2009 Summary Report of Casualties, Accidents and Incidents … · Summary Report of Casualties,...

2009 Summary Report of Casualties, Accidents and Incidents on Isle of Man Registered Vessels

Isle of Man Government Department of Trade and Industry

Published January 2009

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Introduction The IOMSR (Isle of Man Ship Registry) is committed to helping seafarers, managers, owners and operators concerned with all Manx vessels in achieving continued high standards of safety and pollution prevention. Occasionally things go wrong. When they do the Master, Skipper or Operator is required by law to submit a report on what has occurred. From these reports we can alert the shipping industry about areas and activities where any additional safety controls may be necessary and hopefully prevent similar occurrences from happening again. We also aim to produce statistics based on report findings. Where any trends are identified we can also work with shipping companies and other organisations in an effort to reduce these occurrences on board Isle of Man vessels. The reporting scheme is reliant upon Masters, Skippers or Operators reporting as accurately and in as timely a manner as possible. For submitting reports or if you have any questions then please contact the Isle of Man Ship Registry at:- Peregrine House, Peel Road, Douglas, Isle of Man, IM1 5EH, British Isles Tel +44 1624 688500 Fax +44 1624 688501 Email: [email protected] Website: www.iomshipregistry.com

Contents

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3 What is an Occurrence 4 Reporting Occurrences 6 ARF Reports Received 8 Analysis of ARF Reports Received in 2009

10 Casualties in 2009 14 Accidents in 2009 17 Incidents in 2009 19 Breakdown of Occurrences by Cause 22 Conclusion

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What is an Occurrence Under the Regulations (MS Accident Reporting and Investigation - SD815/01) an „occurrence‟ is either a Casualty, an Accident or an Incident. These are defined:- Casualty This means “any contingency which results in:- (a) loss of life or major injury to any person on board, or the loss of any person from, a ship

or a ship‟s boat; (b) the loss or presumed loss of any ship or the abandonment of any ship or a ship suffers

material damage; (c) a ship goes aground, is disabled or is in collision; (d) any loss of life or major injury, or serious harm to the environment, is caused by a ship; (e) any major damage to the environment brought about by damage to a ship and caused

by, or in connection with, the operation of the ship.” Accident This means “any occurrence of the following type provided that it caused material damage to any ship or structure, or damage to the health of any person, or serious injury:- (a) the fall of any person overboard; (b) any fire or explosion resulting in material damage to a ship; (c) the collapse or bursting of any pressure vessel, pipeline or valve or the accidental

ignition of anything in a pipeline; (d) the collapse or failure of any lifting equipment, access equipment, hatchcover, staging or

bosun‟s chair or any associated load-bearing parts; (e) the uncontrolled release or escape of any harmful substance or agent; (f) any collapse of cargo, unintended movement of cargo sufficient to cause a list, or loss of

cargo overboard; (g) any snagging of fishing gear which results in the vessel heeling to a dangerous angle; or (h) any contact by a person with loose asbestos fibre except when full protective clothing is

worn.” Incident This means “any occurrence, not being a casualty or an accident as a consequence of which the safety of a ship or any person is imperilled, or as a result of which material damage to any ship or structure or damage to the environment might be caused.” Incidents can also be referred to as „Near Misses‟ or „Near Accidents‟. Vessel inspections by the IOMSR have shown that the type of incidents reported to technical managers range from „minor incidents‟, eg a person forgetting to wear a safety helmet on deck, to „major incidents‟, eg narrowly avoiding a swung load suspended from a lifting appliance. The IOMSR encourages the Master, Skipper or technical mangers to use their judgement in determining a „minor incident‟ and a „major incident‟. All „major incidents‟ should be reported to the IOMSR using the ARF Form. If there is any doubt then report to IOMSR.

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Reporting Occurrences Who has to Report The Master, Skipper or Operator of any Manx Registered vessel wherever they may be. The Master, Skipper or Operator of any foreign flagged vessel in Manx territorial waters. A vessel means any description of watercraft ranging from Pleasure vessels, Fishing boats, Commercial Yachts, Passenger and Cargo vessels. Occurrences on board ships in ports, with the exception of those involving stevedores or shore-based workers, are covered and must be reported. Occurrences involving shore-based workers should also be reported to the country‟s Health and Safety Department or equivalent body. When to Report When a CASUALTY occurs the Master, Skipper or the operator must inform the IOMSR as soon as possible after becoming aware of the casualty and the Master or Skipper must send a report to the IOMSR as soon as is practicable by the quickest means available. When any ACCIDENT occurs the Master, Skipper or the operator must inform the IOMSR as soon as is practicable and by the quickest means available. A report is required to be sent to the IOMSR no later than within 24 hours of the vessel‟s next arrival in port. When an INCIDENT occurs the Master, Skipper or the operator must report the incident to the IOMSR before the vessel departs from the next port. How to Report Initial reports can be made directly by telephone, fax or email to the IOMSR. When the occurrence has been investigated on board the Master, Skipper or Operator should complete the Accident Report Form (ARF – see right) and forward it to the IOMSR by fax, email or mail. Any additional Report Forms used on board to document the occurrence may also be submitted to the IOMSR along with the completed ARF Form. It is recommended that a copy of the Report Form is kept on board as a record. Copies of the ARF Form are available on request from the IOMSR or available for download from the IOMSR website. For vessels with an Official Log Book it is recommended that a brief statement is included in the narrative section.

