MAIB Safety Digest: April 2015

The latest MAIB safety digest was published earlier in April with reports into nine recreational craft investigations.

According to the Steve Clinch, The Chief Inspector, failure to plan is common theme running through latest investigations:

The consequences of failing to properly plan a voyage on a large merchant ship are graphically described in Case 2 but Case 20 describes a similar outcome, this timenarrowboat_a on a leisure vessel. Previous Safety Digests have regularly highlighted the importance of wearing lifejackets when working on the open decks of fishing vessels and leisure craft. Fitting spray hoods to lifejackets and investing in Personal Locator Beacons (PLBs) and an EPIRB can also save lives. Fitting a liferaft, even though one may not be required by regulation, is also a smart move – should the worst happen, why get wet when you can remain relatively dry and warm until help arrives?
Any accident can be life changing – not only for those directly involved but also for their colleagues and loved ones. Therefore, before commencing any potentially hazardous task, whether on deck, in the engine room, on a large ship or small, get into the habit of asking yourself “what’s the worst that could happen?” then check that the necessary barriers are in place to protect yourself, the ship and everyone on board.
The full digest can be read here.

NWSF News & Updates

Boating & Watersports Participation Surges to Highest Level Since 2007
Participation rates in core boating and watersports activities surged in 2013 according to research released by by BMF, MCA, RNLI, RYA, BCU and MMO.
A total of 3.5 million adults (7.1% of the population) took to the water across a number of activities including power boating, sailing, canal boating and rowing/skulling.
This reflects an increase of 23% in the number of participants from 2012 when 2.8 million adults, took part in at least one of the activities. Within this total, canoeing and kayaking in particular proved popular, recording an all-time high of 1.5 million adults (3% of the population). Read more: http://www.britishmarine.co.uk/news__press/press_article.aspx?ArticleId=4282
Water sport safety information from the NWSF: http://www.nationalwatersafety.org.uk/professional/advice.asp

Neknominate ‘game’ leads to a false emergency call
After receiving reports from that a teenager was threatening to jump into the rough seas, Humber Maritime Rescue Coordination Centre sent the Redcar RNLI Lifeboat to Saltburn Pier. When the teams on scene couldn’t find the teenager further investigations revealed that he was at home. He had posted his intention to jump from the Pier on social media. Humber Coastguard Watch Manager Bev Allen said;
“If you have been drinking, your judgement will be impaired and you will be more likely to be overcome by the cold, dark sea. Your acceptance of the dare is highly likely to be life threatening. Alcohol is a contributory factor in a significant number of coastal drownings every year. Alcohol and sea water really don’t mix” http://www.dft.gov.uk/mca/mcga07-home/newsandpublications/press-releases.htm?id=96B5848B506AE7DC&m=2&y=2014

National Watersports Month
The British Marine Federation (BMF) and strategic partners the Royal Yachting Association (RYA), British Canoe Union (BCU) and British Rowing are working together on a new initiative, to encourage the nation to get on the water this coming May.
National Watersports Month will focus on promoting events across the country providing a variety of boating and watersports activities. Sailing, windsurfing, rowing, canoeing, kayaking, inland waterway cruising events and more will be taking place – to find out more and to get involved visit: http://www.watersportsmonth.co.uk
Water sport safety information from the NWSF: http://www.nationalwatersafety.org.uk/professional/advice.asp

MAIB Safety Bulletin 1/2014 – Eshcol
Carbon monoxide poisoning on board the scallop-dredger Eshcol in Whitby, North Yorkshire resulting in two fatalities. Read the report: http://www.maib.gov.uk/cms_resources.cfm?file=/Safety%20Bulletin%201_2014.pdf

MAIB Safety Bulletin 2/2014 – ECC Topaz
MAIB Safety Bulletin on the fire and subsequent foundering of workboat ECC Topaz 11nm east of Lowestoft on 14 January 2014, was published on 26 February 2014. http://www.maib.gov.uk/cms_resources.cfm?file=/Safety%20Bulletin%202_2014.pdf

Accident Investigation Report 6/2014: Sirena Seaways
MAIB Report on the investigation of Sirena Seaways’s heavy contact with the berth at Harwich International Port on 22 June 2013. Download report: http://www.maib.gov.uk/cms_resources.cfm?file=/SirenaSeaways.pdf

