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VERY SERIOUS MARINE CASUALTY REPORT NO 6/2019 MAY 2019

Report on the investigation of the

capsize and foundering of the fishing vessel

Nancy Glen (TT100)with the loss of two lives

Lower Loch Fyne, Scotland

18 January 2018

Extract from

The United Kingdom Merchant Shipping

(Accident Reporting and Investigation)

Regulations 2012 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident

Reporting and Investigation) Regulations 2012 shall be the prevention of future accidents

through the ascertainment of its causes and circumstances. It shall not be the purpose of an

investigation to determine liability nor, except so far as is necessary to achieve its objective,

to apportion blame.”

NOTE

This report is not written with litigation in mind and, pursuant to Regulation 14(14) of the

Merchant Shipping (Accident Reporting and Investigation) Regulations 2012, shall be

inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to

attribute or apportion liability or blame.

© Crown copyright, 2019

You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned.

All MAIB publications can be found on our website: www.gov.uk/maib

For all enquiries:Marine Accident Investigation BranchFirst Floor, Spring Place105 Commercial RoadSouthampton Email: maib@dft.gov.ukUnited Kingdom Telephone: +44 (0) 23 8039 5500SO15 1GH Fax: +44 (0) 23 8023 2459

Press enquiries during office hours: 01932 440015Press enquiries out of hours: 020 7944 4292

CONTENTS

GLOSSARY OF ABBREVIATIONS AND ACRONYMS

SYNOPSIS 1

SECTION 1 - FACTUAL INFORMATION 2

1.1 Particulars of Nancy Glen and accident 21.2 Background 41.3 Narrative 4

1.3.1 The accident 41.3.2 Search and rescue 6

1.4 Crew 61.5 Nancy Glen 7

1.5.1 General description 71.5.2 Modifications 8

1.6 Fishinggearandfishinggrounds 101.6.1 Fishinggear 101.6.2 Lower Loch Fyne seabed 12

1.7 Underwater survey 121.7.1 SD Northern River 121.7.2 Northern Lighthouse Board 131.7.3 MAIB survey 131.7.4 Side scan and ROV survey 131.7.5 Wreck recovery 13

1.8 Stability 151.9 Stability assessments 16

1.9.1 Assessmentin2002 161.9.2 MAIB calculations 161.9.3 Verticalload 18

1.10 Developmentofregulationsandguidancerelatingtostability 191.10.1 2001CodeofPractice 191.10.2 Wolfsonguidance 191.10.3 MGN332(M+F) 201.10.4 2007CodeofPractice 201.10.5 MGN427(F) 201.10.6 MGN502(F) 211.10.7 MGN503(F) 211.10.8 Fishermen’sSafetyGuide 211.10.9 2017CodeofPractice 22

1.11 Stability awareness 221.11.1 Training 221.11.2 RNLI campaign 23

1.12 MCA inspections 231.13 Previous accidents 24

1.13.1 Stella Maris 241.13.2 JMT 24

SECTION 2 - ANALYSIS 26

2.1 Aim 262.2 Fatigue 262.3 The accident 262.4 Loss scenario 262.5 Loss condition 272.6 Considerationgiventotheeffectofmodifications 29

2.6.1 2002stabilityassessmentandmodifications 292.6.2 The Kort nozzle 292.6.3 2016proposedmodifications 292.6.4 Adoptionofthelivecatchstoragetanks 302.6.5 Substantialmodifications 302.6.6 2017/18cranereplacement 302.6.7 Summary 31

2.7 Stability awareness 312.8 Stabilityinformation 322.9 Regulation 33

SECTION 3 - CONCLUSIONS 34

3.1 Safety issues directly contributing to the accident that have been addressed or resulted in recommendations 34

3.2 Other safety issues directly contributing to the accident 343.3 Safety issues not directly contributing to the accident that have been addressed

or resulted in recommendations 35

SECTION 4 – ACTIONS TAKEN 36

4.1 MAIB actions 364.2 Actions taken by other organisations 36

SECTION 5 - RECOMMENDATIONS 37

FIGURES

Figure 1 - Chart showing Nancy Glen’sestimatedtrackandthecapsizepositionwith overview inset

Figure 2 - Nancy Glen's upturned hull

Figure 3 - Nancy Glen–generalarrangementbeforemodifications

Figure 4a - Nancy Glen with original propeller arrangement

Figures 4b and c - Nancy GlenafterKortnozzlefitting

Figure 5a - Nancy Glen – previous Guerra crane

Figure 5b - Nancy Glen – replacement Thistle crane

Figure 6 - General arrangement of twin rigged prawn trawling

Figure 7 - Nancy Glen’strawlingarrangementshowingthenetdrums,towingchains and banana bar

Figure 8 - Sonarimageryofseabedshowingthedebrisfield,Nancy Glen and configurationofthenets

Figure 9 - ROV imagery showing Nancy Glen’sstarboardnet

Figure 10 - Nancy Glen – aluminium prawn storage tanks and lifting arrangement

Figure 11 - Graph showing a minimum required GZ curve for over 15m LOA fishingvesselscomparedwithresultsfromNancy Glen calculations

TABLES

Table 1 - Nancy Glen – estimated stability through life

ANNEXES

Annex A - Extract from The Code of Practice for the Safety of Small Fishing Vesselsoflessthan15mlengthoverall(2017)

Annex B - ExtractsfromTheFishingVessels(SafetyProvisions)Rules1975

Annex C - MGN427(F)–StabilityGuidanceforFishingVesselsofunder15mOverall Length

Annex D - MGN503(F)–ProcedureforCarryingoutaRollorHeelTesttoAssess Stability for Fishing Vessel Owners and Skippers

Annex E - ExtractfromtheFishermen’sSafetyGuide

Annex F - Safety Flyer to the Fishing Industry

GLOSSARY OF ABBREVIATIONS AND ACRONYMS

ALB - All weather lifeboat

C - Celsius

CGOC - Coastguard Operations Centre

CoC - CertificateofCompetency

CRT - Coastguard rescue team

DSC - Digitalselectivecalling

FISG - Fishing Industry Safety Group

GM - Metacentric height

GZ - Heelrightinglever

IBC - Intermediate bulk container

ILB - Inshore lifeboat

IMO - International Maritime Organization

kg - kilogramme

kW - kilowatt

l - litre

L - Registered length

LOA - Length overall

LOLER - TheMerchantShippingandFishingVessels(LiftingOperationsandLiftingEquipment)Regulations2006

m - metre

MCA - Maritime and Coastguard Agency

MGN - Marine Guidance Note

MSN - Merchant Shipping Notice

NATO - North Atlantic Treaty Organization

NLB - Northern Lighthouse Board

NLV - Northern Lighthouse Vessel

nm - nautical miles

RNLI - Royal National Lifeboat Institution

ROV - Remotely Operated Vehicle

Seafish - SeaFishIndustryAuthority

SI - Statutory Instrument

t - tonne

UTC - Universal Co-ordinated Time

VCB - Vertical centre of buoyancy

VCG - Vertical centre of gravity

VHF - VeryHighFrequency

TIMES: all times used in this report are UTC unless otherwise stated

1

SYNOPSIS

Atabout1750on18January2018,theprawntrawlerNancy Glen capsized and later sank inLowerLochFyne,Scotland;onlyoneofthethreecrewsurvived.

Nancy Glen was trawling when its starboard net became fouled with mud and debris fromtheseabedduringaturntostarboard,andthevesselcapsizedrapidly.Oneofthecrew escaped but the skipper and the other crewman were trapped inside. The missing crewmen’sbodieswererecoveredwhenthewreckwassalvaged.

TheMAIB’sinvestigationestablishedthatthroughlifemodificationstoNancy Glen,culminatinginthereplacementofthecranewithaheaviermodel,hadreducedthevessel’sstability,significantlyincreasingitsvulnerabilitytocapsize.Despitetheskipper’sattempttobringthesituationundercontrol,thecombinedeffectoftheincreasedtowingloadfromthefoulednet,theturntostarboardandthelimitedstabilitymeantthatNancy Glen was unable to recover from the rapid heel to starboard.

Evidencefromsmallfishingvesselcapsizes,coupledwiththelimitedadoptionoftheWolfsonMark,suggeststhatownersandskippersareunawareoftherisksofnotconductingstabilityassessments.Thecaseforintroducingstabilitycriteriaforsmallfishingvessels has been made by the Marine Accident Investigation Branch and accepted by the MaritimeandCoastguardAgency.Nevertheless,untilsuchcriteriahavebeenimplemented,the risk of capsize resulting from unknown stability conditions will endure.

A safety recommendation has been made in this report to the Maritime and Coastguard Agencytoensurethatthestabilityofsmallfishingvesselsisregularlyassessed.

2

SECTION 1 - FACTUAL INFORMATION

1.1 PARTICULARS OF NANCY GLEN AND ACCIDENT

SHIP PARTICULARSVessel’sname Nancy GlenFlag United KingdomClassificationsociety Not applicableIMOnumber/fishingnumbers TT100Type Twin rig prawn trawlerRegistered owner Privately ownedManager(s) Not applicableConstruction SteelYear of build 1991Length overall 12.98mRegistered length 11.98mGross tonnage 19.55tMinimum safe manning Not applicableAuthorised cargo Not applicable

VOYAGE PARTICULARSPort of departure TarbertPort of arrival Tarbert(intended)Type of voyage CoastalCargo information PrawnsManning 3

MARINE CASUALTY INFORMATIONDateandtime 18January2018,about1750Type of marine casualty or incident Very Serious Marine CasualtyLocation of incident 5553.80N00522.65WPlace on board Over sideInjuries/fatalities Two fatalitiesDamage/environmentalimpact Vessellost,noenvironmentaldamageShip operation TrawlingVoyage segment Mid-waterExternal & internal environment Airtemperature2ºC,occasionalsnowshowers,

seatemperature6ºC,seastatecalm.

Persons on board 3

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1.2 BACKGROUND

Nancy GlenwasaprawntrawlerthatoperatedfromitshomeportofTarbert,Scotland.TrawlingwasusuallyconfinedtoLowerLochFyneand,duetotheconfinesoftheloch,normallycarriedoutonnortherlyorsoutherlyheadingswithshorteasterlyorwesterlypassagesasthevesselturned.Haulingandre-shootingthenetstook20to30minutes,theneachtowlastedupto5hourswiththeskipperand crew taking turns to rest during the towing periods.