When Reports are received the Department (IOM Dept of Trade and Industry) decides whether or not an investigation is warranted. Not all Occurrences are investigated by the Department, this may be because:-

It has been agreed that investigation is being conducted by another Investigation Authority; or

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The Shipboard Staff and/or Technical Managers have completed a thorough investigation and the underlying cause is clear (the Department may request additional information).

Investigations are carried out in accordance with SOLAS Ch1 Reg 21 and using the guidance contained in IMO Resolutions A849(20) and A884(21). It is not the intention of these reports to apportion blame or economic liability. The initial part of an investigation seeks to establish the causes and circumstances of what has happened, with a view to deciding whether or not any further investigation is warranted. This is called a „preliminary examination‟. When a preliminary examination is complete, the Department will decide if it is appropriate to conduct further investigation. Where Occurrences are investigated a report is made. A provision is made for any person likely to be affected by a report to see the draft and comment on the facts and analysis therein before it is finalised. Sometimes due to the circumstances surrounding the investigation it is not always possible to publish the reports. Published reports are primarily for the benefit of all seafarers, managers and owners concerned with Manx vessels in the hope that lessons learnt may prevent similar occurrences from happening again. The names, addresses and any other details of anyone who has given evidence to an investigator are not disclosed unless a Court determines otherwise. Any reports published are available on the IOMSR website. ISM Coded Vessels Where vessels comply with the International Safety Management (ISM) Code the Safety Management System (SMS) should include procedures for ensuring accidents and hazardous situations are reported to the Company (ISM9.1). The IOMSR will accept the vessel‟s reporting form in lieu of the ARF Form provided it contains all of the information contained on the ARF Form. Where vessels have a Safety Officer on board as required by the Regulations (MS Safety Officials, General Duties & Protective Equipment - SD816/01) then the Safety Officer should be involved in the investigation on board. It is recommended that the SMS includes a procedure for reporting occurrences to IOMSR so there is no confusion. Reports Published in 2009 None. Historical reports can be found on the IOMSR website. Investigations by IOMSR in 2009 Type of Vessel Nature of Casualty Oil Tanker Death on Board Bulk Carrier Death on Board Fishing Vessel Flooded Fish Hold and Engine Compartment Bulk Carrier Death on Board Bulk Carrier Collision with another vessel General Cargo Collision with another vessel General Cargo Death on Board General Cargo Collision with another vessel

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ARF Reports Received In 2009 the IOMSR received a total of 57 ARF Reports. There were no reported occurrences on foreign flagged vessels in Isle of Man territorial waters in 2009. The table below shows the number of ARFs received by type of occurrence in 2009 and the preceding 4 years.

2005 2006 2007 2008 2009

Casualties 10 7 6 9 15

Accidents 42 33 29 25 26

Incidents 8 7 1 1 16

60 47 36 35 57

Collision, foundering or Stranding 17 11 4 3 7 Fire 2 2 3 6 3

Explosion - - - 1 - Pleasure Vessel: Explosion, collapse or Bursting - - - - -

Pipe Systems: Explosion Collapse or Bursting 2 1 - - 3 Sudden uncontrolled Release of any substance

from a system or pressure vessel 1 1 1 2 3

Accidental Ignition of Flammable material 1 - - 1 - Electrical Short Circuit or Overload - 1 1 - -

Failure of any Lifting device - - 1 1 3 Failure of any Access Equipment - - - - -

Involving Access to or from the ship 3 4 1 1 2 Slips or Falls (same level) 4 5 4 4 3

Slips of Falls (different levels) 3 5 5 2 7 Involving mooring Ropes or Hawses 2 2 4 2 4

Involving Lifting Equipment 6 1 1 3 4 Exposure to hazardous or toxic substances - 2 - - -

Man Overboard - - 1 - 2 Electric Shock - - 1 - -

Violence to the person 1 - - 2 - Other 18 12 9 7 16

Total 60 47 36 35 57

The Table below compares Occurrences with the total Isle of Man registered fleet over 5 years.

