ANNUAL REPORT

2021
Marine Accident Recommendations and Statistics
M AR I N E A C C ID E N T I N V E ST I G A TI O N B R AN C H

This document is posted on our website: www.gov.uk/maib

Marine Accident Investigation Branch Email: [email protected]

First Floor, Spring Place Telephone: 023 8039 5500
105 Commercial Road
Southampton, SO15 1GH
United Kingdom June 2022
 MARINE ACCIDENT INVESTIGATION BRANCH
The Marine Accident Investigation Branch (MAIB) examines and investigates all types of marine accidents to
or on board UK vessels worldwide, and other vessels in UK territorial waters.
Located in offices in Southampton, the MAIB is a separate, independent branch within the Department
for Transport (DfT). The head of the MAIB, the Chief Inspector of Marine Accidents, reports directly to the
Secretary of State for Transport.

© Crown copyright 2022

This publication, excluding any logos, may be reproduced free of charge in any format or medium for research, private study or
for internal circulation within an organisation. This is subject to it being reproduced accurately and not used in a misleading
context. The material must be acknowledged as Crown copyright and the title of the publication specified.

Details of third party copyright material may not be listed in this publication. Details should be sought in the corresponding
accident investigation report or [email protected] contacted for permission to use.
CONTENTS

CHIEF INSPECTOR'S STATEMENT 1

PART 1 - 2021: CASUALTY REPORTS TO MAIB 5

Statistical overview 5
Investigations started in 2021 8

PART 2: REPORTS AND RECOMMENDATIONS 10

Background 10
Recommendation response statistics 2021 11
Recommendation response statistics from previous years 11

Summary of 2021 publications and recommendations issued 12

2021 Recommendations - Progress Report 14

Progress of recommendations from previous years 29

2020 Recommendations - Progress Report 31
2019 Recommendations - Progress Report 36
2018 Recommendations - Progress Report 37
2017 Recommendations - Progress Report 38
2016 Recommendations - Progress Report 40
2015 Recommendations - Progress Report 41
2014 Recommendations - Progress Report 42
2013 Recommendations - Progress Report 42
2012 to 2010 Recommendations - Progress Report 44
2009 Recommendations - Progress Report 44
2008 Recommendations - Progress Report 45

PART 3: STATISTICS 46
UK vessels: accidents involving loss of life 46
UK merchant vessels >= 100gt 48
UK merchant vessels < 100gt 57
UK fishing vessels 58
Non-UK commercial vessels 66

ANNEX A - STATISTICS COVERAGE 67

ANNEX B - SUPPORTING INFORMATION 68

GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS 72

FURTHER INFORMATION 73
 CHIEF INSPECTOR'S STATEMENT

INTRODUCTION
I am pleased to introduce MAIB’s annual report 2021. It was another busy
and successful year for the branch improving safety at sea by our sustained
output of safety investigation reports, safety digests, and safety bulletins
despite lockdown conditions affecting work early in the year. The branch
raised 1 530 reports of marine accidents and commenced 22 investigations
in 2021.
Marine Casualties Reported Investigations Investigations
Year and Marine Incidents started involving loss of life
2021 1 530 22 14
2020 1  217 19 10
2019 1  090 22 13
2018 1  227 23 7

Figure 1 shows how the number of accidents reported compares with the previous 5-year average. The
increased total in 2021 is largely attributable to our industry request to report sub-standard pilot ladders
along with a rise in leisure craft and small commercial craft notifications.

200

150

100

50

0
1 2 3 4 5 6 7 8 9 10 11 12
Month

5-year average 2021

Figure 1: Reported Marine Casualties and Marine Incidents by month to MAIB

SAFETY ISSUES

Merchant Vessels
The MAIB received no reports of fatal accidents to seafarers on UK registered merchant vessels of 100gt
or more during the year but did commence investigations into fatalities on two Red Ensign Group vessels
and one fatality on a Cyprus registered vessel operating in UK waters. From these investigations two
themes emerge: the first is that mooring deck fatalities as a result of snap-back continue to occur, despite
well published guidance on the hazard; the second is that marshalling vehicles on roll-on/roll-off vessels
remains extremely hazardous. More worrying is that there is a clear gap between ‘work as imagined’ and
‘work as done’, with marshallers frequently standing in unsafe areas and drivers losing sight of marshallers.

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 CHIEF INSPECTOR'S STATEMENT

The branch issued a safety bulletin in November to highlight the problem of loading into dead-end bays
and, when published, the investigation report will say more about initiatives to further improve vehicle
deck safety.

At industry meetings concerns about dangerously weighted heaving lines and unsafe pilot ladders are
regularly voiced. In response, the branch asked that all such incidents, no matter how minor, be reported so
a fuller picture of the problems could be gained. In respect of weighted heaving lines, the branch received
just 16 reports; far fewer than anecdotal reporting would suggest, perhaps indicating that this extremely
hazardous practice is still being under-reported. Much stronger evidence emerged in terms of pilot ladders.
In 2021, the branch received 194 reports about sub-standard pilot ladders. Of those, 172 pilot ladders
(88.6%) were not rigged in compliance with SOLAS guidance, and 22 were observed by the pilot as being
in a materially poor condition (Figure 2). Fortunately, serious accidents have been rare, but the potential
clearly exists and the branch will continue to collate statistics in 2022.

Figure 2: Example of
a failed pilot ladder

Commercial Fishing Vessels

Ten commercial fishermen lost their lives in 2021, the highest annual figure for a decade and a stark
contrast to the low loss of life in 2020. That is a little short of one death per 1 000 qualified fishing vessel
crew; possibly a statistical blip, but a truly appalling annual fatality rate nonetheless. I therefore make
no excuse for a longer than normal section on fishing safety in this introduction as commercial fishing
investigations accounted for nine of the 22 investigations commenced in-year.
It is unsurprising, but disappointing, that the most significant safety issues were, again, small fishing vessel
stability and man overboard fatalities. I will not decry any of the various initiatives that are ongoing to
improve fishing vessel safety – a lot of people are doing some very good work – but the evidence shows that
the messages are not yet changing behaviours to a significant extent.

The branch will say much more shortly as the FV Joanna C (BM 265) and FV Nicola Faith (BS 58) investigation
reports are to be published very soon, but together they exemplify the small vessel stability problem,
which is worth reiterating here. Firstly, it is important that owners and skippers understand their boat’s

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 CHIEF INSPECTOR'S STATEMENT

limitations, especially before embarking on any modifications. In both of the above cases the vessels had
recently been modified, and those modifications had reduced their overall stability and so reduced safety
margins. The second lesson is that even relatively stable boats can capsize if inappropriately laden with
extra gear and a bumper catch. If it all goes wrong, the boat is lost (Figure 3), the catch is lost, and the crew
are lost; so is it worth the risk?

Figure 3: Survey image

of Joanna C’s wreck
Image courtesy of Trinity House
from THV Galatea

Turning to man overboard, I recently attended an awareness event for fishing vessel crew held in an
environmental pool in Aberdeen capable of creating realistic sea conditions. Each individual in turn was
invited to jump into the pool wearing boots and oilskins, but without a personal flotation device. Some
lasted a few minutes before being assisted into shallow water by the rescue swimmer, but all were fighting
for breath at that point. They then re-entered the water wearing the same kit, plus an inflated lifejacket,
and realisation dawned. They floated without effort, could breathe easily, and were able to perform rescue
tasks. My feeling is that everyone understood the messages: lifejackets save lives and they are useless unless
worn. I hope they spread the word so others do not have to learn the hard way.

OTHER INVESTIGATIONS

The branch commenced two investigations during the year that deserve comment due to their unusual
nature.
The first is the investigation into the tragic deaths, on 30 October, of four stand-up paddleboarders while
attempting to cross a weir at Haverfordwest on the River Cleddau. The sheer enormity of this tragedy
selected it for attention and, inevitably, lots of safety lessons emerged as the layers were peeled away. It will
be a few months before the report is published, but engagement with stakeholders has so far been excellent
and I am hopeful that many safety improvements will be in place before the main UK holiday season.
The second, commenced in January this year, is the investigation into the emergency response to the
presumed sinking of a boat of migrants while attempting to cross the English Channel on 24 November. At
least 27 migrants perished in that accident. While the MAIB’s investigation report is unlikely to be read by
the traffickers, the investigation is identifying safety learning that will be of future benefit if interventions
continue to be necessary to save life when migrant boats are attempting the crossing.

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 CHIEF INSPECTOR'S STATEMENT

RECOMMENDATIONS

The MAIB made 35 recommendations to 23 separate addressees in 2021, of which 77.1% were either
accepted and implemented or accepted, yet to be implemented. Three recommendations were rejected for
reasons as set out in the report and there has been no response received to five recommendations made
to overseas companies. While the acceptance rate is down on the high level of acceptance achieved in 2020
(>90%), it nonetheless validates our process of whenever possible involving stakeholders in the formulation
of recommendations during the final stages of an investigation.

BRANCH ACTIVITY AND DEVELOPMENT

The year saw the country start to emerge from the restrictions of COVID-19 and for the MAIB a
recommencement of business as normal. Inroads have been made into the backlog of training built up
during lockdown and, as I write, the time taken to publish full investigation reports has reduced to 12.9
months and concise reports to 8.3 months. The reports of a few protracted investigations have yet to be
published, but the trajectory is in the right direction.
During 2021, the UK was audited by the International Maritime Organisation (IMO) to assess its compliance
with the standards set out in the IMO Instruments Implementation Code (III Code). This included an audit
of how the MAIB discharges the UK’s responsibilities under the Casualty Investigation Code, including
the investigative activity it undertakes on behalf of the Red Ensign Group. I am very pleased to record
that the UK passed the audit, and no observations or non-conformities were raised relating to accident
investigation; a very significant achievement.
Looking ahead, two main initiatives are planned for 2022. The first is to simplify and streamline the
reporting of Marine Casualties and Marine Incidents with the introduction of an online portal/app. The
second is to provide public access to the statistical element of the MAIB’s database. Specific case enquiries
will still have to be submitted for manual handling, but access to accident data should be of significant
benefit to marine organisations, companies and researchers. A potential cloud on the horizon is the recent
government announcement that it intends to reduce the Civil Service by circa 20% to around 2016 levels
over the next 3 years. However, that is for the future. For the present, the branch is fully staffed and able to
discharge its statutory functions.

FINANCE

The annual report deals principally with the calendar year 2021. However, for ease of reference, the figures
below are for the financial year 2021/22, which ended on 31 March 2022. The MAIB’s funding from the DfT is
provided on this basis, and this complies with the government’s business planning programme.

£ 000s 2021/22 Budget 2021/22 Outturn

Costs – Pay 3 429 3 440

Costs – Non Pay 1 435 1 286

Totals 4 864 4 726

Captain Andrew Moll OBE

Chief Inspector of Marine Accidents

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 STATISTICAL OVERVIEW

PART 1 - 2021: CASUALTY REPORTS TO MAIB

In 2021, 1 530 accidents (casualties and incidents1) to UK vessels or in UK coastal waters were reported to
the MAIB. These involved 1 622 vessels.
658 are not included in this overview, e.g. they were accidents to people that did not involve any actual or
potential casualty to the vessel.
There were 872 accidents involving 929 commercial vessels that involved actual or potential casualties to
vessels. These are broken down in the following overview:

1 As defined in Annex B on page 68.

Chart 1: UK accidents - commercial vessels

650

600 567 accidents

(593 vessels)
550

500

450

400

350

300

221 accidents
250
(251 vessels)
200

150
74 accidents
100 (75 vessels)

50 10 accidents
(10 vessels)
0
Very Serious Serious Less Serious Marine Incident

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 STATISTICAL OVERVIEW

Chart 2: UK merchant vessels of 100gt or more

140
117 accidents
120 (119 vessels)

100

80

60
35 accidents
40 (36 vessels)
12 accidents
20 0 accidents (12 vessels)
(0 vessels)
0
Very Serious Serious Less Serious Marine Incident

Chart 3: UK merchant vessels of under 100gt

140

120
87 accidents 90 accidents
100 (92 vessels)
(95 vessels)
80

60
29 accidents
40 (29 vessels)
20 3 accidents
(3 vessels)
0
Very Serious Serious Less Serious Marine Incident

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 STATISTICAL OVERVIEW

Chart 4: UK fishing vessels

140

120

100

80 64 accidents
(64 vessels)
49 accidents
60 (51 vessels)
40 20 accidents
(20 vessels)
20 6 accidents
(6 vessels)
0
Very Serious Serious Less Serious Marine Incident

Chart 5: Non-UK commercial vessels - in UK 12 mile waters

360 324 accidents

(331 vessels)
320

280

240

200

160

120

80 46 accidents
(56 vessels)
40 14 accidents
1 accident
(14 vessels)
(1 vessel)
0
Very Serious Serious Less Serious Marine Incident

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 INVESTIGATIONS STARTED IN 2021

SUMMARY OF INVESTIGATIONS STARTED

Date of
occurrence Occurrence details

Loss of the UK registered fishing vessel Nicola Faith (BS 58) along with its three crew members in the area of
27 Jan
Rhos-On-Sea, Conwy County, North Wales.