Thecrew’sroutinecompriseddailyvoyagesonweekdays,usuallydepartinginthelate evening and returning early the following evening to land the catch and rest beforereturningtothefishinggrounds.OncompletionoffishingonaFriday,thefueltankswererefilledinpreparationforthefollowingweek.Thelocalfishmarkethadbeen closed over the Christmas to New Year period and had re-opened on Monday 8January2018.

1.3 NARRATIVE

1.3.1 The accident

Nancy GlensailedfromTarbertHarbouratabout2230on17Januaryandtrawlingcommencedsoonafter.Sunseton18Januarywasat1626,andatabout1750withthelochindarkness,theskipperwasatthewheelpart-waythroughthelasttowoftheday.HewasturningNancy Glen to starboard onto a southerly heading (Figure 1) in preparation for hauling the nets prior to heading back to Tarbert. The two crewmen had completed washing down and tidying the deck and were intheaccommodationwaitingtobecalledtoassistwiththefinalhaul.Weatherconditionswererelativelybenign,withcalmseaandverylittlewind.Therehadbeenoccasionalsnowflurrieswithanairtemperatureof2°Candseatemperatureof6°C.

Duringtheturn,Nancy Glen began to list to starboard. The list rapidly increased andcausedlooseitemsinthecabintofallandtherefrigeratordoortoflyopen.Initially the two crewmen were unconcerned as the vessel normally listed during turns.However,asthelistcontinuedtoincrease,theybecameincreasinglyworried.Oneofthecrewmenshoutedtohiscolleaguetogetout,thenmadehiswayupintothewheelhouse.There,henotedthattheskipperwasatthewheelandthatthevessel was listing at such a severe angle that the main deck guardrails were starting tobecomeimmersed.Heheardtheskippershoutthathedidnotknowwhatwashappening;thecrewmanthenrepeatedhiscalltogetoffthevessel.

Toescapefromthewheelhousethecrewmanhadtoclimboverthetrawlwinch,travelalongthemaindeckandclimbontothesideofthenetdrum.Hethenjumpedoffthenetdrumandoverthesternintothesea.HeswamawayfromNancy Glen toavoidbecomingtrappedifitsank.Onceawarethatthevesselhadnotsunk,thecrewmanswambacktotheupturnedhulltotrytofindhiscolleagues.Afterrealisingthathecouldnotaccesstheupturnedhull,thecrewmansawtheliferaftcanisterthathadfloatedfreefromthevessel;heattemptedtoinflatetheliferaftbypullingonthepainter,butthiswasnotsuccessful.Shortlyafterthis,asearchlightilluminatedNancy Glen and the crewman was able to attract the attention of the crew on board alocalfishfarmvessel.Thecrewmanwasrescuedfromthewaterand,followinga search around the upturned Nancy Glen (Figure 2)forothersurvivors,hewastransferredtoanotherfishingvesselandtakenashoreformedicalassessmentandtreatment.

5

Figure 1: Chart showing Nancy Glen's estimated track and the capsize position with overview inset

ReproducedfromAdmiraltyCharts2381and0002bypermissionofHMSOandtheUKHydrographicOffice

Tarbert

Accident location

Estimated track prior to capsize

Figure 2: Nancy Glen's upturned hull

6

1.3.2 Search and rescue

At1800,CoastguardOperationsCentre(CGOC)Belfastreceiveda‘999’callreporting the capsize of Nancy Glen. This was supported by a digital selective calling(DSC)alertraisedbythecrewofthefishfarmvesselLady Inger. CGOC Belfastbroadcasta‘MaydayRelay’at1819reportingthatthefishingvesselNancy Glen had capsized 1.2nm north-east of Barmore Island (Figure 1) with two persons missing.

AnumberoffishingvesselsandsmallboatsfromTarbertimmediatelyjoinedLady Inger in the search area. The ferry Loch Riddon and the research vessel SD Northern Riveralsorespondedtothe‘MaydayRelay’and,attherequestofCGOCBelfast,proceededtowardsthescene.

TheRNLIallweatherlifeboat(ALB)fromCampbeltownandinshorelifeboats(ILB)fromCampbeltown,ArranandTighnabruaichwerealllaunched.Onceonsite,co-ordinationofthelocalsearchandrescueeffortwasundertakenbytheALB.Thesearchandrescue(SAR)helicopter,R199,fromPrestwick,wasalsoinvolvedinthesearch.

By1845Loch Riddon had arrived on scene and attached a mooring rope to Nancy Glen’sKortnozzle1. At 1915 Loch Riddon’screwreportedthatNancy Glen’ssternwas,bythen,belowthesurfacewithonly1metre(m)ofthebowremainingvisible. Shortly after this a local dive boat arrived and a diver entered the water and attached an additional line from Loch Riddon to Nancy Glen’scranepedestal.SD Northern Riverstoodby,clearofNancy Glen,awaitingfurtherdirection.

It was then decided to attempt to use the deck crane on SD Northern River to support Nancy Glen. Two local divers took strops and shackles from SD Northern Riverandattemptedtoassembleasuitableliftingrigaroundthefishingvessel’swheelhouse.

At2033themooringropeattachingNancy Glen to Loch Riddon parted as the fishingvesselsank;thetwodiversweresafelyrecoveredfromthewater.

The liferaft painter remained attached to Nancy Glen and the action of the vessel sinkingresultedintheliferaftinflating;theweaklinkthenbroke,allowingtheliferaftto ascend to the surface.

Shorelinesearcheswereco-ordinatedbyTarbertCoastguardRescueTeam(CRT).

1.4 CREW

Nancy GlenhadsailedfromTarbertHarbourwithacrewofthreecomprisingtheskipper and two crewmen.

The46yearoldskipper,DuncanMacDougall,wasapartownerofthevessel,theothershareholdersbeinghisfatherandhisuncle.Hewasanexperiencedfishermanandskipperandhadworkedonfishingvesselssinceleavingschoolattheageof16.DuncanhadcompletedthemandatorySeaFishIndustryAuthority(Seafish2)safety

1 The Kort nozzle was around Nancy Glen’spropeller–seeSection1.5.2.2 Seafishisanon-departmentalpublicbodywithamissiontosupportaprofitable,sustainableandsocially

responsible future for the seafood industry.

7

training courses3comprisingBasicSeaSurvival,BasicFireFightingandPrevention,BasicFirstAid,andSafetyAwarenessandRiskAssessment,thatweresufficientfor him to act as skipper of Nancy Glen. There is no record of him having completed any training relating to stability awareness and he did not hold the voluntary under 16.5mSkipper’sCertificate.

PrzemyslawKrawczykwasa38yearoldPolishnationalwhohadlivedinTarbertforanumberofyears.HewasconsideredtobeanexperiencedfishermanandhadpreviouslyskipperedanothervesseloperatingfromTarbert.Seafishtrainingrecordsindicate that he had completed only Safety Awareness and Risk Assessment training.HeheldnoSTCW(F)954orequivalentcertificatesissuedinPoland.

Thethirdmemberofthecrewwasa34yearoldlocalfishermanwhohadbeena crewman on Nancy Glensinceleavingschool.Hehadcompletedthefourmandatoryfishingsafetytrainingcourses.

1.5 NANCY GLEN

1.5.1 General description

Nancy Glen was originally named La Hai Roi,sidenumberLH18.Itwasdesignedand built by Coastal Marine Boatbuilders of Eyemouth and its keel was laid in 1991. The owners at the time of the accident had purchased and renamed the vessel in 1995.

Nancy Glen had been designed as a twin rig stern trawler with the wheelhouse at the forward end of the main deck. The accommodation - a four-berth cabin - forward of the wheelhouse was above the engine room. There was a small ventilation hatch in the deckhead of the cabin. The working deck with the main trawl winch and net drumswasaftofthewheelhouse.Therewasaninsulatedbutnotrefrigeratedfishhold aft of the engine room. Access to the wheelhouse was from the main deck via a short companionway. The cabin was accessed from the wheelhouse using a similar companionwayandtherewasashelteroverthemaindeck,whichextendedjustaftof midships. Nancy Glen’soriginallayoutisatFigure 3.Acrane,locatedattheaftendoftheshelterdeck,wasusedformovingnetsandcatchwhenthevesselwasinharbour.

Lifejacketswerestoredinalockerintheaccommodation,andafloatfreeliferaftwaslocated in a frame on top of the wheelhouse.

Nancy Glenwasfittedwitha201kilowatt(kW)CumminsNT855Mmainenginewithatwindisc5:1reductiongearboxthatsuppliedpropulsion,withapowertake-offforhydraulicpower.Therewasa2000litre(l)capacityfueltanklocatedontheportsideoftheengineroomanda2600lcapacitytankonthestarboardside.Thetankswere alternated daily with fuel spill returns going back to the tank in use. The engine typicallyconsumed300to350l/dayduringnormalfishingoperations.

The owners and previous skippers of Nancy Glen considered the vessel to be a ‘goodseaboat’.

3 FishermenwhoworkintheUKarerequiredtocompletebasicsafetytrainingcoursesinseasurvival,first-aid,fire-fightingandprevention,andhealthandsafety.Fishermenwithover2years’experiencearealsorequiredtocompleteaSeafishsafetyawarenessandriskassessmentcourse.

4 InternationalConventiononStandardsofTraining,CertificationandWatchkeepingforFishingVesselPersonnel,1995.

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1.5.2 Modifications

In2002Nancy Glen’sownerscontractedaboatdesignerandnavalarchitecttoprepareaspecificationformodificationstobecarriedout,whichincludedextendingthe shelter deck aft to the gantry position. It also included replacing the existing crane(aPalfingercranethathadinsufficientreachforoperatingonTarbertHarbourfishingberths),locatingitontheshelterdeck,replacingthenetdrumwithasplitdrum,andfittinganewGilsonwinchtotheshelterdeck.Theworkalsorequiredrelocatinganaccesshatchfromtheshelterdecktothemaindeck,removalofthetrawlgallowsandresitingoftheliftingpole.Priortotheworkbeingagreed,intactstabilitycalculationswerecarriedoutbythenavalarchitect(Section1.9.1).

