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Loss Prevention 

Case Studies

Introduction 

Contents 

Case studies are summaries of claims that have 

been notified to the Club. We produce these to 

raise awareness of the causation of claims and their 

outcome so that other Members can benefit from the 

misfortune of others and pass this knowledge on to all 

relevant sectors of their organisations. 

The case studies within this publication are arranged by vessel type and then 

categorised by area of claim e.g. Navigation, Personal Injury/Illness and Operations. 

We hope that Members will find the following compilation of case studies useful. 

David Heaselden 


Loss Prevention Manager

Section 1 

Dry Cargo Vessels 

3

Dry Cargo: 

Bulk 

Personal Injury/Illness 

Only Use Equipment for it’s Designated Purpose 

The Incident: 

In this case the barge concerned was secured 

alongside, working cargo. A coastal vessel then 

entered the port and without obtaining permission 

from the terminal moored alongside (double 

banked) to the barge. After berthing the crew of 

the coastal vessel reportedly went ashore by passing 

through the accommodation of the barge. It was 

at this time (1035 hrs) that the crew of the barge 

noticed that a breast line at the after end of the 

barge had parted and therefore proceeded aft to 

replace it. Upon arriving at the stern they found one 

of the crew members from the coastal vessel lying 

injured on the port side of the main deck adjacent 

to the accommodation. It appeared he had been 

struck by the rope as it parted. The barge’s crew 

immediately reported the matter to their shore 

office who in turn informed the Hong Kong Marine 

Department and other officials. Shortly afterwards 

police officers attended the barge along with an 

ambulance and the fire department. Personnel from 

the ambulance were unable to board the barge 

on account of the prevailing heavy sea conditions. 

Therefore oxygen equipment was passed to the 

barge’s crew who were duly instructed on its use. 

The firemen then boarded the barge and hoisted 

the injured person ashore where he was taken to 

hospital. Unfortunately the injured person died later 

in hospital. 

Observations: 

The nylon rope (8 inches in circumference) had 

been used as a mooring line and was observed in 

poor condition. The eye splice had been extensively 

cut with only a few strands remaining which were 

rust stained. The vessel’s crew noted that the rope 

had been used for towing prior to being utilised as a 

mooring line. It is imperative that ropes are utilised 

for their intended use. Once they have been used 

to perform a function they should not be reused 

for other purposes. Ropes should be subject to 

regular examination including telltale signs of wear 

(powdering in the case of nylon ropes). 

Root Cause: 

Incorrect use of vessel equipment. 

Financial Cost: 

US$43,362. 

Issue Date: 05/02/08 

Case No. 50055 

4 5

Cargo 

Loading During Rain Causes Cargo Claim 

The Incident: 

A 1,200 ton gearless bulk carrier was discharging her cargo of rape seed meal. Shortly 

after discharge commenced cargo operations were suspended during a heavy rain 

shower. The crew had some difficulties in reopening the hatch covers and as a result 

discharge was delayed. 

Following this incident stevedores requested that discharge continue during periods of 

rain. The Master asked for written authorisation and this was reportedly promised by the 

stevedores. On the strength of the promise of a letter of authorisation to work in the 

rain the Master allowed discharge to continue in the rain and made no attempt to cover 

the hold during lunch breaks. 

When a cargo claim for wet damage was presented by the consignee the stevedores 

refuted any knowledge of a letter of authorisation to permit working during periods of rain. 

Observations: 

The only people with the power to authorise the 

discharge of water-sensitive cargo during periods of 

rain are the shippers or consignees. Stevedores do 

not normally have the authority to do so. 

In many parts of the world stevedores are paid by 

ton of cargo loaded or discharged with the result 

that interruptions to the cargo operations because 

of rain represent a loss of income. When requested 

to continue loading or discharging water-sensitive 

cargoes in the rain Masters should ensure that they 

have received written authority to do so from the 

shipper or consignee or someone acting with their 

authority. In cases where the authorisation is given 

by persons other than the shipper or consignee the 

Master should ensure that the person authorising 

the operation has the power to do so otherwise 

responsibility for damage to the cargo may remain 

with the ship. 

Root Cause: 

Non compliance with good cargo 

operational practices. 


17.5 tons of cargo were damaged with a market 

value of over US$3,000. 



6 7

Navigation 

Grounding as a Result of Poor Navigational Practices 

The Incident: 

This case concerns the grounding 

of a vessel in mid-afternoon 

during a coastal passage. At the 

time of the grounding visibility 

was good with a light easterly 

breeze, smooth sea and no swell. 

The Master was on the bridge 

chatting to the officer of the 

watch and there was also a deck 

cadet on the bridge. 

The vessel was on a regular 

run between two ports in an 

area of relatively shallow water, 

liberally scattered with coral 

reefs. The Admiralty Pilot advises 

mariners that charts of the area 

were based on old surveys, (few 

systematic surveys have been 

carried out), and that much of 

the information is derived from 

lines of soundings taken by vessels 

on passage. The working chart 

carried the following caution: 

Unsurveyed Areas 

No hydrographic survey has been conducted and 

accordingly mariners attempting to enter these 

areas should proceed with extreme caution as 

unidentified shoals, reefs and other navigational 

hazards may exist. 

The chart shows a recommended track for 

transiting the area which passed to the south of 

an offshore reef. The vessel’s course line did not 

follow the recommended track. Instead the Master 

inked in a course which cut a corner, passing to the 

north of the reef through an area clearly marked as 

unsurveyed. The Master had apparently regularly 

followed that route when a junior office on a smaller 

vessel. His departure from the recommended track 

was increased by the second mate who, after fixing 

the vessel’s position at 16.00 hrs, decided to alter 

course to cut the corner even more, taking the 

vessel further into unsurveyed waters. 

Observations: 

The grounding was the result of sub-standard 

navigational practices. The Master and Owners 

had allowed a culture of corner-cutting to 

develop. Subsequent investigation revealed that 

recommended tracks were often ignored when a 

straight line between two points would save a little 

distance. In many cases this took the vessel into 

close proximity to shallow water whilst saving only 

minimal time and distance. 

Numerous other areas of sub-standard navigational 

practices were revealed including failure to correct 

charts in accordance with the latest Notices to 

Mariners. This working chart had not been corrected 

for over two years and the Admiralty Pilot for the area 

was missing the latest supplement which contained 

information relevant to the area of grounding. 

In addition it appears that almost total reliance was 

placed on GPS despite being in close proximity to 

a steep coastline with numerous features, giving a 

good clear radar echo and ample opportunity to 

take visual bearings. The working chart is endorsed 

with the caution: 

SATELLITE-DERIVED POSITIONS 

Positions obtained from satellite navigation 

systems are normally referred to the WGS Datum; 

adjustments for plotting such positions cannot be 

determined for this chart. Mariners must determine 

the position of their vessel in relation to the charted 

positions of dangers and navigational features by 

visual or radar means. 

Fortunately the vessel suffered no major damage in 

the grounding and was refloated within 12 hours. 

The Master was relieved of his command. 

ROOT CAUSE: 

Inadequate navigational practices. 

FINANCIAL COST: 


Case No.28862 

8 9

Navigation 

Intermittent Faults can be more Serious than a Permanent One 

The Incident: 

The Club has recently dealt with a number of claims 

that have been caused by known intermittent faults 

occurring at the wrong time. 

This particular incident involved a 500 gt Dry Cargo 

vessel fitted with a main engine gearbox. 

After loading a cargo of stone the vessel proceeded 

on her laden passage without problem. The discharge 

port was located inland from the coast requiring 

passage through locks and a canal. The vessel entered 

the lock without event, but upon departing, the 

Master experienced difficulties engaging the gearbox 

from ahead to astern. After several attempts the 

problem “disappeared” and the vessel left the lock. 

Shortly afterwards the decision was taken to 

moor the vessel alongside a layby berth and whilst 

manoeuvring alongside the gearbox again failed to 

engage astern. As a result the vessel made heavy 

contact with the quay, she came off and after several 

further attempts the gearbox successfully engaged 

and the vessel was safely berthed. 

The damage to the vessel was severe enough to 

warrant the attendance of a Class surveyor. As can 

be seen from the photograph above, the quay was 

also badly damaged as was a section of public road 

that ran along it. 

Observations: 

The Master and Chief Engineer had both recently 

joined the vessel and were not aware of any 

previous problems with the gearbox. However, the 

vessel’s Superintendent upon hearing of the incident 

advised the Master that it was a known problem and 

had been experienced on previous occasions. 

It is very disappointing to note that the previous 

Master and Chief Engineer did not consider 

problems engaging astern movement of the vessel 

serious enough to warrant advising their reliefs, or 

that the ship’s managers via the superintendent did 

not take any positive action in trying to solve the 

problem. At least the relief Master should have been 

advised to take suitable precautions until such time 

as the fault had been rectified. 

Root Cause: 

Onboard maintenance programme failure. 


The cost to the Member is in excess of US$45,000. 



The Member was fortunate that the incident took 

place after entry into the lock; if the vessel had hit 

the lock gates the incident could have had very 

serious repercussions. 

Intermittent faults should be considered serious on 

two counts. Firstly they are notoriously difficult to 

detect and rectify by their very nature and secondly, 

because they are intermittent, complacency arises 

and quite often contingency plans do not take into 

account any recurrence, when in fact they should. 

10 11

Operations 

Crate Dropped During Lowering 

The Incident: 

Please note that this Case Study 

has been provided by The 

Nautical Institute’s International 

and Confidential Marine Accident 

Reporting Scheme (MARS) 

- Report No. 200824 

On a ship at anchor, a crate 

containing machinery spares, 

reeved with two webbing 

slings, was being lowered into 

the engine room through the 

engine room hatch using the 

ship’s stores crane. During the 

lowering process, a corner of 

the base of the crate caught on 

a section of ducting immediately 

below the hatch coaming, 

became unbalanced and tipped 

through the slings, falling to 

the deck below. The impact 

destroyed the crate; however, 

there were no injuries or damage 

other than that the spares were 

rendered unusable. 

Root cause/contributory factors 

1. Failure to sling the crate properly; webbing slings 

not tight around the top of the crate; 

2. Ship rolling slightly at anchorage, causing the crate 

to swing during passage through the hatch; 

3. Failure to conduct/review formal risk assessment 

prior to the lifting operation; 

4. It is thought that the spare part was inadequately 

secured inside the crate and as the crate tilted, the 

internal shift of weight assisted the ‘tipping’ motion; 

5. The crate’s height was greater than the other two 

dimensions, which made it more prone to tipping; 

6. The crate had no fitting to prevent the slings from 

slipping off in case the load became unbalanced; 

7. ‘Routine task’ complacency and inadequate 

understanding of risk assessment among 

the ratings. 

Corrective actions 

1. The company issued notices to Masters and 

safety bulletins on risk assessment, work planning 

and safe lifting techniques. 

2. Crane operator familiarisation training was 

conducted on board and will be supplemented 

by further computer based or practical training in 

crane operations and rigging/slinging. 

3. Permit to work system presently applying only 

to lifts within hazardous areas to be extended to 

include all lifting tasks. 

4. Investigate and solicit vessel proposals for a steel 

cage/box to be used for lifting operations into the 

engine room. 

Lessons learnt 

1. Expensive and relatively fragile components 

should be given a higher level of planning and 

supervision. 

2. Although a task review was conducted during 

the initial work planning, it was not documented 

and should have been followed up with a risk 

assessment and a tool box meeting. 

3. There was a failure to assess the risks adequately, 

specifically vessel motion and the possibility of the 

crate contents shifting. 



12 13

Miscellaneous 

Smoking is Not Good for Your Health 

The Incident: 

This case involves a vessel on which 1.5 million 

cigarettes (150 boxes) were discovered in the 

fore peak hidden under a tarpaulin during a search 

by the Customs and Federal Police. The search 

was thought to be the result of a ‘tip off’ by the 

European Bureau for Fraud. 

During subsequent interviews the Master and 

Chief Mate denied all knowledge of the smuggling 

but a crew member confessed, admitting full and 

sole responsibility. He stated that he purchased the 

cigarettes with money obtained from the sale of 

his apartment, transported the cigarettes by van 

to the vessel and brought the cigarettes on board 

the vessel without assistance. He alleged that on 

the vessel’s arrival in the discharge port he was to 

liaise with a Russian man only known to him by the 

name of ‘Sergei’. 

The body was recovered two months later and 

despite the fact his left ankle was tightly bound 

with rope the inquest concluded death by 

drowning with no obvious signs of violence. 

Observations: 

Criminal charges were initially brought against the 

seaman, the Master and our Members. Due to the 

seaman’s death the criminal charges against him have 

been dropped. No civil charges have been made as 

the cigarettes have been seized. 

Root Cause: 

Illegal smuggling. 


A nominal fine was incurred. 


Case No: 48633 

A week later, while the authorities were still 

investigating the case and prior to obtaining an order 

to seize the vessel or formally make charges, the 

vessel was allowed to depart. During the following 

voyage the seaman concerned went missing. A full 

vessel search was immediately made which lead to 

the discovery of a suicide note in his cabin. It stated 

again that he was fully and solely responsible. 

Article 265 Section 3 of the Belgian Customs Code 

provides that in cases like this Members could be 

held vicariously liable for fines and costs which are 

imposed on conviction of the Master. Accordingly, it 

may also be possible for Members to be found liable 

to pay not only a fine imposed directly on them but 

also any fine imposed on the Master. 

14 15

Dry Cargo: 

General 


Crane Collapse Results in Death of Bystander 

The Incident: 

This incident involves a gearless dry cargo vessel 

which had been equipped with a large mobile crane 

to enable it to operate at berths without cargo 

handling equipment. The crane had been designed 

for industrial operations ashore. Its tracks had been 

removed and it was temporarily bolted to the deck 

of the vessel. The crane was fitted with a jib 120 

foot long and had a maximum capacity of 136 tons 

at an 18 foot radius of operation. As a heavy lift was 

being discharged the vessel listed slightly and the 

crane jib collapsed. The jib fell on a vehicle killing the 

occupant. The ship itself was undamaged but the 

cargo was a total loss. 

Observations: 

The design of the crawler crane was typical of 

its type, having a long narrow latticework boom. 

These cranes are designed for use on a level steady 

surface where the boom acts merely as a strut in 

compression and is not subjected to sideways or 

twisting forces. In this case as the load was slowly 

swung over the vessel’s side, the vessel began to 

list causing the load to swing out of the plane of the 

jib. The list also increased the effective radius of 

operation, increasing the stress. The combination 

of increased load and side force caused the jib to 

fail at its base where it was attached to the body of 

the crane. 

Extreme care must be taken to avoid excessive 

side loads on cranes not designed for marine use. 

Detailed guidance from the crane’s manufacturers 

and national authorities should be sought. As a 

general rule however the vessel should not be 

allowed to list more than 5° during the discharge 

operation and the load should never exceed 50% of 

the crane’s safe working load for operation on land. 

The vessel’s stability was adequate but in order 

to counteract the anticipated list as the load was 

swung towards the wharf, orders were given to 

deballast the double bottom tanks on that side. 

The deballasting had not been completed at the 

time the load was moved horizontally and the 

free surface effect of the liquid in the partially 

filled tanks served to increase the vessel’s list. The 

number of slack tanks must be kept to a minimum 

when heavy loads are handled. 


The cargo claim was settled for US$500 in line with 

the package limitation contained in the bill of lading. 

The claim of the vehicle driver was covered by his 

motor insurers who rather surprisingly failed to 

subrogate their claim against our Member before it 

became time-barred. The owners faced a number 

of prosecutions brought for alleged breaches of the 

Canada Shipping Act and the Tackle Regulation, 

most of which were quashed at trial. Despite a 

very favourable resolution of the claims, the costs 

incurred in investigating and defending the Member 

reached US$33,000. 

Root Cause: 

Incorrect operation of equipment. 

Issue Date: 01/02/02 Case No. 16415 

16 17

Cargo 

Flammable Gases Cause Explosion 

The Incident: 

This incident involved a large explosion on board a 

general cargo vessel when flammable gases given 

off by the cargo were ignited by an electrical spark. 

The explosion killed two crew members, injured 

several more and caused severe damage to the ship. 

The vessel’s forward hatch covers were blown off, 

landing on and severely damaging two tugs moored 

nearby. Extensive damage was caused to surrounding 

buildings and a nearby papermill was shut down for a 

week following the explosion. 

Observations: 

The vessel was loading a cargo of spent pot liner, the 

carbon-based lining of an aluminium smelter which 

absorbs impurities from the metal. It eventually 

becomes saturated and has to be replaced. The 

impurities in the spent pot liner react slowly with 

water producing inflammable gases. 

Our investigations revealed that the cargo loaded 

into number 1 hatch had come from two different 

storage areas. Wet reacted cargo from an open 

stockpile had been mixed with dry unreacted 

cargo which had been stored in a closed shed. 

Moisture from the weathered cargo migrated to 

the dry, causing it to react with the result that an 

accumulation of inflammable gases built up in the 

hold and fan rooms overnight. These gases were 

ignited by an electrical contactor operating the 

hydraulic system for the hatch covers. 

The shippers, although aware of the problem 

of inflammable gases, did not advise owners or 

charterers of the danger, nor did they provide 

the vessel with a copy of their material safety 

data sheet. Information on spent pot lining was 

not available from the IMDG Code, the IMO 

Code of Safe Practice for Solid Bulk Cargoes, the 

Dangerous Bulk Materials Regulations or any other 

official publication. 

The explosion could have been avoided if all the pot lining had been weathered prior to 

shipment or proper steps had been taken by the shipper to ensure that wet cargo was 

kept separate from dry unreacted cargo. The shippers should have provided the vessel 

with safety data sheets. Appropriate measures could then have been taken to ensure 

that the cargo was kept adequately ventilated and the accumulation of explosive gas 

could have been avoided. 

Root Cause: 

Unsafe loading practice. 


The claims arising out of the explosion totalled 

over US$30 million. In the end they were settled 

for just under US$11 million with the shippers of 

the cargo bearing by far the greatest proportion. 

Nevertheless the costs of investigation, defending 

the various legal actions and with a very modest 

contribution towards the settlements brought 

the cost to our Members the charterers to 

US$1.3 million. 



18 19

Miscellaneous 

Corrosion – The Hidden Enemy 

The Incident: 

Please note that this case study has been provided 

by the MAIB Safety Digest 2/2007, Case 6. 

After completing the weekly planned maintenance 

routine on a rescue boat and its crane, it was usual 

for the crew to lower the boat to the water for 

training purposes while alongside. The boat was 

lowered and manoeuvred in the water for a short 

time and then brought back to be hoisted on board. 

As the boat was being hoisted, the wire rope parted 

and the boat fell into the sea. 

Fortunately, the company had already identified this 

as a high risk operation and had stopped the practice 

of having the crew in the boat while hoisting or 

lowering during training exercises. There were no 

injuries, and the boat was not damaged. 

On investigation, it was found that a new wire rope 

had been fitted 14 months previously, and it had 

passed a thorough examination about five months 

before the incident. It was also inspected/greased 

on a weekly basis as part of the ship’s planned 

maintenance programme. Despite the checks, the 

incipient corrosion had not been discovered and 

the wire eventually failed at the top of the steel ball 

counter weight. 

The accelerated corrosion was partly due to the 

harsh environment in which the rescue boat and 

its crane were located, at the aft end of the vessel. 

The ball weight had a crevice at the top where the 

wire passed through, and this formed an ideal trap 

for sea water, salt and sulphur deposits from nearby 

exhaust outlets to accumulate and obstruct regular 

inspection. 

The investigation discovered that unsuitable grease 

had been applied, and this had not been effective in 

lubricating the wire core and served to obscure the 

underlying corrosion (see photograph of wire and 

crane ball indicating the point of failure). 

The failed segments of the wire rope were sent 

to a laboratory for testing, and the subsequent 

report confirmed that the wire rope had failed 

through ductile tensile fractures of wires wasted 

by corrosion. The laboratory was also able to 

confirm that a contributory cause of the failure was 

inadequate maintenance greasing over a significant 

period of time. 

The body was recovered two months later and 

despite the fact his left ankle was tightly bound 

with rope the inquest concluded death by 

drowning with no obvious signs of violence. 

Conclusion: 

1. The inspection of all wire ropes should be 

thorough, and should include the removal of old 

grease to assess the condition of the wire rope 

before re-coating with fresh wire lubricant. 

2. Senior staff should regularly monitor planned 

maintenance procedures which are carried out 

by crew. 

3. Consideration should be given to the use of a 

thinner self penetrating lubricant on seldom used 

wire ropes, especially where they are used or 

stored in a harsh corrosive environment. 


Case No: 12377 

20 21

Dry Cargo: 

Containers 

Cargo 

Capsize During Loading 

The Incident: 

As the last few containers were being loaded on the 

deck of a 3,000 gross ton inter-island cargo vessel 

she capsized and sank alongside the dock, damaging 

the dock as she went down. The Port Authority 

issued a wreck removal order. The Club invited 

tenders for the removal operation and a contract 

was finally agreed with a Singapore-based salvage 

company. The wreck removal was effected using a 

large sheerlegs which had to be towed over 2,000 

miles to the site of the accident. The wreck was cut 

up into manageable sections and dumped at sea. 

The berth was finally cleared some five months 

after the ship went down. The majority of the cargo 

was a total loss. 

Observations: 

Our investigations revealed that the cause of the loss was an error in 

calculating the vessel’s stability. The Chief Officer had failed to make 

proper allowance for the height of a stow of bagged cement in the 

lower hold when calculating the vessel’s vertical centre of gravity. As 

a result his calculations produced an over-optimistic prediction of the 

vessel’s stability on completion of loading. There was no established 

procedure on this ship for an independent check of the Chief Officer’s 

calculation. Had there been one it is highly likely that the mistake 

would have been noticed and the loss of the vessel avoided. 

Root Cause: 

Error in stability calculation. 


Cargo claims totalling over US$3 million were submitted to the 

owners. By using package limitation and defences available to the 

owners under the Hague Rules, those claims were finally settled for 

less than US$500,000. 

The costs of removing the wreck of the vessel approached 

US$1.5 million. 

Claims by the Port Authority and individual crew members brought 

the total cost of the claim to almost US$2.2 million. 


22 23

Cargo 

Stability Needs Careful Attention 

The Incident: 

A Feeder Container vessel had completed cargo 

operations at one berth and was in the process 

of shifting to a second berth. A harbour tug 

commenced pushing the vessel towards the berth 

when the Member’s vessel began to heel over. 

When heeled over to approximately 10 to 15 

degrees, containers began to fall off the vessel; the 

tug stopped pushing, and this action in conjunction 

with the loss of containers enabled the vessel to 

return to near upright. 

Observations: 

The subsequent investigations showed that poor 

operational practices were allowed on board, 

with very little regard given to the safety of the 

vessel. The centre of gravity (KG) of the vessel 

was determined to be well above the maximum 

permitted and no account had been taken of the 

numerous free surfaces in the ballast tanks. To 

make matters worse, it was calculated that the 

vessel was in fact 400t overloaded, resulting in a 

reduction in the freeboard of 30cms less than the 

minimum permitted. 

These factors combined to result in a drastic 

reduction of transverse stability which was 

insufficient to withstand the forces created by the 

pushing tug. 

Ironically, the top tiers of containers had not been 

secured but this allowed the containers to fall off 

and the vessel returned to the upright. 

One of the contributing factors to the overloading 

was the under declaration of the containers 

weights by the shipper. This case highlights the 

need to monitor the vessel’s condition at all times. 

By observing the drafts, the overloading would 

have been noted at an early stage and the vessel’s 

lack of adequate stability detected. 

Root Cause: 

Failure to observe stability requirements. 


The total cost of this claim was in excess of 

US$660,000; a great deal of this was accounted for 

in recovering containers that sank in the approach 

channel to the berth. 



24 25

Cargo 

Be Prepared 

The Incident: 

This incident occurred on a 316 TEU feeder container vessel/bulk carrier immediately 

after loading had been completed. 

On completion of loading the vessel had a 1° list to starboard. This slowly increased. 

Corrective action was taken, but despite this the list continued to increase. By the time 

it had reached approximately 15°, a number of containers fell off the top tier into the 

harbour waters. The vessel then violently rolled to port. The list increased until the 

water line had reached the hatch coamings and progressive flooding started to take 

place. Fortunately more containers fell off the top tier, reducing the list. The situation 

was eventually brought under control by discharging cargo and the vessel returned to 

an even keel. 