Year 2005 2006 2007 2008 2009

Total Occurrences / Fleet Size 6.0% 4.9% 3.8% 3.6% 5.5%

Casualties / Fleet Size 1.0% 0.7% 0.6% 0.9% 1.5%

Accidents / Fleet Size 4.2% 3.5% 3.1% 2.6% 2.5%

Incidents / Fleet Size 0.8% 0.7% 0.1% 0.1% 1.5%

The following graph shows a comparison between the number of reports received and the number of all Isle of Man registered vessels over the last 5 years. Isle of Man registered vessels means Merchant Ships, Small Ships, Commercial Yachts, Pleasure Yachts, Fishing Vessels, and Demise Charter Ships. The total number of vessels on the Register each year is calculated as an average from the number of vessels per month as vessels register and deregister.

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The Table below compares Occurrences with the fleet size (excluding Pleasure Vessels) over 5 years.

Year 2005 2006 2007 2008 2009

Total Occurrences / Fleet Size 10.4% 7.7% 5.8% 5.5% 8.7%

Casualties / Fleet Size 1.7% 1.1% 1.0% 1.3% 2.3%

Accidents / Fleet Size 7.3% 5.4% 4.6% 4.1% 4.0%

Incidents / Fleet Size 1.4% 1.1% 0.2% 0.2% 2.4%

The graph below compares the number of ARF Reports received with the number of Registered Vessels (excluding Pleasure Vessels) over a period of 5 years.

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Analysis of ARF Reports Received in 2009 Number of ARF Reports Received in 2009 per Vessel Type

IOMSR Comment The IOMSR recognises that the previous chart may not reflect the total number of incidents being recorded by vessels and reported to their technical managers using the vessel‟s own incident reporting procedure. The majority of incidents being reported to technical mangers are therefore presumed to be minor incidents. Type of Occurrences

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IOMSR Comment The above chart shows that in addition to the „Other‟ category the majority of occurrences were slips/falls and collisions. 2009 also saw a marked increase in the number of occurrences involving lifting gear and mooring line failures where the wire and lines have been parting. This stresses the need for adequate inspection and maintenance of lifting gear and mooring lines. Where crew members are suspended by a rope to conduct work activities it is vitally important the rope is inspected each time before use by a competent person. Where permits to work are used for such activities it is recommended that inspections of the equipment are a requirement of the permit. Place Where Occurrences Happened

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Casualties in 2009 A total of 15 Casualties were reported in 2009. The Charts below show what activities where being carried out that led to a casualty and what injuries were incurred from the casualties.

Brief Summary of All 15 Casualties in 2009 1. ‘Other’ Cargo Vessel – A rating was transferring to an MOB boat by ladder from another vessel when he misjudged his step, slipped and fell into the MOB boat. The rating suffered a fractured and dislocated shoulder. Sea conditions were 1.5m and wind 15kts. After one attempt was aborted due to the vessels motion another attempt soon followed after the vessel‟s motion became less. The rating followed another seaman who successfully transferred. It was considered both men had sufficient experience to complete the transfer safely. 2. Commercial Yacht – Whilst on passage in the N. Atlantic the vessel encountered a series of large waves. The Rescue Boat suffered severe damage and rendered unusable. The emergency generator (in the bow area) was also severely flooded through a hatch blowing several fuses and breakers including a steering pump. Major water ingress was also observed in forward crew cabins. The water ingress later resulted in emergency lighting, some backups and navigation equipment malfunctioning.

