UK Marine Accident Investigation Branch Publishes Their 2008 Anual Report
Here’s the Chief Inspector’s introductory letter:
1. Complacency continues to be a major factor in many of the accidents investigated by the MAIB. As I have explained on numerous occasions, the word “complacency” is used by the MAIB, not to imply smugness or self satisfaction (one dictionary definition), but to reflect the natural human consequence resulting from familiarity with a task or operation. The difference in 2009, from when I first raised the issue in the 2005 Annual Report, is that the issue is now broadly recognised across the industry, and safety conscious operators are taking steps to address the problem.
2. The number of UK merchant vessels (over 100 gt) involved in accidents in 2008, while higher than the historic low in 2007, was similar to the number in 2006. The number of crew deaths has resumed broadly at the same level as each of the preceding 15 years after a significant increase in 2007. Each death is a tragedy, and each was avoidable.
3. Fatalities from enclosed spaces featured in two MAIB investigations which took place during 2008. These, together with the triple fatality on board Viking Islay in 2007 (MAIB investigation report published in 2008), and many similar accidents identified by the Marine Accident Investigators’ International Forum, clearly illustrate the need for concerted international action to address this issue.
4. A large number of vessels on the short sea trade continue to trade around the UK with insufficient crew to operate safely. Many still fail to have a dedicated bridge lookout when required, and fatigued officers of the watch are a hazard to themselves and to others. In the case of Antari, which grounded in Northern Ireland in January 2008, the OOW had been asleep for over 3 hours before the accident, while the vessel ploughed on like an unguided missile. The MAIB made recommendations to the Department for Transport and the Maritime and Coastguard Agency to take this issue back to the International Maritime Organization to get this issue addressed internationally, and also to take robust action unilaterally.
5. As a result of the MAIB investigation into the sinking of the tug Flying Phantom, with the loss of three of her crew, a major review of the Port Marine Safety Code has been undertaken, and a Guide to Good Practice for ports is being produced. This renewed focus on the safety of port operations has been timely.
6. In November 2008, the MAIB published a “Fishing Vessel Safety Study”, which had been conducted over the previous 18 months. The study was an important piece of work and has been broadly welcomed. As a result of the study, a number of useful initiatives have been developed which should improve safety within the fishing industry.
7. In August 2008, 3 fishermen died in a fire on board Vision II while alongside inFraserburgh. This accident highlighted a relatively new phenomenon: with many UK fishing vessels employing crew members from overseas, fishermen were now routinely living on board while in their home port; with limited shore power available, often poor access/egress, and most safety systems optimised for use at sea, many vessels are not suitable as living accommodation alongside. Urgent action is now being taken to address this issue.
8. The number of recommendations issued in 2008 reflects the downward trend in recent years. Since 2004 the MAIB has encouraged appropriate corrective action to be taken as soon as possible after an accident has occurred. This has resulted in ownership of corrective actions being taken by the appropriate bodies in the industry, and safety issues being addressed in the most timely way. Such actions are now routinely recorded in MAIB investigation reports, and reduce the need for formal MAIB recommendations.
9. Of the recommendations issued, over 92% have been accepted. It is inevitable that a number have yet to be fully implemented, but our follow up system continues to monitor progress on these. The table on page 13 shows that the vast majority of those recommendations outstanding at the end of previous years have now been implemented.
10. This Annual Report deals principally with the calendar year of 2008. However, for ease of reference, the figures below are for the 2008/09 financial year, which ended on 31 March 2009; MAIB’s funding from the Department for Transport is provided on this basis, and this also complies with the Government’s business planning programme.
£ 000s Budget Outturn
Costs 4,116 3,897
Receipts* 70 89
Totals 4,046 3,808
* 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.
The outturn fell below budget due to the schedule for MAIB’s office relocation being put back by 6 months to August 2009.
11. In a year when personnel changes left the MAIB short staffed for a number of months, the workload was challenging. 46 Preliminary Examinations and 28 Full Investigations have been commenced, and 21 investigation reports have been published. The fishing vessel safety study, and the ongoing investigation into the loss of the ro-ro cargo ship Riverdance have, in particular, demanded extra effort. Additionally, support has been given to other administrations, including technical training for all EU Member States and an accident investigation training course in South Africa.
CHIEF INSPECTOR’S REPORT
12. A new IMO Code on “Practices for a Safety Investigation” has been adopted, and will come into force in 2010. A European Directive “governing the investigation of accidents in the maritime transport sectors” has been approved, and will come into force in 2011.
The Directive will require a revision of the Regulations governing the work of the MAIB, and work is in hand to minimise the adverse effect the changes could have on the independence of the MAIB, and our flexibility to focus our efforts effectively.
13. After a good year in 2008, and with the bonus of the better facilities afforded by our new offices, the MAIB is well placed for the coming year.
Chief Inspector of Marine Accidents
For the rest of the report, see: