SAFETY FLASH

IMCA Safety Flash 30/20 October 2020

These flashes summarise key safety matters and incidents, allowing wider dissemination of lessons learnt from them. The information below has been
provided in good faith by members and should be reviewed individually by recipients, who will determine its relevance to their own operations.
The effectiveness of the IMCA safety flash system depends on receiving reports from members in order to pass on information and avoid repeat incidents.
Please consider adding the IMCA secretariat (imca@imca-int.com) to your internal distribution list for safety alerts and/or manually submitting information
on specific incidents you consider may be relevant. All information will be anonymised or sanitised, as appropriate.
A number of other organisations issue safety flashes and similar documents which may be of interest to IMCA members. Where these are particularly relevant,
these may be summarised or highlighted here. Links to known relevant websites are provided at www.imca-int.com/links Additional links should be submitted
to info@imca-int.com
Any actions, lessons learnt, recommendations and suggestions in IMCA safety flashes are generated by the submitting organisation. IMCA safety flashes
provide, in good faith, safety information for the benefit of members and do not necessarily constitute IMCA guidance, nor represent the official view of the
Association or its members.

1 Windfarm Support Vessel Njord Forseti hit wind turbine tower – Jersey Maritime Administration
What happened?

The Jersey Maritime Administration has published a

report into its investigation of the causes of an
allision between a windfarm support vessel and a
windfarm tower in the Southern North Sea on 23
April 2020. The report can be found on the web here.

What went wrong?

Shortly after 1800 local time, the vessel was released

from duties on a windfarm and at 1811 departed for
the return passage to port. Aboard the vessel were
three crew members, and one windfarm technician
who was being transferred ashore. Sea conditions
were calm with light winds and low swell. Weather
was fair with good visibility.

Whilst transiting between windfarms at

approximately 20 knots, Njord Forseti hit a turbine tower. The impact resulted in serious damage to the vessel.
Two crew members were evacuated by air to hospital, and the third was required to have a subsequent medical
examination. Immediate assistance was provided by a nearby offshore construction vessel. The Njord Forseti
returned to port under her own power with temporary crew members provided by a sister vessel.

Findings

The Jersey Maritime Administration report drew the following conclusions:

 For an indeterminate period between departure from the windfarm until the incident occurred, the vessel crew
were not keeping a proper look out as required by Rule 5 of the International Regulations for Preventing
Collisions at Sea (COLREGS);
 The primary reason why a proper lookout was not being kept was because the Master was distracted from his
primary role;
 It is possible that the Master was distracted from his primary role as he may have been adjusting of settings on
the VHF radio which is mounted immediately to starboard of his seat. However, this has not been positively
determined and distractions caused by other means cannot be ruled out;
 At the time of the incident the vessel was not following the established passage plan from the windfarm to
port, but was undertaking an alternative route. Whilst this route was safe, ineffective monitoring of the vessels
track, position and proximity to navigational hazards contributed to the incident.

Recommendations

The Jersey Maritime Administration report made the following recommendations:

 There should be renewed emphasis on the importance of compliance with COLREGS, and particularly Rule 5;
 Identify tasks, equipment and functions that may give rise to possible distractions for the person having the
conduct of a vessel whilst underway, and implement measures to ensure that the safe conduct of the vessel is
not impaired by these or other factors;
 Review the methods by which Masters monitor the safe progress of a vessel’s passage and make changes as
necessary, including where necessary, additional training;
 Under the Workboat Code, other than the need for at least one person to ensure the safe conduct of the vessel
whilst underway, there is no specified minimum number of (deck) watchkeepers required. Operations should
be assessed and policies updated where necessary to ensure that the wheelhouse is always sufficiently and
appropriately manned. Where appropriate, specific guidance should be provided to the Master in exercising
his / her judgement in setting the wheelhouse manning level during the course of a voyage (IMCA emphasis);
 Develop principles and techniques of crew resource management (CRM) to ensure that whilst underway the
conduct of the vessel is carried out in the most effective and efficient means possible.