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3. Oil Tanker – A cadet entered the cargo pump room without authorisation and fell to his death. 4. ‘Other’ Cargo Ship – A crew member was tasked to segregate movable bulkheads whilst in a lifting basket. The basket was fixed to the eyes of a gantry wire by nylon strops (SWL 5t). A nylon strop parted as a result of being cut on the gantry wire and the basket fell into the cargo hold with a crew member in it. 5. Offshore/Standby vessel – A crew member was carrying out mooring operations at the aft of the vessel with another vessel. The crew member was making a turn on the bitts when he observed a heaving line being thrown back to the vessel in his direction. To avoid being hit by the Monkey‟s fist the crew member stepped back, lost his footing and fell fracturing his wrist. 6. Bulk Carrier – Whilst transiting a lock system some ratings were tasked to prepare a pilot/gangway combination ladder. During the task a rating fell from the gangway onto a wooden fender attached to the lock side. A rescue was immediately organised by the lock workers. The rating later died in hospital. The reason why he fell is un-determined. The rating was observed to be wearing PPE but no safety harness despite a safety harness being provided at the place of work. 7. ‘Other’ Cargo Vessel – A vessel was alongside in port when a painting boat was being lowered into the water using a vessel‟s store crane. An AB and cadet boarded the boat at the main-deck level. Once in the boat the lifting wire parted causing the boat to drop 8m into the water. The crew members suffered major bruising as a result of the fall. No permit or risk assessment was carried out prior to the task. The crane used was untested (despite the tested crane being adjacent), the wire fall which parted was also uncertificated. The use of this equipment was unauthorised. Following this the crane was immobilised, uncertificated wire fall removed. 8. Offshore/Standby Vessel – Three ratings were tasked with moving steel plates vertically stowed to an area 10m away by sliding them across the deck. The steel plates were to be sent ashore using slings. When moving the 4th steel plate, 3 steel plates stowed inboard toppled over causing excessive weight on the plate being moved. A rating then tried to hold up the plates (each plate weighing approx 100-200kg) with his leg long enough allowing another rating to escape uninjured. The rating was unable to continue holding the plates with his leg and the plates fell crushing his leg causing a severe fracture. What was not taken into account during the task was that the remaining plates had moved into a more vertical position than the plates first moved. Following this a new risk assessment was made which included individual lashings and rack storage and movement of the plates is to be conducted by crane in future. 9. Offshore/Standby Vessel – An AB was working on the main deck assisting with cargo operations. When he was walking to a container he slipped, twisting his right ankle and fell which in turn caused the leg to break just above the ankle. Cargo operations then ceased while emergency first aid was administered. The exact cause of the slip is undetermined however, it‟s possible the AB slipped on a wooden deck described as “smooth and wet”.

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IOMSR Comment It‟s also possible that traces of algae/bio growth contributed to the slippery deck. It is recommended that wooden decks are treated with biocide and power-washed at appropriate intervals. 10. Fishing Vessel – The fishing vessel was moored alongside where all the crew proceeded ashore and went home for the weekend. The following morning the vessel was reported as sinking, listing and trimmed by the stern at a large angle. The local fire brigade attended and pumped out a large quantity of water from the fish hold and engine room. Upon investigation it was found that the bilge valve from the fish hold had debris under the seat preventing it from closing fully and the sea suction to the deck wash had been left open which allowed water to flow through a common manifold and into the fish hold. The engine room and fish hold had flooded to around 3 feet of water causing major damage to the electrical systems and damage to some mechanical systems which required overhauling. 11. Bulk Carrier – Stores and provisions were being loaded using the ships gantry crane. During this operation an AB was on the crane‟s maintenance platform suffered a fatal head injury, possibly due to hitting his head on the surrounding structures. Upon investigation it was found that after a previous breakdown and subsequent repair, it became common practice to have one person monitor the cable drum to ensure it wound on. This involved sitting on the crane maintenance platform whilst the crane was in operation. No Job Hazard Analysis nor any Risk Assessment was made for this task which was outside the “day to day” operation of the crane. It was found that the crane had been properly maintained as part of the vessels Safety Management System. Procedures on board stated no maintenance should be carried out on the crane while the crane is in use. IOMSR Comment The fact that the AB was required to be in the maintenance platform form is debatable. Any abnormal tasks on board vessels should be subject to adequate Risk Assessment with participants briefed as to the risks involved and any safety measures required. All crew members involved with abnormal tasks such as this should have good situational awareness too. 12. Bulk Carrier – The vessel departed port with no cargo on board. Prior to altering course to join a Traffic Separation Scheme, the vessel was transiting a Precautionary Area, when it was involved in a collision with an Oil Tanker fully loaded with Naphtha. The collision caused a massive explosion, significant structural damage to both vessels, killed nine crewmembers and injured other crewmembers on the Oil Tanker. Other than Naphtha cargo spilled into the sea (which was consumed by fire) there was no marine pollution. Burn injuries were sustained on board the bulk carrier when some of the crew went outside to the Muster stations and were burned by the searing air temperature. An investigation is ongoing. 13. ‘Other’ Cargo Vessel – The vessel was making way during the hours of daylight in good visibility when it was involved in a collision with a fishing vessel. The vessel was the “stand-on” vessel in a crossing situation where the fishing vessel was the “give way” vessel. The fishing vessel was not engaged in fishing nor displaying any fishing signals, ie. a power driven vessel with the same responsibilities under the COLREGS.

