MAIB Report 18 2016 Aquarius Very Serious Marine Casualty

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Extract from,The United Kingdom Merchant Shipping,Accident Reporting and Investigation. Regulations 2012 Regulation 5, The sole objective of the investigation of an accident under the Merchant Shipping Accident. Reporting and Investigation Regulations 2012 shall be the prevention of future accidents. through the ascertainment of its causes and circumstances It shall not be the purpose of an. investigation to determine liability nor except so far as is necessary to achieve its objective. to apportion blame, This report is not written with litigation in mind and pursuant to Regulation 14 14 of the. Merchant Shipping Accident Reporting and Investigation Regulations 2012 shall be. inadmissible in any judicial proceedings whose purpose or one of whose purposes is to. attribute or apportion liability or blame,Crown copyright 2016. You may re use this document publication not including departmental or agency logos free of. charge in any format or medium You must re use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source. publication Where we have identified any third party copyright material you will need to obtain. permission from the copyright holders concerned, All MAIB publications can be found on our website www gov uk maib.
For all enquiries,Marine Accident Investigation Branch. Spring Place,105 Commercial Road,Southampton Email maib dft gsi gov uk. United Kingdom Telephone 44 0 23 8039 5500,SO15 1GH Fax 44 0 23 8023 2459. Press enquiries during office hours 01932 440015,Press enquiries out of hours 020 7944 4292. GLOSSARY OF ABBREVIATIONS ACRONYMS AND TERMS,SYNOPSIS 1.
SECTION 1 FACTUAL INFORMATION 2,1 1 Particulars of Aquarius and accident 2. 1 2 Narrative 3,1 3 Environmental conditions 9,1 4 Crew 9. 1 5 Aquarius 10,1 5 1 General 10,1 5 2 Fishing gear 11. 1 6 Crew working patterns 11,1 7 Marking the trawl warps 11. 1 8 The rope stopper 13, 1 9 The Code of Safe Working Practice for the Construction and Use of 15 to 24.
Metre Fishing Vessels 13,1 10 Surveys and inspection requirements 16. 1 10 1 Certification process for 15 to 24 metre fishing vessels 16. 1 10 2 Annual self certification 16, 1 10 3 Offshore industry guard ship inspections 17. 1 11 Survey and inspection performance record 17,1 12 Post accident inspection 18. 1 13 Management of deficiencies 18,1 14 Life saving appliances 19. 1 15 Vessel Safety Management 20,1 15 1 General duties 20.
1 15 2 Safety management system 20,1 15 3 Emergency procedures and drills 21. 1 15 4 Risk assessments 23,1 15 5 Work equipment inspections 23. 1 15 6 Personal protective equipment and working lifejackets 24. 1 15 7 Stability 25,1 16 Safe working practices 25. 1 16 1 General safety guidance 25, 1 16 2 Guidance provided by the International Maritime Organization 25. 1 16 3 The Fishermen s Safety Guide 26,1 16 4 Marine Guidance Notes 26.
1 16 5 The Code of Safe Working Practices for Merchant Seamen 26. 1 17 Hours of work and rest requirements 27, 1 18 Previous incidents on Aquarius and similar accidents 28. 1 18 1 Aquarius 28, 1 18 2 UK fishing vessel fatal man overboard accidents 29. 1 18 3 Annual self certification 30,SECTION 2 ANALYSIS 31. 2 1 Aim 31,2 2 Overview 31,2 3 The failure of the rope stopper 31. 2 4 Working practices on board Aquarius 32,2 4 1 Marking the trawl 32.
2 4 2 Standards of general seamanship 33,2 4 3 Leadership and teamwork 34. 2 5 Man overboard 34,2 6 Emergency response 34,2 7 Emergency preparedness 35. 2 8 The use of personal flotation devices on deck 36. 2 9 Effects of tiredness and fatigue 37,2 10 Hours of work and rest 37. 2 11 Vessel safety management 38,2 11 1 Vessel s safety management system 38. 2 11 2 Risk assessment 38, 2 11 3 Safety culture and its effect on behaviours 39.
2 12 Certification process and equipment maintenance 39. 2 12 1 Vessel owner s annual self certification process 39. 2 12 2 Regulatory oversight and the management of deficiencies 40. SECTION 3 CONCLUSIONS 41, 3 1 Safety issues directly contributing to the accident that have been addressed or. resulted in recomendations 41, 3 2 Safety issues not directly contributing to the accident that have been addressed. or resulted in recommendations 41,SECTION 4 ACTIONS TAKEN 43. 4 1 MAIB Actions 43,4 2 Actions taken by other organisations 43. SECTION 5 RECOMMENDATIONS 44,Figure 1 Demersal trawl net arrangement.
