MAIB Annual Report 2009

MARINE ACCIDENT INVESTIGATION BRANCH
ANNUAL REPORT 2009

Extract from The Merchant Shipping (Accident Reporting and Investigation)
Regulations 2005
The sole objective of the investigation of an accident under these Regulations 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.
Marine Accident Investigation Branch

Mountbatten House
Grosvenor Square
Southampton
SO15 2JU
All reports can also be found on our website:

www.maib.gov.uk
For all other enquiries:

Email: maib@dft.gsi.gov.uk
Tel: +44 (0)23 8039 5500
Fax: +44 (0)23 8023 2459
Contents
Chief Inspector’s Report 1
Part 1 - Full Investigations and Report Publications 4
Part 2 - Recommendations 9
Background 11
Recommendation response statistics 12
Recommendation methodology 13
Section A - Level 1 Recommendations 14
Section B - Level 2 Recommendations 21
Section C - Level 3 Recommendations 32
Section D - Recommendations to multiple recipients 43
Section E - Withdrawn recommendations 44
Section F - Recommendations brought forward from previous years 45
Part 3 - Statistics 53
UK vessel accidents involving loss of life 54
UK merchant vessels >= 100gt 56
UK merchant vessels < 100gt 61
UK non-commercial vessels 62
UK fishing vessels 63
Non-UK commercial vessels 68
Annex - Statistics Coverage 69
Glossary of abbreviations and acronyms 71

C H I E F I N S P E C TO R ’ S R E P O RT
Chief Inspector’s Report

There continues to be a significant number of unnecessary accidents at sea, few of which
can be attributed to the convenient excuse of “the sea being a hazardous environment”.
1663 marine accidents and incidents were reported to the MAIB in 2009, with many non-
commercial casualties still going unreported. It is quite evident from the accidents we
investigate that safety standards, supervision, training, inspection and enforcement are
routinely well below that expected ashore. Although improvements are taking place,
these are normally driven by accident investigations conducted by the MAIB and similar
organisations in other countries.
Despite its small size and budget, the MAIB is seen as a world leader in the field. With a total
staff of just 39, we have had to consider the issues in every one of these 1663 reports; the
majority of the 1461 which detailed analysis determined fell within the remit of the MAIB, were
then followed up to satisfy ourselves that appropriate actions were taking place to prevent
such incidents recurring. In 46 of the cases, it was judged necessary for the MAIB to deploy
a team and commence an investigation in order to establish the circumstances and all the
causal factors of the incident and thus derive potential recommendations to improve future
safety. Twenty of these developed into full investigations leading to major reports being
published.
This workload is heavy for a small team. It is kept manageable by putting a large amount
of effort into selecting which incidents are likely to yield the most important issues for future
safety. It is only these that we investigate, and even then fewer than half are judged essential
to be taken through from preliminary examination stage to full investigation. This focus of
effort allows a “lean and mean” organisation to deliver our legal and our moral obligations in
an effective and timely manner. It is a matter of some pride to the MAIB, that representatives
of many other countries from around the world come to Southampton to find out how we can
do so much for so little.
However, there is a danger that the flexibility on which this focussed approach depends may
soon be lost. An EU Directive has been passed which requires, from June 2011, that the
MAIB must conduct a full investigation into all “very serious accidents”, and to give reasons
for any “serious accidents” into which we do not intend to conduct a full investigation. This
could in theory double or treble the MAIB’s workload, at a time of considerable resource
restraints. We will continue to work with our lawyers and others to ensure that we can meet
the intent of the Directive within current resources.
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M A I B A N N U A L R E P O RT 2 0 0 9
INVESTIGATIONS
A wide variety of accidents to merchant vessels were investigated in 2009. Thankfully, the
number of fatalities remained low, and the number of injuries to crew has shown a significant
reduction. On the negative side, the Belgian and Cypriot administrations have failed to
respond to a number of recommendations, despite a crewman being severely injured; and
a European manufacturer sees no reason to redesign a windlass motor despite a series of
accidents, two of which resulted in crewmen being severely injured when windlass motor
casings shattered, spraying shrapnel around the adjacent decks.
Thirteen fishermen died in accidents in 2009. This is the second largest total since 2000, and
equates to a fatality rate of 102 against a national accident at work rate of less than 11. This
rate, which has shown little sign of decreasing over the last 30 years, led to a recommendation
being made in May 2010 to the Department for Transport to:
“Recognise the consistent and disproportionate rate of fatalities in the UK fishing

industry and take urgent action to develop a comprehensive, timely and properly
resourced plan to reduce that rate to a level commensurate with other UK occupations”.
RECOMMENDATIONS
Of the recommendations issued, 88% have been accepted. A large proportion of those
organisations that have not accepted our recommendations are outside the UK.
As recommendations may take a long time to complete, it is inevitable that a number have yet
to be fully implemented. Our follow-up system continues to monitor progress on these.
FINANCE
This Annual Report deals principally with the calendar year of 2009. However, for ease of
reference, the figures below are for the 2009/10 financial year, which ended on 31 March
2010; MAIB’s funding from the Department for Transport is provided on this basis, and this
complies with the Government’s business planning programme.
£ 000s Budget Outturn

Costs 4,272 4,116
Receipts* 100 107
Totals 4,172 4,009
* The MAIB gains receipts from investigations carried out on behalf of other administrations, and
from the provision of technical services and training conducted on behalf of EMSA and the IMO.
1
Industrial fatality rates are measured per 100,000 worker-years.
2
C H I E F I N S P E C TO R ’ S R E P O RT
CIVIL SERVICE AWARD FOR SCIENCE ENGINEERING AND

TECHNOLOGY
The MAIB prides itself on its ability to beg, borrow and steal (the last not literally). On
a shoestring we have developed a world-leading analysis suite for marine accident
investigation. This suite has now been bought by countries as widespread as Norway, the
United States and Australia. As a result of this work, our technical team of 2 beat major
departments from across Whitehall to win the coveted Civil Service Award for Science
Engineering and Technology in 2009.
AND FINALLY...
I leave the MAIB in August, after little over 8 years as the Chief Inspector. There have
been many challenges. When I joined, I was naïve enough to think that everyone would
be on the side of independent investigation, the sole purpose of which was future safety.
In fact, few are on our side, as everyone involved in an accident has some form of vested
interest, and others often have a particular axe to grind. I have also had to fight to maintain
the independence and integrity of the MAIB, and our right to operate free from the growing
culture of blame and litigation. That we have continued to operate so successfully in the
face of such challenges has reinforced our credibility and is, I believe, an important outcome
for safety at sea. I have an amazing team in the MAIB who, despite the gruelling nature of
constantly working with death and tragedy, have remained positive and enthused. I wish
them and my successor, Steve Clinch, all fortune in continuing this important task.
Stephen Meyer
Chief Inspector of Marine Accidents
3
PART 1
FULL INVESTIGATIONS AND
REPORT PUBLICATIONS
4
PART 1: INVESTIGATIONS/PUBLICATIONS
FULL INVESTIGATIONS LIST
Full Investigations started in 2009

Date Name Of Vessel Type Of Vessel Nationality Size Nature of Incident
Merchant Vessels
28 Jan Stena Voyager High speed ro-ro UK 19 638 gt Shift of road tanker on vehicle
ferry deck causing extensive
damage to stern door – Loch
Ryan shortly after leaving
Stranraer
28 Jan Ville de Mars Container ship UK 37 235 gt Fatal fall involving Chief Officer
while descending into ballast
tank – Gulf of Oman
25 Feb Vallermosa Chemical tanker Italy 25 063 gt Contact with two vessels
discharging cargo – Fawley
23 Mar Stellar Voyager Oil tanker Bahamas 58 088 gt Explosion of windlass motor
causing injury to one crewman
– Tees Bay
01 Apr Wellservicer Dive support UK 9 158 gt Fatal accident to rigger

involving a diving bell cursor –
Aberdeen
05 Apr TS Royalist Sail training vessel UK 83 gt Grounding – Chapman’s Pool,

Dorset
06 May Jo Eik Chemical tanker Norway 12 249 gt Chief Officer and AB overcome
by fumes on main deck –
Vopak terminal, Teeside
14 Jun Ijsselstroom Tug Netherlands 71 gt Capsize due to girting –

Peterhead
10 Aug Saetta/Conger Oil tanker/ Greece/ 58 418 gt/ Collision during ship to ship
Chemical tanker Marshall 44 067 gt cargo transfer operation –
Islands North Sea off Southwold,
Suffolk
10 Sep Ever Elite Container ship UK 76 067 gt Fatal accident to AB following

collapse of accommodation
ladder – San Francisco Bay
16 Sep Maersk Kendal Container ship UK 74 642 gt Grounding – Monggok Sebarok

reef in the Singapore Strait
5
Full investigations list
Full Investigations started in 2009

Date Name Of Vessel Type Of Vessel Nationality Size Nature of Incident
Fishing Vessels
12 Feb Maggie Ann Scallop dredger UK 23.2 m Fatal person overboard –
Cardigan Bay
20 Jul Aquila Scallop dredger UK 11.9 m Capsize resulting in three

fatalities – north of the
Ardnamurchan peninsula
10 Oct Olivia Jean Beam trawler UK 29.9 m Crush injury during movement
of gear – English Channel
06 Nov Korenbloem Scallop dredger UK 24.3 m Fatal person overboard –

Dover Strait
11 Nov Osprey III Stern trawler UK 9.2 m Fatal person overboard – East
Coast of Scotland
18 Nov Optik Potter UK 9.2 m Fatal person overboard – East

Coast of Scotland
20 Dec Etoile des Ondes Potter UK 14.5 m Collision resulting in sinking

and the loss of one crew –
English Channel
Small Craft
18 May Sooty RIB UK 6.3 m High speed grounding resulting
on one fatality – Calve Island,
near Tobermory, Isle of Mull
08 Aug Harwich 2011 Racing powerboat UK 6m Collision during race resulting

in one fatality – Dover
6
PART 1: INVESTIGATIONS/PUBLICATIONS
PUBLICATIONS LIST
Reports of Full Investigations published in 2009
Vessel Name
Vessel Type Accident Type Accident Date
(Report No)
Merchant Vessels
Abigail H Dredger Flooding and foundering while alongside 02 Nov 2008

(15/2009) – Heysham
Antari General cargo ship Grounding – near Larne, Northern Ireland 29 Jun 2008
(7/2009)
Astral Product tanker Grounding – Princessa Shoal, east of Isle 10 Mar 2008
(4/2009) of Wight
Eurovoyager Ro-ro passenger ferry Major injury to an engine room fitter 03 Nov 2008
(17/2009) trapped in watertight door – Dover Strait
HMS Westminster/ Royal Navy frigate/ Person overboard during passenger 24 Nov 2008
Princess Rose Class V passenger transfer – River Thames, Gravesend
(16/2009) vessel Reach
Hurlingham Class V passenger Passenger fatality during disembarkation 17 Aug 2008

(12/2009) vessel – River Thames, London
Jo Eik Chemical tanker Chief Officer and AB overcome by fumes 06 May 2009
(24/2009) on main deck – Vopak Terminal, Teeside
Maersk Kithira Container ship Fatal injury and serious injury in heavy 23 Sep 2008
(9/2009) weather – South China Sea
Maersk Newport Container ship Heavy weather damage in English 10 and 15

