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2008 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 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

Page

3 What is an Occurrence 4 Reporting Occurrences 6 ARF Reports Received 8 Analysis of ARF Reports Received in 2008

10 Casualties in 2008 14 Accidents in 2008 17 Incidents in 2008 18 The Human Factor 19 Conclusion

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What is an Occurrence Under the Regulations1 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.

1 SD815/01 Accident Reporting and Investigation Regulations 2001

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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 Department2 decides whether or not an investigation is warranted. Not all Occurrences are investigated, this may be because:-

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

2 The Isle of Man Department of Trade and Industry

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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 any further investigation is warranted. This is called a „preliminary examination‟. When a preliminary examination is complete, the Department will decide whether it is appropriate to conduct further investigation. Where Occurrences are investigated a report may be published. 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 and made publicly available. 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 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 information contained on the ARF Form. Where vessels have a Safety Officer on board as required by the Regulations3 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 the Isle of Man so there is no confusion. Reports Published in 2008 Name of Vessel Type of Vessel Nature of Casualty Ficus Oil/Chemical Tanker Grounding Published reports can be found on the IOMSR website. Investigations by IOMSR in 2008 Type of Vessel Nature of Casualty Oil/Chemical Tanker Grounding – MT “Ficus” Offshore Vessel Oil Spill into the sea Other Cargo Ship Fatality whilst boarding the vessel from the quayside

01

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ARF Reports Received In 2008 the IOMSR received a total of 35 ARF Reports. There were no reported occurrences on foreign flagged vessels in Isle of Man territorial waters received in 2008. The table below shows the number of ARFs received by type of occurrence in 2008 and the preceding 4 years.

2004 2005 2006 2007 2008

Casualties 7 10 7 6 9

Accidents 42 42 33 29 25

Incidents 4 8 7 1 1

53 60 47 36 35

Collision, foundering or Stranding 9 17 11 4 3 Fire 2 2 2 3 6

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

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

from a system or pressure vessel 1 1 1 1 2 Accidental Ignition of Flammable material - 1 - - 1

Electrical Short Circuit or Overload 3 - 1 1 - Failure of any Lifting device - - - 1 1

Failure of any Access Equipment - - - - - Involving Access to or from the ship 1 3 4 1 1

Slips or Falls (same level) 8 4 5 4 4 Slips of Falls (different levels) 7 3 5 5 2

Involving mooring Ropes or Hawses 5 2 2 4 2 Involving Lifting Equipment 2 6 1 1 3

Exposure to hazardous or toxic substances 2 - 2 - - Man Overboard - - - 1 -

Electric Shock 1 - - 1 - Violence to the person - 1 - - 2

Other 11 18 12 9 7

Total 53 60 47 36 35

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

Year 2004 2005 2006 2007 2008

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

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

Accidents / Fleet Size 4.4% 4.2% 3.5% 3.1% 2.6%

Incidents / Fleet Size 0.4% 0.8% 0.7% 0.1% 0.1%

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, Demise Charter Ships. The total number of vessels on the Register each year is calculated from the average 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 2004 2005 2006 2007 2008

Total Occurrences / Fleet Size 10.0% 10.4% 7.7% 5.8% 5.5%

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

Accidents / Fleet Size 7.9% 7.3% 5.4% 4.6% 4.1%

Incidents / Fleet Size 0.8% 1.4% 1.1% 0.2% 0.2%

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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The Graph below shows a comparison of the total number of ARFs received and how they are broken down into Casualties, Accidents or Incidents over 5 years.

Analysis of ARF Reports Received in 2008 Number of ARF Reports Received in 2008 per Vessel Type

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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