Figure 2a Stern view of Aquarius,Figure 2b Port trawl warp. Figure 3a Reconstruction of rope stopper applied, Figure 3b Reconstruction of rope stopper trapped in block after warp. slackened off, Figure 4 Plan view of deck with warp pulled inboard. Figure 5 Reconstruction of marking the warp, Figure 6 Positions of the deck crew when the stopper failed. Figure 7 Track of Aquarius on departing Aberdeen,Figure 8 Wheelhouse electronic displays.
Figure 9 Reconstruction of application of stopper hitch from cleat on port side. to the warp, Figure 10 Reconstruction of stopper trapped in the gantry block as warp is. Figure 11 Endless chain available for use on Aquarius. Figure 12 Chain stopper applied, Annex A Annang Nuerty deceased contract of employment. Annex B MGN 430 F Checks on Crew Certification and Drills. Annex C Annual self certification declaration form. Annex D Guard Vessel Inspection and Specification Document. Annex E Aquarius documented manoverboard recovery procedure. Annex F Aquarius logbook muster and training records. Annex G Risk Assessment General Working on Deck,Annex H Aquarius LOLER record of inspections. Annex I MAIB Safety Flyer,GLOSSARY OF ABBREVIATIONS ACRONYMS AND TERMS. C degrees Celsius, CoSWP Code of Safe Working Practices for Merchant Seamen.
DSC Digital Selective Calling,EPIRB Emergency Position Indicating Radio Beacon. FISG Fishing Industry Safety Group,GMDSS Global Maritime Distress and Safety System. HF High Frequency,IMO International Maritime Organization. ISO International Organization for Standardization. kg kilogram,kt s knot s nautical mile s per hour,kW kilowatt. LOA Length Overall, LOLER The Merchant Shipping Fishing Vessel Lifting Operations.
and Lifting Equipment Regulations 2006,LSA Life Saving Appliance. MCA Maritime and Coastguard Agency,MF Medium Frequency. MGN Marine Guidance Note,mm millimetre,MOB Man Overboard. MSN Merchant Shipping Notice,PFD Personal Flotation Device. PPE Personal Protective Equipment, PUWER The Merchant Shipping Fishing Vessel Provision and Use.
of Work Equipment Regulations 2006,RNLI Royal National Lifeboat Institution. SAR Search and Rescue,Seafish Sea Fish Industry Authority. SFF Scottish Fishermen s Federation,SIAS Ship Inspection And Survey. SOLAS International Convention for the Safety of Life at Sea 1974. VHF Very High Frequency,VTS Vessel Traffic Services. UKFVC United Kingdom Fishing Vessel Certificate,UTC Universal Co ordinated Time.
The Working Time The Fishing Industry Code of Practice on Working. Standards Code Time Standards, 15 24m FV Code Code of Safe Working Practice for the Construction. and Use of 15 metre length overall LOA to less than. 24 metre registered length L Fishing Vessels, TIMES all times used in this report are UTC 1 unless otherwise stated. Image courtesy of Sean Boyce MarineTraffic com, In the early hours of the morning on 17 August 2015 a fisherman on board the 20 8m. twin rig trawler Aquarius was struck and thrown overboard violently by a steel wire trawl. warp when a rope stopper parted The vessel had just cleared the port of Aberdeen. Scotland and its crew were attempting to re mark the trawl warps when the accident. happened The skipper reacted quickly to stop the vessel and the crew threw lifebuoys to. the casualty However the recovery attempt was unsuccessful and the casualty sank out. of view approximately 10 minutes later Despite a search involving numerous vessels and a. helicopter the casualty s body was not recovered, In order to mark the steel wire warp the crew had streamed it over the stern The stopper. was used to take the strain of the trailing warp so that the crew could lower its inboard. section on to the deck The MAIB investigation established that. The stopper parted under tension because a man made fibre rope had been used. instead of a chain and because the way it had been applied deviated from well. established good practice, The casualty was thrown overboard because he had positioned himself within the.
