MAIB safety digest with analyses of 25 accidents volume 1 2019 published

The Marine Accident Investigation Branch (MAIB) has published a digest and analyses of twenty five marine recent incidents and accidents with short descriptions about each involving vessels from the merchant, fishing and recreational sectors. The 70 page report can be accessed and downloaded here or at the foot of this page.

In his introduction to the Digest, Andrew Moll says, “I’d like to thank this edition’s introduction writers. I am delighted that Captain Nick Nash, Andrew Locker and Steve Gravells have agreed to write the introductions to the merchant, commercial fishing and recreational craft sections of this digest. All three have written from both their professional and own personal perspectives, and their words are very powerful. If you read nothing else in this issue, I would encourage you to read the section introductions.

When I took command of HMS YORK, the squadron navigator gave me some advice that has stayed with me throughout my seagoing career. Very simply, it was to check the emergency steering thoroughly before letting go to leave port, or before entering pilotage waters on the way in. Doing this ensured that: everyone was closed-up in their correct position, the communications worked; the rudder angle indicator and gyro repeater in the steering gear compartment were reading correctly and, importantly, the secondary and local steering systems actually functioned. The first time we did this it was a right pain. By the time we were doing it for the third or fourth time everyone’s confidence in and knowledge of the system had increased immeasurably. When one day the primary steering system did fail as we made our way into harbour, we took it in our stride and berthed as if nothing had occurred.

Capt Andrew Moll, Chief Inspector of Marine Accidents, MAIB
Capt Andrew Moll, Chief Inspector of Marine Accidents, MAIB

I’m putting this story in my introduction because this issue of the digest has many examples of accidents that could have been avoided altogether, or at least somewhat mitigated, had the individuals involved spent a bit more time getting to know the reversionary operating modes of their safety critical systems. When things are going wrong, the human endocrine system has a tendency to flood the body with adrenaline. This hormone dates from the time of our earliest ancestors. It is useful if you need to run away from a sabre-tooth tiger, but damn all help if you are trying to read some small print instructions by torchlight when the alarms are sounding all around you. So, please take the time to thoroughly learn your systems before the fur starts flying, and make a point of testing them before you need them.

The second theme I would like to highlight from this issue is that of providing a safe means of access to your vessel. As I write, the MAIB has started two investigations into fatal accidents (see Appendix A). One accident occurred as a crewman was attempting to leave his vessel; the second as a crewman was trying to board. Both accidents happened when the vessels were moving or about to move. It is likely that both individuals were trying to be helpful and to get things done quickly, but there were better ways of getting the lines ashore or letting go, and the shortcuts cost them their lives. The investigation reports will be published later in the year, but in the meantime may I ask you to review your procedures for passing and letting go mooring lines to ensure you are not putting anyone at risk.

As always, when you have finished reading this edition of the MAIB’s Safety Digest, please pass it to someone you feel will genuinely benefit from reading these articles – there is no limit to the number of people who can learn from the experiences of others.”

Andrew Moll
Chief Inspector of Marine Accidents

Download the 70 page digest: 2019-SD1-MAIBSafetyDigest

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