IOMSR Comment The previous chart shows that a significant proportion of the occurrences in 2008 were caused by fires on board and slipping and falling (same or different levels). Fortunately 5 out of the 6 fires (accidents) were relatively small and easily extinguishable with no injuries resulting from any of the fires. The fires ranged from switchboard, pump and lagging fires to a religious candle setting a Chief Officer‟s cabin on fire. The IOMSR would like to stress the importance of good housekeeping and effective maintenance and inspection. Slips and falls on vessels is a reoccurring theme. It is important that when moving about the vessel the deck surfaces are as free as practicable from slipping hazards, well lit and that safe methods of working are properly utilised. When working aloft it is important that due regard is had for the risk of falling and these risks are mitigated to an acceptable level using appropriate working procedures and equipment. In one of the fall cases the crew member was wearing the appropriate safety equipment after the relevant risk assessment and permits to work was issued but forgot to attach the safety harness to a secure point. Out of the 7 “Other” occurrences 4 were accidents which included trapping fingers in a fire door, a cargo bar under tensions striking a crewmember in the face as he attempted to remove the cargo securing, a crewmember hitting himself in the face with a wrench as it slipped off a nut and a crewmember severely cutting his fingers during maintenance of a fan.

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Place Where Occurrences Happened

IOMSR Comment The chart above shows that the majority of occurrences occurred in the engine room and main deck areas. They highlight the need for safe working practices and good housekeeping. The “Other” area included the vessel‟s bottom when the vessel grounded.

Casualties in 2008 A total of 9 Casualties were reported in 2008. The Charts below show what activities where being carried out that led to a casualty and what injuries were incurred from the casualties.

IOMSR Comment The two “no activity being carried out” were a suicide attempt and pump failure leading to the main engine being shut down and the vessel subsequently towed to port.

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Brief Summary of Casualties in 2008 01/02/2008, Other Cargo Vessel The vessel was forced to stop whilst on passage after it was discovered that the part of the Shaft Roller Bearing had crumbled so it would not be possible to use the Main Engine. The vessel was eventually towed to a port to effect repairs. 27/02/2008, Oil/Chemical Tanker The vessel grounded whilst making a large alteration of course on the final leg of the Passage Plan before picking up the local pilot. The vessel was loaded with approximately 25600t of non-persistent Oil Cargo. Fortunately all of the oil cargo was contained on board and there were no injuries to any ship personnel and no pollution to the marine environment. The vessel sustained significant structural damage to the ship‟s bottom. The limestone shelf seabed was damaged as a result of the vessel making contact whilst making way and when the vessel became firmly aground. The Officer of the Watch and Helmsman were the bridge team leading up to the grounding. The Master arrived on the bridge immediately prior to the grounding. The Master had intended to be on the bridge earlier for the course alteration but was preoccupied in his cabin with preparing port paper work. IOMSR Comment The IOMSR investigated the grounding and published a report. The report concludes that human error was the cause of the grounding. The Officer of the Watch altered course too early, failed to control the turn sufficiently and lost his situational awareness during the turn. Actions to rectify the situation proved ineffective and may have been hampered by the wind conditions. 04/03/2008, Other Cargo Vessel Whilst on passage a member of the crew was found in his cabin after attempting to commit suicide due to personal reasons. The crew member had seriously cut himself. The crewmember was made stable and eventually landed ashore to receive medical treatment. 19/05/2008, Other Cargo Vessel The vessel was approaching the intended harbour entrance with a docking pilot who had recently boarded after the river pilotage. Whilst entering the harbour the vessel collided with another vessel moored alongside. There were no reported injuries or pollution of the marine environment. While negotiating the turn into the harbour the vessel made momentary contact with the moored vessel near the break of the forecastle despite using the bow thruster on full load and the helm on full rudder angle to avoid the moored vessel. The bow was slow to respond to the helm and bow thrusters. This may be attributed to the effects of wind and tidal stream acting upon the stern and therefore was not adequate to clear the other vessel. As a result of the impact, structural damage was sustained to both vessels. An investigation into the collision was conducted and concluded the following:- A combination of a strong flood tide and prevailing F4 wind (possibly exacerbated by the 2 high sided vessels) acting upon the vessel were not adequately compensated for seems to be the most probable cause. No mechanical problems were identified.