Theworkpackagewasconfirmedasfeasiblefollowingstabilitycalculations,andtheworkwascompletedinlate2002.

In2012theownersdecidedtoreplacethepropellerandfitaKortnozzle(Figures 4a-c).Thiscomprisedafixed,annularforwardextendingductaroundthepropeller.The propeller operated with a small gap between blade tips and the nozzle internal wall. The nozzle ring had a cross-section shaped as a hydrofoil (Figure 4c) that improvedpropellerefficiencyandhelpedtoreducefuelconsumption.

Inordertofitthenozzle,enhancementstotheinternalsupportingstructurewererequired.Thisinvolvedfittinglongitudinalmemberstosupplementtheoriginaltransverse frames. Although additional weight was added in respect of the nozzle andsupportingstructure,nochangesweremadetotheconcreteballastlocatedin

Figure 3: Nancy Glen–generalarrangementbeforemodifications

Net drums

Fish hold Engine room

Accommodation

Wheelhouse

Communications mast

Companionway to wheelhouse

Companionway to main deck

Original shelter

Permanent concrete ballast

9

thefishhold.Theadditionstothesupportingstructurewerecarriedoutfollowinginformal advice from a naval architect and a boatyard engineer. Although no stability calculationswerecarriedoutinrespectoftheeffectofthesemodifications,theforward fresh water tank was kept full as ballast to counter the stern trim caused by the Kort nozzle.

Figure 4a: Nancy Glen with original propeller arrangement

Figure 4b and c: Nancy GlenafterKortnozzlefitting

Photographs courtesy of www.trawlerpictures.net

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In2016,considerationwasgiventoraisingtheheightofthewheelhousetoimprovevisibility,andtorelocatingthenetdrums.However,followingfurtherinvestigation,includingadvicefromanavalarchitect,itwasdecidedtorefurbishtheexistingarrangementsinstead.Atthistimethevessel’swiringwascompletelyrenewedandthe steel communication mast was replaced with a lighter aluminium structure.

Laterin2016andfollowingthedecisionnottoraisetheheightofthewheelhouse,some of the concrete ballast was removed to reduce Nancy Glen’ssterntrim,whichhad increased as a result of the additional weight from the Kort nozzle installation.

InSeptember2016,theownersrealisedthatabetterreturncouldbeachievedinwinterbymarketinglivecatch.Tofacilitatethis,theyplacedanaluminiumtankinthefishholdtostorethetubedprawns.Thetankneededtoberegularlyflushedwithsea water in order to maintain the condition of the prawns.

ThetankwasremovedaroundApril2017whentheownersrevertedtokeepingthecatchoniceinthefishholdforthesummerseason.InSeptember2017,toimproveutilityforthe2017/18winterseason,thealuminiumtankwasdividedintotwo and relocated on the shelter deck either side of the wheelhouse (Figure 5b). Thestoragearrangementsweresupplementedwitha1tonne(t)intermediatebulkcontainer(IBC)locatedonthemaindeckaftofthefishholdhatch,andfilledasrequired.

Duringthe2017/18Christmaslayover,thecrane(aGuerraMC40.55A1)wasreplaced with a Thistle Marine MKB7 Crane (Figures 5a and 5b). The Guerra crane hadadryweightof700kilogramme(kg)whilethereplacementwasmorethandoubletheweight,at1500kg.Tocompensatefortheadditionalweightthesteelcod end lifting post was replaced with an aluminium structure. Although the weight differencewasconsidered,noempiricalassessmentregardingtheeffectonthevessel’sstabilitywascarriedoutpriortocompletingthesemodifications.

1.6 FISHING GEAR AND FISHING GROUNDS

1.6.1 Fishing gear

Nancy Glenwasconfiguredasatwinriggedprawntrawlerwithportandstarboardnetsstoredonasplitnetdrum.TheHarknessprawnnetshadapproximately7.6mofrockhopperdiscgroundgearconnectedtorubbercoveredlinkchain,givinganoverallgroundgearlengthof17.7m.Thenetswereconnectedto2mDunbartrawldoorsanda400kgclumpweight(Figure 6).Thetowinggearcomprised400mof14mm rubber covered wire warps.

Oncedeployed,eachofthethreewarps(twotowingwarpsandtheclumpweight)was connected to the single towing point on the banana bar using a chain stopper (Figure 7). This arrangement allowed the vessel to turn more quickly as the loadandtheeffectivetowingpointwasfreetomovealongthebarasthevesselmanoeuvred.FortrawlinginLowerLochFyne,approximately400mofwarpsweredeployed.

Oncompletionofeachtow,thenetswererecoveredusingthetrawlwinch.ThecodendswerethenliftedusingaGilsonwinch,whichallowedthecatchtobedischarged through the access hatch in the shelter deck and deposited on the main deck.

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Figure 5a: Nancy Glen – previous Guerra crane

Figure 5b: Nancy Glen – replacement Thistle crane

PhotographcourtesyofDavidMcAllister PhotographcourtesyofJohnMacDougall

Steel cod end lifting arrangement

Guerra crane Aluminium cod end lifting arrangement

Thistle crane

Aluminium tank on

starboard side

Figure 6: General arrangement of twin rigged prawn trawling

ImagecourtesyofSeafish

Trawl doors

Clump weight Buoyed

headrope

Rock hopper ground gear

Cod ends

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1.6.2 Lower Loch Fyne seabed

Admiralty charts for Nancy Glen’sregularfishinggroundsindicatethattheseabedconsists of mud and broken shells. They also identify a permanent obstruction (knownlocallyas‘theanchor’)approximately0.5nmsouthoftheaccidentlocation.

Trawlersoperatinginthearea,includingNancy Glen,hadreportedinstancesof‘muddieddoors’5 and choked nets.

1.7 UNDERWATER SURVEY

1.7.1 SD Northern River

Immediately following the foundering of Nancy Glen,SD Northern River deployed aremotelyoperatedvehicle(ROV)tolocatethewreckandtoascertainwhetherfurther rescue attempts could be initiated. The ROV was operated by a team from JFD6,whowereonboardSD Northern River and had been training with the NATO Submarine Rescue System.

5 Aphenomenonwherebyatrawldoorcollapsesandbecomesburiedintheseabed,causingasuddenloadtocomeontothefishinggear.Thisusuallyoccursasthevesselisturning,andcanbecounteredbyapplyingastern propulsion and coming back over the trawl gear.

6 PartofJamesFisherandSonsplc,JFDincorporatesDivex,JamesFisherDefenceandtheNationalHyperbaricCentre(NHC).JFDoperatesinanumberofdifferentmarketsectorsincludingoffshore,inshoreandonshorecommercialdiving,defencediving,submarinerescue,hyperbaricmedicalandrenewableenergy.

Figure 7: Nancy Glen'strawlingarrangementshowingthenetdrums, towing chains and banana bar

ImagecourtesyofDavidMcAllister

Towing chains

Banana bar

Net drums

13

DespitepoorvisibilitytheROVoperatorslocatedthewreckofNancy Glen and positioned a locator beacon close to it on the seabed. Attempts to map the wreck site using sonar were unsuccessful due to obstructions that ultimately resulted in damage to the ROV.

1.7.2 Northern Lighthouse Board

The MAIB requested NLV Pharos,alighthousetenderoperatedbytheNorthernLighthouseBoard(NLB),tosurveytheseabedaroundthewrecksiteusingmulti-beamsonar.However,duetothedepthofwaternousableimagerywasgathered from the survey attempt.

1.7.3 MAIB survey

Afteraninitialcasereview,theMAIBdecidedtocarryoutanunderwatersurveytogather evidence from Nancy Glen’slocation;specificallytheconditionofthevesselanditstrawlingequipment.Itwasdecidedthatsidescansonarimagery,coupledwithunderwatervideofootage,couldbeanalysedtodeterminewhethertoconsiderraising the wreck in order to support the investigation.

1.7.4 Side scan and ROV survey

Followingacommercialtenderingprocess,theMAIBawardedKeynvorMorLiftLtda contract to carry out an underwater survey of the wreck site. The site was initially mappedusinga‘towedfish’sidescansonar.ThiswasfollowedbythedeploymentofanROVfittedwithvideoandmulti-beamsonar.

Thesidescansonarsurveyshowedtwodistinctdebrisfieldsontheseabed:onebelow the position where Nancy Glencapsized,andasecondinthevicinityofitsfinallocationontheseabed.Identifiableitemsincludedoneoftheshelterdeckprawn storage tanks and a number of tubed prawn boxes (Figure 8).

The ROV survey showed that the ventilation hatch in the deckhead of the accommodation was closed and the access hatch from the shelter deck to the main deck was open.

Sonarimagesrevealedthatthetrawlnetswerelyinginaneast/westdirectiononthe seabed7. The images showed that the port net was on top of the seabed with thebuoyedheadropefloatingandthemouthofthenetopen.Thestarboardnetwasburied with the buoyed headrope close to the seabed (Figure 8).

Althoughthevideosurveywashamperedbypoorvisibility,imagesconfirmedthatthe port net was open with the rockhopper ground gear on the seabed and the buoyedheadropefloatingfree.Thestarboardnetwasfoundtobeburiedwiththebuoyed headrope lying on the seabed. Further examination indicated that the main bodyofthestarboardnetwasfilledwithmudfromtheseabed(Figure 9).

1.7.5 Wreck recovery

AsdirectedbytheScottishGovernment,on13April2018thewreckofNancy Glen was raised from the seabed and taken to a secure location ashore. The bodies of bothmissingfishermenwererecoveredfrominsidethewreck.

7 Thetrawlgearwaslyingeast/westbutthenetshadbeendisturbedthroughtheactionoflocaltrawlersassisting in the search post-accident and before the sonar survey was conducted.

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1.8 STABILITY

Stability is the capacity of a vessel to return to an upright condition following a heel. Stabilityisdependentonthevessel’sweightandbuoyancyandisdeterminedbytherelationshipbetweentheverticalcentreofgravity(VCG)8 and the vertical centre of buoyancy(VCB)9.

Avessel’smetacentricheight(GM)isameasurementofitsinitialstaticstability.GMiscalculatedasthedistancebetweenthevessel’sVCGanditsmetacentre10. A largerGMimpliesgreaterinitialstabilityagainstoverturning.AswellasGM,reserveof buoyancy and righting levers are important.