Observations: 

This incident was caused by a poorly prepared 

stow plan resulting in the vessel having negative 

stability upon completion of loading. The onboard 

calculations were incorrectly executed, as they 

appear not to have taken the effects of free surface 

into account, so masking the true stability condition 

of the vessel. 

Feeder container vessels are renowned for 

their short turn round times and frequent cargo 

changes. Operators of these vessels should ensure 

procedures are in place to minimise the potential 

for errors. Shore prepared stow plans must be 

checked for accuracy, preferably by a second 

person before they are issued. Means should 

be provided to assist ship’s staff in assessing the 

stability condition of the vessel so as to reduce 

the possibilities of errors being made in hastily 

completed calculations. This could take the form of 

computers or encouragement to use prepared pro 

forma. Owners should satisfy themselves that the 

senior officers on board are fully familiar with the 

stability requirements of their vessel. 

Root Cause: 

Inadequate lashing. 


This turned out to be a very expensive claim as 

enormous efforts had to be made to locate the 

sunken containers that fell overboard. The final 

cost was in the region of US$580,000. 



26 27

Cargo 

Complacency Rules 

The Incident: 

This claim arose on a river craft specifically designed 

for a container feeder service between two 

terminals. 

Whilst manoeuvring off one of the terminals with 

a cargo of 92 twenty and forty foot containers, the 

vessel experienced a squall and started rolling as she 

turned beam on to the wind. 

A number of containers moved as the vessel rolled, 

striking adjacent containers. The lashings on two of 

the containers struck consequently failed and two 

forty foot units were lost overboard. 

Observations: 

This claim arose because of poor operational 

practices on board. Investigations showed that the 

lashing system employed was far from satisfactory. 

Local regulations did not require operators to have 

approved securing manuals and the operators did 

not have any requirements or guidelines of their 

own. Consequently the securing of the containers 

was left to the crew who relied on their experience. 

No procedures had been established requiring 

calculation of the vessel’s stability and therefore the 

Master had no indication of the stability condition of 

the vessel (e.g. too large or too small a GM) when 

she sailed. 

The lashing system did not follow normal acceptable 

practices and a number of deficiencies came to light 

during the Club’s investigations: 

• the lashing gear was not certified or provided 

with identification marks; 

• the amount of lashing gear used was insufficient. 

Where used, twist locks were only applied to 

two corners of each container and not all four 

and only minimal wire lashings were used 

(see pictures) 

• in-board containers were not secured at all; 

• the leads for the lashing wires were totally 

inappropriate and bulldog wire rope grips were 

insufficient in number, positioning and size; 

• it is doubtful whether the lashing gear utilised was 

in fact of sufficient strength for the task required 

of it; 

• no account appeared to have been taken of the 

differences in height between standard and high 

cube units, which prevented the satisfactory use 

of bridge fittings; 

• no maintenance programme was in place for the 

upkeep of the lashing gear. 

Root Cause: 



Salvage teams fortunately were able to recover 

these containers therefore the Members have only 

been liable for their salvage and loss of contents. 

This is estimated to cost US$7,000. 



28 29

Operations 

It will be Alright – But it Wasn’t 

The Incident: 

This incident involved loading containers into a hold 

that contained water and was compounded by the fact 

that the bilge pumping system was not operational. 

On completion of discharging, water was noted 

lying on the tank top and efforts to remove it failed 

because the bilge pumping system was found to be 

inoperative. Time constraints apparently prevented 

any other means to remove the water to be utilised. 

Loading was then commenced and the vessel 

subsequently sailed. 

During the course of the voyage the hold bilge levels 

were reportedly monitored although some doubt 

exists as to whether or not the bilge sounding pipes 

were clear enabling soundings to be taken. It would 

appear that during the voyage, the bilge levels did in 

fact rise. 

Once the hold in question was discharged, the 

majority of the lower tier of containers were found 

to have had their bases immersed in water. 

Observations: 

Notwithstanding the source of the water leak into 

the hold, the prime cause of this claim was the poor 

condition of the hold bilge pumping system. Access 

to bilge wells can be restricted due to the compact 

nature of container stowage and it is not always 

possible to use portable pumps to remove cargo 

hold bilge water if the main system fails. Therefore 

it is of the utmost importance to ensure that the 

bilge pumping arrangement is regularly tested 

and maintained in full working order. Similarly the 

sounding pipes must be kept clear at all times. 

The water entered the hold through cracks which 

had developed at the base of the cell guides where 

they connect with the tank top. During the course 

of loading and discharging, these guides suffer 

considerable physical stress and if the bases are 

weakened through corrosion at all, cracks will 

eventually occur. It is important therefore that these 

areas are inspected regularly and repairs carried out 

promptly. 

It is apparent that the amount of water noted in the 

hold on completion of discharging and during the 

voyage was not considered significant, but obviously 

no allowance was made for the fact that the level 

will rise and fall when the vessel rolls and pitches in 

a seaway. Any water in a cargo hold is unacceptable 

and should be removed as soon as it is detected. 

Root Cause: 

Insufficient maintenance. 


This claim was settled for US$60,000. 



30 31

Operations 

Free Water and Poor Maths Result in Delays 

The Incident: 

This incident took place on a 25 year old 370 TEU 

feeder container ship. Shortly before arriving at 

the pilot station, an unexplained port list suddenly 

developed. The list was corrected and “sounding 

round” showed there to be about 100 cm of water in 

her hold. 

Until berthed, the vessel had flopped one way 

or another on a number of occasions, each time 

corrected by moving ballast. Alongside she lay with 

a 15° list against the quay. 

The Chief Officer carried out an assessment of the stability and deemed 

the vessel to be unstable. The port authority subsequently refused to give 

permission for cargo operations to commence until the vessel was upright, 

the cause of the listing was determined and stability was confirmed by the 

Classification Society. 

Efforts to pump out the hold bilge were thwarted by choked suctions. 

The services of a local salvage company were engaged to pump out the 

hold and remove the top tier of containers in order to regain positive 

stability. The ballast tanks were closely monitored during this operation 

and it became apparent that water from two ballast tanks was entering 

the hold. The stability calculations were reworked and showed the vessel 

to have positive stability. This was later confirmed by the Classification 

Society. 

Permission for cargo operations to commence was given nearly three days 

after the vessel’s arrival at the port. 

Observations: 

The incident was caused by free water in the cargo 

hold. 

Choked hold bilge suctions prevented the water 

being pumped out by the ship’s staff. 

Investigations showed that the vessel had sustained 

two fractures in the tank top. These were believed 

to have been caused by the heavy landing of 

containers during loading. The problem was further 

exacerbated by the fact that the heeling tank filling 

pipe had corroded through. Ironically therefore, 

ballast water used to correct the list increased the 

leakage into the hold, aggravating the problem. 

The Master was criticised for not conducting a 

more thorough investigation at the time of the initial 

listing. 

A regular systematic daily sounding programme is 

a well established procedure of good seamanship 

and would give an early indication of any problem. 

It would do away with the need to engage in the 

dangerous practice of entering enclosed spaces to 

visually check the hold. 

The difficulties in pumping out the hold once the 

water had entered were reportedly due to the 

suctions being choked with debris. This highlights the 

need for the holds to be kept free of rubbish and the 

regular proving of the pumping arrangements. The 

provision of a hold bilge alarm would have given a 

very early indication of the water entering the hold. 

The original erroneous stability calculation was a 

major contributing factor to the delay suffered by 

the vessel. This should have been carried out prior 

to leaving the load port. Third party calculations can 

not be relied upon. 

The base of cell guides which carry the brunt of 

heavy container movements, should be inspected 

on a regular basis so that corrosion and weakness 

can be detected at an early stage. 

Root Cause: 

Inadequate maintenance procedures. 


The total claim is expected to be in the region of 

US$75,000 to US$100,000. 



32 33

Dry Cargo: 

Ro-Ro 

Cargo 

Premature Signing for Cargo Consignment Causes Hangover 

The Incident: 

This case involves cargo theft within the port area. A brewery shipped 

a consignment of 282 cartons of beer on three shrink wrapped pallets 

between two depots in south east Asia. There was no direct shipping 

service between the depots. The beer was therefore shipped to an 

intermediate port where it was discharged for trans-shipment. The 

beer was loaded onto trucks for delivery to our Member’s vessel. As 

was their custom, our Member signed for receipt of the beer at their 

dock gate office. The truck and its consignment of beer disappeared 

somewhere between the dock gate office and the ship’s side. As a 

result of poor communications between the ship and the dock office, 

the disappearance of the beer was not noticed and it was only after 

the voyage was completed and a claim for non-delivery was received 

from the brewery that the circumstances came to light. The brewery 

was able to produce the road hauliers documents signed by the 

shipowner showing that the beer had been delivered and had been 

accepted into the care of the shipowner. As a result the owners had to 

pay for the loss. 

Observations: 

Shipowners accepting cargo into their custody 

must take reasonable precautions to prevent loss 

or damage of the cargo. The custom and practice 

at the load port was for shipowners to accept 

consignments at the dock gate rather than at the 

ship’s side. There was however no system for 

controlling or monitoring the progress of the cargo 

from there to the ship. In this case the loss could 

have been avoided either by only signing for the 

cargo when it had been actually delivered to the 

vessel itself or ensuring that proper procedures 

were in place for monitoring the progress of the 

cargo after acceptance at the dock gate. 

Root Cause: 

Lack of shore procedures. 


The cost to the shipowner exceeded US$5,000. 



34 35

Cargo 

Poor Lashing Procedures Cause Destruction 

The Incident: 

During a voyage across the English Channel in 

heavy weather some vehicles on the car decks 

broke their lashings with the result that 18 lorries, 

their cargoes and three cars were damaged, 

resulting in many claims. 

Observations: 

Surveyors appointed by the Club reported that the 

principal cause of the damage was the ship’s crew’s 

failure to properly lash the articulated vehicles. Our 

surveyors reported that there was no company 

operating manual on board giving the crew guidance 

on car deck operations and safety. M-Notices and 

IMO publications were also unavailable. The Master 

had given no standing orders relating to car deck 

safety, nor had he set weather criteria above which 

cargo should be lashed. 

Root Cause: 



The damage to the vehicles amounted 

to US$128,150. 



The majority of the damage was caused by a 

number of articulated vehicles which were only 

secured by four lashings, one at each corner of the 

combined vehicles. This lashing system was totally 

inadequate for vehicles that did not form a rigid 

unit. In each case the damage was caused by the 

vehicles jack-knifing, i.e. hinging at the joint between 

the tractor and trailer units. The jack-knifing 

resulted in the general slackening of the lashings 

which were then subjected to shock loadings 

from the movement of ship and vehicles, with the 

consequence that they eventually parted. 

The claims that resulted from this incident were 

completely avoidable. Lashing the vehicles in 

accordance with IMO guidelines would have 

prevented the jack-knifing and consequent damage. 

Companies operating ro-ro ferries are now required 

to provide their vessels with a comprehensive cargo 

securing manual and Masters should issue standing 

instructions on when lashing is required and who 

has responsibility for ensuring that it is done. 

36 37

Section 2 

Tankers 

39

Tankers: 

Petroleum 


Explosion in Dockyard 

The Incident: 

A small tanker went into a repair yard to have damage to her 

starboard bow repaired. The vessel habitually carried premium 

motor spirit in all her cargo tanks and prior to arriving at the yard 

had cleaned and gas freed the tanks by filling them to overflowing 

with seawater. Before hot work commenced the owners brought 

in a surveyor to test for explosive atmosphere and issue a gas free 

certificate. The certificate declared the vessel fit for hot work and 

indicated that all cargo tanks had been tested and found gas free. 

As shipyard workers started to cut away the damaged section an 

explosion occurred in the fore peak tank, severely damaging the 

vessel and badly injuring two workers. 

Observations: 

The explosion almost certainly occurred as a result 

of an accumulation of explosive vapours in the fore 

peak tank. The reason for the accumulation was 

never discovered. The coffer dam separating the 

fore peak tank from the cargo tanks was found 

to be clean, dry and free of cargo vapours. The 

incident highlights the desirability of testing the 

atmosphere in all enclosed spaces on tankers prior 

to commencing hot work. 

In this case there was no formal contract between 

the vessel’s owners and the repair yard. The 

question of responsibility for ensuring that the 

vessel was fit for hot work to be carried out was 

not clear. We would recommend that owners 

ensure this subject is addressed in every repair 

contract and that where possible the shipyard be 

given this responsibility. 

Root Cause: 

Insufficient safety procedures. 


The entire fore part of the vessel had to be replaced 

at a cost of US$200,000. Claims by the injured 

workers were met by the shipyard’s insurers. In 

addition to this surveyor’s fees exceeding US$4,000 

were incurred. 



40 41


Injury During Unmooring Operation 

The Incident: 

This accident involves a serious injury during 

unmooring operations as the vessel prepared to 

sail. The crew had been sent to stations and the 

vessel had been singled up while awaiting customs 

clearance. The last two lines on the foredeck were 

those permanently stored on the windlass drums. 

At 08.30 customs clearance was obtained and 

the order was given to let go forward. When the 

foredeck crew tried to slack down the line on the 

starboard drum for letting go it would not do so. 

During efforts to free the rope the chief officer’s 

foot was caught in the machinery, resulting in very 

serious injuries to his toes. 

Observations: 

The berth had been exposed to a heavy swell 

which had caused the vessel to surge continually 

whilst alongside. The surging action had resulted 

in the mooring rope on the starboard windlass 

drum becoming buried in itself. When it became 

necessary to slacken down the line it jammed. The 

chief officer attempted to pull the line clear and 

in the process put his foot on the winch-bearing 

A-frame support forward of the starboard drum. 

The A-frame support is close to the drum face 

which had four flat bar stiffeners welded to it. The 

stiffeners passed close to the support, creating a 

guillotine-like effect. The mate’s foot was caught in 

the gap when the drum rotated and despite wearing 

steel-capped safety boots he was severely injured. 

The mate was fortunate as immediate hospitalisation and extensive microsurgery 

managed to save his toes. 

Following this incident the winch drums were modified to prevent a recurrence. 

This accident highlights the dangers of working too close to winches. The accident would 

have been avoided if the chief officer had employed a method of freeing the rope which 

did not involve close proximity to the machinery. One possible method might have been 

to put a stopper on the mooring rope while continuing to veer, thus using the power of 

the winch to free the rope without creating the necessity for personnel to be in close 

proximity to it. 

Root Cause: 

Defect with equipment design. 




42 43


Severe Injuries Result From Failure to Follow Proper Procedures. 

The Incident: 

This incident occurred on board a tanker lying at anchor in 

sheltered waters. The vessel had been having trouble with its SSB 

radio and the radio officer had been instructed to investigate this 

problem. 

Shortly after lunch the Master was awakened from his afternoon 

nap by a loud thump. When he investigated he found the radio 

officer lying injured on the deck having fallen 18 metres from the 

mast. The radio officer who had broken both legs, an arm, a rib and 

sustained internal injuries, was evacuated immediately to hospital 

where he was placed in intensive care. 

This company had compiled and provided the ship with a safety 

manual which included detailed instructions for working aloft. In 

addition several copies of the Code of Safe Working Practices for 

Merchant Seamen were available on board for the crew’s use. The 

radio officer had not complied with the requirements of either the 

Code or the safety manual. He was working alone and had not 

advised the duty deck officer that he would be working aloft. He 

was not wearing a safety harness. 

Observations: 

Although the owners had provided the vessel with a considerable 

quantity of safety documentation, that in itself was insufficient to 

instil a safety-conscious attitude amongst the crew. Unless senior 

management take a close interest in enforcing a proper safety 

regime on board, a safety culture will not develop within the 

company. If safety consciousness had been highly developed, the 

radio officer would probably not have considered working aloft 

without taking the proper precautions. 

Root Cause: 

Insufficient safety environment. 


The owners had to pay substantial compensation to the radio officer 

even though he was primarily responsible for the accident occurring. 

The total cost to the company after costs were taken into account 

was almost US$40,000. 



44 45

Cargo 

Deviation from Agreed Discharge Plan Leads to Cocktail 

The Incident: 

The vessel involved in this case is a coastal tanker carrying a full cargo of four grades of 

lubricating oil. The vessel arrived at the discharge berth where she was due to discharge 

into both shore tanks and barges moored alongside. After the ship was ullaged and samples 

taken, a written discharge plan was agreed between the ship and the terminal. The plan 

was signed by the ship’s officers but retained by the terminal with no copy being left on 

board. The details of the plan were recorded in the duty officer’s notebook. It had been 

agreed that initially two parcels, 500 SN and 100 SN, would be discharged to the shore 

followed by 200 SN and 150 SN. 

The 500 SN and 100 SN manifolds were prepared for the cargo hoses. After the 500 SN 

hose had been connected the jetty operator asked whether the second open manifold 

was for 150 SN. The duty officer advised him that it was the 100 SN manifold. The jetty 

operator told the duty officer that he wanted the 150 SN not the 100 SN. The duty 

officer reminded the jetty operator that it had been agreed in writing that the 100 SN 

would be discharged before the 150 SN. Despite this the jetty operator continued to insist 

that he wanted 150 SN and as a result the manifolds were changed over and the hose 

connected to the 150 SN manifold. After approximately 1½ pumping the shore asked the 

vessel to stop despite the fact there was approximately 70 metric tons left on board. On 

investigation it turned out that despite what the jetty operator had said, the terminal had 

been adhering to the original discharge plan with the result that 180 tons of 150 SN had 

been pumped into the wrong tank, contaminating the 220 tons of 100 SN it contained. 

Observations: 

The vessel had followed the correct procedure up 

until the time the second cargo hose was connected. 

At that point the duty officer agreed to deviate from 

the written plan without proper authorisation. If 

the officer on watch had insisted that a new cargo 

discharge plan had been drawn up or the original 

one amended in writing, the confusion within the 

terminal would have become apparent and the 

contamination would have been avoided. 

Root Cause: 

Non compliance with procedures. 


The shipowners and terminal operators negotiated 

a commercial settlement with the owners of the oil. 

The cost of investigating this incident and obtaining 

the legal advice on which negotiations were based 

amounted to US$17,000. 



46 47

Cargo 

The Cost of Ensuring the Vessel’s Turnaround 

Time can be Outweighed by the Final Overall Cost 

The Incident: 

This claim involved a 5000gt products tanker 

discharging two grades of cargo simultaneously. 

During the course of the discharge cross grade 

contamination occurred. 

The vessel is designed so that she can carry 

a maximum of three grades of cargo whilst 

maintaining two valve separation and on this 

particular occasion two grades were carried. 

Loading was completed without incident. 

Discharge of the two grades was commenced 

simultaneously utilising No.1 pump for one grade 

and No.3 for the second grade. During the 

course of the discharge, No.1 pump developed 

a leak at the forward seal and the pump became 

unserviceable. The pump was stopped and 

the pipelines set up to discharge the unleaded 

gasoline via No.2 cargo pump. The discharge was 

continued. At some stage thereafter the terminal 

advised the vessel that contamination between 

grades had been noted ashore. 

Observations: 

The design of the vessel is such that two valve 

separation can only be maintained when each of the 

three pumps is used on its own designated tanks 

or the two outside pumps (nos 1 & 3) are utilised; 

whenever consecutive pumps are lined up on tanks 

of one of the other systems then only one valve 

separation is possible. Unfortunately in this incident, 

the decision to utilise No.2 pump on No.1 system 

cargo tanks resulted in single valve separation 

between the two grades. (It is believed that during 

the stripping phase of discharging one of the grades, 

the pressure differential across the valve allowed the 

contamination to take place). 

Two valve separation between grades is considered 

the minimum acceptable by the petroleum industry 

as the likelihood of two valves failing at the same 

time is considered to be acceptably less than the 

failure of a single valve. [Failure can be caused by: i) 

a defective seal; ii) debris lying in the valve seat; and 

iii) the valve not being closed fully]. 

In this incident, the decision to continue discharging 

both grades simultaneously after the pump 

failure was wrong, however it is not known what 

commercial pressures, if any, were placed upon the 

vessel to expedite the discharge. 

In such circumstances if shore terminals insist on 

ships continuing operations, the representative 

making the request should be made fully aware 

of the possible consequences and requested to 

accept the responsibility for any adverse effects. If 

responsibility is to lie with the Master and vessel, 

then the operation should be continued within the 

limitations of the vessel’s design. 

Root Cause: 

Failure to comply with vessel design. 


The cost of this claim is US$110,000. 



48 49

Cargo 

Two Valves are Better than One 

The Incident: 

This vessel was a small parcel tanker time chartered to an oil major, 

plying between two of their terminals. The vessel was fitted with five 

sets of cargo wing tanks, fed by a ring main pipeline system. On the 

voyage in question the vessel was ordered to load two grades of motor 

spirit. The first, unleaded petrol, was loaded into 2 and 4 wing tanks. 

This was followed by leaded petrol being loaded into 1 and 5 wing tanks. 

Number 3 wing tanks remained empty. 

On arrival at the discharge berth both grades were to be discharged 

ashore simultaneously, the leaded petrol was to be discharged using 

the portside pump/line system and the unleaded via the starboard 

side pump/line system. Shortly after discharge commenced the 

starboard pump broke down. As a consequence 1 and 5 wing tanks 

were completely discharged whereafter the line was flushed with fresh 

water and disconnected. The unleaded hose was then connected to the 

portside pump/line system which was then used to discharge the second 

parcel. Shortly after discharge resumed terminal personnel informed 

the vessel that measurement of shore tanks indicated that an additional 

90 cubic metres of product had been discharged with the first parcel of 

leaded petrol. Discharge operations were stopped and an investigation 

was mounted. The investigation revealed that a crossover gate valve in 

number 2 port cargo tank had not been properly closed, with the result 

that unleaded petrol had been drawn from the starboard line system 

and discharged with the leaded petrol. 

Observations: 

The tanker’s ring main system only permitted single valve separation 

between the two grades of cargo with the result that the failure of 

a valve or operator error in the manipulation of the valves would 

inevitably result in cross contamination. Subsequent to this incident 

the vessel’s pipeline system was modified to give proper segregation 

between cargo grades. 

Root Cause: 

Failure to comply with vessel design requirement. 


On this occasion the oil company was able to resolve the problem 

of the contaminated fuel by blending and no cargo claim was made. 

Nevertheless the costs of investigating the matter amounted to 

approximately US$1,000. 



50 51

Cargo 

Poor Tanker Practices Leads to Expensive Delay for Member. 

The Incident: 

This tanker had been chartered to a company which had a contract of 

affreightment with a major oil company. The vessel was ordered to load 

premium motor spirit and automotive diesel oil at two separate berths. 

The motor spirit was loaded in 2 wings and 4 wings at the first berth 

and the automotive diesel oil was loaded in 1 and 3 wings at the second 

berth. On arrival at the discharge port the cargo in 2 wings was rejected 

by the consignee as being off-spec. The remaining cargo was found 

to be within the specification and was discharged. After discharge the 

shore tank was sampled and it was discovered that not only were both 

parcels off-specification but the outturn of volume of the motor spirit 

had apparently increased by over 100 tons while the volume of diesel 

oil had decreased by a similar figure. The contaminated oils could not be 

reprocessed at the discharge port and the vessel was delayed for over 

seven weeks while owners, charterers and the oil company argued over 

the disposal of the contaminated oil. The terminal lodged a claim for 

US$420,000, this being the value of the entire cargo. 

Observations: 

A thorough investigation by surveyors appointed 

by the Club revealed that the vessel had only been 

designed to carry a single grade of cargo, with 

the result that it was impossible to follow normal 

tanker practice in separating different grades of 

product by two or more valves. The surveyors also 

discovered that after completing loading at the first 

berth, certain valves were left open, allowing the 

cargo in 2 wings to become contaminated with 

diesel oil. The surveyor’s investigation also showed 

that during the discharge operation some more 

valves were opened in error, contaminating the 

remainder of the cargo. The surveyors were critical 

of the method and effectiveness of line-clearing at 

the discharge port. 

Root Cause: 

Failure to comply with ship design requirements. 


