO’sMaritimeSafetyCom

mitteeon:

•RevisionofSOLA

SRegulation15(openingsinwatertightbulkheadsin

passengerships)toreflectthecontentsofS

ection4.3.8andSection

8ofMSC/Circ.1176whichrequirestheprovisionofalocalvisual

indicationtoindicatewhenawatertightdoorisbeingoperatedinthe

remotemode.

•TheapplicationofSOLA

SRegulation15toallvesselsfittedwith

watertightdoors.

No

resp

onse

to d

ate.

16

MAIBANNUALREPORT2009Pa

rtia

lly A

ccep

ted

Num

ber

Focu

sIn

vest

igat

ion

Add

ress

ed T

oR

ecom

men

datio

n141

General

Maritime

Abi

gail

HMaritimeand

CoastguardAgency

(MCA)

Introduceamandatoryrequirement,forallvesselsgreaterthan24m

lengthandlessthan500grosstons,forthefittingofbilgealarmsinengine

room

sandothersubstantialcom

partm

entsthatcouldthreatenthevessel’s

buoyancyandstabilityifflooded.Theseandanyotheremergencyalarms

shouldsoundinallaccommodationspaceswhenthecentralcontrolstation

isunm

anned.Inadditiontofunctioninginthevessel’snormaloperational

modes,alarmsshouldbecapableofoperatingwhenmainpowersupplies

areshutdow

n,andbeabletowakesleepingcrewinsufficienttimefor

them

toreactappropriately.

MCAResponse

The

reco

mm

enda

tion

can

best

be

impl

emen

ted

by in

trodu

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a

requ

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ent i

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the

Mer

chan

t Shi

ppin

g (L

oad

Line

) Reg

ulat

ions

, rem

ovin

g th

e re

stric

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for b

ilge

alar

ms

to b

e fit

ted

only

whe

re e

ngin

e ro

oms

are

unm

anne

d, a

nd a

ddin

g a

requ

irem

ent f

or th

e bi

lge

alar

ms

to b

e fit

ted

in

the

carg

o ho

ld. T

his

will

mirr

or th

e re

quire

men

t of S

OLA

S fo

r shi

ps o

f ove

r 50

0gt.

The

regu

latio

n co

uld

also

requ

ire th

at th

e bi

lge

alar

m s

ound

s in

the

acco

mm

odat

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shou

ld th

e ce

ntra

l con

trol s

tatio

n no

t be

man

ned

– ag

ain,

in

a s

imila

r man

ner t

o th

e re

quire

men

t for

the

engi

neer

’s a

larm

in S

OLA

S.

The

part

of th

e re

com

men

datio

n to

“… b

e ca

pabl

e of

ope

ratin

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hen

mai

n po

wer

sup

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s ar

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ut d

own”

can

not b

e m

ade

a m

anda

tory

requ

irem

ent

unde

r UK

law

. The

reco

mm

enda

tion

to “…

be

able

to w

ake

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ping

cre

w in

su

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ent t

ime

for t

hem

to re

act a

ppro

pria

tely

” aga

in w

ould

be

very

diffi

cult

in la

w.

It is

con

clud

ed th

at th

e in

tent

of t

hese

par

ts o

f the

reco

mm

enda

tion

are

bette

r man

aged

by

risk

asse

ssm

ent a

nd in

spec

tion

of th

e ve

ssel

s as

pr

opos

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roug

h th

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spon

se to

Rec

omm

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tion

2009

/142

.

MA

IB C

omm

ent

MC

A co

mm

ents

are

not

ed.

17

PART2:RECOMMENDATIONSN

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

148a

Com

mercial

Shipping

Eur

ovoy

ager

MCA

PresentajointpapertotheIMO’sMaritimeSafetyCom

mitteeon:

•RevisionofSOLA

SRegulation15(openingsinwatertightbulkheads

inpassengerships)toreflectthecontentsofS

ection4.3.8and

Section8ofMSC/Circ.1176whichrequirestheprovisionofa

localvisualindicationtoindicatewhenawatertightdoorisbeing

operatedintheremotemode

•TheapplicationofSOLA

SRegulation15toallvesselsfittedwith

watertightdoors.

MCAResponse

•RecognisestheneedforchangetoSOLA

SRegulation15toreflect

contentsofM

CS/Circ1176(seeabove).How

ever,theMCAisonly

preparedtosupportthepapertoIMOifpresentedbytheflagstateof

thevesselconcerned.

•RecognisestheneedtoapplySOLA

SRegulation15toallvessels.

MA

IB C

omm

ent

The

MC

A’s

actio

ns w

ith re

spec

t to

this

reco

mm

enda

tion

mea

n th

at

any

initi

ativ

e to

real

ise

a re

visi

on o

f SO

LAS

Reg

ulat

ion

15 re

sts

with

the

adm

inis

trat

ions

of B

elgi

um a

nd C

ypru

s. N

o re

spon

se to

th

is re

com

men

datio

n ha

s be

en re

ceiv

ed fr

om e

ither

the

Bel

gium

or

Cyp

rus

adm

inis

trat

ion.

18

MAIBANNUALREPORT2009A

ccep

ted

– Ye

t to

be Im

plem

ente

d

Num

ber

Focu

sIn

vest

igat

ion

Add

ress

ed T

oR

ecom

men

datio

n115b

Com

mercial

Shipping

Ant

ari

MCA

PresstheInternationalM

aritimeOrganizationforanurgentreview

oftheprinciples

andprocessusedtoestablishsafemanninglevelsinternationallyandtheuseof

dedicatedlookouts.

Pred

icte

d im

plem

enta

tion

date

: Jun

e 20

10125

Cel

tic P

ione

erInconsultationwiththeMCA,continuetoworktowardstheproductionofan

industryapprovedcodeofpracticeforthrill-typeboatrideoperators,takinginto

accountthesafetyissuesraisedinthisreportandtherequirementslaiddow

ninthe

VibrationRegulations.

125a

General

Maritime

Professional

Boatman’s

Association

Pred

icte

d im

plem

enta

tion

date

: Wor

k in

pro

gres

s.

125b

General

Maritime

PassengerBoat

Association

Pred

icte

d im

plem

enta

tion

date

: Wor

k in

pro

gres

s.

126a

Com

mercial

Shipping

Cel

tic P

ione

erMCA

Reviewandrevisethedeckmanningandqualificationrequirementsofthe

harmonisedSCVCodetakingintoaccountthespeedofcraftandthetypeofactivity

intendedinadditiontothedistancefrom

shoreandenvironm

entalconditions.

Pred

icte

d im

plem

enta

tion

date

: Yet

to b

e ad

vise

d153

Riv

erda

nce

Conductanurgentstudyintostabilityandoperationalissueswhichim

pingeon

thesafetyofro-rovesselsoperatingfromUKports.Inparticular,thestudyshould

identifyhowthestow

ageplanshouldbeproducedandimplem

ented,how

masters

canestablishthestabilityoftheirvesselbeforesailing,andundervaryingconditions

ofservice,thesecuringoftrailers,andthesecuringofcargowithintrailersto

preventtheirmovem

entw

hilstatsea.

Pred

icte

d im

plem

enta

tion

date

: D

ecem

ber 2

010

153a

Com

mercial

Shipping

Departmentfor

Transport(DfT)

153b

Com

mercial

Shipping

MCA

19

PART2:RECOMMENDATIONSA

ccep

ted

– Im

plem

ente

d –

Rec

omm

enda

tion

clos

ed b

y M

AIB

Num

ber

Focu

sIn

vest

igat

ion

Add

ress

ed T

oR

ecom

men

datio

n109

Com

mercial

Shipping

Moo

ndan

ceBaham

asMaritime

Authority(BMA)

Takeurgentactiontoreview

thevalidityofS

eatruckShipholdingLimited’s

SafetyManagem

entS

ystemstoensuretheyaresufficientlyrobustforsafe

operationofitsvessels.

115a

Com

mercial

Shipping

Ant

ari

DfT

Pressforanurgentreview

oftheprocessandprinciplesofsafemanningat

theIMOtoreflectthecriticalsafetyissuesoffatigueandtheuseofdedicated

lookouts.

116

Ant

ari

Toinstigaterobust,unilateralm

easurestoaddressthefatigueofbridge

watchkeepingofficersonvesselsinUKwatersandtoensurethatadedicated

lookoutisalwayspostedatnight,duringrestrictedvisibilityandasotherwise

requiredinhazardousnavigationalsituations.

116a

Com

mercial

Shipping

DfT

116b

Com

mercial

Shipping

MCA

122

General

Maritime

Mae

rsk

Kith

iraMCA

Developandpromulgateformaladvicetomarinersonthespecificrisksto

beconsideredwhenassessingtheneedtogoontotheopendeckinheavy

weather.Suchadviceshould:

•Provideguidanceontheheightandfrequencyofsignificantlylarger

wavesthatmaybeencountered.

•Urgeparticularcautionwhenassessingtheneedtogoontotheopen

deckduringdarknessinviewofthedifficultiesthatmaybeexperienced

inassessingthemagnitude/directionofapproachingwaves.

•Listcontrolm

easuresthatshouldbeadoptedwhensendingpersonnel

ontotheopendeckinheavyweather.

Theaboveformaladviceshouldunderpinthedraftguidancecurrentlybeing

developedandbeincorporatedintothenextrevisionoftheCodeofSafe

WorkingPracticesforM

erchantS

eamen.

20

MAIBANNUALREPORT2009N

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

126b

General

Maritime

Cel

tic P

ione

erRoyalYachting

Association(RYA

)Reviewandrevisethedeckmanningandqualificationrequirementsofthe

harmonisedSCVCodetakingintoaccountthespeedofcraftandthetype

ofactivityintendedinadditiontothedistancefrom

shoreandenvironm

ental

conditions.

133

Com

mercial

Shipping

Hur

lingh

amMCA

ImprovethetargetingofinspectionsontheoperationofClassVvessels

(particularlythoseworkingduringtheevening)to:

•VerifycompliancewiththeproceduresspecifiedintheirD

SMC.

•Promotetheadoptionofproceduresthatreflectbestpractice,such

asthosedescribedintheCodeofPracticeforP

assengerVessel

OperationsontheTham

es2009.

147b

Com

mercial

Shipping

Eur

ovoy

ager

MCA

ThroughrepresentationstotheEuropeanCom

mission,takestepstoensure

thatofficialguidanceprovidedforinspectorsinrespecttotheapplicationofEU

Directive1999/35/ECisamendedtoreflectSOLA

Srequirementsregardingthe

operationofwatertightdoorsatsea.

21

PART2:RECOMMENDATIONS

SECTION B

LEVEL 2 RECOMMENDATIONSTheserecommendationsareaddressedtoindustrybodiesandorganisationswhichmaycallforchangesorreinforcementofbestpractice.

Summary Table

Focus TotalAccepted

Action Implemented

Accepted Action yet

to be Implemented

PartiallyAccepted Rejected

No Response Received

General Maritime 16 4 10 1 - 1

Commercial Shipping 26 20 3 3 - 1

Fishing Vessels 4 1 3 - - -

Leisure Vessels - - - - - -

Total 46 25 16 4 - 2

22

MAIBANNUALREPORT2009Le

vel 2

Rec

omm

enda

tions

– B

reak

dow

n

Responsestorecommendationswhichhave

not b

een

acce

ptedhavebeengroupedtogetherandpresentedfirst.

Thosewhichhavebeena

ccep

tedarepresentedsecondlyandbrokendownintotheirvesseltype.

No

Res

pons

e R

ecei

ved

Num

ber

Focu

sIn

vest

igat

ion

Add

ress

ed T

oR

ecom

men

datio

n149b

Com

mercial

Shipping

Eur

ovoy

ager

Belgium

Federal

PublicService,

Mobilityand

Transport

EnsurethatwheninspectingferriesunderE

UDirective199/35/EC,

InspectorsalsotakeaccountofE

Ulegislation,suchasPUWER,w

hichrelate

tothehealthandsafetyofworkers.

No

resp

onse

to d

ate.

149c

Com

mercial

Shipping

Eur

ovoy

ager

CyprusMaritime

Adm

inistration

EnsurethatwheninspectingferriesunderE

UDirective199/35/EC,

InspectorsalsotakeaccountofE

Ulegislation,suchasPUWER,w

hichrelate

tothehealthandsafetyofworkers.