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The vessel first noticed the fishing vessel at a range of 1.5nm and attempted to contact the fishing vessel by VHF radio and gave a single blast on the ships whistle (the correct signal should have been 5 short blasts under the COLREGS). The fishing vessel did not respond and maintained her course and speed. At a range of 0.6nm the vessel made a small alteration of course to starboard on the autopilot before eventually attempting a hard-a-starboard manoeuvre in manual helm control. As the vessel turned the port quarter collided with the fishing vessel‟s starboard bow. There were no injuries and no pollution from either vessel. The vessel was equipped with the required navigation equipment for her size and age. The radar was working properly. An investigation concluded it is likely there was no one keeping a lookout in the wheelhouse of the fishing vessel. This case highlights the importance of keeping a good lookout and taking early action to avoid collision. The case also highlights that valuable time can be wasted in attempting to contact other vessels by VHF for collision avoidance particularly where the time would be better spent taking action to avoid the collision. 14. ‘Other’ Cargo Vessel – The cook was returning to the vessel following a trip ashore with a fellow crew member. The cook attempted to board the vessel and fell between the quay and ship into the water. The cook subsequently died. An investigation is ongoing pending the findings of a post mortem examination. 15. ‘Other’ Cargo vessel – After completing cargo operations the vessel set sail with a pilot on board. The duty AB escorted the pilot down to the pilot ladder; the pilot disembarking safely at the pilot station. At this time the Master and Second Officer remained on the bridge. The visibility was good; wind was from the South West force 4 and the sea state slight to moderate. Just before midnight the third officer arrived on the bridge to take up his watch and the second officer left the third officer on the bridge following the handover. The master also left the bridge at midnight to send a departure report. The Look-out AB had gone below to change clothes prior to taking up his bridge watch keeping duty. Whilst sailing transiting a TSS precautionary zone the vessel was involved in a collision with another vessel crossing on her starboard side. The vessel suffered significant structural damage in the bow area and a fire in the forward paint locker. It took around 4 hours to extinguish the fire. The Chief Officer was taken ashore for medical treatment. The vessel later proceeded to a nearby port with tug assistance. It was reported that the crew on board the other vessel were going to abandon ship as the engine room was flooding along with some of the cargo holds. All the crew safely abandoned ship and were rescued. The vessel was later towed to a port of refuge. An investigation concluded that the OOW failed to apply the Colregs correctly, particularly the Rules concerning crossing situations and his responsibility to still keep clear where the Rules dictate even in a TSS and Precautionary zone. Failings were also found in identifying risk of collision and action taken to avoid collision. The investigation also highlighted poor bridge team management where the Master allowed the OOW to remain on his own on the bridge during the hours of darkness. The investigation also found that the fire fighting equipment was not in a state of readiness and valuable time was subsequently lost from fighting the fire whilst assembling fireman‟s outfits and SCBA kits.

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Accidents in 2009 A total of 26 accidents were reported in 2009. The following Charts show what activities were being carried out that led to an accident and what injuries were incurred from that accident.

IOMSR Comment On some occasions more than one injury occurred during an accident. The majority of injuries from accidents are puncture wounds, cuts, lacerations and „other fractures‟. In the majority of these cases the cause was attributed to personal negligence. The majority of injuries sustained follow the same trend as the previous year. This stresses the need for seafarers to be more careful, safe working practices are properly followed and equipment is in good working order. Brief Summary of Some Selected Accidents in 2009 1. ‘Other’ Cargo Vessel – The Chief Officer was using a set of portable ladders placed on top of a hatch cover to climb on top of a deck container. The ladders slipped on the wet surface causing the Chief Officer to fall onto the hatch cover. The Chief Officer suffered broken bones in his hand. The ladder had not been secured by any means.