In this case the owners were extremely fortunate 

as the provisions of the charter party enabled them 

to pass responsibility for cargo contamination on 

to the charterers. Nevertheless the costs of the 

investigation alone amounted to US$17,000. In 

addition to this the owners were unable to trade 

the vessel for approximately two months. 

This vessel is no longer entered in the Club. 



52 53

Cargo 

Master’s Commercial Awareness could have Reduced Claim 

The Incident: 

The claim arose on board a coastal tanker carrying 

premium motor spirit. The bill of lading was issued 

using the shore terminal’s figures. As this figure was 

greater than the quantity calculated a letter of protest 

was issued by the Master to the loading terminal. 

At the discharge port the vessel’s cargo pumps 

lost suction before the tanks were completely 

dry. It proved impossible to regain suction and the 

cargo remaining on board was considered to be 

unpumpable. On completion of discharge the vessel 

was heavily trimmed by the stern with the result 

that the cargo residues lay in wedges at the ends of 

the cargo tanks aft of the sounding pipes. The actual 

quantity remaining on board could not therefore be 

accurately assessed. 

The receiving terminal claimed short delivery of 

over 50 metric tons based solely on the difference 

between the bill of lading figure and the shore outturn 

figure. 

At the next berth surveyors appointed by the Club 

attended on board and by reducing the vessel’s trim 

were able to accurately establish the amount of 

cargo remaining on board. It was found to be just 

under 22 metric tons and not over 50 as alleged 

by the consignee. The value of the difference was 

approximately US$7,000. The evidential value of our 

surveyor’s report was however seriously weakened 

because the survey took place some time after 

discharge had been completed, when consignee’s 

representatives were not in attendance. 

Observations: 

If the vessel’s Master had reduced the vessel’s trim and properly 

quantified the unpumpable ROB before leaving the discharge berth 

while the consignee’s surveyor was still in attendance, the owners 

would have been in a much stronger position to resist the short 

delivery claim. 

Root Cause: 

Insufficient operation procedures. 


It was possible to negotiate a settlement of the short landing claim 

however the total cost including surveyor’s fees exceeded US$9,000. 



54 55

Cargo 

Out of Sight Really Can Mean Out of Mind 

The Incident: 

This claim involved a products tanker delivering 

contaminated cargo on three consecutive voyages. 

On the first two occasions the terminal accepted the 

cargo, but although finally accepting it the third time 

it was with some reluctance. 

During the course of each of the three discharges 

the products to varying degrees were found to 

be contaminated with water. Blending or further 

refining was required to return the products to the 

original specifications. 

The cause of the contamination proved difficult 

to find because the water was noted to have very 

low chlorides which indicated (incorrectly) that 

the contamination was not caused by seawater. In 

addition, during the final discharge the contamination 

was noted to be intermittent. 

It was finally assumed that the water was entering 

the cargo tanks through defective valve glands – 

although the cargo sample from the tanks was within 

specification! 

Upon completion of the third discharge the vessel 

sailed and anchored off the port. 

Further investigation by the crew at this time 

determined that “several years” prior to this spate 

of contaminations, the vessel had experienced cargo 

leaking out through a sea valve. As a result a 6mm 

blank was inserted on the outboard side of the sea 

valve, and unfortunately this had been forgotten. As 

time passed the blank had corroded through and 

when ballasting, unbeknown to the ship’s crew, a 

section of the pipeline filled with water. When cargo 

was subsequently being discharged, this water was 

then drawn into the cargo. 

Observations: 

Whenever a blank is inserted into a pipeline it 

should be made as conspicuous as possible and all 

staff associated with cargo operations made aware 

of its existence, including subsequent crews. 

In addition, a blank inserted in a pipeline as a result 

of a leaking valve is only a temporary measure and 

should not be left in place for years on end. The 

efficiency of the overhaul of ship side valves during 

dry docking must also be questioned. 

Root Cause: 

Insufficient maintenance procedures. 


Because the receivers accepted most of the 

contaminated cargoes without complaint, the overall 

cost of this claim is US$5,000. 



56 57

Cargo 

Poor Line Washing Probably Caused Contamination 

The Incident: 

This is a case of cargo contamination on board a parcel tanker. On its previous voyage the 

tanker carried a full cargo of gas oil. After discharge the tanks were washed in preparation 

for carrying a number of high quality products. Prior to loading the tanks were inspected 

by an independent inspector and passed as being clean, dry and suitable for the products 

to be loaded. A number of products were then loaded including a parcel of solvent C9 in 

4 wings. On arrival at discharge port the samples of the solvent taken by the consignees’ 

surveyor showed a slight change in colour. Gas chromatography analysis revealed that the 

product had been contaminated by very small quantities of gas oil. Consignees claimed that 

the slight change in colour was sufficient to render the product unmarketable and rejected 

the entire consignment. The contaminated cargo was eventually sold to a salvage buyer for 

less than half its original value. 

Observations: 

This incident highlights the importance of tank cleaning and line washing in preparation 

for the carriage of high grade products and chemicals. In this case the cause of the 

contamination was never properly determined. The vessel’s tank coatings were in good 

condition and the tanks had been passed by an independent surveyor. The most likely 

source of contamination seems to be inadequate or incomplete line washing, with the 

result that a plug of the previous cargo became trapped in the pipeline system. It is vital 

that line washing be arranged in such a way as to ensure that every section of the pipeline 

system is thoroughly flushed through during the process. 

Root Cause: 

Inadequate line washing. 


The total cost of this claim after the proceeds of the salvage sale had been taken into 

account exceeded US$73,000. 



58 59

Navigation 

With the Tide is Against Convention 

The Incident: 

This incident occurred when a 1,500 GRT tanker was berthing at an 

oil jetty. During the berthing manoeuvre the vessel’s bow came into 

contact with the hose gantry on the jetty, damaging both the gantry and 

two cargo hoses. In his statement the Master alleged that the cause of 

the contact was the vessel failing to respond to an astern engine order. 

Observations: 

According to both the Chief Engineer and Engineering Officer of 

the watch, there was no mechanical problem during the berthing 

operation. Subsequent investigation by a surveyor revealed that the 

Master had been attempting to berth with the tide under his stern. It 

is highly likely that the Master simply misjudged the effect of the tide 

when applying astern power. This accident would probably have been 

avoided if the Master had adopted a conventional uptide approach to 

the berth. 

Root Cause: 

Human error. 


The costs of repairs to the jetty exceeded US$46,000. 



60 61

Navigation 

Member’s Involvement with Delay to Deep Sea Vessel Proves Expensive. 

The Incident: 

This incident involved a small bunker barge which had 

been engaged to supply lube oil to an ocean going 

vessel at anchor. During the bunkering operation the 

deep sea vessel’s gangway had been lowered and 

used to provide access to and from the bunker barge. 

After bunker operations had been completed the 

crew did not hoist the gangway before casting off 

the barge’s mooring lines. As the barge manoeuvred 

away from the side of the ocean going vessel it came 

into contact with, and damaged, the ship’s gangway. 

Although the negligence of the deep sea vessel’s crew 

was a major contributing factor in this loss, the Club 

was advised that the barge would be held liable for 

not exercising sufficient care while manoeuvring away 

from the vessel’s side. 

Observations: 

This claim illustrates how a relatively minor incident 

can be greatly inflated if the damage causes delay to 

a large vessel. In this case the problem could have 

been avoided if the bunker barge had insisted on the 

gangway being raised clear before departing. 

Root Cause: 

Failure to comply with procedures. 


Repairs to the accommodation ladder took four 

days and cost US$13,000. In addition to the cost of 

repairs the owners of the deep sea vessel claimed 

four days’ loss of hire which when combined 

with additional port dues, survey fees and other 

miscellaneous expenses brought the total claim 

against our Member to almost US$36,000. Although 

we were successful in negotiating a settlement at a 

reduced figure, the total cost to the barge owners 

after surveyors’ and correspondents’ fees had been 

paid exceeded US$27,000. 



62 63

Navigation 

Rushed Approach Results in Collision 

The Incident: 

In the early hours a bunker tanker finished loading a cargo of fuel oil 

and left the berth bound for the anchorage to await the arrival of the 

deep sea vessel she was to service. The anchorage was crowded and 

the vessel worked through the moored vessels at slow speed looking for 

a suitable spot to drop the anchor. The vessel came upon a clear area 

and the Master made a snap decision to anchor in that spot. The tanker 

had the wind on her starboard quarter and a 2 knot following tide. To 

bring the vessel head to wind and tide the helm was put hard aport and 

the engine full astern. Unfortunately the Master totally misjudged the 

strength of the tide and the vessel was swept broadside onto the bows 

of an anchored vessel. Number 3 cargo oil tank was breached and over 

20 cubic metres of heavy fuel oil spilled into the water. 

Observations: 

This incident would probably have been avoided if 

the Master had not been in such a hurry to anchor 

and had adopted a more conventional approach. 

Instead of trying to swing the vessel immediately 

he should have continued on until he could turn his 

vessel safely and approach the anchorage position 

heading into wind and tide. The method of approach 

adopted prevented him properly assessing the 

effects of wind and tide on his vessel and as a result 

he completely misjudged his approach. 

Root Cause: 

Human error. 


In addition to the cost of repairs to the anchored 

tanker the owners received a substantial claim from 

the Port Authority for oil pollution monitoring and 

clean up operations. This brought the total cost 

excluding the cost of damage to his own vessel to 

over US$82,000. 



64 65

Navigation 

But We’ve Always Done it That Way 

The Incident: 

We have been advised of the following case, 

featured in the Marine Accident Investigation Branch 

(MAIB) safety digest No1/2007 (see below link for 

the document) that we feel will be of great interest 

to our Members. 

“Poor bridge team management practices while 

approaching and entering a narrow channel led 

directly to the grounding of a 1,845gt tanker. It had 

been the early hours of the morning and the vessel 

was returning to her usual load port, in ballast. The 

bridge watch consisted of an officer of the watch, a 

lookout and the Master. 

The vessel had passed through the same channel a 

few days earlier on her loaded passage, and reciprocal 

courses had been chosen for the return passage. 

The planned track involved a 40 degree alteration 

of course just one ship’s length before the entrance 

to the channel. The bridge that spanned the narrow 

passage at its entrance had a white transit light which 

marked the centre of the bridge and the channel. 

As the vessel approached the channel at full speed, 

the Master took the con, switched the helm to hand 

steering and, against company instructions, started 

to steer the vessel himself towards and through 

the narrow entrance. The officer of the watch 

was looking on without a defined monitoring role. 

However, he had plotted a position on the chart, 

which showed the vessel to be north of the charted 

course line, and the Master had altered the vessel’s 

heading slightly in an attempt to partly compensate. 

Before the vessel had moved far towards her track, 

the Master decided to steer directly for the white 

light which indicated the centre of the bridge’s span. 

The vessel had recently been fitted with an 

electronic chart system following a similar accident 

on another of the company’s ships. The Master 

could see the electronic chart display, but was not 

using it other than to give him a rough indication 

of her position. He had never received any formal 

training in the use of this equipment. 

As the vessel passed under the centre of the bridge, 

the Master used 10 degrees of port helm to bring 

her around 40 degrees to the required heading for 

passage. No allowance, mental or otherwise, had 

been made for the vessel’s advance and, unsurprisingly, 

she grounded on the southern edge of the channel. 

The vessel sustained significant hull damage. She was 

holed in one segregated ballast tank but, fortunately, 

there was no pollution as a result of the incident. 

Observations: 

1. The MAIB has frequently heard it argued that it 

is unrealistic to expect coastal shipping to adopt 

the navigational practices that would normally be 

found on deep sea vessels, because of the nature 

of the trade and the size of crews. Owners and 

Masters must ensure that they do not use this 

argument to justify bad practice and complacency. 

2. The wheelhouse was well manned with qualified 

personnel, but the team was not used effectively 

to ensure the vessel’s safe passage. In this case, 

a better arrangement would have been for the 

seaman to have steered the vessel while the 

OOW plotted positions and the Master oversaw 

the whole safe operation. 

3. Passage planning was ineffective. A planned track 

that allowed the vessel to alter course and steady 

up on the new heading well before the entrance 

to the channel would have ensured this accident 

was avoided. Reciprocal courses were chosen 

for expediency, without consideration of this and 

possibly other factors. The use of parallel indexing 

techniques would have helped to ensure the 

vessel was on, and maintaining, the correct track. 

4. Some of these lessons had been discovered by 

the company as a result of a very similar accident 

a few months previously. However, the lessons 

had not been effectively communicated to this 

vessel or her Master. It is an unfortunate truth 

that accidents are a key source of useful safety 

advice, and every effort should be taken to learn 

and promulgate the lessons so that recurrence 

can be avoided”. 

Source of information - Marine Accident 

Investigation Branch (MAIB) safety digest No1/2007 

- http://www.maib.gov.uk/publications/safety_ 

digests/2007/safety_digest_1_2007.cfm 

Root Cause: 

Insufficient navigation procedures. 



66 67

Navigation 

Insufficient Ballast Causes Loss of Control While Berthing 

The Incident: 

This incident involved damage to a loading arm 

at a small oil jetty. The oil jetty in question was 

specifically designed for small vessels and is typical of 

many in the region. The berth consisted of a central 

section containing the loading arms on either side 

of which was a mooring dolphin connected to the 

berth by walkways. 

The incident occurred as the tanker was 

manoeuvring alongside the berth. The tanker was 

berthing in a light condition without tug assistance. 

The forward draft was only 0.6 metres. The wind 

was blowing onto the berth as the Master made 

his approach into the current. As he stopped 

his vessel parallel to the berth, the high windage 

forward caused the bows to fall off. The bow of 

the vessel entered the space between the dolphin 

and the berth, coming to rest with the vessel’s bow 

in contact with the central section. To extricate 

himself the Master put his engines astern and in the 

process the fo’c’sle railing caught the end loading 

arm, severely damaging it. 

Observations: 

Cargo loading arms on small jetties are particularly 

susceptible to damage by ships as they are usually 

mounted close to the edge of the berth. This 

incident could have been avoided by ballasting the 

forward end of the tanker to reduce the windage 

and increase the grip of the forefoot in the water. 

If operational considerations made this undesirable 

then the assistance of a tug should have been sought. 

Root Cause: 

Inadequate operational considerations. 


The cost of repairs to the loading arm exceeded 

US$100,000. 



68 69

Navigation 

Know Your Ship 

The Incident: 

This accident occurred as a 3,000 GRT tanker attempted to berth alongside an oil jetty in 

marginal conditions without tug assistance. The vessel was trying to berth for the fourth 

time, the three prior approaches had to be aborted because of the effects of wind and 

current. On this occasion the approach to the berth was going well with the vessel due 

to dock portside to. As she approached the berth the helm was put hard astarboard, 

the forward spring sent way and the engines put astern. The vessel did not respond to 

the helm and the ship’s port bow landed heavily on the jetty, damaging the concrete 

structure and the fendering system. 

Observations: 

The Club appointed a surveyor to investigate the occurrence. The surveyor discovered 

that the vessel was fitted with a lefthanded propeller. The transverse thrust generated 

when a lefthanded propeller is run astern tends to cant the bow to port rather than 

to starboard as is the case with the more usual righthanded propeller. It is likely that in 

the marginal circumstances the transverse thrust generated when the engines were put 

astern was sufficient to counteract the effect of putting the helm hard astarboard. 

Root Cause: 

Crew unfamiliar with their vessel. 


The cost of repairs to the jetty including survey costs totalled US$15,500. 



70 71

Navigation 

Good Seamanship is Still as Important as Ever 

The Incident: 

This case involves damage to a deep sea vessel while unberthing a bunkering barge. 

The deep sea vessel was lying head to tide which was running at approximately 1 knot. 

The wind was blowing on her starboard bow at about force 3 to 4. The bunker barge 

was secured alongside her starboard side. After delivering the fuel the Captain of the 

bunker barge gave instructions to single up to one headline and the forward spring. By 

steaming gently ahead into the spring and heaving on the headline the stern was sprung 

off to an angle of about 30°. The lines were let go and the engines put slow astern. With 

the bunker barge in a light condition the bows were high in the water and as she moved 

away the wind caught the bows, swinging them towards the deep sea vessel. The Captain 

of the bunker barge stopped his engines in the hope of softening the contact, the wind 

however continued to push the vessel’s bows to leeward with increasing speed until she 

collided with the deep sea vessel, scraping down her side. 

Observations: 

In conditions such as these it is essential that full 

account is taken of the effects of wind and tide. 

Bold and decisive action must be taken and full use 

made of engine and rudder. If the Captain of the 

bunker barge had put his engines to full astern after 

springing his stern out it is quite possible that he 

would have gained sufficient stern way to carry his 

ship clear of the ocean going vessel before much 

damage was done. In stopping his engines he left his 

vessel at the mercy of the wind and rendered the 

collision inevitable. 

With the prevailing wind and current the Master 

of the bunker barge should have let go forward 

and held onto his stern spring, steaming astern as 

necessary to spring the bow off. The current on the 

bow would have been sufficient to counteract the 

effects of the wind and the transverse thrust from 

the propeller as she moved off ahead would help lift 

the bunker barge’s stern clear of the deep sea vessel. 

Root Cause: 

Human error. 


This owner was fortunate for although the damage 

to the deep sea vessel extended for some distance 

down its side the indentation was not deep enough 

to worry the class society and as a result a claim was 

not pursued. 



72 73

Operations 

Luck has Staring Role in Preventing Pollution 

The Incident: 

A bunker tanker was engaged in delivering bunkers 

to an ocean going vessel. The transfer plan was to 

discharge numbers 2 and 5 tanks simultaneously 

using a separate pump on each tank but discharging 

into a common line. As the oil transfer commenced 

it was noted that the discharge pressure gauge 

on the pump connected to number 5 cargo tank 

showed no appreciable reading. As there was no 

improvement after a few minutes all pumping was 

stopped and the matter was investigated. 

The pump was found to be full of air which was bled 

out through the air cock valve. As the pumps were 

restarted number 5 cargo oil tank overflowed on 

to the deck. Both pumps were stopped, all valves 

closed. Fortunately the oil spill was contained on the 

deck of the bunker barge. 

Observations: 

The problem with the cargo pump had allowed 

oil pumped from number 2 cargo tank into the 

common discharge line to flow back into number 5 

cargo oil tank. This flow would have continued even 

after the pumps were stopped as gravity would have 

caused the oil in the discharge line to siphon back 

into the bunker tanker below. Had the vessel been 

fitted with high-level alarms it is likely that this spill 

could have been avoided. Adhering to good tanker 

practice by starting the discharge from one tank at 

a time and positively confirming that oil was flowing 

out of the tank before starting the next one would 

have done much to avoid the problem. 

Root Cause: 

Ship design failure. 


In this instance although no oil reached the water, 

the company received a bill from the Port Authority 

for more than US$600. In addition to this the owner 

faced additional costs in disposing of the oil on deck 

and cleaning the vessel. 



74 75

Operations 

Hose Bursts Under Pressure 

The Incident: 

In recent months, the Club has been involved in a 

large number of pollution incidents which have been 

caused by transfer hoses bursting during bunkering 

operations. The following is a typical example. 

The Member’s vessel was employed in the process of 

transferring 600mt of heavy fuel oil into a receiving 

ship. She was tied up starboard side alongside and the 

transfer was being effected by using one cargo pump 

and a 30 metre long 6 inch diameter cargo hose. 

The Bunker Requisition Form was agreed between 

both parties indicating a pumping rate of 200 mt/hr 

with a maximum manifold pressure of 2kg/cm2 . The 

transfer began at 0950. 

At 1125 a bang was heard and oil was seen leaking 

out of a section of the transfer hose lying on the deck 

of the Member’s vessel. Pumping operations were 

stopped and both crews implemented measures to 

reduce the spilling of oil into the harbour. After a 

short while the harbour authorities’ launch arrived 

and undertook clean up operations to minimise the 

effects of the oil spill. 

Observations: 

At the time of the incident, the receiving vessel had 

40 metric tonnes of the stem left to receive and the 

cause of the hose bursting was considered to have 

been over pressurisation when the tank valves were 

possibly closed in as the receiving vessel’s tanks 

were being topped off. 

However investigations carried out by the Club 

surveyor showed the condition of the cargo hoses 

to be poor. Several splits were noted in the outer 

covering. The point at which the hose burst was 

located within a section of hose that had been 

parcelled to give protection against chaffing so any 

deformations or damage to this section would not 

be readily apparent. What the condition of the hose 

played in the incident is unknown. 

Notwithstanding any regulations, if hoses (or any 

equipment) exhibit defects they should be tested 

immediately and measures taken to replace them. 

Satisfactory test results only show the hose is in an 

acceptable condition at the time of testing. It does 

not provide a guarantee the hose’s condition will 

remain satisfactory when subjected to further wear 

and tear. It should also be borne in mind that bunker 

vessels, by the very nature of their work, place 

a greater burden on their equipment than other 

tanker types and therefore their equipment should 

be examined on a more frequent basis. 

Root Cause: 

Inadequate maintenance programme. 

The Member had complied with the local authority 

requirements for the testing of the hose which 

required a pressure test to be carried out twice 

every five years with a maximum interval between 

tests of three years. The regulations do not make 

any reference to the general condition of the hose. 

Because of the poor condition, the Club only agreed 

to provide security when it was proven that the 

local regulations had been complied with. 


The Club put up security for US$40,000 to cover 

the port authority costs. 


76 77

Pollution 

Pollution 

Good Record Keeping Wins the Day 

New Ship, New Crew – Same Old Problems 

The Incident: 

This incident occurred during bunkering operations in 

sheltered waters. The bunker tanker was delivering 

gas oil to an ocean going vessel when the gaskets on 

the strainer box on board the deep sea vessel burst, 

with the result that gas oil spilt over the deck and into 

the sea. The deep sea vessel was fined by the Port 

Authority and sought indemnity for this and the cost 

of cleaning their vessel. The deep sea vessel alleged 

that the bunker barge had greatly exceeded the 

agreed loading rate. 

Fortunately the personnel on board the bunker barge 

had kept proper records of the transfer operation 

and we were able to show quite conclusively that the 

agreed loading rate had never been exceeded. It is 

likely that the increase in pressure which caused the 

packing to burst was the result of valves being closed 

on the deep sea vessel. 

Observations: 

This case highlights the need to keep proper records 

during oil transfer operations. Had the barge’s crew 

not been diligent in recording events, taking regular 

tank soundings and noting pump speeds, we would 

have found it much more difficult to avoid liability. 

Root Cause: 

Inadequate maintenance programme. 


Nil. 



The Incident: 

This minor oil spill occurred during a bunkering 

operation in sheltered waters. The bunker barge was 

supplying fuel to the deep sea vessel from tanks 2 and 

4. As the bunkering operation neared completion 

tank 5, containing a different grade of oil, overflowed 

on to the deck. The officer in charge of the cargo 

operation promptly stopped the bunkering operation. 

The spill was largely contained within the vessel’s oil 

spill coaming where plugged scuppers prevented the 

accumulated oil from flowing over the ship’s side. 

Nevertheless the vessel was fined by the harbour 

authorities. 

The cargo of 380 CST oil in number 5 tank was 

contaminated by approximately 50 tons of 180 CST 

oil bringing the average viscosity down to 300 CST. 

No claim was made by the charterers who were able 

to dispose of this oil with no loss of value. Surprisingly 

no claim for short delivery of bunkers was made by 

the deep sea vessel involved. 

Observations: 

The spill was caused by a crew member operating 

the wrong valves. This vessel had only joined the 

fleet a week prior to the incident and the crew 

were unfamiliar with the vessel. The valves were not 

colour coded nor were they clearly marked. The 

instructions given to the crewman were generic 

and did not specify precisely which valves should 

be operated. It is likely that this incident could 

have been avoided had the crew had more time to 

become familiar with the vessel, the valves been 

clearly marked and the crewman given precise 

instructions. 

Root Cause: 

Human error. 


This Member was fortunate as the fine and costs 

incurred did not exceed US$6,000. It could have 

been much greater. 

Issue Date: 

Case No. 

78 79

Pollution 

High Loading Rate + Too Few Crew = Pollution 

The Incident: 

This incident involves an oil spill while loading a small 

bunker tanker. The bunker tanker had returned from 

supplying fuel to an ocean going vessel. It had oil 

remaining in numbers 2, 3 and 4 wing tanks. The plan 

was to load number 1 port and starboard first and 

thereafter top up 2, 3 and 4 wings, finishing in number 

4. An 8 inch hose was connected and although the 

vessel was only due to lift 810 metric tons, the loading 

rate was agreed at 600 tons per hour. As number 2 

wings were being topped off, the crew failed to shut 

the tank valves in time and oil overflowed onto the 

deck and into the sea. 