Withpositivestability,asavesselheels,arightinglever(GZ)iscreatedbetweenthe forces acting from the VCB and VCG as the shape of its underwater volume changes. This righting lever creates a restoring moment to bring the vessel upright.

8 Thecentreofgravityisthepointwherethemassofavesselisactingdownward.Itisaffectedbytheconstruction and layout of the vessel and the weight and location of equipment. The centre of gravity will alter ifweightsaremoved,addedorremoved,butisnotaffectedbythevessel’smotion.

9 Buoyancyisavessel’sabilitytofloat.Allofthehullbelowthewaterlinecontributestoavessel’stotalbuoyancy.Thecentreofbuoyancymovesdependingondraught,trimandheel.

10 Metacentre is a point through which the force of buoyancy acts on a vessel. If a line of buoyancy force is extended it will meet the line of gravitational force. This point of intersection is called the metacentre.

Figure 9: ROV imagery showing Nancy Glen's starboard net

Image courtesy of KML

Buoys

Headrope

Nets embedded in seabed

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The righting lever increases to a maximum when the angle of heel corresponds to deckedgeimmersion,thereafteritreducesasthevesselheelsfurtherandwaterfloodsthedeck.

Avessel’soriginalVCGcanbealteredbymodificationsinvolvingtheaddition,removaland/orrelocationofweight,andchangestoitsfreeboard11.

1.9 STABILITY ASSESSMENTS

1.9.1 Assessment in 2002

Priortoundertakingthe2002modificationstoNancy Glen,anavalarchitect,whowascontractedbytheownerstodeveloptheworkpackage,undertookasimplifiedintactstabilitycalculationwiththeaimofconfirmingthattheproposedmodificationswould provide a safe level of stability.

No stability information was required under the extant regulations when Nancy Glenwasconstructedin1991.Inaddition,therewerenobuilddrawings(lineplansetc.)availabletothenavalarchitect.Hethereforebasedhiscalculationsusingthehydrostaticsfromasimilarvessel,FV Aeolus,inthe‘departport’conditionforwhichhis company had produced a stability book.

Vessel Waterline length BeamFV Aeolus 13.1 5.25FV Nancy Glen 12.7 5.0

The naval architect carried out an inclining experiment on Nancy GleninApril2002andcalculatedthatitsGMwasapproximately0.37m.TheminimumrequirementstatedinTheFishingVessels(SafetyProvisions)Rules1975forGMforvesselsof12mormoreregisteredlength(L)was0.35m.Hethencalculatedtheeffectoftheproposedmodifications(includingamarginoferror)andconcludedthatpost-modificationtheGMwouldbereducedto0.35m.

Inaddition,thenavalarchitectusedtheinformationcollectedfromtheincliningexperimenttoderiveafactorofsafetyasrecommendedintheSeafishConstructionStandardsissuedin2001.Thecalculatedsafetyfactorof1.23exceededtheminimumrecommendedfactorof1.0.ThefactorofsafetymethodwasnotretainedwhentheSeafishConstructionStandardswereupdatedin2004.

Asaresultofhiscalculations,thenavalarchitectwrotetoNancy Glen’sownerssuggestingthatthemodificationscouldbecarriedoutbutthattopweightshouldbekept to a minimum.

1.9.2 MAIB calculations

Nancy Glenwasnotinclined,orlightshipcheckedduringthe16yearsofitslifepriortotheaccidenton18January2018.Unlikevesselsof15mormorelengthoverall(LOA),Nancy Glen was required neither to satisfy intact stability criteria nor to be assessed at least every 5 years to ensure the vessel had not sustained weight growth,whichcouldhaveinvalidatedthestabilityinformation12.

11 Freeboardisameasureoftheheightofavessel’ssidebetweenthewaterlineandthehighestwatertightdeck.12 Builtin1991,withalengthoverallof12.98m,Nancy Glen’sregisteredlengthwas11.98m,whichmeantthat

stabilitycriteriaforfishingvesselsunder12mregisteredlengthdidnotapply.

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TheMAIBhasidentifiedthefollowingmodificationsmadetoNancy Glensince2002:

● installationoftheKortnozzleandsubsequentballastadjustment;

● replacement of the steel communications mast with a lighter aluminium structure;

● useofthealuminiumprawnstoragetanks;

● useoftheIBCcontainer,and;

● replacement of the crane on the shelter deck.

Whenusingtheprawnstoragetanks,Nancy Glennolongercarriediceinthefishhold.Concurrentwiththecranereplacement,thecodendliftingarrangementwasalsomodified,replacingsteelwithaluminiumtoreducetopweight.Theweightofequipmenttakenoffandtheequipmentaddedwerenotrecorded(Figure 10).

Figure 10: Nancy Glen – aluminium prawn storage tanks and lifting arrangement

ImagecourtesyofJohnMacDougall

Cod end lifting arrangement

Communications mast

Port and starboard prawn storage tanks

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Following the recovery of Nancy Glen,ateamofmarineconsultantswasengagedtodevelopacomputermodelofthevessel,using3Dimagingandlaserscanning.Themodel was subsequently used to carry out stability calculations.

Nancy Glen was inclined by the consultants with an MAIB naval architect in attendance.Theresultsoftheincliningtrialandthe3DmodelwereusedbytheMAIBtoenableanassessmentofthevessel’sstability.

Allavailableevidence,includingapproximatefiguresformodificationsthroughthevessel’slife,wereassessedandusedtoestimateNancy Glen’sstabilityatthetimeofloss.Byreviewingthemodificationsundertakentothevesselitwasalsopossibleto estimate Nancy Glen’sstabilityin2002.

Calculationsindicatethatfollowingthemodificationsmadein2002,andalthoughtheregulationsdidnotapply,Nancy Glenwouldnothavesatisfiedtheintactstabilitycriteria13forfishingvesselsover15mlengthoverall,anditisalsounlikelythatthevesselwouldhavesatisfiedthesecriteriaatbuild.Table 1summarisesthevessel’sthroughlifestability,basedonthedepartportcondition,i.e.100%fuel,water,lubricatingoil,withfishinggearand1toficeinthefishhold.

Displacement (t)

Trim by stern (m)

GM (m)

Max GZ (m)

2002aftermodifications 70.45 0.46 0.281 0.099@24º2012fittingKortnozzle 71.45 0.55 0.299 0.101@23º2016removalofballast 70.45 0.47 0.292 0.103@24º2018aftercranerenewal 71.44 0.59 0.232 0.075@20º

Table 1 - Nancy Glen - estimated stability through life

Thetableonlyincludesthemodificationsforwhichfigurescanbeestimated.Othermodifications14havenotbeenaccountedforasnoweightsofequipment,addedorremoved,wererecorded.

Nancy Glen’sconditionatthetimeoflosswasestimatedwithfuelat70%,twoprawntanksontheupperdeckandtheIBCcontaineronthemaindeck(allfilledwithseawater/catch),andthefishinggeardeployedoverthestern.

1.9.3 Vertical load

The vertical load for which the vessel just achieved a positive righting lever with the loadsuspendedfromthebananabartowingpoint,atitsmaximumstarboardextent,was then estimated both before and after replacing the crane on the shelter deck.

WiththeoriginalGuerracrane,Nancy Glen nominally had positive stability with a 6tverticalloadoffsetonthebananabar.AfterreplacingthecranewiththeheavierThistleMarineCranethisloaddroppedto4t,a33%reductionintheloadthetrawlgear could experience before Nancy Glen’sstabilitybecamenegligible.

13 Theover15mintactstabilitycriteriawouldrequireaminimumGMof0.35mandaminimumrightinglever(GZ)of0.2at30ºorgreaterwiththemaximumGZoccurringatnotlessthan25⁰.

14 Othermodificationsincludedreplacingasteelcommunicationsmastwithanaluminumstructureandfittingalighter stern roller.

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1.10 DEVELOPMENT OF REGULATIONS AND GUIDANCE RELATING TO STABILITY

1.10.1 2001 Code of Practice

Awiderangeofsafetystandards,includingstabilitycriteriaforfishingvessels,wasintroducedinTheFishingVessels(SafetyProvisions)Rules1975(knownasthe1975Rules).Theserulesfirstintroducedmandatoryintactstabilitycriteriaforallvesselsof12mregisteredlength(L)andover.The1975RuleswereamendedwiththeintroductionofTheFishingVessels(CodeofPracticefortheSafetyofSmallFishingVessels)Regulations2001.ThefulltextoftheCodewassetoutintheMaritimeandCoastguardAgency’s(MCA)MerchantShippingNotice(MSN)1756(F)–TheFishingVesselsCodeofPracticefortheSafetyofSmallFishingVesselsunder12metresinlength.Amendment1toMSN1756(F)wasintroducedin2002and stated that all previous references to under 12m registered length will now read under 15m length overall and apply to the whole Code.Thisamendmenteffectivelyremovedtherequirementforstabilitycriteriatobeappliedtoanyfishingvesselunder 15m LOA.

Therewasnorequirementinthe2001Regulations,norinMSN1756(F),eithertoassessavessel’sstabilityortoadviseorrecordequipmentormaterialchangestoexistingvessels.Newvessels,definedasthosewhosekeelwaslaidorconstructionorlay-upwasstartedafter1April2001,wererequiredtocomplywithconstructionstandardsissuedbySeafishortoanequivalentstandard.Notwithstandingthis,theconstruction standards did not require a formal stability assessment.

1.10.2 Wolfson guidance

InMay2006,theUniversityofSouthampton’sWolfsonUnitcompletedaresearchproject commissioned by the MCA aimed at developing loading guidance for small fishingvessels(nominallyunder15mLOA).

Theproject’sreportproposedamethodofgeneratingsimplifiedstabilityguidancelinked to recommended maximum wave heights through the application of a freeboard mark on the hull referenced to a stability notice displayed in the wheelhouse. The guidance derived from the Wolfson stability notice and mark is intendedtoprovidefishermenwithabasicindicationofsafetybasedonavessel’sresidualfreeboardwhenloadingandlifting,andtheseastate.