No

resp

onse

to d

ate.

Part

ially

Acc

epte

d

Num

ber

Focu

sIn

vest

igat

ion

Add

ress

ed T

oR

ecom

men

datio

n140

Com

mercial

Shipping

Ste

llar V

oyag

erTT

SKocksGmbH

Identifythetechnicalreasonsforthecatastrophicfailureofitswindlass

motorsanddetermineengineeringanddesignsolutionstopreventsimilar

accidentsonboardvesselsfittedwithitsequipm

ent.

TTSKocks

Response

Has

iden

tified

the

tech

nica

l rea

son

for t

he c

atas

troph

ic fa

ilure

of i

ts w

indl

ass

mot

or b

ut b

elie

ves

no m

odifi

catio

n to

the

desi

gn o

f its

equ

ipm

ent i

s re

quire

d.

In th

e m

anuf

actu

rer’s

opi

nion

the

failu

re w

as s

olel

y du

e to

ope

rato

r err

or/b

ad

seam

ansh

ip.

MA

IB C

omm

ent

The

man

ufac

ture

r app

ears

to h

ave

mis

sed

the

key

poin

t of t

his

reco

mm

enda

tion.

It is

ess

entia

l tha

t shi

ps’ e

quip

men

t is

desi

gned

suc

h th

at it

doe

s no

t fai

l in

a m

anne

r whi

ch c

an c

ause

ser

ious

inju

ry o

r dea

th.

In th

is c

ase

the

win

dlas

s m

otor

cas

ing

shat

tere

d, s

pray

ing

shra

pnel

ar

ound

the

adja

cent

dec

ks, w

hich

sev

erel

y in

jure

d th

e w

indl

ass

oper

ator

.

23

PART2:RECOMMENDATIONSN

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

149a

Com

mercial

Shipping

Eur

ovoy

ager

MCA

EnsurethatwheninspectingferriesunderE

UDirective199/35/EC,Inspectors

alsotakeaccountofE

Ulegislation,suchasPUWER,w

hichrelatetothe

healthandsafetyofworkers.

MCAResponse

MC

A’s

cons

ider

ed v

iew

is th

at th

is re

com

men

datio

n ha

s hu

ge im

plic

atio

ns fo

r sh

ips

with

wat

ertig

ht d

oors

and

that

it w

ould

not

be

prac

tical

or f

ully

just

ified

un

der t

he c

osts

ver

sus

bene

fits

to re

quire

all

wat

ertig

ht d

oors

to c

ompl

y w

ith

EU

legi

slat

ion

rega

rdin

g P

UW

ER

. We

note

the

poin

ts m

ade

in th

e re

port

and

will

writ

e to

the

Eur

opea

n C

omm

issi

on to

see

k a

view

on

the

appl

icat

ion

and

impa

ct th

is w

ill h

ave

on e

nfor

cing

PU

WE

R o

n w

ater

tight

doo

r arr

ange

men

ts.

The

times

cale

for t

his

can

only

be

that

we

rais

e th

e is

sue

with

the

EC

by

Nov

embe

r 200

9 an

d ca

nnot

pre

dict

the

furth

er o

utco

me.

MA

IB C

omm

ent

The

MC

A po

sitio

n is

not

ed.

164b

Com

mercial

Shipping

Ste

na V

oyag

erVehicleand

OperatorS

ervices

Agency(VOSA)

Conductaco-ordinatedprogrammeofroadside/docksideinspectionsoffreight

vehiclespresentingforshipm

entatU

Kports,toidentifythosevehiclesthatdo

notcom

plywiththeIMOandMCAguidanceonferrysecuringarrangem

ents,

andtakeanyappropriateactionsavailabletoincreaselevelsofawareness

andcompliance.

VOSAResponse

VO

SA

cont

ends

that

an

insp

ectio

n re

gim

e as

out

lined

in th

e re

com

men

datio

n is

out

side

its

curr

ent r

emit

and

no fu

ndin

g is

pro

vide

d fo

r thi

s pu

rpos

e.

MA

IB C

omm

ent

MA

IB is

aw

are

that

VO

SA a

nd th

e M

CA

have

bee

n w

orki

ng c

lose

ly

toge

ther

to p

rodu

ce in

form

atio

nal l

itera

ture

aim

ed a

t shi

p op

erat

ors,

se

afar

ers,

road

hau

liers

and

veh

icle

driv

ers

whi

ch h

ighl

ight

the

requ

irem

ents

and

pre

caut

ions

that

nee

d to

be

obse

rved

whe

n tr

ansp

ortin

g ar

ticul

ated

lorr

ies

and

trai

lers

by

sea.

175

General

Maritime

Valle

rmos

aInternational

Association

ofMaritime

Institutions(IAMI)

TailorB

ridgeResourceManagem

enttrainingcourses,asguidedbytheoutput

oftheUKMPG,B

PAandMPA

MarineWorkingGroup,toincludeintegrationof

pilotsintothebridgeteam

duringpilotage.

IAMIresponse

Nofurtherchangetosyllabusrequired.

MA

IB C

omm

ent

Cha

nges

to s

ylla

bus

will

be

pred

icat

ed b

y th

e ou

tcom

e of

wor

k cu

rren

tly

bein

g un

dert

aken

by

UK

MPG

, BPA

and

MPA

.

24

MAIBANNUALREPORT2009A

ccep

ted

– Ye

t to

be Im

plem

ente

d

Num

ber

Focu

sIn

vest

igat

ion

Add

ress

ed T

oR

ecom

men

datio

n118

Fishing

Vessel

Visi

on II

MCA

Broadenthescopeofitsreview

ofthesafetyissuesassociatedwithcrew

livingonboardfishingvesselstoinclude:Theim

pactofsecurityarrangements

onemergencyaccessandegress;safeaccessrequirementstoandfrom

the

vessel.

Pred

icte

d im

plem

enta

tion

date

: Dec

embe

r 201

0119

Fishing

Vessel

Visi

on II

TheSeafish

IndustryAuthority

Reviewitssurveyprocedurestoensurethattheyareeffectiveincheckingnew

buildvesselscom

plywithmandatedconstructionstandards,specificallythat

electricalsystemsareappropriatelycheckedandapproved.

Pred

icte

d im

plem

enta

tion

date

: Jun

e 20

10127

General

Maritime

Cel

tic P

ione

erRYA

Raisetheaw

arenessofthedangersofshockandvibrationinsmallhigh-

speedcraftthroughitspowerboattrainingsyllabi.

Pred

icte

d im

plem

enta

tion

date

: Dec

embe

r 201

0142

General

Maritime

Abi

gail

HMCA

Issueguidance,andthroughsurveyandinspection,checkthatowners

conductaproperlystructuredassessm

entofriskstocrewsleepingonboard

allvesselslessthan500grosstonsthataremooredalongsideandhavebeen

shutdow

novernight.W

heresuchrisksareidentified,checkthatappropriate

proceduresareinplacetomitigatethem

.Pr

edic

ted

impl

emen

tatio

n da

te: D

ecem

ber 2

010

144

General

Maritime

HM

S

Wes

tmin

ster

/ P

rince

ss R

ose

MCA

Provideguidanceon:

•Theconductofpassengertransfersbetweenvesselsthatare

underwayandmakingway.

•Themovem

entofpassengerstoandfrom

vesselswhicharenot

securedtoaquay,includingtheuseofverticalladders

Pred

icte

d im

plem

enta

tion

date

: A

ugus

t 201

0

25

PART2:RECOMMENDATIONSN

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

147a

Com

mercial

Shipping

Eur

ovoy

ager

DfT

ThroughrepresentationstotheEuropeanCom

mission,takestepstoensure

thatofficialguidanceprovidedforinspectorsinrespecttotheapplicationofEU

Directive1999/35/ECisamendedtoreflectSOLA

Srequirementsregarding

theoperationofwatertightdoorsatsea.

Pred

icte

d im

plem

enta

tion

date

: Yet

to b

e ad

vise

d158

Fishing

Vessel

Mag

gie

Ann

MCA

Aspartofitseffortstorealiseimprovedsafetywithinthefishingindustry:

•Expediteitscurrentw

orkontheuseofpersonalflotationdevices

andpersonallocatorbeaconsintheUKfishingIndustry(M

AIB

Recom

mendation2008/173refers).

•Ensureem

ergencydrills,plusinstructionandguidanceonhow

toconductriskassessm

entandim

provesafetyawarenessare

undertakentoaconsistentstandardbysurveyorsandinspectorsof

fishingvesselsthroughouttheUK.

•IncorporateguidanceintoitsrevisionofM

GN265(F

)designedto

precludetheneedforS

callopfishermentoleanoutboardofthe

bulwarkduringtippingoperations.

Pred

icte

d im

plem

enta

tion

date

: Apr

il 20

15165

Com

mercial

Shipping

Ste

na V

oyag

erMCA

ReviewthecargosecuringmanualsofallUKflaggedHSCcarryingfreight

vehiclestoensurecompliancewiththenumbersoflashingpointsrequiredin

theUKCodeofPractice.

Pred

icte

d im

plem

enta

tion

date

: Jun

e 20

10166

Com

mercial

Shipping

Ste

na V

oyag

erMCA

AtthenextS

MCauditorEUFerryDirective(1999/35)surveyofallUK-

flaggedfreight-carryingro-roferriesandallforeign-flaggedfreight-carrying

ro-roferriesoperatingtoUKports,checkthecargosecuringarrangem

entsto

confirmthat:

•Onboardpracticeisinlinewiththeapprovedcargosecuringmanual

andtheproceduresdetailedinavessel’ssafetymanagem

entsystem.

•Shipboardproceduresincludemeasurestoverifythattheparking

brakesofallvehicles,includingsem

i-trailers,havebeenapplied.

Pred

icte

d im

plem

enta

tion

date

: May

201

0 –

Upd

ate

requ

este

d.

26

MAIBANNUALREPORT2009N

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

172

Valle

rmos

aTasktheUKMPG/BPA

MarinePilotageW

orkingGroupinconsultationwith

theUKMPA

todefinetheirexpectationsofbridgeteam

/pilotperformance,and

fromthis:

•Determinethetrainingrequirementsnecessarytoensurepilotscan

integrateeffectivelyintobridgeteam

sduringtheperformanceoftheir

duties.Toreinforcethebenefitsandrationaleofintegrationwithbridge

team

s,suchtrainingshouldmakeclearthenegativeimpactstress/

overloadwillhaveonindividuals’cognitivefunctions.

•Determinetherequiredlevelofsupportprovidedbybridgeteam

sduring

actsofpilotageandensurethisexpectationisdisseminatedtovessels

arrivingattheirports.

172a

General

Maritime

UKMajorPorts

Group(U

KMPG)

Pred

icte

d im

plem

enta

tion

date

: Yet

to b

e ad

vise

d

172b

General

Maritime

BritishPorts

Association(BPA

)Pr

edic

ted

impl

emen

tatio

n da

te: Y

et to

be

advi

sed

172c

General

Maritime

UKMaritime

PilotsAssociation

(UKMPA

)

Pred

icte

d im

plem

enta

tion

date

: Yet

to b

e ad

vise

d

173

Valle

rmos

aEncouragetheirm

emberstodevelopfeedbackmechanism

sforpilotstoreport

onsubstandardbridgeteam

performance,andtakeappropriateactionas

necessary.

173a

General

Maritime

UKMPG

Pred

icte

d im

plem

enta

tion

date

: Yet

to b

e ad

vise

d

173b

General

Maritime

BPA

Pred

icte

d im

plem

enta

tion

date

: Yet

to b

e ad

vise

d

173c

General

Maritime

UKMPA

Pred

icte

d im

plem

enta

tion

date

: Yet

to b

e ad

vise

d

174

General

Maritime

Valle

rmos

aMCA

Disseminatetotheshippingindustryspecificdetailedinformationonthe

expectedlevelsofsupportwhichshouldbeprovidedbybridgeteam

swhena

pilotisem

barked.