Fatal accident on board the UK registered fishing vessel Cornishman (PZ 512), 55nm south-south-west of the
6 Feb
Isles of Scilly.

Fatal man overboard from the UK registered fishing vessel Copious (LK985), approximately 30nm south-south-
18 Feb
east of Sumburgh Head, Shetland, Scotland.

Injuries to crew members inside a lifeboat that rolled onto its side then fell overboard during a launching drill on
4 Mar
the research vessel RRS Sir David Attenborough (9798222) in Loch Buie, Scotland.

Serious injury to crew member following the failure of part of the equipment during lifting operations on board
3 Apr
the fish farm support workboat Annie E (9827190) near the Island of Muck, Inner Hebrides, Scotland.

Man overboard from the single-handed UK registered fishing vessel Saint Peter (LH22) with the loss of one life,
2 May
near the port of Cove, south of Dunbar, south-east of Scotland.

Capsize and foundering of the UK registered fishing vessel Angelena (BM271), south-east of Exmouth, England.
18 Jun
The skipper was rescued uninjured from the vessel’s liferaft.

Man overboard from the UK registered fishing vessel Reul A Chuain (OB915) with the loss of one life in the Sound
24 Jun
of Rùm near Mallaig, Scotland.

6 Jul The flooding and loss of the UK registered survey vessel Bella in Lynmouth Bay, England.

Fatal injury to crew member on the Cyprus registered vessel Clipper Pennant (9372688) while loading freight
20 Jul
vehicles in the port of Liverpool, England2.

Grounding of the Portuguese registered general cargo vessel BBC Marmara (9454228) on Eilean Trodday, north
25 Jul
of Skye, Scotland.

Fatal man overboard from the UK registered fishing vessel Pioneer (NN200) approximately 4.5nm south of
29 Jul
Hastings, England.

Fatal injury to a crew member during mooring operations on board the Isle of Man registered3 bulk carrier Mona
26 Aug
Manx (9801706) while berthing at Las Ventanas, Chile.

2 A safety bulletin (https://www.gov.uk/maib-reports/safety-warning-about-crushing-injuries-in-stowage-spaces-after-the-loss-of-1-life-on-ro-ro-ferry-

clipper-pennant) was issued on 4 November 2021
3 Under investigation on behalf of the Isle of Man Ship Registry in accordance with our Memorandum of Understanding (https://www.gov.uk/government/
publications/mou-between-maib-and-reg-category-1-registries)

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 INVESTIGATIONS STARTED IN 2021

Date of
occurrence Occurrence details

Fatal man overboard from the UK registered fishing vessel Harriet J (AH180) near the port of St Abbs, south-east
28 Aug
Scotland.

Fatal injury to a crew member during mooring deck operations on board the Isle of Man registered4 bulk carrier
30 Aug
Teal Bay (9343637) in the Kavkaz South anchorage, Russia.

Auxiliary engine room fire on board the Finland registered ro-ro cargo ship Finnmaster (9132014) while
19 Sep
departing Hull, England5.

Poisoning of a shore worker due to inhalation of phosphine gas being used as a cargo fumigant on board the
11 Oct
Marshall Islands registered general cargo vessel Thorco Angela (9359935) in Liverpool6.

Capsize of the single-handed creel fishing vessel Goodway (FR23) with the loss overboard and presumed death
16 Oct
of the one crew member near Cairnbulg, north-east Scotland.

Grounding of the Liberian registered chemical/products tanker Chem Alya (9486166) in the Needles Channel,
25 Oct
west of the Isle of Wight, England7.

30 Oct Four fatalities during a stand-up paddleboard activity on the River Cleddau, near Haverfordwest, Wales.

The accident involves the presumed sinking of a migrant boat while attempting to cross the English Channel,
but the exact circumstances and the number of persons or vessels involved has not been determined. However,
24 Nov evidence indicates that at least 27 migrants either drowned or died of hypothermia in the English Channel.

The MAIB investigation will focus on the emergency response to the accident. If it is determined that none of the
events leading up to the fatalities occurred in UK waters, the MAIB’s investigation will cease.

Collision between the UK registered general cargo vessel Scot Carrier (9841782) and the Danish registered
13 Dec
construction vessel Karin Høj (8685844) off the coast of southern Sweden, resulting in the loss of two lives.

4 Under investigation on behalf of the Isle of Man Ship Registry in accordance with our Memorandum of Understanding (https://www.gov.uk/government/
publications/mou-between-maib-and-reg-category-1-registries)
5 A safety bulletin (https://www.gov.uk/maib-reports/safety-warning-issued-after-discovery-of-blocked-fixed-co2-fire-extinquishing-system-pilot-hoses)
was issued on 10 March 2022
6 A preliminary assessment (https://www.gov.uk/maib-reports/fumigant-poisoning-on-general-cargo-vessel-thorco-angela-with-1-person-injured) was
published on 18 March 2022 and the case closed.
7 A preliminary assessment (https://www.gov.uk/maib-reports/grounding-of-chemical-tanker-chem-alya) was published on 18 March 2022 and the case
closed.

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 REPORTS AND RECOMMENDATIONS

PART 2: REPORTS AND RECOMMENDATIONS

Investigations published in 2021 including recommendations issued

The following pages list the accident investigation reports and safety bulletins published by the MAIB
during 2021. Where the MAIB has issued safety recommendations following an investigation, the current
status of the recommendation and any applicable comments made by the MAIB accompany the entry*.
Recommendations from previous years that remain open are also included on the following pages.

For details of abbreviations, acronyms and terms used in this section please refer to the glossary on page
72.
*Status as of 13 May 2022

Background

Recommendations are a key element of MAIB investigations. They are issued to promulgate the lessons
from accidents 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 an investigation the MAIB will, normally, make a number of recommendations. These will be
contained within the published report but will also be addressed in writing to the individuals or senior
executives of organisations concerned. Urgent safety recommendations may also be made in safety
bulletins or by letter from the Chief Inspector to the organisations involved, which can be published or
issued at any stage of an investigation.
Recommendations are made to a variety of addressees who might have been involved in, or have an
interest in, the accident. These can range from those organisations that have a wider role in the maritime
community, such as the Department for Transport (DfT), the Maritime and Coastguard Agency (MCA) or an
international organisation, through to commercial operators and vessel owners/operators.

The Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 require that the person
or organisation to whom a recommendation is addressed considers the recommendation and replies to
the Chief Inspector within 30 days of its receipt. The reply shall include details of the plans to implement
the recommendation or, if it is not going to be implemented, an explanation as to why not. Under the
Regulations, the Chief Inspector must annually inform the Secretary of State of those matters and make
them publicly available. This Annual Report to the Secretary of State for Transport fulfils this requirement.

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 REPORTS AND RECOMMENDATIONS

Recommendation response statistics 2021

35 recommendations were issued to 23 distinct addressees8 in 2021. The percentage of all

recommendations that are either accepted and implemented or accepted, yet to be implemented is 77.1%.

Accepted Action
Yet to be Partially No Response
Year Total* Implemented Implemented Accepted Withdrawn Rejected Received
2021 35 21 6 0 0 3 5

*Total number of recommendations issued

Recommendation response statistics from previous years

The chart below shows the number of recommendations issued under the closed-loop system that remain
open at the time of this publication. There are no outstanding recommendations from 2004 to 2008, 2010 to
2014, and 2018.

Outstanding recommendations - Addressees by industry type

4

0
2020 2019 2017 2016 2015 2009

Regulator Other government dept. Merchant vessel industry

Fishing vessel industry Mixed industries Other

8 For the purposes of these statistics, recommendation 2021/109M to all UK Operators of small commercial high speed craft such as Rigid Inflatable Boats,
sports boats and other vessels engaged in carrying passengers on trips and charters has been classed as 1 distinct addressee.

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 REPORTS AND RECOMMENDATIONS

SUMMARY OF 2021 PUBLICATIONS AND RECOMMENDATIONS ISSUED

Publication date (2021) and
Vessel name(s) Category Page
report number

Very Serious Marine 28 January

Minx/Vision 14
Casualty No 1/2021

25 February
Finlandia Seaways Serious Marine Casualty 15
No 2/2021

30 March
Cruise ships - anchor failures Marine Incident 16
No SB1/2021

Very Serious Marine 9 April

Ocean Quest (FR 375) 16
Casualty No 3/2021

Very Serious Marine 15 April

Diversion 17
Casualty No 4/2021

Very Serious Marine 12 May

Olivia Jean (TN 35) 17
Casualty No 5/2021

Very Serious Marine 20 May

Seadogz 18
Casualty Unnumbered interim report

Very Serious Marine 26 May

Beinn Na Caillich 19
Casualty No 6/2021

3 June
Kaami Serious Marine Casualty 19
No 7/2021

Very Serious Marine n/a, recommendation issued

Joanna C 21
Casualty pre-publication by letter

2 July
Arrow Serious Marine Casualty 21
No 8/2021

20 July
Stolt Groenland Serious Marine Casualty 22
No 9/2021

Very Serious Marine 6 August

Globetrotter 23
Casualty No 10/2021

9 September
Shearwater/Agem One Serious Marine Casualty 24
No 11/2021

Very Serious Marine 22 September

Cimbris 25
Casualty No 12/2021

Very Serious Marine 14 October

Norma G 26
Casualty No 13/2021

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 REPORTS AND RECOMMENDATIONS

Publication date (2021) and

Vessel name(s) Category Page
report number

Very Serious Marine 4 November

Clipper Pennant 27
Casualty No SB2/2021

Very Serious Marine 3 December

Achieve/Talis 27
Casualty No 14/2021

16 December
Key Bora Serious Marine Casualty 28
No 15/2021

Image: Shearwater

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 REPORTS AND RECOMMENDATIONS

2021 Recommendations - Progress Report*

*Status as of 13 May 2022

Minx/Vision Report number: 1/2021

Motor yachts Accident date: 25/5/2019
Collision with a moored yacht at Île Sainte-Marguerite, near Cannes, France with loss of
one life

Safety Issues
▶ Unsafe navigation of the vessel – conduct of unplanned high-speed pass
▶ Loss of control of vessel due to hydrodynamic effects
▶ Use of recreational drugs by crew

No Recommendation(s) to: Royal Yachting Association and the Professional Yachting

Association

2021/101 Promulgate the safety lessons from this fatal accident as widely as possible to owners and
operators in the commercial motor yacht industry sector.
RYA - appropriate action implemented

PYA - appropriate action implemented

▶ 14 ◀
 REPORTS AND RECOMMENDATIONS

Finlandia Seaways Report number: 2/2021

Ro-ro cargo vessel Accident date: 16/4/2018
Engine failure and fire off Lowestoft, England resulting in injury to one crew member

Safety Issues
▶ The failed connecting rod small end was not overhauled in accordance with the engine manufacturer’s
instructions and stress raisers introduced during the process increased the likelihood of failure
▶ Quality control and technical oversight processes did not identify the issue
▶ There were no Emergency Escape Breathing Devices located along the emergency escape route
▶ The crew were unable to determine the number of CO2 cylinders that discharged after the fixed fire
extinguishing system was activated

No Recommendation(s) to: DFDS Seaways AB - Lithuania

2021/102 Review and improve how its chief engineers conduct class-related equipment examinations
as part of the Continuous Survey Machinery cycle to ensure that examinations are conducted
thoroughly and reported accurately.
Appropriate action implemented

No Recommendation(s) to: Diesel Service Group (Klaipeda)

2021/103 Fully apply equipment manufacturers’ maintenance and repair guidance and procedures.
No response received

2021/104 Review and, as necessary, amend its record keeping in order to generate a full and auditable
record of the maintenance carried out by its staff.
No response received

2021/105 Review and update staff training to ensure familiarity with engineering methods appropriate for
the various repair and overhaul tasks, backed up with a suitable quality assurance process to
ensure standards are maintained.
No response received

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 REPORTS AND RECOMMENDATIONS

Cruise ship anchor failures Bulletin number: SB1/2021

Cruise ship(s) Accident date: autumn/winter 2020-21
Multiple anchor failures off the UK south coast

Safety Issues
▶ The anchoring of cruise ships for prolonged periods of time
in adverse weather conditions and strong tidal streams
▶ Anchor system design criteria exceeded and component
wear rate accelerated

The MAIB identified a trend in the nature of anchoring equipment failures during the COVID-19
enforced operational pause, which saw many cruise vessels anchored off the UK south coast.
This safety bulletin was issued to the cruise industry to mitigate against further losses both in the
short term and when the vessels return to normal operations. No recommendations were made.