Accident Investigation Report 7/2014 Prospect
MAIB Report on the investigation of the fv Prospect grounding on Skibby Baas and foundering in the North entrance to Lerwick Harbour, Shetlands Islands.Read more: http://www.maib.gov.uk/cms_resources.cfm?file=/Prospect.pdf

Accident Investigation Report 8/2014 Danio
MAIB’s investigation into the grounding of the general cargo vessel Danio in the Farne Islands nature reserve, off the east coast of England. Read more: http://www.maib.gov.uk/cms_resources.cfm?file=/Danio.pdf

NWSF News & Updates October ’13

The 2012 UK Water related fatalities; Water Incident Database Report has been released!

This report is the first release of WAID fatality information for 2012, and has been compiled by members of the National Water Safety Forum.
We gratefully acknowledge those organisations that have contributed data and special thanks are also extended to the contributing police, fire and rescue services. For further information on the WAID service please see: http://www.nationalwatersafety.org.uk/waid
Previous WAID UK Annual Fatal Incident reports, dating back to 2009 are available on the Forum’s website: http://www.nationalwatersafety.org.uk/waid/reports.asp

MAIB Safety Bulletin 3/2013 – Wacker Quacker 1 / Cleopatra published

Summary: The MAIB has issued Safety Bulletin 3/2013 following the sinking of the DUKW amphibious vehicle Wacker Quacker 1 in Salthouse Dock, Liverpool on 15 June 2013 and the fire on board the DUKW amphibious vehicle Cleopatra on the River Thames, London on 29 September 2013. Issued 28 October 2013. Safety Bulletin 3_2013.pdf (4.38 kb) http://www.maib.gov.uk/cms_resources.cfm?file=/Safety%20Bulletin%203_2013.pdf

Arklow Meadow Accident Investigation Report 21/2013 published

Summary: MAIB Report on the investigation into a release of phosphine gas during cargo discharge on board Arklow Meadow, Warrenpoint, Northern Ireland on 5 December 2012. Report No 21/2013. Published 3 October 2013. View or download the full report: http://www.maib.gov.uk/publications/investigation_reports/2013/arklow_meadow.cfm

mv Amber Accident Investigation Report 22/2013 published

Summary: The MAIB report on the investigation of the contact and grounding of the bulk carrier mv Amber at Gravesend Reach, River Thames on 15 November 2012, was published on 24 October 2013. Report No 22/2013. View or download the full report: http://www.maib.gov.uk/cms_resources.cfm?file=/mvAmber.pdf

Busiest summer in years – Says the RNLI

The RNLI have released provisional figures from over the summer period, showing sharp rises in the number of lifeboat launches across the UK. Across the UK and Republic of Ireland, the charity’s lifeboats launched 4,300 times – the most in 24 years – and lifeguards attended 14,814 Incidents.

Wales – Lifeboat launches across Wales between June – August rocketed by 43 per cent compared with summer 2012. Statistics reveal RNLI lifeboats and lifeguards across Wales have been exceptionally busy, with RNLI lifeguards responding to 946 incidents and RNLI lifeboats launching 726 times. Of the 31 lifeboat stations in Wales, 24 reported an increase in emergency calls with some experiencing dramatic rises. http://rnli.org/NewsCentre/Pages/RNLI-in-Wales-reports-busiest-summer-in-24-years.aspx

Northern Ireland – The lifeboats in Northern Ireland launching 138 times during the months of June, July and August, an increase of 20 per cent on the previous summer. The charity’s lifeguards were also busy on ten beaches with 259 recorded incidents, an increase from 142 incidents in 2012. http://rnli.org/NewsCentre/Pages/RNLI-figures-show-busy-summer-for-Northern-Ireland-lifeboats-and–lifeguards.aspx

Manx Lifeboat – Lifeboat launches across the Isle of Man between June – August rocketed by nearly 50 per cent. Of the five RNLI lifeboat stations on the island, Douglas, Peel and Ramsey have all reported a marked increase in call-outs. The most notable rise has been in services by the island’s all-weather lifeboats which have increased from 13 incidents in 2012 to 26 in 2013. http://rnli.org/NewsCentre/Pages/Rise-in-Manx-lifeboat-launches-as-RNLI-reports-busiest-summer-in-24-years.aspx