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Having due regard for the experience of the Master and the Pilot, and the manoeuvrability of the vessel, a tug assisting from the stern may have avoided this incident. With the number of hazards presented in way of the manoeuvre, a human error in judgement or mechanical failure could lead to an incident. Tug assistance was only taken when the wind speeds are high while berthing / unberthing. Though the Master had completed a Master/Pilot exchange form for this pilotage, the proximity of the pilot boarding position for the docking pilot to the harbour entrance implies that there is very little opportunity to discuss the intended manoeuvre from the time that the pilot boards the vessel to the instant that the vessel negotiates the turn into the harbour. However, owing to the proximity of hazards and a small turning basin, it was recommended that a tug be used under more moderate wind conditions and a strong flood tide. The investigator suggested that a risk assessment be carried out by the ships for this port initially, and for other ports subsequently. On the basis of the risk assessment the need for using a tug should be re-assessed. 11/06/2008, Pleasure Vessel Whilst the vessel was alongside the chef was cleaning out the fridges when he sliced his hand open severely on a sharp piece of metal associated with the bracketing. He was immediately taken to hospital where emergency surgery was performed on the tendons and nerves. The onboard investigation highlighted the need to either round off sharp edges or cover them with insulated rubber. 16/06/2008, Other Cargo Vessel The vessel was on passage navigating at night in the South China. The weather conditions were favourable and the visibility was good. The Master was the OOW and had a lookout also. All bridge gear was on and working satisfactorily. The radars were set up with an ARPA alarm whilst the Master was busy at the communications terminal. The Lookout was permitted by the Master to go to the mess room for a snack. At this point the Master stopped the ARPA alarm whilst his vision was adjusting to night vision. The Master then noticed some lights from fishing boats and immediately switched to hand steering. The wooden mast of the fishing boat hit the bulwark of the vessel on the starboard side. No communication was able to be made by radio with the fishing boat. The vessel reduced speed, prepared the rescue boat and proceeded on a reciprocal course with search lights in use. The ballast tanks were also sounded as a precaution. The vessel eventually met with some other fishing boats, one of which had rescued the fishing boat crew. The vessel eventually towed the damaged fishing boat back to port before proceeding on its voyage. There were no injuries nor any pollution to the marine environment reported. IOMSR Comment This case clearly shows poor bridge team management and the lack of an effective lookout. The Master was clearly distracted from lookout duties by being busy at the communications terminal and overly relied on the lookout and ARPA alarm without maintaining an effective lookout himself. 18/06/2008, Bulk Carrier Whilst on passage a crewmember was working aloft painting the foremast when he fell approximately 5m to the deck fracturing his spine and pelvis. A risk assessment had been carried out and a work permit was issued for the job. The crew member was wearing a safety

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harness but during the course of the work he failed to reattach it after repositioning himself. The crew member was eventually landed ashore and taken to hospital. The onboard investigation concluded that personal negligence was the main reason why the crewmember forgot to reattach his safety harness. IOMSR Comment It is vitally important that all safety procedures are followed and all safety equipment is utilised effectively. Where more than one crewmembers are involved in such jobs it is urged that crewmembers look out for each other where possible to ensure that everyone in the group is using their safety equipment appropriately. 22/07/2008, Other Cargo Vessel The vessel was alongside when the Master permitted the 2nd Officer and other crewmembers shore leave before the vessel had to change berth later that night. On return to the vessel the 2nd Officer was the last person to approach the vessel‟s gangway. The main engine was running and the variable pitch propeller was held in neutral. The gangway net had been removed from the underside of the gangway in preparation for shifting. As the 2nd Officer leaned forward and attempted to grab the gangway stanchion ropes he appeared to miss his footing and stumbled. His momentum caused him to fall forwards from the quayside downward between the quay and ship‟s starboard side. He disappeared from view in front of the crew on the vessel and did not re-surface. The crew tried in vain to rescue the 2nd Officer, this included throwing overboard a lifebuoy and a crew member jumped into the water between the quay and vessel. Others directed shipside lights and torches into the water. Nothing more was seen of the 2nd Officer. The Master summoned the emergency services to the scene. A thorough underwater search was carried out by divers. However, they could not find any sign of the 2nd Officer. The vessel shifted berth using the mooring lines some time later at the request of the harbour authority. The Master was informed by the local police department that a body had been found in the vicinity of the berth. The 2nd Officer was formally identified by the Master and Company DPA. IOMSR Comment This was an extremely sad and unfortunate case with the loss of the 2nd Mate. The IOMSR conducted an investigation into this matter. The 2nd Officer lost his balance as he approached the gangway, whether this was caused by tripping over a steel rail or due to the amount alcohol consumed ashore, could not be determined. There was insufficient illumination provided from the ship surrounding the part of the gangway on the quayside. This was contributed by the failure of the ship to provide adequate lighting by portable means. There was insufficient illumination surrounding the approach area of the gangway from the quayside. The case highlights the importance of maintaining safe access to the vessel at all times and consuming alcohol responsibly in accordance with alcohol policies on board. 22/10/2008, Oil Tanker The vessel was on a ballast passage when the gear box lube oil servo pump failed which would have eventually resulted in a loss of propulsion. The contamination of the gearbox lubricating/control oil system caused the collapse of the driven gear shaft bearings on the