Fordeckedvesselswithnostabilitydata,onlyavessel’sLOAandbreadtharerequiredtocalculatewheretopositionthefreeboardguidancemarks,andthecorresponding safety zones. The safety zones are:

● Green: ‘Safe’inallbutextremeseastates. ● Amber: ‘Lowlevelofsafety’andshouldberestrictedtolowseastates. ● Red: ‘Unsafe,anddangerofcapsize’unlessrestrictedtocalm

conditions and used with extreme caution.

The report recommended:

‘That guidance freeboard marks be placed on fishing vessels for which the guidance information is based on freeboard alone. These will enable the fishermen to relate the guidance information to his vessel directly.’ [sic]

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1.10.3 MGN 332 (M+F)

TheMCA’sMarineGuidanceNotice(MGN)332(M+F)-TheMerchantShippingandFishingVessels(LiftingOperationsandLiftingEquipment)Regulations2006(LOLER),providedrequirementsforthefittingandoperationofliftingequipment.Guidance for the implementation of Regulation 6 stated the following:

‘In addition to the vessel’s structure, consideration must be given to the effect upon stability, angle of heel and consequent down-flooding from the use of a crane, derrick or other lifting device fitted on any vessel. This is especially important where cranes are fitted on work boats and other small vessels and MCA would strongly recommend that advice is sought from the crane manufacturer where it is proposed to fit cranes on such vessels. In addition it is recommended that prior to installation a check of the vessel’s stability should be carried out by a suitably qualified person to ensure that the vessel is capable of operating safely with the crane fitted and in use. Failure to do this could have serious consequences. Information and instruction on these effects as well as maximum safe working loads, including variable maximum safe working loads where these vary with the crane configuration, must be given to the master or skipper of the vessel.’

1.10.4 2007 Code of Practice

In2007,the2001Codewasrevised(andannexedtoMSN1813(F)-TheFishingVesselsCodeofPracticefortheSafetyofSmallFishingVessels).ThestatedaimoftherevisedCodewastoimprovethesafetyoffishingvesselsoflessthan15mLOA.MSN1813(F)includedarecommendationthatstabilityinformationbeprovidedforfishingvesselsof12mLto15mLOA(Annex A),andtheCoderecommendedthatowners arrange for a lightship check at intervals not exceeding 5 years to verify that theirvessel’sstabilityinformationremainedvalid.

ThestabilityinformationrecommendedbyMSN1813(F)referredtothatcontainedinsections16and74ofTheFishingVessels(SafetyProvisions)Rules1975(Annex B).

1.10.5 MGN 427 (F)

InDecember2010,theMCApublishedMGN427(F)–StabilityGuidanceforFishing Vessels of under 15m Overall Length (Annex C).

TheMGNstatedthatfullstabilityrequirementsfor12mLto15mLOAfishingvesselswouldbereintroducedinthenearfuture,andindicatedthattherewasnointentiontointroducecompulsorystabilitycriteriatofishingvesselsunder12mL.

TheMGNstatedthatwhilenospecificrequirementsexistedforthestabilityofsmallfishingvessels,theowner,skipperandothershadlegalresponsibilitiesasdetailedinTheMerchantShippingandFishingVessels(HealthandSafetyatWork)Regulations1997,andthatitwasnotacceptabletodonothingandassume

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thevessel’sstabilitywassatisfactory.Itfurtherstatedthatitwasbettertoassessthesituationorobtainprofessionaladvice,andofferedfivemethodsofstabilityassessment:

● Fullstabilityinformation,incliningexperimentandcalculation.

● Small Commercial Vessel Code standard.

● AmodifiedSmallPassengerVesselstandard.

● IMO Roll Period Approximation.

● Wolfson Guidance.

MGN427(F)alsostatedthatanoticeentitled‘SimpleEffortsforMaintainingStability’orsimilarshouldbepostedinaprominentpositiononboardafishingvessel,andthatskippersandcrewshouldattendSeafishstabilityawarenesstraining(Section1.11.1).

1.10.6 MGN 502 (F)

InApril2014,MGN502(F)-TheCodeofPracticefortheSafetyofSmallFishingVessels-StandardswhichcanbeusedtoprepareforyourMCAInspection,waspublished.ThisMGNprovidedavoluntarysmallfishingvesselcodeofpracticethatwasbasedonMSN1813(F)andconsideredthefindingsofanumberofMAIBinvestigations(Section1.13).Itsrecommendationsincluded:

● SubstantialmodificationsoralterationstobenotifiedtotheMCApriortoworktaking place.

● Stability requirements for vessels of 12m L to less than 15m LOA.

1.10.7 MGN 503 (F)

AlsoissuedinApril2014wasMGN503(F)–ProcedureforCarryingoutaRollorHeelTesttoAssessStabilityforFishingVesselOwnersandSkippers.Thiswasintendedtoallowowners/skippersofsmallfishingvesselstoassesswhethertheirvesselwastenderorstiffinaparticularcondition(Annex D).

1.10.8 Fishermen’s Safety Guide

InMay2015,theMCApublishedanupdatedversionoftheFishermen’sSafetyGuide–Aguidetosafeworkingpracticesandemergencyproceduresforfishermen.Asinpreviousversions,theguideprovidedadviceonawiderangeofoperatingpracticesonboardfishingvessels.Asectiononstabilityexplainedtheeffectonavessel’scentreofgravityof:liftingaloadfromahighpoint,loosewaterorfishondeck,loadingandunloading,andfreeboard(Annex E).

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1.10.9 2017 Code of Practice

On23October2017,StatutoryInstrument2017No.943(SI943),TheFishingVessels(CodesofPractice)Regulations2017cameintoforce.Article7(1)ofSI943placedanobligationontheownerofaUKregisteredfishingvesseltonotifytheMCA15‘of the details of any proposal to alter or modify the structure of that vessel, remove or reposition engines or machinery or change the mode of fishing’.

FollowingpublicationofSI943,theMCAwithdrewMSN1813(F)andMGN502(F)andreplacedthemwithMSN1871(F),TheCodeofPracticefortheSafetyofSmallFishingVesselsoflessthan15mLOA.MSN1871(F)includedastatementthat‘…substantial modifications or alterations affecting the vessel’s dimensions, structure or stability, the removal or repositioning of machinery or engines, changes in the vessel’s mode of fishing and/or its gear or the fitting of additional equipment shall only be undertaken after consultation and with the MCA’s approval to ensure it complies with the requirements of the Code, as applicable to a new vessel, to the satisfaction of the MCA.’

MSN1871(F)alsorequirednewfishingvesselsof12mLtolessthan15mLOA,andvesselsthatwerebuiltbefore2007andcomingontotheUKfishingregisterforthefirsttime,tohaveapprovedstabilityinformationrelevanttotheirintendedmethodofoperation.

1.11 STABILITY AWARENESS

1.11.1 Training

Seafishprovidedstabilityawarenesstrainingforfishermenat‘newentry’‘experienced’and‘advanced’levels.ThecourseswereprovidedfreeofchargeandcompletionofstabilitytrainingwasaprerequisiteforawardoftheSeafishvoluntaryunder16.5mSkipper’sCertificate.

Thecourses,whichusedaseriesofvisualanimationsandamodelboat,werespecificallydesignedtoexplainkeyaspectsofstabilityandtoprovideskippersandcrew with a greater understanding of the issues involved. The model boat featured aninterchangeablestructuretosimulatearangeofdifferentfishingvesseltypesand,inconjunctionwithawatertankandavarietyofweights,arangeofoperatingconditionscouldbetestedtoreflectthedangersofadditionaltopweight,freesurfaceeffect,catchondecketc.

The stability awareness training included:

● Theprinciplesofflotationastheyapplytofishingvessels.

● The terms used to describe basic vessel stability.

● Howthemovementofweightcaninfluenceavessel’sstability.

● Thedifferentstatesofvesselequilibrium.

● Howthehaulingofgearandlandingofcatchinfluenceavessel’sstability.

15 ThewordingusedintheSIis‘SecretaryofState’,whichinpracticeistheMCA.

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● Freesurfaceeffect.

● Roll periods.

● Weight‘creep’orgrowth.

Tofurtherimpressuponfishermentheimportanceoftheseissues,specificMAIB accident investigations were highlighted. An end of course multiple-choice assessmentrequiredapassmarkof70%.

1.11.2 RNLI campaign

InJanuary2015,theRNLIinitiatedacampaignaimedatimprovingthestabilityawarenessofcommercialfishermen,specificallytargetingvesselsoflessthan15mLOA.

Thecampaignwasentitled‘KeepitStable,BringitHome’,andfeaturedfiveshortvideos giving practical advice on the hazards associated with:

● Vesselmodifications.

● Freesurfaceeffect.

● Haulingoperations.

● Overloading.

● Watertight integrity.

Thevideosweredistributedtofishermenviasocialmedia.

1.12 MCA INSPECTIONS

UnderMSN1813(F)TheCodeofPracticefortheSafetyofSmallFishingVessels,theownersofunder12mLfishingvesselswererequiredtopresenttheirvesselsforinspectionbytheMCAevery5yearsandtocarryoutannualself-certificationtoconfirmthatthevesselcompliedwiththeCode.RecordsshowthatNancy Glen was inspectedbytheMCAin2005,2010andmostrecentlyon24July2015.Duringthe2015inspectionanumberofdeficiencieswerenoted.Theseincluded:

● Nofiredetectioninmachineryspaces.

● Smokealarmnotfittedinaccommodation.

● Fishholdbilgealarmnotfitted.

● Engine room bilge pipe holed and heavily corroded.

Thesedefectswerepromptlyrectified,andtheMCAwasnotified.ASmallFishingVesselInspectionCertificate(MSF1316)wasthenissuedinDecember2015withanexpirydateof23July2020.

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1.13 PREVIOUS ACCIDENTS

1.13.1 Stella Maris

On28July2014,the9.96mLOAtrawlerStella Maris capsized and sank while haulingfishinggear.Thevessel’stwocrewwereuninjured.Stella Maris had been significantlymodifiedpriortoitsloss,includingthefittingofan‘A’framegantryanda winch for lifting the cod end. No calculations had been required or carried out regardingtheeffectsofthisworkonthevessel’sstability.