Members may wish to refer to

 Seamanship: Vessel Collision With Fishing Boat
 Small Workboats used on offshore wind farms: combined report on Windcat 9 and Island Panther incidents
 Collision Between Crew Boat And Anchored Barge

2 Firefighting (FiFi) Tank Outlet Blockage

What happened?

A member reports a blockage of the outlet of a dive chamber fire fighting water tank, caused by the failure of a
floating plug.

On this particular DSV the saturation diving chamber complex has

six firefighting water tanks. Each tank has a water outlet at the
bottom with a floating plug that blocks the outlet if all the water
drains from the tank. See line drawing of the bottom of one of the
FiFi tanks.

The floating plug assembly consists of a buoyant float and a nylon

conical endcap plug with recessed O-ring, which sinks in water. The
floating plug assembly is highlighted red in the line drawing. The
float is connected to the endcap plug with a threaded rod through
the centre, as shown on Figure 3. The floating plug is retained in
the tank by a guide tube.

What were the causes?

The endcap plug unscrewed itself over time and eventually

detached from the float. Because the endcap plug is heavier than Figure 1 - Endcap Plug detached from float
water it sank to the bottom of the guide tube and blocked the tank and blocked tank
outlet.
That would result in no water being supplied from the tank, and therefore it could have life-threatening
repercussions in the event of an emergency. In normal circumstances it would only be detected during routine 6
monthly maintenance. (IMCA emphasis).

Figure 2 Drawing showing bottom of FiFi tank

Figure 3 – Floating Plug with threaded rod position Figure 4 – Blocked Guide Tube Float
shown in red

Actions taken? lessons learned?

The floating plug assemblies were removed from all 6 x FiFi tanks on the vessel and the endcap plugs were
permanently bonded to the floats to prevent this failure from happening again.

Each DSV should review the water storage tanks in their system for any similar failure mechanisms. This failure was
identified in a dive system FiFi tank, it could equally occur in other water tanks in any vessel.
3 Two deaths of military divers
What happened?

Incident 1 - UK

The UK Health and Safety Executive has issued the Ministry of Defence (MoD) with a “Crown Censure” after a
military diver died during training. The UK HSE press release, dated 2 September 2020, is found here.

In March 2018, a diver being trained was brought back to surface after he stopped responding to lifeline signals
while he was underwater. He was sadly pronounced dead after CPR was performed. He had been on a training
course at the National Diving and Activity Centre in Chepstow. The diver and
his dive buddy were tasked with attaching a distance line from the base of a A “Crown Censure” is the way
shot line to the underwater wreck of a helicopter at a depth of 27m. When he in which the UK HSE formally
was recovered his cylinders were found to be empty. records the decision that, but
The UK HSE served two Crown Improvement Notices relating to the failure to for Crown immunity, the
train all army divers how to undertake air endurance calculations and to assess evidence of a Crown body's (in
the risk of a diver running out of air. this case the MoD) failure to
comply with health and safety
Julian Tuvey, a HSE inspector who specialises in diving, said: “This was a law would have been sufficient
tragedy for all concerned however just like any other employer, the MoD has a to provide a realistic prospect
responsibility to reduce dangers to its personnel, as far as they properly can. of securing a conviction.
The scenario of a diver running out of air is a very real risk that needs to
managed.”

The Ministry of Defence accepted the Crown Censure and hence admitted
breaching its duty under Section 2(1) of the Health and Safety at Work etc. Act 1974 in that they failed to ensure,
so far as was reasonably practicable, the health, safety and welfare at work of all its employees, in relation to the
risks associated with diving exercises.