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2. Passenger Vessel – Whilst alongside the mooring lines were tended to adjust for the change in tide and high wind conditions. As the crew member held the line the line parted due to the vessel‟s motion. The mooring line snapped back and hit the crew member‟s side causing injury. No cargo or passenger operations were being conducted at the time. 3. Oil Tanker – A crew member was joining a vessel whilst at anchor by way of a pilot/combination ladder. The crewmember fell into the water while climbing the ladder from the boat. The crewmember was wearing a lifejacket which had inflated. The crew member was picked out of the water by the launch boat crew. The crew member suffered only minor scratches to his leg. IOMSR Comment It is the company‟s policy that anyone boarding the vessel from a launch is to wear an inflatable lifejacket. The crew member was very fortunate to be wearing the lifejacket which prevented a potentially more life threatening situation from occurring. 4. ‘Other’ Cargo Vessel – Whilst the 2nd Eng and Electrician were doing their weekly checks on the lifeboat the aft release hook was partially tripped resulting in the hook releasing the aft end of the boat and dropping by 25mm from the stowed position. After testing the release mechanism with the boat in the water it was found that the release block could not be reset easily. The block was eventually reset with extra securing and raised to the davits with no personnel on board. Upon further inspection it was found that the wire connecting the aft hook to the hook releasing handle inside the boat had been stretched by approximately 25mm but still operational. The lengthening of the wire was caused by a failure of the ferrule at the releasing handle end of the wire. Whilst the release mechanism was still operational, when the handle was in the secured position the lengthening of the wire caused the hook mechanism not to be fully secured. 5. Oil Tanker – The Freefall lifeboat was launched while the vessel was at anchor. When the boat was being retrieved the hooks were connected and the slack taken up to keep the boat steady in the water. When the weight came on, the aft wire slings parted. No one was injured and the rescue boat was on standby to assist with the retrieval of the crew and manoeuvring the boat. The wires had a protective plastic covering and had suffered heavy corrosion on the outside of the wires. IOMSR Comment Working on and launching/recovering lifeboats (freefall and davit launched) can be one of the most hazardous work crewmembers may be tasked with. Extra care and checks are strongly recommended when working with this equipment. 6. ‘Other’ Cargo Vessel – The 2nd Officer was on a hatch cover observing cargo operations by stevedores. Whilst helping to position cargo being loaded by crane the 2nd Officer‟s foot became trapped between the cargo and a guide post. His foot was fractured due to being crushed and he was subsequently taken to the local hospital. The 2nd Officer was wearing correct PPE including Safety Shoes. It was reported that the cargo slung under the crane unexpectedly moved when the vessel listed due to cargo operations on another hatch.

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7. Oil Tanker – The Chief Officer and 3 other crew members went forward to the vessel‟s Bow Loading Station to work on the protection cover. After a “toolbox” talk to discuss the job and prepare the equipment the team used a chain block to force the lip back into position. When the lip was almost aligned the chain block hook slipped and hit the Chief Officer on the jaw. First Aid treatment was given and using radio medical advice it was decided the jaw was broken and the Chief Officer should be taken ashore for medical treatment. Helicopter transportation was arranged and the Chief Officer was sent ashore to hospital. 8. Oil Tanker – Whilst conducting hose connection operations at an SPM the crane runner wire parted while the hose was being lifted out of the water. This caused the hose to fall back into the water along with the chain and block. All crew members were standing well clear when the wire parted so there were no injuries incurred. No pollution was reported either. The chain block was later recovered by local workers assisting the vessel. 9. Commercial Yacht – Whilst alongside the Chief Officer (who is also the Safety Officer) deliberately jumped down onto a concrete dock from the main deck of the vessel and badly injured his knee on impact. The Chief Officer decided to take this short cut to save time from walking an extra 30m round to the area on the dock. The Chief Officer was later taken to hospital. Following this the crew were briefed on the dangers of moving about the vessel in a dangerous manner. IOMSR Comment The decision to jump by the Chief Officer was caused by a lack of judgement in an effort to save negligible time. All crews on all ship types are covered by the Means of Access Regulations and are required to use the safe means of access provided by the vessel. 10. Oil Tanker – Whilst the vessel was at sea the fire alarms sounded and muster teams assembled. On investigation smoke was found coming from the main deck garbage storage area. A small fire was extinguished using portable extinguishers and fire hoses. A fire watch was then maintained and the surrounding area checked for hotspots. Upon investigation it was found that the fire resulted from the spontaneous combustion of rags soaked in linseed oil. It was found that the plastic garbage receptacle was not as per the Garbage Management Plan which states the storage of oily rags should be in metal receptacles with a lid. The linseed oil used had no MSDS information available. Following the fire, changes were made to the garbage management plan and the crew briefed for the handling of oily rags and all chemicals with no MSDS information were removed. 11. Oil Tanker – The 2nd Eng was refitting a water condensate return line when he suffered scalding to his upper torso, arms and hands when he was sprayed with hot water. After receiving first aid on board he was evacuated by helicopter to hospital ashore. The job was carried out after a leak was initially discovered. Some of the services feeding the line were isolated and a section of pipe was removed with blanks fitted. The system was eventually restored. The following day the refit was to be completed, a “toolbox” talk was held and work permit issued. The 2nd Eng isolated the system, however, he neglected to isolate all of the systems feeding the line. The 2nd Eng was working at the top of a portable ladder wearing PPE including a safety harness. When removing the blank the hot water sprayed out covering the 2nd Eng. The way the 2nd Eng had secured his safety harness made it more difficult to avoid the scalding water until he disconnected himself. The immediate causes of the accident were

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found to be the condensate system not being fully isolated, lack of appreciation of steam and pressure build up and ineffective use of fall protection equipment. IOMSR Comment When planning this type of work it is vitally important the person responsible has a sound knowledge of pipe system involved and special checks are made to ensure all services are isolated. When securing safety harnesses consideration should be given to them not being overly restrictive for the job in hand, yet providing adequate fall protection.