Observations: 

Oil spills are most likely to occur when vessels are 

topping off their tanks. Extreme caution should be 

exercised at this stage and adequate personnel need 

to be stationed on deck to ensure that there are 

sufficient hands available to manipulate the valves as 

necessary. The loading rate should be reduced while 

tanks are being topped off. This procedure should 

be agreed with terminal personnel in advance. This 

incident occurred while cargo was being loaded at 

the full 600 tons per hour and only one man was 

available to monitor the tank level and manipulate 

the valves. The spill could have been avoided if 

the loading rate had been reduced and additional 

personnel utilised. 

Root Cause: 

Insufficient operational procedures. 


The cost of clean up operations and the fine 

imposed by the Port Authority brought the total 

value of this claim to almost US$9,000. 



80 81

Tankers: 

Gas 

Miscellaneous 

Capsize at Sea 

The Incident: 

This case concerns the capsize and total loss of 

a 690 ton gas tanker. The vessel was steaming 

between islands in the Philippines fully laden 

with LPG when she received a message from her 

charterers announcing a change of destination. On 

receipt of these new orders to return to a port that 

they had already passed, the helm was put hard to 

starboard while the vessel was proceeding at full 

speed. The vessel listed heavily into the turn and 

the list progressively increased until the result that 

the vessel capsized. Because of the buoyant nature 

of her cargo the tanker did not sink completely but 

came to rest floating vertically in the water with her 

fo’c’sle structure above the water level. Hull and 

machinery underwriters immediately declared the 

vessel to be a total loss, leaving the owners with the 

problem of disposing of the wreck. After a lengthy 

salvage operation the vessel was refloated with 

her cargo intact. Considerable difficulty was found 

in disposing of the vessel and her cargo because 

none of the major oil companies were prepared to 

let a damaged LPG tanker berth in their terminal. 

The vessel and her cargo were ultimately sold to a 

salvage buyer for a fraction of their true value. 

Observations: 

The most likely cause of the casualty is a reduction 

in stability caused by free surface effect of liquids on 

board the vessel. Subsequent investigation revealed 

that the vessel was having problems with leakage. In 

this case there was no formal contract between the 

vessel’s owners and the repair yard. The question 

of responsibility for ensuring that the vessel was 

fit for hot work to be carried out was not clear. 

We would recommend that owners ensure this 

subject is addressed in every repair contract and 

that where possible the shipyard be given this 

responsibility. 

Root Cause: 

Poor maintenance programme. 


The cost of refloating and disposing of the ship and 

cargo exceeded US$820,000. 



82 83

Section 3 

Fishing Vessels 

85

Fishing Vessels 


Although Out of Sight it should be Kept in Mind 

The Incident: 

This incident took place on a beam trawler and a 

resulted in a non-fatal injury to a crew member. 

During a late evening in fine weather conditions the 

fishing gear was being hauled. Four crew members 

were positioned on the top deck waiting to attend 

to the beams as they came on board. 

As they cleared the water, with the derrick standing 

vertically, the starboard topping wire parted. It came 

down with some force and struck a deckhand. It was 

later found he had sustained a fracture to an ankle 

and there is some doubt as to his ability to return to 

a life in the fishing industry. 

Observations: 

Unfortunately the head block was lost overboard 

during the incident and it is a matter of conjecture 

whether the block failed causing the wire to part or 

whether the wire parted causing the block to fail. 

The wire was reportedly only seven months old. 

The rigging arrangement for the derrick was such 

that the topping wire only moved between 150mm 

to 200mm when raising or lowering the booms, 

thus the length which rounded the block had been 

hidden from view since it was reeved. 

Although the skipper had in place a thorough greasing 

routine for the wire and blocks, the only way to 

examine this small section of wire was to land the 

derrick on to a quay, which had never been carried out. 

Both ends of the wire were noted to be frayed 

which indicates that it was likely the wire had parted, 

destroying the block. 

Root Cause: 

Inadequate maintenance programmes. 


The cost of this claim is US$80,000. 



It is not uncommon for static sections of wire to 

corrode significantly in a short period of time and 

Members and Skippers should ensure that such 

sections of wire are frequently examined and greased. 

86 87


The Importance of Good Risk Assessment Highlighted 

The Incident: 

The accident occurred when a 

crew member was attending the 

gilsen derrick guys as a catch was 

being brought on board. Three 

turns had been taken round the 

port warping drum of the trawl 

winch. The drum was rotating at a 

steady speed as the controls had 

been locked in position by the 

use of a piece of wood wedged 

between the control lever and 

frame. The crew member was 

tailing the rope behind the drum, 

surging or heaving as required 

when the fingers of his left hand 

became caught between the rope 

turns and the drum. There were 

no witnesses to the accident but 

it seems likely that a riding turn 

developed on the drum and 

instead of letting the rope go and 

stopping the winch by pulling on a 

small rope attached to the piece 

of wood, the crewman tried to 

clear the guy while the machinery 

was still rotating. Despite medical 

intervention he lost the tips to 

three fingers. 

Observations: 

There were two contributing factors to this incident. 

Firstly, the crew member was very inexperienced 

in working on a fishing vessel although the task he 

was involved in was not an unusual one in terms of 

seamanship. However it appears he tried to clear the 

riding turn whilst the winch was rotating. Secondly, 

despite two other crew members being present on 

deck, no one was designated to operate the winch 

which was left in the hauling mode by means of 

a makeshift modification. The crew member had 

allegedly been told to stop the winch in the event 

of any problems, but failed to do so. Had a winch 

operator been present, stopping the winch would 

have been easily achieved and the accident avoided. 

Indeed he should have been better supervised in 

view of his relevant inexperience. 

Root Cause: 

Inadequate operational practices. 


The claim was settled for US$117,000. 

Issue Date: 

Case No. 

88 89


No Excuse for Reduced Maintenance Regimes 

The Incident: 

A Skipper was killed and two women injured when the starboard 

derrick, which had been topped up to its fully raised position, suddenly 

fell down on them as they stood on the quayside next to the vessel. It 

transpired that the eye of the starboard topping lift block had failed and 

subsequent investigation attributed its failure to the sudden propagation 

of a brittle fracture from a pre-existing manufacturing defect. 

The claims eventually came to trial and the claimants’ primary case 

was that the Members had failed to put in place an adequate system of 

inspection and maintenance of the fishing gear. The Members asserted 

that their system of inspection and maintenance was in accordance 

with all applicable regulations and matched prevailing standards within 

the industry. They contended that, in any event, any shortcomings in 

maintenance were not causative of the loss since the block failed as a 

result of a latent manufacturing defect which could not have been, and 

was not, detected by the exercise of reasonable diligence. 

Observations: 

The judge found that the 

Members’ practice of leaving 

all aspects of maintenance and 

safety to the crew was indeed in 

accordance with industry practice 

but that it was “simply naive to 

assert that good practice cannot 

call for more than compliance with 

the relative statutory regime”. He 

said that there should have been 

a system of planned preventative 

inspection and maintenance 

of all lifting gear blocks every 

six months by a person with 

sufficient practical experience and 

theoretical knowledge. He saw 

no reason to distinguish between 

the regime of inspection required 

of cargo ships’ derricks and lifting 

gear on a fishing vessel. As to 

causation, the metallurgist experts 

for both parties were agreed that 

the developing defect in the block 

would not have been detected 

during a routine inspection 

and overhaul of the vessel’s 

equipment. However, the judge 

found that the crew were wholly 

untrained to recognise degrees of 

wear or corrosion in the vessel’s 

equipment, that there were other 

defects in the block which were 

patent and that a proper system 

of maintenance would have 

required the block to have been 

tested with the specific intention 

of identifying cracks. 

Members’ attention is drawn to our 

Lookout article 06 of 2004 where 

a maintenance regime for lifting 

tackle on fishing vessels based on 

MCA requirements is detailed. 

Root Cause: 

Inadequate shore maintenance 

procedure. 


The Members paid substantial 

compensation to the Skipper’s 

widow and the two injured 

women. With the associated 

costs, the total value of this claim 

was in excess of US$2,155,000. 



90 91


Death from Hydrogen Sulphide Poisoning 

The Incident: 

The vessel involved in this case 

was a 97 foot fishing vessel 

which had left her home waters 

in Alaska to fish for albacore 

tuna in the South Pacific. The 

vessel experienced problems 

with her refrigeration system 

which culminated in a full catch 

of approximately 15 tons of tuna 

being rejected as being unfit for 

human consumption. 

The skipper decided to cut his 

losses and return to Alaska, 

hoping to sell the catch as bait. It 

appears however that problems 

with the refrigeration system 

worsened and six days into the 

voyage the refrigeration system 

was shut down altogether. The 

three man crew started to dump 

the fish over the side. Nine tons 

were disposed of before the smell 

of decomposing fish became 

overwhelming. The Captain 

decided to partially flood the 

fish hold in the hope that the fish 

would rapidly break down into 

a soup which could be pumped 

overboard. After leaving the fish 

to decompose for a few days they 

commenced pumping the 

mixture but after a short period 

the strum box clogged with fish 

remains. The skipper descended 

the ladder into the fish hold to 

try to clear the pump. Within 

seconds he was overcome by 

hydrogen sulphide gas given off 

by the rotting fish. The engineer 

attempted to rescue him and also 

succumbed. The one remaining 

crew member was unable to 

operate the radio to summon 

assistance and steamed in the 

general direction of Honolulu until 

the boat’s generator ran out of 

fuel and the electrical supplies to 

the steering gear failed. At that 

point he abandoned ship and set 

off the EPIRB. He was rescued by 

the US Coastguard. 

Observations: 

This unusual incident highlights the dangers of 

entering enclosed spaces. The atmosphere of 

any enclosed or confined space which is not 

continuously and adequately ventilated may be 

deficient in oxygen or contain flammable/toxic 

fumes, gases or vapours. Crews should be made 

aware of the dangers and instructed not to enter 

enclosed spaces if there is any reason to suspect that 

the atmosphere may be hazardous. On no account 

should rescue attempts be made without wearing 

breathing apparatus, a rescue harness and lifeline. 

In this case the crew were aware that the fish were 

rotting but were ignorant of the effects of the gas 

being given off. The vessel carried no breathing 

apparatus, gas testing equipment or oxygen 

analysing equipment. This accident could have been 

avoided if the crew had been aware of the risks of 

enclosed spaces and not attempted to deal with the 

problem without proper equipment. 

Root Cause: 

Inadequate enclosed space entry procedures. 


The cost of this claim exceeded US$650,000. 

Issue Date:01/01/02 


The survivor claimed damages for 

post traumatic stress disorder. 

Claims were made by the families 

of the two dead crew. 

92 93


Makeshift Platform Results in a Severe Injury 

The Incident: 

The stern trawler involved in this 

incident was lying in a port in 

Alaska undergoing repair work. 

The vessel’s trawl deck area 

was equipped with two cranes, 

one located at the forward 

starboard corner and the 

other portside aft. Repair work 

was being carried out on the 

starboard forward crane by 

independent contractors. 

The work involved cutting out 

and replacing a portion of a 

starboard forward crane. The 

after port crane was used to 

assist in the repair work. 

The contractors could not reach the damaged portion of the crane 

from deck level. The contractors brought a large piece of plywood 

on board, placed it on top of the starboard trawl winch, which was 

conveniently situated just aft of and adjacent to the crane. At some 

point during the repair work it became evident to the contractors 

that as they moved about on the plywood sheet it pressed through 

the control ears activating the winch. The contractors approached the 

ship’s crew to ask whether it would be possible to turn the hydraulic 

power supply to the winch off and the ship’s crew advised that it was 

possible but as the deck cranes and trawl winches were operated from 

the same hydraulic supply, the contractors would lose the use of the 

aft port crane. The contractors however needed power to the crane 

and asked that the hydraulic power be left on. Not long afterwards the 

trawl winch was accidentally activated, trapping the foot of one of the 

contractors’ workmen. The injuries were so severe that the workman 

lost the big and first toe on his left foot, which disabled him to the 

extent that he was unable to continue with his previous occupation. 

Observations: 

This incident highlights the dangers of makeshift 

working platforms. This incident could have been 

avoided if the had erected a proper scaffolding 

around the crane to provide a safe platform for 

his men to work from. In this case despite the 

contractor and his employees being fully aware that 

the movement of the plywood sheet was causing 

the winch to operate unexpectedly, they took 

no steps to replace the plywood with a proper 

structure or take any steps to guard the controls. 

Furthermore the contractor’s men were still using 

the winch as a stepping stone to reach parts of the 

crane knowing that it was liable to operate without 

warning. 

Root Cause: 

Failure of 3rd party working practices. 



94 95


Importance of a Safe Means of Access 

The Incident: 

This incident occurred in harbour at the end of 

the fishing season. The vessel was being laid up for 

some months and the crew had been removing 

their belongings from the vessel dock. No proper 

gangway had been rigged and the only access to the 

vessel was by way of a jacob’s ladder tied to the top 

railing on the starboard side of the pilot house deck. 

As a crew member was clambering over the top of 

the railing he lost his balance and fell approximately 

12 feet to the dock injuring himself. 

The crew member suffered a severely broken 

wrist which required the insertion of metal pins. 

He was also found to have herniated a disc in 

his upper spine which gave rise to neck pain and 

dizziness. His doctors advised him that he should 

not return to work at sea. 

Observations: 

This is one of the many injuries that occur every year 

as a result of the use of unsafe means of access to 

and from vessels. Small vessels often have greater 

problems ensuring safe means of access than their 

larger sisters. In this particular case it would have 

been difficult if not impossible to rig a conventional 

gangway. The accident could however have been 

avoided if the jacob’s ladder had been rigged 

adjacent to an opening in the ship’s rail which would 

have avoided the crew member having to clamber 

precariously over the ship’s rail. Alternatively a rigid 

vertical ladder extending above the level of the 

vessel’s rails could have been used. 

Root Cause: 

Inadequate means of access. 


The total cost of this claim to the 

Shipowner was $214,114. 



96 97


It Pays to Plan Ahead 

Root Cause: 

It Pays to Plan Ahead. 


The cost of this claim was in excess of US$117,000. 



The Incident: 

The Member’s vessel was tied up alongside and a diving company was employed to 

undertake underwater cleaning of the hull. The diver reported to the Master and then 

proceeded ashore where he changed into his diving gear and entered the water. 

The Master remained on deck to check work being carried out on a hydraulic winch. 

Soon after, the Chief Engineer approached the Master and requested permission to start 

the main engine so that electrical power could be provided to test the winch. The Master 

refused permission on account of the diver being in the water. Because of language 

difficulties the Chief Engineer had not understood what the Master had said 

and proceeded to the engine room to start the engine. The diver was working in the 

vicinity of the propeller and when the engine started he was instantly killed. 

Observations: 

The main cause of this fatality was a failure of the 

Master to ensure that all crew members were 

aware of the attendance of a diver whilst the vessel 

was alongside. By ensuring the facts were known 

beforehand, the possibility of the engines being used 

would not have arisen. Precautionary measures could 

have been taken including notices being placed on the 

starting handles and telegraphs. This case also highlights 

the need to ensure facts are clearly understood 

when language difficulties may arise due to different 

nationalities being employed on board. It is important 

that all senior crew members have at least a good 

working knowledge of one common language and can 

communicate effectively with their department staff. 

98 99


Heat of the Moment 

The Incident: 

The skipper of a fishing vessel was leaning into an ice 

box when the lid, weighing half a ton, fell on to him. 

He suffered serious chest injuries and has a 10% 

body impairment as a result. The normal procedure 

for opening the lid was to raise it by means of a rope 

and tackle and then insert a safety prop to hold it 

up. 

Observations: 

Unfortunately, on this occasion the skipper relied 

on the rope to hold the lid open and did not use 

the prop. The lead of the synthetic rope was such 

that it came into contact with the funnel and the 

heat had a degrading effect on it which caused the 

rope to eventually part. Had the safety prop been 

used this accident would have been prevented. In 

all likelihood the rope would have parted when the 

lid was being either opened or closed and the crew 

standing clear. 

This incident highlights 

several facts: 

• Never rely on a wire or rope 

to hold a hatch lid open. A 

safety prop or securing pin 

should always be used to 

secure it in the open position. 

Such a restraint must enable 

clear access to the opening. 

• Wherever there is a possibility 

of a synthetic rope coming into 

contact with an indirect heat 

source, it should be replaced, 

preferably by a wire rope or at 

least by a natural fibre one. 

• Lifting arrangements should 

be subjected to a thorough 

visual examination at regular 

intervals. In this particular 

incident, it was reported that 

the damaged section of rope 

was not obvious to a casual 

observer. 

Root Cause: 

Human error. 



100 101


When Applying First Aid – Ensure you Know What you are Doing 

The Incident: 

This claim involved a Vietnamese 

fisherman who, due to the medical 

treatment he received on board, 

had his lower leg amputated. 

Whilst fishing, a trawl wire 

became entangled around the 

propeller. During efforts to free 

the wire, the crewman became 

trapped between the wire and 

bulwark. As a result he suffered a 

fracture to his right tibia, injuries 

to his pelvis and serious bruising 

and abrasions. 

Shortly after the accident, the 

victim was transferred to another 

larger fishing vessel which was 

proceeding to the nearest port. 

Once this vessel was within range, 

the ship’s helicopter was used 

to transfer him to the nearest 

island with medical facilities. The 

medical staff at the hospital did 

what they could for the fisherman 

but decided he needed more 

specialist care and arrangements 

were made to airlift him to the 

main land. Upon examination the 

attending surgeon was left with 

no alternative but to amputate 

the right leg from the knee. 

Observations: 

As a result of the accident the 

fisherman was bleeding heavily. 

The fracture to the tibia was open 

and a tourniquet was applied to 

stem the bleeding. This remained 

in place until he reached the first 

hospital 14 hours later. 

A tourniquet can be used to 

restrict blood flow to limbs, but 

the use of such a device has to 

be closely monitored because 

by restricting the blood flow 

the affected part of the body 

undergoes metabolic changes 

and unless blood flow is restored 

it slowly dies. In the case of the 

fisherman, the lower leg muscles 

had died by the time he received 

professional medical help and the 

surgeon was left with no alternative 

but to remove the lower leg. 

A tourniquet is no longer 

recommended as a means of 

restricting blood flow from a wound. 

The preferred option is to apply 

pressure to the wound by using a 

heavy pad held in place by bandages 

or even ones hand (preferably whilst 

wearing disposable gloves). The 

blood will eventually clot and the 

blood flow stemmed. 

As a matter of last resort and if it 

is considered absolutely necessary 

to use a tourniquet, then it must 

be released every ten or fifteen 

minutes for a short time in order 

to supply the tissue with blood. 

However the wound must be 

covered by a heavy pad and 

bandage to stem any blood flow. 

In this case the injuries sustained, 

although serious, were treatable 

and a good if not full recovery 

would have been made if a 

tourniquet had not been used. 

The Administration overseeing 

a vessel will have requirements 

for the medical qualifications 

required to be held by a vessel’s 

crew, and this case highlights the 

importance of ensuring regular 

training is undertaken. 

Root Cause: 

Inadequate crew training. 


The cost of this claim was 

over US$77,000. 



102 103


A Real Eye Opener 

The Incident: 

This claim involved a purse seine fishing vessel engaged in fishing for tuna. 

The Chief Engineer was working in the vessel’s workshop when a foreign body entered 

his eye. The eye proved painful and the Master decided to land the injured engineer 

ashore for medical treatment. The nearest port was three days steaming away. 

Doctors removed the foreign body and the vessel returned to the fishing grounds. 

Observations: 

The medical examination revealed the foreign 

body (a piece of rusted metal) was “lodged 

superficially” on the eye and was easily removed 

by the attending doctor. 

Two points arise from this incident. Firstly, if the 

Chief Engineer had been wearing safety goggles, 

the chances of the metal entering the eye would 

have been prevented and the incident would not 

have occurred. Secondly it is a little surprising that 

no apparent attempt was made to treat the injured 

party on board. The foreign body was superficially 

lodged and the vessel carried a medical outfit 

compliance with flag state requirements. 


The cost to the Member in terms of the deviation 

was US$15,500 comprising fuel, port and hospital 

costs. The cost to the Member in lost fishing time 

during the 7 day deviation far exceeds this amount. 



Root Cause: 

Poor Safety Practices. 

104 105


Carbon Monoxide Poisoning on Fishing Vessels 

The Incident: 

An experienced crewman of a 16 metre potter, 

who was both working and living on board the 

vessel, died as he slept due to carbon monoxide 

poisoning. This was caused by the exhaust fumes 

of a petrol-driven generator running inside the fish 

hold. The generator had been brought on board by 

the crewman himself to power an electric heater, 

TV and radio. 

Observations: 

The bulkhead between the fish hold and the 

crewman’s sleeping cabin was neither watertight 

nor gastight. 

Putting a petrol generator inside the fish hold 

introduced a number of hazards to the vessel: 

Carbon Monoxide: 

• Has no smell or taste 

• Symptoms of poisoning are similar to the flu 

• People may not be aware they are being poisoned 

Fire/Explosion: 

• Petrol gives off highly flammable fumes 

• A petrol engine below decks can potentially cause 

explosive fumes 

• Other neighbouring boats could also be 

destroyed 

Electrical Hazard: 

• Household appliances are not designed for use in 

conditions often found on board fishing vessels 

• Correct wiring essential 

When living on board a vessel it is crucial 

to conduct a risk assessment so that: 

1. Sufficient power is provided for 

accommodation and lighting 

2. There is adequate ventilation (more needed 

for burners and stoves) 

3. There are adequate alarms to warn 

sleeping crewmen of problems 

4. Crew can escape from accommodation 

in an emergency 

5. It is safe for a lone crewman to board or 

leave the vessel at night 

Source - Maritime and Coastguard Agency 

Email: fishing@mcga.gov.uk 



106 107


Careless Action Severely Injures Colleagues 

The Incident: 

Whilst trawling the net became entangled on its 

reel. A crew member climbed onto the net reel to 

clear the tangled section. Whilst clearing the net, the 

deck boss, who was operating the winch, moved the 

net reel without warning and without checking that 

the crewman was clear. As a result the crewman fell 

from the winch and fractured his leg and severely 

damaged his kneecap. 

Observations: 

The incident was caused by the 

failure of the winch operator to 

ensure all crew were clear before 

he operated the winch. It is not 

uncommon for winch controls to 

be positioned such that the winch 

operator is unsighted and in such 

circumstances clear procedures 

must be put in place to prevent 

the winch being turned without 

the prior knowledge of those 

working in the vicinity. Conversely, 

if a crew member has to approach 

a winch he should ensure the 

winch operator is made aware of 

his impending actions. 

Root Cause: 

Dangerous operational practices. 


US$200,575. 



As is the case with most of 

these incidents, saving time is 

considered to be more important 

than safety and shortcuts are 

taken. It is only when injuries 

are suffered that crew have 

more than enough time to 

reflect on the consequences of 

compromising safety. 

108 109


Good Intentions Result in a Very Large Claim 

The Incident: 

This accident occurred to an engineer on board a 

fishing vessel. 

During fishing operations a hydraulic hose developed 

a leak. The vessel’s engineer was called and after 

examining the hose, the engineer placed his thumb over 

the hole and then instructed another crew member to 

operate the controls. As a result of this, hydraulic oil at 

1600 psi was injected into his thumb. 

The skipper was called to the scene. He examined 

the injury which initially resembled an insect bite. 

The skipper suggested that the vessel returned 

to port. The engineer himself opposed this idea 

and dismissed the injury as a trivial matter of no 

consequence. The skipper did not seek further 

medical advice. 

The vessel returned to port three days later. By the 

time the engineer reached hospital his thumb had 

swollen considerably and he was in severe pain. 

Over the following two years he underwent a series 

of operations, but despite this he has been left with 

a permanent disability which prevents him from ever 

returning to work as an engineer. 

Observations: 

Although it was clear the injury was caused by the 

engineer’s own actions, the long term effects of 

the injury were due to the lack of prompt medical 

treatment. If the injury had been treated within 12 

hours of the incident, it would have been unlikely that 

any serious or permanent injuries would have resulted. 