East of England – 15 stations in the east coast of England launched a total 319 times between June and August 2013. This represents a very small drop of just 4.7 per cent from the 335 launches recorded in 2012. In addition, the charity’s lifeguards, which operate on 15 beaches in the east of England, were kept busy as they responded to 904 incidents during the 2013 summer season. http://rnli.org/NewsCentre/Pages/A-busy-summer-2013-for-lifeboat-crews-and-lifeguards-in-the-East-of-England.aspx

London’s lifeboat – Statistics from the charity, which runs lifeboats from three bases along the River Thames, show there were a total of 263 separate lifeboat launches between June and August 2013. This is just a handful more than the 253 launches recorded in the same period in 2012. Once again two of the RNLI’s London lifeboat stations were in the top five busiest of all 236 lifeboat stations around the UK and Republic of Ireland. The busiest was Tower station, which operates from a floating pier below Waterloo Bridge. Meanwhile Chiswick station, situated at Corney Reach Pier in the town, was ranked third busiest overall. http://rnli.org/NewsCentre/Pages/Lifesaving-statistics-show-a-busy-summer-2013-for-RNLI-London-lifeboats.aspx

North of England – The charity’s volunteer lifeboat crews carried out 598 rescue launches in June, July and August – a 28.9% increase on the previous year. Only the summers of 2003 (632 launches) and 2009 (634 launches) were busier. RNLI lifeguards also experienced a busy season in the north, dealing with 1,408 incidents compared to 1,143 last summer – a 23.2% increase. http://rnli.org/NewsCentre/Pages/Busy-summer-for-the-RNLIs-lifesavers-in-the-north-of-England.aspx

South-West RegionRNLI teams across the South West have been kept busy this summer, provisional statistics for the period June, July and August show a 24% increase in incidents for RNLI lifeguards, and lifeboat crews attending 652 rescues. RNLI lifeguards dealt with 10,615 incidents across the south west, including water based rescues, major and minor first aids and missing children.http://rnli.org/NewsCentre/Pages/Summer-sunshine-keeps-south-west-RNLI-lifesavers-busy.aspx

Scotland – There were more than five lifeboat launches a day Scotland-wide, during a busy summer for the RNLI’s lifeboats. The total number of launches for June, July and August was 476 across Scotland’s 47 stations, just short of the record-breaking Summer of 2008 when there were 480 launches. There were 440 launches during the 2012 summer.
The busiest station in Scotland was Broughty Ferry with 43 launches for its two boats, compared with 23 the previous year.
http://rnli.org/NewsCentre/Pages/Tobermory-RNLI-is-busiest-all-weather-lifeboat-station-in-Scotland-in-Summer-2011.aspx

Ireland – RNLI volunteer lifeboat crews in Ireland were kept busy this summer, with the charity’s lifeboats launching 571 times during the months of June, July and August. The figure represents an increase of 43 per cent on the previous summer.
http://rnli.org/NewsCentre/Pages/RNLI-figures-show-major-increase-in-Irish-lifeboat-launches-during-busy-summer.aspx

NWSF News & Updates July ’13

HM Coastguard sees an increase in incidents during July’s Summer sun
HM Coastguard has seen a 23% increase in incidents in the past month, as many take the opportunity to enjoy the summer sunshine along the UK coastline.
It’s not only swimmers in difficulty that HM Coastguard has recently dealt with. Other emergencies or calls for assistance include medical evacuations, mechanical problems with small boats, divers in difficulty, people stuck in mud, cliff falls and people cut off by the tide. Peter Dymond, Chief Coastguard, says:
“From 15th June to 16th July this year, HM Coastguard dealt with 2,859 incidents. An increase of 668 compared to the same period in 2012”.
Read the full story: http://www.dft.gov.uk/mca/mcga07-home/newsandpublications/press-releases.htm?id=CF4D1BD60000244C&m=7&y=2013

The Marine Accident Investigation Branch has published its ‘Annual Report for 2012’.
Covers Leisure, Merchant, and Fishing vessel accident investigations by the MAIB. Includes full investigations, report publications, recommendations and statistics
One leisure investigation of note: Lion (No 4/2012) Reflex 38 yacht Fatal man overboard 14.5 miles south of Selsey, 18th Jun 2011.
Download the 2012 report: http://www.maib.gov.uk/cms_resources.cfm?file=/MAIBAnnualReport_2012.pdf