Pred

icte

d im

plem

enta

tion

date

: D

ecem

ber 2

010

27

PART2:RECOMMENDATIONSA

ccep

ted

– Im

plem

ente

d –

Rec

omm

enda

tion

clos

ed b

y M

AIB

Num

ber

Focu

sIn

vest

igat

ion

Add

ress

ed T

oR

ecom

men

datio

n103

Ast

ral

ProvideguidancetoyourV

TSOsonthelanguageandterminologyused,

particularlytononEnglishspeakers,incommunicatingwithships’m

asters

andofficerstominimisethepossibilityofm

isunderstandingorconfusionand,

whereappropriate,toissuemasterswithclearinstructions.

103a

Com

mercial

Shipping

AssociatedBritish

PortsSoutham

pton

103b

Com

mercial

Shipping

Queen’sHarbour

MasterP

ortsmouth

104

Com

mercial

Shipping

Ast

ral

RederiABVeritas

Tankers

ReviewyourS

MSinstructionsandenhanceyourauditingproceduresto

ensurethatmastersandships’officers:

•Areprovidedwith,andarefamiliarwith,correctandclearanchoring

procedures.

•Understandthelim

itationsoftheirvessel’sanchoringsystem

.•

Understandthecompany’semergencyresponseproceduresandare

implem

entingtheseplanseffectively.

105

Ast

ral

Encourageyourm

embersprovidingtrainingtodeckofficers,toconductafull

review

ofthestudyprogram

mesdeliveredtoensurethatdeckofficersgain

effectiveinstructionon:

•Navigationplanningforanchoring,includingtheconstructionof

swingingcircles,holdinggroundandpositionmonitoringwhileat

anchor.

•Thestrengths,weaknessesandlim

itationsofvessels’anchoring

system

s.•

Com

mandconsiderationsforsafeanchoring,includingwindandtide

effects,yaw

ing,whentodepartananchorageandactionstotaketo

preventdraggingandtotakewhendraggingisdetected.

105a

Com

mercial

Shipping

IAMI

105b

Com

mercial

Shipping

GlobalMET

formallyAMETIAP

28

MAIBANNUALREPORT2009N

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

106

Nor

ma

UndertheleadoftheMaritimeandCoastguardAgency:

•Consolidatetheguidanceavailablefordivingoperations

conductedfrom,orw

ithincloseproximitytomerchantvessels.

•Developgenericchecklistswhereappropriate.

•Ensuresuchguidanceiswidelyprom

ulgatedwithintheshipping

andcommercialdivingindustries.

106a

Com

mercial

Shipping

MCA

106b

Com

mercial

Shipping

HealthandSafety

Executive(HSE)

106c

Com

mercial

Shipping

International

MarineContractors

Association

106d

Com

mercial

Shipping

Associationof

DivingContractors

107

Com

mercial

Shipping

Nor

ma

International

Chamberof

Shipping(IC

S)

Throughyourmem

bershipprom

ulgatetheguidancefordivingoperations

conductedfrom,orw

ithincloseproximityto,m

erchantvesselsassoonas

thishasbeendevelopedbytheMaritimeandCoastguardAgency,theHealth

andSafetyExecutive,InternationalM

arineContractorsAssociationand

AssociationofDivingContractors.

108

Com

mercial

Shipping

Nor

ma

International

Associationof

Classification

SocietiesLtd.

(IACS)

Highlighttoyourm

embershiptheneedtoidentifykeyshipboardoperations

integraltoavessel’sintendedandpotentialemploymentandtoensure

appropriateassociatedprocedureshavebeendevelopedwhenever

conductingISMCodeauditsasrecognisedorganisationsonbehalfofflag

states.

120

Fishing

Vessel

Visi

on II

MacduffShipyards

Ltd

Reviewyourqualitymanagem

entsystemtoensurethattheelectricalsystem

ofnew

vesselsfullycom

plieswiththerelevantsectionsoftheSeaFish

IndustryAuthorityconstructionstandards,andequipmentissuitableforits

intendedpurposeandisinstalledinaccordancewithmanufacturers’fitting

instructions.

129

Com

mercial

Shipping

Cel

tic P

ione

erBayIslandVoyages

Reviewyourriskassessmentsandoperatingprocedurestakinginto

considerationthesafetyissuesidentifiedinthisreport,andensurethatall

suchproceduresarefollowed.

29

PART2:RECOMMENDATIONSN

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

134

Com

mercial

Shipping

Hur

lingh

amMCA

IssueimprovedinformationtooperatorsofC

lassIII–VI(A)D

omestic

Passengershipstoguidethem

onthemeasurestheyshouldtaketocom

ply

effectivelywiththeDom

esticPassengerShipsSafetyManagem

entC

ode.

135

General

Maritime

Hur

lingh

amLondonRiver

Services(LRS)

Assesstherisksassociatedwiththemovem

entandcontrolofpassengerson

yourpiersatnight,to:

•Clarifywheretheresponsibilityforpassengersafetylies,andensure

thatadequatecontrolm

easuresareinplacetoensurepassenger

safety,particularlyinemergencysituations.

•Ensurethelightingandmarkingarrangementsofthepieredges

makeadistinctcontrastwiththesurroundingwaterinallam

bientlight

conditions.

•RequireallvesselsusingLR

SpierstoadheretotheCodeofPractice

forP

assengerVesselO

perationsontheTham

es2009.

138

Com

mercial

Shipping

Pac

ific

Sun

PrincessCruises

•Reviewtheroleofactivestabilisersinensuringpassengersafety.The

review

shouldincludesystem

redundancy,plannedmaintenance,and

theneedtofitsuitablealarmstowarnofsystemdegradationorfailure.

•Carryoutafleet-w

ideassessmentoftheriskofinjuryfrommoving

furnishingsandobjectsfollowinglargeanglesofheel.Thisshould

includethecalculationoftheforcesinvolvedandidentifysuitable

meansofsecuringobjectsbothroutinely,andforheavyweather.

•Developastandardforsecuringfurnishingsandequipm

entinpublic

spaces,particularlyinmusterstationsandtheiraccessroutes.

•Developyourheavyweatherguidanceandinstructionstoinclude

actionstoreducetheriskofinjury.

139a

Com

mercial

Shipping

Pac

ific

Sun

CruiseLines

International

Association(CLIA)

•UsethePrincessCruises’standardforsecuringfurnishingsand

equipm

entinpassengervessels(oncecompleted)asabasisfor

developingaguideonindustrybestpractice.

•Disseminatethesafetyissues,actionstakenandlessonslearnt

followingthisaccidenttoyourmem

bers.

152

General

Maritime

Cel

tica

Hav

PerthandKinross

Council

Ensurethattherecentlyincreasedminimum

underkeelclearancerequiredby

vesselspassingovertheShellNGLpipelineisstrictlyadheredto,andthatthe

risksassociatedwithanyproposeddredginginthevicinityofthepipelineare

fullyassessedinconsultationwithkeystakeholders.

30

MAIBANNUALREPORT2009N

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

154

Riv

erda

nce

Provideguidancetoshippersontheadditionalsecuringofcargoontotrailers

intendedforshippingbyseatowithstandthedynamicforcesthatmaybe

experienced.

154a

Com

mercial

Shipping

TheRoadHaulage

Association

154b

Com

mercial

Shipping

FreightTransport

Association

155

Riv

erda

nce

Ensureproperandeffectivemethodsexisttopromulgateanddisseminate

safetyinformationproducedbyIMO,andotherrelevantorganisations,toship

operators.

155a

Com

mercial

Shipping

MCA

155b

Com

mercial

Shipping

BMA

156

Com

mercial

Shipping

Riv

erda

nce

ICS

Reviewexistingguidancetoownerson“EmergencyPreparedness”and

prom

otecarefulconsiderationofthemeritsofusingEmergencyResponse

Services.

164a

Com

mercial

Shipping

Ste

na V

oyag

erMCA

Conductaco-ordinatedprogrammeofroadside/docksideinspectionsoffreight

vehiclespresentingforshipm

entatU

Kports,toidentifythosevehiclesthatdo

notcom

plywiththeIMOandMCAguidanceonferrysecuringarrangem

ents,

andtakeanyappropriateactionsavailabletoincreaselevelsofawareness

andcompliance.

177

General

Maritime

Ste

llar V

oyag

erAmericanBureau

ofShipping

ProposetotheInternationalAssociationofClassificationSocietiesthat:

•IACSUnifiedRequirement-Aformooringandanchoringequipm

ent

isrevisedtoincludemeasurestopreventthecatastrophicfailureof

windlasshydraulicmotorsthroughover-pressurisationandover-speed

andtherebyremovethepotentialtocauseinjurytopersons.

Whenevercatastrophicfailureofclassapprovedequipm

entoccurs,itshall

beaconditionofcontinuedapprovalthatIA

CSmem

bersrequiretherelevant

manufacturerto:

•Conductadetailedinvestigationintothecausesofthefailure.

•Promulgatethefindingsofitsinvestigationtotheclassificationsociety

andusersoftheequipm

ent.

•Whereappropriate,takecorrectivedesignmeasurestoprevent

catastrophicfailureinthefuture.

31

PART2:RECOMMENDATIONS

SECTION C

LEVEL 3 RECOMMENDATIONSTheseareaddressedtoindividualorganisations,ownersorcompaniesthatarespecifictotheirarea,vesselorcompany.Theyhavenodirectimpactontheshippingindustryasawhole,althoughthelessonsarepromulgatedthroughtheindividualinvestigationreports,throughmediacoverageofthereportandthroughtheMAIB’sSafetyDigests.

Summary Table

Focus TotalAccepted

Action Implemented

Accepted Action yet to be

implemented

PartiallyAccepted Rejected

No Response Received

General Maritime 9 5 3 1 - -

Commercial Shipping 36 30 4 - - 2

Fishing Vessels 3 3 - - - -

Leisure Vessels 3 3 - - - -

Total 51 41 7 1 - 2

32

MAIBANNUALREPORT2009Le

vel 3

Rec

omm

enda

tions

– B

reak

dow

n

Responsestorecommendationswhichhave

not b

een

acce

ptedhavebeengroupedtogetherandpresentedfirst.

Thosewhichhavebeena

ccep

tedarepresentedsecondlyandbrokendownintotheirvesseltype.

No

Res

pons

e R

ecei

ved

Num

ber

Focu

sIn

vest

igat

ion

Add

ress

ed T

oR

ecom

men

datio

n131

Com

mercial

Shipping

Mae

rsk

New

port

Servymandel

EstrechioS.L.

Reviewhotworkprocedurestoensurethat:

•WorkersareequippedwithaVHFradiotocom

municatewitheach

otherandthecrew

inanem

ergency.

•Anominatedsafetywatchmanisalwaysreadilyavailableandthata

replacem

entisallocatedduringhis/herabsence.

No

resp

onse

to d

ate.

132

Com

mercial

Shipping

Mae

rsk

New

port

Servymandel

EstrechioS.L.

Adoptindustrybestpracticeby:

•Carryingoutleaktestsonnew

lyassem

bledoxy/acetylene

connections.

•Separating“inuse”gasbottlesfromthoseinthestorageareawhere

thisisfeasible.

•Ensuringthatnoflammablematerials,includingclothing,areleftin

thevicinityofoxygen/acetylenebottles.

No

resp

onse

to d

ate.

33

PART2:RECOMMENDATIONS Pa

rtia

lly A

ccep

ted

Num

ber

Focu

sIn

vest

igat

ion

Add

ress

ed T

oR

ecom

men

datio

n179

General

Maritime

Ste

llar V

oyag

erTT

SKocksGmbH

Ensurecomprehensivetechnicalandoperationalinstructionsareprovidedfor

allthecom

ponentsofitswindlassmachinery,includingthosesuppliedfrom

otherm

anufacturers.

TTSKocks

Response

•Issendingoperationalinstructionstooperatorsofvesselsequipped

withhydraulicdrivenwindlassessuppliedbyTTS

Kocks/F.R.Kocks

GmbH

.•

Issupplyinganinstructionplateprovidingoperatingguidancewhich

willbefixedatalocationclearlyvisibletotheoperatorontheanchor

winch.