Although the skipper acted with the best intentions 

and was guided in his evaluation of the injury by 

the engineer himself, the fact that he did not obtain 

proper medical advice resulted in the shipowner 

being found liable. If they are in any doubt a Master 

should always seek medical advice. Such advice is 

readily available by radio and is free of charge. 

Root Cause: 

Human error. 



110 111

Navigation 

When a Lookout should Lookout 

The Incident: 

This claim involves a collision 

between a fishing vessel and a 

17000 gt products tanker. 

The Member’s vessel, a stern 

trawler was proceeding to 

her intended fishing grounds, 

which required her to cross a 

traffic separation scheme. The 

Member’s vessel contravened 

Rule 10c of the Collision 

Regulations by not crossing the 

traffic lane at right angles. 

The Master had left the 

wheelhouse and an inexperienced 

17 year old deckhand was left 

alone on watch. 

A radar target was noted 

approximately 3 miles on the 

starboard bow, and after making 

a visual check, the watch-keeper 

made the assumption that 

the vessel would pass clear to 

starboard; having made this 

assessment the watch-keeper paid 

no further attention to his lookout 

duties. More than one vessel was 

in fact within the immediate vicinity 

and the fishing vessel collided with 

another ship shortly thereafter. 

The watch-keeper realised 

a collision was to take place 

seconds before it actually 

occurred. He put the wheel 

over, but as he had not 

disconnected the auto pilot 

there was no response. 

Fortunately there was no loss 

of life, but each vessel sustained 

heavy damage. 

Observations: 

The Member’s vessel failed to maintain a proper 

lookout and this was compounded by the fact that 

an inexperienced crew member was left in charge 

of the watch whilst transiting an area of heavy 

traffic. Having noted a radar target on the starboard 

bow and making an initial assessment , no further 

observations were made until it was too late. 

The importance of maintaining a proper lookout 

cannot be over emphasised nor can the need to 

monitor all vessels closely when navigating in busy 

waterways. Consideration should always be given to 

“doubling up” watches in these circumstances. 

Root Cause: 

Inadequate lookout. 


The claim is expected to be no less than 

US$400,000. 



112 113

Navigation 

Distracted Skipper Dims Beacon Light 

The Incident: 

This incident involved an Australian cray fishing vessel. In common with the majority of 

this fleet this small vessel is highly powered and navigates at high speed. 

The vessel in question had just undergone engine repairs to try to cure an overheating 

problem with the main engines. The skipper and one deckhand took the vessel out 

on sea trials. During the trials the skipper was keeping a careful eye on the engine 

temperature gauges. As no problems were encountered the vessel’s speed was steadily 

increased until she was travelling at approximately 18 knots. The skipper’s attention was 

so firmly fixed on the engine gauges that he failed to notice a navigational marker dead 

ahead. Fortunately the deckhand who had just come onto the bridge spotted the beacon 

before the collision, enabling the Master to kill the power. Nevertheless the resulting 

collision severely damaged the boat and the beacon. 

Observations: 

This incident emphasises the need to maintain 

a good lookout at all times as required by the 

International Regulations for the Prevention of 

Collision at Sea. Had the deckhand not arrived 

on the bridge at the time he did, the vessel would 

have undoubtedly ploughed into the beacon at full 

speed with possibly disastrous consequences for 

those on board. 

Root Cause: 

Inadequate lookout. 


The repairs to the beacon cost A$96,500 

(US$76,405). 



114 115

Navigation 

Total Loss 

The Incident: 

A 360 ton deep sea fishing 

vessel had called at Pago Pago in 

American Samoa for bunkers en 

route to her fishing grounds east 

of Tahiti. She left Pago Pago in the 

afternoon, steering an easterly 

course set to pass nine miles north 

of Rose Atoll, the only US National 

Wildlife Reserve in the southern 

hemisphere. At approximately 4 

a.m. in clear weather the vessel 

ran hard aground on the south 

western side of the atoll. The 

forward double bottom tank 

below the fish holds ruptured 

immediately and oil started to spill 

from the vessel. The vessel was 

abandoned later in the morning 

after the engine room began to 

flood. The crew were picked 

up by a passing vessel without 

serious injury or loss of life. 

The nearest suitable salvage 

vessel was 2,000 miles from the 

site and by the time it arrived 

the fishing vessel had broken up, 

spilling nearly 100,000 gallons 

of gas oil bunkers. Damage 

to the reef caused by the 

grounding and the toxic effects 

of the oil extended to a radius 

of approximately 1 km from 

the wreck. The US authorities 

required that a clean-up 

operation be mounted and the 

remains of the vessel removed. 

Observations: 

There were only two qualified 

officers on the fishing vessel, the 

Master and the Chief Officer. 

The Chief Officer’s responsibility 

was apparently confined to the 

operation and maintenance of 

the fishing gear. He was not 

involved in navigational duties. 

After sailing the Master remained 

on the bridge until midnight 

when the vessel passed south 

of Manua Island. Before retiring 

the Master set bridge watches 

which consisted of one senior 

and one junior seaman. The only 

instruction given to the seamen by 

the Master were to call him if they 

saw any lights. Rose Atoll is not lit. 

None of the seamen given the task of keeping watch had any 

navigational training. They had no knowledge of the collision 

regulations and were not even sure in which direction the vessel 

was steaming. They had no knowledge of navigational hazards in the 

vicinity and there was no chart on the bridge. They were untrained 

in the use of radar and the set was switched off. The vessel was 

equipped with a GPS navigation system however the watchkeepers 

did not know how to ascertain their position and were unable 

to check whether the vessel was following the course set by the 

Master. 

Root Cause: 

Insufficient manning. 


In addition to losing a multi million dollar vessel the owner faced a 

bill of over US$1 million for clean-up and was also liable for fines and 

penalties under American pollution laws. 



116 117

Navigation 

Fatigue Causes Grounding and Total Loss 

The Incident: 

This incident involves the grounding and subsequent 

total loss of a seine fishing vessel. The vessel was 

returning to its home port at the end of the salmon 

fishing season. She was proceeding in company 

with another fishing vessel owned and operated by 

the captain’s brother. The maximum speed of this 

vessel was approximately 4 knots less than our ship. 

The two brothers believed that travelling rafted 

together in sheltered water would reduce their 

overall passage time. Thus when the vessels entered 

the Greenville Channel which forms part of the 

Inner Passage between the off lying islands and the 

coast of British Columbia the vessels were lashed 

alongside one another and proceeded as a rafted 

unit. In the early hours of the morning both vessels 

ran hard aground on a small promontory on the 

port side of the channel at a point where there was 

a slight bend to starboard. An order to remove the 

vessels was issued by the Department of Fisheries. 

Observations: 

No agreement had been reached for controlling 

the navigation of the combined unit. Neither vessel 

could control the course or engines of the other. 

Both vessels were on autopilot. The wheelhouse of 

each vessel was manned by a single watchkeeper 

whose only method of communication with his 

counterpart was by VHF radio. At the time of the 

grounding the watchkeeper on the other fishing 

vessel had reportedly left the wheelhouse to relieve 

himself and the watchkeeper on our vessel had fallen 

asleep. 

At some point shortly before the grounding the 

vessels had run into a bank of fog however this was 

probably not causative of the loss. The most likely 

explanation is that with one bridge unmanned and the 

other watchkeeper asleep the vessels failed to make 

the slight alteration of course necessary to follow the 

channel. The problem was probably compounded 

by the fact that the more powerful vessel lay on the 

starboard side of the other, making the combined unit 

more likely to veer to port. 

Root Cause: 

Poor navigational practices. 


The smaller vessel was a 

constructive total loss and 

the larger vessel was severely 

damaged. Both vessels were 

refloated by their respective 

owners’ efforts. Nevertheless 

the costs incurred exceeded 

US$20,000. 



It is unlikely that both vessels would have grounded 

had they been navigating independently. With the 

vessels rafted side by side both on autopilot and 

with no system for controlling the course or the 

engines of the other, the slightest error by either 

watchkeeper would almost inevitably end in disaster. 

118 119

Navigation 

If Only he could Swim 

The Incident: 

This incident involved a boom trawler stranding 

whilst fishing for prawns and is one of a number 

of similar incidents the Club has been involved 

with recently. 

The vessel was fishing approximately 0.5 miles 

from the shore with the Skipper on watch, alone. 

At approximately 23:00 on the evening in question, 

the engineer advised the Skipper that a problem had 

developed with the hydraulic pump for the trawl 

winch, rendering it inoperative. The Skipper left 

the wheelhouse to assess the situation for himself 

and returned shortly afterwards to telephone 

his managers. Whilst on the phone, the vessel 

grounded. After a list of some 35º developed, 

the crew donned their lifejackets, two liferafts 

were launched and the vessel was abandoned. 

Unfortunately the cook could not swim and, 

on entering the water, he panicked and 

subsequently drowned. 

Observations: 

The prime cause of the incident 

was the fact that the wheelhouse 

was undermanned. The vessel 

grounded only 100 metres from 

the shoreline which shows that 

during the time the Skipper’s 

attention had been diverted, 

the wind and current had set 

the vessel in towards the shore. 

Being alone on watch the Skipper 

had many tasks to attend to 

not least the navigation of the 

vessel, keeping a lookout and 

steering, all whilst operating 

close inshore. The failure of the 

hydraulic pump increased the 

demands placed on the Skipper 

which led to the wheelhouse 

being left unmanned for a period 

of time and navigation continuing 

unmonitored whilst the telephone 

call to the managers took place. 

The incident was caused by a 

failure on the Skipper’s part to 

call for suitable assistance in 

the wheelhouse. There were 

no moves to supplement the 

wheelhouse watch whilst the 

Skipper’s attention was diverted 

to the problems with the 

hydraulic pump which is difficult 

to understand considering the 

proximity of the vessel to the 

shore. Manning levels on fishing 

boats, whilst in accordance with 

Flag State requirements do not 

always provide for the luxury of 

spare qualified crew members, 

but when circumstances dictate, 

as in this case, adjustments to 

work routines should be made 

to ensure the safety of the crew 

and vessel. 

In all likelihood, had the cook 

been able to swim, he would not 

have panicked to the extent he 

did and would probably still be 

alive today. He was found wearing 

his lifejacket. The Flag States 

Code of Safe Working Practices 

for Fishing Vessels recommends 

that all fishermen should be able 

to swim. So do we. 

Root Cause: 

Inadequate navigational practices. 


The cost to the Club was only 

US$2,776. Fortunately the vessel’s 

diesel oil was blown out to sea 

with no beach pollution taking 

place. The crew were covered 

under the Flag States Workman’s 

Compensation Act and the 

Club was not required by the 

authorities to remove the wreck 

even though it had grounded in a 

scientifically sensitive area. 

The cost to the cook and his 

family was beyond calculation. 



120 121

Navigation 

Unmanned Wheelhouses Cause Collision 

The Incident: 

The vessel involved in this collision was a 

19 metre steel trawler which worked the 

scallop and prawn fishery off the coast of 

Queensland, Australia. The vessel fished by 

night and anchored during the day. She was 

manned by a crew of two. On the morning 

of the collision they finished fishing at 7 

a.m. The skipper set course for her home 

port, handing over the watch to the deck 

hand in late morning. In the early afternoon 

the vessel collided with another fishing 

vessel which was lying at anchor. 

Observations: 

At the time of the collision neither vessel 

was keeping a proper lookout as required 

by the International Regulations for 

the Prevention of the Collisions at sea. 

No anchor watch had been set on the 

anchored vessel and all her crew were 

turned in. The crew member that was 

supposed to be keeping a navigational 

watch on our Member’s vessel was in 

fact on the afterdeck cleaning when the 

collision occurred. The vessel was not 

fitted with a watch alarm, nor did it have a 

guardring facility on the radar. 

Root Cause: 

Inadequate navigational lookout. 


Repairs to the anchored vessel cost over 

A$100,000. It was out of action at the height of 

the scallop season for over two months, giving rise 

to a substantial claim for loss of profits, which was 

eventually settled for A$45,000. In addition to this 

there was substantial damage to our Member’s 

vessel and it too was out of action for a substantial 

period at the height of the season. 



122 123

Navigation 

A fatal nap 

The Incident: 

The crew of a longline fishing vessel had to abandon 

ship in violent seas at night after she grounded 

on rocks. The skipper drowned and one crew 

member’s body was never recovered. Two other 

crew members were tossed against rocks in stormy 

seas for hours. Before the grounding, no one had 

been keeping an anchor watch. 

The 18 metre steel-hulled commercial longliner set 

off on a three day voyage at a time when heavy storm 

warnings were issued for all of the country, and most 

vessels in the area were heading for safe anchorage. 

In the late afternoon of the second day, the skipper 

anchored in a large bay. To get there, the vessel 

steamed about 20 nautical miles past a safe and open 

port and instead anchored approximately 300 metres 

from a rocky coastline in about two metre seas. 

The nearby port’s Harbour Master saw the vessel 

‘punching’ through the seas and thought it peculiar 

for the vessel to stay at sea in such conditions. 

About an hour before the vessel weighed anchor, 

a nearby wave buoy recorded wave heights of 3.2 

metres, reaching 6.2 metres and increasing. Soon 

after midnight, the crew all turned in for the night. 

No anchor watch was kept. The vessel was fitted 

with radar and a GPS, depth sounder and course 

plotter, but none of these were set to supplement 

an anchor watch or provide an alert. 

At about 3 am, the crew were woken by heavy 

waves battering the vessel. They soon discovered 

the vessel had dragged her anchor and was almost 

aground against the rocky coastline. Wave buoy 

recordings show that by this time the swells had 

increased to 5.2 metres, reaching a maximum of 9.1 

metres. At the vessel’s position, the waves would have 

been significantly higher in the shallow water. 

Waves had damaged the vessel, and she was set in to 

the shore with big seas breaking over her. The crew 

attempted to recover the anchor, but the winch would 

not operate. Attempts to cut the anchor wire with 

bolt cutters failed. When the vessel hit the rocks, the 

skipper gave the order to abandon ship and set off a 

distress beacon. All four on board dived into the sea. 

The skipper and one crew member drowned. 

The two remaining crew members spent hours in 

the water, being smashed by waves. One suffered 

a collapsed lung and extensive cuts and bruising. 

The other managed to crawl onto a small beach 

and suffered hypothermia. They were eventually 

rescued by helicopter and flown to hospital. 

Observations: 

1. Given the weather conditions from the outset 

of the voyage and the forecast, the vessel should 

not have set sail. Once en route, there were two 

ports within timely reach of the vessel where she 

could have berthed safely. 

2. The position the skipper chose to anchor in was 

unsuitable for the conditions, but the skipper did 

not seek local knowledge about a better location 

from Marine Radio or the Harbour Master. 

3. No anchor watch was kept by the crew. Maritime 

rules require that a proper lookout is maintained 

at all times and, given the conditions, was essential 

for the safety of the vessel. 

4. In addition to its four crew members, the vessel 

was fitted with radar and a GPS, depth sounder 

and chart plotter, which could have been set 

to assist the designated watchkeepers. Failing 

to maintain an anchor watch appeared to be 

standard practice on this vessel. 

5. The company that had contracted the vessel had 

adopted a ‘hands-off’ approach to monitoring 

the safety performance of vessels it contracted. 

The operations manager knew this vessel was 

departing into the storm and, despite discussing 

the potential catch with the crew, made no 

mention of the weather. It was company policy 

to neither require nor dissuade a crew from 

undertaking a particular voyage. 

6. The need for keeping an anchor watch, 

particularly in adverse weather or when 

anchored on an open coastline, should have 

been reinforced by the contracting company. 

Both factors applied in this case and the failure 

directly contributed to the loss of the vessel 

and two lives. This dangerous failing could have 

been identified and corrected. 

7. As a result of this tragedy, the contracting 

company was fined and required to pay 

reparations to the victims’ families. The court 

found that the company failed to implement 

adequate policies or processes to ensure the 

vessel’s crew properly followed maritime rules 

by ensuring a proper anchor watch was kept.. 

Trading Area: 

Australasia & Pacific 


Case No. 230810 

This case study has been taken from: 

Maritime New Zealand’s ‘lookout’ issue 17. 

124 125

Pollution 

Short Cuts can take Longer 

The Incident: 

This incident involved the inadvertent spill overboard 

of oil during an internal transfer of bunkers. 

The day prior to the oil spill, the engineers had 

been pumping waste oil to a shore reception facility. 

Because it was felt the operation would take too 

long utilising the standard connection as required by 

the MARPOL regulations, a cross connection had 

been fabricated to fit between the bilge and bunker 

systems. The waste oil was then pumped ashore 

via the bunker manifold without incident. When an 

internal transfer of oil was commenced the following 

day, heavy fuel oil spilled onto deck through an open 

manifold connection and then spilt overboard. 

Observations: 

The vessel was detained by the 

harbour authorities on a number 

of deficiencies which came to 

light during investigations into 

the incident. These included:- 

1. Oil Record Book not being 

correctly maintained 

2. SOPEP not updated 

3. Crew not familiar with 

the procedures required 

by the SOPEP 

4. Unauthorised cross 

connection between the 

bilge and bunker systems. 

Notwithstanding the illegal cross 

connection, the primary cause of 

this oil spill was the fact that valves 

utilised during the previous day’s 

operation had not been closed 

upon completion nor had the 

manifold connection been blanked. 

It is imperative that pipeline 

systems are fully closed down 

after use and when utilised again, 

the pipelines and valves are 

checked during the early stages 

to ensure the oil is only flowing 

to the required destination and 

nowhere else. 

The ironic aspect of this incident 

was that the time saved in 

pumping the waste oil ashore via 

the bunker system was lost in 

the detention of the vessel which 

lasted four days. 

Root Cause: 

Inadequate SOPEP procedures. 


The cost of this incident including 

fines and clean up charges is 

estimated to be US$90,000. 


Case No.42370 

126 127

Pollution 

Environmentally Unfriendly Bunkering 

The Incident: 

The Club is concerned at the number of oil pollution claims arising 

from oil transfer operations carried out by large fishing vessels, 

particularly in European ports. 

Typical examples are: 

1. A 7300 GT fishing vessel was to pump the contents of her sludge 

tank ashore to a road tanker hired for the purpose. The hose was 

connected and, immediately upon commencement of pumping, 

oil escaped on to the deck and into the dock from the outboard 

connection. Investigation showed that this unused connection had 

been left with its valve open and blank flange missing. 

2. A vessel of 2417 GT commenced bunkering heavy fuel oil. 

Approximately 30 minutes later, personnel observed oil spilling on 

to the deck and into the harbour waters. The leak was traced to a 

loose flange on an elbow piece at the manifold connection. 

3. In another case oil was observed spilling out of an air vent and 

subsequently over the vessel’s side. Investigations showed that the 

labels on the filling connections had been incorrectly placed and 

the wrong tank was being filled. (It should be pointed out that this 

bunkering operation was usually carried out on the other side of the 

vessel without incident, but due to operational reasons this was not 

possible on this occasion). 

4. During the final stages of a bunkering operation, heavy fuel 

oil spilled out of the receiving tanks air pipe. Operations were 

immediately stopped but not before a quantity of oil had run 

out through the scupper pipes. It is thought the cause was an air 

bubble in the bunker tank which probably arose because of the 

vessel’s three degree list and large stern trim at the time. The other 

possibility was an incorrect assessment of the capacity available. 

Observations: 

To some extent, these incidents are all attributable 

to lax bunkering procedures. In one case, none of 

the vessel’s staff were on board overseeing the 

operation. All could have been prevented with a 

little more conscientious monitoring of operations. 

Loose flanges and open ended pipes appear to be a 

common feature. 

All the vessels in question have a gross tonnage 

in excess of 400 tonnes, so are governed by the 

MARPOL regulations, in particular the Shipboard 

Oil Pollution Emergency Plan (SOPEP) which is in 

place to prevent instances described above. 

The non-mandatory section of a vessel’s SOPEP 

Manual should contain the operating company’s 

bunkering procedures. Equally, vessels to which the 

regulations do not apply would be well advised to 

have in place similar procedures. 

Such procedures we believe should include the 

following requirements: 

1. All valves in a pipeline system not required to be 

opened should be confirmed as being closed. 

2. All flanges not in use should be blanked off. 

3. A crew member should be detailed to remain on 

deck at or near the manifold connection during 

the entire operation. 

4. Bunkering operations should be started and 

completed at a slow rate until a) it is confirmed 

that the oil is going into the correct tank and 

there are no leaks and b) the tanks are “topped 

off” in a controlled manner. 

5. Scupper plugs should be fitted and if this is 

not feasible, savealls fitted around the bunker 

connections and air vents should be of a practical 

size. 

6. Oil spill clean up equipment and absorbents 

should be placed on deck. 

Root Cause: 

Inadequate bunkering procedures. 



128 129

Section 4 

Passenger Vessels 

131

Passenger Vessels 


To be Forewarned should mean you are Forearmed 

The Incident: 

Shortly after boarding the vessel, a small passenger 

ferry, a young girl aged 10 fell down a storeroom 

access. She apparently climbed out of the 2 metre 

deep opening via a fixed ladder of her own accord. 

Her parents notified the crew and alerted the 

shore based emergency services. She was taken 

to hospital and spent twelve days in the Intensive 

Care Unit as she was diagnosed as having a 

ruptured spleen. Subsequently the young girl 

made a full recovery. 

Apart from the girl’s parents, there were no 

witnesses to the incident. 

Observations: 

Doubt exists as to whether or not the hatch cover 

used to secure the opening was in fact closed and 

the view taken is that a 10 year old girl, whilst not 

incapable of opening such a device would be unlikely 

to. However, the facts are that no warning or “No 

Admittance” notices were posted on or in the vicinity 

of the hatch cover and apart from a hook, the cover 

was not locked to prevent unauthorised opening. 

During investigations into the incident, the Chief 

Engineer admitted that he had observed on more 

than one occasion young passengers opening the 

hatch cover out of curiosity, but unfortunately he 

had neither taken any action to secure the opening 

or advise anyone else of what he had observed. 

There are no safety reasons for the hatch cover not 

to have been padlocked closed when not in use as it 

only served a storeroom. Had it been secured in this 

manner, this incident would not have happened. 

The posting of warning or prohibitive signs would 

have made passengers aware of the dangers and 

would have helped the Member’s defence. 

Root Cause: 

Insufficient safety signs. 


The lawyers were of the opinion that the Member 

would be held liable for the incident as it would 

be very difficult and expensive to prove any 

contributory negligence on behalf of a minor, thus 

the case was settled out of court. 

Total cost US$34,000. 


132 133


Difficult Step Causes Passenger Injury 

The Incident: 

This incident involves an injury to an elderly 

lady passenger disembarking from a tourist craft 

operating in north eastern Australia. The craft 

itself was of unusual construction, being a semisubmersible 

vessel which was designed to allow 

passengers to view coral reefs through windows in 

the lower deck below water level. 

The incident occurred after the vessel had returned 

to the dock. The passenger and her husband had 

not disembarked with the main body of passengers 

as they had remained on board to search for a 

lost piece of camera equipment. Having found the 

missing item they ascended to the main deck and 

moved towards the gangway. To do so they had 

to negotiate a change in level on the upper deck 

where there was a 27 cm. step. In doing so the lady 

stumbled and fell, severely breaking her ankle. 

Observations: 

The raised section of the upper deck was covered 

to within 6 cms. of the step by a black plastic mat. 

The lower level and the 6 cm. strip along the edge 

of the higher level was painted with white non-skid 

paint. The result was that the edge of the step was 

difficult to detect visually. There were no handrails 

and there were no warning notices or other visual 

warnings. Although crew members had been 

assigned to assist passengers at the gangway close 

by, none were assigned to assist passengers who 

negotiated the step. 

This accident should never have been allowed to 

happen. Our investigations revealed that crew 

members assigned to the gangway had observed 

passengers stumbling on the step on numerous 

occasions. If the company had implemented a safety 

management system the crew members would 

have a means of reporting their observations and 

appropriate measures could then have been taken 

to minimise the risk to passengers. Those measures 

could have included painting the edge of the step 

in high visibility paint, of contrasting colour placing 

appropriate warning notices in the vicinity, fitting 

a handrail and stationing crew members to assist 

frail passengers in negotiating the change in level. 