(13/2009) Channel and subsequent fire while Nov 2008
alongside in Algeciras, Spain
Moondance Ro-ro cargo ship Electrical blackout and subsequent 29 Jun 2008
(5/2009) grounding – Warrenpoint, Northern Ireland
Norma Self propelled crane Hazardous diving incident – Dover Strait 21 Jun 2008
(3/2009) barge
Pacific Sun Cruise ship Injuries to 77 passengers and crew in 30 Jul 2008
(14/2009) heavy weather – Pacific Ocean
Pride of Canterbury Ro-ro passenger ferry Grounding – off Deal, Dover Strait 31 Jan 2008
(2/2009)
Riverdance Ro-ro cargo ship Grounding and subsequent loss – 31 Jan 2008
(18/2009) Cleveleys Beach, Lancashire
7
Publications list
Vessel Name
Vessel Type Accident Type Accident Date
(Report No)
TS Royalist Sail training vessel Grounding – Chapman’s Pool, Dorset 05 Apr 2009
(26/2009)
Saga Rose Cruise ship Fatality in ballast tank – Southampton 11 Jun 2008
(1/2009)
Scot Isles/ General cargo ship/ Collision in the Dover Strait 29 Oct 2008
Wadi Halfa Bulk carrier
(10/2009)
Stellar Voyager Oil tanker Explosion of windlass motor causing injury 23 Mar 2009
(25/2009) to one crewman – Tees Bay
Stena Voyager High speed Shift of road tanker on vehicle deck 28 Jan 2009
(21/2009) ro-ro ferry causing extensive damage to stern door –
Loch Ryan shortly after leaving Stranraer
Vallermosa Chemical tanker Contact with two vessels discharging 25 Feb 2009
(23/2009) cargo – Fawley
Ville de Mars Container ship Fatal fall involving Chief Officer while 28 Jan 2009
(20/2009) descending into ballast tank – Gulf of
Oman
Fishing Vessels
Maggie Ann Scallop dredger Fatal person overboard – Cardigan Bay 12 Feb 2009
(19/2009)
Vision II Trawler Fire resulting in 3 fatalities – alongside in 01 Aug 2008

(8/2009) Fraserburgh
Small Craft
Celtic Pioneer RIB Injury to passenger – Bristol Channel off 26 Aug 2008
(11/2009) Cardiff
RIB 6 RIB Capsize resulting in one injury – Menai 01 Jul 2008

(6/2009) Strait
Sooty RIB High speed grounding resulting on one 18 May 2009

(22/2009) fatality – Calve Island, near Tobermory,
Isle of Mull
8
PA RT 2 : R E C O M M E N D AT I O N S
PART 2
RECOMMENDATIONS
9

RECOMMENDATIONS
Responses to safety recommendations issued by the Marine Accident Investigation Branch.
This report is submitted to the Secretary of State for Transport in accordance with The
Merchant Shipping (Accident Reporting and Investigation) Regulations 2005, regulation
15(5).
Page
Background 11
Recommendation response statistics 12
Recommendations methodology 13
Section A - Level 1 Recommendations 14
Section B - Level 2 Recommendations 21
Section C - Level 3 Recommendations 32
Section D - Recommendations to multiple recipients 43
Section E - Withdrawn recommendations 44
Section F - Recommendations brought forward from previous years 45
For details of abbreviations and acronyms used in this Section please refer to the Glossary
on page 71.
10
BACKGROUND
Recommendations are the prime output of MAIB investigations. They are made to
promulgate the lessons from accidents and incidents investigated by the MAIB, with the aim
of improving the safety of life at sea and the avoidance of future accidents. The issue of a
recommendation shall in no case create a presumption of blame or liability.
Following a preliminary examination (PE) or full investigation the MAIB may make a number
of recommendations. These may take the form of a Chief Inspector’s letter following a PE
or, in the case of a full investigation, be contained within the published report. Urgent safety
recommendations may also be made in Safety Bulletins that can be published at any stage
of a PE or full investigation. It is of no consequence whether a recommendation is made as
a result of a PE or full investigation, as they are processed in the same manner.
Recommendations are made to a variety of addressees who may have been involved in,
or have an interest in, the incident or accident. These may range from those organisations
which have a wider role in the maritime community such as the Department for Transport
(DfT), Maritime and Coastguard Agency (MCA) or an international organisation, through
to commercial operators and vessel owners/operators who may have specific issues to
address on their vessels.
It is required by the Merchant Shipping (Accident Reporting and Investigation) Regulations

2005 that the person organisation to whom a recommendation is addressed, consider the
recommendation, and reply to the Chief Inspector within 28 days on the plans to implement
the recommendation or, if it is not going to be implemented, an explanation as to why not.
The Regulations also require the Chief Inspector “to inform the Secretary of State of those
matters” annually, and to make the matters publicly available. This report to the Secretary of
State for Transport fulfils this requirement.
11
RECOMMENDATION RESPONSE STATISTICS 2009

84 recommendations were issued to 117 addressees in 2009. Each addressee is considered
separately for the purposes of these statistics. Of these the percentage total of all 117
recommendations that are either “accepted” or “accepted yet to be implemented” is 88.0%.
Throughout the report recommendations are categorised under four broad headings
according to the industry sector to which they apply, General Maritime, Commercial
Shipping, Fishing Vessels and Leisure Vessels.
subtotal Accepted –
Accepted No
Action Partially
Focus – Action Rejected Response
yet to be Accepted
Implemented Received
% of total Implemented
General 30
11 15 3 - 1
Maritime
25.6%
Commercial 77
56 11 4 - 6
Shipping
65.8%
Fishing 7
4 3 - - -
Vessels
6.0%
Leisure 3
3 - - - -
Vessels
2.6%
subtotal 117 74 29 7 - 7
% of total 100% 63.2% 24.8% 6.0% - 6.0%
Details of all these recommendations are at Sections A-C.
RECOMMENDATION RESPONSE STATISTICS 2004 to 2008

The following table shows the equivalent status of recommendations issued in 2004 to 2008
as published in the MAIB’s previous Recommendations Annual Reports.
Accepted Accepted –
Partially No Response
Year Total – Action Action yet to be Rejected
Accepted Received
Implemented Implemented
2008 110 71 31 5 - 3
2007 136 109 23 1 1 2
2006 139 103 30 3 3 -
2005 140 122 14 1 1 2
2004 171 93 52 11 11 4
Of the 150 recommendations accepted – yet to be implemented (at time of publication of

relevant annual report):
• 76.7% have now been fully implemented
• 23.3% remain planned to be implemented.
Details of the recommendations still to be implemented are at Section F.
12
RECOMMENDATION METHODOLOGY
Sections A-E to this report present the recommendations made throughout 2009, Sections
D and E are not included in the statistics. Section F lists the recommendations that are still
outstanding accepted – yet to be implemented from previous years.
The recommendations have been broken down into three levels, shown in Sections
A-C. These are then further divided, as shown below. Emphasis has been given to those
recommendations which have been rejected or partially accepted and their entries
include the response received by the MAIB, together with an MAIB comment.
Rejected,
Level 1 Recommendations Partially accepted,
These have the broadest No Response Received
Section
importance, and may include the
A Accepted - yet to be implemented
requirement for new legislation or
changes in policy.
Accepted - implemented
Rejected,
Addressed to industry bodies and No Response Received
Section
organisations which may call for
B Accepted - yet to be implemented
changes or reinforcement of best
practice.
Rejected,
Those which are addressed to No Response Received
Section
individual owners or companies
C Accepted - yet to be implemented
which are specific to their vessel or
company.
Recommendations to multiple recipients

Lists the small number of recommendations that have been addressed to large multiple
Section
recipients. As a result, it has not been possible to track responses under the closed-
D
loop system. Such multiple addressee recommendations are avoided whenever
possible.
Section
Withdrawn recommendations.
E
Recommendations brought forward from previous years.

Section
Lists the ongoing outstanding recommendations shown as accepted – yet to be
F
implemented in previous reports.
13
Section A
LEVEL 1 RECOMMENDATIONS
These have the broadest application, and may include the requirement for
new legislation or changes in policy.
Summary Table
Accepted
Accepted No
Action yet Partially
Focus Total Action Rejected Response
to be Accepted
Implemented
General
7 2 2 1 - -
Maritime
Commercial
13 6 4 1 - 3
Shipping
Fishing
- - - - - -
Vessels
Leisure
- - - - - -
Vessels
Total 20 8 6 2 - 3
14
Level 1 Recommendations – Breakdown
Responses to recommendations which have not been accepted have been grouped together and presented first.
Those which have been accepted are presented secondly and broken down into their vessel type.
No Response Received
Number Focus Investigation Addressed To Recommendation

147c Commercial Eurovoyager Belgium Federal Through representations to the European Commission, take steps to ensure
Shipping Public Service, that official guidance provided for inspectors in respect to the application of EU
Mobility and Directive 1999/35/EC is amended to reflect SOLAS requirements regarding the
Transport operation of watertight doors at sea.
No response to date.
148b Commercial Eurovoyager Belgium Federal Present a joint paper to the IMO’s Maritime Safety Committee on:
Shipping Public Service,
15
Mobility and • Revision of SOLAS Regulation 15 (openings in watertight bulkheads in
Transport passenger ships) to reflect the contents of Section 4.3.8 and Section
8 of MSC/Circ.1176 which requires the provision of a local visual
indication to indicate when a watertight door is being operated in the
remote mode.
• The application of SOLAS Regulation 15 to all vessels fitted with
watertight doors.
148c Commercial Eurovoyager Cyprus Maritime Present a joint paper to the IMO’s Maritime Safety Committee on:
Shipping Administration
• Revision of SOLAS Regulation 15 (openings in watertight bulkheads in
passenger ships) to reflect the contents of Section 4.3.8 and Section
8 of MSC/Circ.1176 which requires the provision of a local visual
indication to indicate when a watertight door is being operated in the
remote mode.
watertight doors.
Partially Accepted
141 General Abigail H Maritime and Introduce a mandatory requirement, for all vessels greater than 24m
Maritime Coastguard Agency length and less than 500 gross tons, for the fitting of bilge alarms in engine
(MCA) rooms and other substantial compartments that could threaten the vessel’s
buoyancy and stability if flooded. These and any other emergency alarms
should sound in all accommodation spaces when the central control station
is unmanned. In addition to functioning in the vessel’s normal operational
modes, alarms should be capable of operating when main power supplies
are shut down, and be able to wake sleeping crew in sufficient time for
them to react appropriately.

