Accident Investigation Report 17/2016
Investigation report into marine accident including what happened and safety lessons learned:
This reports the MAIB’s investigation into a fire in the engine room of the dredger Arco Avon while the vessel was loading a sand cargo approximately 12 miles off Great Yarmouth, UK. The fire claimed the life of the vessel’s third engineer, who was attempting to repair a failed fuel pipe when fuel, under pressure in the pipe, ignited.
Statement from the Chief Inspector of Marine Accidents
The sad death of an experienced officer serving on a UK registered ship serves as a salient reminder of the risks that crews can be exposed to when policies and procedures designed to mitigate such risks are not followed, and recognised safe systems of work are allowed to lapse. Robust risk assessments and safe systems of work are important barriers that prevent marine accidents. Everyone, from the individual seafarer to the senior company executive ashore, needs to develop shared company safety cultures that make the use of risk assessments and safe systems of work an unquestioned part of life when working on board UK registered vessels.
- The third engineer’s decision to act autonomously without informing either the OOW or CEO was contrary to documented standing orders but was commensurate with the onboard culture of regular lone working
- The fact that sparks generated by using fixed and portable angle grinders produce a hot work hazard is not currently acknowledged in marine industry guidance
- The contents of International Maritime Organization (IMO) circular MSC. 1/Circ.1321, which recommends a 6 monthly inspection of fuel system pipework to be included in a vessel’s SMS, had not been formally promulgated to the UK shipping industry
- Merchant Shipping Notices relating to personal protective equipment in engine rooms are inadequate, suggesting that cotton garments could provide fire protection
- The Ship Captain’s medical guide gave confusing and inconsistent advice on the treatment of serious burns
The Maritime and Coastguard Agency has been recommended (2016/136) to more widely promulgate the contents of IMO Circular MSC.1/Circ.1321 and Bureau Veritas has been recommended (2016/138) to advise its surveyors of the contents of the circular.
Hanson Aggregates Marine Limited has been recommended (2016/137) to review and, as appropriate, amend its safety management system to ensure, inter alia, that manning levels, watchkeeping duties and communication procedures provide for safe engine room operations at all times.