Alternatively it might have been possible to replace 

the step with a ramp. 

Root Cause: 

Inadequate access. 


The cost of this incident exceeded US$46,000. 



134 135


One for the Water 

The Incident: 

The Members’ vessel was engaged on a wine and 

sightseeing tour. As the boat was leaving a jetty after 

a stop for refreshments and sightseeing, to return 

down river to her home berth, a passenger appeared 

to stand on the bow, step over the railings and jump 

or dive into the water. The skipper was alerted and 

he immediately put the engines into neutral. Efforts 

were then made to manoeuvre the vessel to pick up 

the passenger. However, because of the configuration 

of the twin hulls the passenger went under the 

bow and between the hulls where she caught her 

legs in the propeller housing causing the eventual 

amputation of both her feet. 

Observations: 

Lawyers acting for the passenger 

commenced proceedings alleging 

that she had fallen into the water 

as a result of insufficient guard 

railings and that her retrieval 

from the water was delayed 

for some 20 minutes while the 

Master negligently manoeuvred 

the vessel causing her injury. (It is 

important to note that the official 

investigation by the authorities 

exonerated the Master from any 

professional blame). 

The Members asserted in defence 

that the passenger deliberately 

jumped into the water and was 

entirely responsible for her own 

injury. Witness evidence appeared 

to support the Members’ position 

that the passenger jumped off 

the boat but also confirms that 

she was apparently intoxicated at 

the time. Despite this evidence 

the Members bore the brunt of 

the responsibility of this incident 

despite the fact that it would 

appear the passenger acted of 

her own volition. This case proves 

that the courts hold the carrier 

liable in such circumstances. 

Members are responsible for 

ensuring that passengers are 

not permitted to board their 

vessel whilst under the apparent 

influence of alcohol or drugs, or 

to drink excessively whilst on 

board. If it is considered that the 

actions of passengers may put 

either themselves or others in 

danger, efforts must be made by 

the ship’s crew to prevent such 

conduct getting out of hand. 

Prevention is better than cure! 

Root Cause: 

Lack of passenger supervision. 


This claim was finally settled at 

US$608,500. 



136 137


Reminder to Carry Out Frequent Risk Assessments, 

Especially on Routine Matters 

The Incident: 

This case involved an embarking passenger who 

slipped into a gap between the vessel’s starboard 

gangway and the ship. 

The passenger, who has difficulty walking/climbing 

steps due to his weight, started to board the vessel 

assisted by two crew members. At the top of the 

steps the passenger paused for a few moments. As 

he continued he lost his balance whilst lifting his 

foot and he fell backwards into the gap between 

the steps and the vessel. The passenger’s leg was 

crushed. Due to the passenger’s weight the two 

crew members that were holding the passenger’s 

hands fell with him, one was injured. First aid was 

administered to the passenger and an ambulance 

was called. It was later learnt the passenger had a 

history of health, heart and leg problems. 

During the incident two ABs and the Chief Officer 

were present, advising and monitoring passenger 

embarkation. The sea was calm. 

The passenger had two operations to rectify the 

crushed skin on the damaged leg. 

Observations: 

Plaintiff’s lawyers alleged the vessel’s employees 

were negligent in that they failed to provide and 

ensure suitable and safe embarkation devices or aids 

and/or failed to control and secure the vessel during 

embarkation. 

As stated above three of the ship’s crew were 

present during the embarkation operation, ample 

safety notices were posted and company safety 

procedures were in place and being followed. 

This event highlights the importance of carrying 

out risk assessments in operational matters even if 

ample procedures are in place. 

Root Cause: 

Lack of passenger supervision. 


The claim was settled at S$12,500. 



138 139


Expect the Unexpected 

The Incident: 

This incident involved a 21 metre 

twin hulled passenger vessel 

engaged on a sightseeing voyage. 

The vessel was certified to carry 

240 passengers and at the time 

of the incident she had on board 

121 passengers. 

As the voyage progressed, the 

weather conditions were fair to 

good with a moderate easterly 

wind with 0.5 metre waves on a 

1 to 2 metre swell. 

Approximately 15 passengers 

were standing on the foredeck. 

As the vessel turned into 

a bay, the Master made an 

announcement over the 

public address system advising 

passengers that the seas may 

become “more choppy” and 

that they should take care when 

moving about the ship. Shortly 

afterwards, a higher than normal 

wave was experienced and the 

vessel rose and fell; this wave was 

followed by an even larger wave 

which caused the vessel’s bow 

to rise even higher than with the 

previous wave and then fall into 

the steep trough that followed. 

The effect of the vessel falling 

into the trough was to bodily lift a 

number of the passengers located 

on the fore deck and as the bow 

rose quickly on the next wave, 

the deck came up to meet the still 

falling passengers. As a result four 

passengers were seriously injured. 

Observations: 

The wave experienced could have been described as a rogue or freak wave, but the 

following investigation concluded that the possibility of experiencing such a wave could 

have been expected in the area that was being navigated. (The generation of such waves 

is very complex and is caused by two or more wave trains, being deflected by islands in 

the vicinity, meeting which can cause a resultant wave with irregular heights). 

None of the passengers sitting within the accommodation were hurt and careful 

consideration must be given as to when to allow passengers out on to the foredeck. If 

such practice is restricted to periods of smooth waters or when the swells are low and 

even, the repetition of such an incident is unlikely. 

The authorities found that the Master and crew handled the post incident situation in a 

competent manner. 

The above case study is based on an investigation carried out by the Transport Accident 

Investigation Commission of New Zealand. 



140 141


Good Record Keeping would have Reduced Claim 

The Incident: 

This accident happened to an elderly female passenger whilst 

disembarking from a tourist vessel operating off the west coast of 

Australia. As she was disembarking the passenger tripped, with the 

result that she lost her balance and fell injuring her right knee on the 

jetty. The passenger claimed that the principal cause of the accident was 

inadequate lighting. 

The first notice of a claim came in the form of a letter from a lawyer 

many months after the event. On investigation we found that no 

contemporary records of the incident existed. The deck log could not 

be found, there was no accident report, nor was there an entry in the 

accident book. In addition during the intervening period there had been 

staff changes, with the result that only one of the deck crew could be 

traced. From the evidence of this one witness we learnt that it was 

possible that the gangway was not in use at the time of this particular 

incident. Apparently it had been the practice of crew not to use the 

gangway if the state of the tide brought the deck of the vessel level with 

the jetty. In those circumstances the passengers were simply assisted 

across the narrow gap. 

Observations: 

The biggest problem the Club encountered in dealing with this case 

was simply lack of information. In the words of the lawyers advising the 

Club “in the light of .... your Member’s inability to refute the plaintiff’s 

version of the events, we are of the opinion that you would probably 

be found liable”. 

Root Cause: 



The claim was finally settled for US$13,000. However Members should 

note that the costs incurred simply trying to piece together what had 

happened exceeded $5,000. 



142 143


Good Record Keeping Prevents Claim 

The Incident: 

The owners of this vessel received a letter 

from lawyers representing an elderly lady who 

alleged that she had been injured when boarding 

the Member’s vessel 18 months previously. No 

incident had been recorded in the accident 

book on the day in question. The Master was 

interviewed and was quite emphatic that if an 

accident had occurred and the crew been aware 

of it, it would have been recorded. The other crew 

no longer worked for the company and two were 

known to have gone abroad. The remainder were 

traced but had no recollection of any accidents 

around the date in question. 

To board the vessel passengers simply stepped on 

to the deck. The gap between the vessel and the 

dock varied between 2 and 10 cms. The claimant 

alleged that as she stepped across the boat moved 

away from the dock and her leg slipped between 

the vessel and the dock whereupon the boat moved 

back towards the dock, crushing her leg. 

An investigation of her medical history revealed that 

the lady had suffered from osteoarthritis for some 

time and had been treated for the problem by her 

general practitioner prior to the alleged incident. 

There was no mention of an accident in her medical 

records. Some seven months after the incident 

was alleged to have occurred she had arthroscopic 

surgery on her knee joint and later underwent 

further surgery for a total knee replacement. 

Surgery however was not successful and she was left 

with a permanent disability. It was only then that a 

claim was made against the vessel owner. 

Observations: 

This case is typical of many instances where 

claimants suffering from degenerative conditions 

try to link that condition to some ‘accident’ aboard 

a Member’s vessel in the hope of extorting large 

sums of money in ‘compensation’. These cases 

are often difficult to defend as first notice of the 

problem often comes many months after the 

alleged incident when it is difficult to identify the 

crew on board at the time and when recollections 

are no longer fresh in the mind. It emphasises the 

need to keep detailed records of crew and the 

need to document every accident, however minor, 

to provide a body of evidence to demonstrate to 

a court that utmost care was taken and even the 

most minor incidents were recorded. It is then 

easier to convince a court that an unrecorded 

incident is unlikely to have taken place. 

Root Cause: 

Inadequate access arrangements. 


This claim was settled at nuisance value however the 

cost of lawyers, medical experts and investigation 

brought the total bill to over US$21,000. 



144 145


Uncovered Hawse Pipe Leads to Expensive Passenger Trip 

The Incident: 

The vessel in question is a 

Mississippi type showboat 

steamer that carried out harbour 

cruises during which time 

passengers could enjoy meals 

and cabaret type entertainment. 

Passengers were actively 

encouraged to walk freely around 

the open decks, including the 

fore and after decks, to enjoy the 

views as the cruise proceeded. 

At approximately 21.15 on the 

day in question, the attention 

of ship’s staff was drawn to the 

fact one 57 year old female 

passenger had sustained injuries 

to her leg after falling in the bow 

region of the vessel. Initially the 

injuries, although painful, were not 

considered severe enough to land 

the passenger immediately; in fact 

she expressed a wish to watch 

the evening’s entertainment. She 

was sent to hospital by taxi once 

the vessel returned to her berth 

later that evening. 

Initial medical opinion did not 

believe there to be any fractures 

to her leg, but specialists later 

discovered she had in fact suffered 

a fracture behind her knee. 

Observations: 

Situated in the bow area of the vessel was the 

windlass/winch arrangement and an associated 

hawse pipe which had not been provided with 

a cover (an oversight since building), leaving 

it exposed to all who passed by. It is not clear 

whether the fall was caused by the plaintiff stepping 

into the open pipe or catching her walking stick 

on it as she passed by. However the contributing 

factor to this incident is the fact the opening was 

not covered or fenced off. Another factor was 

considered to be the subdued lighting in the area 

with shadows masking the hazards. 

People who are unused to a marine environment 

may not appreciate dangers that are readily 

apparent to a vessel’s crew. With this in mind, all 

areas to which passengers are permitted access 

must be regularly assessed for potential hazards 

and suitable precautions taken to prevent accidents, 

even if this means limiting access to non ship’s staff. 

Root Cause: 

Insufficient safety signs. 


The case was settled at US$330,365. 



146 147


Passenger Injury on Access Ramp 

The Incident: 

This incident arose on board a harbour ferry operating in smooth 

water. The harbour ferry was fitted with hydraulic ramps designed 

for the embarkation or disembarkation of passengers. The ramps had 

been lowered to enable passengers to board the vessel and having 

been positioned hydraulics were ‘locked’. Shortly after passengers 

started to board another vessel backed into an adjacent wharf 

creating some wash. The combination of that wash and wave actions 

in the harbour caused the ferry to surge and roll. The movement 

resulted in the hydraulic ramp fitted to the ferry rising a few inches 

up off the connecting hydraulic ramp fitted to the jetty. When the 

vessel rolled back a passenger’s foot was trapped between the 

ramps. 

Observations: 

Surprisingly the claimant’s lawyers did not argue 

that the ramp was unsafe because it did not hinge. 

Instead they concentrated on the fact that the 

wharfhand on duty had been preoccupied with tying 

up another vessel when the accident occurred and 

that the ramp was unattended. Plaintiff’s lawyers 

alleged that had the crewman been at his place of 

duty he could have warned passengers of the danger 

and prevented them from boarding until it was safe 

to do so. 

While there were considerable doubts about 

whether the presence of a company employee 

would have had any material effect on the incident, 

our lawyers advised that the simple fact that the 

Member did not have an employee on the spot 

overseeing the boarding process would almost 

certainly have led the courts to the conclusion that 

our Member had not discharged their duty of care 

to the passenger. This illustrates the high standards 

that are expected from the operators of passenger 

vessels carrying the general public and the levels of 

care which they are expected to maintain. 

Root Cause: 



This claim was settled within the Member’s 

deductible. 



148 149


Passenger Dies of Heat Attack Despite 

Determined Effort by Crew to Save Him. 

The Incident: 

The incident occurred on board a tourist vessel 

ferrying passengers out to a resort pontoon 

on the Great Barrier Reef. Although weather 

conditions were moderate a passenger succumbed 

to seasickness during the voyage. On arrival at the 

pontoon most passengers then boarded a glass 

bottom boat to view the flora and fauna on the 

reef but the sick passenger and his wife remained 

on the pontoon. The crew provided a cabin for the 

gentleman so that he could lie down. Some minutes 

later his wife called for assistance as her husband was 

having chest pains. The passenger had a history of 

heart problems and it was clear that he was having 

a heart attack. The passenger carried medication 

for his condition which the crew supplemented with 

oxygen. The passenger was placed in a semi-sitting 

position with his legs elevated to reduce the strain 

on his heart. The Captain contacted his head office 

to arrange to evacuate the passenger. The head 

office were unable to locate a seaplane but were 

able to find a helicopter although that could not get 

to the ship for over two hours. The office called a 

doctor to the radio so that the Captain could obtain 

medical advice. 

Initially the passenger responded well to treatment 

but shortly after 1 p.m. the passenger stopped 

breathing. The ship’s crew was swiftly to organise 

resuscitation. Their efforts were supplemented by a 

registered nurse and an anaesthetist from amongst 

the passengers. The crew’s efforts to revive the 

passenger continued until the helicopter containing 

a doctor and paramedic arrived and took over. 

Although the attempts to resuscitate the passenger 

continued for a further hour they were not successful. 

Observations: 

Although on this occasion the crew’s efforts did not save the passenger’s life, they did 

everything possible for him. In addition in the heat of the crisis they still found time to 

look after his wife and attend to her needs, comfort her during the ordeal and keep her 

fully informed of what was happening and the efforts being made to save her husband. 

The passenger’s wife later wrote to the company praising the efforts of all on board and 

commending them for their efforts and support. 

This incident illustrates the benefits of maintaining good communication between the 

crew and the friends and relatives of a sick or injured passenger. It is essential to keep 

friends and relatives fully advised of all developments and the action being taken to help 

the passenger. Bad communication can increase 

anxiety and create distrust, leaving friends and 

relatives feeling that the ship’s staff could or should 

be doing more, which could in the future lead to 

acrimony and litigation. 



150 151


Explosion in Battery Locker 

The Incident: 

The vessel involved in this 

incident was a purpose-designed 

sail training vessel built in 1991. 

The vessel carried a substantial 

bank of lead acid batteries to 

power emergency systems, radios 

and fire detection systems. The 

batteries were housed in a locker 

on the port side of the main deck 

below the wheelhouse. 

In addition to a permanent crew 

the vessel carried 31 students 

who, in addition to pursuing 

academic studies, assisted in the 

sailing and maintenance of the 

vessel. On the morning of the 

incident a party of students had 

been assigned the task of scaling 

and painting the port side of the 

deck house. During the work 

an explosion occurred in the 

battery locker. The blast threw 

one student overboard. Despite 

an extensive air and sea search he 

was never recovered. 

Observations: 

The student who died had been removing rust accumulations from 

around the battery locker door with a rotary grinding machine. The 

battery locker door was secured by four lugs and wing nuts. In order 

to grind off rust around the lugs the student loosened the wing nuts 

and lifted them clear of the lugs. Sparks from the grinding machine 

entered the locker and ignited an accumulation of hydrogen gas causing 

the explosion. 

The battery locker door was marked with the word ‘batteries’ in large 

red letters. Signs were fitted inside the locker to alert personnel to 

the presence of corrosive acid and the dangers of corrosive acid burns. 

There were no external warning signs prohibiting naked lights and 

smoking, nor was there any warning of the explosive risk. 

Subsequent investigations revealed that the locker’s ventilation 

arrangements consisted of a single 20 mm diameter vent pipe which 

made no provisions for through ventilation. This was inadequate to 

dissipate the quantity of hydrogen gas given off at high charge rates. 

Root Cause: 

Unsafe wing practices. 



152 153


Hasty Exit Brings Slide of Despair 

The Incident: 

In this case a passenger fell off his motorbike whilst 

disembarking from a ferry via the vessel’s ramp. 

The accident occurred as the front tyre made 

contact with the ramp. This resulted in the bike 

sliding from under the claimant. 

The passenger sustained an injury to his right hand 

and the motorbike sustained damage to the body 

work on the upper and lower right hand side. The 

rear bike pedal was also snapped off. 

Observations: 

It is alleged that the accident occurred due to 

the combination of the highly polished surface of 

the aluminium ramp, which was wet due to the 

prevailing weather, and the motorbike’s speed. 

It is recommended that an anti-slip paint or other 

means, e.g. raised treads, be applied to ramps and 

other passenger access areas as a preventative 

measure. 

Speed restriction signs should be displayed in 

prominent positions. 

Root Cause: 

Inadequate speed restrictions. 


US$2,333.39 



154 155


Passenger Impatience Leads to Injury 

The Incident: 

This incident concerns a serious injury suffered by 

a middle aged male passenger while disembarking 

from a harbour ferry. The passenger was a 

construction worker who had used the ferry service 

for several weeks before the incident to travel to 

and from work. 

During the crossing he occupied a seat near the 

bows of the ferry on the lower deck. As the vessel 

approached its berth an announcement was made 

to passengers asking them to remain seated until 

the ferry had berthed and the gangway had been 

lowered. Despite this the passenger, along with 

many others, left his seat to join a mass of people 

eager to disembark at the earliest moment. As the 

vessel came alongside the man somehow came to 

fall between the vessel and the dock suffering severe 

crush injuries to his pelvis. The exact cause of his fall 

has never been adequately explained however there 

has been speculation that the passenger had either 

tried to disembark by an unorthodox manner or 

had somehow been pushed over the bulwark by the 

pressure of the crowd. 

Observations: 

The ferry berthed at a purposedesigned 

terminal. It was 

equipped with permanent 

gangways, which are hinged 

at deck level and lowered 

like a drawbridge onto the 

dock, which was level with the 

deck. There is solid bulwark 

extending to deckhead level 

for over two meters either side 

of the gangway. Beyond that 

there is a conventional solid 

bulwark to waist height which is 

supplemented by an additional rail 

approximately 30cm above the 

bulwark cap in all areas except 

adjacent to mooring bits. 

Prior to docking the crew 

routinely make an announcement 

warning passengers to remain 

seated and the passenger decks 

are liberally supplied with 

multilingual notices to that effect. 

The passenger sued claiming 

substantial damages alleging that 

the owners failed to erect railings 

in the region of the mooring 

bulwarks to prevent passengers 

falling off the ferry and that the 

owner failed to take appropriate 

steps to ensure that passengers 

remain seated while the ferry 

was in motion. The court in Hong 

Kong gave judgement on case in 

November 2000. Judge Seagroaat 

found that the bulwarks near 

the mooring bits where there 

are no additional railings was 

high enough to protect the 

passengers disembarking properly 

at the appropriate time. More 

importantly however, the 

Judge carefully considered the 

duties and obligations on vessel 

owners on crowd control. In 

his judgement, Judge Seagroaat 

commented that passengers who 

leave their seats despite oral and 

written warnings to the contrary 

know, as any reasonable person 

knows, that the reason for such 

warnings or advice is that there is 

always a risk of sudden movement 

of the ferry or of it hitting the 

pontoon with some force thereby 

causing passengers to loose their 

balance and fall. Anyone who 

ignores such warnings does so at 

his or her own risk. 

The Judge went on to say that 

he did not think the defendants 

could do anything to deter such 

action other than by announced 

and visible warnings. He did 

not consider it practicable or 

reasonable to require the size 

of the crew to be increased to 

such proportions as to be able to 

physically restrain adult persons 

hellbent on early disembarkation. 

Consequently he found the ferry 

operators were not liable for the 

passenger’s injuries. 

Root Cause: 


Issue Date: 01/01/02 Case No. 

28627 

156 157


Certainly not a toast to good health 

The Incident: 

A steward onboard the vessel, washing the dishes as usual, poured 

some concentrated industrial detergent into an empty green mineral 

water bottle, to assist in measuring the correct quantity to be put into 

the dishwashing machine. The partly filled drinking water bottle was 

then placed without any label indicating the contents with cleaning 

chemicals, near the galley sink. 

The next day, the unlabelled mineral water bottle, partly filled with 

detergent was put in the refrigerator, obviously being mistaken 

for drinking water. Subsequently it was placed on the lunch table. 

Unfortunately the liquid was odourless and the unsuspecting seaman 

poured it into a glass and took a few quick sips. He immediately 

became aware of an acute burning sensation in his mouth and 

throat. Fortunately, the yacht was in port and he was sent ashore 

to the local clinic, however it was not equipped to handle such 

serious cases and the seaman had to be transported to a hospital 

in a nearby larger town. By then, he was suffering from breathing 

problems, had a swollen tongue and a purple face. The hospital 

managed to administer suitable treatment and confirmed that the 

seaman had suffered internal burns. His permanent disability was 

assessed at 7% and as a result of his injuries, he will suffer from a 

bitonal voice and slow digestion. 

Observations: 

The use of a drinking water bottle for handling 

chemicals and also its careless stowage without any 

warning labels was the root cause of the incident. 

Furthermore, its storage within an area (the galley) 

where it was easily mistaken for drinking water was 

another major contributing factor. Chemicals should 

only be stored in containers specifically designated 

and adequately marked for the purpose. They should 

not be handled in any containers that can be easily 

mistaken for anything else. Only the required quantity 

should be used and the remaining quantity, if possible, 

must be returned to its storage container. The mixing 

containers should be cleaned appropriately and 

stowed back in their designated place.. 


The total cost of this claim was USD 69,000 

Trading Area: 

Europe 



158 159

Navigation 

Familiarity Breeding Contempt 

The Incident: 

This case involved two high speed passenger ferries 

owned and operated by the same company, which 

collided in reduced visibility. 

During the course of the early morning, both vessels 

had successfully carried out a number of runs 

between their designated ports. One vessel then 

commenced a scheduled new run that involved a 

reciprocal course to the other vessel in a relatively 

narrow channel. Both Masters were aware that the 

prevailing fog patches were reducing the visibility to 

50 metres or less. 

At the time of entering the same fog patch, the 

Masters each detected the other vessel on radar. Over 

the VHF, one Master requested a “green to green” 

passing but the other Master declined requesting “red 

to red” and at the same time put his helm to hard a 

starboard and reduced engine revolutions. 

Shortly thereafter the vessels collided. Fortunately, 

of the combined total of 127 passengers and 7 crew 

there were no injuries. 

Observations: 

The principal factors causing the collision were the 

excessive speeds of both vessels and the short radar 

ranges utilised by the Masters immediately prior to 

the collision. Investigations showed that the vessels 

had a combined closing speed of 36 knots yet both 

radars were set on the 0.75n.m. range. This resulted 

in the maximum duration of 75 seconds from the 

time the echo appeared at the edge of the screen 

to the time of impact. There were a number of 

additional contributory factors including a failure 

to comply with the Rules for the Prevention of 

Collisions at Sea, a failure to follow the company’s 

own procedures and the lack of a suitably qualified 

lookout on either vessel. 

The speed of both vessels was excessive for the 

conditions and the basic principle of frequently 

scanning greater radar ranges in order to permit the 

early detection of other vessels in restricted visibility 

was not followed. The manning scales on board 

both vessels meant that the Masters were the only 

suitably qualified mariners on board, thus placing 

a great burden on both men at times of reduced 

visibility. The company had in place procedures 

and recommendations for courses to be followed, 

specifically designed to prevent end on situations 

and these were not adhered to. 

Root Cause: 

Failure to comply with collision regulations. 



160 161

Navigation 

If Only they had Tried Something Different 

The Incident: 

A passenger vessel with 26 passengers and 12 crew 

on board ran aground in unsurveyed waters. At 

the time of the grounding the Master was alone 

on the bridge and the vessel was in automatic 

navigation mode. In this mode, course adjustments 

were initiated by a GPS linked to an electronic 

chart system which transmitted course alteration 

information to the auto pilot. 