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integral oil pump. The shaft end roller bearings collapsed allowing the pump element to abrade into the pump casing. The particulate from this abrasion saturated the lubricating oil filters on the discharge side of the pump causing a significant drop in the differential pressure. The filters saturated at an increasing rate. Since continued operation of the pump without effective filtering would have likely resulted in gear box failure the decision was made to stop the engine. The vessel was drifting away from land in a F6 wind but as the forecast was for F9/10 the decision was made to tow the vessel to a safe haven. The vessel was eventually towed to port to effect repairs and conduct an investigation. A new pump was fitted and the vessel returned to service shortly afterwards.

Accidents in 2008 A total of 25 accidents were reported in 2008. The following Charts show what activities where being carried out that led to an accident and what injuries were incurred from accidents.

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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. This stresses the need for seafarers to be more careful, safe working practices are properly followed and equipment is in good working order. The two cases where “no activities were being carried out” involved an explosion in a diesel generators exhaust trunking due to fuel issues. The other case involved economiser lagging catching fire after some oily residue had dripped onto it from above. Brief Summary of Selected Accidents in 2008 29/05/2008, Offshore Vessel Whilst the vessel was on passage the 2nd Engineer was alone in the control room performing routine maintenance tasks which involved transferring marine diesel fuel between the storage and service tanks. During this operation an unrelated alarm sounded in the engine room. The 2nd Engineer went out to investigate the cause of the alarm whilst forgetting about the running transfer pump. A short time later the service tank overflowed through the tank vent onto the main deck area covering an approximate area of 24m² with an estimated 1.7 m³ of MDO spilling overboard. The spill was discovered by two personnel who independently alerted the bridge about the spill. The prevailing weather conditions quickly began to disperse the non-persistent oil making clean up operations unfeasible. The IOMSR was involved in the investigation and a report was written. The report highlighted that although the transfer of oil was a fairly routine operation the company procedures for oil transfer were not followed. The 2nd Engineer was alone in the Engine Control Room when the operation was initiated and was distracted from the operation because he went to check another alarm. The oil transfer continued without anyone monitoring the ongoing operation and there was nobody in ECR to stop the fuel pump when the tank was full. The high level alarms (set for 85% level) only give an alert in way of flashing light indicators on a computer bar graph and do not stop the pumps. The Deck department and deck personnel were not aware of the ongoing transfer, so nobody was on deck to monitor the overflow system. The scuppers were not plugged on deck, allowing some of the spill to go directly overboard. However due to the proximity of the tank vent, ships side, pilot access and water freeing ports any spill is likely to go overboard. IOMSR Comment This case highlighted the importance of using correct procedures and better organisation of work. The system design and pumping rates could also be modified to reduce the risk of a similar occurrence. 21/09/2008, Oil Tanker A vessel was lying at anchor in fair conditions with no drift observed by the Officer of the Watch. When the vessel weighed anchored and the anchor was sighted it was noticed there were no flukes present on the anchor.