The subsequent MAIB investigation report16identifiedthatStella Maris capsized as aresultofinsufficientstabilityduetoanoverlyhighgantrysupportingaheavycodend lifted by a winch with excessive power. Stella Maris had a sister vessel that had beensimilarlymodified.

Thereporthighlightedanumberofsmallfishingvessellosses(Heather Anne,Sally Jane,Charisma,Kirsteen Anne,Amber and Auriga)thathadresultedfrominsufficientstability.Italsoidentifiedcountriesthatrequiredintactstabilitycriteriaforsmallfishingvessels,including:Norway,NewZealand,theRepublicofIreland,Denmark,Greenland,Canada,PolandandRussia.

Followingtheaccident,theMCAundertookto:

‘Include a requirement for fishing vessel owners to notify and seek approval from the agency prior to carrying out substantial modifications in MGN 502.’17

TheMCAwasalsorecommended(MAIBrecommendation2015/165)to:

‘Introduce intact stability criteria for all new and significantly modified decked fishing vessels of under 15m in length.’

ThisrecommendationwasacceptedbytheMCA,whichstatedthat:

‘…as part of our work to progressively align the standards of the Small Fishing Vessel Code with the Workboat Code, the MCA will consider the application of suitable stability standards for new and significantly modified vessels of under 15m.’

TheMCA’stargetdateforthecompletionofthisactionis31December2020.

1.13.2 JMT

Duringtheafternoonof9July2015,routinecontactwaslostwiththeskipperand crewman on board the 11.4m LOA scallop dredger JMT,whichwasfishingoffPlymouth,England.Asearchandrescueoperationwasinitiatedthefollowingmorning when the vessel did not return alongside as expected. The body of the crewmanwasfoundfloatinginalife-ring;hewasnotwearingalifejacket.Thewreckofthevesselwaslocated3.8milesoffRameHeadinadepthof51mbutitsskipperwas not found. There was no pollution and JMT was recovered from the seabed the following month.

16 MAIBreportno29/2015.17 ThiswasincludedinthevoluntarycodeintroducedthroughMGN502(F)andsubsequentlybecamea

mandatoryrequirementfollowingtheintroductionofMSN1871(F).

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The MAIB investigation18identifiedthat:

● JMThadonly25%ofthereserveofstabilityrequiredforlargerfishingvessels.

● Thevessel’sstabilityhadbeenadverselyaffectedbystructuralmodificationsand by aspects of its operation.

● Capsize was possibly triggered by the release of the contents of the starboard dredges while the port dredges and their contents remained suspended.

TheMCAwasrecommended(MAIBrecommendations2016/130and2016/131)to:

‘Include in its intended new legislation introducing stability criteria for all new and significantly modified decked fishing vessels of under 15m in length a requirement for the stability of new open-decked vessels, and all existing vessels of under 15m to be marked using the Wolfson Method or assessed by use of another acceptable method.’

‘Require skippers of under 16.5m fishing vessels to complete stability awareness training.’

TheMCA’stargetdateforimplementingappropriateactioninresponsetobothoftheaboverecommendationsis31December2020.

18 MAIBreportno15/2016

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SECTION 2 - ANALYSIS

2.1 AIM

The purpose of the analysis is to determine the contributory causes and circumstances of the accident as a basis for making recommendations to prevent similar accidents occurring in the future.

2.2 FATIGUE

Thereisinsufficientevidencetoconcludewithcertaintythatfatiguecontributedtothisaccident.However,thecumulativeeffectoflongworkingdays(routinely20hoursfromportdeparturetoarrivalfor5dayseachweek)couldhaveimpactedonthecrew’sabilitytoreacttoanemergency.Longhourswithlimitedbreaksremainacommonfeatureofcommercialfishing.

2.3 THE ACCIDENT

Evidence gathered during the investigation indicates that unexpected weight came ontothestarboardtrawl,causingNancy Glen to heel heavily to starboard. The heel was exacerbated as the vessel turned to starboard. Nancy Glen was unable to recoverfromtheheelandrapidlycapsized;itinitiallyremainedinvertedonthelochsurface.

As Nancy Glenrolledover,onecrewmanwasabletoescapefromtheaccommodation,scrambleacrossthemaindeckandjumpoverthevessel’sstern;the remaining crewman and the skipper remained trapped in the upturned hull. The vessel then foundered by the stern and sank to the seabed in approximately 143m of water.

The focus of the MAIB investigation and subsequent analysis has been centred on the reason for Nancy Glen’ssuddenheeltostarboard,whyitfailedtorecoverfromthe heel and why the skipper and one crewman were unable to escape from the vessel.

2.4 LOSS SCENARIO

Underwater surveys following the loss of Nancy Glen show that the port net was empty and on top of the seabed while the starboard net was full of mud and largely buried beneath the seabed surface.

It is concluded that Nancy Glen’sturnmovedthesingletowingpointtostarboardduetothebananabararrangementandthis,coupledwiththeincreasedloadfromthefoulingofthestarboardnet,resultedintheheel.Thevessel’srightingleverwasinsufficienttoovercometheeffectoftheheelingmoment.Consequently,Nancy Glen’sstabilitywasinsufficienttoovercomethecombinedeffectofthesefactorsandso was unable to prevent the vessel from capsizing.

Theacceptedindustrypractice,andthatexercisedonNancy Glen,wastoattempttorecover from any excessive heel by reducing the towing load. This can be achieved byeitherreducingthevessel’sforwardmomentumbyputtingthepropulsionintoneutralandthusallowingthevesselto‘comeback’ontothegearorreleasingthefishinggearinitsentirety.

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Onthisoccasion,theheelingmomentdevelopedrapidlytoapointatwhichthevessel’srightinglevervanishedbeforetheskipperwasabletotakeanyeffectiverestorative action.

Thesurvivorrecognisedthattheheelwassignificantandthatthevesseldidnotappeartoberecovering,soheimmediatelyexitedtheaccommodationtoescapefrom the capsizing vessel. In the very short time that it took for him to climb the companionway from the accommodation to the wheelhouse and escape onto themaindeck,Nancy Glenwasalreadyonitssideandclosetocapsize.Hehadshoutedtohiscrewmatetofollowhimout,andduringhisrapidtransitofthewheelhouse,shoutedattheskippertoleavethestrickenvessel.

The crew of Nancy Glen was not concerned when the boat initially started heeling as this was not unusual and the vessel would normally level out as the turn completed.Despiteonecrewmandashingtoescape,itishighlylikelythattheskipper remained in the wheelhouse to take actions intended to bring the situation undercontrol.Indarkness,itwillalsohavebeendifficulttovisuallyjudgetheboat’slossofforwardmomentumasthestarboardnetdugintotheseabed.Moreover,therapidsubsequentcapsize,inrushofwatertothewheelhouse,displacementofloose gear and disorientation will have denied the skipper and second crewman the chance to escape.

2.5 LOSS CONDITION

Snagsorfasteners,‘muddieddoors’anddebrisinthenets,areanacknowledgedheelinghazardexperiencedbybottomtrawlingfishingvessels.Butvesselsarenormallyabletorecoverfromthesesituations,particularlythosevesselsthatmeetthestabilitycriteriacurrentlyrequiredforneworsignificantlymodifiedfishingvesselsof12mLormore.Duringthesummerof2017,bothofNancy Glen’snetshadfilledwith mud and seaweed while trawling. The nets were recovered as far as possible onto the net drums and the cod ends were secured to the transom until divers could be arranged to release the cod ends and clear the debris.

Nancy Glenhadoperatedsuccessfullysincethemodificationscarriedoutin2002,andhadcontinuedtooperatewithoutincidentfollowingthevariousmodificationstoitsstructureandequipment.However,thecumulativeeffectofthosemodifications,culminatinginthereplacementofthecraneduringthe2017/18Christmaslayover,wastoreducethevessel’sstability,significantlyincreasingitsvulnerabilitytocapsize.

Figure 11 shows Nancy Glen’sGZcurvesderivedfromthe2018incliningcomparedwith a GZ curve meeting the minimum stability requirements for a vessel over 15m LOA(curvea).Thecurvesb,canddwerecalculatedwiththevesselfulloffuelandwithiceinthefishhold.Curveewastheestimateddepartureconditionon18January2018(70%fuelandnoicebutwiththethreeprawntanksfullofwater).

In addition to Nancy Glen’sincreasedinherenttopweight,astheweek’sfishingprogressedtheamountoffuel,storedlowinthevessel,wouldhavedecreased.Assuming that Nancy GlenhaddepartedTarbertHarbourwithfulltankson15January,itislikelytohaveusedapproximately1200loffuelbythetimeoftheaccident,equatingtoapproximately1tofweightbeingremovedfromlowdowninthevessel and consequently raising its VCG.

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2.6 CONSIDERATION GIVEN TO THE EFFECT OF MODIFICATIONS

2.6.1 2002 stability assessment and modifications

Nancy Glen’sreducedstabilitycanbedirectlyattributedtotheeffectofthemodificationscarriedouttothevesselsince2002.

Themodificationscompletedin2002,whichincludedbothreplacementofmachinery(netdrumsandcrane)andalterationstothevessel’sstructure(shelterdeckextension),felloutsideanyregulatoryrequirement,atthetime,toassessthevessel’sstabilityortonotifytheMCA.Nonetheless,theactionoftheownerstoengageanavalarchitecttoplanthechanges,andhissubsequentstabilitycalculations,demonstratedanawarenessoftheneedtomonitorthepotentialeffectsofthemodificationsonthevessel’sstability.Thesealterationswerecarriedouttoincrease the utility of the main deck and improve crew working conditions through extensionoftheshelter,toimprovehandlingofthenets,andtoallowtransferofnetsandequipmenttothequayside(theoriginalPalfingercranewouldnotplumbthejettyatTarbertHarbour).

The MAIB calculations using a model developed from the post salvage inclining of Nancy Glen,indicatethat,despitetheuseofafactorofsafety,thetheoreticalcalculationscompletedin2002arelikelytohaveresultedinanoptimisticestimateofthevessel’sinitialstability(GM).

Althoughtheincliningcarriedoutin2002allowedanestimateofNancy Glen’sGM,the lack of empirical stability data from build prevented the naval architect from assessing the righting lever curve. Although not directly applicable to Nancy Glen,theMAIB’scalculationsindicatethattherightingleverin2002wouldhavefallenshortoftheintactstabilitycriteriaappliedtofishingvesselsofover15mLOA.