Ocean Quest Report number: 3/2021

Fishing vessel (FR 375) Accident date: 18/8/2019
Flooding and foundering off Fraserburgh, Scotland

Safety Issues
▶ Hull failure was probably the result of shell plating or hull weld failure below the main engine
▶ Onboard bilge and salvage pumping arrangements not fully utilised
▶ Training and the conduct of drills provide critical preparation for emergencies

No recommendations were made as a result of the investigation; however, this accident highlights
the importance of readiness to respond to emergency situations.

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 REPORTS AND RECOMMENDATIONS

Diversion Report number: 4/2021

Motor cruiser Accident date: 4/12/2019
Carbon monoxide poisoning alongside the Museum Gardens quay on the River Ouse,
York, England with loss of two lives

Safety Issues
▶ Carbon monoxide detector/alarm was not fitted on board the
boat
▶ Diesel-fuelled cabin heater was not correctly installed and its
exhaust system was not gas tight
▶ Diesel-fuelled cabin heater was not inspected by a suitably
qualified engineer following its installation and had not been
serviced
▶ The cabin ventilation system did not meet the accepted standard

As a result of the actions taken after the publication of safety bulletin 2/20209, no recommendations
were made.

Olivia Jean Report number: 5/2021

Fishing vessel (TN 35) Accident date: 28/6/2019
Accident while off Aberdeen, Scotland with loss of one life

Safety Issues
▶ Ineffective supervision and control of work activities on deck
▶ Poor levels of spoken English by foreign crew and the lack of a
common language led to communication problems
▶ Risk assessment control measures were not fully implemented
▶ Vessel safety management system incomplete and not being used or
maintained on the vessel

No Recommendation(s) to: TN Enterprises Ltd

2021/106 Review its fleet operations and ensure that the mandatory requirements of International
Labour Organization Convention No. 188, The Work in Fishing Convention, and applicable
Maritime and Coastguard Agency codes of practice are adhered to. In particular, take action
to ensure its safety management system fully implements the recommendations made by the
Maritime and Coastguard Agency in its Fishing Safety Management Code.
Appropriate action implemented

2021/107 Undertake a review of the levels of English language comprehension of its foreign crews and
ensure that they share a common language.
Appropriate action implemented

9 https://www.gov.uk/maib-reports/safety-warning-about-carbon-monoxide-poisoning-after-the-loss-of-2-lives-on-the-motor-cruiser-diversion

▶ 17 ◀
 REPORTS AND RECOMMENDATIONS

2021/108 Introduce a pre-employment formal evaluation process to establish the standard of English of
its potential crew members.
Appropriate action implemented

Seadogz Report Number: Interim Report

High speed passenger craft Accident date: 22/8/2020
Collision with a navigation buoy off Southampton, England with loss of one life

Safety Issues
▶ The conduct of high speed manouevres in close proximity to navigation buoys and other vessels
▶ The single-handed operation of small commercial passenger craft
▶ Increased risk of hooking or spinning out
▶ Lack of compliance with the controls set out in the Passenger Safety on Small Commercial High
Speed Craft & Experience Rides voluntary Code of Practice10

No Recommendation(s) to: All UK Operators of small commercial high speed craft such as
Rigid Inflatable Boats, sports boats and other vessels engaged
in carrying passengers on trips and charters

2021/109M Review the risk assessments for the operation of their vessels and take measures, as
appropriate, to ensure that they comply with the safe working practices and standards
contained in the Passenger Safety on Small Commercial High Speed Craft & Experience Rides
voluntary Code of Practice. Where an operator cannot comply with the provisions outlined
in the Code of Practice, steps should be taken to mitigate against risk, and details of those
measures included in the relevant operating procedures.
Appropriate action implemented

MAIB comment: The MAIB received a number of positive responses to the recommendation that
reported appropriate action has been taken.

10 HSPV Code of Practice can be downloaded from here: https://britishmarine.co.uk/Services/Business-Support/Industry-Codes-of-Practice

▶ 18 ◀
 REPORTS AND RECOMMENDATIONS

Beinn Na Caillich Report number: 6/2021

Category 2 workboat Accident date: 18/2/2020
Accident to a fish farm worker at Ardintoul, Glenshiel, Scotland with loss of one life

Safety Issues
▶ Boat transfers not properly planned, supervised or
controlled
▶ Absence of effective marine safety management system
▶ Crew not fully prepared to deal with the emergency –
lack of safety drills

No Recommendation(s) to: Mowi (Scotland) Ltd

2021/110 Apply the standards set out in the Workboat Code Edition 2 to all its existing workboats and,
specifically, to fully implement a safety management system across its fleet that complies with
the principles of the International Safety Management Code.
Appropriate action implemented

2021/111 Ensure that appropriate marine expertise is present or provided to its senior management team
to oversee the safety of its vessels and marine operations.
Appropriate action implemented

Kaami Report number: 7/2021

General cargo Accident date: 23/3/2020
Grounding on Sgeir Graidach, the Little Minch, Scotland

Safety Issues
▶ ECDIS safety features not fully utilised
▶ Voyage plan not checked, navigational hazard not identified and
vessel position not properly monitored
▶ Manning levels contributed to navigational operations

No Recommendation(s) to: Misje Rederi AS

2021/112 Review the numbers of watchkeeping officers on vessels in its fleet with the specific aim of
ensuring there are sufficient personnel to conduct essential tasks effectively during periods
of high workload and to protect the watchkeepers against the effects of fatigue, taking into
account the guidance contained in IMO Resolution A.1047(27) Principles of Minimum Safe
Manning.
Appropriate action implemented

▶ 19 ◀
 REPORTS AND RECOMMENDATIONS

2021/113 Review and amend the guidance contained in its safety management system regarding voyage
planning using ECDIS to ensure that:
• a company standard for safe under keel clearance and safety depth and the method for
calculation is present and followed;
• the correct application of safety contours and alert limit settings is positively confirmed on
all company vessels;
• if the voyage planning must be conducted by the master then a second check by a different
navigating officer must take place;
• support is given to the navigating officer to ensure they have the time to develop the
voyage plan and check it for errors.
Appropriate action implemented

2021/114 Confirm fleetwide compliance with acceptable navigational procedures, specifically with ECDIS
by:
• ensuring all staff auditing the fleet have an appropriate level of knowledge, through
training and experience, to enable the effective audit of the use of ECDIS on board;
• engaging an independent navigational audit provider, until such time as their internal
audit team is appropriately trained;
• employ a system that ensures that relevant learning opportunities are followed up and
implemented.
Appropriate action implemented

2021/115 Ensure that lookouts in the fleet are being fully integrated into bridge teams using the good
practice principles highlighted in the ICS Bridge Procedures Guide, and to amend the safety
management system to provide the appropriate level of supporting guidance.
Appropriate action implemented

▶ 20 ◀
 REPORTS AND RECOMMENDATIONS

Joanna C Recommendation letter issued by the Chief Inspector

Fishing vessel (BM 265) Accident date: 21/11/2020
Capsize and foundering off Newhaven, England with loss
of two lives

Safety Issues
▶ Failure of liferaft to inflate and float free
▶ The buoyancy of the submerged liferaft was insufficient to activate
the inflation mechanism

No Recommendation(s) to: British Standards Institution

2021/116 Propose to the International Organization for Standardization that the revised ISO 9650
standard includes a buoyancy requirement for uninflated canister-packed liferafts when
intended for use with float free, automatic inflation devices. The buoyancy requirement should
be sufficient to exceed, by a suitable factor of safety, the force required to activate the liferaft’s
inflation mechanism.
Appropriate action planned: 30 December 2022

Arrow Report number: 8/2021

Ro-ro freight ferry Accident date: 25/6/2020
Grounding in the approach channel of Aberdeen Harbour, Scotland

Safety Issues
▶ Ineffective bridge resource management; bridge team and navigation aids not fully utilised
▶ Inadequate passage planning and monitoring
▶ Lack of preparation for restricted visibility
▶ Poor bridge ergonomics

Given the subsequent actions taken by Seatruck Ferries Limited and Aberdeen Harbour Board to
improve safety and prevent recurrence, no safety recommendations were made as a result of this
investigation.

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 REPORTS AND RECOMMENDATIONS

Stolt Groenland Report number: 9/2021

Chemical tanker Accident date: 28/9/2019
Investigation on behalf of Cayman Islands Government11:
Cargo tank explosion and fire at Ulsan, Republic of Korea

Safety Issues
▶ The temperature of heat sensitive cargo was not monitored during
the voyage – critical temperature reached prior to berthing
▶ Heat sensitive cargo was stowed without adequate recognition of
the potential for heat transfer through intermediate tanks
▶ Similar incident on another vessel not reported

No Recommendation(s) to: Cayman Islands Shipping Registry, through the UK as the

Member Government for the Red Ensign Group to the
International Maritime Organization

2021/117 Propose to the IMO a revision to Section 15.13 of the IBC Code to:
• Include in the certificate of protection the actions to be taken in the event of a cargo falling
outside of the manufacturer’s specified oxygen and temperature limits, and that
• Any actions should be realistic, taking account of the limitations on board ships regarding
the monitoring, adding, and mixing of inhibitor during the voyage.
Appropriate action planned: No date given

No Recommendation(s) to: International Chamber of Shipping

2021/118 Promulgate this report to its members.

Appropriate action implemented

No Recommendation(s) to: INTERTANKO

2021/119 Promulgate this report to its members.

Appropriate action implemented

No Recommendation(s) to: Chemical Distribution Institute

2021/120 Amend its publication ‘Chemical Tanker Operations for the STCW Advanced Training Course – A
Practical Guide to Chemical Tanker Operations’ to make it clear that:
• The stowage of heated and inhibited cargoes can result in a dynamic situation in which the
degree of heat transfer may be complex and difficult to predict.

11 In accordance with our Memorandum of Understanding (https://www.gov.uk/government/publications/mou-between-maib-and-reg-category-1-

registries)

▶ 22 ◀
 REPORTS AND RECOMMENDATIONS

• One tank separation between heated and heat sensitive cargoes might not be sufficient.
• Promulgate this report to its members.
Appropriate action planned: 31 December 2022

No Recommendation(s) to: Plastics Europe (Styrene Producers Association)

2021/121 Work with its members to incorporate the lessons learned from this accident in its Styrene
Monomer: Safe Handling Guide.
Appropriate action planned: Update requested

No Recommendation(s) to: Stolt Tankers B.V

2021/122 Share with INTERTANKO the circumstances and lessons learned from the Stolt Focus incident
and the results of its research into improved stowage software, to enable prediction of heat
transfer and cargo behaviour.
Rejected

MAIB comment: Stolt rejected this recommendation as it considered the circumstances of the Stolt
Focus incident was adequately covered in MAIB's report and following its own research
felt that prediction of heat transfer rates between tanks was too complex for existing
software and software currently under development.