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18/10/2008, Other Cargo Vessel The vessel was on passage when an auxiliary engine caught fire. CO2 was released into the engine room and the fire was extinguished. There were no reported injuries and no pollution to the marine environment. The vessel was stopped and drifted to assess the damage with all power fed from the emergency generator. Initial investigation discovered found that an auxiliary engine was completely burn out. Out of the two remaining auxiliary engines one auxiliary engine was completely stuck and could not rotate and another suffered major damage requiring temporary repairs on board before it was eventually restarted. The vessel eventually proceeded to port under its own power before major repair work was carried out and an investigation conducted. The probable cause of the fire was a high pressure pipe in the fuel system failing and that fuel from this fuel pipe spread to the hot surfaces of the auxiliary engine and ignited. 31/10/2008, Other Cargo Vessel The vessel was moored alongside when the 2nd Engineer was cleaning the engine room bilges on his own. The work required the bilge covers to be removed. Whilst repositioning a suction hose the 2nd Engineer fell down and hit a step dislocating his shoulder. It was some time before the 2nd Engineer was discovered by other crew members and subsequently taken ashore to hospital. The internal investigation identified that the work is made more difficult by the poor layout of the engine room and that better communication and organisation of work was required. IOMSR Comment It is unfortunate that the 2nd Engineer had to lie in pain unable to move for some time before being discovered. As the internal investigation identified better organisation of the work with additional crew members may have prevented the fall and better communication with other crewman on duty may have reduced the amount of time the 2nd Engineer had to lie in considerable pain.

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Incidents in 2008 08/06/2008, Oil Tanker The vessel was alongside when the 2nd Engineer and the Engine Cadet entered a lifeboat to carry out the routine weekly engine maintenance. The boats are davit launched and totally enclosed. They are fitted with two hydraulic handles complete with securing pins for the internal release of the hooks on reaching the water. These handles are painted in a high visibility red colour. There are two large high visibility warning signs in close proximity to the handles. One sign states “Danger, these handles are only to be operated in an emergency and when the boat reaches the water”, the second sign states “When the boat reaches the water the red handles are only to be operated by the Master or his appointed deputy”. For reasons best known to himself, the 2nd Engineer removed the security pins and „waggled‟ the handles to „prove‟ they were free. The boat moved its weight onto the gripes. The 2nd Engineer stopped the engine and both men left the boat. As they left the boat the Master asked the Cadet to help him with another task. The Cadet informed the Master that he thought it was wrong to touch the handles. Before the Master could react the gripes carried away and the boat plummeted to the water. There were no injuries to any party. The lifeboat suffered significant structural damage. An Investigation found that the primary cause was the failure of the 2nd Engineer to follow instructions and safety signage. There was clear signage in the boat to indicate that the handles should not be operated. There was also evidence to show that the crew had been well drilled and that they understood the operation of the lifeboats. The 2nd Engineer is a trained safety officer with some 30 years seagoing experience. He has a CPSC certificate and is familiar with survival craft. The cadet recognised that the 2nd Engineer was doing something wrong in operating the handles but due to his rank did not feel empowered to tell him. Follow up action by the company included:-

The whole fleet had to carry out an extraordinary boat drill were all the parts of the boat were talked through and a walk through of a launch and recovery exercise carried out.

Advising the fleet that every single crew member is empowered to intervene when they are not convinced that something is safe.

Certificated safety pennants were supplied to each vessel with davit launched lifeboats to be put in place as a backup securing mechanism whilst the boats are being worked on.

IOMSR Comment The 2nd Engineer and Engine Cadet were both very fortunate to escape serious injuries. This case highlights the importance of observing safety instructions and familiarity with the Life Saving Appliances. The use of harbour pins or other devices to prevent the accidental release of a lifeboat whilst being worked on should always be considered.

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The Human Factor Out of all the ARF1 Reports received many Occurrences where partly attributed to the human factor. By „human factor‟ we mean the act or omission of a person to do something that leads to the occurrence happening. The graph below shows how a variety of human factors played a significant part in a number of different occurrences in 2008.

As can be seen from the above graph “Personal Negligence or carelessness” is the most common human factor and has contributed in the majority of different occurrences where the human factor has played a part.

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Conclusion Despite best efforts it is an unfortunate fact of life that occurrences will always occur. 2008 saw a downward trend in the number of Accidents and Incidents on board Isle of Man vessels. The IOMSR hopes that this trend continues. However it was disappointing to note that the number of casualties increased compared to the previous year. 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. Equipment and machinery failure also featured in many of the cases in 2008 highlighting the importance of effective maintenance and inspection regimes. 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. 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. Additional Information

Manx Shipping Notice No. 3 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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