A number of passengers received minor injuries as 

a result of the initial impact. 

Observations: 

The investigation deemed that the most likely 

cause of this incident was a discrepancy between 

the vessel’s true position and that determined by 

the GPS. Because total reliance was placed on 

the GPS with no other means used to verify the 

vessel’s position, the discrepancy went unnoticed. 

In addition, it was clear that with the Master being 

alone on the bridge, a proper lookout could not 

be kept and this is all the more pertinent as the 

vessel was navigating in uncharted waters. The 

investigation also raised concerns over the fatigue 

the Master may have been suffering, brought on by 

his intensive work routine. 

Other navigational irregularities were highlighted 

including the fact the electronic chart system in use 

was not approved, in that the computer was not 

dedicated to the vessel’s navigation system but was 

also used for the ship’s administration. 

This case study is based on the investigation report 

prepared by the Australian Transport Safety Bureau. 

Root Cause: 

Incorrect navigational procedures. 



This incident shows that no matter how 

technologically advanced a vessel’s navigation 

system is, there is no substitute for good old 

fashioned seamanship! 

162 163

Navigation 

Paperwork Leads to Grounding 

The Incident: 

This incident occurred on the inland waterways of southern Australia. A passenger 

excursion vessel on a river passage collided with the river bank in good conditions and 

broad daylight. Fortunately little damage was done and passenger injuries were limited to 

a few cuts and bruises. 

Subsequent investigation revealed that the Mate was not paying attention to his duties. 

He was trying to catch up with his paperwork and was not looking where he was going. 

Observations: 

In recent years ever-increasing amounts of legislation 

have increased the administrative workload on 

board ship. Ships’ officers are spending increasing 

amounts of time on paperwork. Owners must 

however ensure that their officers’ attention is not 

distracted from their principal responsibilities in 

relation to the safe navigation of the ship and safety 

of life on board. Duties should be arranged so that 

adequate time is allowed for the completion of 

paperwork in a manner that will not interfere with 

an officer’s primary responsibilities. 

Root Cause: 

Failure to perform correct lookout. 


Although no claims arose from this occurrence 

the costs for a precautionary investigation to 

protect the owners from potential injury claims 

from passengers and any possible inquiry by the 

regulatory authorities exceeded US$5,000. 



164 165

Navigation 

Collision Alongside 

The Incident: 

The claim involved three passenger 

vessels, two of which collided, 

whilst performing unberthing/ 

berthing operations in a river. 

Two of the vessels were berthed 

alongside a quay. To allow the 

inner vessel, with passengers on 

board, to sail the outer vessel 

manoeuvred “crabways” to 

starboard. When the route was 

clear the inner vessel sailed. 

During this time the third vessel 

was approaching the same quay 

from astern of the other two 

vessels. The outer vessel began 

to return to the berth by moving 

“crabways” to port and did not 

observe the closing third vessel. 

A collision occurred between 

the second vessel on its port aft 

corner and the third vessel on its 

starboard fore corner. 

Minor bruises were noted on 

some of the passengers on the 

third vessel and damage occurred 

to the second vessel. 

Observations: 

• The approaching vessel assumed both vessels ahead were 

clearing the berth but never made contact to confirm 

• Neither vessel made any effort to ascertain the 

actions of the other vessels in the vicinity 

• Complacency on the part of the vessel returning to the berth 

• No effective port control 

This claim reiterates the importance of keeping an efficient look out at all times, especially 

whilst performing manoeuvres in close proximity to fixed and floating objects. If in doubt 

contact should be made with the other vessels to confirm their intentions. 

Root Cause: 

Insufficient communication. 


Approximately €35,000. 



166 167

Navigation 

Intermittent Main Engine Fault Leads to Dock Damage 

The Incident: 

This incident occurred when a harbour ferry failed to respond to the 

main engine controls with the result that she collided with the dock. 

The ferry had been approaching the berth at slow speed when the 

Master tried to engage astern power. At this point he lost bridge 

control of the main engines with the result that the vessel continued 

forward, colliding with the piles at the end of the jetty. 

Observations: 

Investigation into the accident revealed that a similar problem had 

been encountered by the Master of the vessel during the previous 

shift. On that occasion power had been restored by jiggling the key 

in the engine control selector switch panel. Apart from completing a 

defects report no further investigation or repair work was undertaken. 

The vessel remained in passenger service and no special precautions 

were taken during the berthing operation to minimise the risk from 

sudden control failure. After the accident the control switches were 

replaced. Had the problem been properly investigated immediately 

and appropriate corrective action taken, this accident need not have 

occurred. In this case the two Captains would have benefited from 

clear guidelines on removing the vessel from service. 

Root Cause: 

Insufficient maintenance system. 


The cost of repairs to the dock exceeded US$15,000. 



168 169

Section 5 

Offshore Vessels 

171

Offshore Vessels 


A Scenic View but a Dangerous Place to Stand 

The Incident: 

The Member’s tug was standing by an anchored 

dumb barge which was being loaded with sawn 

timber. The tug Master noted that in the rough sea 

conditions, the barge was dragging her anchor and 

starting to drift towards shallow water. The decision 

was made to tow the barge back out to clear water. 

The Chief Officer and Chief Engineer were 

instructed to pass the tow line to the barge, but in 

the weather conditions they experienced difficulty. 

The cook was observing the operation and, 

characteristically, offered his assistance. With the 

cook’s help the line was successfully made fast. The 

Master then took the strain on the tow line. The 

configuration of the tug, tow line and barge was such 

that the line was in contact with the tug’s towing 

pins. As the strain on the tow line was increased, the 

towing pin failed and the tow line struck the cook 

who was standing in close proximity. The force of 

the blow threw him overboard and his body was 

never recovered. 

Observations: 

This fatality arose because the 

cook was standing in entirely the 

wrong place when the strain was 

being taken up on the tow line. 

From the diagram it can be seen 

that the other two crew members 

were safely standing clear and 

were never in any danger. 

The investigation into this incident 

did not determine the events or 

signals that were made between 

the Chief Officer and the 

Master once the tow had been 

successfully made fast, however it 

is abundantly clear that the cook 

was allowed to place himself in 

danger. The Chief Officer should 

not have given the all fast signal 

to the Master until all crew had 

cleared the danger area. 

Whilst the cook’s voluntary 

efforts in his willingness to 

assist his fellow crew mates are 

commendable, this incident 

shows how naivety can have 

disastrous consequences. 

Catering and engineering staff are 

not necessarily natural seamen 

and do not always appreciate 

the dangers that tow lines pose, 

nor the destruction that can take 

place when a line under strain 

fails through whatever cause. It 

would appear that in this case no 

guidance at all was given to the 

cook – if it was and ignored then 

a formal order should have been 

given and towing not commenced 

until everyone was standing clear 

and thereafter kept clear until 

operations were over. 

Root Cause: 

Poor operational practice. 



172 173


Short Cuts do not Always Result in a Quick Job 

The Incident: 

This incident resulted in the 

death of a seaman whilst securing 

a container on deck. 

A single 20 foot container 

weighing about 10 tonnes had 

been loaded onto the deck of 

an Anchor Handling Tug. 

The crew were engaged in 

securing the container by means 

of a 3 inch polypropylene 

mooring rope which was secured 

at one end and then led around 

the container. The loose end was 

placed on the drum end of an 

anchor handling winch and the 

slack was being taken up. 

The rope parted and struck 

the victim in the face. He 

was immediately evacuated 

to hospital. Never regaining 

consciousness he died fifteen 

days later. 

Observations: 

Investigations showed the rope to be old and in a 

poor condition brought about by its age, heat and 

exposure to sunlight. The conclusion drawn was that 

the rope was severed as it passed over the sharp 

edge of the container. The victim was positioned 

by the warping drum obscured from the winch 

operator’s view. 

The method used to secure the container was 

inefficient and inherently dangerous. The vessel 

was fitted with more than an adequate number of 

dedicated securing rings and fixing points which 

would have enabled a correct method of securing to 

have been used. 

This incident highlights the dangers of taking shortcuts, 

poor work practices and the use of old rope. 

Root Cause: 

Poor working practices. 


The cost of the claim was US$33,000. 



174 175


Prevention is Necessary as there is No Cure 

The Incident: 

A tug belonging to one of the 

Club’s Members was stationed 

off Point Noire Congo when 

one of the crew took seriously ill 

one evening. He was transferred 

to a nearby rig and, after 

assessment by a doctor, was 

transferred ashore to hospital 

where he later died. The 

diagnosis was a severe strain of 

cerebral malaria. 

On passage to the next port, 

another crew member was taken 

ill with a mild strain of malaria and 

was repatriated. 

A few days later, the Master took 

ill and the vessel was diverted to 

the nearest port but unfortunately 

he died before medical assistance 

could be arranged. His death was 

caused by malaria. 

The families of the deceased took 

legal action against the Members 

for failing to provide adequate antimalarial 

protection for the crew. 

Observations: 

An expert in tropical medications examined this case and confirmed that 

the Members had not taken appropriate measures to ensure the health 

and safety of the crew. The anti-malarial medicine made available was 

of the wrong type for the area the vessel was operating in, and it was 

concluded that if the correct medication had been made available the 

fatalities would have been avoided. 

In the malarial regions of the world, different strains of the infection build 

up resistance to the various medications available and it is important that 

medical advice is obtained for the area in question prior to the vessel 

arriving. 

The Ship Captain’s Medical 

Guide and Marine Guidance 

Note 257 (M) (published by the 

UK’s Maritime and Coastguard 

Agency) contain advice on the 

precautions to be taken and the 

medicines available. The Health 

Authorities of the Members’ 

country of domicile will be able 

to give advice on the type of 

preventative medicines to be 

administered whilst the vessel is in 

a malarial region. 

Root Cause: 

Inadequate medical procedures. 


Case No.35489 

176 177


Safety Goggles - Not Just for Hindsight 

The Incident: 

This incident occurred on board an anchor handling 

supply vessel operating off the west coast of Africa. 

The second engineer was supervising the cleaning 

of the mechanism of the vessel’s towing pins as part 

of the vessel’s routine maintenance programme. 

The cleaning was being carried out using a 

high-pressure water jet. The operator of the highpressure 

jet was wearing protective clothing in 

accordance with the manufacturer’s instructions. 

During the cleaning operation the second engineer 

who was wearing no protective clothing was hit in 

the left eye at a distance of about one metre by the 

jet of water from the high-pressure washer. 

His vision was affected and a few days later was 

examined by an ophthalmologist in Point Noire 

in the Congo. The ophthalmologist diagnosed a 

simple eye irritation. The ophthalmologist treated 

the engineer for approximately two months with 

antiseptic eye lotions without improvement. 

During this period there was no discernible 

improvement in his condition. The engineer 

completed his normal tour of duty. On his return 

home the second engineer consulted his own 

doctors who immediately diagnosed a detached 

retina. The officer underwent immediate eye 

surgery but because of the delay the doctors were 

unable to restore his vision. 

Observations: 

This accident would have been avoided if the second 

engineer had set a good example to the crew by 

wearing goggles while in the vicinity of the work. 

Masters should be given clear guidelines about 

reporting on-going medical problems to head 

office. The fact that the second engineer’s condition 

did not improve quickly should have been cause 

for concern. If the second engineer had been 

repatriated earlier he may not have lost the sight of 

his eye. 

Root Cause: 

Human Error. 


Although the engineer received benefits from 

his State’s welfare system the cost to the owners 

exceeded US$25,000. 


Case No.21940 

178 179

Navigation 

Close Quarters Manoeuvring Results in Sinking 

The Incident: 

This anchor handling supply vessel had been 

chartered to deploy anchors for a pipelaying barge 

operating in shallow water. In addition to the new 

pipeline there was an old pipeline and an unmarked 

subsea wellhead in the vicinity. While retrieving one 

of the barge’s anchors the anchor handler hit the 

wellhead, breaching the engine room. The vessel’s 

pumps could not keep up with the ingress of water 

and it sank to the seabed impaled on the wellhead. 

Observations: 

A few days before the incident occurred the barge 

Master had given the Master a new chart of the 

working area. Although the well’s position was 

accurately shown to within a metre the depth 

information was incorrect, leading the Master to 

believe that he would have an underkeel clearance 

of approximately two metres when in fact he had 

none. The barge was equipped with a sophisticated 

positioning system utilising differential GPS which 

was accurate to +/- 3 metres. Additional equipment 

on board the anchor handler allowed the surveyors 

on the barge to monitor the position of the anchor 

handler’s stern roller, enabling them to position the 

anchors with great accuracy. The anchor handler 

however was not given a monitor and had no way 

of accessing this information. The wellhead was 

not buoyed and the Master had no visual reference 

other than the barge. As a result he had been 

manoeuvring solely on the orders of the barge. 

Modern position fixing systems permit many 

operations to take place in closer proximity to 

navigational hazards than was possible in the past. 

Offshore personnel must however remain aware of 

the practical problems in accurately manoeuvring 

a large anchor handler without visual reference. In 

this case the anchor had been positioned only 30 

metres from the wellhead, with the result that the 

Master was required to manoeuvre his vessel within 

less than half a ship’s length of the hazard without 

the benefit of a visual reference or a GPS monitor. 

This incident could have been avoided if divers 

had checked the depth over the wellhead and its 

position had been marked with a buoy. 

Root Cause: 

Inadequate third party procedures. 


The anchor handler valued at approximately US$3 

million was a total loss. In addition to this the costs 

of removing the wreck from the wellhead and 

disposing of it exceeded US$2.25 million. 


Case No.21777 

180 181

Navigation 

A Good Case for Adequate Bridge Manning 

The Incident: 

This claim involved a small dredger operating a 

three times a week service between two local 

ports. She was manned by a senior and junior 

Master, two engineers and two ABs who were split 

into two teams of three, operating a six on, six off 

watchkeeping rota. 

At the time in question the junior Master, at the 

request of the senior Master, had taken the bridge 

watch early upon the vessel’s departure from the 

berth at 1745. 

As the vessel proceeded down a buoyed channel 

the VTS observed that the vessel was straying to 

port of her advised track and unsuccessful efforts 

were made to alert the vessel. Shortly thereafter 

the vessel should have made a substantial alteration 

of course to port, but did not make the turn, 

instead headed across the main shipping channel 

and towards a pier and shallow waters. The VTS 

again tried to make contact with the vessel to 

advise of the impending danger but no response 

was received. After narrowly missing a marina the 

vessel collided with a pier, causing severe structural 

damage. Fortunately no injuries were sustained. 

Observations: 

The official investigation into the cause of this 

incident found that the junior Master had very little 

recollection of events. It was concluded that his 

performance was greatly reduced through a possible 

combination of tiredness, alcohol consumption 

prior to taking over the watch and the taking of 

prescribed medication. In addition, at the time of the 

incident he was the sole watchkeeper on the bridge 

after the AB had left following an altercation. 

The vessel complied with the minimum manning 

requirements of the governing authority however 

the rest periods as required by the Hours of 

Work regulations were not being fully met for 

a number of reasons. The junior Master had 

been ashore immediately prior to the vessel’s 

departure consuming alcohol and he was also 

taking anti-depressants. 

As is the case with these incidents, the causation 

was a collection of factors, not least of all bridge 

manning that did not comply with the regulations, 

the sole bridge watchkeeper having consumed 

sufficient alcohol to exceed the legal road driving 

limits and an element of tiredness due to poor use 

of off-duty periods. 

Members are advised to ensure that their vessels 

are manned so that all regulatory requirements can 

be met and Masters instructed accordingly. This case 

has shown that familiarity with a navigating area is 

not an excuse for allowing standards to slip. 

Root Cause: 

Inadequate Navigation Lookout. 


US$795,000 



182 183

Navigation 

Keeping a Proper Lookout at ALL Times 

The Incident: 

This incident involved a harbour tug which collided with a moored tanker. 

The tug had completed one assignment and was crossing the port to its next job. The 

skipper was assisted on the bridge by a deck hand, who prior to the incident had a 

prolonged toilet break. The skipper made a final alteration of course towards the vessel 

she was to assist. Shortly afterwards the tug collided head on with a vessel moored at 

the terminal. This caused damage to some sections of the tanker’s shell plating and the 

vessel had to be taken out of service for repairs. Fortunately no-one was hurt. 

Observations: 

The Master and crew man stated that they had 

fallen asleep in the period between the alteration of 

course and the collision, although this was at most 

six minutes. Notwithstanding the reason, the fact 

is that an effective lookout was not kept on the tug 

and it is very fortunate that the result of the collision 

was not a lot worse than it was. 

The importance of keeping a good lookout at all 

times on all types of vessels when underway cannot 

be over emphasised. It also raises the ever present 

question of fatigue which must not be ignored. 

Root Cause: 

Inadequate navigational lookout. 


The claim was settled for US$200,000 



184 185

Navigation 

A Moment’s Lapse of Concentration Causes Collision 

The Incident: 

The supply vessel in question 

had been chartered by a drilling 

contractor to service a semisubmersible 

rig. The barge Master 

of the rig had instructed the 

supply vessel to act as safety boat 

on the starboard side of the rig 

while service personnel worked 

on a flare boom. The supply 

vessel was being manoeuvred in 

close proximity to the rig by an 

experienced Master. 

Some of the supply vessel’s crew 

were using a hose to wash down 

the bridge and accommodation 

block. Water from their hose 

came into the bridge through an 

open bridge wing door, splashing 

the radar and other electrical 

equipment. The Master left the 

aft controls to close the door but 

in that short period the vessel 

moved astern and the port 

quarter came into contact with 

the centre starboard column of 

the semi-submersible. 

Observations: 

This incident highlights the risks of a momentary 

lapse of attention on the part of the officer in charge 

when manoeuvring in very close proximity to other 

vessels or structures. The incident would not have 

occurred if the Master had ignored the distraction 

and not left the controls. The Master should have 

used the deck loudhailer system to draw the 

attention of the crew to the problem. 

Root Cause: 

Human error. 


Repairs to the rig alone cost US$55,000 and by the 

time surveyors’ fees and other costs had been taken 

into account the total cost to the owner was over 

US$60,000. 


Case No.23178 

186 187

Navigation 

Thruster Failure Causes Rig Damage 

The Incident: 

This vessel was one of two anchor handlers shifting a semisubmersible 

rig. Conditions were not ideal. A strong wind was 

blowing on the port bow of the rig and a current of over 1 knot 

setting onto that side. The anchor handler was ordered to retrieve 

the no. 2 anchor on the port side which was run out at an angle of 

about 60° from the rig’s centre line. The anchor was lifted clear of the 

bottom and hauled up to the stern roller. The tug then manoeuvred 

slowly astern towards the rig while the anchor chain was being 

recovered by the windlass on the rig. As the tug approached the rig 

the barge Master asked that it swing aft to a position on the beam 

of the rig in order to give a better clearance to the no. 1 port side 

anchor wire. This brought the wind onto the beam of the anchor 

handler. To hold this position required full power from the bow 

thruster which started to overheat and eventually tripped out, 

with the result that the bow fell off the wind. The loss of the bow 

thruster made the supply vessel difficult to manoeuvre. Attempts 

were made to pass the anchor pennant wire to the barge crane, 

however the shark’s jaws malfunctioned and the pennant wire could 

not be released. The tug, pinned by the anchor wire at the stern, 

was swept down onto the rig by wind and tide. She landed heavily on 

the port side ranging up and down causing severe damage. 

Observations: 

This incident shows how a number of factors can 

often combine to create a serious incident. It also 

emphasises the need to ensure that equipment 

is properly maintained in full working order, 

particularly when close quarters manoeuvring is 

envisaged. Although this was the first time the 

shark’s jaws had failed, overheating was a recurrent 

problem with the bow thruster which had never 

been properly repaired. In this case failure of either 

the bow thruster or the shark’s jaws alone would 

not have resulted in a collision, but when the effects 

of the two were combined when the vessel was in 

close proximity to the rig it became inevitable. 

Root Cause: 

Insufficient maintenance 

programme. 


The rig was out of action for 

10½ days. The claim for damage 

and loss of use exceeded the 

tug’s limitation fund under the 

1976 Convention. The claim was 

settled for the limitation fund 

but nevertheless the total cost 

exceeded US$450,000. The tug 

itself suffered heavy damage as a 

result of the collision. 


Case No.23047 

188 189

Navigation 

Tidal Calculation Error Results in Bridge Damage 

The Incident: 

A coastal tug towing a barge 

carrying 6,000 tons of cargo 

encountered difficulties 

manoeuvring on the way up 

river at her destination. The tug 

lost control of the barge which 

collided with a swing railway 

bride causing damage valued at 

US$180,000. 

The tug had brought the barge 

up the coast, arriving off the river 

mouth at midday. Before starting 

up the river the tug Master 

shortened up the tow, bringing 

the tow line right in until only the 

bridle remained out board - this 

brought the swim bow of the 

barge close up to the stern of 

the tug. The tug and barge then 

proceeded at slow speed up the 

north arm of the Fraser river, 

aiming to arrive below the Arthur 

Laing Bridge after the ebb had 

started to flow. Arrangements 

had been made for a harbour tug 

to rendezvous with the flotilla 

at this point to assist them in 

rounding the bend and passing 

through the Marpole swing 

railway bridge. Despite the lead 

tug plying full helm and maximum 

power the flotilla failed to 

complete the turn and the barge 

struck the swing span protection 

pier, causing serious damage. 

Observations: 

The reasons why the barge 

did not negotiate the turn 

successfully have never been fully 

explained. There were however 

a number of factors which 

contributed to the accident. 

Both tug skippers had carried out 

this operation many times before. 

Perhaps because of this there 

was no communication between 

the skippers when they met and 

no instructions were given by the 

lead tug. 

This unsatisfactory situation was 

compounded by the fact that the 

barge completely blocked the 

coastal tug’s view astern, with the 

result that its skipper was unable 

to see where the assist tug was 

pushing. The primary function of 

the assist tug is to help hold the 

barge close to the north side of 

the channel. If the assist tug pushes 

too far aft on the barge’s side it 

counteracts the lead tug’s efforts 

to pull the barge’s head round. 

Tidal streams upriver are less 

predictable than at the river 

mouth. The flotilla may have 

arrived at the turn too early, 

before the flood had ceased. 

The last of the flood tends to flow 

from north to south across the 

basin between the bridges, which 

would have set the flotilla sideways 

down on to the railway bridge. 

The incident could have been 

avoided by delaying the flotilla’s 

arrival until the ebb was flowing 

strongly and by proper planning 

and better communication 

between the tug skippers. 

Root Cause: 

Inadequate operational planning. 


Case No.16344 

190 191

Navigation 

Master’s Failure to take Control Causes Dock Damage 

The Incident: 

A large cargo handling crane constructed in China was being transported to a new berth 

in South East Asia on the deck of a large ocean-going barge. Pilotage was compulsory at 

the port of destination and as the tug and barge combination approached its berth the 

vessel was effectively being controlled by the pilot. To assist the tug Master a company 

superintendent had been stationed on the barge itself and was in radio contact with the 

tug. In the final stages of the approach it became apparent to the superintendent that 

the angle of approach was too steep and the speed was too great. This information was 

passed to the Captain of the tug who requested the pilot abort the berthing manoeuvre. 

The pilot refused to do so. The Master did not take control of the situation and allowed 

the manoeuvre to continue. The barge made heavy contact with the dock, causing 

damage to the fendering system. 

Observations: 

National laws and Port bye-laws normally hold 

vessels strictly liable for damage done to harbour 

works. The relevant law in this case provided “any 

damage done to wharves ..... by a vessel whether 

due to the incompetence or carelessness of the 

authority pilot .... shall be made good by the owner, 

Master or agent of the vessel”. 

In any event pilots invariably contract on terms 

which severely limit their liability or absolve them 

entirely of responsibility for their actions. A pilot’s 

function is to advise and assist the vessel’s Master, 

who remains ultimately responsible for the handling 

of his vessel. The Master should have taken control 

and aborted the manoeuvre. 

Root Cause: 

Human error. 


The Port Authority’s claim exceeded US$50,000. 

On this occasion however they did accept that the 

pilot was largely to blame and the agreed to settle 

for two thirds of the actual repair costs. The pilot 

concerned was subsequently sacked. 