MA

IB C

omm

ent

The

addi

tiona

l ope

ratio

nal g

uida

nce

prov

ided

by

the

man

ufac

ture

r is

wel

com

e ho

wev

er it

is d

isap

poin

ting

to n

ote

ther

e ap

pear

s to

be

no in

tent

ion

to im

prov

e th

e qu

ality

/con

tent

of t

echn

ical

inst

ruct

ion

man

uals

to fa

cilit

ate

bette

r/cor

rect

rout

ine

mai

nten

ance

of t

he e

quip

men

t.

34

MAIBANNUALREPORT2009A

ccep

ted

– Ye

t to

be Im

plem

ente

d

Num

ber

Focu

sIn

vest

igat

ion

Add

ress

ed T

oR

ecom

men

datio

n128

Cel

tic P

ione

erWhenavailable,promulgatetheapprovedcodeofpracticeforthrill-typeboat

operators,andstronglyencouragelocalauthoritieswithintheUnitedKingdom

torequireoperatorstoadheretothecodeasaconditionoflicensing.

128a

General

Maritime

LocalAuthorities

Coordinators

ofRegulatory

Services

(LACORS)

Pred

icte

d im

plem

enta

tion

date

: To

be a

dvis

ed a

s th

e co

de o

f pra

ctic

e is

no

t yet

ava

ilabl

e.

128b

General

Maritime

Instituteof

Licensing

Pred

icte

d im

plem

enta

tion

date

: To

be a

dvis

ed a

s th

e co

de o

f pra

ctic

e is

no

t yet

ava

ilabl

e.137

Com

mercial

Shipping

Hur

lingh

amTham

esCruises

Ltd

Reviewthepassengeraccessarrangem

entsonallitsvesselstoensurethat:

•Passengersareprotectedintheeventthatamooringlineorotherpart

ofthemooringsystem

fails.

•Accesspointsarepositionedappropriatelytominimisetheriskofa

passengerfallingoverboardwhileembarkingordisem

barking,andthat

gangwaysareusedwherenecessary.

Pred

icte

d im

plem

enta

tion

date

: Wor

k in

pro

gres

s150

Com

mercial

Shipping

Eur

ovoy

ager

MCA

Explorepotentialm

eansofimprovingthesafeuseofpow

eredwatertight

doors,throughindustrybodiessuchastheNationalO

ccupationalH

ealth

andSafetyCom

mittee,takingintoaccountshipcrew

s'apparentreluctance

toobserveexistingguidelines,currenttechnologyandtheneedtokeep

watertightdoorsclosedatsea.

Pred

icte

d im

plem

enta

tion

date

: Nov

embe

r 201

0161

Com

mercial

Shipping

Ville

de

Mar

sShipmanager:

CMA-CGMGroup

Withthehelpofhum

anfactorsexperts,conductastudytotryandidentify

waysofdevelopingapositivesafetycultureandreducingcom

placencyon

boardyourships,andtosharetheresultsofthisstudywithothersviathe

MCA'sHum

anElementA

dvisoryGroup.

Pred

icte

d im

plem

enta

tion

date

: Dec

embe

r 201

0

35

PART2:RECOMMENDATIONSN

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

178

General

Maritime

Ste

llar V

oyag

erOilCom

panies

International

MarineForum

(OCIMF)

Atthenextrevisionofitspublication‘AnchoringSystemsandProceduresfor

LargeTankers’includeguidanceonweighinganchor,highlightingthelessons

fromthisaccidentandstressingtheimportanceofminimisingthetensionon

theanchorchainwhen‘heavingin’onthewindlass.

Pred

icte

d im

plem

enta

tion

date

: Sep

tem

ber 2

010

183

Com

mercial

Shipping

Jo E

ikICS

Includethefollowingsafetyissuesidentifiedinthisreportinthenextperiodic

review

andamendm

entoftheTankerS

afetyGuideChemicals:

•EmphasisetheneedforthecargospecificMSDStobeheldonboard

assuppliedbytheshipper.

•ThatthecargospecificMSDSispromulgatedtoreceivers(terminalor

transhipm

entships/barges)eitherdirectlyfrom

theshiporviatheship

operatororagentsothatriskcontrolm

easuresarebasedonaccurate

information.

•ThatareasofthedeckwhichfallintotheIMO’sdefinitionofan

EnclosedSpaceareidentified,andthatappropriatecontrolm

easures

areinplacefollowingriskassessment.

Pred

icte

d im

plem

enta

tion

date

: D

ecem

ber 2

012

36

MAIBANNUALREPORT2009A

ccep

ted

– Im

plem

ente

d –

Rec

omm

enda

tion

clos

ed b

y M

AIB

Num

ber

Focu

sIn

vest

igat

ion

Add

ress

ed T

oR

ecom

men

datio

n101

Prid

e of

C

ante

rbur

yPromulgatetoshipow

ners/managerstheMAIBSafetyFlyerdescribingthis

accidentandtheprincipallessonstobelearnedfromit.

101a

Com

mercial

Shipping

Interferry

101b

Com

mercial

Shipping

ICS

102

Ast

ral

CirculatetheMAIB'sSafetyFlyeronanchoringprocedurestoallyour

mem

bers.

102a

Com

mercial

Shipping

ICS

102b

Com

mercial

Shipping

TheNautical

Institute

110

Com

mercial

Shipping

Moo

ndan

ceSeatruckFerries

ShipholdingLtd

ProvideguidancetosuitablytrainedinternalIS

Mauditorsonthescopeof

theirresponsibilities,includingassessmentofcrewknowledge,departmental

managem

entandinter-departm

entalcom

munications.

111

Com

mercial

Shipping

Moo

ndan

ceSeatruckFerries

ShipholdingLtd

Undertakeareview

oftheonboardriskassessm

entprocedurestoensureyour

vesselscomplywithSeatruckFerriesShipholdingLimited'spolicy.

112

Leisure

Vessel

RIB6

PlasMenaiCentre

Reviewyourriskassessmentsandthereafteramendyourstaffhandbookto

providestaffw

ithfurtherguidanceandinstructionon:

•Operatingareas,limitationsandpersonalflotationrequirements,

•Restrictionstooperationsdependentonseatingavailability,

•Considerationsfor'journeying'andsimilaractivities,

•Proceduresforamending/changingauthorisedactivities;and

•Emergencyresponseprocedures.

113

Leisure

Vessel

RIB6

PlasMenaiCentre

Reviewyourcom

municationsstrategiesandprocureequipmentasnecessary,

toensurethatallcentreactivitiesareeffectivelysupportedbyappropriate

meansofcom

municationatalltim

es.

37

PART2:RECOMMENDATIONSN

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

114

Leisure

Vessel

RIB6

RYA

Promulgatetoyourcentreprincipals,trainersandinstructorsthelessons

fromthisaccident,andem

phasisethatsafetyofliferemainsanessential

requirementduringallactivities,w

hichbecom

esofparam

ountim

portanceas

soonastheactivityceasestofollowthebriefedplan.

117

Com

mercial

shipping

Ant

ari

BrieseSchiffahrts

GMBH&Co.

Reviewandamendyoursafetymanagem

entsystemtoensureyourinternal

auditingpoliciesverifythefollowing:

•Com

pliancewithhoursofrestregulations

•EffectivepassageplanninginaccordancewithSOLA

SChapterV,

Regulation34

•Understandingoftherequirementsfornotifyingcoastalstates

•Theappropriateuseoflookoutsandwatchalarmsatsea.

121

Fishing

Vessel

Visi

on II

MBVisionLLP

Developworkinstructionsforcrewstaskedwithconnectingitsvesselsto,

anddisconnectingshorepower.Theinstructionsshouldinclude,interalia:

Identificationofthosebreakersconsideredsafetoswitchoff;Highlightthe

dangersofisolatinganyem

ergencysystem

;Electricalschem

aticdiagram

s.

123

Com

mercial

Shipping

Mae

rsk

Kith

iraMaerskShip

Managem

ent

Amendyoursafetymanagem

entsystemtoinclude:

•Additionalheavyweatherchecklistm

easurestoensurewatertight

integrity.

124

Sco

t Isl

es/W

adi

Hal

faPromulgatetoyourrespectivemem

berstheMAIBSafetyFlyeraccom

panying

thisreporttohighlightthedangersofcom

placencyinbridgewatchkeeping

officersandtheimportanceofestablishinganeffectivebridgeteam

capableof

maintainingaproperlookout,usingallavailablemeans,atalltim

es.

124a

Com

mercial

Shipping

ICS

124b

Com

mercial

Shipping

UKChamberof

Shipping

124c

Com

mercial

Shipping

TheNautical

Institute

124d

Com

mercial

Shipping

International

Federationof

Shipm

asters’

Associations

38

MAIBANNUALREPORT2009N

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

130

Com

mercial

Shipping

Mae

rsk

New

port

A.P.M

øllerM

aersk

Reviewandamendyourcurrentprocedurestoensure:

•CasualtyCom

mitteecom

positionisappropriatetothespecific

circum

stances.

•Com

pliancewiththeaccidentreportingrequirementsforU

nited

Kingdom

registeredvessels.

•Effectiveandinclusivecommunicationsbetweenshoremanagem

ent,

contractorsandship'sstaff.

•Allidentifiedsafetyrelateddeficienciesaresufficientlyassessedfor

fleetwidenotification.

•Ship'sstaff,regardlessofm

anagem

entinvolvement,maintains

oversightofcontractorsandthatthehotw

orkPermittoW

ork

procedures,asspecifiedintheGlobalShipManagem

entS

ystem,are

strictlycom

pliedwith.

•Foreignlanguageworkapprovalsaretranslatedforcom

pliance

purposes.

•GlobalShipManagem

entS

ystemincludesdetailedinstructionsfor

thepreservationofVoyageDataRecorderinformationforaccident

investigationpurposes.

39

PART2:RECOMMENDATIONSN

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

136

Com

mercial

Shipping

Hur

lingh

amTham

esCruises

Ltd

Reviewandamendyoursafetymanagem

entsystem,asnecessary,tocom

ply

withtheCodeofPracticeforP

assengerVesselO

perationsontheTham

es

2009and,specifically,to:

•Implem

entasystemtorecordaccidentsandnearm

isses,identifythe

lessonstobelearned,andreview

andupdateyourriskassessm

ents

andem

ergencyprocedures.

•Conducteffectiveem

ergencytrainingdrillstopracticeresponding

totherangeofhazardsidentifiedinyourriskassessmentsofvessel

operations.

•Introduceemploymentprocedurestoensure,asfaraspossible,that

crew

areworkinginaccordancewiththeregulationsforhoursofw

ork

andrest.

•Providemasterswithclearguidanceontheconductofoperationsand,

specifically,therequirementtoensurethewheelhouseismannedatall

timeswhenthevessel’sengineisingear.

•Introduceprocedurestoensurethatmarinecrew

sarenotdistractedby

commercialactivities,includingresponsibilityforthebar,w

hichcould

detractfrom

theperformanceoftheirprimaryduties.

139b

Com

mercial

Shipping

Pac

ific

Sun

PassengerShip

Association(PSA)

•UsethePrincessCruises’standardforsecuringfurnishingsandequipm

ent

inpassengervessels(oncecompleted)asabasisfordevelopingaguide

onindustrybestpractice.

•Disseminatethesafetyissues,actionstakenandlessonslearntfollowing

thisaccidenttotheirm

embers.

143

General

Maritime

Abi

gail

HWyreMarine

Services

Improveexistingprocedurestokeepthelevelofoilywasteinthebilgesof

yourvesselstoaminimum

andintroduceroutineinspectionsofpipew

ork

andinternalsurfacesofhullplatingtoidentifyvulnerableareasandgivethe

maximum

warningofpotentialfailures.

40

MAIBANNUALREPORT2009N

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

145

General

Maritime

HM

S

Wes

tmin

ster

/P

rince

ss R

ose

CityCruisesPlc

Carryoutacom

prehensiveriskassessm

entonvesselsyouusetoconduct

passengertransferswhenmakingway.Theassessmentshouldexam

ine

allaspectsofthetransferoperationandleadtothedevelopm

entofrobust

procedures,guidanceandappropriatemanninglevelsforthistypeofoperation.

146

General

Maritime

HM

S

Wes

tmin

ster

/P

rince

ss R

ose

CityCruisesPlc

Providetrainingforyourm

astersemployedinconductingpassengertransfers

betweenvesselsmakingwaythroughthewater.Thetrainingshouldbe

tailoredtotakeaccountofthecharacteristicsofspecificvesselsandshouldbe

incorporatedintothetrainingschedulecontainedwithinyourcom

pany'ssafety

managem

entsystem.