MCA Response The recommendation can best be implemented by introducing a
requirement into the Merchant Shipping (Load Line) Regulations, removing
the restriction for bilge alarms to be fitted only where engine rooms are
unmanned, and adding a requirement for the bilge alarms to be fitted in
the cargo hold. This will mirror the requirement of SOLAS for ships of over
500gt. The regulation could also require that the bilge alarm sounds in the
16
accommodation should the central control station not be manned – again,
in a similar manner to the requirement for the engineer’s alarm in SOLAS.
The part of the recommendation to “… be capable of operating when main

power supplies are shut down” cannot be made a mandatory requirement
under UK law. The recommendation to “… be able to wake sleeping crew in
sufficient time for them to react appropriately” again would be very difficult
in law. It is concluded that the intent of these parts of the recommendation
are better managed by risk assessment and inspection of the vessels as
proposed through the response to Recommendation 2009/142.
MAIB Comment MCA comments are noted.
148a Commercial Eurovoyager MCA Present a joint paper to the IMO’s Maritime Safety Committee on:
Shipping • Revision of SOLAS Regulation 15 (openings in watertight bulkheads
in passenger ships) to reflect the contents of Section 4.3.8 and
Section 8 of MSC/Circ.1176 which requires the provision of a
local visual indication to indicate when a watertight door is being
operated in the remote mode
watertight doors.
MCA Response • Recognises the need for change to SOLAS Regulation 15 to reflect
contents of MCS/Circ 1176 (see above). However, the MCA is only
prepared to support the paper to IMO if presented by the flag state of
the vessel concerned.
• Recognises the need to apply SOLAS Regulation 15 to all vessels.
MAIB Comment The MCA’s actions with respect to this recommendation mean that
17
any initiative to realise a revision of SOLAS Regulation 15 rests
with the administrations of Belgium and Cyprus. No response to
this recommendation has been received from either the Belgium or
Cyprus administration.
Accepted – Yet to be Implemented

115b Commercial Antari MCA Press the International Maritime Organization for an urgent review of the principles
Shipping and process used to establish safe manning levels internationally and the use of
dedicated lookouts.
Predicted implementation date: June 2010
125 Celtic Pioneer In consultation with the MCA, continue to work towards the production of an
industry approved code of practice for thrill-type boat ride operators, taking into
account the safety issues raised in this report and the requirements laid down in the
Vibration Regulations.
125a General Professional Predicted implementation date: Work in progress.
Maritime Boatman’s
Association
125b General Passenger Boat Predicted implementation date: Work in progress.
Maritime Association
18
126a Commercial Celtic Pioneer MCA Review and revise the deck manning and qualification requirements of the
Shipping harmonised SCV Code taking into account the speed of craft and the type of activity
intended in addition to the distance from shore and environmental conditions.
Predicted implementation date: Yet to be advised
153 Riverdance Conduct an urgent study into stability and operational issues which impinge on
the safety of ro-ro vessels operating from UK ports. In particular, the study should
153a Commercial Department for
identify how the stowage plan should be produced and implemented, how masters
Shipping Transport (DfT)
can establish the stability of their vessel before sailing, and under varying conditions
153b Commercial MCA of service, the securing of trailers, and the securing of cargo within trailers to
Shipping prevent their movement whilst at sea.
Predicted implementation date: December 2010
Accepted – Implemented – Recommendation closed by MAIB

109 Commercial Moondance Bahamas Maritime Take urgent action to review the validity of Seatruck Shipholding Limited’s
Shipping Authority (BMA) Safety Management Systems to ensure they are sufficiently robust for safe
operation of its vessels.
115a Commercial Antari DfT Press for an urgent review of the process and principles of safe manning at
Shipping the IMO to reflect the critical safety issues of fatigue and the use of dedicated
lookouts.
116 Antari To instigate robust, unilateral measures to address the fatigue of bridge
watchkeeping officers on vessels in UK waters and to ensure that a dedicated
116a Commercial DfT
lookout is always posted at night, during restricted visibility and as otherwise
Shipping
required in hazardous navigational situations.
116b Commercial MCA
Shipping
19
122 General Maersk Kithira MCA Develop and promulgate formal advice to mariners on the specific risks to
Maritime be considered when assessing the need to go onto the open deck in heavy
weather. Such advice should:
• Provide guidance on the height and frequency of significantly larger
waves that may be encountered.
• Urge particular caution when assessing the need to go onto the open
deck during darkness in view of the difficulties that may be experienced
in assessing the magnitude/direction of approaching waves.
• List control measures that should be adopted when sending personnel
onto the open deck in heavy weather.
The above formal advice should underpin the draft guidance currently being
developed and be incorporated into the next revision of the Code of Safe
Working Practices for Merchant Seamen.
126b General Celtic Pioneer Royal Yachting Review and revise the deck manning and qualification requirements of the
Maritime Association (RYA) harmonised SCV Code taking into account the speed of craft and the type
of activity intended in addition to the distance from shore and environmental
conditions.
133 Commercial Hurlingham MCA Improve the targeting of inspections on the operation of Class V vessels
Shipping (particularly those working during the evening) to:
• Verify compliance with the procedures specified in their DSMC.
• Promote the adoption of procedures that reflect best practice, such
as those described in the Code of Practice for Passenger Vessel
Operations on the Thames 2009.
147b Commercial Eurovoyager MCA Through representations to the European Commission, take steps to ensure
Shipping that official guidance provided for inspectors in respect to the application of EU
Directive 1999/35/EC is amended to reflect SOLAS requirements regarding the
operation of watertight doors at sea.
20
SECTION B
These recommendations are addressed to industry bodies and organisations
which may call for changes or reinforcement of best practice.
Summary Table
Accepted
Accepted No
Action yet Partially
Focus Total Action Rejected Response
to be Accepted
Implemented
General
16 4 10 1 - 1
Maritime
Commercial
26 20 3 3 - 1
Shipping
Fishing
4 1 3 - - -
Vessels
Leisure
- - - - - -
Vessels
Total 46 25 16 4 - 2
21
149b Commercial Eurovoyager Belgium Federal Ensure that when inspecting ferries under EU Directive 199/35/EC,
Shipping Public Service, Inspectors also take account of EU legislation, such as PUWER, which relate
Mobility and to the health and safety of workers.

Transport No response to date.
149c Commercial Eurovoyager Cyprus Maritime Ensure that when inspecting ferries under EU Directive 199/35/EC,
Shipping Administration Inspectors also take account of EU legislation, such as PUWER, which relate
to the health and safety of workers.
22
Partially Accepted
140 Commercial Stellar Voyager TTS Kocks GmbH Identify the technical reasons for the catastrophic failure of its windlass
Shipping motors and determine engineering and design solutions to prevent similar
accidents on board vessels fitted with its equipment.
TTS Kocks Has identified the technical reason for the catastrophic failure of its windlass
Response motor but believes no modification to the design of its equipment is required.
In the manufacturer’s opinion the failure was solely due to operator error/bad
seamanship.
MAIB Comment The manufacturer appears to have missed the key point of this
recommendation. It is essential that ships’ equipment is designed such
that it does not fail in a manner which can cause serious injury or death.
In this case the windlass motor casing shattered, spraying shrapnel
around the adjacent decks, which severely injured the windlass
operator.
149a Commercial Eurovoyager MCA Ensure that when inspecting ferries under EU Directive 199/35/EC, Inspectors
Shipping also take account of EU legislation, such as PUWER, which relate to the
health and safety of workers.
MCA Response MCA’s considered view is that this recommendation has huge implications for
ships with watertight doors and that it would not be practical or fully justified
under the costs versus benefits to require all watertight doors to comply with
EU legislation regarding PUWER. We note the points made in the report and
will write to the European Commission to seek a view on the application and
impact this will have on enforcing PUWER on watertight door arrangements.
The timescale for this can only be that we raise the issue with the EC by
November 2009 and cannot predict the further outcome.
MAIB Comment The MCA position is noted.
164b Commercial Stena Voyager Vehicle and Conduct a co-ordinated programme of roadside/dockside inspections of freight
Shipping Operator Services vehicles presenting for shipment at UK ports, to identify those vehicles that do
Agency (VOSA) not comply with the IMO and MCA guidance on ferry securing arrangements,
23
and take any appropriate actions available to increase levels of awareness
and compliance.
VOSA Response VOSA contends that an inspection regime as outlined in the recommendation
is outside its current remit and no funding is provided for this purpose.
MAIB Comment MAIB is aware that VOSA and the MCA have been working closely
together to produce informational literature aimed at ship operators,
seafarers, road hauliers and vehicle drivers which highlight the
requirements and precautions that need to be observed when
transporting articulated lorries and trailers by sea.
175 General Vallermosa International Tailor Bridge Resource Management training courses, as guided by the output
Maritime Association of the UKMPG, BPA and MPA Marine Working Group, to include integration of
of Maritime pilots into the bridge team during pilotage.
Institutions (IAMI)
IAMI response No further change to syllabus required.
MAIB Comment Changes to syllabus will be predicated by the outcome of work currently
being undertaken by UKMPG, BPA and MPA.

118 Fishing Vision II MCA Broaden the scope of its review of the safety issues associated with crew
Vessel living on board fishing vessels to include: The impact of security arrangements
on emergency access and egress; safe access requirements to and from the
vessel.
119 Fishing Vision II The Seafish Review its survey procedures to ensure that they are effective in checking new
Vessel Industry Authority build vessels comply with mandated construction standards, specifically that
electrical systems are appropriately checked and approved.

127 General Celtic Pioneer RYA Raise the awareness of the dangers of shock and vibration in small high-
Maritime speed craft through its powerboat training syllabi.
142 General Abigail H MCA Issue guidance, and through survey and inspection, check that owners
24
Maritime conduct a properly structured assessment of risks to crew sleeping on board
all vessels less than 500 gross tons that are moored alongside and have been
shut down overnight. Where such risks are identified, check that appropriate
procedures are in place to mitigate them.
144 General HMS MCA Provide guidance on:
Maritime Westminster/ • The conduct of passenger transfers between vessels that are
Princess Rose underway and making way.
• The movement of passengers to and from vessels which are not
secured to a quay, including the use of vertical ladders
Predicted implementation date: August 2010
147a Commercial Eurovoyager DfT Through representations to the European Commission, take steps to ensure
Shipping that official guidance provided for inspectors in respect to the application of EU
Directive 1999/35/EC is amended to reflect SOLAS requirements regarding
the operation of watertight doors at sea.
Predicted implementation date: Yet to be advised
158 Fishing Maggie Ann MCA As part of its efforts to realise improved safety within the fishing industry:
Vessel • Expedite its current work on the use of personal flotation devices
and personal locator beacons in the UK fishing Industry (MAIB
Recommendation 2008/173 refers).
• Ensure emergency drills, plus instruction and guidance on how
to conduct risk assessment and improve safety awareness are
undertaken to a consistent standard by surveyors and inspectors of
fishing vessels throughout the UK.
• Incorporate guidance into its revision of MGN 265 (F) designed to
25
preclude the need for Scallop fishermen to lean outboard of the
bulwark during tipping operations.
Predicted implementation date: April 2015
165 Commercial Stena Voyager MCA Review the cargo securing manuals of all UK flagged HSC carrying freight
Shipping vehicles to ensure compliance with the numbers of lashing points required in
the UK Code of Practice.
166 Commercial Stena Voyager MCA At the next SMC audit or EU Ferry Directive (1999/35) survey of all UK-
Shipping flagged freight-carrying ro-ro ferries and all foreign-flagged freight-carrying
ro-ro ferries operating to UK ports, check the cargo securing arrangements to
confirm that:
• Onboard practice is in line with the approved cargo securing manual
and the procedures detailed in a vessel’s safety management system.
• Shipboard procedures include measures to verify that the parking
brakes of all vehicles, including semi-trailers, have been applied.
Predicted implementation date: May 2010 – Update requested.
172 Vallermosa Task the UKMPG/BPA Marine Pilotage Working Group in consultation with
the UKMPA to define their expectations of bridge team/pilot performance, and
from this:
• Determine the training requirements necessary to ensure pilots can
integrate effectively into bridge teams during the performance of their
duties. To reinforce the benefits and rationale of integration with bridge
teams, such training should make clear the negative impact stress/
overload will have on individuals’ cognitive functions.
• Determine the required level of support provided by bridge teams during
acts of pilotage and ensure this expectation is disseminated to vessels
arriving at their ports.

172a General UK Major Ports Predicted implementation date: Yet to be advised
Maritime Group (UKMPG)
172b General British Ports Predicted implementation date: Yet to be advised
Maritime Association (BPA)
172c General UK Maritime Predicted implementation date: Yet to be advised
26
Maritime Pilots Association
(UKMPA)
173 Vallermosa Encourage their members to develop feedback mechanisms for pilots to report
on substandard bridge team performance, and take appropriate action as
necessary.
173a General UKMPG Predicted implementation date: Yet to be advised
Maritime
173b General BPA Predicted implementation date: Yet to be advised
Maritime
173c General UKMPA Predicted implementation date: Yet to be advised
Maritime
174 General Vallermosa MCA Disseminate to the shipping industry specific detailed information on the
Maritime expected levels of support which should be provided by bridge teams when a
pilot is embarked.

103 Astral Provide guidance to your VTSOs on the language and terminology used,
particularly to non English speakers, in communicating with ships’ masters
103a Commercial Associated British
and officers to minimise the possibility of misunderstanding or confusion and,
Shipping Ports Southampton
where appropriate, to issue masters with clear instructions.
103b Commercial Queen’s Harbour
Shipping Master Portsmouth
104 Commercial Astral Rederi AB Veritas Review your SMS instructions and enhance your auditing procedures to
Shipping Tankers ensure that masters and ships’ officers:
• Are provided with, and are familiar with, correct and clear anchoring
procedures.
• Understand the limitations of their vessel’s anchoring system.
• Understand the company’s emergency response procedures and are
27
implementing these plans effectively.
105 Astral Encourage your members providing training to deck officers, to conduct a full
review of the study programmes delivered to ensure that deck officers gain
105a Commercial IAMI
effective instruction on:
Shipping
• Navigation planning for anchoring, including the construction of
105b Commercial GlobalMET
swinging circles, holding ground and position monitoring while at
Shipping formally AMETIAP
anchor.
• The strengths, weaknesses and limitations of vessels’ anchoring
systems.
• Command considerations for safe anchoring, including wind and tide
effects, yawing, when to depart an anchorage and actions to take to
prevent dragging and to take when dragging is detected.
106 Norma Under the lead of the Maritime and Coastguard Agency:
106a Commercial MCA • Consolidate the guidance available for diving operations
Shipping conducted from, or within close proximity to merchant vessels.
• Develop generic checklists where appropriate.
106b Commercial Health and Safety • Ensure such guidance is widely promulgated within the shipping
Shipping Executive (HSE) and commercial diving industries.
106c Commercial International

Shipping Marine Contractors
Association
106d Commercial Association of
Shipping Diving Contractors
107 Commercial Norma International Through your membership promulgate the guidance for diving operations
Shipping Chamber of conducted from, or within close proximity to, merchant vessels as soon as
Shipping (ICS) this has been developed by the Maritime and Coastguard Agency, the Health
28
and Safety Executive, International Marine Contractors Association and
Association of Diving Contractors.
108 Commercial Norma International Highlight to your membership the need to identify key shipboard operations
Shipping Association of integral to a vessel’s intended and potential employment and to ensure
Classification appropriate associated procedures have been developed whenever
Societies Ltd. conducting ISM Code audits as recognised organisations on behalf of flag
(IACS) states.
120 Fishing Vision II Macduff Shipyards Review your quality management system to ensure that the electrical system
Vessel Ltd of new vessels fully complies with the relevant sections of the Sea Fish
Industry Authority construction standards, and equipment is suitable for its
intended purpose and is installed in accordance with manufacturers’ fitting
instructions.
129 Commercial Celtic Pioneer Bay Island Voyages Review your risk assessments and operating procedures taking into
Shipping consideration the safety issues identified in this report, and ensure that all
such procedures are followed.
134 Commercial Hurlingham MCA Issue improved information to operators of Class III – VI (A) Domestic
Shipping Passenger ships to guide them on the measures they should take to comply
effectively with the Domestic Passenger Ships Safety Management Code.
135 General Hurlingham London River Assess the risks associated with the movement and control of passengers on
Maritime Services (LRS) your piers at night, to:
• Clarify where the responsibility for passenger safety lies, and ensure
that adequate control measures are in place to ensure passenger
safety, particularly in emergency situations.
• Ensure the lighting and marking arrangements of the pier edges
make a distinct contrast with the surrounding water in all ambient light
conditions.
• Require all vessels using LRS piers to adhere to the Code of Practice
for Passenger Vessel Operations on the Thames 2009.
138 Commercial Pacific Sun Princess Cruises • Review the role of active stabilisers in ensuring passenger safety. The
29
Shipping review should include system redundancy, planned maintenance, and
the need to fit suitable alarms to warn of system degradation or failure.
• Carry out a fleet-wide assessment of the risk of injury from moving
furnishings and objects following large angles of heel. This should
include the calculation of the forces involved and identify suitable
means of securing objects both routinely, and for heavy weather.
• Develop a standard for securing furnishings and equipment in public
spaces, particularly in muster stations and their access routes.
• Develop your heavy weather guidance and instructions to include
actions to reduce the risk of injury.
139a Commercial Pacific Sun Cruise Lines • Use the Princess Cruises’ standard for securing furnishings and
Shipping International equipment in passenger vessels (once completed) as a basis for
Association (CLIA) developing a guide on industry best practice.
• Disseminate the safety issues, actions taken and lessons learnt
following this accident to your members.
152 General Celtica Hav Perth and Kinross Ensure that the recently increased minimum under keel clearance required by
Maritime Council vessels passing over the Shell NGL pipeline is strictly adhered to, and that the
risks associated with any proposed dredging in the vicinity of the pipeline are
fully assessed in consultation with key stakeholders.
154 Riverdance Provide guidance to shippers on the additional securing of cargo onto trailers
intended for shipping by sea to withstand the dynamic forces that may be
154a Commercial The Road Haulage
experienced.
Shipping Association
154b Commercial Freight Transport
155 Riverdance Ensure proper and effective methods exist to promulgate and disseminate
safety information produced by IMO, and other relevant organisations, to ship
155a Commercial MCA
operators.
Shipping
155b Commercial BMA

Shipping
156 Commercial Riverdance ICS Review existing guidance to owners on “Emergency Preparedness” and
Shipping promote careful consideration of the merits of using Emergency Response
Services.
164a Commercial Stena Voyager MCA Conduct a co-ordinated programme of roadside/dockside inspections of freight
Shipping vehicles presenting for shipment at UK ports, to identify those vehicles that do
30
not comply with the IMO and MCA guidance on ferry securing arrangements,
and take any appropriate actions available to increase levels of awareness
and compliance.
177 General Stellar Voyager American Bureau Propose to the International Association of Classification Societies that:
Maritime of Shipping • IACS Unified Requirement - A for mooring and anchoring equipment
is revised to include measures to prevent the catastrophic failure of
windlass hydraulic motors through over-pressurisation and over-speed
and thereby remove the potential to cause injury to persons.
Whenever catastrophic failure of class approved equipment occurs, it shall
be a condition of continued approval that IACS members require the relevant
manufacturer to:
• Conduct a detailed investigation into the causes of the failure.
• Promulgate the findings of its investigation to the classification society
and users of the equipment.
• Where appropriate, take corrective design measures to prevent
catastrophic failure in the future.
SECTION C
These are addressed to individual organisations, owners or companies that
are specific to their area, vessel or company. They have no direct impact
on the shipping industry as a whole, although the lessons are promulgated
through the individual investigation reports, through media coverage of the
report and through the MAIB’s Safety Digests.
Summary Table
Accepted Accepted No
Partially
Focus Total Action Action yet to be Rejected Response
Accepted
Implemented implemented Received
General
9 5 3 1 - -
Maritime
Commercial
36 30 4 - - 2
Shipping
Fishing
3 3 - - - -
Vessels
Leisure
3 3 - - - -
Vessels
Total 51 41 7 1 - 2
31
131 Commercial Maersk Newport Servyman del Review hot work procedures to ensure that:
Shipping Estrechio S.L. • Workers are equipped with a VHF radio to communicate with each
other and the crew in an emergency.

• A nominated safety watchman is always readily available and that a
replacement is allocated during his/her absence.
132 Commercial Maersk Newport Servyman del Adopt industry best practice by:
Shipping Estrechio S.L. • Carrying out leak tests on newly assembled oxy/acetylene
32
connections.
• Separating “in use” gas bottles from those in the storage area where
this is feasible.
• Ensuring that no flammable materials, including clothing, are left in
the vicinity of oxygen/acetylene bottles.
Partially Accepted
179 General Stellar Voyager TTS Kocks GmbH Ensure comprehensive technical and operational instructions are provided for
Maritime all the components of its windlass machinery, including those supplied from
other manufacturers.
TTS Kocks • Is sending operational instructions to operators of vessels equipped
Response with hydraulic driven windlasses supplied by TTS Kocks/F.R.Kocks
GmbH.
• Is supplying an instruction plate providing operating guidance which
will be fixed at a location clearly visible to the operator on the anchor
winch.
MAIB Comment The additional operational guidance provided by the manufacturer is
welcome however it is disappointing to note there appears to be no intention
to improve the quality/content of technical instruction manuals to facilitate
33
better/correct routine maintenance of the equipment.

128 Celtic Pioneer When available, promulgate the approved code of practice for thrill-type boat
operators, and strongly encourage local authorities within the United Kingdom
to require operators to adhere to the code as a condition of licensing.
128a General Local Authorities Predicted implementation date: To be advised as the code of practice is
Maritime Coordinators not yet available.
of Regulatory
Services
(LACORS)
128b General Institute of Predicted implementation date: To be advised as the code of practice is
Maritime Licensing not yet available.
137 Commercial Hurlingham Thames Cruises Review the passenger access arrangements on all its vessels to ensure that:
Shipping Ltd • Passengers are protected in the event that a mooring line or other part
of the mooring system fails.
34
• Access points are positioned appropriately to minimise the risk of a
passenger falling overboard while embarking or disembarking, and that
gangways are used where necessary.
Predicted implementation date: Work in progress
150 Commercial Eurovoyager MCA Explore potential means of improving the safe use of powered watertight
Shipping doors, through industry bodies such as the National Occupational Health
and Safety Committee, taking into account ship crews' apparent reluctance
to observe existing guidelines, current technology and the need to keep
watertight doors closed at sea.
Predicted implementation date: November 2010
161 Commercial Ville de Mars Ship manager: With the help of human factors experts, conduct a study to try and identify
Shipping CMA-CGM Group ways of developing a positive safety culture and reducing complacency on
board your ships, and to share the results of this study with others via the
MCA's Human Element Advisory Group.
178 General Stellar Voyager Oil Companies At the next revision of its publication ‘Anchoring Systems and Procedures for
Maritime International Large Tankers’ include guidance on weighing anchor, highlighting the lessons
Marine Forum from this accident and stressing the importance of minimising the tension on
(OCIMF) the anchor chain when ‘heaving in’ on the windlass.
Predicted implementation date: September 2010
183 Commercial Jo Eik ICS Include the following safety issues identified in this report in the next periodic
Shipping review and amendment of the Tanker Safety Guide Chemicals:
• Emphasise the need for the cargo specific MSDS to be held on board
as supplied by the shipper.
• That the cargo specific MSDS is promulgated to receivers (terminal or
transhipment ships/barges) either directly from the ship or via the ship
operator or agent so that risk control measures are based on accurate
information.
• That areas of the deck which fall into the IMO’s definition of an
Enclosed Space are identified, and that appropriate control measures
35
are in place following risk assessment.