Incidents in 2009 A total of 16 incidents were reported in 2009. The following Charts show what activities were being carried out that led to an incident.

Brief Summary of Some Selected Incidents in 2009 1. ‘Other’ Cargo vessel – During the cutting of steel stoppers from a hatch cover, flying sparks ignited plastic packaging in the vicinity. The emergency alarm was sounded and the small fire was soon extinguished by portable dry powder extinguishers. The Internal investigation recommended that adjacent materials be removed or covered by flame proof coverings. 2. Offshore/Standby Vessel – Whilst alongside the vessel‟s daughter craft and fast rescue craft were lowered into the water. The daughter craft crew then boarded the fast rescue craft proceeded to test the engines and take the craft on a „familiarisation tour‟ of the harbour area. The crew were not authorised to do this nor had they informed the Master or Chief Officer. On return to the vessel it was observed that the boat‟s coxswain was not wearing a lifejacket. The coxswain stated he simply forgot to don a lifejacket feeling under pressure from a crane driver to get the job done. IOMSR Comment Fortunately no accident occurred on this occasion. Safety procedures were not followed by the coxswain by not wearing a lifejacket when driving the fast rescue craft at high speed.

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3. Oil Tanker – Whilst cleaning the engine room fixed CO2 bottles the manual release was knocked on two bottles and gas released into the manifold feeding the engine room. No gas was released into the engine room as the distribution valve remained closed. The manifold was vented to atmosphere. The manual releases were reset and it was later discovered about half the contents of each bottle had been discharged. 4. ‘Other Cargo Ship’ – Whilst cutting off steel stoppers on a „tween deck by a burner sparks and molten metal dropped onto tarpaulin covering a cargo unit containing diesel (approx 47t). The tarpaulin began to melt and generate thick smoke. The fire alarm was sounded and the tarpaulin was eventually extinguished by portable extinguisher. IOMSR Comment Two very similar incidents have occurred involving the use of oxy-acetylene torches in cargo spaces. Before this work commences it is very important to check the surrounding vicinity for materials likely to combust and move these items to a safe distance. If the materials cannot be moved then fire proof coverings should be considered. It is recommended that this type of work is subject to Risk Assessment and permits to work, which should identify potential sources of fire in the vicinity and have the risks removed. 5. Gas Carrier – Whilst mooring a headline parted in the vicinity of the warping drum and snapped back hitting a crew member causing minor bruising. The forward mooring arrangements had been modified by the ship‟s crew. The forward mooring party are limited in numbers and require the help of the aft mooring party when they are finished aft. The forward mooring arrangements also make it difficult to sight all line handling. An investigation found that the immediate cause was excessive loading on the mooring line and the situational awareness of the injured party stood in the vicinity of the mooring winch. It was also found that the Officer in Charge could not monitor all of the line handling simultaneously. It was recommended that measures are introduced to improve communication, each line is deployed under the direct supervision of the Officer in Charge and that additional training and marking is provided concerning snap back zones. 6. Commercial Yacht – Whilst entering port the vessel experienced an „unrequested‟ main engine shutdown of both main engines. The Chief Engineer was requested to restart the engines while the Master ordered the anchors let go. As the vessel drifted forward (assisted by the prevailing wind) it collided with another yacht which was moored stern to the quay before the anchors could be released. The damage caused internal and external damage to both vessels. It was observed the bow thruster was running during the collision which did not abate the situation. The fact that the bow thruster was running is inconsistent with the vessel systems during a main engine failure. The vessel had recently been delivered to the owners and had also suffered other mechanical breakdowns not connected with the main engine or bow thruster. An investigation is ongoing which includes representatives from the machinery manufacturers.

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Breakdown of Occurrences by Cause The following represents a breakdown of all the occurrences by cause divided into several categories represented on the ARF Form. Determination of the cause is following an investigation into the Occurrence by either Ship‟s Staff, Company Investigators or an External Investigating body. It is important to remember that an occurrence may be the result of several causes across different categories. Working Method

The chart above shows that the predominant working method cause has been attributed to unsafe working methods. This stresses the need for safety procedures to be followed correctly which includes effective use of safety equipment. Mechanical & Other Equipment

The chart above shows that the majority of mechanical and other equipment causes has been attributed to the failure of ropes or hawsers. This stresses the need for effective inspection and maintenance of lines to ensure they are in good condition and fit for purpose.