Globetrotter Report number: 10/2021

Motorboat Accident date: 31/5/2020
Foundering off Fleetwood, England with the loss of one life

Safety Issues
▶ Owner did not appreciate the risks of taking his boat to sea
– it was in poor condition and was not seaworthy
▶ Vessel grounded due to inadequate passage planning and
position monitoring
▶ Personal flotation devices not worn

No recommendations have been made as a result of this

investigation; however, the MAIB wrote to the Royal Yachting Association, the UK Harbour Masters’
Association, the Cruising Association, British Marine, and the Angling Trust to highlight the lessons
learned from this accident and other similar accidents and requested assistance with promulgating
the advice contained in Emily’s Code12 to leisure boat users.

12 https://www.rya.org.uk/knowledge/safety/emilys-code

▶ 23 ◀
 REPORTS AND RECOMMENDATIONS

Shearwater/Agem One Report number: 11/2021

Dredger/Unmanned barge Accident date: 9/4/2020
Immobilisation and flooding of a dredger after repeated collisions with an unmanned
barge near Kinlochbervie, Scotland

Safety Issues
▶ Insufficient planning, risk assessments or safe systems of work
for the towing operation being conducted
▶ Shearwater was not suitable for use as a coastal towing vessel
▶ The crew did not have the necessary competence to undertake
the operation
▶ Flag state certification did not provide sufficient assurance

No Recommendation(s) to: Maritime and Coastguard Agency

2021/123 Adopt measures to ensure that the certification of vessels over 24m load line length and under
500gt includes the application of all appropriate regulatory conditions taking full account of the
vessel’s intended function and area of operations.
Appropriate action planned: 31 August 2022

No Recommendation(s) to: Northern Dredging Limited

2021/124 Undertake risk assessments for all intended operations to identify hazards, and ensure that safe
systems of work are in place to mitigate all foreseeable risks. Additionally, procedures should
be in place for all potential emergencies.
Rejected

2021/125 Ensure that company vessels are safely manned by a master and crew members who are
suitably qualified and experienced for the operations being undertaken, and that obligations
for hours of work and rest are met.
Rejected

MAIB comment: Following the accident Shearwater's owner re-flagged the dredger. Despite
several requests from MAIB, he has not responded on the implementation of the
recommendation and therefore it has been classed as rejected and closed.

▶ 24 ◀
 REPORTS AND RECOMMENDATIONS

Cimbris Report number: 12/2021

General cargo vessel Accident date: 14/7/2020
Investigation on behalf of Cayman Islands Government13: Accident while a gantry crane
was moving a hatch cover at Antwerp, Belgium with loss of one life

Safety Issues
▶ Weak ship-to-shore safety communication
▶ Unsafe system of work; banksmen not used, load carried over workers
▶ Stevedore placed himself in a position of danger
▶ Stevedore was unsighted by ship’s gantry crane operator

No Recommendation(s) to: Briese Dry Cargo GmbH & Co. KG

2021/126 Take appropriate actions to improve the level of safety culture on board Cimbris and its other
managed vessels.
Appropriate action implemented

No Recommendation(s) to: Centrale der Werkgevers aan de Haven van Antwerpen

2021/127 Take appropriate actions to improve the level of safety culture among its registered workers.
No response received

2021/128 Review compliance with safe working practices on board customer vessels, to better ensure the
safety of its registered workers and vessel crews.
No response received

13 In accordance with our Memorandum of Understanding (https://www.gov.uk/government/publications/mou-between-maib-and-reg-category-1-

registries)

▶ 25 ◀
 REPORTS AND RECOMMENDATIONS

Norma G Report number: 13/2021

Motor cruiser Accident date: 25/5/2020
Capsize in the Camel Estuary, Cornwall, England with loss of one life

Safety Issues
▶ The dangers of being near the Doom Bar in a small boat close to low water were not fully appreciated
▶ No aids to navigation marking the extremities of the Doom Bar
▶ Inconsistent navigation advice
▶ Lower safety standards on older boats – lack of buoyancy

No Recommendation(s) to: Padstow Harbour Commissioners

2021/129 Update their port passage plan and navigation guide to provide up-to-date chart information
and unambiguous guidance to mariners entering or leaving the River Camel.
Appropriate action planned: No date given

2021/130 Consider, as part of their navigation risk assessment, placing an aid to navigation to mark the
north-east extremity of the Doom Bar.
Appropriate action implemented

No Recommendation(s) to: Wadebridge Boating Club

2021/131 Review and amend the information provided to its members, including the Membership Card
and Club Rules booklet, to include, inter alia:
• reference to navigational safety information published by Padstow Harbour
Commissioners.
• reference to boating safety information published by the RYA, RNLI, and local sources of
training.
Appropriate action implemented

▶ 26 ◀
 REPORTS AND RECOMMENDATIONS

Clipper Pennant Bulletin number: SB2/2021

Ro-ro ferry Accident date: 20/7/2021
Fatal crushing injury on ferry's upper vehicle deck in Liverpool, England

Safety Issues
▶ Extreme risk of crushing injuries in stowage spaces adjacent to the vessel’s structure, with limited areas
to remain clear or escape

This safety bulletin was issued to highlight to operators of vessels with roll-on/roll-off vehicle decks
that, where tractor units are being used to push semi-trailers, safety procedures must be in place to
ensure that deck crew are not standing in the vehicle’s path. No safety recommendations were made.

Achieve/Talis Report number: 14/2021

Fishing vessel (HL 257)/ General cargo ship Accident date: 8/11/2020
Collision between a fishing vessel and a general cargo ship resulting in the sinking of the
fishing vessel off Tynemouth, England

Safety Issues
▶ No effective lookout on board Achieve – unmanned wheelhouse
▶ Cargo ship Talis’s action to avoid collision was too late
▶ Ineffective use of radar in fog and no sound signals
▶ No radar reflector rigged on board Achieve

No Recommendation(s) to: Achieve’s owner/skipper

2021/132 Ensure that policies and procedures are put into place on any future vessels he might own or
skipper that clearly state the obligation to keep a proper lookout at all times, as required by the
COLREGs.
Appropriate action implemented

▶ 27 ◀
 REPORTS AND RECOMMENDATIONS

No Recommendation(s) to: WeShips Denizcilik ve Ticaret A.Ş.

2021/133 Issue a fleet safety bulletin to remind its masters and navigation officers of their obligations
to comply with the COLREGs, particularly the requirements of Rule 5 (Lookout) and Rule 19
(Conduct of vessels in restricted visibility).
Appropriate action implemented

Key Bora Report number: 15/2021

Chemical tanker Accident date: 28/3/2020
Grounding in the approaches to Kyleakin pier, Isle of
Skye, Scotland

Safety Issues
▶ Inappropriate use of local (inaccurate) hydrographic survey data
▶ Ineffective bridge team management
▶ ECDIS not used effectively for passage planning or execution
▶ Mowi’s Kyleakin facility was not being operated in accordance
with the Port Marine Safety Code

No Recommendation(s) to: Mowi Scotland Limited

2021/134 Ensure that marine operations at Kyleakin follow the guidance in the Port Marine Safety Code
and its associated Guide to Good Practice.
Appropriate action implemented

2021/135 Consider applying for a Harbour Empowerment Order in order to establish a statutory harbour
authority, delivering the associated maritime safety benefits, at Kyleakin.
Appropriate action implemented

▶ 28 ◀
 REPORTS AND RECOMMENDATIONS

PROGRESS OF RECOMMENDATIONS FROM PREVIOUS YEARS

Vessel name Publication date/report number Page

2020 Recommendations - Progress Report 31

9 January
Artemis (FR 809) 31
No 1/2020

17 January
European Causeway 31
No 3/2020

6 February
Seatruck Performance 32
No 4/2020

19 March
ANL Wyong/King Arthur 32
No 7/2020

n/a, recommendation issued

Diamond Emblem 1 33
prepublication by letter14

4 November
Fire and rescue service boats 33
No 17/2020

n/a, recommendation issued

Rib Tickler/Unnamed Personal Watercraft 34
prepublication by letter15

10 December
Sunbeam (FR487) 35
No 19/2020

2019 Recommendations - Progress Report 36

31 January 2019
Unnamed Rowing Boat (throw bag rescue line) 36
No 2/2019
30 May 2019
Nancy Glen (TT100) 37
No 6/2019
20 June 2019
CV30 37
No 7/2019

2018 Recommendations - Progress Report 37

No recommendations outstanding for 2018

2017 Recommendations - Progress Report 38

12 April 2017
CV21 38
No 7/2017
18 May 2017
Osprey/Osprey II 38
No 10/2017
7 December 2017
Nortrader 39
No 26/2017

14 A full accident investigation report was subsquently published on 5 May 2022: https://www.gov.uk/maib-reports/person-overboard-from-motor-cruiser-
diamond-emblem-1-with-loss-of-1-life
15 A full accident investigation report was subsquently published on 17 February 2022: https://www.gov.uk/maib-reports/collision-between-rigid-inflatable-
boat-rib-tickler-and-a-personal-watercraft-with-loss-of-1-life

▶ 29 ◀
 REPORTS AND RECOMMENDATIONS

Vessel name Publication date/report number Page

2016 Recommendations - Progress Report 40

7 July 2016
JMT (M99) 40
No 15/2016

2015 Recommendations - Progress Report 41

29 April 2015
Cheeki Rafiki 41
No 8/2015

10 December 2015
Stella Maris (HL705) 41
No 29/2015

2014 Recommendations - Progress Report 42

No recommendations outstanding for 2014

2013 Recommendations - Progress Report 42

2 May 2013
Purbeck Isle (PH 104) 42
No 7/2013

13 June 2013
Sarah Jayne (BM 249) 42
No 13/2013

20 June 2013
Vixen 43
No 16/2013

2012 to 2010 Recommendations - Progress Report 44

No recommendations outstanding for 2012, 2011 and 2010

2009 Recommendations - Progress Report 44

21 May 2009
Celtic Pioneer 44
No 11/2009

1 July 2009
Abigail H 44
No 15/2009

2008 Recommendations - Progress Report 45

28 November 2008
Fishing Vessel Safety Study 1992 to 2006 45
FV Safety Study

▶ 30 ◀
 REPORTS AND RECOMMENDATIONS

2020 Recommendations - Progress Report*

*Status as of 13 May 2022

Artemis Report number: 1/2020

Fishing vessel (FR 809) Accident date: 29/4/2019
Fall through internal wheelhouse hatch while berthed alongside at Kilkeel, Northern
Ireland with loss of one life

№ Recommendation(s) to: Watchful Ltd16

2020/102 Are recommended to:

• Review and update the generic drug and alcohol policy in their safety folders to reflect
the issues identifed by this investigation. These policies should include: the Railways and
Transport Safety Act 2003 alcohol limits; a clear defnition of when crew are on or of duty;
and, parameters under which the skipper or other authorised person may direct a crew
member to undergo drug and alcohol testing.
Appropriate action implemented

European Causeway Report number: 3/2020

Ro-ro passenger ferry Accident date: 18/12/2018
Cargo shift and damage to vehicles on a ro-ro vessel during a voyage from Larne,
Northern Ireland, to Cairnryan, Scotland

№ Recommendation(s) to: P&O Ferries Ltd

2020/107 Amend its SMS to provide specific guidance on the lashing of cargo in heavy weather to all
vessels in its fleet, to ensure that it meets industry best practice and the guidance provided in
the MCA’s Code of Practice – Roll-on/Roll-off Ships – Stowage and Securing of Vehicles.
Appropriate action implemented

16 The original recommendation was made to Rockall Ltd (no longer trading) and Seafish. However, the SafetyFolder is now being managed by Watchful Ltd,
and it has since implemented the intent of the recommendation.