101 Pride of Promulgate to ship owners/managers the MAIB Safety Flyer describing this
Canterbury accident and the principal lessons to be learned from it.
101a Commercial Interferry
Shipping
101b Commercial ICS
Shipping
102 Astral Circulate the MAIB's Safety Flyer on anchoring procedures to all your
members.
102a Commercial ICS
Shipping
102b Commercial The Nautical
Shipping Institute
110 Commercial Moondance Seatruck Ferries Provide guidance to suitably trained internal ISM auditors on the scope of
Shipping Shipholding Ltd their responsibilities, including assessment of crew knowledge, departmental
36
management and inter-departmental communications.
111 Commercial Moondance Seatruck Ferries Undertake a review of the onboard risk assessment procedures to ensure your
Shipping Shipholding Ltd vessels comply with Seatruck Ferries Shipholding Limited's policy.
112 Leisure RIB 6 Plas Menai Centre Review your risk assessments and thereafter amend your staff handbook to
Vessel provide staff with further guidance and instruction on:
• Operating areas, limitations and personal flotation requirements,
• Restrictions to operations dependent on seating availability,
• Considerations for 'journeying' and similar activities,
• Procedures for amending/changing authorised activities; and
• Emergency response procedures.
113 Leisure RIB 6 Plas Menai Centre Review your communications strategies and procure equipment as necessary,
Vessel to ensure that all centre activities are effectively supported by appropriate
means of communication at all times.
114 Leisure RIB 6 RYA Promulgate to your centre principals, trainers and instructors the lessons
Vessel from this accident, and emphasise that safety of life remains an essential
requirement during all activities, which becomes of paramount importance as
soon as the activity ceases to follow the briefed plan.
117 Commercial Antari Briese Schiffahrts Review and amend your safety management system to ensure your internal
shipping GMBH & Co. auditing policies verify the following:
• Compliance with hours of rest regulations
• Effective passage planning in accordance with SOLAS Chapter V,
Regulation 34
• Understanding of the requirements for notifying coastal states
• The appropriate use of lookouts and watch alarms at sea.
121 Fishing Vision II MB Vision LLP Develop work instructions for crews tasked with connecting its vessels to,
Vessel and disconnecting shore power. The instructions should include, inter alia:
Identification of those breakers considered safe to switch off; Highlight the
dangers of isolating any emergency system; Electrical schematic diagrams.
37
123 Commercial Maersk Kithira Maersk Ship Amend your safety management system to include:
Shipping Management • Additional heavy weather checklist measures to ensure watertight
integrity.
124 Scot Isles/Wadi Promulgate to your respective members the MAIB Safety Flyer accompanying
Halfa this report to highlight the dangers of complacency in bridge watchkeeping
124a Commercial ICS
officers and the importance of establishing an effective bridge team capable of
Shipping
maintaining a proper lookout, using all available means, at all times.
124b Commercial UK Chamber of
Shipping Shipping
124c Commercial The Nautical
Shipping Institute
124d Commercial International
Shipping Federation of
Shipmasters’
Associations
130 Commercial Maersk Newport A.P. Møller Maersk Review and amend your current procedures to ensure:
Shipping • Casualty Committee composition is appropriate to the specific
circumstances.
• Compliance with the accident reporting requirements for United
Kingdom registered vessels.
• Effective and inclusive communications between shore management,
contractors and ship's staff.
• All identified safety related deficiencies are sufficiently assessed for
fleet wide notification.
• Ship's staff, regardless of management involvement, maintains

oversight of contractors and that the hot work Permit to Work
procedures, as specified in the Global Ship Management System, are
strictly complied with.
• Foreign language work approvals are translated for compliance
purposes.
38
• Global Ship Management System includes detailed instructions for
the preservation of Voyage Data Recorder information for accident
investigation purposes.
136 Commercial Hurlingham Thames Cruises Review and amend your safety management system, as necessary, to comply
Shipping Ltd with the Code of Practice for Passenger Vessel Operations on the Thames
2009 and, specifically, to:
• Implement a system to record accidents and near misses, identify the
lessons to be learned, and review and update your risk assessments
and emergency procedures.
• Conduct effective emergency training drills to practice responding
to the range of hazards identified in your risk assessments of vessel
operations.
• Introduce employment procedures to ensure, as far as possible, that
crew are working in accordance with the regulations for hours of work
and rest.
• Provide masters with clear guidance on the conduct of operations and,
specifically, the requirement to ensure the wheelhouse is manned at all
times when the vessel’s engine is in gear.
39
• Introduce procedures to ensure that marine crews are not distracted by
commercial activities, including responsibility for the bar, which could
detract from the performance of their primary duties.
139b Commercial Pacific Sun Passenger Ship • Use the Princess Cruises’ standard for securing furnishings and equipment
Shipping Association (PSA) in passenger vessels (once completed) as a basis for developing a guide
on industry best practice.
• Disseminate the safety issues, actions taken and lessons learnt following
this accident to their members.
143 General Abigail H Wyre Marine Improve existing procedures to keep the level of oily waste in the bilges of
Maritime Services your vessels to a minimum and introduce routine inspections of pipework
and internal surfaces of hull plating to identify vulnerable areas and give the
maximum warning of potential failures.
145 General HMS City Cruises Plc Carry out a comprehensive risk assessment on vessels you use to conduct
Maritime Westminster/ passenger transfers when making way. The assessment should examine
Princess Rose all aspects of the transfer operation and lead to the development of robust
procedures, guidance and appropriate manning levels for this type of operation.
146 General HMS City Cruises Plc Provide training for your masters employed in conducting passenger transfers
Maritime Westminster/ between vessels making way through the water. The training should be
Princess Rose tailored to take account of the characteristics of specific vessels and should be
incorporated into the training schedule contained within your company's safety
management system.
151 Commercial Eurovoyager Transeuropa Adopt measures, including the review of VDR data, to ensure that your
Shipping Shipping Lines Ltd procedures for the operation of watertight doors are strictly observed.
157 Riverdance Promulgate to ship owners/managers the MAIB Safety Flyer describing this
accident and the principal lessons learned from it.
157a Commercial ICS
Shipping
157b Commercial Interferry
Shipping
40
159 Fishing Maggie Ann AGR Fishing Improve the safe operation of your vessel by:
Vessel Company • Modifying working procedures as necessary to preclude the need for
crew to lean outboard of the bulwark during tipping operations.
• Ensuring that the skipper conducts regular emergency drills.
• Implementing a robust inspection and maintenance regime for all
working equipment.
160 Fishing Maggie Ann The Scallop Endorse and promulgate through its membership the fishing accident flyer
Vessel Association published by the MAIB which highlights the safety lessons learned from this
tragic accident.
162 Commercial Ville de Mars CMA-CGM Group Review and improve your internal audit procedures such that follow up action
Shipping taken to address non conformity is properly documented and verified.
163 Commercial Stolt Petrel Stolt Tankers B.V. Review the controllable pitch control systems on board your vessels to ensure
Shipping that the risks of systems failure are identified, and the potential effects of their
failure mitigated.
167 Commercial Stena Voyager Stena Line Ltd Seek assurance through operational trials/inspections that, following the
Shipping implementation of its safety manager’s recommendations, the crews on board
its HSS 1500 vessels are able to stow and secure all vehicles in accordance
with the cargo securing manual prior to leaving the berth within the scheduled
turnaround times.
168 Commercial Stena Voyager Turner’s (Soham) Ensure all its freight vehicles intended for shipment by ferry are fitted with
Shipping Ltd ferry securing rings in accordance with the guidance given in the ISO 9367
standards.
169 Commercial Velox Faversham Ships Ensure that your company's Safety Management System captures all safety
Shipping Ltd significant activities carried out on board company vessels, and that the
associated equipment is effectively operated, maintained and inspected by
competent personnel.
41
170 Leisure Sooty Un-named private Examine their departure procedures and methods of navigation when operating
Vessels boat owner leisure craft, with a view to ensuring that:
• A proper passage plan is produced before departure.
• A proper and effective lookout is maintained at all times.
• Passage is conducted at a safe speed.
• Position is monitored.
• The person in charge has not consumed alcohol in excess of the limit
currently prescribed for drivers of road vehicles.
171 General TS Royalist The Marine Society Develop a structured system for the selection and audit of relief masters.
Maritime and Sea Cadets
176 General TS Royalist The Association Promulgate the safety lessons learned from the accident by distributing the
Maritime of Sail Training MAIB Flyer on its investigation to the ASTO membership.
Organisations
(ASTO)
180 Commercial Jo Eik Jo Tankers AS Provide Butterworth hatch closing arrangements to reduce cargo vapour
Shipping discharge when using tank portable washing equipment.
181 Commercial Jo Eik Jo Tankers AS Implement management control measures to verify:
Shipping • Pre-arrival conferences are conducted as close to the arrival at the
loading/discharge port as possible.
• Cargo checklists are completed diligently; tank washing defects are
identified and corrective action taken to maintain the principle of "closed
operations" as far as is practicable.
• Crews use the respiratory protection in accordance with its QMS
instructions.
• Terminal emergency procedures are clearly promulgated and that key
personnel, in addition to the chief officer, are familiar with them.
182 Jo Eik Promulgate via your membership the MAIB's Safety Flyer which highlights the
circumstances and lessons to learn from this investigation.
182a Commercial ICS
Shipping
42
182b Commercial Tank Storage
182c Commercial Federation
Shipping of Inspection
Agencies
184 Commercial Jo Eik Intertek OCA Review its procedures for accessing cargo specific MSDSs to ensure that
Shipping cargo surveyors are equipped with the appropriate PPE respiratory protection.
SECTION D
RECOMMENDATIONS TO MULTIPLE RECIPIENTS

Lists the small number of recommendations that have been addressed
to large multiple recipients. As a result, it has not been possible to track
responses under the closed-loop system. Such multiple addressee
recommendations are now being avoided wherever possible, so as to
make the closed-loop system as effective as possible.
No recommendations were addressed to multiple recipients in 2009
43
SECTION E
WITHDRAWN RECOMMENDATIONS
No recommendations were withdrawn during 2009
44
SECTION F
RECOMMENDATIONS BROUGHT FORWARD FROM

PREVIOUS YEARS
Lists the ongoing outstanding recommendations shown as accepted – yet to
be implemented in previous reports.
45
RECOMMENDATIONS BROUGHT FORWARD FROM PREVIOUS YEARS
Recommendations are listed by year/number.

2008/ Commercial CFL Performer IAMI Encourage its members providing training in ECDIS to align this as closely as
188a Shipping possible with the IMO model course and to determine the successful completion of
such training through practical assessment and examination.
Predicted implementation date: May 2009 – update requested.
2008/ Commercial CFL Performer MCA Continue to strongly support the expeditious adoption of current proposals for
186 Shipping the formal inclusion of an ECDIS competence and its mandatory assessment in
the STCW Code and, in doing so, to press for an urgent review of the IMO model
course syllabus for ECDIS training to ensure it remains fit for purpose and that
successful completion of the course is determined by examination and practical
assessment.
46
2008/ Fishing Shark/Royalist MCA Review and expand the content and application of MGN 336(F) - Overseas
148 Vessel Management, to include management of all UK, 24 metre in length and over
fishing vessels, and the following additional management issues:
• The conduct and proper recording of mandatory emergency drills and the
importance of crew familiarisation training.
• The need to ensure that all crew understand key safety information and can
communicate effectively with each other during an emergency.
• The requirement to maintain and regularly test fire detection and
emergency equipment.
Predicted implementation date: March 2010 – Update requested
2008/ Fishing Shark/Royalist MCA Amend its survey and inspection procedures for 24 metre in length and over
147 Vessel fishing vessels, to include measures to:
• Alert owners to Intermediate Surveys in the same manner as for Renewal
Surveys and, in consultation with Defra, establish administrative procedures
that will lead to fishing vessel licence suspension in the event of non-
compliance.
• Check officers hold appropriate CoC and CEC qualifications and crews have
completed mandatory safety training courses.
• Establish auditable procedures to ensure that the rectification of defects
identified during survey are verified within prescribed timescales.
• Carry out emergency drills during survey/inspection and to confirm that
mandatory emergency drills are conducted and properly recorded.
Predicted implementation date: April 2010 – Update requested
2008/ Leisure Last Call Department Seek a review, through the Recreational Craft Sectoral Group and the European
47
140 Vessel for Business, Commission, of guidance provided to manufacturers of recreational craft and
Innovation and Notified Bodies, to ensure that, when significant improvements to safety are
Skills (BIS) mandated, such standards are applied to all new craft including new “series
production” craft sold in the UK.
Predicted implementation date: Not given
2008/ Leisure Last Call BIS In conjunction with HMRC, seek to develop procedures whereby HMRC can notify
139 Vessel local authorities of the import of recreational leisure craft into the Community
market. This is to enable local authorities to conduct such checks as they deem
necessary to ensure that individuals and companies importing such craft comply
with the Recreational Craft Directive and that non CE marked craft undergo a post-
construction assessment.
Predicted implementation date: Not given
2008/ General Viking Islay MCA Consider changes to regulation and guidance regarding the nature and extent of
137 Maritime training and drills in the use of EEBDs on board ships. It is recommended that
awareness of the correct use of EEBDs is firmly reinforced by practical “hands-on”
experience of actual equipment capabilities and limitations, to be undertaken in a
safe, yet realistic environment. The use of “dummy” EEBDs for training purposes
should be discouraged.
Predicted implementation date: November 2010
2008/ Commercial MSC Napoli IACS Research and review the technological aids available which would assist masters
130 Shipping to measure hull stresses in port and at sea.