Case No.23774 

192 193

Navigation 

Grounding/Pollution because of Bad Lookout 

The Incident: 

This incident involves the 

accidental grounding of 

a rig standby vessel in an 

environmentally sensitive 

area. The vessel which was 

carrying 160 tons of oil at 

the time suffered extensive 

bottom damage and her engine 

room was flooded. Pollution 

prevention measures were 

immediately put in place and the 

vessel was finally salvaged. 

Observations: 

The vessel had been returning to her home port 

with the Master as sole watchkeeper. As he 

approached land the Master moved to the after 

end of the wheelhouse to make a radio telephone 

call. What the Master believed would be a short call 

proved more complex than expected. The Master 

lost track of time and the vessel continued under 

autopilot, eventually driving itself hard aground 

at full speed at the base of cliffs adjacent to the 

port. This incident occurred as a direct result of 

the Master’s failure to keep a proper lookout and 

maintain a safe navigational watch. The accident 

could have been avoided by augmenting the bridge 

watch to cope safely with the additional workload as 

the vessel closed the land. 

Root Cause: 

Failure to maintain proper lookout. 


The cost of salving and repairing the vessel 

exceeded US$2.3 million. Anti-pollution measures 

added a further US$50,000 to the bill. 


Case No.12868 

194 195

Navigation 

Knock for Knock Clause Fails to Protect Owner from Rig Damage Claim 

The Incident: 

The incident occurred as a supply vessel was 

backloading drill casing from a semi-submersible 

rig. The vessel was backed up to the rig with her 

stern into the prevailing current and the wind on 

her port quarter. The vessel was being held in 

position by her engines and bow thruster. 

During cargo transfer operations the port engine 

pitch control failed and although its control was 

set to give forward thrust, the pitch moved to 

full astern. Despite the Master’s prompt actions 

in declutching the engine and applying full ahead 

power on the starboard engine, the vessel collided 

with and seriously damaged the rig leg. 

Observations: 

This incident highlights the 

risks inherent in close quarters 

manoeuvring. In this particular 

situation there was little more 

that the Master could have done 

to avoid the collision. The vessel’s 

pitch control was arranged in the 

‘conventional’ manner with the 

fail-safe position being full astern. 

For rig supply vessels however 

the greatest danger arises when 

the vessel is backed up to a rig 

and for this reason it is generally 

considered good practice for these 

vessels’ pitch controls to fail-safe to 

the full ahead position. Although 

there was a knock-for-knock clause 

in the charterparty its effect was 

restricted to claims between the 

owners of the supply vessel and 

the charterers in relation to their 

respective personnel and property. 

In this case the rig was not the 

charterer’s property and the rig’s 

owners were not bound by those 

contractual terms. If the knockfor-knock 

clause had been worded 

in such a way as to include the 

contractors and sub-contractors of 

each party, then the owners of the 

supply boat would not have had to 

pay for the damage to the rig. 


Repairs to the rig were carried 

out concurrently with a routine 

refit. Nevertheless by the time 

surveyors’ fees and classification 

survey costs had been taken into 

account the total cost rose to 

almost US$160,000. 


Case No.25250 

196 197

Miscellaneous 

When is a Master Off Duty 

The Incident: 

Whilst alongside a lay-by berth 

on the UK east coast, the Master 

of an oil rig supply vessel was 

informed by charterers that 

the vessel was not required 

for working until the following 

morning. As usual on this vessel 

under such circumstances the 

Chief Officer went on duty for 

the night and deck and engine 

port watches were set. 

The Master went ashore and 

returned some time later in the 

evening having consumed three 

or four pints of beer. Some 

hours after his return an incident 

occurred that necessitated police 

attendance. However, despite the 

incident not involving the Master 

he was breathalysed by the police 

and arrested and charged on 

suspicion of being a professional 

Master of a ship while on duty 

with a proportion of alcohol in his 

breath which exceeded the 

prescribed limits of 35 micrograms 

of alcohol in 100 millilitres of 

blood, contrary to Section 78.1(a) 

of the United Kingdom’s “Railways 

and Transport Safety Act 2003”. 

A further test at the police station 

confirmed that he was over the 

prescribed limit. 

A forensic toxicology report 

indicated that the Master would 

have been below the prescribed 

limit at 08:00 the following day 

when he was due to come back 

on duty. Furthermore, the amount 

of alcohol consumed did not put 

him in breach of his Company’s 

Drug and Alcohol Regulations. 

The case was tried in the local 

Magistrates Court before a 

District Judge. 

The case turned on whether the 

Master was ‘always on duty’ and 

particularly whether he was always 

on duty for the purposes of the Act. 

The Act did not define ‘duty’ and 

furthermore ‘duty’ is not defined 

elsewhere. It is often thought that a 

Master is always on duty from the 

moment he/she signs on a vessel to 

the moment he/she signs off. It was 

argued that a Master’s duty was not 

unlimited in its breadth or scope; 

to find otherwise would confuse 

performance and discharge of duty 

with the existence of a status or 

responsibility. Furthermore, to do 

so would fail to distinguish between 

the different facets of a Master’s 

duties, which include duties by 

common law, statute, regulation, 

custom and by contract. 

It was argued on behalf of the 

Master that the correct definition 

of ‘duty’ for the purposes of the 

Act is:- 

“Whilst on duty means, in the 

course of his employment as a 

professional Master of a ship, 

performing or being liable to be 

called onto perform a safety critical 

function, in the operation of the 

ship, which it is his duty to perform.” 

The Judge accepted this definition, 

accepted that the Master had 

not performed any ‘safety critical 

functions’ at the time he was ‘over 

the prescribed limit’ and acquitted 

the Master accordingly. 

Whilst the definition of ‘duty’ put 

forward on behalf of the Master 

was accepted by the Court, 

the facts of the case assisted 

the Master’s defence, and in 

particular:- 

The vessel was laid up with 

no orders to sail until the 

following morning. 

1. The Chief Officer was certified 

to act as Master on this 

particular vessel. 

2. The level of alcohol consumed, 

whilst over the prescribed limit, 

was relatively low. 

3. The Master complied with 

all company regulations and 

procedures as regards alcohol. 

4. The vessel complied with all 

the local harbour regulations 

and bye-laws. 

5. Toxicology tests showed that 

the Master would have been 

sober upon taking up his duties 

the following morning. 

The outcome could have been 

different had any of these facts 

been different, for example, had 

the Master been breathalysed and 

found to be over the limit one 

hour before sailing. 

Therefore whilst it is up to individual 

companies to decide whether they 

run dry ships, those that do not still 

need to ensure their staff are fully 

aware of their obligations under 

the Act in addition to any company 

procedures that may be in place, 

because the Master being removed 

from his vessel by the authorities 

can have serious commercial 

implications beyond those personal 

consequences suffered by the 

Master himself. 

Although this case has arisen 

under the law in the UK, similar 

legislation exists in many countries 

around the world and it is 

appropriate to circulate it widely. 



198 199

Miscellaneous 

Early Request for Club Assistance could have Buoyed up Members Defence 

The Incident: 

During a transit of the Suez 

Canal our Member’s vessels were 

alleged to have hit and severely 

damaged a navigation buoy. 

The first notice that the owners had 

was a letter from the Suez Canal 

Authority alleging that their vessel 

had damaged a navigational mark 

and inviting them to attend a joint 

survey. Our Member contacted 

the tug Master and the pilot, both 

of whom denied that there had 

been any contact. In view of this 

our Member wrote back to the 

Authority denying liability. A few 

weeks later they were shocked to 

find that the Suez Canal Authority 

had unilaterally deducted Egyptian 

£89,000 from their deposit. 

At that point the Member contacted the Club who instructed its 

correspondent lawyers in Egypt to defend the Member’s interests. 

Our lawyers advised that their past experience was that once the 

deduction had been made and it had been recorded in the accounts 

of the Canal Authority, it was almost impossible to persuade 

them to re-open the case. We were able to demonstrate that our 

Member’s vessel’s passed the buoy in the early hours of the morning 

and that the damage was not reported until mid-afternoon. In the 

intervening period the entire southbound convoy passed the location 

of the buoy and also some of the northbound ships, any of which 

could have done the damage. The Canal Authority prevented our 

correspondents from taking statements from the pilot or any other 

canal personnel. They refused to provide any documents, reports 

or other evidence to substantiate their claim that our Member was 

responsible for the loss. 

The Canal Authorities remained intransigent and faced with an 

expensive legal battle which might not be resolved for ten years or 

more, the Members decided not to pursue the matter. 

Observations: 

Members should be aware that in many parts of 

the world Canal Authorities, Harbour Authorities 

and other quasi-governmental bodies enjoy special 

status where the normal rules of business dealing 

may not apply. Members encountering problems 

with such bodies are advised to obtain assistance 

from the Club at an early stage while the matter is 

still open to discussion. 


The costs to our Member exceeded US$26,000. 



200 201

Miscellaneous 

A Good Case for Tracking 

The Incident: 

A Member’s tug was towing a barge laden with coal between ports in South East Asia. 

Late one evening whilst on passage she was boarded by a gang of ten men, two of 

whom were armed. The crew were tied up and the towline to the barge cut. The crew 

were then taken near to the shore in the pirates’ speed boat and left to swim ashore, 

unharmed. The speed boat returned to the barge. The pirates then turned the tug 

through 180 degrees, presumably heading for a port at which they could disguise the tug. 

Unknown to the pirates, the Member had installed a tracking device on the tug. Upon her 

failure to arrive at the discharge port as expected, an investigation was carried out and 

it soon became clear to the Member what had occurred. The authorities were advised 

and within 36 hours both the tug and barge (which had been drifting at the mercy of the 

elements) were located and arrangements made to recover them. 

Observations: 

The Member’s foresight in equipping the tug with 

a satellite tracking system prevented a major claim. 

The cost of installation was recovered from this one 

unsuccessful attempt at hijacking the tug. 

The speed in which recovery was possible clearly 

demonstrates the value of the tracking equipment. 

The Club would encourage all Members who 

operate such vulnerable craft, to consider seriously 

installing a satellite tracking system. 


No claim arose out of this incident and 

fortuitously all the crew were unharmed. 



202 203

Miscellaneous 

Corrosion Causes Sinking of Laid-Up Vessel 

The Incident: 

This 14 year old vessel had been inactive for three years. She was laid 

up unmanned at a shipyard belonging to an associated company. One 

morning the vessel’s agent noticed that she was listing 15° to port and 

reported this to the yard. Yard personnel were mobilised to investigate 

the listing of the vessel however prior to any remedial action being 

possible the vessel capsized, landing on her port side on a soft mud 

bottom. As there was no-one on board at the time she capsized there 

were no injuries. Shortly after the capsize an oil sheen started to 

appear on the surface. The Port Authority and the shipyard mobilised 

their pollution clean-up team. An oil boom was placed around the 

vicinity of the capsized vessel and dispersant was sprayed on the 

escaping oil. The Port Authority issued a wreck removal order. The 

vessel was salvaged ten days later. 

Observations: 

An investigation into the cause of the sinking traced the 

source of sea water ingress to a small sea water pipe 

between the sea suction strainer and the refrigeration 

cooling water pump. During the period the vessel was 

laid up an elbow progressively corroded away at the 

welded seams on either side until it was so weakened 

that it fell off. The subsequent ingress of sea water 

slowly flooded the engine room space, initially causing 

the vessel to sink deeper into the water and then, as 

the starboard bilge grounded on the uneven bottom, 

to list and ultimately capsize. 

The loss would have been avoided if good practice 

had been followed and all sea valves had been closed 

when the vessel was laid up. The leak would also have 

been detected if the owners had made arrangements 

with the shipyard for regular housekeeping 

inspections to be carried out by yard personnel. 

Root Cause: 

Inadequate Procedure. 


The owners were fortunate that heavy lifting 

equipment was already available in the port, thereby 

avoiding heavy mobilisation costs. Nevertheless 

raising the vessel still cost over US$125,000 and the 

cost of anti-pollution measures reached US$20,000. 

Sea water had destroyed all the electrical equipment 

and installations and much of the machinery, 

with the result that the vessel required complete 

refurbishment. 


Case No.27691 

204 205

Section 6 

Harbour Craft 

207

Harbour Craft 


Face the Danger 

The Incident: 

The following accident report issued by the MAIB 

concerns an incident where a deckhand suffered 

multiple fractures to his arm whilst connecting a 

tug’s towing wire: 

“The tug’s tow rope messenger was led through a 

Panama lead, around the bits at a 100˚ angle and 

on to the winch end whipping drum. The drum 

end seaman was standing with his back to the 

working part of the rope and the supervisor, 

as he hauled on the rope. 

Unfortunately the tug was not paying out slack at 

a controlled speed and, feeling the strain of the 

jerking motion, the drum end seaman attempted to 

apply more turns to the whipping drum. During this 

process, the messenger rope snapped back, and the 

whiplash of the working part connected with, and 

broke, the drum end seaman’s arm. 

The supervisor, who was standing in the precarious 

position of the bight of the rope, escaped injury. 

Had the rope come clear of the bits, the outcome 

for him could have been extremely serious.” 

Conclusion: 

Messenger rope arrangement 

1. Stand facing the danger: always put the winch 

between the operative and the potential danger 

zone. This, in itself, creates a safety barrier, allows 

full visual contact with the mooring team and 

surroundings, allows controlled surging on the 

drum end and keeps the operative clear of the 

working part. 

2. Be aware of the dangers of sharp nips – these 

cause excess strain on machinery, fittings and 

ropes – and use fairleads wherever possible. 

3. During our first day at sea, most of us were made 

aware of the dangers of standing in bights of rope; 

a brief lapse of attention to this ordinary practice 

can so easily cause grief. 

4. Watch out for shipmates and their work 

practices. Ships operate on efficient teamworking, 

part of which involves looking out for 

our shipmates and recognising potential dangers 

to them. It is so much easier to stop bad habits 

than to patch up broken bodies. 



208 209


Girting Capsizes Small Tug 

The Incident: 

This incident occurred as a small passenger vessel 

was being towed from a river into a harbour basin. 

This dead tow was being performed by a harbour 

tug acting as lead tug and a tug/workboat which 

was made fast aft. The Masters of the two tugs had 

agreed that the towlines would be shortened off the 

basin entrance and that the lead tug would then tow 

the vessel into the basin with the workboat holding 

the stern of the passenger vessel up into the ebb 

tide, which was running downriver at approximately 

3 knots. As they commenced the final stage of the 

tow the tug/workboat was girted and capsized, 

drowning its skipper. 

Observations: 

Once the towline had been shortened and the 

slack had been picked up the lead tug called the 

workboat to confirm that they were ready to 

proceed. On receiving the all-clear the lead tug 

progressively applied power, turning the tow into line 

with the approach. Power had been brought up to 

approximately half ahead when the tug received a 

VHF message asking it to stop. Almost simultaneously 

crew members on board the tow shouted to the lead 

tug that the workboat had capsized. 

Based on information from the survivor and 

witnesses on the tow, it appears that the workboat 

skipper had intended to let the his boat drift into 

line with the stern of the passenger vessel as the 

slack on the towline was taken up. It seems that the 

workboat did not turn as fast as expected for when 

the weight came on the workboat was still lying at 

an angle of about 140° to the fore and aft line of 

the tow. It appears that the skipper realising the 

danger abruptly put his engines full ahead intending 

to swing his vessel into line with the tow. Before 

the workboat could turn the tow started to pull 

the workboat along with it. The workboat listed 

to starboard and a combination of the workboat’s 

engines, the river current and the forward motion 

of the tow dragged the starboard quarter under, 

with the result that the workboat capsized. The 

eye of the towline from the passenger vessel to the 

workboat had been placed over the bitts. There was 

no means of releasing the towline in an emergency. 

Root Cause: 

Equipment design failure. 


The workboat, although eventually refloated, was 

a constructive total loss. The measures taken to 

prevent pollution together with the fees of lawyers 

and consultants exceeded US$14,000. The skipper’s 

family was compensated by the State Workers’ 

Compensation scheme. 

Footnote: Following the incident another 

Member of the Club designed an automatic quick 

release towing hook specifically for small craft/ 

workboats. Full details of the ‘Detach-Matic’ 

hook can be obtained from Navimar Corporation 

Ltee in Quebec, Canada, telephone number 

(418) 692 4830. 



210 211



Delayed Action has Painful Result 

Handling of Heavy Cargo Load Without Rope Tails Leads to Crushed Fingers 

The Incident: 

This claim involved a work boat 

which developed an engine 

fault. The fault was reported 

to the General Manager, who 

subsequently arranged for the 

company fitter to attend, although 

he could not do so immediately. 

The following morning, before the 

fitter had attended and carried 

out the repairs, a new boatman 

took the boat out onto the water. 

Whilst manoeuvring alongside 

another vessel the engine went 

astern instead of ahead, contrary 

to the control lever, and the boat 

landed heavily against the vessel 

causing the boatman to fall. This 

incident resulted in the crewman 

suffering multiple rib fractures and 

a broken arm. 

Observations: 

This incident would not have 

occurred if procedures had 

been in place to deal with the 

reported fault. In particular 

no positive steps had been 

taken to prevent the boat from 

being used prior to the fault 

being rectified. The General 

Manager reportedly gave verbal 

instructions not to use the boat, 

but this clearly was not sufficient. 

When any item of machinery is 

known to be defective, positive 

action must be taken to prevent 

further use until the problem 

has been rectified. This applies 

to all types of equipment no 

matter how important it is to a 

vessel’s operation. 

Root Cause: 

Inadequate maintenance 

procedures. 



The Incident: 

This incident occurred on board 

a harbour craft servicing ships in 

the anchorage at Singapore. The 

vessel had carried a load of stores 

and spare gear out to the oceangoing 

vessel and was backloading 

a 14 ton piece of machinery. The 

small vessel was rolling slightly in 

the swell and while conditions 

were not ideal it was considered 

safe for the operation to proceed. 

The machine was lowered from 

the ocean-going ship to just 

above deck level where it was 

suspended while our Member’s 

crew adjusted its position. One 

of the crew members involved 

inadvertently placed his hand 

in a position where it could be 

trapped and realising the danger 

immediately tried to retract it, 

but his hand was caught by the 

load. Fortunately he was able to 

pull his hand clear before the full 

pressure of the load came to bear. 

Nevertheless he suffered serious 

crush injuries to the middle and 

index fingers of his right hand. 

Observations: 

This incident illustrates the 

dangers that crew members can 

be exposed to if they have to 

work in close proximity to heavy 

loads being landed on deck. If this 

load had been fitted with rope 

tails it would have allowed the 

crew members to remain at a safe 

distance from the load while final 

positioning was carried out. 

Root Cause: 

Inadequate safety procedures. 



212 213

Operations 

Size does matter 

The Incident: 

This incident occurred when two tugs were employed 

in shifting a floating dry dock of approximately 3,400 

tonnes into deep water so that she could be ballasted 

down to sail out a vessel within. 

The operation required the dock to be manoeuvred 

across the port approach channel, down which a 

supply vessel was navigating. In order to give this 

vessel more sea room, the tugs towing the dock eased 

off. The dock then started to drift towards vessels 

moored at a nearby berth and despite the best efforts 

of the tugs, the dock continued towards the moored 

vessels, eventually making contact with one. 

Observations: 

Two factors played a part in the cause of 

this incident. The bollard pull of the tugs was 

considered insufficient for the size of the dock. 

A strong current was flowing at the time of the 

operation and the tugs were not of sufficient 

power to regain control. Secondly, neither the 

dry dock operations department nor the tug 

masters took it upon themselves to inform the 

port control of the operation. 

Had this been done, the manoeuvre would 

have probably been delayed until the channel 

was clear or the inbound vessel prevented 

from entering the channel. 


Whilst damage claimed was extensive we 

eventually concluded settlement in the 

modest sum of US$14,737. 

Trading Area: 

Europe and Middle East 



All in all the operation was very poorly planned. 

214 215

Section 7 

Barges 

217

Barges 

Operations 

You Get What You Pay For 

The Incident: 

This incident involved a dumb barge loading 

containers using her own gear. Whilst positioning a 

20 foot container on the barge the eye plate used 

to secure the topping lift block sheared away from 

the tripod mast. The container, derrick boom and 

gear all fell onto containers already loaded on the 

barge. Three 40 foot and two 20 foot containers 

in addition to the one being loaded were damaged. 

Fortunately there were no injuries to any of the 

crew or stevedores. 

Observations: 

Investigations showed that the eye plate appears to 

have been repaired some time prior to the incident 

and the standard of the welding was very poor. 

There was minimal penetration in places and the 

remainder of the welding was uneven. The surveyor 

was of the opinion that the repair work had been 

carried out by poorly trained personnel. Needless 

to say this is entirely unacceptable, especially 

when the safe working load (SWL) of the derrick 

(approximately 30 tons) is taken into consideration. 

Whenever major repairs are carried out on lifting 

gear or the associated fittings, a specialist company 

should be used that employs fully trained staff. Upon 

completion of these repairs the gear should be 

proof tested and a record entered in the Register of 

Lifting Appliances and Cargo Handling Gear. 

Root Cause: 

Inadequate maintenance procedures. 


US$14,541 



218 219

Contact Us 

London Office 

Singapore Office 

Vancouver Office 

Charles Hume 

Chief Executive 

Email: charles.hume@shipowners.co.uk 

Skype: charles.hume 

Ralph Coton 

Business Services Director 

Email: ralph.coton@shipowners.co.uk 

Skype: ralph.d.coton 

Ian Edwards 

Underwriting Services Development Manager 

Email: ian.edwards@shipowners.co.uk 

Skype: ian.edwards11 

Adam Howe 

Underwriting Manager 

Email: adam.howe@shipowners.co.uk 

Skype: adam.howe18 

Britt Pickering 

Claims Manager 

Email: britt.pickering@shipowners.co.uk 

Skype: britt.pickering 

Louise Hall 

Loss Prevention Manager - London 

Email: louise.hall@shipowners.co.uk 

Skype: louise.hall4 

Simon Swallow 

Commercial Director 

Email: simon.swallow@shipowners.co.uk 

Skype: simon.swallow1 

Lawrence Aspinall 

Finance Director 

Email: lawrence.aspinall@shipowners.co.uk 

Skype: lawrence.aspinall 

Mark Harrington 


Email: mark.harrington@shipowners.co.uk 

Skype: mark.harrington83 

William Tobin 


Email: william.tobin@shipowners.co.uk 

Skype: william.tobin3 

Kevin Lowe 

Finance Manager 

Email: kevin.lowe@shipowners.co.uk 

Skype: kevin.lowe2983 

The Shipowners’ Protection Limited 

St Clare House, 30-33 Minories, 

London, EC3N 1BP 

Tel: +44 (0) 207 488 0911 

Fax: +44 (0) 207 480 5806 

Email: info@shipowners.co.uk 


Principal Officer / Director 

Loss Prevention Manager 

Email: david.heaselden@shipowners.com.sg 

Skype: davidh2009 

Steve Randall 

General Manager / Director 

Email: steve.randall@shipowners.com.sg 

Skype: sd.randall 

Shipowners’ Asia Pte Ltd 

6 Temasek Boulevard 

#36-05 Suntec Tower 4 

Singapore 038986 

Tel: +65 (65) 930420 

Fax: +65 (65) 930449 

Email: info@shipowners.com.sg 

www.shipownersclub.com 

Rosemary Adams 

General Manager / Head of Underwriting Vancouver Branch 

Email: rosemary.adams@shipownersclub.ca 

Skype: rosemary.adams 

Shipowners’ North America Protection Limited 

1157-409 Granville Street 

Vancouver, British Columbia 

V6C 1T2 

Tel: +1 604 681 5999 

Fax: +1 604 681 3946 


Luxembourg Office 

Pascal Herrmann 

General Manager 

Email: pascal.herrmann@shipowners.lu 

The Shipowners’ Mutual Protection 

& Indemnity Association 

16 Rue Notre-Dame 

L-2240 Luxembourg 

Tel: +352 229 7101 

Fax: +352 229 7102 

Email: info@shipowners.lu 



220

The Shipowners’ Protection Limited 

St Clare House, 30-33 Minories, London EC3N 1BP 

Tel: +44 (0)20 7488 0911 Fax: +44 (0)20 7480 5806 

Email: info@shipowners.co.uk 


October 2010

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