2.6.2 The Kort nozzle

In2012Nancy GlenwasfittedwithaKortnozzletoimprovebothfuelefficiencyandtowing characteristics. In order to accommodate the nozzle and improve the rudder postarrangements,additionalstiffeningofthesupportstructurewasrequired.Theadditionalsupportworkwascompletedontheadviceofanavalarchitect,andaboatyardengineerwasconsultedontheKortnozzlefitment.AlthoughpublishedstabilityguidancehadbeenintroducedintheformofMGN427(F)forfishingvesselsofunder15mLOA,noempiricalcalculationswerecarriedoutpriortothismodification.However,additionalweightwouldhaveimprovedthevessel’soverallGM,andalsoincreasedthevessel’ssterntrimbyapproximately0.1mtothedetrimentofwheelhousevisibility,particularlywhiletowing.

2.6.3 2016 proposed modifications

The2016proposaltoraisetheheightofthewheelhousetoimprovevisibility,andtorelocatethenetdrums,wasnotcompletedfollowingadvicefromanavalarchitect.It would have been possible to raise the wheelhouse height by replacing the steel structurewithaluminium,butitwasdecidedthatthebenefitwouldbeoutweighedby the cost. The relocation of the net drums was vetoed as this would have had adetrimentaleffectonthevessel’stopweight.Thedecisiontoreplacethesteelcommunication mast with an aluminium structure was taken as a measure to reduce

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top weight. The employment of a naval architect to advise on these proposed changesagaindemonstratedanawarenessoftheneedtoconsidertheeffectofmodificationsonvesselstability.

Thesubsequentremovalofconcreteballastfromthefishhold,carriedouttoadjustthevessel’striminordertoimprovewheelhousevisibility,wasnotcarriedoutwith professional advice. The removal of concrete ballast could be considered a structuralmodificationthatMGN502(F)recommendedshouldbenotifiedtotheMCA prior to the work taking place. It is estimated that around 1t of ballast was removed,butitislikelythatitequatedapproximatelytotheadditionalweightoftheKortnozzle.TheMAIB’scalculationsestimatedthatremovaloftheballastreducedthesterntrimbyapproximately0.1m.Althoughtheremovalofballastreducedthevessel’sGM,theMAIBestimatesindicateamarginalimprovementintherightinglever due to the increase in the freeboard at the aft end of the vessel.

2.6.4 Adoption of the live catch storage tanks

Duringthewinterof2016,analuminiumstoragetankwaspositionedinthefishhold.Thetankwasfilledwithseawaterandusedtostoreliveprawns,whichincreasedthevalueofthecatch.Duringsummermonthstheskipperrevertedtostoringtheprawnsonice.Forthewinter2017/18season,thealuminiumtankwasdividedintotwotanksandthetankswererelocatedtotheupperdeck.Thismodificationmade it easier to refresh the seawater in the tanks. The two aluminium tanks were supplemented with a 1t IBC located on the main deck. The new tanks could also be interpretedasstructuralmodifications.Theeffectofusingthesetankswastomoveweightfromlowdowninthevesseltohigherup,whichultimatelyhadtheeffectofreducingthevessel’sGM.Theuseofthesetanksbothin2016andagainin2017precededthemandatoryrequirementtonotifytheMCAofproposedmodifications(Section2.6.5).

2.6.5 Substantial modifications

InOctober2017,SI943(Section1.10.9)placedanobligationonfishingvesselownerstonotifytheMCAaboutanyproposedmodifications.The2017CodeofPracticefortheSafetyofSmallFishingVessels(MSN1871(F))wasissuedasaconsequenceofSI943comingintoforce.MSN1871(F)mandatedthatsubstantial modifications or alterations… shall only be undertaken after consultation and with the MCA’s approval. ThewordingoftheMCA’sMSN1871(F)wasinconsistentwithSI 943 as it allowed vessel owners to make a judgement about the interpretation of whetherproposedvesselmodificationswerenotifiabletotheMCAas substantial or not.

2.6.6 2017/18 crane replacement

Duringthe2017/18Christmaslayover,Nancy Glen’sownersdecidedtoreplacethedeckcrane.TheGuerracranehadbecomeunreliableand,followingdiscussionswiththesupplier,itwasdeemedmoreeconomicallyviabletorenewthecraneratherthan refurbish the existing one.

IfthewordingofMSN1871(F)hadbeenconsistentwiththatofSI943,whichgavean obligation to notify the MCA of anyproposedchangestostructure,engines,machineryormodeoffishing,itispossiblethattheownerswouldhaverecognisedthatthisappliedtothereplacementcrane.However,becausetheownersconsidered

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thereplacementcranetobesimilartotheexistingone,noactionwastakentonotifytheMCAoftheproposedchangesortoassessthelikelyeffectonNancy Glen’sstability.ThesedecisionswereunderpinnedbythefactthattheownershadassessedthestabilitywhentheoriginalGuerracranehadbeenfittedin2002.

It is apparent that no empirical stability assessments were carried out in respect ofthechangeofcrane,althoughanattemptwasmadetocompensatefortheadditional weight of the new crane by replacing the steel lifting post with an aluminiumstructure.TheMAIB’scalculationsindicatethattheinstallationofaheaviercranehadasignificantanddetrimentaleffectonthevessel’sstability.Thiscan be seen in Table 1 and Figure 11,whichidentifybothareductioninGMandGZ,coupledwithanincreaseinsterntrim.Inpracticalterms,followingthechangeofcraneandwiththevesselinatowingcondition,theapplicationofasuddenincreasedloadoffsetfromthecentrelineonthetrawlwireswouldrapidlyovercomethevessel’sinherentstability,significantlyincreasingthevessel’svulnerabilitytocapsize.

2.6.7 Summary

Despitethelackofempiricalassessment,itisapparentthatNancy Glen’sownershadmadetheirownstabilityjudgmentand,insomecases,hadtakenprofessionaladviceontheeffectofthroughlifevesselmodificationsbeforetheywereimplemented.However,withnobaselineandwithoutconductingregularchecksofthevessel’sstabilityusingheelorrolltests,theactualcumulativeeffectonstabilityofthesemodificationswasunknown.

2.7 STABILITY AWARENESS

Allvesselsmusthavesufficientstabilityinordertooperatesafely.Itisthereforevitalthatownersandskippersareawareofthefactorsthataffectthestabilityoftheirvessels.

RelevanttrainingisavailablethroughSeafish,andguidanceisprovidedbytheMCA,particularlythroughitsFishermen’sSafetyGuide,andbytheRNLI,notablyasaresultofits2016campaign.However,therewasnomandatedrequirementforanystabilitytrainingorqualificationforskippersorcrewworkingonvesselsunder16.5mL.Thisomissionlimitstheirabilitytoconducteffectivestabilityassessments.Following the loss of JMTin2016,theMAIBrecommendedthattheMCAintroduceamandatoryrequirementforskippersofunder16.5mLfishingvesselstocompletestability awareness training.

Withnoformaltrainingandthereforelimitedknowledgeofstabilityfundamentals,theowners and previous skippers of Nancy Glen relied on their experience of operating thevessel,andhowitfeltatsea,tosupporttheirdecisionsinrespectofvesselmodifications.TheownershadalwaysfeltthatNancy Glenwasa‘goodseaboat’.However,asstatedinMGN427(F):

‘A vessel which appears very sea-kindly and comfortable with a slow roll period can actually be potentially unsafe in terms of stability.’

Theexperienceoffishinginvariousconditionscouldeasilyhaveledtheownersand previous skippers to overestimate Nancy Glen’sstabilityfollowingthevariousmodificationscarriedoutsince2002.

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Although training can provide an understanding and appreciation of the potential fordiminishingstabilitythroughmodifications,theneteffectonresidualstabilityfollowingamodificationwillstillbebasedpurelyonanestimationunlesstheoriginalstabilityconditionisknown.Thisappliesequallytoowners,skippers,navalarchitectsandtheMCA.Therefore,regardlessofanyrequirementorrecommendationtoseekprofessionaladviceand/orapprovalforanyproposedvesselmodification,unlessavessel’sstabilityisknown,therewillbeuncertaintyastotheextenttowhichthatmodificationmayincreasethepotentialforthevesseltocapsize.

2.8 STABILITY INFORMATION

The only stability information available to the owners of Nancy Glen was developed bythenavalarchitectpriortocompletingmodificationstothevesselin2002.Themethodology used in these calculations was unusual in that it used data derived fromadifferentsizedvesselthatwasextrapolatedtorepresentNancy Glen. Not onlywasthebasisforthecalculationsestimated,butalsothederivedinformationwas limited and the report to the owners stated only that the GM was consistent with1975buildrequirementsforlarger(over12mL)fishingvessels,albeitattheminimumlimitof0.35m.Notwithstandingthis,thereporttotheownersstatedthat,basedonthecalculations,anyadditionaltopweightshouldbekepttoaminimum.

Itiscommendablethatin2002,priortocompletingmodifications,anavalarchitectwas consulted to assess Nancy Glen’sstability.However,theassessmentwasverysimple,usingGMasameasureandaSeafishConstructionStandardsfactorofsafety method that was discontinued 2 years later.

When Nancy Glenwasconstructed,nostabilityrequirementswerespecifiedinTheFishingVessels(SafetyProvisions)Rules1975forfishingvesselsunder12mL. Nancy Glen,at11.98mL,incommonwithmanyotherfishingvesselswasbuiltasa‘rulebeater’tocircumventtheapplicationofthemorestringentrequirementsstipulatedforover12mLvesselsinthe1975Rules,particularlyinrespectofstability.

TheFishingVessels(CodeofPracticefortheSafetyofSmallFishingVessels)Regulations2001placednospecificrequirementforstabilityonfishingvesselsunder12mL.Since2001,furtheramendmentstotheCodeandMGNshavebeenissuedthatprovideguidanceonstability,butnominimumstabilityforunder12mLvesselshaseverbeenintroduced.Instead,theMCAhasplacedrelianceonownersand skippers to exercise their legal responsibilities for health and safety by following its published guidance on stability assessment.