Leisure centre operator sentenced after child drowning
The operator of an Essex leisure centre has been ordered to pay more than £190,000 in fines and costs after a seven year-old girl drowned in a swimming pool. Michelle Gellard, from East London, died after she went swimming with a number of other children at the Blackwater Leisure Centre in Maldon on 14th June 2008 after attending a judo competition.
Bedfordshire-based Leisure Connection Ltd, which operates the pool, was prosecuted under Section 3(1) of the Health and Safety at Work etc Act 1974 on the 18th July by the Health and Safety Executive (HSE); after an investigation into the death identified serious failings with lifeguard cover.
The HSE investigation concluded that Leisure Connection Ltd failed over a period of time to ensure that sufficient, suitably positioned lifeguards were always on poolside duty to ensure the safety of pool users. The Blackwater leisure centre was not compliant with its own procedures, and the procedures in place at the site were inadequate.

Leisure Connection Ltd, of Potton House, Wyboston Lakes, Great North Road, Wyboston, Bedfordshire, was fined £90,000 with costs of £101,663 after admitting breaching Section 3(1) of the Health and Safety at Work etc Act 1974. Section 3 of the HASAW Act places general duties on employers and the self-employed towards people other than their employees.

After the hearing, HSE inspector Antonina Drury said: “In this case, Michelle Gellard was robbed of her chances of rescue and survival by Leisure Connection’s failures.Evidence emerged in the course on the investigation that Leisure Connection failed to identify and address the fact that the amount of life guarding it was paying its staff to provide at Blackwater Leisure Centre was noticeably less than the amount it knew was required for full and safe operation of the pool.”
More on this article: http://www.hse.gov.uk/press/2013/rnn-e-02613.htm

Boat Safety Scheme issues gas warning to boaters and 10 key gas safety points
The Boat Safety Scheme is urging boaters to avoid using portable gas camping stoves, lamps and heaters on board boats because of the risks of explosions, fire and carbon monoxide poisoning. The alert for this summer follows yet another gas stove explosion, this time in the close confines of a tent on a North Wales campsite. The two young people inside were taken to hospital with facial burns, very similar to when two boaters were severely injured in an explosion on a boat on the Norfolk Broads in 2010.
Such equipment is designed for use in open air and is not suitable for use in the limited space of a boat cabin, where both explosions and carbon monoxide would have disastrous consequences.
Any boater deciding to use portable gas appliances need to be completely familiar with the correct and safe way of operation – from taking out of its storage case to fitting new fuel canisters. These are the 10 key safety points that can help to keep boat crews safe:
1. Only use portable appliances onshore
2. Stow any canisters, (used or unused) and any appliance (if it has a canister inserted), in a self-draining gas locker, or on open deck where any escaping gas can flow overboard.
3. Be familiar with the operating instructions before use
4. Before you start, check the appliance’s condition, if the gas canister seal looks damaged, or if the appliances/ gas canister is extremely rusty and deteriorated, do not use it
5. To avoid gas leaks and carbon monoxide poisoning check that all equipment has been correctly assembled before turning it on
6. Never attempt to fit a new canister to an appliance when aboard, wait until you are onshore.
7. Before fitting a canister, put out all open flames and smoking materials
8. Ensure that you have the correct type of gas canister for your appliance and that it is being inserted in the right place and in the right way
9. If you smell or hear gas leaking before attempting to light an appliance, don’t use it
10. If any gas is leaking, ensure that it is being dispersed in free air well away from the boat or any sparks or other sources of ignition
Read more on the Canal & rivers Trust website: http://canalrivertrust.org.uk/news-and-views/news/boat-safety-scheme-issues-gas-warning-to-boaters