bight of the slackened trawl warp, The crew were unable to recover the casualty back on board because neither. they nor their vessel had been adequately prepared to deal with such emergency. situations, The casualty s body was not recovered because he was not wearing a lifejacket or. other type of personal flotation device while working on the open deck. The Maritime and Coastguard Agency had surveyed and inspected Aquarius on numerous. occasions during the previous 9 years It had identified Aquarius as a poorly run vessel and. issued it with 137 deficiencies many of these related to safety management and were of a. repetitive nature, The underlying factors that contributed to this accident included a total lack of proactive. safety management a poor level of onboard safety culture and the crew suffering from. tiredness and fatigue, Recommendations have been made to the owners of Aquarius the vessel s manning. agency and the Maritime and Coastguard Agency These are aimed at improving the levels. of safety management and emergency preparedness on board Aquarius the working. conditions and hours of rest for non UK nationals on board UK flagged fishing vessels and. the capability of the electronic systems used by the Maritime and Coastguard Agency to. manage and monitor deficiencies and poor performing fishing vessels. SECTION 1 FACTUAL INFORMATION,1 1 PARTICULARS OF AQUARIUS AND ACCIDENT.
SHIP PARTICULARS,Vessel s name Aquarius,Classification society Not applicable. Fishing numbers BF 89,Type Stern trawler,Registered owner MB Aquarius Ltd. Manager s n a,Construction Steel,Year of build 1994. Length overall 20 80m,Gross tonnage 189t,Main engine power 600kW. Minimum safe manning Not applicable,Authorised cargo Fish.
VOYAGE PARTICULARS,Port of departure Aberdeen,Intended port of arrival Aberdeen. Type of voyage Fishing,MARINE CASUALTY INFORMATION. Date and time 17 August 2015 at about 0140, Type of marine casualty or incident Very Serious Marine Casualty. Location of incident 2 miles east of Aberdeen harbour. Place on board Aft main deck,Injuries fatalities One fatality. Damage environmental impact None,Ship operation Single rig trawling for squid.
External internal environment Westerly wind at 10kts calm to. slight sea visibility good night sea,temperature 13 8 C. Persons on board 6,1 2 NARRATIVE, Shortly after midnight on Monday 17 August 2015 the UK registered fishing vessel. Aquarius entered Aberdeen harbour Scotland and berthed on the fish quay Once. secure alongside the vessel s crew landed their catch of 47 boxes of squid On. completion the skipper moved Aquarius to an adjacent quay to create space for. another fishing vessel to come alongside, Before departure from Aberdeen the skipper gathered his five man crew together. and informed them that he needed to re mark the vessel s steel wire trawl warps. Figure 1 He explained that this would be done once the boat was clear of the. harbour and that he wanted the warps to be marked at 125 fathoms1. At about 0100 the crew let the mooring ropes go and the skipper manoeuvred. Aquarius away from the quayside As the boat was manoeuvred out of the harbour. the crew secured the trawl doors to the stern gantry and disconnected the port side. trawl warp Figures 2a and 2b, Once Aquarius was clear of the harbour entrance the crew veered the port trawl. warp winch drum and lowered the warp over the stern and into the sea The crew. stopped the winch at the warp s 100 fathom marker and waited for the skipper to. come aft and measure the additional 25 fathoms The skipper was busy navigating. the vessel clear of harbour traffic and directed Annang Nuertey one of the vessel s. Ghanaian deck crew to carry on and complete the job. Under Annang s instruction the warp was veered a further 25 fathoms and marked. temporarily with adhesive tape One of the crewmen then used a length of synthetic. fibre rope to apply a stopper2 to the tensioned steel wire warp Figures 3a and 3b. The winch was again veered and the inboard section of the warp became slack as. the strain transferred to the rope stopper, With the weight of the streamed warp being taken by the rope stopper the crew.
pulled the slackened section of warp inboard and laid it on the deck Figure 4. Annang knelt on the deck outboard of the slackened warp and began to open its. wire strands with a marlin spike his intention was to insert a fibre rope marker. Figure 5 Another crew member knelt on the opposite side of the warp to assist in. holding it securely The three remaining crew members stood inboard of the warp. towards the stern of the boat Figure 6 At the same time the skipper was gradually. altering the vessel s course to head south towards his intended fishing grounds. VERY SERIOUS MARINE CASUALTY REPORT NO 18 2016 OCTOBER 2016 Report on the investigation of a fatal man overboard from the fishing vessel Aquarius BF 89 east of Aberdeen on 17 August 2015 Extract from The United Kingdom Merchant Shipping Accident Reporting and Investigation Regulations 2012 Regulation 5 The sole objective of the investigation of an accident under the Merchant

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