TheMAIBhasinvestigatedthecapsizeofnumeroussmallfishingvesselsandhasrecommendedrepeatedlythatbetterstabilityinformationbeprovidedtofishermen.In2014theMAIBinvestigatedthecapsizeandsinkingofthetrawlerStella Maris and consequently recommended that the MCA introduces intact stability criteria forallnewandsignificantlymodifieddeckedfishingvesselsofunder15mLOA.FollowingthecapsizeandlossofthefishingvesselJMTin2015,theMAIBextendeditsrecommendationforstabilityrequirementstoapplytoallnewandexistingfishingvessels of less than 15m LOA. The MCA accepted these recommendations and statedthatitstargetdateforimplementingappropriateactionwas31December2020.

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TheMAIB’scalculationsdemonstratethatNancy Glen’sstabilityhaddeterioratedsincetheassessmentin2002.Giventhelackofanyrequirementtoassessitsstability,Nancy Glen’sresidualstabilityfollowingitsvariousmodificationssince2002remained unknown.

The loss of Nancy Glen,andothersmallfishingvesselshighlightedinpreviousMAIBinvestigations,confirmsthatthelackofclearstabilitycriteriafornewfishingvesselsunder12mLandexistingfishingvesselsunder15mLOAcontinuestoputcrewsofsmallfishingvesselsatconsiderablerisk.

Therearecurrently(asof31December2018)5603UKregisteredfishingvessels,ofwhich4872(87%)arelessthan12mLOA.Noneofthesehaveeverbeensubjecttoany stability criteria relating either to their original build condition or following through lifemodifications.Unlessstabilitystandardsareintroducedandretrospectivelyapplied,thesevesselswillremainexposedtounassessedriskuntiltheyareretiredfromservice.Vesselsengagedintrawlingandotherformsofbulkfishingareparticularly at risk.

The evidence from multiple investigations into the capsize and foundering of small fishingvessels,coupledwiththenegligibleadoptionoftheWolfsonMark,clearlyindicates that most owners and skippers of small vessels are unaware of the risks of not conducting stability assessments of their vessels. There is no lack of published guidance,butitisbeingignoredwiththeconsequencethatvesselsandlivescontinuetobelost.ThecaseforintroducingstabilitycriteriaforsmallfishingvesselshasbeenmadebytheMAIBandhasbeenacceptedbytheMCA.However,untilstabilitycriteriaforsmallfishingvesselsisintroduced,theirpotentialvulnerabilitytocapsize,ashighlightedinthisreport,willremain.

2.9 REGULATION

The current Code of Practice for the Safety of Small Fishing Vessels of less than 15mLOA,whichreintroducedstabilitycriteriafornewandsignificantlymodifiedfishingvesselsof12mLtolessthan15mLOA,iswelcomed.However,theapplicationofstabilityrequirementstoencompassallnewandexistingfishingvesselsoflessthan15mLOAremainsuncertain,bothintermsofscopeandtiming.

TheFishingVessels(Safetyof15-24MetreVessels)Regulations2002,whichwereintroducedon23November2002,inadvertentlyremovedtherequirementforfishingvessels of 12m L to 15m LOA to be built with or to maintain stability information. This waseventuallycorrectedinTheFishingVessels(CodesofPractice)Regulations2017,whichcameintoforceon23October2017,almost15yearsaftertheoriginalerror.Duringtheseinterveningyearsnumerousfishingvesselsbetween12mand15m have been built without any regulatory requirement for stability information.

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SECTION 3 - CONCLUSIONS

3.1 SAFETY ISSUES DIRECTLY CONTRIBUTING TO THE ACCIDENT THAT HAVE BEEN ADDRESSED OR RESULTED IN RECOMMENDATIONS

1. Nancy Glen’sstabilitywasinsufficienttoovercomethecombinedeffectofincreasedloadingofthestarboardtrawlwarpandthevessel’ssimultaneousturntostarboard.[2.4]

2. ThecumulativeeffectofthevariousmodificationstoNancy Glen carried out since 2002,culminatinginthereplacementofthecraneduringthe2017/18Christmaslayover,wastoreducethevessel’sstability,andsignificantlyincreaseitsvulnerabilitytocapsize.[2.5,2.6]

3. Nancy Glen’sownershadmadetheirownstabilityassessmentand,insomecases,hadtakenprofessionaladviceontheeffectofthroughlifevesselmodificationsbeforetheywereimplemented.However,therewasnorequirementfortheskipperorcrewofunder16.5mregisteredlengthfishingvesselstoundertakestabilityawarenesstraining,whichlimitedtheirabilitytoconducteffectivestabilityassessments.[2.6.7,2.7]

4. Regardless of any requirement or recommendation to seek professional advice and/orapprovalforanyproposedvesselmodification,unlessavessel’sstabilityisknown,therewillbeuncertaintyastotheextenttowhichthatmodificationmayincrease the potential for the vessel to capsize. [2.6]

5. The evidence from multiple investigations into the capsize and foundering of small fishingvessels,coupledwiththenegligibleadoptionoftheWolfsonMark,clearlyindicatesthat,despiteavailableguidancemostownersandskippersofsmallvesselsare unaware of the risks of not conducting stability assessments. The case for introducingstabilitycriteriaforsmallfishingvesselshasbeenmadebytheMAIBandhasbeenacceptedbytheMCA.However,untilsuchcriteriahavebeenderivedandimplementeditislikelythatmorevesselswillbelost.[2.8]

6. The2017CodeofPracticeonlyrequiredownersofUKfishingvesselstonotifytheMCA of substantial modifications;however,thiswasinconsistentwithSI943thatobligated owners to notify the MCA of any proposals to alter or modify a vessel. This inconsistency introduced an environment where owners could exercise judgement on what constituted a substantialmodification,ratherthanmeetingtherequirementof SI 943. [2.6.5]

3.2 OTHER SAFETY ISSUES DIRECTLY CONTRIBUTING TO THE ACCIDENT

1. Theheelingmomentdevelopedrapidlytoapointatwhichthevessel’srightinglevervanishedbeforetheskipper’srestorativeactioncouldtakeeffect.[2.4]

2. The rapid capsize and inversion of Nancy Glenwouldhaveresultedinsignificantdisplacementofanyloosegearwhich,coupledwiththemen’sinevitabledisorientationexacerbatedbydarkness,islikelytohaveimpededtheirattemptstoexit the vessel. [2.4]

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3. Inadditiontothevessel’sincreasedinherenttopweight,astheweek’sfishingprogressedtheamountoffuel,storedlowinthevessel,wouldhavedecreased,therebyraisingthevessel’sVCGandnegativelyimpactingonitsinherentstability.[2.5]

3.3 SAFETY ISSUES NOT DIRECTLY CONTRIBUTING TO THE ACCIDENT THAT HAVE BEEN ADDRESSED OR RESULTED IN RECOMMENDATIONS

1. Thecumulativeeffectoflongworkingdayscouldhaveimpactedontheskipperandcrew’sabilitytoreacttoanemergency.[2.2]

2. TheFishingVessels(Safetyof15-24MetreVessels)Regulations2002,whichwereintroducedon23November2002,inadvertentlyremovedtherequirementforfishingvessels of 12m L to 15m LOA to be built with or to maintain stability information. This waseventuallycorrectedinTheFishingVessels(CodesofPractice)Regulations2017,whichcameintoforceon23October2017,almost15yearsaftertheoriginalerror.Duringtheseinterveningyearsnumerousfishingvesselsbetween12mand15m have been built without any regulatory requirement for stability information. [2.9]

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SECTION 4 – ACTIONS TAKEN

4.1 MAIB ACTIONS

The MAIB has:

1. Issuedasafetyflyertothefishingindustry(Annex F).

2. Previously recommended the MCA to:

‘Include in its intended new legislation introducing stability criteria for all new and significantly modified decked fishing vessels if under 15m in length a requirement for the stability of new open decked vessels, and all existing vessels of under 15m to be marked using the Wolfson Method or assessed by use of another acceptable method.’19

‘Require skippers of under 16.5m fishing vessels to complete stability awareness training.’20

4.2 ACTIONS TAKEN BY OTHER ORGANISATIONS

Althoughnotdirectlyasaresultofthisaccident,theMCA has published the following guidance and direction:

1. MGN526(F)Stability Guidance for Fishing Vessels – Using the Wolfson Method. MGN526(F)replacedMGN427(F)(Section1.10.5)andprovidedguidanceforfishingownersonthesafeoperationofvesselsusingtheWolfson Method of assessing stability.

2. The Fishing Vessel Stability Guidance booklet. The aim of this booklet was to helpfishermentounderstandtheprinciplesofstability,theassociatedrisksandhazards,andactionsthatcanbetakentomanagestabilityeffectively.

3. MSN1884(F)21 Application of the Fishing Vessels (Working Time: sea fishermen) Regulations 2004 as amended.MSN1884(F)explainedtherequirementsfortheprovisionofadequaterestforallfishermen,whetheremployed or self-employed.

19 MAIBrecommendation2016/13020 MAIBrecommendation2016/13121 MSN1884(F)waspublishedinOctober2018sodidnotapplytoNancy Glen at the time of the accident.

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SECTION 5 - RECOMMENDATIONS

The Maritime and Coastguard Agency is recommended to:

2019/109 Includeinitsnewlegislationaddressingthestabilityofexistingfishingvesselsofunder15m,arequirementtoundertakebothafreeboardcheckandstabilitycheck,whichshouldberecordedandrepeatedatintervalsnotexceeding 5 years.

Provide guidance on the conduct of 5-yearly stability checks to ensure the resultscanbeeffectivelycomparedtodeterminewhetherthevessel’sstabilityhas altered.

AlignthetextofMSN1871(F),TheCodeofPracticefortheSafetyofSmallFishingVesselsoflessthan15mLengthOverall,tomirrorStatutoryInstruments2017No.943MerchantShipping,TheFishingVessel(CodesofPractice)Regulations2017.Thisamendmentshouldbeinrespectofvesselowners’obligationtonotifytheMCAofanyproposaltoalterormodifyavessel’sstructure,removeorrepositionenginesormachineryorchangethemodeoffishing.

Include in its new legislation introducing stability criteria for all new and substantiallymodifiedvessels,arequirementforthistobevalidatedbya5-yearly lightship check.

Safety recommendations shall in no case create a presumption of blame or liability

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