2008/ Commercial MSC Napoli IACS Review the contents of URS 11 (Longitudinal Strength Standard) to ensure:
128 Shipping • Hull girder strength and buckling checks are carried out at all critical
sections along the entire length of the hull
• An evaluation of the suitability of current URS 11 design wave bending
moment criteria for vessels with low block coefficient is undertaken
48
• Member societies use common methodologies when complying with the
requirements of this rule.
2008/ Fishing Blithe Spirit/ MCA Ensure candidates’ understanding of the additional risks posed by the operation of
124 Vessel Lady Hamilton the higher speeds associated with non displacement fishing vessels is fully tested
of Helford when developing the syllabus for the <16.5m fishing vessel skippers’ certificate.
Predicted implementation date: April 2010 – Update requested
2008/ General 8m Rigid Director of Put in place measures to ensure that approval for cadet forces to conduct an
118 Maritime Raider Reserve Forces activity outside the usual syllabus is subject to its inclusion in an advance training
and Cadets plan submitted through the chain of command, and that approval is given only after
compliance with pertinent policies and procedures has been determined.
2008/ Fishing Shark MCA Review the survey status and manning arrangements of all foreign controlled UK
116 Vessel fishing vessels to ensure:
• Required surveys and inspections have been completed
• Crews hold appropriate qualifications, including CECs where required and
have attended mandatory safety training courses.
Where doubt over the survey status and/or manning arrangements exist,
implement an urgent programme of inspection to ensure:
• Manning of the vessel is appropriate, with crew holding required
qualifications and having attended mandatory safety training courses
• Skipper/mate is able to communicate in English
• Vessel is seaworthy, fire-fighting and life saving equipment is fitted and
maintained to an appropriate standard
• A programme of emergency drills is being conducted as required by the
applicable regulations.
49
Predicted implementation date: May 2010 – Update requested
2007/ Commercial Thomson MCA Recognising the need for additional training, to achieve a level of competence
153 Shipping Celebration appropriate to operating large capacity passenger tenders, develop and take
forward to IMO, through the most appropriate channels, competency requirements
for passenger ship tender coxswains and crew.
Predicted implementation date: March 2011
2007/ Commercial Thunder DfT In considering its decisions on the Harbour Revision Orders submitted by the
144 Shipping Environment Agency and Mostyn Docks Limited, take into account the need to
clarify the status of the Mostyn Outer Channel, such that the responsible authority
has the necessary powers to ensure the safety of navigation in the channel.
Predicted implementation date: June 2010 – Update requested
2007/ Commercial Thunder Port of Mostyn • Reinstate the recommended pilotage service from the North Rhyl buoy, and
142 Shipping Ltd ensure that all applicable charts and hydrographic publications are amended
accordingly.
Predicted implementation date: Subject to 2007/144
• Amend its port passage plan to provide comprehensive guidance for masters
of vessels using the channel and anchoring in the approaches to Mostyn.
Implemented
• Review its emergency response procedures for marine accidents, ensuring
that the necessary actions for each emergency are identified, and that port
and harbour personnel are trained and familiar with the requirements.
Implemented
2007/ Fishing Danielle MCA Amplify and expand on current advice contained in MSN 1768 (M&F) such that
119 Vessels fishermen are reminded:
• Medical scale requirements provide the minimum levels of medical stores only.
Additional stores may be provided at the skipper’s/owner’s discretion.
50
2007/ Fishing Danielle MCA Provide details of the hazards associated with “tipping” and whipping drums on
117 Vessels board scallop dredgers in the next revision of MGN 265 (F).
Predicted implementation date: March 2010 – Update requested
2007/ Fishing Sian Elizabeth MCA Implement The Merchant Shipping and Fishing Vessels (Provision and Use
114 Vessels of Work Equipment) Regulations 2006 and amalgamate the provisions of the
regulations into guidance for fishing vessel inspectors and surveyors.
Predicted implementation date: Not yet advised
2006/ Commercial P&O Nedlloyd MCA Consult with the United Kingdom Chamber of Shipping and representatives from
199 Shipping Genoa the marine insurance industry, with the objective of including in ships’ stability
information, for the use by the ship’s crew, vessel specific parametric rolling data.
Predicted implementation date: Not yet advised
2006/ Fishing Ocean Harvest MCA Require the regular insulation testing of electrical systems to be introduced for all
161 Vessels II UK fishing vessels and establish measures for confirming this has taken place.
(MCA Ministerial Target #4, 2006-07 refers).
Predicted implementation date: August 2010
2006/ General Mollyanna British Propose to the International Standards Organisation that the requirements of
147 Maritime Standards the wind stiffness test in EN ISO 12217-2 and EN ISO 12217-3 be reviewed,
Institution (BSI) particularly regarding onboard signage and the information to be included in
owners’ manuals, with a view to providing users with a more comprehensive
knowledge of a craft’s limitations, and of the appropriate precautions to be taken.
In this review, consideration should be given to limiting the application of this test
to boats of greater than a defined medium displacement or length.
2004/ Fishing Kingfisher II MCA In its current work in defining future Standards of Training, Certification and
248 Vessels Watchkeeping (Fishing), specify qualifications and training requirements for fishing
vessel skippers.
51
2004/ Fishing Elegance MCA Instruct surveyors to verify that specific operating instructions for CO2 fixed
200 Vessels extinguishing systems are on board fishing vessels & crew conversant in operation
of system.
PART 3
STATISTICS
52
PA RT 3 : S TAT I S T I C S
STATISTICS
Page
UK vessel accidents involving loss of life 54
UK merchant vessels >= 100gt 56
UK merchant vessels < 100gt 61
UK non-commercial vessels 62
UK fishing vessels 63
Non-UK commercial vessels 68
For details of reporting requirements and terms used in this section please see Annex -
Statistics Coverage on page 69.
53
UK vessel accidents involving loss of life

Table 1 - UK Vessel Accidents involving Loss of Life
Deaths
Name of
Date Vessel Type of Vessel Location Accident
Merchant Vessels 100gt and over 

28 Jan Ville de Mars Container ship Gulf of Oman Fall involving Chief Officer while 1
descending into ballast tank
2 Feb Pride of Dover Ro-ro passenger Dover Passenger overboard 1
ferry
1 Apr Wellservicer Dive support Aberdeen Accident to rigger involving a diving bell 1
vessel cursor
25 Jul Hyundai Tokyo Container ship Bering Sea Person overboard 1
10 Sep Ever Elite Container ship San Francisco Accident to AB following collapse of 1
Bay accommodation ladder
19 Nov Ever Smile Container ship Taipei Harbour Person overboard during mooring 1
operation
3 Dec Goole Star Cargo barge Marchwood, Carbon monoxide poisoning 1

Southampton
Fishing Vessels 
12 Feb Maggie Ann Scallop dredger Cardigan Bay Person overboard 1
18 Feb Mercurius Scallop dredger Milford Haven Person overboard while alongside in 1
harbour
6 Apr Contest Stern trawler Mallaig Person overboard while alongside in 1
harbour
25 Apr Ryanwood Pair trawler North Sea, Person overboard 1
East Coast of
Scotland
7 Jun Ajax Stern trawler Fraserburgh Drowning after falling into water while 1
accessing vessel
20 Jul Aquila Scallop dredger North of the Capsize 3
Ardnamurchan
peninsula
9 Oct Noronya Potter NW of Orkney Person overboard 1
6 Nov Korenbloem Scallop dredger Dover Strait Person overboard 1
11 Nov Osprey III Stern trawler East Coast of Person overboard 1
Scotland
18 Nov Optik Potter East Coast of Person overboard 1
Scotland
20 Dec Etoile des Potter English Channel Collision followed by sinking 1
Ondes
54
UK vessel accidents involving loss of life
Deaths
Name of
Date Vessel Type of Vessel Location Accident
Pleasure Craft (Non-Commercial) 

28 Feb Jensa Angling boat River Crouch, Person overboard 1
Essex
21 Mar - Open dinghy Loch Awe, Drownings following presumed 4
Scotland foundering
1 May - Kayak River Tay, Drowning while kayaking 1
Scotland
2 May Ben Brack Star Motor Cruiser Upper Lough Person overboard 1
Erne, Northern
Ireland
18 May Sooty RIB Calve Island, High speed grounding 1
near Tobermory,
Isle of Mull
22 May Cobra Narrowboat Pewsey, Kennet Fire 1
and Avon Canal
22 Jun Nine Moons Motor yacht Corsica Grounding resulting in accident to 1
person
27 Jun - Kayak Lunan Bay, Drowning while kayaking in surf 1
Montrose
12 Jul Laser Stratos Sailing dinghy Keilder Water Capsize followed by entrapment in 2
132 rigging
30 Jul Harry Narrowboat Varney’s Lock, Injuries sustained after falling into lock 1
Oxford Canal
31 Jul Stella Maris 8m open power Near Capri, Collision 2
boat Mediterranean
1 Aug - Rowing boat River Dart Drowning following capsize 1
8 Aug Harwich 2011 Racing Dover Collision during race 1

powerboat
23 Aug - Canoe Loch Maree, Drowning following capsize 2
Scotland
21 Nov - Kayak River Dart Drowning while kayaking 1
1 Dec - Inflatable dinghy Christchurch Person overboard 1

Bay
13 Dec Edward Motor yacht River Dart Person overboard 1

 See definitions in Annex
 Not all accidents involving pleasure craft (as defined in Annex) and recreational craft hired on a bareboat
basis are required to be reported to the MAIB. While we would encourage all such accidents/incidents
to be reported, we do not consider this to be a definitive or comprehensive register of waterborne fatal
accidents
55
UK merchant vessels >= 100gt
Table 2 - Merchant Vessel Total Losses 2009

LOA
Date Name of Vessel Type of Vessel Age gt Nature of Accident
Metres
* 20 Mar Humber Star Product Tanker 40 274 45 Foundering
* Constructive total loss
Table 3 – Merchant Vessel Losses: 1997-2009
Number Lost UK Fleet Size gt Lost

1997 1 1 055 869
1998 1 1 072 3 476
1999 - 1 035 -
2000 1 1 050 12 778
2001 1 1 047 11 217
2002 1 1 210 671
2003 - 1 343 -
2004 2 1 406 832
2005 6 1 443 1 579
2006 - 1 480 -
2007 5 1 518 54 304
2008 2 1 578 645
2009 1 1 564 274
Table 4 - Merchant Vessels in Accidents: 1997-2009

Accidents/1 000
Vessels UK fleet size vessels
1997 237 1 055 225
1998 217 1 072 202
1999 160 1 035 155
2000 139 1 050 132
2001 134 1 047 128
2002 129 1 210 107
2003 145 1 343 108
2004 145 1 406 103
2005 197 1 443 137
2006 129 1 480 87
2007 116 1 518 76
2008 135 1 578 86
2009 125 1 564 80
56
UK merchant vessels >= 100gt
Table 5 - Merchant Vessels in Accidents by Nature of Accident and Vessel Category