Marine guidance note 446 (M): The Rescue Boat Code (Code of Practice for Open Rescue Boats of less than 15 metres in length).
This Code is published as being representative of industry best practice of those inshore rescue boats operating in United Kingdom waters. This Marine Guidance Note reminds users of the operational requirements in the ‘Inland Waters Small Passenger Boat Code’ – for towing vessels operating from a beach or harbour, and encourages use of the same guidelines for towing operations taking place on inland lakes. The Rescue Boat Code covers both the use of the rescue boat for rescue purposes and also the work of the boat in support of those rescue boat activities, such as training, trials and ancillary publicity and fundraising for the rescue boat organisation.
This Marine Guidance Note introduces the MCA publication, The Rescue Boat Code (The Code of Practice for Open Rescue Boats of Less Than 15 Metres in Length), which offers a more appropriate standard, on a voluntary basis, to rescue boat organisations for their inshore rescue boats; that might otherwise be subject to the Small Commercial Vessel and
Pilot Boats Code (SCV Code, published as MGN 280). HMCG Declared Facilities that are less than 15 m in length are required to meet this Code. The Code does not apply to rescue boats carried on ships as part of their Life Saving Appliances required under SOLAS or national regulations. Download the Rescue Boat Code: http://www.dft.gov.uk/mca/466.pdf

Port Security Regulations 2009: consultation on proposed amendments
Minor amendments to the Port Security Regulations 2009 are proposed to add clarity and align the regulations more with the directive – This consultation closes on 11 September 2013
The Port Security Regulations 2009 bring into force Directive 2005/65/EC, a legislative act of the European Parliament about enhancing port security. Minor amendments are proposed which add clarity and bring the regulations more in line with the directive. Read more: https://www.gov.uk/government/consultations/port-security-regulations-2009-consultation-on-proposed-amendments

Celebrate 60 years of search and rescue
The Fleet Air Arm Museum in Somerset is celebrating 60 years of Royal Navy helicopter search and rescue with a summer exhibition. In 1953, the Royal Navy took delivery of its first Westland Dragonfly aircraft to form dedicated search and rescue squadrons and units around the UK.
At the heart of the display will be the Sea King flown by Prince Andrew in the Falklands Conflict, which was used to conduct a rescue mission during the campaign, and a Dragonfly, the small helicopter which began the rich tapestry of lifesaving and heritage. Young visitors can really get a feel for what it is like to be a rescue hero, with flight overalls and helmets to try on, and they can experience what it might feel like to await rescue at sea by trying out a life raft. Visit the Fleet Air Arm Museum website for further information about this exhibition and the museum’s other summer highlights. The exhibition runs until 5th September.

MAIB Safety Bulletin 2/2013 – Arniston

The MAIB has published a Safety Bulletin following the carbon monoxide poisoning on board the Bayliner 285 motor cruiser Arniston in Windermere, Cumbria on 1 April 2013, resulting in two fatalities.

Marine MAIB Safety Bulletin 2/2013 – Arniston
Incident date: 01 April 2013
Category: Leisure
Summary: Carbon monoxide poisoning on board the Bayliner 285 motor cruiser Arniston on Windermere, Cumbria resulting in two fatalities. Issued May 2013

A bank holiday weekend on board an 11 year old Bayliner 285 motor cruiser ended tragically when a mother and her 10 year old daughter died. Initial findings indicate the deceased were poisoned by carbon monoxide. A “suitcase” type portable petrol-driven generator had been installed in the motor cruiser’s engine bay to supply the boat with 240v power. The generator had been fitted with an improvised exhaust and silencer system which had become detached from both the generator and the outlet on the vessel’s side. As a result, the generator’s exhaust fumes filled the engine bay and spread through gaps in an internal bulkhead into the aft cabin where the mother and daughter were asleep.

When the owner of the boat awoke in the boat’s forward cabin, he was suffering from carbon monoxide poisoning but was able to raise the alarm. The mother and daughter could not be revived. The boat’s carbon monoxide sensor system did not alarm because it was not connected to a power supply.