▶ 31 ◀
 REPORTS AND RECOMMENDATIONS

Seatruck Performance Report number: 4/2020

Ro-ro freight ferry Accident date: 8/5/2019
Grounding of a ro-ro freight ferry in Carlingford Lough, Northern Ireland

№ Recommendation(s) to: Seatruck Ferries Ltd

2020/108 Take further measures to enhance the safe navigation of its vessels by optimising its use of
electronic navigation systems to provide real time positional information, and enhancing its
Bridge Resource Management training.
Appropriate action implemented

ANL Wyong/King Arthur Report number: 7/2020

Container vessel/Gas carrier Accident date: 4/8/2018
Collision between a container vessel and a gas carrier in the approaches to Algeciras,
Spain

№ Recommendation(s) to: Maritime and Coastguard Agency

2020/116 Propose to the International Maritime Organization that the navigation status information
in the automatic identification system be reviewed to ensure that a vessel’s status can be
accurately described, including vessels underway but not making way.
Appropriate action implemented

▶ 32 ◀
 REPORTS AND RECOMMENDATIONS

Diamond Emblem 1 Recommendation letter issued by the Chief Inspector

Motor Cruiser Accident date: 19/08/2020
Fatal person overboard at Great Yarmouth Yacht Station, England

№ Recommendation(s) to: Association of Inland Navigation Authorities

2020/129 Revise the Code of Practice for Hire Boats to include:

• A requirement for hire boat companies to assess the risk of people falling overboard and
implement suitable control measures, particularly for areas that are in frequent use or
where the risk of a fall is identified as high (Hire Boat Code Section 2.6 and Annex II).
• A requirement for hire boat companies operating vessels with multiple helm positions to
comply, where possible, with international standards for a positive visual indication of
the active helm position and interlocks to prevent inadvertent engine operation from an
inactive helm position (3.2.2).
• Guidance on conduct of handover to include a thorough demonstration of a vessel’s
engine and steering controls where more than one helm position exists (3.3.3).
• A requirement for in-water trial, before handover, to assess the competence of those
expected to drive the boat, irrespective of their previous experience or length of hire of the
vessel (3.3.4).
Partially accepted - action implemented

MAIB comment: AINA has implemented the intent of bullets 1, 3 and 4. The intent of bullet 2 was
readdressed in a recommendation (2022/123) to the Boat Safety Scheme in the
investigation report17.

Fire and rescue service boats Report number: 17/2020

Inflatable boat/Rigid inflatable boat Accident date: 17/09/2019
Collision on the River Cleddau, Milford Haven, Wales with loss of one life

№ Recommendation(s) to: National Fire Chiefs Council

2020/133 Consult with the Maritime and Coastguard Agency and the UK Harbour Masters’ Association
to introduce a standard code for the operation of all fire and rescue service craft when in
categorised or non-categorised waters.
Appropriate action implemented

17 https://www.gov.uk/maib-reports/person-overboard-from-motor-cruiser-diamond-emblem-1-with-loss-of-1-life

▶ 33 ◀
 REPORTS AND RECOMMENDATIONS

Rib Tickler/Unnamed Personal Watercraft

Recommendation letter issued by the Chief Inspector
RIB/Personal Watercraft Accident date: 08/08/2020
Fatal collision in the Menai Straits, Wales

№ Recommendation(s) to: Royal Yachting Association

2020/136 Review and amend its Personal Watercraft and Start Powerboating handbooks to provide
guidance on:
• The importance and conduct of the over-the-shoulder pre-manoeuvre check;
• How to safely operate in company with other craft, with particular focus on
communication and safe distances;
• The oversight of inexperienced/untrained helms in an informal setting;
• Crossing waves and wakes, with particular focus on control of personal watercraft and safe
distances from vessels creating wake, and:
• Disseminate to their members a summary of the safety messages from this accident prior
to the start of the 2021 boating season.
Consideration should also be given to including the above topics in the relevant training course
syllabi.
Appropriate action planned: Update requested

▶ 34 ◀
 REPORTS AND RECOMMENDATIONS

Sunbeam Report number: 19/2020

Fishing vessel (FR487) Accident date: 14/08/2018
Fatal enclosed space accident in Fraserburgh, Scotland

№ Recommendation(s) to: Maritime and Coastguard Agency

2020/137 Implement measures for the safe conduct of enclosed space operations on board fishing
vessels, specifically:
• Amend the Merchant Shipping (Entry into Dangerous Spaces) Regulations, 1988, or any
subsequent regulations for potentially hazardous spaces, to include fishing vessels.
Consideration should also be given to aligning UK regulations and guidance with the IMO
terminology for enclosed spaces.
• Update fishing vessel codes of practice and surveyor’s checklists to reflect enclosed space
safety and operations, specifically including atmosphere monitoring and crew preparation
for emergencies.
Appropriate action implemented

2020/138 Review Letters of Delegation to its Recognised Organisations in order to ensure clarity of
understanding with regard to responsibility for survey of machinery items.
Appropriate action implemented

№ Recommendation(s) to: Owners of Sunbeam

2020/139 Implement an onboard safety management system in accordance with the MCA’s Fishing
Safety Management Code, specifically ensuring that safe systems of work are in place for all
operations.
Appropriate action implemented

▶ 35 ◀
 REPORTS AND RECOMMENDATIONS

2019 Recommendations - Progress Report*

*Status as of 13 May 2022

Unnamed Rowing Boat Report number: 2/2019

Rowing boat Accident date: 24/3/2018
Failure of a throw bag rescue line during a capsize drill at a rowing club in Widnes,
England

№ Recommendation(s) to: British Standards Institution

2019/105 Develop an appropriate standard for public rescue equipment ensuring that the topic of throw
bags and their rescue lines is addressed as a priority.
Appropriate action planned: No date given

▶ 36 ◀
 REPORTS AND RECOMMENDATIONS

Nancy Glen Report number: 6/2019

Twin rig prawn trawler (TT100) Accident date: 18/1/2018
Capsize and sinking in Lower Loch Fyne, Scotland with the loss of two lives

№ Recommendation(s) to: Maritime and Coastguard Agency

2019/109 Include in its new legislation addressing the stability of existing fishing vessels of under 15m,
a requirement to undertake both a freeboard check and stability check, which should be
recorded and repeated at intervals not exceeding 5 years.
Provide guidance on the conduct of 5-yearly stability checks to ensure the results can be
effectively compared to determine whether the vessel’s stability has altered.
Align the text of MSN 1871 (F), The Code of Practice for the Safety of Small Fishing Vessels of
less than 15m Length Overall, to mirror Statutory Instruments 2017 No. 943 Merchant Shipping,
The Fishing Vessel (Codes of Practice) Regulations 2017. This amendment should be in respect
of vessel owners’ obligation to notify the MCA of any proposal to alter or modify a vessel’s
structure, remove or reposition engines or machinery or change the mode of fishing.
Include in its new legislation introducing stability criteria for all new and substantially modified
vessels, a requirement for this to be validated by a 5-yearly lightship check.
Appropriate action implemented

CV30 Report number: 7/2019

Commercial racing yacht Accident date: 18/11/2017
Fatal man overboard approximately 1500nm west of Fremantle, Australia

№ Recommendation(s) to: British Standards Institute Committee

2019/110 Review and amend ISO 12401 and ISO 15085 at the earliest opportunity in light of lessons
learned from this accident to:
• Ensure the danger of snagging of tether hooks is highlighted and suitable precautions are
taken for terminating jackstays.
• Clarify that the ISO 12401 standard test assumes that the tether is loaded longitudinally
and that the hook must be free to rotate to align with the load, and lateral loading of the
hook must be avoided.
• Clarify what force should be applied during an accidental hook opening test.
• Consider including a requirement for a tether overload indicator.
Appropriate action planned: 31 December 2023

2018 Recommendations - Progress Report

There are no outstanding recommendations for 2018.

▶ 37 ◀
 REPORTS AND RECOMENDATIONS

2017 Recommendations - Progress Report*

*Status as of 13 May 2022

CV21 Report number: 7/2017

Commercial racing yacht Accident dates: 4/9/2015 and 1/4/2016
Combined report on the investigations of the fatal accident while 122nm west of Porto,
Portugal on 4 September 2015 and the fatal person overboard in the mid-Pacific Ocean on
1 April 2016

№ Recommendation(s) to: Royal Yachting Association/World Sailing/British Marine

2017/109 Work together to develop and promulgate detailed advice on the use and limitations of
different rope types commonly used, including HMPE, in order to inform recreational and
professional yachtsmen and encourage them to consider carefully the type of rope used for
specific tasks on board their vessels.

RYA: Appropriate action implemented

World Sailing: Appropriate action implemented

British Marine: Appropriate action planned: No date given

MAIB comment: The implementation project was delayed in 2020 due to the impact of COVID-19
restrictions and Brexit workloads and is yet to be restarted.

Osprey/Osprey II Report number: 10/2017

RIBs Accident date: 19/7/2016
Collision between two rigid inflatable boats on Firth of Forth, Scotland resulting in
serious injuries to one passenger

№ Recommendation(s) to: Maritime and Coastguard Agency

2017/115 Include in its forthcoming Recreational Craft Code with respect to commercially operated
passenger carrying RIBs:
• A requirement for the certificated maximum number of passengers to be limited to the
number of suitable seats designated for passengers.
• Guidance on its interpretation of "suitable" with respect to passenger seating.
• A requirement for passengers not to be seated on a RIB’s inflatable tubes unless otherwise
authorised by the Certifying Authority and endorsed on the RIB’s compliance certificate
with specified conditions to be met for a particular activity.

Appropriate action planned: 1 January 2023

▶ 38 ◀
 REPORTS AND RECOMMENDATIONS

Nortrader Report number: 26/2017

General cargo vessel Accident date: 13/1/2017
Explosion of gas released from a cargo of unprocessed incinerator bottom ash while at
anchorage in Plymouth Sound, England

№ Recommendation(s) to: Maritime and Coastguard Agency

2017/154 Update The Merchant Shipping (Carriage of Cargoes) Regulations 1999 with appropriate
references to the IMSBC Code.

Appropriate action planned: 31 December 2022

▶ 39 ◀
 REPORTS AND RECOMMENDATIONS

2016 Recommendations - Progress Report*

*Status as of 13 May 2022

JMT Report number: 15/2016

Fishing vessel (M99) Accident date: 9/7/2015
Capsize and foundering of a small fishing vessel 3.8nm off Rame Head, English Channel
with loss of two lives

№ Recommendation(s) to: Maritime and Coastguard Agency

2016/130 Include in its intended new legislation introducing stability criteria for all new and significantly
modified decked fishing vessels of under 15m in length a requirement for the stability of new
open decked vessels, and all existing vessels of under 15m to be marked using the Wolfson
Method or assessed by use of another acceptable method.
Appropriate action implemented

2016/131 Require skippers of under 16.5m fishing vessels to complete stability awareness training.

Appropriate action planned: 30 April 2023

▶ 40 ◀
 REPORTS AND RECOMMENDATIONS

2015 Recommendations - Progress Report*

*Status as of 13 May 2022

Cheeki Rafiki Report number: 8/2015

Sailing yacht Accident date: 16/5/2014
Loss of a yacht and its four crew in the Atlantic Ocean, approximately 720 miles
east-south-east of Nova Scotia, Canada

№ Recommendation(s) to: British Marine Federation18

2015/117 Co-operate with certifying authorities, manufacturers and repairers with the aim of developing
best practice industry-wide guidance on the inspection and repair of yachts where a GRP matrix
and hull have been bonded together.
Appropriate action planned: 23 July 2023

№ Recommendation(s) to: Maritime and Coastguard Agency

2015/120 Include in the SCV Code a requirement that vessels operating commercially under ISAF19 OSR
should undergo a full inspection to the extent otherwise required for vessels complying with
the SCV Code.
Appropriate action planned: 1 January 2023

Stella Maris Report number: 29/2015

Fishing vessel (HL705) Accident date: 28/7/2014
Capsize and foundering 14 miles east of Sunderland, England

№ Recommendation(s) to: Maritime and Coastguard Agency

2015/165 Introduce intact stability criteria for all new and significantly modified decked fishing vessels of
under 15m in length.
Appropriate action implemented

18 British Marine Federation now known as British Marine.

19 International Sailing Federation (ISAF) is now known as World Sailing.

▶ 41 ◀
 REPORTS AND RECOMMENDATIONS

2014 Recommendations - Progress Report

There are no outstanding recommendations for 2014.

2013 Recommendations - Progress Report*

*Status as of 13 May 2022

Purbeck Isle Report number: 7/2013

Fishing vessel (PH 104) Accident date: 17/5/2012
Foundering 9 miles south of Portland Bill, England with the loss of three lives

№ Recommendation(s) to: Maritime and Coastguard Agency

2013/204 Align its hull survey requirements for fishing vessels of <15m length overall with those applied
to workboats under the Harmonised Small Commercial Vessels Code.
Partially accepted - action implemented

MAIB comment: MCA has enhanced the hull survey requirements for fishing vessels less than 15m
length overall and this recommendation has been closed. The changes made did
not fully align with the requirements applied to work boats and therefore the
recommendation was assessed to be partially accepted.