Dry Passenger Passenger Tanker/ Other
cargo cargo combination commercial Total
carrier
Cargo Handling Failure 1 1 - - 1 3
Collision 10 5 - 3 6 24
Contact 13 9 1 3 5 31
Fire/Explosion 1 - - - 1 2
Flooding/Foundering - 2 - 1 1 4
Grounding 7 6 - 2 3 18
Heavy Weather 1 2 - - 1 4
Hull Failure 2 - - - - 2
Machinery Failure 8 7 2 1 7 25
Person Overboard 3 3 - 1 3 10
Pollution - 1 - 1 - 2
Total 46 36 3 12 28 125
Table 6 - Merchant Vessels in Accidents by Nature of Accident: 1997-2009
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Capsize/Listing - - 1 - 1 - - 2 1 - 2 - -
Cargo Handling Failure 2 2 1 8 1 1 3 1 1 2 1 4 3
Collision 30 23 10 25 16 18 12 16 38 25 14 21 24
Contact 24 23 18 14 13 25 37 28 33 20 30 27 31
Escape of Harmful 15 27 15 4 11 - - 4 2 1 2 1 -
Substance
Fire/Explosion 26 24 19 18 21 26 22 24 22 7 7 12 2
Flooding/Foundering 4 3 3 2 3 1 3 3 6 4 2 4 4
Grounding 21 20 16 7 18 14 13 15 26 21 11 26 18
Heavy Weather 2 4 2 5 1 4 3 4 1 6 4 4 4
Machinery Failure 50 55 48 50 39 28 41 42 51 30 36 23 25
Person Overboard 15 8 11 5 10 10 8 5 13 11 7 11 10
Other 48 28 16 1 - 2 3 1 3 2 - 2 4
Total 237 217 160 139 134 129 145 145 197 129 116 135 125
57
Table 7 - Deaths and Injuries of MV Crew and Other Workers

by Place
Where Number of people
Accommodation space - crew 25
Accommodation space - passengers 4
Cargo or other tank space 4
Engine room 18
External stairway/ladder/gangway 8
External working deck/shelter 29
Galley 12
Hotel service areas 14
Internal stairway/ladder 13
Mooring deck 13
Navigation/communication control space 3
Overside/aloft 3
Ro-ro vehicle deck/ramp 7
Ship’s boat 6
Store space 3
Workshop 2
Other external deck 14
Other internal deck/space 10
Other machinery space 4
Other 11
Total 203
Table 8 - Deaths and Injuries of MV Crew and Other Workers

by Rank
Rank/specialism Number of people
Master/Skipper 1
Chief Engineer 4
Officer, Deck 19
Officer, Electrical 2
Officer, Engineering 17
Rating 7
Rating, Deck 62
Rating, Engineering 17
Rating, General purpose 15
Other Crew 54
Worker (Non-Crew) 5
Total 203
58
Table 9 - Deaths and Injuries of Merchant Vessel MV Crew and Other Workers
by Injury
Main injury Number of people
Amputation of hand/fingers/toe 5
Bruising 22
Burns/shock (electrical) 2
Burns/scalds (non electrical) 3
Chemical poisoning/burns from contact or inhalation 1
Concussion/unconsciousness due to head injury 9
Crush injury 14
Cuts/wound/lacerations 22
Death - confirmed 4
Death - presumed 2
Dislocations 11
Eye injuries 3
Fracture - of the skull/spine/pelvis/major bone in arm or leg 27
Fracture - other 24
Strains - other strains/sprains/torn muscles/ligaments 33
Strains - strained back 14
Other 7
Total 203
Table 10 - Deaths and Injuries to Merchant Vessel Crew: 1997-2009

Crew Injured Of which resulted in death
1997 327 5
1998 330 2
1999 288 4
2000 300 3
2001 296 3
2002 302 5
2003 288 3
2004 307 4
2005 246 2
2006 231 3
2007 242 12
2008 225 5
* 2009 203 6
* 2009 and subsequent years: Include workers on board vessels who are not crew members
59
Table 11 - Deaths and Injuries to Passengers by Injury

Main injury Number of people
Bruising 17
Crush injury 2
Death - confirmed 1
Dislocations 9
Fracture - other 35
Unknown 2
Total 116
Table 12 - Deaths and Injuries to Passengers: 1997-2009

Number of injuries Of which resulting in death
1997 94 -
1998 120 2
1999 80 1
2000 137 1
2001 138 1
2002 134 -
2003 186 -
2004 146 -
2005 109 1
2006 114 1
2007 106 -
2008 170 2
2009 116 1
60
UK merchant vessels <100gt

Table 13 - UK Flagged Merchant Vessels Under 100gt - Losses
Date Name of vessel Type of vessel LOA metres Nature of accident
5 Jan ROA Workboat 8 Foundering
Small Commercial Motor
* 24 Jan Fossils Venture 12 Fire
Vessel
11 Jul Aquanaut Dive Support 12 Foundering
Wappen Von Small Commercial Motor
20 Sep 16 Foundering
Laboe Vessel
Small Commercial Motor
30 Sep Ocean Blue 10 Foundering
Vessel - Catamaran
* Constructive Total Loss
Table 14 - UK Flagged Merchant Vessels Under 100gt - by Nature of Accident

and Vessel Category
Passenger Other commercial
Associated with offshore industry
Small commercial sailing vessel

Small commercial motor vessel
Other passenger vessel
Survey/research
Other/Unknown
Overall Total
Port service
Megayacht
Workboat
Ferry
Total
Total
Capsize/Listing - - - - - - - 1 - - - 1 1
Cargo Handling Failure - - - - - - - - - 1 - 1 1
Collision 1 8 9 - - 5 4 8 - - 1 18 27
Contact 1 2 3 - - 4 1 5 1 1 1 13 16
Fire/Explosion - - - - - 1 4 1 - - 1 7 7
Flooding/Foundering - - - - - - 7 - 1 - - 8 8
Grounding 4 1 5 1 1 - 12 7 1 1 2 25 30
Hazardous Incident - - - - - - - - - - 1 1 1
Heavy Weather Damage - - - - - - - 1 - - - 1 1
Machinery Failure 1 7 8 1 1 3 20 7 1 2 - 35 43
Person Overboard - 2 2 1 - 2 2 2 - 1 - 8 10
Total 7 20 27 3 2 15 50 32 4 6 6 118 145
Injured  1 5 6 3 1 10 14 18 1 8 4 59 65
Deaths  - - - - - - 1 - - - - 1 1
 These rows include accidental injuries and deaths on vessels where the vessel itself was not involved in an
accident. These figures include crew, other workers (non-crew) and passengers.
61
UK non-commercial vessels
Table 15 - UK Non-Commercial Vessels in Accidents

by Nature of Accident and Vessel Category
Other (non-commercial)
craft 
lifeboat
Naval
Total
RNLI
Collision 1 1 2
Total 1 1 2
Injuries  - 10 -
Deaths  - - -
 Naval Craft accident/injuries are outside the remit of the MAIB, unless involved with non naval vessel.
62
UK fishing vessels
There were 6222 UK-registered fishing vessels at the end of 2009. During 2009, 237 accidents
involving these vessels were reported to the MAIB. Figures in the following tables are accidents and
injuries involving UK-registered vessels that were reported to the MAIB in 2009.
14 fishing vessels were reported lost (0.23% of the total fleet) and there were 13 fatalities to crew.
Table 16 - Fishing Vessel Total Losses
Date Name of vessel Age gt Nature of accident

Under 15m Length Overall (loa)
1 Jan Dalriada 33 9.11 Foundering
3 Feb Silver Fern 30 4.98 Foundering
11 Feb Jubilee Star 33 24.84 Capsize
* 17 Mar Emma Kate 37 2.06 Foundering
2 Apr Jenemi 24 9.64 Foundering
13 May Kalahari 38 8.55 Foundering
* 20 Jul Aquila 21 28.79 Capsize
23 Oct Jean M 25 2.18 Machinery Failure
23 Oct Bellatrix 27 12.47 Fire
6 Dec Brilliant 44 6.33 Foundering
15m Length Overall - Under 24m Registered Length (reg)
* 22 Mar Niamh Aine 18 122.00 Grounding
* 24 Mar Bussard 50 23.66 Foundering
3 Jun Transcend 23 171.77 Foundering
20 Dec Etoile des Ondes 52 40.00 Collision
* Constructive Total Loss
63
UK fishing vessels
Table 17 - Fishing Vessel Losses: 1997-2009
Under 15m loa to 24m reg Total

15m loa <24m reg and over lost UK registered % Lost
1997 12 10 1 23 7 779 0.30
1998 12 5 4 21 7 605 0.28
1999 17 10 6 33 7 460 0.44
2000 15 18 7 40 7 194 0.56
2001 16 17 1 34 7 200 0.47
2002 7 6 5 18 7 046 0.26
2003 16 8 4 28 6 731 0.42
2004 16 9 - 25 6 693 0.37
2005 20 11 3 34 6 314 0.54
2006 11 7 1 19 6 346 0.30
2007 16 5 - 21 6 330 0.33
2008 14 4 3 21 6 763 0.31
2009 10 4 0 14 6 222 0.23
Table 18 - Fishing Vessels in Accidents

Incident rate per 1 000
Nature of Accident Number of vessels involved vessels at risk
Capsize/Listing 2 0.3
Collision 10 1.6
Contact 6 1.0
Fire/Explosion 8 1.3
Flooding/Foundering 31 5.0
Grounding 26 4.2
Heavy Weather Damage 3 0.5
Machinery Failure 139 22.3
Person Overboard 13 2.1
Total 238 38.2
64
UK fishing vessels
Table 19 - Fishing Vessels in Accidents by Nature of Accident: 1997-2009
Nature of accident 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Capsize/Listing 8 11 15 4 3 5 4 2 6 5 3 2 2
Collision 22 20 15 25 17 15 17 12 23 12 18 17 10
Contact 4 - 7 2 6 1 7 3 3 3 4 2 6
Fire/Explosion 17 11 15 16 10 13 13 19 16 15 9 11 8
Flooding/Foundering 51 62 54 59 46 40 50 40 54 34 32 34 31
Grounding 44 40 31 40 29 26 38 29 19 24 24 28 26
Heavy Weather Damage 1 2 4 4 - 2 1 2 3 1 5 - 3
Machinery Failure 316 247 232 174 212 181 221 202 232 240 213 156 139
Missing Vessel - 1 - 1 - - 1 1 - 1 - - -
Person overboard 14 8 8 11 11 6 7 6 11 14 8 7 13
Other - 1 - 1 - - 1 1 1 - 1 - -
Total 477 403 381 337 334 289 360 317 368 349 317 257 238
65
UK fishing vessels
Table 20 - Fishing Vessels in Accidents - by Nature of Accident
Nature of accident Number of vessels involved Incident rate per 1 000 vessels at risk
Under 15m Length Overall (loa) - Vessels at risk (5 513)
Capsize/Listing 2 0.4
Collision 6 1.1
Contact 2 0.4
Grounding 17 3.1
165 29.9
15m loa - 24m reg (531)
Collision 3 5.6
Contact 2 3.8
Grounding 6 11.3
54 101.7
24m reg and over (178)
Collision 1 5.6
Contact 2 11.2
Grounding 3 16.9
19 106.7
Fleet total 238 38.2
66
UK fishing vessels
Table 21 - Deaths and Injuries to Fishing Vessel Crew and Other Workers
by Injury
Main Injury Number of People
Amputation of hand/fingers/toe 5
Bruising 5
Burns/scalds - other 3
Crush injury 8
Death - confirmed 10
Death - presumed 3
Dislocations 1
Eye injury 1
Fracture - other 5
Hypothermia 5
Unknown 6
Total 78
Table 22 - Deaths and Injuries to Fishing Vessel Crew by Vessel Length

