Safety Digest: Informative and Interesting Read

MAIB Safety Digest

By Dione Lee 2016-01-06 00:43:48

In October of 2015, the UK Marine Accident Investigation Branch (MAIB) published volume 2 of their “Safety Digest”, which provides research and analysis of incidents to help provide lessons learned to the maritime community. Since 1990 MAIB has been publishing between 1 to 3 volumes per year of extremely useful and distilled information from incident investigations in the hopes of preventing re-occurrence.

The most recent “Safety Digest” includes Lessons from 25 different incidents investigated in 2015: 16 involved merchant vessels, including ships and workboats; 6 fishing vessels; and, 3 small craft vessels. Reading through them I was able to glean something from each section that can be applied to all sectors within the maritime industry. Some common themes I discovered included:

- Incomplete or poor understanding of vessel and equipment in different operating conditions

- Not standing proper watches

- Poor communication skills

- Safety equipment misuse or lack of use from a “kill cord” to PFDs

- Taking unnecessary risks with weather

One incident that stood out from the rest was “Case 1 Rule 13* - Unlucky For Some.” I found this one interesting, because it seems to be a re-occurring theme of other incidents and issues that have been brought to my attention lately. This particular incident was a collision at sea between an LPG tanker and cargo vessel. Based on the evidence presented, I took editorial liberty of further condensing the event, highlighting issues discovered and lessons learned.

Summary of Event

Both vessels collided while proceeding in the same direction of a TSS (Traffic Separation Scheme). There were fog patches in the area with no lookouts posted on either vessel. The master of the cargo vessel acquired a radar target of the tanker, but the master choose to show true vectors and true trails and not the target’s information from the AIS receiver on the X-band radar, which was fitted with ARPA. The third officer on the tanker detected the cargo vessel on radar and noticed it was overtaking on the AIS receiver; however, their ARPA and the gyro compass were not working properly. In addition, the tanker officer could not see the cargo vessel visually, but thought the overtaking cargo vessel would follow COLREGS – Rule 13 and remain clear. The vessels ended up colliding with one another. The cargo vessel master was prosecuted for COLREG offences and fined $2,400.

Issues Discovered

- No dedicated lookouts were posted on either vessel during fog.

- Neither vessel, after initial detection, was monitored by either officer on respective bridges to ensure they didn’t collide.

-The officer from the cargo ship had non-operational personnel on the bridge and may have been distracted; in addition, the officer had blind spots on the bridge created by deck cranes and didn’t move around to get a complete view.

Lessons Learned

-Know and follow COLREGS - International Regulations for the Prevention of Collisions at Sea 1972 (as amended), specifically: Rule 13 (Overtaking) (a)…*”any vessel overtaking any other shall keep out of the way of the vessel being overtaken.”

-Avoid any and all distractions on the bridge, especially in higher risk situations, like navigating in low visibility and high traffic areas.

-Be familiar with and use appropriate navigational equipment onboard.

-Monitor vessels position, especially during low visibility situations.

There were two other cases presented that were a result of poor situational awareness of not keeping a good visual lookout or using and monitoring tools such as Radar, ARPA and AIS. In addition to the cases presented from incident investigations and resulting lessons learned, this volume contains a safety bulletin on mooring line failure.

The “Safety Digest” is an informative and interesting read. I found that the different “cases” freely provided by MAIB (as long as MAIB is given credit, Crown copyright acknowledged, and the title of the publication specified) could be used to supplement training materials and safety meetings to help illustrate teaching points with valuable examples and lessons learned.   

Thank you MIAB for helping the maritime community to be safer and providing useful information to do our jobs better. MAIB “Safety Digests” are available online at

The opinions expressed herein are the author's and not necessarily those of The Maritime Executive.