151

Com

mercial

Shipping

Eur

ovoy

ager

Transeuropa

ShippingLinesLtd

Adoptmeasures,includingthereview

ofV

DRdata,toensurethatyour

proceduresfortheoperationofwatertightdoorsarestrictlyobserved.

157

Riv

erda

nce

Promulgatetoshipow

ners/managerstheMAIBSafetyFlyerdescribingthis

accidentandtheprincipallessonslearnedfromit.

157a

Com

mercial

Shipping

ICS

157b

Com

mercial

Shipping

Interferry

159

Fishing

Vessel

Mag

gie

Ann

AGRFishing

Com

pany

Improvethesafeoperationofyourvesselby:

•Modifyingworkingproceduresasnecessarytoprecludetheneedfor

crew

toleanoutboardofthebulwarkduringtippingoperations.

•Ensuringthattheskipperconductsregularemergencydrills.

•Implem

entingarobustinspectionandmaintenanceregimeforall

workingequipment.

160

Fishing

Vessel

Mag

gie

Ann

TheScallop

Association

Endorseandpromulgatethroughitsmem

bershipthefishingaccidentflyer

publishedbytheMAIBwhichhighlightsthesafetylessonslearnedfromthis

tragicaccident.

162

Com

mercial

Shipping

Ville

de

Mar

sCMA-CGMGroup

Reviewandim

proveyourinternalauditproceduressuchthatfollowupaction

takentoaddressnonconformityisproperlydocum

entedandverified.

41

PART2:RECOMMENDATIONSN

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

163

Com

mercial

Shipping

Sto

lt P

etre

lStoltTankersB.V.

Reviewthecontrollablepitchcontrolsystemsonboardyourvesselstoensure

thattherisksofsystemsfailureareidentified,andthepotentialeffectsoftheir

failuremitigated.

167

Com

mercial

Shipping

Ste

na V

oyag

erStenaLineLtd

Seekassurancethroughoperationaltrials/inspectionsthat,followingthe

implem

entationofitssafetymanager’srecommendations,thecrewsonboard

itsHSS1500vesselsareabletostowandsecureallvehiclesinaccordance

withthecargosecuringmanualpriortoleavingtheberthwithinthescheduled

turnaroundtimes.

168

Com

mercial

Shipping

Ste

na V

oyag

erTurner’s(S

oham

)Ltd

Ensureallitsfreightvehiclesintendedforshipm

entbyferryarefittedwith

ferrysecuringringsinaccordancewiththeguidancegivenintheISO9367

standards.

169

Com

mercial

Shipping

Velo

xFavershamShips

Ltd

Ensurethatyourcom

pany'sSafetyManagem

entS

ystemcapturesallsafety

significantactivitiescarriedoutonboardcompanyvessels,andthatthe

associatedequipmentiseffectivelyoperated,m

aintainedandinspectedby

competentpersonnel.

170

Leisure

Vessels

Soo

tyUn-namedprivate

boatowner

Examinetheirdepartureproceduresandmethodsofnavigationwhenoperating

leisurecraft,withaviewtoensuringthat:

•Aproperpassageplanisproducedbeforedeparture.

•Aproperandeffectivelookoutismaintainedatalltim

es.

•Passageisconductedatasafespeed.

•Positionismonitored.

•Thepersoninchargehasnotconsumedalcoholinexcessofthelim

itcurrentlyprescribedfordriversofroadvehicles.

171

General

Maritime

TS R

oyal

ist

TheMarineSociety

andSeaCadets

Developastructuredsystemfortheselectionandauditofreliefm

asters.

176

General

Maritime

TS R

oyal

ist

TheAssociation

ofSailTraining

Organisations

(ASTO

)

Promulgatethesafetylessonslearnedfromtheaccidentbydistributingthe

MAIBFlyeronitsinvestigationtotheASTO

mem

bership.

42

MAIBANNUALREPORT2009N

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

180

Com

mercial

Shipping

Jo E

ikJoTankersAS

ProvideButterworthhatchclosingarrangementstoreducecargovapour

dischargewhenusingtankportablewashingequipment.

181

Com

mercial

Shipping

Jo E

ikJoTankersAS

Implem

entm

anagem

entcontrolm

easurestoverify:

•Pre-arrivalconferencesareconductedasclosetothearrivalatthe

loading/dischargeportaspossible.

•Cargochecklistsarecom

pleteddiligently;tankwashingdefectsare

identifiedandcorrectiveactiontakentomaintaintheprincipleof"closed

operations"a

sfarasispracticable.

•CrewsusetherespiratoryprotectioninaccordancewithitsQMS

instructions.

•Terminalemergencyproceduresareclearlypromulgatedandthatkey

personnel,inadditiontothechiefofficer,arefamiliarwiththem

.182

Jo E

ikPromulgateviayourm

embershiptheMAIB'sSafetyFlyerw

hichhighlightsthe

circum

stancesandlessonstolearnfromthisinvestigation.

182a

Com

mercial

Shipping

ICS

182b

Com

mercial

Shipping

TankStorage

Association

182c

Com

mercial

Shipping

Federation

ofInspection

Agencies

184

Com

mercial

Shipping

Jo E

ikIntertekOCA

ReviewitsproceduresforaccessingcargospecificMSDSstoensurethat

cargosurveyorsareequippedwiththeappropriatePPErespiratoryprotection.

43

PART2:RECOMMENDATIONS

SECTION D

RECOMMENDATIONS TO MULTIPLE RECIPIENTSListsthesmallnumberofrecommendationsthathavebeenaddressedtolargemultiplerecipients.Asaresult,ithasnotbeenpossibletotrackresponsesundertheclosed-loopsystem.Suchmultipleaddresseerecommendationsarenowbeingavoidedwhereverpossible,soastomaketheclosed-loopsystemaseffectiveaspossible.

No recommendations were addressed to multiple recipients in 2009

44

MAIBANNUALREPORT2009

SECTION E

WITHDRAWN RECOMMENDATIONS

No recommendations were withdrawn during 2009

45

PART2:RECOMMENDATIONS

SECTION F

RECOMMENDATIONS BROUGHT FORWARD FROM PREVIOUS YEARS

Liststheongoingoutstandingrecommendationsshownasaccepted – yet to be implemented inpreviousreports.

46

MAIBANNUALREPORT2009R

ECO

MM

END

ATIO

NS

BR

OU

GH

T FO

RW

AR

D F

RO

M P

REV

IOU

S YE

AR

S

Recom

mendationsarelistedbyyear/num

ber.

Acc

epte

d –

Yet t

o be

Impl

emen

ted

Num

ber

Focu

sIn

vest

igat

ion

Add

ress

ed T

oR

ecom

men

datio

n2008/

188a

Com

mercial

Shipping

CFL

Per

form

erIAMI

Encourageitsmem

bersprovidingtraininginECDIStoalignthisascloselyas

possiblewiththeIMOmodelcourseandtodeterminethesuccessfulcom

pletionof

suchtrainingthroughpracticalassessm

entandexamination.

Pred

icte

d im

plem

enta

tion

date

: May

200

9 –

upda

te re

ques

ted.

2008/

186

Com

mercial

Shipping

CFL

Per

form

erMCA

Continuetostronglysupporttheexpeditiousadoptionofcurrentproposalsfor

theformalinclusionofanECDIScom

petenceanditsmandatoryassessm

entin

theSTC

WCodeand,indoingso,topressforanurgentreview

oftheIM

Omodel

coursesyllabusforE

CDIStrainingtoensureitremainsfitforpurposeandthat

successfulcom

pletionofthecourseisdeterminedbyexam

inationandpractical

assessment.

Pred

icte

d im

plem

enta

tion

date

: Jun

e 20

102008/

148

Fishing

Vessel

Sha

rk/R

oyal

ist

MCA

ReviewandexpandthecontentandapplicationofMGN336(F)-Overseas

Managem

ent,toincludemanagem

entofallUK,24metreinlengthandover

fishingvessels,andthefollowingadditionalm

anagem

entissues:

•Theconductandproperrecordingofm

andatoryemergencydrillsandthe

importanceofcrewfamiliarisationtraining.

•Theneedtoensurethatallcrew

understandkeysafetyinformationandcan

communicateeffectivelywitheachotherduringanemergency.

•Therequirementtomaintainandregularlytestfiredetectionand

emergencyequipm

ent.

Pred

icte

d im

plem

enta

tion

date

: Mar

ch 2

010

– U

pdat

e re

ques

ted

47

PART2:RECOMMENDATIONSN

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

2008/

147

Fishing

Vessel

Sha

rk/R

oyal

ist

MCA

Amenditssurveyandinspectionproceduresfor24metreinlengthandover

fishingvessels,toincludemeasuresto:

•Alertow

nerstoIntermediateSurveysinthesamemannerasforR

enew

al

Surveysand,inconsultationwithDefra,establishadministrativeprocedures

thatwillleadtofishingvessellicencesuspensionintheeventofnon-

compliance.

•CheckofficersholdappropriateCoC

andCECqualificationsandcrewshave

completedmandatorysafetytrainingcourses.

•Establishauditableprocedurestoensurethattherectificationofdefects

identifiedduringsurveyareverifiedwithinprescribedtimescales.

•Carryoutemergencydrillsduringsurvey/inspectionandtoconfirmthat

mandatoryemergencydrillsareconductedandproperlyrecorded.

Pred

icte

d im

plem

enta

tion

date

: Apr

il 20

10 –

Upd

ate

requ

este

d2008/

140

Leisure

Vessel

Last

Cal

lDepartment

forB

usiness,

Innovationand

Skills(B

IS)

Seekareview

,throughtheRecreationalC

raftSectoralG

roupandtheEuropean

Com

mission,ofguidanceprovidedtomanufacturersofrecreationalcraftand

NotifiedBodies,toensurethat,w

hensignificantim

provem

entstosafetyare

mandated,suchstandardsareappliedtoallnewcraftincludingnew“series

production”craftsoldintheUK.

Pred

icte

d im

plem

enta

tion

date

: Not

giv

en2008/

139

Leisure

Vessel

Last

Cal

lBIS

InconjunctionwithHMRC,seektodevelopprocedureswherebyHMRCcannotify

localauthoritiesoftheimportofrecreationalleisurecraftintotheCom

munity

market.Thisistoenablelocalauthoritiestoconductsuchchecksastheydeem

necessarytoensurethatindividualsandcompaniesim

portingsuchcraftcom

ply

withtheRecreationalC

raftDirectiveandthatnonCEmarkedcraftundergoapost-

constructionassessment.

Pred

icte

d im

plem

enta

tion

date

: Not

giv

en

48

MAIBANNUALREPORT2009N

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

2008/

137

General

Maritime

Viki

ng Is

lay

MCA

Considerchangestoregulationandguidanceregardingthenatureandextentof

traininganddrillsintheuseofEEBDsonboardships.Itisrecommendedthat

awarenessofthecorrectuseofE

EBDsisfirmlyreinforcedbypractical“hands-on”

experienceofactualequipmentcapabilitiesandlim

itations,tobeundertakenina

safe,yetrealisticenvironm

ent.Theuseof“dum

my”EEBDsfortrainingpurposes

shouldbediscouraged.

Pred

icte

d im

plem

enta

tion

date

: Nov

embe

r 201

02008/

130

Com

mercial

Shipping

MS

C N

apol

iIACS

Researchandreview

thetechnologicalaidsavailablewhichwouldassistm

asters

tomeasurehullstressesinportandatsea.

Pred

icte

d im

plem

enta

tion

date

: Dec

embe

r 201

02008/

128

Com

mercial

Shipping

MS

C N

apol

iIACS

ReviewthecontentsofU

RS11(LongitudinalStrengthStandard)toensure:

•Hullgirderstrengthandbucklingchecksarecarriedoutatallcritical

sectionsalongtheentirelengthofthehull

•AnevaluationofthesuitabilityofcurrentURS11designwavebending

mom

entcriteriaforvesselswithlowblockcoefficientisundertaken

•Mem

bersocietiesusecommonmethodologieswhencomplyingwiththe

requirementsofthisrule.

Pred

icte

d im

plem

enta

tion

date

: Dec

embe

r 201

02008/

124

Fishing

Vessel

Blit

he S

pirit

/ La

dy H

amilt

on

of H

elfo

rd

MCA

Ensurecandidates’understandingoftheadditionalrisksposedbytheoperationof

thehigherspeedsassociatedwithnondisplacem

entfishingvesselsisfullytested

whendevelopingthesyllabusforthe<16.5mfishingvesselskippers’certificate.

Pred

icte

d im

plem

enta

tion

date

: Apr

il 20

10 –

Upd

ate

requ

este

d2008/

118

General

Maritime

8mRigid

Raider

Directorof

ReserveForces

andCadets

Putinplacemeasurestoensurethatapprovalforcadetforcestoconductan

activityoutsidetheusualsyllabusissubjecttoitsinclusioninanadvancetraining

plansubmittedthroughthechainofcom

mand,andthatapprovalisgivenonlyafter

compliancewithpertinentpoliciesandprocedureshasbeendetermined.

Pred

icte

d im

plem

enta

tion

date

: Dec

embe

r 201

0

49

PART2:RECOMMENDATIONSN

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

2008/

116

Fishing

Vessel

Sha

rkMCA

ReviewthesurveystatusandmanningarrangementsofallforeigncontrolledUK

fishingvesselstoensure:

•Requiredsurveysandinspectionshavebeencom

pleted

•Crewsholdappropriatequalifications,includingCECswhererequiredand

haveattendedmandatorysafetytrainingcourses.

Wheredoubtoverthesurveystatusand/orm

anningarrangementsexist,

implem

entanurgentprogram

meofinspectiontoensure:

•Manningofthevesselisappropriate,w

ithcrewholdingrequired

qualificationsandhavingattendedmandatorysafetytrainingcourses

•Skipper/mateisabletocom

municateinEnglish

•Vesselisseaworthy,fire-fightingandlifesavingequipmentisfittedand

maintainedtoanappropriatestandard

•Aprogrammeofemergencydrillsisbeingconductedasrequiredbythe

applicableregulations.

Pred

icte

d im

plem

enta

tion

date

: May

201

0 –

Upd

ate

requ

este

d2007/

153

Com

mercial

Shipping

Thom

son

Cel

ebra

tion

MCA

Recognisingtheneedforadditionaltraining,toachievealevelofcom

petence

appropriatetooperatinglargecapacitypassengertenders,developandtake

forwardtoIM

O,throughthemostappropriatechannels,com

petencyrequirements

forpassengershiptendercoxsw

ainsandcrew.

Pred

icte

d im

plem

enta

tion

date

: Mar

ch 2

011

2007/

144

Com

mercial

Shipping

Thun

der

DfT

InconsideringitsdecisionsontheHarbourRevisionOrderssubm

ittedbythe

Environm

entA

gencyandMostynDocksLimited,takeintoaccounttheneedto

clarifythestatusoftheMostynOuterChannel,suchthattheresponsibleauthority

hasthenecessarypowerstoensurethesafetyofnavigationinthechannel.

Pred

icte

d im

plem

enta

tion

date

: Jun

e 20

10 –

Upd

ate

requ

este

d

50

MAIBANNUALREPORT2009N

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

2007/

142

Com

mercial

Shipping

Thun

der

PortofM

ostyn

Ltd

•Reinstatetherecommendedpilotageservicefrom

theNorthRhylbuoy,and

ensurethatallapplicablechartsandhydrographicpublicationsareamended

accordingly.

Pred

icte

d im

plem

enta

tion

date

: Sub

ject

to 2

007/

144

•Amenditsportpassageplantoprovidecom

prehensiveguidanceform

asters

ofvesselsusingthechannelandanchoringintheapproachestoMostyn.

Impl

emen

ted

•Reviewitsem

ergencyresponseproceduresform

arineaccidents,ensuring

thatthenecessaryactionsforeachem

ergencyareidentified,andthatport

andharbourpersonnelaretrainedandfamiliarwiththerequirements.

Impl

emen

ted

2007/

119

Fishing

Vessels

Dan

ielle

MCA

AmplifyandexpandoncurrentadvicecontainedinMSN1768(M&F)suchthat

fishermenarereminded:

•Medicalscalerequirementsprovidetheminimum

levelsofm

edicalstoresonly.

Additionalstoresmaybeprovidedattheskipper’s/owner’sdiscretion.

Pred

icte

d im

plem

enta

tion

date

: May

201

0 –

Upd

ate

requ

este

d2007/

117

Fishing

Vessels

Dan

ielle

MCA

Providedetailsofthehazardsassociatedwith“tipping”andwhippingdrum

son

boardscallopdredgersinthenextrevisionofM

GN265(F

).Pr

edic

ted

impl

emen

tatio

n da

te: M

arch

201

0 –

Upd

ate

requ

este

d2007/

114

Fishing

Vessels

Sia

n E

lizab

eth

MCA

Implem

entTheMerchantS

hippingandFishingVe

ssels(ProvisionandUse

ofW

orkEquipment)Regulations2006andam

algamatetheprovisionsofthe

regulationsintoguidanceforfishingvesselinspectorsandsurveyors.

Pred

icte

d im

plem

enta

tion

date

: Not

yet

adv

ised

2006/

199

Com

mercial

Shipping

P&

O N

edllo

yd

Gen

oaMCA

ConsultwiththeUnitedKingdom

ChamberofS

hippingandrepresentativesfrom

themarineinsuranceindustry,w

iththeobjectiveofincludinginships’stability

information,fortheusebytheship’screw,vesselspecificparam

etricrollingdata.

Pred

icte

d im

plem

enta

tion

date

: Not

yet

adv

ised

51

PART2:RECOMMENDATIONSN

umbe

rFo

cus

Inve

stig

atio

nA

ddre

ssed

To

Rec

omm

enda

tion

2006/

161

Fishing

Vessels

Oce

an H

arve

st

IIMCA

Requiretheregularinsulationtestingofelectricalsystemstobeintroducedforall

UKfishingvesselsandestablishmeasuresforconfirmingthishastakenplace.

(MCAMinisterialTarget#4,2006-07refers).

Pred

icte

d im

plem

enta

tion

date

: Aug

ust 2

010

2006/

147

General

Maritime

Mol

lyan

naBritish

Standards

Institution(BSI)

ProposetotheInternationalStandardsOrganisationthattherequirementsof

thewindstiffnesstestinENIS

O12217-2andENIS

O12217-3bereview

ed,

particularlyregardingonboardsignageandtheinformationtobeincludedin

owners’m

anuals,w

ithaviewtoprovidinguserswithamorecomprehensive

know

ledgeofacraft’slim

itations,andoftheappropriateprecautionstobetaken.

Inthisreview

,considerationshouldbegiventolimitingtheapplicationofthistest

toboatsofgreaterthanadefinedmediumdisplacem

entorlength.

Pred

icte

d im

plem

enta

tion

date

: Dec

embe

r 201

22004/

248

Fishing

Vessels

Kin

gfish

er II

MCA

Initscurrentw

orkindefiningfutureStandardsofTraining,Certificationand

Watchkeeping(Fishing),specifyqualificationsandtrainingrequirementsforfishing

vesselskippers.

Pred

icte

d im

plem

enta

tion

date

: May

201

0 –

Upd

ate

requ

este

d2004/

200

Fishing

Vessels

Ele

ganc

eMCA

InstructsurveyorstoverifythatspecificoperatinginstructionsforC

O2fixed

extinguishingsystemsareonboardfishingvessels&crewconversantinoperation

ofsystem.

Pred

icte

d im

plem

enta

tion

date

: Dec

embe

r 201

0

52

MAIBANNUALREPORT2009

PART 3STATISTICS

53

PART3:STATISTICS

STATISTICS

PageUKvesselaccidentsinvolvinglossoflife 54UKmerchantvessels>=100gt 56UKmerchantvessels<100gt 61UKnon-commercialvessels 62UKfishingvessels 63Non-UKcommercialvessels 68

FordetailsofreportingrequirementsandtermsusedinthissectionpleaseseeAnnex-StatisticsCoverageonpage69.

54

MAIBANNUALREPORT2009

UK vessel accidents involving loss of l i fe

Table 1 - UK Vessel Accidents involving Loss of Life

DateName of Vessel Type of Vessel Location Accident D

eath

s

Merchant Vessels 100gt and over 28Jan Ville de Mars Containership GulfofOman FallinvolvingChiefOfficerwhile

descendingintoballasttank1

2Feb Pride of Dover Ro-ropassengerferry

Dover Passengeroverboard 1

1Apr Wellservicer Divesupportvessel

Aberdeen Accidenttoriggerinvolvingadivingbellcursor

1

25Jul Hyundai Tokyo Containership BeringSea Personoverboard 1

10Sep Ever Elite Containership SanFranciscoBay

AccidenttoABfollowingcollapseofaccommodationladder

1

19Nov Ever Smile Containership TaipeiHarbour Personoverboardduringmooringoperation

1

3Dec Goole Star Cargobarge Marchwood,Southampton

Carbonmonoxidepoisoning 1

Fishing Vessels 12Feb Maggie Ann Scallopdredger CardiganBay Personoverboard 118Feb Mercurius Scallopdredger MilfordHaven Personoverboardwhilealongsidein

harbour1

6Apr Contest Sterntrawler Mallaig Personoverboardwhilealongsideinharbour

1

25Apr Ryanwood Pairtrawler NorthSea,EastCoastofScotland

Personoverboard 1

7Jun Ajax Sterntrawler Fraserburgh Drowningafterfallingintowaterwhileaccessingvessel

1

20Jul Aquila Scallopdredger NorthoftheArdnamurchanpeninsula

Capsize 3

9Oct Noronya Potter NWofOrkney Personoverboard 16Nov Korenbloem Scallopdredger DoverStrait Personoverboard 111Nov Osprey III Sterntrawler EastCoastof

ScotlandPersonoverboard 1

18Nov Optik Potter EastCoastofScotland

Personoverboard 1

20Dec Etoile des Ondes

Potter EnglishChannel Collisionfollowedbysinking 1

55

PART3:STATISTICS

UKvessel accidents involv ing lossof l i fe

DateName of Vessel Type of Vessel Location Accident D

eath

s

Pleasure Craft (Non-Commercial) 28Feb Jensa Anglingboat RiverCrouch,

EssexPersonoverboard 1

21Mar - Opendinghy LochAwe,Scotland

Drowningsfollowingpresumedfoundering

4

1May - Kayak RiverTay,Scotland

Drowningwhilekayaking 1

2May Ben Brack Star MotorCruiser UpperLoughErne,NorthernIreland

Personoverboard 1

18May Sooty RIB CalveIsland,nearTobermory,IsleofMull

Highspeedgrounding 1

22May Cobra Narrowboat Pewsey,KennetandAvonCanal

Fire 1

22Jun Nine Moons Motoryacht Corsica Groundingresultinginaccidenttoperson

1

27Jun - Kayak LunanBay,Montrose

Drowningwhilekayakinginsurf 1

12Jul LaserStratos132

Sailingdinghy KeilderWater Capsizefollowedbyentrapmentinrigging

2

30Jul Harry Narrowboat Varney’sLock,OxfordCanal

Injuriessustainedafterfallingintolock 1

31Jul Stella Maris 8mopenpowerboat

NearCapri,Mediterranean

Collision 2

1Aug - Rowingboat RiverDart Drowningfollowingcapsize 1

8Aug Harwich 2011 Racingpowerboat

Dover Collisionduringrace 1

23Aug - Canoe LochMaree,Scotland

Drowningfollowingcapsize 2

21Nov - Kayak RiverDart Drowningwhilekayaking 1

1Dec - Inflatabledinghy ChristchurchBay

Personoverboard 1

13Dec Edward Motoryacht RiverDart Personoverboard 1

SeedefinitionsinAnnex Notallaccidentsinvolvingpleasurecraft(asdefinedinAnnex)andrecreationalcrafthiredonabareboatbasisarerequiredtobereportedtotheMAIB.Whilewewouldencourageallsuchaccidents/incidentstobereported,wedonotconsiderthistobeadefinitiveorcomprehensiveregisterofwaterbornefatalaccidents