Sarah Jayne Report number: 13/2013

Fishing vessel (BM 249) Accident date: 11/9/2012
Capsize and foundering 6nm east of Berry Head, Brixham, England with the loss of one
life

№ Recommendation(s) to: Maritime and Coastguard Agency

2013/213 As part of its intended development of new standards for small fishing vessels, review and
include additional design and operational requirements as necessary to ensure that a vessel
engaged in bulk fishing remains seaworthy throughout its intended loading procedure. Specific
hazards that should be addressed include:
• The increased risk of capsize from swamping if freeing ports are closed.
• The risk of downflooding if flush deck scuttles and fish hold hatch covers are opened at
sea.
Appropriate action implemented

▶ 42 ◀
 REPORTS AND RECOMMENDATIONS

Vixen Report number: 16/2013

Passenger ferry Accident date: 19/9/2012
Foundering in Ardlui Marina, Loch Lomond, Scotland

№ Recommendation(s) to: Stirling Council/West Dunbartonshire Council

2013/216 Take action to:

• Establish a boat licensing system for inland waters falling under the Council’s area of
responsibility and which adopts the Inland Waters Small Passenger Boat Code as the
standard applied for small passenger boats carrying fewer than 12 passengers on its
categorised waters.
• Require such boats to be regularly surveyed by a competent person employed by a
Certifying Authority or similar organisation as may be recommended by the Maritime and
Coastguard Agency.

Stirling Council: Rejected

West Dunbartonshire Council: Appropriate action implemented

MAIB comment: It is disappointing that after several years of correspondence with Stirling Council they
have not been able to implement this recommendation.

▶ 43 ◀
 REPORTS AND RECOMMENDATIONS

2012 to 2010 Recommendations - Progress Report

There are no outstanding recommendations for 2012, 2011 and 2010.

2009 Recommendations - Progress Report*

*Status as of 13 May 2022

Celtic Pioneer Report number: 11/2009

RIB Accident date: 26/8/2008
Injury to a passenger during a boat trip in the Bristol Channel, England

№ Recommendation(s) to: Maritime and Coastguard Agency

2009/126 Review and revise the deck manning and qualification requirements of the 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.
Appropriate action planned: 1 January 2023

Abigail H Report number: 15/2009

Grab hopper dredger Accident date: 2/11/2008
Flooding and foundering in the Port of Heysham, England

№ Recommendation(s) to: Maritime and Coastguard Agency

2009/141 Introduce a mandatory requirement, for all vessels greater than 24m length and less than 500
gross tons, for the fitting of bilge alarms in engine 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.
Appropriate action implemented

▶ 44 ◀
 REPORTS AND RECOMMENDATIONS

2008 Recommendations - Progress Report*

*Status as of 13 May 2022

Fishing Vessel Safety Study

Analysis of UK Fishing Vessel Safety 1992 to 2006

№ Recommendation(s) to: Maritime and Coastguard Agency

2008/173 In developing its plan to address the unacceptably high fatality rate in the fishing industry,
identified in its study of statistics for the years 1996 to 2005, in addition to delivering the actions
outlined at 6.2, the MCA is recommended to consider the findings of this safety study, and in
particular to:
• Clarify the requirement for risk assessments to include risks which imperil the vessel such
as: environmental hazards; condition of the vessel; stability etc.
• Work towards progressively aligning the requirements of the Small Fishing Vessel Code,
with the higher safety standards applicable under the Workboat Code.
• Clarify the requirements of The Merchant Shipping and Fishing Vessels (Health and Safety
at Work) Regulations 1997 to ensure that they apply in respect of all fishermen on board
fishing vessels, irrespective of their contractual status.
• Ensure that the current mandatory training requirements for fishermen are strictly
applied.
• Introduce a requirement for under 15m vessels to carry EPIRBs.
• Review international safety initiatives and transfer best practice to the UK fishing industry
with particular reference to the use of PFDs and Personal Locator Beacons.
• Conduct research on the apparent improvement in safety in other hazardous industry
sectors, such as agriculture, construction and offshore, with the objective of identifying
and transferring best safety practice from those industries to the fishing industry.

Appropriate action implemented

MAIB comment: Following the latest revision of the Code of Practice for the Safety of Small Fishing
Vessels of Less Than 15m Length Overall, this key fishing vessel safety recommendation
is considered to be closed.

▶ 45 ◀
 UK VESSELS: ACCIDENTS INVOLVING LOSS OF LIFE

PART 3: STATISTICS
For details of reporting requirements and terms used in this section please see the annex - Statistics
Coverage on page 67 and the glossary on page 72.

Table 1: Loss of life in 2021 reported to the MAIB

Date Name of vessel Type of vessel Location Accident description

Merchant vessels 100gt and over

None reported to the MAIB in 2021

Merchant vessels under 100gt (including commercial recreational)

River Cleddau, near Organised stand-up paddleboard group

30 Oct Paddleboards Other craft
Haverfordwest, Wales crossed a weir, resulting in four fatalities.

Fishing vessels

Colwyn Bay, North Foundering of vessel, with the loss of three

28 Jan Nicola Faith (BS 58) Whelk potter
Wales lives.
55nm south-west of the Derrick collapsed, resulting in one injury and
6 Feb Cornishman (PZ 512) Beam trawler
Isles of Scilly one fatality.
30nm south-east of the
18 Feb Copious (LK985) Stern trawler Person overboard, resulting in one fatality.
Shetland Islands
East of Torness Point, Person overboard while hauling pots,
2 May Saint Peter (LH22) Potter
Scotland resulting in one fatality.
Sound of Rùm, Fall overboard while trying to recover another
24 Jun Reul A Chuain (OB915) Prawn trawler
Scotland person in the water.
South-east of Hastings,
29 Jul Pioneer (NN200) Potter Person overboard, resulting in one fatality.
Scotland
West of Fast Castle
28 Aug Harriet J (AH180) Potter Head, south-east Person overboard, resulting in one fatality.
Scotland
Near Inverallochy, Vessel found capsized and its lone crew
16 Oct Goodway (FR23) Potter
Scotland member remains missing.

Recreational craft (excluding commercial recreational)

Capsized sit-on kayak trapped paddler on a

22 Mar - Kayak River Tweed, Scotland white water section of a river, resulting in one
fatality.
Collision between an inflatable dinghy and
Inflatable Inish viaduct, upper a jet ski. The occupant of the dinghy was
3 Apr Honwave
dinghy Lough Erne, Scotland recovered from the water and declared
deceased.
Capsized kayak. The occupant was recovered
9 May - Kayak Tywyn, North Wales from the water 30 minutes later and declared
deceased.

▶ 46 ◀
 UK VESSELS: ACCIDENTS INVOLVING LOSS OF LIFE

Date Name of vessel Type of vessel Location Accident description

Recreational craft (excluding commercial recreational) continued
Capsized motor cruiser, resulting in one
1 Jun - Motorboat Firth of Forth, Scotland
fatality.
Off Pagham Harbour,
12 Jun - Kayak Capsized kayak, resulting in one fatality.
West Sussex, England
Swamped and capsized angling vessel,
Near Inverbervie,
21 Aug Cristomy Motorboat resulting in three persons in the water and
Scotland
one loss of life.
Sailboat (aux. Sailing yacht crew member found deceased
19 Oct Athena II Off Bute, Scotland
motor) next to vessel.

Image: Nicola Faith

▶ 47 ◀
 UK MERCHANT VESSELS >= 100gt

Table 2: Merchant vessel total losses

Date Name of vessel Type of vessel loa Casualty event

There were no losses of UK merchant vessels >= 100gt reported to the MAIB in 2021

Table 3: Merchant vessel losses — 2012-2021

Number lost UK fleet size Gross tonnage lost

2012 - 1 450 -

2013 - 1 392 -

2014 - 1 361 -

2015 - 1 385 -

2016 - 1 365 -

2017 - 1 356 -

2018 - 1 332 -

2019 - 929 -

2020 - 1 242 -

2021 - 1 199 -

▶ 48 ◀
 UK MERCHANT VESSELS >= 100gt

Table 4: Merchant vessels in casualties by nature of casualty and vessel category20

Liquid cargo ship Solid cargo ship Passenger ship Service ship Total

Capsizing/listing - - - 1 1

Collision - 5 4 4 13

Contact - 1 2 1 4

Fire/explosion - - 2 - 2

Grounding - 4 1 10 15

Machinery 1 3 2 7 13

Total 1 13 11 23 4821

Table 5: Deaths and injuries to merchant vessel crew — 2012-2021

Number of crew injured Of which resulted in death

2012 186 3

2013 134 1

2014 142 -

2015 141 2

2016 133 2

2017 153 -

2018 114 -

2019 105 3

2020 78 -

2021 74 -

20 Vessel groups include vessels operating on inland waterways.

21 48 casualties represents a rate of 40 casualties per 1 000 vessels on the UK Fleet.

▶ 49 ◀
 UK MERCHANT VESSELS >= 100gt

Table 6: Deaths and injuries of merchant vessel crew by rank

Rank/specialism Number of crew

Officer, deck 12

Officer, engineering 10

Chief mate 1

Assistant/cadet 1

Rating, deck 17

Rating, engine 12

Rating, electro-technical 1

Hotel service staff 7

Other crew member 13

Total 74

Officer, deck: 12
Other crew member: 13

Hotel service staff: 7

Officer, engineering: 10

Rating, electro-technical: 1
Chief mate: 1

Assistant/cadet: 1

Rating, engine: 12

Rating, deck: 17

Chart 6

▶ 50 ◀
 UK MERCHANT VESSELS >= 100gt

Table 7: Deaths and injuries of merchant vessel crew by place

Number Number Number

Place of crew Place of crew Place of crew

Accommodation Cargo and tank areas Ship

Alleyway 1 Cargo hold 1 Deck 22

Bathroom, shower, toilet 2 Open deck cargo space 1 Stairs/ladders 5

Cabin space – crew 1 Ro-ro vehicle deck ramp 2 Other 6

Galley spaces 7 Engine department Other

Mess room, dayroom 1 Engine room 12 Over side 1

Stairway/ladders 3 Auxiliary engine room 2 Unknown 3

Other 3 Boiler room 1 Total 74

Other: 4

Accommodation: 18

Cargo and tank areas: 4

Ship: 33

Engine department: 15

Chart 7

▶ 51 ◀
 UK MERCHANT VESSELS >= 100gt

Table 8: Deaths and injuries of merchant vessel crew by part of body injured

Number
Part of body injured of crew

Whole body and multiple sites

Multiple sites of the body affected 5

Head 12.2%
6.8%
Head
Whole body and
Eye(s) 2 Neck 1.4%
multiple sites

Facial area 2

Head, brain and cranial nerves and vessels 3 14.9%

Head, multiple sites affected 2 41.9% Back

Neck
Upper limbs
Neck, inclusive spine and vertebra in the
1
neck

Upper limbs
4.1%
Finger(s) 8
Torso and
Hand 7 organs

Wrist 3

Arm, including elbow 7

Shoulder and shoulder joints 6 18.9%

Back Lower limbs

Back, including spine and vertebrae in the

11
back

Torso and organs

Chest area, including organs 1

Note: Percentages may not add up to 100% due to rounding
Rib cage, ribs including joints and shoulder
1
blade
Chart 8
Pelvic and abdominal area including organs 1

Lower limbs

Foot 6

Ankle 3

Leg, including knee 4

Hip and hip joint 1

Total 74

▶ 52 ◀
 UK MERCHANT VESSELS >= 100gt

Table 9: Deaths and injuries of merchant vessel crew by deviation*

Number
Deviation* of crew

Lifting, carrying, standing up 3

Pushing, pulling 6
Body movement under or with physical
stress (generally leading to an internal Putting down, bending down 3
injury)
Treading badly, twisting leg or ankle, slipping without falling 4

Other 4

Body movement without any physical Being caught or carried away, by something or by momentum 13
stress (generally leading to an external
injury) Uncoordinated movements, spurious or untimely actions 5