Incident 2 – New Zealand

The New Zealand Defence Force was sentenced at the Auckland District Court for health and safety failings following
the death of a trainee diver. In March 2019 a group of trainees was taking part in an 18 week advanced diving
course. Following a full day of dive exercises, the trainees were undertaking a night dive when one of the trainees
was identified as in trouble and pulled unresponsive from the water. The trainee later died as a result of a brain
injury due to oxygen deprivation.

Investigation found the exercise went against the Defence Force’s own training standards. It also found trainees
were covertly switching their breathing apparatus from nitrox to oxygen mode, which ran the risk of leading to
oxygen deprivation. This switching activity was known between trainees but not to their supervisors in the Defence
Force.

Further information can be found in the press release here: https://worksafe.govt.nz/about-us/news-and-

media/defence-force-sentenced-over-diver-fatality/

IMCA notes: These incidents reinforces IMCA’s published position that self-contained underwater breathing
apparatus (SCUBA) has inherent limitations and is not a suitable technique for work covered by the IMCA
International Code of Practice for Offshore Diving (IMCA D 014).

4 UK HSE: employee foot crushed by forklift at maritime freight logistics company

Applicable
Life Saving
Rule:
What happened? Line of Fire

The UK Health and Safety Executive has prosecuted a maritime freight and logistics company after a worker suffered
multiple bone fractures to his foot when a forklift truck was driven over it. The worker was injured when a 15 tonne
forklift truck drove over his foot during unloading and stacking of steel coils in a shed at premises in South Wales.

What were the causes? What went wrong?

HSE investigation found that there was inadequate control of workplace transport risks. The company had also
failed to conduct a suitable and sufficient assessment of controls for workplace transport.

The HSE inspector said “Failure to ensure that workplace

transport is managed safely is a serious breach of
fundamental health and safety duties.”

See the press release here.

Members may wish to refer to

 IMCA SEL 032 Guidance on safety in shipyards
 Crewman Struck And Injured By Forklift Truck
 Two Yard-Based Fatal Road Traffic Accidents (UK HSE)
 Fatal Traffic Accident On Board A Large Vessel

5 MSF: Grub screws and perished valves – trouble with methanol transfer
What happened?

The Marine Safety Forum (MSF) has published Safety Alert 20-06 relating to problems with methanol transfer
caused by problems with grub screws and perished valves. A vessel was advised by an installation of a discrepancy
in the quantity of methanol received compared to what was expected.

Investigation revealed that these discrepancies whereby a quantity of methanol was unaccounted for, had been
occurring for years. Unknown to the crew, during the transfer of methanol to the installations, a quantity of the
methanol was also being discharged to sea via the system flushing line. This was possible as a spool piece was
incorrectly left in place and two valves either side of the spool piece were passing fluid.

What were the causes? What went wrong?

One rubber valve was found to be perished and the other Teflon valve was found with signs of corrosion. On closer
inspection it was found that a grub screw, for limiting the movement of the gears was too far in and was restricting
the range of movement. This resulted in the Teflon valve not closing fully and had been that way most likely from
newbuild.

The MSF’s member identified the following root causes:

 Insufficient knowledge of the methanol cargo system;
 Insufficient Planned maintenance;
 Insufficient transfer procedures in place;
 Poor communication.
Actions and recommendations
 Proper and recorded confirmation from the receiving installation that they have received the correct quantity
of cargo;
 Review cargo systems or any appropriate liquid transfer systems to ensure that any set-up designed to avoid
discharge to sea is correctly in place;
 Update planned maintenance system.
Members may wish to refer to
 “The Carriage of Methanol in Bulk Onboard Offshore Vessels” recently published in conjunction with Oil
Companies International Marine Forum: https://www.marinesafetyforum.org/guideline/the-carriage-of-
methanol-in-bulk-onboard-offshore-vessels/
 High Potential dropped object near-miss: antenna fell to deck [immediate cause: two grub screws were found
to have come loose.]
 Failure Of Chamber Door Hydraulic Actuator [immediate cause: All the seals inside the actuator were found to
be completely perished inside.]