56

MAIBANNUALREPORT2009

UK merchant vessels >= 100gt Table 2 - Merchant Vessel Total Losses 2009

Date Name of Vessel Type of Vessel Age gt LOA Metres Nature of Accident

* 20Mar Humber Star ProductTanker 40 274 45 Foundering*Constructivetotalloss

Table 3 – Merchant Vessel Losses: 1997-2009

Number Lost UK Fleet Size gt Lost1997 1 1055 8691998 1 1072 34761999 - 1035 -2000 1 1050 127782001 1 1047 112172002 1 1210 6712003 - 1343 -2004 2 1406 8322005 6 1443 15792006 - 1480 -2007 5 1518 543042008 2 1578 6452009 1 1 564 274

Table 4 - Merchant Vessels in Accidents: 1997-2009

Vessels UK fleet sizeAccidents/1 000

vessels1997 237 1055 2251998 217 1072 2021999 160 1035 1552000 139 1050 1322001 134 1047 1282002 129 1210 1072003 145 1343 1082004 145 1406 1032005 197 1443 1372006 129 1480 872007 116 1518 762008 135 1578 862009 125 1 564 80

SeedefinitionsinAnnex

57

PART3:STATISTICS

Table 5 - Merchant Vessels in Accidents by Nature of Accident and Vessel CategoryDry

cargoPassenger Passenger

cargoTanker/

combination carrier

Other commercial

Total

CargoHandlingFailure 1 1 - - 1 3Collision 10 5 - 3 6 24Contact 13 9 1 3 5 31Fire/Explosion 1 - - - 1 2Flooding/Foundering - 2 - 1 1 4Grounding 7 6 - 2 3 18HeavyWeather 1 2 - - 1 4HullFailure 2 - - - - 2MachineryFailure 8 7 2 1 7 25PersonOverboard 3 3 - 1 3 10Pollution - 1 - 1 - 2

Total 46 36 3 12 28 125

Table 6 - Merchant Vessels in Accidents by Nature of Accident: 1997-2009

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009Capsize/Listing - - 1 - 1 - - 2 1 - 2 - -CargoHandlingFailure 2 2 1 8 1 1 3 1 1 2 1 4 3Collision 30 23 10 25 16 18 12 16 38 25 14 21 24Contact 24 23 18 14 13 25 37 28 33 20 30 27 31EscapeofHarmfulSubstance

15 27 15 4 11 - - 4 2 1 2 1 -

Fire/Explosion 26 24 19 18 21 26 22 24 22 7 7 12 2Flooding/Foundering 4 3 3 2 3 1 3 3 6 4 2 4 4Grounding 21 20 16 7 18 14 13 15 26 21 11 26 18HeavyWeather 2 4 2 5 1 4 3 4 1 6 4 4 4MachineryFailure 50 55 48 50 39 28 41 42 51 30 36 23 25PersonOverboard 15 8 11 5 10 10 8 5 13 11 7 11 10Other 48 28 16 1 - 2 3 1 3 2 - 2 4

Total 237 217 160 139 134 129 145 145 197 129 116 135 125

UKmerchantvessels>=100gt

58

MAIBANNUALREPORT2009

Table 7 - Deaths and Injuries of MV Crew and Other Workers by PlaceWhere Number of peopleAccommodationspace-crew 25Accommodationspace-passengers 4Cargoorothertankspace 4Engineroom 18Externalstairway/ladder/gangway 8Externalworkingdeck/shelter 29Galley 12Hotelserviceareas 14Internalstairway/ladder 13Mooringdeck 13Navigation/communicationcontrolspace 3Overside/aloft 3Ro-rovehicledeck/ramp 7Ship’sboat 6Storespace 3Workshop 2Otherexternaldeck 14Otherinternaldeck/space 10Othermachineryspace 4Other 11Total 203

Table 8 - Deaths and Injuries of MV Crew and Other Workers by RankRank/specialism Number of peopleMaster/Skipper 1ChiefEngineer 4Officer,Deck 19Officer,Electrical 2Officer,Engineering 17Rating 7Rating,Deck 62Rating,Engineering 17Rating,Generalpurpose 15OtherCrew 54Worker(Non-Crew) 5Total 203

UKmerchantvessels>=100gt

59

PART3:STATISTICS

UKmerchantvessels>=100gt

Table 9 - Deaths and Injuries of Merchant Vessel MV Crew and Other Workers by InjuryMain injury Number of peopleAmputationofhand/fingers/toe 5Bruising 22Burns/shock(electrical) 2Burns/scalds(nonelectrical) 3Chemicalpoisoning/burnsfromcontactorinhalation 1Concussion/unconsciousnessduetoheadinjury 9Crushinjury 14Cuts/wound/lacerations 22Death-confirmed 4Death-presumed 2Dislocations 11Eyeinjuries 3Fracture-oftheskull/spine/pelvis/majorboneinarmorleg 27Fracture-other 24Strains-otherstrains/sprains/tornmuscles/ligaments 33Strains-strainedback 14Other 7Total 203

Table 10 - Deaths and Injuries to Merchant Vessel Crew: 1997-2009Crew Injured Of which resulted in death

1997 327 51998 330 21999 288 42000 300 32001 296 32002 302 52003 288 32004 307 42005 246 22006 231 32007 242 122008 225 5

* 2009 203 6

*2009andsubsequentyears:Includeworkersonboardvesselswhoarenotcrewmembers

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MAIBANNUALREPORT2009

UKmerchantvessels>=100gt

Table 11 - Deaths and Injuries to Passengers by InjuryMain injury Number of peopleBruising 17Concussion/unconsciousnessduetoheadinjury 2Crushinjury 2Cuts/wound/lacerations 7Death-confirmed 1Dislocations 9Fracture-oftheskull/spine/pelvis/majorboneinarmorleg 39Fracture-other 35Strains-otherstrains/sprains/tornmuscles/ligaments 2Unknown 2Total 116

Table 12 - Deaths and Injuries to Passengers: 1997-2009Number of injuries Of which resulting in death

1997 94 -1998 120 21999 80 12000 137 12001 138 12002 134 -2003 186 -2004 146 -2005 109 12006 114 12007 106 -2008 170 22009 116 1

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PART3:STATISTICS

UK merchant vessels <100gt

Table 13 - UK Flagged Merchant Vessels Under 100gt - LossesDate Name of vessel Type of vessel LOA metres Nature of accident5Jan ROA Workboat 8 Foundering

* 24Jan Fossils Venture SmallCommercialMotorVessel 12 Fire

11Jul Aquanaut DiveSupport 12 Foundering

20Sep Wappen Von Laboe

SmallCommercialMotorVessel 16 Foundering

30Sep Ocean Blue SmallCommercialMotorVessel-Catamaran 10 Foundering

*ConstructiveTotalLoss

Table 14 - UK Flagged Merchant Vessels Under 100gt - by Nature of Accident and Vessel Category

Passenger Other commercial

Ferry

Otherpassengervessel

Tota

l

Associatedwithoffshoreindustry

Megayacht

Portservice

Smallcom

mercialmotorvessel

Smallcom

mercialsailingvessel

Survey/research

Workboat

Other/Unknown

Tota

l

Ove

rall

Tota

lCapsize/Listing - - - - - - - 1 - - - 1 1CargoHandlingFailure - - - - - - - - - 1 - 1 1Collision 1 8 9 - - 5 4 8 - - 1 18 27Contact 1 2 3 - - 4 1 5 1 1 1 13 16Fire/Explosion - - - - - 1 4 1 - - 1 7 7Flooding/Foundering - - - - - - 7 - 1 - - 8 8Grounding 4 1 5 1 1 - 12 7 1 1 2 25 30HazardousIncident - - - - - - - - - - 1 1 1HeavyWeatherDamage - - - - - - - 1 - - - 1 1MachineryFailure 1 7 8 1 1 3 20 7 1 2 - 35 43PersonOverboard - 2 2 1 - 2 2 2 - 1 - 8 10Total 7 20 27 3 2 15 50 32 4 6 6 118 145

Injured 1 5 6 3 1 10 14 18 1 8 4 59 65Deaths - - - - - - 1 - - - - 1 1 SeedefinitionsinAnnex Theserowsincludeaccidentalinjuriesanddeathsonvesselswherethevesselitselfwasnotinvolvedinan accident.Thesefiguresincludecrew,otherworkers(non-crew)andpassengers.

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MAIBANNUALREPORT2009

UK non-commercial vessels

Table 15 - UK Non-Commercial Vessels in Accidents by Nature of Accident and Vessel Category

Other(non-commercial)

Naval

craft

RNLI

lifeboat

Total

Collision 1 1 2Total 1 1 2

Injuries - 10 -Deaths - - - SeedefinitionsinAnnex Theserowsincludeaccidentalinjuriesanddeathsonvesselswherethevesselitselfwasnotinvolvedinan accident.Thesefiguresincludecrew,otherworkers(non-crew)andpassengers. NavalCraftaccident/injuriesareoutsidetheremitoftheMAIB,unlessinvolvedwithnonnavalvessel.

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PART3:STATISTICS

UK fishing vesselsTherewere6222UK-registeredfishingvesselsattheendof2009.During2009,237accidentsinvolvingthesevesselswerereportedtotheMAIB.FiguresinthefollowingtablesareaccidentsandinjuriesinvolvingUK-registeredvesselsthatwerereportedtotheMAIBin2009.

14fishingvesselswerereportedlost(0.23%ofthetotalfleet)andtherewere13fatalitiestocrew.

Table 16 - Fishing Vessel Total Losses

Date Name of vessel Age gt Nature of accidentUnder 15m Length Overall (loa)

1Jan Dalriada 33 9.11 Foundering3Feb Silver Fern 30 4.98 Foundering11Feb Jubilee Star 33 24.84 Capsize

* 17Mar Emma Kate 37 2.06 Foundering2Apr Jenemi 24 9.64 Foundering13May Kalahari 38 8.55 Foundering

* 20Jul Aquila 21 28.79 Capsize23Oct Jean M 25 2.18 MachineryFailure23Oct Bellatrix 27 12.47 Fire6Dec Brilliant 44 6.33 Foundering

15m Length Overall - Under 24m Registered Length (reg)* 22Mar Niamh Aine 18 122.00 Grounding* 24Mar Bussard 50 23.66 Foundering

3Jun Transcend 23 171.77 Foundering20Dec Etoile des Ondes 52 40.00 Collision

*ConstructiveTotalLoss

SeedefinitionsinAnnex

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MAIBANNUALREPORT2009

Table 17 - Fishing Vessel Losses: 1997-2009

Under 15m loa

15m loa to <24m reg

24m reg and over

Total lost UK registered % Lost

1997 12 10 1 23 7779 0.301998 12 5 4 21 7605 0.281999 17 10 6 33 7460 0.442000 15 18 7 40 7194 0.562001 16 17 1 34 7200 0.472002 7 6 5 18 7046 0.262003 16 8 4 28 6731 0.422004 16 9 - 25 6693 0.372005 20 11 3 34 6314 0.542006 11 7 1 19 6346 0.302007 16 5 - 21 6330 0.332008 14 4 3 21 6763 0.312009 10 4 0 14 6 222 0.23

Table 18 - Fishing Vessels in Accidents

Nature of Accident Number of vessels involvedIncident rate per 1 000 vessels at risk

Capsize/Listing 2 0.3Collision 10 1.6Contact 6 1.0Fire/Explosion 8 1.3Flooding/Foundering 31 5.0Grounding 26 4.2HeavyWeatherDamage 3 0.5MachineryFailure 139 22.3PersonOverboard 13 2.1Total 238 38.2