Breakage of material – at joint, at seams 1

Breakage, bursting, splitting, slipping,
fall, collapse of Material Agent Breakage, bursting – causing splinters (wood, glass, metal, stone,
1
plastic, others)
Deviation* by overflow, overturn, leak,
Liquid state – leaking, oozing, flowing, splashing, spraying 1
flow, vaporisation, emission

Electrical problem – leading to direct contact 1

Deviation due to electrical problems,
explosion, fire Fire, flare up 1

Loss of control (total or partial) of Of object (being carried, moved, handled, etc.) 1
machine, means of transport or
handling equipment, handheld tool, Of hand-held tool (motorised or not) or of the material being worked
2
object, animal by the tool

Fall of person – to a lower level 18

Slipping – stumbling and falling – fall of
Fall overboard of person 1
persons
Slipping – Stumbling and falling - Fall of person – on the same level 9

Total 74

*See "Terms" on page 73

▶ 53 ◀
 UK MERCHANT VESSELS >= 100gt

Chart 9: Deaths and injuries of merchant vessel crew by deviation*

2020 2021
0 10 20 30 40

Body movement under/with physical 17

stress 20

Body movement without physical 13

stress 18

Breakage, bursting, splitting, slipping, 0

fall, collapse of Material Agent* 2

Deviation* by overflow, overturn, leak, 2

flow, vapourisation, emission 1

Deviation* due to electrical problems, 0

explosion, fire 2

7
Loss of control
3

38
Slipping, stumbling and falling
28

1
Other
0

*See "Terms" on page 73

▶ 54 ◀
 UK MERCHANT VESSELS >= 100gt

Table 10: Deaths and injuries of merchant vessel crew by type of injury

Number
Main injury of crew

Closed fractures 27
Bone fractures
Open fractures 1

Burns, scalds and frostbites Burns and scalds (thermal) 4

Concussion and internal Concussion and intracranial injuries 4

injuries
Internal injuries 4

Dislocations, sprains and Dislocations and subluxations* 3

strains Sprains and strains 15

Wounds and superficial Open wounds 7

injuries* Superficial injuries* 4

Traumatic amputations (loss of body parts) 1

Multiple injuries 3

Unknown or unspecified 1

Total 74

*See "Terms" on page 73

▶ 55 ◀
 UK MERCHANT VESSELS >= 100gt

Table 11: Deaths and injuries to passengers — 2012-2021

Number of injured passengers Of which resulted in death

2012 50 -

2013 46 -

2014 56 1

2015 55 1

2016 51 1

2017 26 -

2018 81 -

2019 107 -

2020 25 -

2021 23 -

Table 12: Deaths and injuries of passengers by type of injury

Main injury Number of passengers

Bone fractures Closed fractures 21

Traumatic amputations (loss of body parts) 1

Wounds and superficial injuries Open wounds 1

Total 23

▶ 56 ◀
 UK MERCHANT VESSELS < 100gt

Table 13: Merchant vessels < 100gt — total losses

Date Name of vessel Type of vessel loa Casualty event

3 Oct Still Dawn* Motorboat 4.80m Foundering

11 Aug Reine d'Azur Motorboat 29.00m Fire

6 Jul Bella Research 5.62m Flooding

*Constructive total loss

Table 14: Merchant vessels < 100gt by nature of casualty and vessel category
Recreational craft | Power
Inland waterways vessel |

Recreational craft | Other

Service ship | Search and

Recreational craft | Sail

Service ship | Offshore

Service ship | Other

Rescue (SAR) craft

(towing/pushing)
Service ship | Tug
Passenger ship
Worksite craft

Total
Capsizing/listing 1 - 1 - - - 2 - 1 5

Collision - 4 8 3 - 1 6 2 5 29

Contact - - 2 - - 1 3 - 2 8

Fire/explosion 1 - 2 - - - 1 - 1 5

Flooding/foundering - - 1 - - - - - 3 4

Grounding - 2 13 11 - 2 20 - 2 50

Hull failure - 1 - - - - - - - 1

Machinery - 6 3 2 - - 9 1 4 25

Total per vessel

type 2 13 30 16 - 4 41 3 18 127

Deaths - - - - 4 - - - - 4

Injuries 2 3 13 3 - 1 4 4 5 35

▶ 57 ◀
 UK FISHING VESSELS

There were 5 378 UK registered fishing vessels at the end of 2021. During 2021, 89 casualties to vessels
involving these vessels were reported to the MAIB. Figures in the following tables show casualties to vessels
and injuries to crew involving UK registered vessels that were reported to the MAIB in 2021.
Six fishing vessels were reported lost (0.11% of the total fleet) and there were 10 fatalities to crew.

Table 15: Fishing vessel total losses by vessel length

Date Name of vessel Age Gross tonnage Casualty event

Under 15m length overall (loa)

28 Jan Nicola Faith* 34 8.89 Capsizing

18 Jun Angelena 33 19.38 Capsizing

26 Jul Freedom* 23 3.48 Foundering

14 Oct Dunan Star 42 13.64 Grounding

16 Oct Goodway* 17 1.64 Capsizing

30 Nov Ciara Naoimh 31 3.51 Foundering

15m length overall - under 24m registered length (reg)

There were no losses reported to the MAIB in 2021

Over 24m registered length (reg)

There were no losses reported to the MAIB in 2021

*Constructive total loss

▶ 58 ◀
 UK FISHING VESSELS

Table 16: Fishing vessel losses — 2012-2021

Under 15m loa 15m loa to <24m reg 24m reg and over Total lost UK registered % lost

2012 5 4 - 9 5 834 0.15

2013 15 3 - 18 5 774 0.31

2014 9 3 - 12 5 715 0.21

2015 8 5 - 13 5 746 0.23

2016 5 2 1 8 5 745 0.14

2017 5 1 - 6 5 700 0.11

2018 8 - - 8 5 603 0.14

2019 2 2 1 5 5 484 0.09

2020 7 1 - 8 5 443 0.15

2021 6 - - 6 5 378 0.11

Table 17: Fishing vessels in casualties — by nature of casualty

Incident rate
Number of per 1 000 vessels at risk
vessels involved (to one decimal place22)

Capsizing/listing 4 0.7

Collision 5 0.9

Contact 2 0.4

Fire/explosion 3 0.6

Flooding/foundering 9 1.7

Grounding 18 3.3

Machinery 49 9.1

Total 90 16.7

22 Rates may not add up due to rounding.

▶ 59 ◀
 UK FISHING VESSELS

Table 18: Fishing vessels in casualties — by nature of casualty and by length range

Number of vessels involved Incident rate per 1 000 vessels at risk (to one decimal place23)

Under 15m length overall (loa) — vessels at risk: 4  845

Capsizing/listing 3 0.6

Collision 4 0.8

Contact 2 0.4

Fire/explosion 2 0.4

Flooding/foundering 4 0.8

Grounding 12 2.5

Machinery 38 7.8

Total under 15m 65 13.4

15m loa - 24m registered length (reg) — vessels at risk: 410

Capsizing/listing 1 2.4

Collision 1 2.4

Fire/explosion 1 2.4

Flooding/foundering 5 12.2

Grounding 5 12.2

Machinery 6 14.6

Total 15m to 24m 19 46.3

24m reg and over — vessels at risk: 123

Grounding 1 8.1

Machinery 5 40.7

Total 24m or more 6 48.8

Fleet total24 90 16.7

23 Rates may not add up due to rounding

24 Total number of UK registered fishing vessels: 5 378

▶ 60 ◀
 UK FISHING VESSELS

Table 19: Deaths and injuries to fishing vessel crew by type of injury

Number
Main injury of crew

Drowning and non-fatal

8
Drowning and asphyxiation submersions

Asphyxiation 2

Traumatic amputations (loss of body parts) 3

Closed fractures 8
Bone fractures
Open fractures 1

Concussion and intracranial

Concussions and internal 2
injuries
injuries
Internal injuries 4

Dislocations and subluxations 1

Dislocations, sprains and
strains
Sprains and strains 1

Wounds and superficial*

Open wounds 5
injuries

Multiple injuries 1

Total 36

*See "Terms" on page 73

Multiple injuries: 1

Wounds and superficial injuries: 5

Drowning and asphyxiation: 10

Dislocations, sprains and strains: 2

Concussions and internal injuries: 6 Traumatic amputations: 3

Bone fractures: 9 Chart 10

▶ 61 ◀
 UK FISHING VESSELS

Table 20: Deaths and injuries to fishing vessel crew by part of body injured

Number
Part of body injured of crew

Whole body and multiple sites

Head 11.1%
Whole body (systemic effects) 9 25.0%
Head Whole body and
Neck 2.8%
multiple sites
Facial area 1

Head, brain and cranial nerves and vessels 3

Neck
36.1% 11.1%

Back
Neck, inclusive spine and vertebra in the neck 1 Upper limbs

Upper limbs

Finger(s) 5

Hand 2 2.8%

Torso and
Wrist 2 organs 2.8%

Not specified
Arm, including elbow 4

Back
8.3%
Back, including spine and vertebrae in the
3 Lower limbs
back

Back, other parts not mentioned above 1

Torso and organs

Chest area including organs 1

Lower limbs
Note: Percentages may not add up to 100% due to rounding
Leg, including knee 2
Chart 11
Ankle 1

Other

Not specified 1

Total 36

▶ 62 ◀
 UK FISHING VESSELS

Table 21: Deaths and injuries of fishing vessel crew by deviation*

Number
Deviation* of crew

Body movement under or with physical Treading badly, twisting leg or ankle, slipping without falling 1
stress (generally leading to an internal
injury) Other 2

Body movement without

any physical stress (generally leading to Being caught or carried away, by something or by momentum 14
an external injury)

Of means of transport or handling equipment (motorised or not) 2

Of object (being carried, moved, handled, etc.) 1

Loss of control (total or partial) Of hand-held tool (motorised or not) or of the material being worked
4
by the tool

Other 1

Fall of person – to a lower level 1

Slipping - stumbling and falling – fall of
persons
Fall overboard of person 10

Total 36

*See "Terms" on page 73

▶ 63 ◀
 UK FISHING VESSELS

Chart 12: Deaths and injuries of fishing vessel crew by deviation*

2020 2021
0 2 4 6 8 10 12 14 16

Body movement under/with physical 6

stress 3

8
Body movement without physical stress
14

Breakage, bursting, splitting, slipping, 0

fall, collapse of Material Agent* 0

Deviation* by overflow, overturn, leak, 1

flow, vapourisation, emission 0

Deviation due to electrical problems, 2

explosion, fire 0

9
Loss of control
8

11
Slipping, stumbling and falling
11

0
Other
0

1
No information
0

*See "Terms" on page 73

▶ 64 ◀
 UK FISHING VESSELS

Table 22: Deaths and injuries to fishing vessel crew by vessel length (of which, deaths
shown in brackets) 2012-2021

15m loa - under

Under 15m loa 24m reg 24m reg and over Total
2012 21 (4) 22 (2) 7 - 50 (6)
2013 13 (3) 13 (1) 7 - 33 (4)
2014 22 (5) 14 (3) 10 - 46 (8)
2015 10 (4) 17 (1) 8 (2) 35 (7)
2016 16 (7) 19 (2) 5 - 40 (9)
2017 13 (3) 8 (2) 11 - 32 (5)
2018 14 (4) 18 (1) 6 (1) 38 (6)
2019 12 (3) 18 (1) 6 (1) 36 (5)
2020 12 (2) 16 - 10 - 38 (2)

2021 12 (7) 19 (2) 5 (1) 36 (10)

Chart 13: Deaths and injuries to fishing vessel crew by year

60
Number of fishing vessel crew

50
6
8
40 2
9 6 5
30 4 7 10
5

20

10

0
2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

Injuries Of which resulted in death

▶ 65 ◀
 NON-UK COMMERCIAL VESSELS

Table 23: All non-UK commercial vessels total losses in UK waters

Date Name of vessel Type of vessel Flag loa Casualty event

24 Nov Migrant vessel Motorboat None 5m Capsizing

Table 24: All non-UK commercial vessels in UK waters — by vessel type and
by nature of casualty

Solid cargo Liquid cargo Passenger Service Fishing Recreational

ship ship ship ship vessel commercial Total

Capsizing/listing - - - - - 1 1

Collision 17 - - 5 - 2 24

Contact 5 1 - 1 - - 7

Fire/explosion 5 - - - - - 5

Grounding 10 3 1 1 - - 15

Machinery 10 4 2 2 1 - 19

Total per vessel type 47 8 3 9 1 3 71

Deaths 1 - - - - 27 28
Injuries 17 6 13 2 1 - 39

▶ 66 ◀
 ANNEXES, GLOSSARY AND FURTHER INFORMATION

ANNEX A - STATISTICS COVERAGE

1. Data is presented by the year in which the incident was reported to the MAIB. Historic data tables
contain information from the past 10 years.
2. Not all historical data can be found in this report. Further data is contained in previous MAIB Annual
Reports.
3. United Kingdom ships are required by the Merchant Shipping (Accident Reporting and Investigation)
Regulations 201225 to report accidents to the MAIB.
4. Accidents are defined as being Marine Casualties or Marine Incidents, depending on the type of
event(s) and the results of the event(s). See Casualty definitions (see Annex B on page 68) or MAIB’s
Regulations for more information.
5. Details of vessel types and groups used in this Annual Report can be found in Annex B - supporting
information on page 71.
6. 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 notified to us by
bodies such as HM Coastguard.
7. The Maritime and Coastguard Agency, harbour authorities and inland waterway authorities have a duty
to report accidents to the MAIB.
8. In addition to the above, the MAIB monitors news and other information sources for relevant accidents.