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Movement About the Ship

The chart above shows that the predominant movement about the ship cause has been attributed to „other‟ slippery surfaces. Where appropriate Masters should ensure that deck working areas have non-slip surfaces as much as possible. The can be achieved by either clearing/cleaning the deck or effective use of non-slip paint mixes. Crew members should also be aware of any associated risks of slipping when moving about the ship under various conditions. Ship Access

All crew members are required by the Regulations to use the means of access provided. The Master is required to provided appropriate means of access and ensure they are maintained in good condition. Everyone intending to board or leave the vessel should be strongly encouraged to use the means of access provided even if a short cut appears to be an „easy‟ or shorter journey. Crew members joining the vessel from a launch boat are strongly encouraged to wear appropriate lifejackets and only consider the transfer under suitable conditions taking into account the weather conditions and vessel motion.

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Human Factor

The chart above shows the predominant human factor cause has been attributed to personal negligence or carelessness. By „human factor‟ we mean the act or omission of a person to do something that leads to the occurrence happening. This stresses the need for adequate knowledge and training associated with the particular work activity, for the crew member to be made aware of any associated risks and for the crew member to pay attention to what they are doing. Other Miscellaneous Causes

The chart above shows that the predominant other miscellaneous cause has been attributed to the ship movement. Crew members should take into consideration the movement of the vessel when planning and carrying out work activities. If the movement of the vessel is too great the work activity should not be attempted or the vessel positioned to reduce the movement to an acceptable level.

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Conclusion Despite best efforts it is an unfortunate fact of life that occurrences will always happen. Unfortunately 2009 saw an upward trend in the number of Casualties and Incidents where the number of Accidents remained about the same level compared to 2008. Many of the ARFs received show that a large proportion of occurrences are attributed to the Human Factor whereby personal negligence and carelessness remains prevalent and therefore highlights the importance of Safe Working Practices and risk assessment. Occurrences involving lifting gear and mooring lines featured heavily in 2009, highlighting the importance of effective maintenance and inspection regimes. The number of collisions at sea also rose significantly emphasising the need for proper and effective application of the COLREGS. In particular, with more emphasis being placed on keeping a good lookout without distractions, taking timely and effective action to assess the risk of collision and early action being taken to avoid collision in accordance with the COLREGS. In summary some of the collisions occurred as a result of doing too little too late. Seafarers should be aware of their own abilities and limitations and the limitations of the equipment they use. Seafarers should not attempt any work activity where they perceive the risks to be unacceptable or take any unnecessary risks with their safety in order to get the job done. Should unacceptable risks present themselves, then the work should stop, the risks posed investigated and measures introduced to reduce the risks to an acceptable level. The use of Risk Assessment techniques are particularly useful in this situation. If the vessel has an appointed Safety Officer then they should be informed and the circumstances investigated. It is important to remember that if the risks cannot be reduced to an acceptable level then the work activity should not go ahead. Should this occur, then specialist advice / help should be sought. It is the responsibility of the Master or Skipper to ensure that all activities carried out on board are conducted safely, with an acceptable level of risk. Where vessels have technical managers ashore, then the technical managers should ensure that the Master or Skipper is given the necessary support and resources on board to determine the risk and to reduce the risk to an acceptable level. Safety on board a vessel should be everyone‟s concern. Seafarers should be able to observe and monitor their own safety effectively and where possible the safety of those around them. Where a vessel has established safety procedures, it is important that these are observed correctly. The appropriate Personal Protective Equipment should always be worn and used correctly. Any dedicated safety equipment should be regularly maintained and inspected before use. The Code of Safe Working Practices for Merchant Seaman is always a valuable reference source for most work activities conducted on board and should be consulted frequently. Risk Assessments, Permits to Work and plain old common sense are all important factors in reducing the level of risk posed by work activities.

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Additional Information Manx Shipping Notice No. 3 Code of Safe Working Practices for Merchant Seaman Master‟s / Yacht Master‟s Handbook (available free on the IOMSR website) Merchant Shipping (Accident Reporting and Investigation) Regulations 2001 SD815/01 Isle of Man Ship Registry Website – www.iomshipregistry.com Contacting the Isle of Man Ship Registry – email [email protected]

http://www.iomshipregistry.com/

mailto:[email protected]

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The information in this report can be provided in large print or on audio tape, on request. Copyright Notice The contents of this report are the property of the Isle of Man Ship Registry and should not be copied without its permission.

Isle of Man Ship Registry, Peregrine House, Peel Road, Douglas, Isle of Man, IM1 5EH www.iomshipregistry.com

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