UKf ishingvessels

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PART3:STATISTICS

UKf ishingvessels

Table 19 - Fishing Vessels in Accidents by Nature of Accident: 1997-2009

Nature of accident 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009Capsize/Listing 8 11 15 4 3 5 4 2 6 5 3 2 2Collision 22 20 15 25 17 15 17 12 23 12 18 17 10Contact 4 - 7 2 6 1 7 3 3 3 4 2 6Fire/Explosion 17 11 15 16 10 13 13 19 16 15 9 11 8Flooding/Foundering 51 62 54 59 46 40 50 40 54 34 32 34 31Grounding 44 40 31 40 29 26 38 29 19 24 24 28 26HeavyWeatherDamage 1 2 4 4 - 2 1 2 3 1 5 - 3MachineryFailure 316 247 232 174 212 181 221 202 232 240 213 156 139MissingVessel - 1 - 1 - - 1 1 - 1 - - -Personoverboard 14 8 8 11 11 6 7 6 11 14 8 7 13Other - 1 - 1 - - 1 1 1 - 1 - -Total 477 403 381 337 334 289 360 317 368 349 317 257 238

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MAIBANNUALREPORT2009

Table 20 - Fishing Vessels in Accidents - by Nature of Accident

Nature of accident Number of vessels involved Incident rate per 1 000 vessels at risk

Under 15m Length Overall (loa) - Vessels at risk (5 513)Capsize/Listing 2 0.4Collision 6 1.1Contact 2 0.4Fire/Explosion 4 0.7Flooding/Foundering 17 3.1Grounding 17 3.1HeavyWeatherDamage 1 0.2MachineryFailure 112 20.3PersonOverboard 4 0.7

165 29.9

15m loa - 24m reg (531)Collision 3 5.6Contact 2 3.8Fire/Explosion 1 1.9Flooding/Foundering 11 20.7Grounding 6 11.3HeavyWeatherDamage 2 3.8MachineryFailure 22 41.4PersonOverboard 7 13.2

54 101.724m reg and over (178)Collision 1 5.6Contact 2 11.2Fire/Explosion 3 16.9Flooding/Foundering 3 16.9Grounding 3 16.9MachineryFailure 5 28.1PersonOverboard 2 11.2

19 106.7

Fleet total 238 38.2

UKf ishingvessels

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PART3:STATISTICS

UKf ishingvessels

Table 21 - Deaths and Injuries to Fishing Vessel Crew and Other Workers by InjuryMain Injury Number of PeopleAmputationofhand/fingers/toe 5Bruising 5Burns/scalds-other 3Concussion/unconsciousnessduetoheadinjury 3Crushinjury 8Cuts/wound/lacerations 11Death-confirmed 10Death-presumed 3Dislocations 1Eyeinjury 1Fracture-oftheskull/spine/pelvis/majorboneinarmorleg 10Fracture-other 5Hypothermia 5Strains-otherstrains/sprains/tornmuscles/ligaments 2Unknown 6Total 78

Table 22 - Deaths and Injuries to Fishing Vessel Crew by Vessel Length (of which, deaths shown in brackets) 1997-2009

Under 15m loa15m loa - under

24m reg 24m reg and over Total1997 22 (9) 72 (16) 41 (4) 135 (29)1998 30 (12) 34 - 51 (14) 115 (26)1999 16 (4) 28 (2) 37 (3) 81 (9)2000 20 (4) 42 (9) 43 (19) 105 (32)2001 11 (2) 42 (3) 34 (5) 87 (10)2002 12 (3) 24 (4) 19 (1) 55 (8)2003 27 (8) 25 (2) 18 (1) 70 (11)2004 27 (9) 20 (1) 23 - 70 (10)2005 20 (3) 27 (3) 15 (3) 62 (9)2006 21 (6) 30 (8) 18 (2) 69 (16)2007 25 (4) 24 (3) 15 (1) 64 (8)2008 19 (3) 22 (4) 19 (1) 60 (8)

* 2009 32 (5) 33 (7) 13 (1) 78 (13)*2009andsubsequentyears:includesworkersonboardvesselswhoarenotcrewmembers

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MAIBANNUALREPORT2009

Non-UK commercial vessels

Table 23 - Non-UK Commercial Vessels Total Losses in UK Waters

Date Name of vessel Type of vessel Nationality Age gt loa

metresNature of accident

2May Wendy J FishCatching/Processing

ChannelIslands 35 4 9 Foundering

14Jun Ijsselstroom OtherCommercial Netherlands 17 71 19 Capsize

Table 24 - Non-UK Vessels in UK Waters - by Nature of Accident and Vessel Category Dry cargo Passenger Passenger

cargoTanker/

combination carrier

Fishing vessel

Other commercial

Total

Capsize/Listing - - - - - 1 1

Collision 5 - - 13 1 2 21Contact 15 1 1 7 1 9 34Fire/Explosion 1 - - - - - 1

Flooding/Foundering 1 - - - 2 - 3

Grounding 15 - - - 4 - 19HeavyWeatherDamage

2 1 - - - - 3

HullFailure - - - - - 1 1MachineryFailure 16 - - 5 7 2 30

PersonOverboard - - - - - 1 1

Pollution - - - 2 - - 2Total 55 2 1 27 15 16 116

Injuries 12 10 4 8 6 12 52Deaths - - - - 1 1 2

SeedefinitionsinAnnex Theserowsincludeaccidentalinjuriesanddeathsonvesselswherethevesselitselfwasnotinvolvedinan accident.Thesefiguresincludecrew,otherworkers(non-crew)andpassengers.

Non-UKflaggedvesselsarenotrequiredtoreportaccidentstotheMAIBunlesstheyarewithinaUKport/harbourorwithinUK12-mileterritorialwatersandcarryingpassengerstoorfromaUKport.However,theMAIBwillrecorddetailsof,andmayinvestigate,significantaccidentsofwhichwearenotifiedbybodiessuchastheCoastguard.

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ANNEX

ANNEXSTATISTICS COVERAGEReporting RequirementsUnitedKingdomshipsarerequiredbytheMerchantShipping(AccidentReportingandInvestigation)Regulations2005toreportaccidentstoshipsandaccidentstopersonstoMAIB.

Non-UKflaggedvesselsarenotrequiredtoreportaccidentstotheMAIBunlesstheyarewithinaUKport/harbourorwithinUK12mileterritorialwatersandcarryingpassengerstoorfromaUKport.However,theMAIBwillrecorddetailsof,andmayinvestigate,significantaccidentsofwhichwearenotifiedbybodiessuchastheCoastguard.

TheMaritimeandCoastguardAgency,harbourauthoritiesandinlandwaterwayauthoritiesalsohaveadutytoreportaccidentstoMAIB.

ForfulldetailsofreportingrequirementspleaserefertotheRegulationswhichareavailableat:www.maib.gov.uk/resources/index.cfm

Inadditiontotheabove,MAIBmonitorsnewsandotherinformationsourcesforrelevantaccidents.

DataispresentedbytheyeartheincidentwasreportedtoMAIB.Historicdatatablescontaininformationfrom1997;sincethattimethereportingrequirementshavechangedin1999and2005.Significantchangesinclude:

1999-RequirementformosttypesofincidentpreviouslyreportablebyMerchantShipsof100gtormoreas“DangerousOccurrences”tobereportedasaccidentsbyallvesselsexceptpleasurevessels.

2005–Introductionofrequirementforrecreationalcraftonbareboathireandvarioussmallvesselsoflessthaneightmetrestoreportalimitedrangeofaccidents:Death,MajorInjury,Capsize(ofapower-drivencraft),Fire,ExplosionorPollutioncausingsignificantharmtotheenvironment.

Vessel Definitions

UKmerchantvessels>=100gt MerchantvesselsontheUKregisterwithagrosstonnageof100gtormore

UKmerchantvessels<100gt

MerchantvesselsontheUKregisterwithagrosstonnageoflessthan100gt.

Includespleasurecraftofalltypesbeingoperatedcommercially(charter/hire,operatedbyschoolsandothertrainingestablishmentsetc).

UKpleasurecraft(non-commercial) Privatelyownedandoperatedpleasurevesselsofalltypes.

UKnon-commercialvessels

Non-commercialvessels(otherthanpleasurecraft),Navyvessels(wheninvolvedincollisionswithnon-Navyvessels),RNLIlifeboats,non-RNLIlifeboats,publicservicevessels(police,fire,ambulance).

UKfishingvesselsCommercialfishingvesselsregisteredwiththeUKMaritimeandCoastguardAgency’sRegisterofShippingandSeamen.

Non-UKvesselsinUKwaters Non-UKvesselsinvolvedinanaccidentorincidentinUKterritorialwaters(12-milelimit)

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MAIBANNUALREPORT2009

Meaning of “Injury”-anyfracture,otherthantoafinger,thumbortoe;-anylossofalimborpartofalimb;-dislocationoftheshoulder,hip,kneeorspine;-lossofsight,whethertemporaryorpermanent;-penetratinginjurytotheeye;or-anyotherinjury- (i)leadingtohypothermiaortounconsciousness, (ii)requiringresuscitation,or (iii)requiringadmittancetoahospitalorothermedicalfacilityasanin-patientformore

than24hours.

Andanyotherinjury,toapersonemployedorcarriedinashipwhichoccursonboardorduringaccesswhichresultsinincapacityformorethanthreeconsecutivedaysexcludingthedayoftheaccident,orasaresultofwhichthepersonconcernedisputashoreandtheshipsailswithoutthatperson,unlesstheincapacityisknownoradvisedtobeofthreeconsecutivedaysorless,excludingthedayoftheaccident.

Meaning of “Hazardous Incident”HazardousIncidentsareanyevents,otherthanaccidents,associatedwiththeoperationofashipwhichinvolvecircumstancesindicatingthatanaccidentnearlyoccurred.

71

GLOSSARY

GLOSSARY OF ABBREVIATIONS AND ACRONYMSAB - AbleBodiedseaman

ASTO - AssociationofSailTrainingOrganisations

BIS - DepartmentforBusinessInnovationandSkill

BMA - BahamasMaritimeAuthority

BPA - BritishPortsAssociation

BSI - BritishStandardsInstitution

CEC - CertificateofEquivalentCompetency

CLIA - CruiseLinesInternationalAssociation

CO2 - CarbonDioxide

CoC - CertificateofCompetency

Defra - DepartmentforEnvironment,FoodandRuralAffairs

DfT - DepartmentforTransport

DSMC - DomesticSafetyManagementCode

EC - EuropeanCommission

ECDIS - ElectronicChartDisplayandInformationSystem

EEBD - EmergencyEscapeBreathingDevice

EMSA - EuropeanMaritimeSafetyAgency

EU - EuropeanUnion

gt - grosstonnage

HMRC - HMRevenue&Customs

HSC - HighSpeedCraft

HSE - HealthandSafetyExecutive

IACS - InternationalAssociationofClassificationSocieties

IAMI - InternationalAssociationofMaritimeInstitutions

ICS - InternationalChamberofShipping

IMO - InternationalMaritimeOrganization

ISM - InternationalSafetyManagement

ISO - InternationalOrganizationforStandardization

LACORS - LocalAuthoritiesCoordinatorsofRegulatoryServices

loa - lengthoverall

LRS - LondonRiverServices

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MAIBANNUALREPORT2009

m - metres(lengthoverallunlessotherwisestated)

MCA - MaritimeandCoastguardAgency

MGN - MarineGuidanceNote

MPA - MarineProtectedAreas

MSC - MaritimeSafetyCommittee

MSDS - MaterialSafetyDataSheet

MSN - MerchantShippingNotice

NGL - NaturalGasLiquids

nm - nauticalmile

OCIMF - OilCompaniesInternationalMarineForum

PE - PreliminaryExamination

PEC - PilotExemptionCertificate

PPE - PersonalProtectiveEquipment

PSA - PassengerShipAssociation

PUWER - ProvisionandUseofWorkEquipmentRegulations

reg - registeredlength

RFA - RoyalFleetAuxiliary

RIB - Rigid-hulledInflatableBoat

RNLI - RoyalNationalLifeboatInstitution

ro-ro - roll-onroll-off

RYA - RoyalYachtingAssociation

SCVCode - SmallCommercialVesselandPilotBoatCode

SMC - SafetyManagementCertificate

SMS - SafetyManagementSystem

SOLAS - InternationalConventionfortheSafetyofLifeatSea

STCW - StandardsofTraining,CertificationandWatchkeepingforSeafarers

UKMPA - UnitedKingdomMaritimePilots’Association

UKMPG - UnitedKingdomMajorPortsGroup

VDR - VoyageDataRecorder

VHF - VeryHighFrequency

VOSA - VehicleandOperatorServicesAgency

VTSO - VesselTrafficServicesOfficer