(of which, deaths shown in brackets) 1997-2009
15m loa - under

Under 15m loa 24m reg 24m reg and over Total
1997 22 (9) 72 (16) 41 (4) 135 (29)
1998 30 (12) 34 - 51 (14) 115 (26)
1999 16 (4) 28 (2) 37 (3) 81 (9)
2000 20 (4) 42 (9) 43 (19) 105 (32)
2001 11 (2) 42 (3) 34 (5) 87 (10)
2002 12 (3) 24 (4) 19 (1) 55 (8)
2003 27 (8) 25 (2) 18 (1) 70 (11)
2004 27 (9) 20 (1) 23 - 70 (10)
2005 20 (3) 27 (3) 15 (3) 62 (9)
2006 21 (6) 30 (8) 18 (2) 69 (16)
2007 25 (4) 24 (3) 15 (1) 64 (8)
2008 19 (3) 22 (4) 19 (1) 60 (8)
* 2009 32 (5) 33 (7) 13 (1) 78 (13)
* 2009 and subsequent years: includes workers on board vessels who are not crew members
67
Non-UK commercial vessels
Table 23 - Non-UK Commercial Vessels Total Losses in UK Waters

Name of loa Nature of
Date Type of vessel Nationality Age gt
vessel metres accident
Fish Catching/ Channel
2 May Wendy J 35 4 9 Foundering
Processing Islands
Other
14 Jun Ijsselstroom Netherlands 17 71 19 Capsize
Commercial
Table 24 - Non-UK Vessels in UK Waters - by Nature of Accident and Vessel Category

Dry cargo Passenger Passenger Tanker/ Fishing Other Total
cargo combination vessel commercial
carrier
Capsize/
- - - - - 1 1
Listing
Collision 5 - - 13 1 2 21
Contact 15 1 1 7 1 9 34
Fire/
1 - - - - - 1
Explosion
Flooding/
1 - - - 2 - 3
Foundering
Grounding 15 - - - 4 - 19
Heavy
Weather 2 1 - - - - 3
Damage
Hull Failure - - - - - 1 1
Machinery
16 - - 5 7 2 30
Failure
Person
- - - - - 1 1
Overboard
Pollution - - - 2 - - 2
Total 55 2 1 27 15 16 116
Injuries  12 10 4 8 6 12 52
Deaths  - - - - 1 1 2

Non-UK flagged vessels are not required to report accidents to the MAIB unless they are within a UK
port/harbour or within UK 12-mile territorial waters and carrying passengers to or from a UK port. However,
the MAIB will record details of, and may investigate, significant accidents of which we are notified by
bodies such as the Coastguard.
68
ANNEX
ANNEX
STATISTICS COVERAGE
Reporting Requirements
United Kingdom ships are required by the Merchant Shipping (Accident Reporting and Investigation)
Regulations 2005 to report accidents to ships and accidents to persons to MAIB.
Non-UK flagged vessels are not required to report accidents to the MAIB unless they are within a
UK port/harbour or within UK 12 mile territorial waters and carrying passengers to or from a UK port.
However, the MAIB will record details of, and may investigate, significant accidents of which we are
notified by bodies such as the Coastguard.
The Maritime and Coastguard Agency, harbour authorities and inland waterway authorities also have a
duty to report accidents to MAIB.
For full details of reporting requirements please refer to the Regulations which are available at:
www.maib.gov.uk/resources/index.cfm
In addition to the above, MAIB monitors news and other information sources for relevant accidents.
Data is presented by the year the incident was reported to MAIB. Historic data tables contain
information from 1997; since that time the reporting requirements have changed in 1999 and 2005.
Significant changes include:
1999 - Requirement for most types of incident previously reportable by Merchant Ships of 100gt or
more as “Dangerous Occurrences” to be reported as accidents by all vessels except pleasure vessels.
2005 – Introduction of requirement for recreational craft on bareboat hire and various small vessels of
less than eight metres to report a limited range of accidents: Death, Major Injury, Capsize (of a power-
driven craft), Fire, Explosion or Pollution causing significant harm to the environment.
Vessel Definitions
Merchant vessels on the UK register with a gross tonnage
UK merchant vessels >=100gt
of 100gt or more
Merchant vessels on the UK register with a gross tonnage
of less than 100gt.
UK merchant vessels <100gt Includes pleasure craft of all types being operated
commercially (charter/hire, operated by schools and other
training establishments etc).
UK pleasure craft (non-commercial) Privately owned and operated pleasure vessels of all types.
Non-commercial vessels (other than pleasure craft), Navy
vessels (when involved in collisions with non-Navy vessels),
UK non-commercial vessels
RNLI lifeboats, non-RNLI lifeboats, public service vessels
(police, fire, ambulance).
Commercial fishing vessels registered with the UK Maritime
UK fishing vessels and Coastguard Agency’s Register of Shipping and
Seamen.
Non-UK vessels involved in an accident or incident in UK
Non-UK vessels in UK waters
territorial waters (12-mile limit)
69
Meaning of “Injury”
- any fracture, other than to a finger, thumb or toe;
- any loss of a limb or part of a limb;
- dislocation of the shoulder, hip, knee or spine;
- loss of sight, whether temporary or permanent;
- penetrating injury to the eye; or
- any other injury-
(i) leading to hypothermia or to unconsciousness,
(ii) requiring resuscitation, or
(iii) requiring admittance to a hospital or other medical facility as an in-patient for more
than 24 hours.
And any other injury, to a person employed or carried in a ship which occurs on board or during
access which results in incapacity for more than three consecutive days excluding the day of the
accident, or as a result of which the person concerned is put ashore and the ship sails without that
person, unless the incapacity is known or advised to be of three consecutive days or less, excluding
the day of the accident.
Meaning of “Hazardous Incident”

Hazardous Incidents are any events, other than accidents, associated with the operation of a ship
which involve circumstances indicating that an accident nearly occurred.
70
G L O S S A RY
GLOSSARY OF ABBREVIATIONS AND ACRONYMS

AB - Able Bodied seaman
ASTO - Association of Sail Training Organisations
BIS - Department for Business Innovation and Skill
BMA - Bahamas Maritime Authority
BPA - British Ports Association
BSI - British Standards Institution
CEC - Certificate of Equivalent Competency
CLIA - Cruise Lines International Association
CO2 - Carbon Dioxide
CoC - Certificate of Competency
Defra - Department for Environment, Food and Rural Affairs
DfT - Department for Transport
DSMC - Domestic Safety Management Code
EC - European Commission
ECDIS - Electronic Chart Display and Information System
EEBD - Emergency Escape Breathing Device
EMSA - European Maritime Safety Agency
EU - European Union
gt - gross tonnage
HMRC - HM Revenue & Customs
HSC - High Speed Craft
HSE - Health and Safety Executive
IACS - International Association of Classification Societies
IAMI - International Association of Maritime Institutions
ICS - International Chamber of Shipping
IMO - International Maritime Organization
ISM - International Safety Management
ISO - International Organization for Standardization
LACORS - Local Authorities Coordinators of Regulatory Services
loa - length overall
LRS - London River Services
71
m - metres (length overall unless otherwise stated)
MCA - Maritime and Coastguard Agency
MGN - Marine Guidance Note
MPA - Marine Protected Areas
MSC - Maritime Safety Committee
MSDS - Material Safety Data Sheet
MSN - Merchant Shipping Notice
NGL - Natural Gas Liquids
nm - nautical mile
OCIMF - Oil Companies International Marine Forum
PE - Preliminary Examination
PEC - Pilot Exemption Certificate

PPE - Personal Protective Equipment
PSA - Passenger Ship Association
PUWER - Provision and Use of Work Equipment Regulations
reg - registered length
RFA - Royal Fleet Auxiliary
RIB - Rigid-hulled Inflatable Boat
RNLI - Royal National Lifeboat Institution
ro-ro - roll-on roll-off

RYA - Royal Yachting Association
SCV Code - Small Commercial Vessel and Pilot Boat Code
SMC - Safety Management Certificate
SMS - Safety Management System
SOLAS - International Convention for the Safety of Life at Sea
STCW - Standards of Training, Certification and Watchkeeping

for Seafarers
UKMPA - United Kingdom Maritime Pilots’ Association
UKMPG - United Kingdom Major Ports Group

VDR - Voyage Data Recorder
VHF - Very High Frequency
VOSA - Vehicle and Operator Services Agency
VTSO - Vessel Traffic Services Officer
72

MAIB Annual Report 2009

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MAIB Annual Report 2009

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MARINE ACCIDENT INVESTIGATION BRANCH

ANNUAL REPORT 2009

Marine Accident Investigation Branch

All reports can also be found on our website:

For all other enquiries:

Chief Inspector’s Report 1

Part 1 - Full Investigations and Report Publications 4

Annex - Statistics Coverage 69

Glossary of abbreviations and acronyms 71

Chief Inspector’s Report

“Recognise the consistent and disproportionate rate of fatalities in the UK fishing

£ 000s Budget Outturn

CIVIL SERVICE AWARD FOR SCIENCE ENGINEERING AND

FULL INVESTIGATIONS LIST

Full Investigations started in 2009

01 Apr Wellservicer Dive support UK 9 158 gt Fatal accident to rigger

05 Apr TS Royalist Sail training vessel UK 83 gt Grounding – Chapman’s Pool,

14 Jun Ijsselstroom Tug Netherlands 71 gt Capsize due to girting –

10 Sep Ever Elite Container ship UK 76 067 gt Fatal accident to AB following

16 Sep Maersk Kendal Container ship UK 74 642 gt Grounding – Monggok Sebarok

Full investigations list

Full Investigations started in 2009

20 Jul Aquila Scallop dredger UK 11.9 m Capsize resulting in three

06 Nov Korenbloem Scallop dredger UK 24.3 m Fatal person overboard –

18 Nov Optik Potter UK 9.2 m Fatal person overboard – East

20 Dec Etoile des Ondes Potter UK 14.5 m Collision resulting in sinking

08 Aug Harwich 2011 Racing powerboat UK 6m Collision during race resulting

Abigail H Dredger Flooding and foundering while alongside 02 Nov 2008

Hurlingham Class V passenger Passenger fatality during disembarkation 17 Aug 2008

Maersk Newport Container ship Heavy weather damage in English 10 and 15

Vision II Trawler Fire resulting in 3 fatalities – alongside in 01 Aug 2008

RIB 6 RIB Capsize resulting in one injury – Menai 01 Jul 2008

Sooty RIB High speed grounding resulting on one 18 May 2009

It is required by the Merchant Shipping (Accident Reporting and Investigation) Regulations

RECOMMENDATION RESPONSE STATISTICS 2009

% of total 100% 63.2% 24.8% 6.0% - 6.0%

Details of all these recommendations are at Sections A-C.

RECOMMENDATION RESPONSE STATISTICS 2004 to 2008

2007 136 109 23 1 1 2

2006 139 103 30 3 3 -

2005 140 122 14 1 1 2

Of the 150 recommendations accepted – yet to be implemented (at time of publication of

Recommendations to multiple recipients

Recommendations brought forward from previous years.

Number Focus Investigation Addressed To Recommendation

them to react appropriately.

The part of the recommendation to “… be capable of operating when main

Number Focus Investigation Addressed To Recommendation

Number Focus Investigation Addressed To Recommendation

Operations on the Thames 2009.

Mobility and to the health and safety of workers.

Number Focus Investigation Addressed To Recommendation

electrical systems are appropriately checked and approved.

arriving at their ports.

Number Focus Investigation Addressed To Recommendation

106c Commercial International

155b Commercial BMA

other and the crew in an emergency.

Number Focus Investigation Addressed To Recommendation

Number Focus Investigation Addressed To Recommendation

• Ship's staff, regardless of management involvement, maintains

RECOMMENDATIONS TO MULTIPLE RECIPIENTS

No recommendations were addressed to multiple recipients in 2009