The Marine Accident Investigation Branch (MAIB) has published its 2021 annual report. One of the main findings to note is the number of fatalities in the fishing vessel fleet, which hit a 20-year high. In his annual report statement, Chief Inspector of Accidents, Capt. Andrew Moll OBE, says, “I am pleased to introduce MAIB’s annual report 2021. It was another busy and successful year for the branch improving safety at sea by our sustained output of safety investigation reports, safety digests, and safety bulletins despite lockdown conditions affecting work early in the year. The branch raised 1530 reports of marine accidents and commenced 22 investigations in 2021.
The increased total in 2021 is largely atributable to our industry request to report sub-standard pilot ladders along with a rise in leisure craft and small commercial craft notifications.
The MAIB received no reports of fatal accidents to seafarers on UK registered merchant vessels of 100gt or more during the year but did commence investigations into fatalities on two Red Ensign Group vessels and one fatality on a Cyprus registered vessel operating in UK waters. From these investigations two themes emerge: the first is that mooring deck fatalities as a result of snap-back continue to occur, despite well published guidance on the hazard; the second is that marshalling vehicles on roll-on/roll-of vessels remains extremely hazardous. More worrying is that there is a clear gap between ‘work as imagined’ and ‘work as done’, with marshallers frequently standing in unsafe areas and drivers losing sight of marshallers.
The branch issued a safety bulletin in November to highlight the problem of loading into dead-end bays and, when published, the investigation report will say more about initiatives to further improve vehicle deck safety.
At industry meetings concerns about dangerously weighted heaving lines and unsafe pilot ladders are regularly voiced. In response, the branch asked that all such incidents, no matter how minor, be reported so a fuller picture of the problems could be gained. In respect of weighted heaving lines, the branch received just 16 reports; far fewer than anecdotal reporting would suggest, perhaps indicating that this extremely hazardous practice is still being under-reported. Much stronger evidence emerged in terms of pilot ladders.
In 2021, the branch received 194 reports about sub-standard pilot ladders. Of those, 172 pilot ladders (88.6%) were not rigged in compliance with SOLAS guidance, and 22 were observed by the pilot as being in a materially poor condition (Figure 2). Fortunately, serious accidents have been rare, but the potential clearly exists, and the branch will continue to collate statistics in 2022.
Commercial Fishing Vessels
Ten commercial fishermen lost their lives in 2021, the highest annual figure for a decade and a stark contrast to the low loss of life in 2020. That is a little short of one death per 1000 qualified fishing vessel crew; possibly a statistical blip, but a truly appalling annual fatality rate nonetheless. I therefore make no excuse for a longer than normal section on fishing safety in this introduction as commercial fishing investigations accounted for nine of the 22 investigations commenced in-year.
It is unsurprising, but disappointing, that the most significant safety issues were, again, small fishing vessel stability and man overboard fatalities. I will not decry any of the various initiatives that are ongoing to improve fishing vessel safety – a lot of people are doing some very good work – but the evidence shows that the messages are not yet changing behaviours to a significant extent.
The branch will say much more shortly as the FV Joanna C (BM 265) and FV Nicola Faith (BS 58) investigation reports are to be published very soon, but together they exemplify the small vessel stability problem, which is worth reiterating here. Firstly, it is important that owners and skippers understand their boat’s limitations, especially before embarking on any modifications. In both of the above cases the vessels had recently been modified, and those modifications had reduced their overall stability and so reduced safety margins. The second lesson is that even relatively stable boats can capsize if inappropriately laden with extra gear and a bumper catch. If it all goes wrong, the boat is lost (Figure 3), the catch is lost, and the crew are lost; so, is it worth the risk?
Turning to man overboard, I recently attended an awareness event for fishing vessel crew held in an environmental pool in Aberdeen capable of creating realistic sea conditions. Each individual in turn was invited to jump into the pool wearing boots and oilskins, but without a personal flotation device. Some lasted a few minutes before being assisted into shallow water by the rescue swimmer, but all were fighting
for breath at that point. They then re-entered the water wearing the same kit, plus an inflated lifejacket, and realisation dawned. They floated without effort, could breathe easily, and were able to perform rescue tasks. My feeling is that everyone understood the messages: lifejackets save lives, and they are useless unless worn. I hope they spread the word so others do not have to learn the hard way.
The branch commenced two investigations during the year that deserve comment due to their unusual nature. The first is the investigation into the tragic deaths, on 30 October, of four stand-up paddleboarders while attempting to cross a weir at Haverfordwest on the River Cleddau. The sheer enormity of this tragedy selected it for attention and, inevitably, lots of safety lessons emerged as the layers were peeled away. It will be a few months before the report is published, but engagement with stakeholders has so far been excellent and I am hopeful that many safety improvements will be in place before the main UK holiday season.
The second, commenced in January this year, is the investigation into the emergency response to the presumed sinking of a boat of migrants while attempting to cross the English Channel on 24 November. At least 27 migrants perished in that accident. While the MAIB’s investigation report is unlikely to be read by the traffickers, the investigation is identifying safety learning that will be of future benefit if interventions continue to be necessary to save life when migrant boats are attempting the crossing.
The MAIB annual report made 35 recommendations to 23 separate addressees in 2021, of which 77.1% were either accepted and implemented or accepted, yet to be implemented. Three recommendations were rejected for reasons as set out in the report and there has been no response received to five recommendations made to overseas companies. While the acceptance rate is down on the high level of acceptance achieved in 2020 (>90%), it nonetheless validates our process of whenever possible involving stakeholders in the formulation of recommendations during the final stages of an investigation.
Branch activity and development
The year saw the country start to emerge from the restrictions of COVID-19 and for the MAIB a recommencement of business as normal. Inroads have been made into the backlog of training built up during lockdown and, as I write, the time taken to publish full investigation reports has reduced to 12.9 months and concise reports to 8.3 months. The reports of a few protracted investigations have yet to be published, but the trajectory is in the right direction.
During 2021, the UK was audited by the International Maritime Organisation (IMO) to assess its compliance with the standards set out in the IMO Instruments Implementation Code (III Code). This included an audit of how the MAIB discharges the UK’s responsibilities under the Casualty Investigation Code, including the investigative activity it undertakes on behalf of the Red Ensign Group. I am very pleased to record that the UK passed the audit, and no observations or non-conformities were raised relating to accident investigation; a very significant achievement.
Looking ahead, two main initiatives are planned for 2022. The first is to simplify and streamline the reporting of Marine Casualties and Marine Incidents with the introduction of an online portal/app. The second is to provide public access to the statistical element of the MAIB’s database. Specific case enquiries will still have to be submitted for manual handling, but access to accident data should be of significant benefit to marine organisations, companies and researchers. A potential cloud on the horizon is the recent government announcement that it intends to reduce the Civil Service by circa 20% to around 2016 levels over the next 3 years. However, that is for the future. For the present, the branch is fully staffed and able to discharge its statutory functions.”
Download the full report: MAIB Annual Report 2021