SAFETY ISSUES
1. Portable air-cooled petrol generators are readily available and inexpensive, but they are usually intended for use in the open air. The use or permanent installation of these engines on boats, particularly in enclosed spaces or below decks, increases the risk of carbon monoxide poisoning.
2. It is essential that engine exhaust systems are fitted and maintained to direct poisonous fumes outside the vessel clear of ventilation intakes and accommodation spaces. Work on these systems should therefore only be undertaken by suitably qualified marine service engineers using approved parts and following the equipment manufacturer’s instructions for marine installations.
3. Carbon monoxide is a lethal gas, which has no smell, no taste, is colourless and is extremely difficult for human senses to detect. All boaters need to be vigilant and recognise the signs of carbon monoxide poisoning, which can include: headaches, dizziness, nausea, vomiting, tiredness, confusion, stomach pain and shortage of breath.
4. Carbon monoxide is a silent killer that is just as lethal afloat as it is ashore. The correct positioning and the regular testing of any carbon monoxide sensors, whether powered by a boat’s electrical supply or self-contained, is essential. Carbon monoxide sensor alarms that do not work correctly should be replaced. When selecting a carbon monoxide alarm preference should be given to those marked as meeting safety standard EN 50291-2:2010 which are intended for use in a marine environment.

Further advice on how to avoid carbon monoxide poisoning on boats and more detail about carbon monoxide alarms, produced by the Boat Safety Scheme (BSS) and the Council of Gas Detection and Environmental Monitoring (CoGDEM), can be found at: http://www.boatsafetyscheme.org/stay-safe/carbon-monoxide-(co)
Download report: SB2_13.pdf (3,034.93 kb)

MAIB Safety Bulletin 1/2013 – Milly

The Marine Accident Investigation Branch is carrying out an investigation into the ejection of a family of six from a RHIB on 5 May 2013. The unmanned RHIB subsequently executed a series of tight high speed turns, running over members of the family in the water, causing two fatalities and serious injuries to two people.

MAIB Safety Bulletin 1/2013 – Milly
Incident date: 05 May 2013
Category: Leisure
Summary: Ejection of family of six from an 8.0m RHIB in the Camel Estuary leading to two fatalities and serious injuries to two people. Issued May 2013

At this early stage in the investigation, the mechanism that led to the family being ejected from the RHIB into the water, is not clear. At approximately 1549 (BST) on Sunday 5 May 2013 a family of two adults and four children were ejected from their 8.0m rigid hulled inflatable boat (RHIB) into the water. They were manoeuvring the boat at speed in the Camel Estuary near Padstow, Cornwall, UK.

The RHIB was fitted with a kill cord, but this was not attached to the driver at the time of the accident. Consequently, when the driver was ejected from the boat, the kill cord did not operate to stop the engine and the RHIB continued to circle out of control, at speed. As the RHIB circled, it ran over the family in the water a number of times, leading to the death of the father and the 8 year old daughter and serious injuries to the mother and the 4 year old son.

SAFETY LESSON
The kill cord serves only one purpose, to stop the engine when the driver moves away from the controls. To ensure that this tragic accident is not repeated it is essential that all owners and operators of vessels fitted with kill cords:
1. Test them regularly to ensure that the engine stops when the kill cord mechanism is operated.
2. Make sure that the cord is in good condition – not frayed.
3. Always attach the cord securely to the driver, ideally before the engine is started, but certainly before the boat is put in gear.
4. Stop the engine before transferring the kill cord to another driver.

Further information regarding the use of kill cords can be found at http://www.rya.org.uk/go/killcord
Advice and information on Kill Cords from the RYA website: http://www.rya.org.uk/infoadvice/safteytips/Pages/KillCord.aspx

Download report: SB1_13.pdf (675.37 kb)
http://www.maib.gov.uk/cms_resources.cfm?file=/SB1_13.pdf

Two new MAIB investigations begun

An investigation was launched following the sinking of the fishing vessel Sarah Jayne with the loss of one life off Brixham on 11 September. In another accident a small ferry with six passengers onboard sank in Loch Lomond on 19 September. All passengers and the crewman were rescued. MAIB inspectors were deployed to both scenes to gather evidence and interview those involved.

New Merchant Shipping (Accident Reporting and Investigation) Regulations 2012

The Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 came into force on 31 July 2012. The new Regulations contain some minor procedural changes to its predecessor but are primarily designed to transpose into UK legislation the requirements of Directive 2009/18/EC which introduce common standards for the investigation of marine accidents across the European Economic Area. The Regulations were subject to a focused consultation conducted in January and February 2012. The MAIB would like to thank all those who contributed to this consultation process. The new Regulations and a response paper detailing the results of the consultation are available below.
ARI Regulations 2012 (309kb)
Consultation Response Paper (35kb)