25 https://www.gov.uk/government/organisations/marine-accident-investigation-branch/about#regulations-and-guidance

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ANNEX B - SUPPORTING INFORMATION

Casualty definitions used by the UK MAIB - from 2012

Marine Casualty26
An event or sequence of events that has resulted in any of the following and has occurred directly by or in
connection with the operation of a ship:
• the death of, or serious injury to, a person;
• the loss of a person from a ship;
• the loss, presumed loss or abandonment of a ship;
• material damage to a ship;
• the stranding or disabling of a ship, or the involvement of a ship in a collision;
• material damage to marine infrastructure external of a ship, that could seriously endanger the safety
of the ship, another ship or any individual;
• pollution, or the potential for such pollution to the environment caused by damage to a ship or ships.
A Marine Casualty does not include a deliberate act or omission, with the intention to cause harm to the
safety of a ship, an individual or the environment.
Each Marine Casualty is categorised as ONE of the following:
Very Serious Marine Casualty (VSMC) – A Marine Casualty which involves total loss of the ship, loss of
life, or severe pollution.
Serious Marine Casualty (SMC) – A Marine Casualty where an event results in one of:
• immobilisation of main engines, extensive accommodation damage, severe structural damage, such
as penetration of the hull underwater, etc., rendering the ship unfit to proceed;
• pollution;
• a breakdown necessitating towage or shore assistance.
Less Serious Marine Casualty (LSMC) – This term is used by MAIB to describe any Marine Casualty that
does not qualify as a VSMC or a SMC.

Marine Incident (MI)

A Marine Incident is an event or sequence of events other than those listed above which has occurred
directly in connection with the operation of a ship that endangered, or if not corrected would endanger the
safety of a ship, its occupants or any other person or the environment (e.g. close quarters situations are
Marine Incidents).

Accident
Under current Regulations6 Accident means any Marine Casualty or Marine Incident. In historic data,
Accident had a specific meaning, broadly equivalent to (but not identical to) Marine Casualty.

Operation of a ship
To qualify as a Marine Casualty an event/injury etc must be in connection with the operation of the ship on
which it occurs. MAIB’s interpretation of this includes any “normal” activities which take place on board the
vessel (e.g. a chef who cuts himself while preparing food is considered in connection with the operation of
the ship).

26 https://www.legislation.gov.uk/uksi/2012/1743/regulation/3

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 ANNEXES, GLOSSARY AND FURTHER INFORMATION

Changes to UK MAIB Casualty Event Definitions - with introduction of EU Directive 2009/18/

EC (the Directive).

Collisions/Contacts – Until 2012 the UK defined a collision as a vessel making contact with another vessel
that was subject to the collision regulations, after 2012 a collision is any contact between two vessels, i.e.
Until 2012
Collision - vessel hits another vessel that is underway, floating freely or is anchored.
Contact - vessel hits an object that is not subject to the collision regulations e.g. buoy, post, dock, floating
logs, containers etc. Also another ship if it is tied up alongside. In order to qualify as the equivalent of a
Marine Casualty the contact must have resulted in damage.
From 2013
Collision - a casualty caused by ships striking or being struck by another ship, regardless of whether the
ships are underway, anchored or moored.
This type of casualty event does not include ships striking underwater wrecks. The collision can be with
other ship or with multiple ships or ship not underway.
Contact - a casualty caused by ships striking or being struck by an external object. The objects can be:
floating object (cargo, ice, other or unknown); fixed object, but not the sea bottom; or flying object.
Injury - The UK currently continues to follow the EU requirement that injuries are reported if they are
“3 day” injuries. This is described in more detail in section 4.2 of the European Statistics on Accidents at
Work (ESAW) Summary methodology27 (Note that in this context the term “Accident” means an injury.)
“Accidents at work with more than three calendar days’ absence from work. Only full calendar days of
absence from work have to be considered, excluding the day of the accident. Consequently, ‘more than
three calendar days’ means ‘at least four calendar days’, which implies that only if the victim resumes
work on the fifth (or subsequent) working day after the date on which the accident occurred should the
incident be included.”
UK injury data also includes “serious” injuries. In addition to “3 day” injuries these are:
• 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;
• any other injury
◦ leading to hypothermia or unconsciousness,
◦ requires resuscitation, or
◦ requiring admittance to a hospital or other medical facility as an inpatient for more than 24 hours;
In the IMO Casualty Investigation Code28 (section 2.18) Serious injury means an injury which is sustained
by a person in a casualty resulting in incapacitation for more than 72 hours commencing within seven days
from the date of injury.
Due to the special working conditions of seafarers, injuries to seafarers while on board a vessel off-duty are
considered to be occupational accidents in MAIB Annual Reports29.

27 http://ec.europa.eu/eurostat/en/web/products-manuals-and-guidelines/-/KS-RA-12-102
28 https://wwwcdn.imo.org/localresources/en/OurWork/MSAS/Documents/Res.MSC.255(84)CasualtyIinvestigationCode.pdf (page 9, 2.18)
29 http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:91:0::NO::P91_SECTION:MLC_A4 (Article II 1.(f) & Standard A4.3)

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 ANNEXES, GLOSSARY AND FURTHER INFORMATION

Machinery failure/Loss of control/Damage to equipment

Until 2012
The UK used the generic term “machinery failure” to describe most mechanical failures that caused
problems to a vessel. In order to be considered the equivalent of a Marine Casualty the vessel needed to
be not under command for a period of more than 12 hours, or the vessel needed assistance to reach port.
From 2013
In MAIB Annual Reports a machinery failure is a Marine Casualty that is either:
• Loss of control – a total or temporary loss of the ability to operate or manoeuvre the ship, failure of
electric power, or to contain on board cargo or other substances:
◦ Loss of electrical power – the loss of the electrical supply to the ship or facility;
◦ Loss of propulsion power – the loss of propulsion because of machinery failure;
◦ Loss of directional control – the loss of the ability to steer the ship;
◦ Loss of containment – an accidental spill or damage or loss of cargo or other substances carried on
board a ship.
or,
• Damage to equipment – damage to equipment, system or the ship not covered by any of the other
casualty types.
Grounding/Stranding
Until 2012
Grounding means making involuntary contact with the ground, except for touching briefly so that no
damage is caused.
From 2013
Grounding/stranding - a moving navigating ship, either under command, under power, or not under
command, drifting, striking the sea bottom, shore or underwater wrecks.

Persons overboard
Until 2012
Any fall overboard from a ship or ship's boat was the equivalent of a Marine Casualty.
From 2013
Any fall overboard from a ship or ship's boat (that does not result in injury or fatality) is a Marine Incident.

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 ANNEXES, GLOSSARY AND FURTHER INFORMATION

Vessel categories used in MAIB Annual Report statistics from 2013 to date

Merchant vessels >=100gt

Trading and non-trading vessels of 100 gross tonnage (gt) or more (excluding fish processing and catching).
Note that this category includes vessel types such as inland waterway vessels and vessels on government
service that are specifically excluded from the scope of the Directive12. It excludes Royal Navy vessels and
platforms and rigs that are in place.

Merchant vessels <100gt

Vessels of under 100gt known, or believed to be, operated commercially (excluding fish processing and
catching).

Commercial recreational
May be a subset of either of the above two entries. Those over 100gt may, for instance, be a tall ship or
luxury yacht. Those under 100gt may be a chartered yacht or a rented dinghy.

UK fishing vessels
Commercial fishing vessels registered with the UK Maritime and Coastguard Agency’s Registry of Shipping
and Seamen. Note that this category includes under 15 metre fishing vessels that are specifically excluded
from the scope of the Directive.

Passenger
In addition to seagoing passenger vessels this category also includes inland waterway vessels operating on
inland waters.

Service ship
Includes, but not limited to, dredgers, offshore industry related vessels, tugs and SAR craft.

SAR craft
Until 2012 the MAIB considered SAR craft to be non-commercial. From 2013 onwards they are considered
commercial.

Recreational craft
Recreational craft may be commercial or non-commercial. In the statistics section of each Annual Report
only “Table 1: Loss of life…” includes non-commercial recreational craft.

Non-UK vessels in UK waters

Vessels that are not known, or believed to be, UK vessels, and the events took place in UK territorial waters
(12 mile limit).

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 ANNEXES, GLOSSARY AND FURTHER INFORMATION

GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS

Abbreviations and Acronyms

circ. - circular
CO2 - carbon dioxide
COLREGs - International Regulations for Preventing Collisions at Sea, 1972, as amended
ECDIS - Electronic Chart Display and Information System
EPIRB - Emergency Position Indicating Radio Beacon
ESAW - European Statistics on Accidents at Work
EU - European Union
GRP - glass reinforced plastic
gt - gross tonnage
HMPE - high modulus polyethylene
IBC Code - International Code for the Construction and Equipment of Ships Carrying Dangerous
Chemicals in Bulk
ICS - International Chamber of Shipping
IMO - International Maritime Organization
IMSBC Code - International Maritime Solid Bulk Cargoes Code
ISO - International Organization for Standardization
loa - length overall
LSMC - Less Serious Marine Casualty
m - metre
MCA - Maritime and Coastguard Agency
MI - Marine Incident
MSC - Maritime Safety Committee
MSN (M&F) - Merchant Shipping Notice (Merchant and Fishing)
OSR - Offshore Special Regulations
PYA - Professional Yachting Association
reg - registered length
RIB - rigid inflatable boat
RNLI - Royal National Lifeboat Institution
ro-ro - roll-on/roll-off
RYA - Royal Yachting Association
SAR - search and rescue
SCV Code - Small Commercial Vessel Code
SMC - Serious Marine Casualty
SMS - safety management system
STCW - International Convention on Standards of Training, Certification and Watchkeeping for
Seafarers 1978, as amended (STCW Convention)
UK - United Kingdom
VSMC - Very Serious Marine Casualty

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Terms

Deviation - The last event differing from the normal working process and leading to an
injury/fatality.
Material agent - A tool, object or instrument.
Subluxation - Incomplete, or partial dislocation.
Superficial injuries - Bruises, abrasions, blisters, etc.
the Directive - EU Directive 2009/18/EC.

FURTHER INFORMATION
Marine Accident Investigation Branch
First Floor, Spring Place
105 Commercial Road
Southampton
SO15 1GH

Email
[email protected]

General enquiries 24 hour accident reporting line

+44 (0)23 8039 5500 +44 (0)23 8023 2527

Press enquiries Press enquiries (out of office hours)

+44 (0)1932 440015 +44 (0)30 0777 7878

Online resources

www.gov.uk/maib https://twitter.com/maibgovuk

www.facebook.com/maib.gov www.youtube.com/user/maibgovuk

www.linkedin.com/company/marine-accident-investigation-branch

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MAIB Annual Report