CASUALTY ANALYSES by benbenzhou

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									                                                    CASUALTY ANALYSES CONSIDERED AND APPROVED BY THE SUB-COMMITTEE
                                               ON FLAG STATE IMPLEMENTATION AT ITS TENTH AND ELEVENTH SESSIONS in 2002 and 2003
    The following analysis is aimed at identifying overall trends or issues of potential concern to the International Maritime Organization. It is based on
casualty reports submitted to IMO. No corroborating data is available and the analysis should not be used for any other purpose.

    The accuracy of the data received by analysts cannot be guaranteed. Where appropriate, reference is made to relevant existing rules and regulations
and codes of practice, IMO resolutions and circulars, and other relevant documents.

Type of Casualty                                                                                                                                                                                                               Page 1
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                              Issues raised
                       Date of
Reporting State        casualty                    Event                                                 Causes                                                                      Human factor
Second ship (if any)
COLLISION              12/12/2000   The bulk carrier was inbound for the                Steerage was lost when the pilot reduced the speed of   To the Associated British Ports :
ABERDEEN
OIL TANKER
                                    Immingham Dock located near Immingham Oil           the bulk carrier.                                       Further highlighting the prohibited area off the IOT on the charts and in sailing directions
BAHAMAS                             Terminal (IOT) where an oil tanker had been         The wind and tidal stream probably induced the swing    for the area.
47274                               berthed. The bulk carrier had secured a tug on      of the bow to port.                                     Monitoring the exclusion zone off the IOT and, if deemed to improve overall safety, to
UNITED KINGDOM
XU CHANG HAI
                                    her bow and another tug was positioned at the       The tug aft was not available to assist before the      incorporate it in navigational bylaws.
BULK CARRIER                        stern, but her tow wire was not connected until     collision.                                              Prescribing specific locations for tugs to meet inbound vessels.
PANAMA                              immediately prior to the collision. The pilot       The language difficulties between the Master and the    Implementing procedures to be followed should tugs not be connected.
18074
                                    reduced the vessel's speed in order to turn off     pilot.                                                  Amending navigational bylaws to clarify whether the 5 knot speed limit refers to speed
                                    the entrance to Immingham Dock as the vessel        The speed limit off the IOT is ambiguous.               through the water, or speed over the ground.
                                    approached the oil terminal. Making 3 knots
                                    through the water, with a 20-knot wind on her                                                               To the Owner of the bulk carrier :
                                    port quarter, and in a strong flood stream. The                                                             Ensure its vessels have a pilot card available containing the information, and in the format,
                                    bulk carrier lost steerage and turned towards                                                               suggested in the ICS Bridge Procedures Guide.
                                    the moored oil tanker. The pilot took corrective                                                            Ensure its masters and navigational watchkeeping officers have an adequate knowledge of
                                    action using helm, engine and the bow tug, but                                                              the English language for safe pilotage operations.
                                    failed to prevent the bulk carrier colliding with
                                    the moored oil tanker.
                                    Both vessels were damaged.
COLLISION              10/04/1998   Bulk carrier AGAWA CANYON was readying              Apparent limit in ship handling skills.                 Need to understand hydrodynamic interaction and squat effect.
AGAWA CANYON
BULK CARRIER
                                    to enter lock, but experiencing manoeuvring         Breach of standard procedures in allowing EMERALD       Need to follow procedures and recognize routine violations.
CANADA                              difficulties, involving stern suction and loss of   STAR to leave lock before bulk carrier secure.          Importance of communications.
16290                               control of bow.                                     Lack of communications between two vessels.             The risk of ‘routine violation’ of procedures becoming accepted.
CANADA
EMERALD STAR
                                    EMERALD STAR moving from lock to pass               Ship’s speed and hydrodynamic interaction.              Better training in hydrodynamic interaction.
CHEMICAL TANKER                     AGAWA CANYON.
CANADA
6262
GROUNDING/STRANDING    30/04/2000   Touching the ground during fairway navigation Probably effect of tide’s current in river’s turning and      Port Authority to review conditions, including tidal conditions, under which vessels enter
AL DEERAH
OIL TANKER
                                    in a river under pilotage.                    alteration course.                                            and depart the port.
KUWAIT                              Damages in 2 bottom and side ballast tanks.
26356
AUSTRALIA
Type of Casualty                                                                                                                                                                                                                 Page 2
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                Issues raised
                       Date of
Reporting State        casualty                    Event                                                 Causes                                                                        Human factor
Second ship (if any)
MACHINERY DAMAGE       26/06/1999   While on a voyage between Firth of Forth and                                                                   The ship was adrift for approximately 18 hours before the towing vessel arrived.
ALANDIA STREAM
OIL TANKER
                                    Merseyside, both in the United Kingdom, the                                                                    The Master, after assessing the situation, felt that there was no danger to the vessel while
BAHAMAS                             main propulsion engine stopped and could not                                                                   adrift and the ship did not enter into a shipping lane or a nearby Area to be Avoided.
49995                               be restarted. The Chief Engineer checked the                                                                   However, the delay in the Company notifying the Flag and Coastal States about the loss of
BAHAMAS
                                    engine and determined that the governor drive                                                                  propulsion was unacceptable.
                                    shaft had broken. Shore assistance was
                                    required to affect the repairs and a towing
                                    vessel was ordered. The vessel was towed to
                                    port where repairs under the cognizance of the
                                    engine manufacturer's representative were
                                    performed.
OTHER                  18/11/1999   Mooring line failure while docking the vessel      Limited docking Pilot visibility due to darkness.           Importance of good communications and feedback to Pilot regarding orders and
ALFA BRITANNIA
OIL TANKER
                                    resulted in injuries, some serious, to four line   Pilot/Master miscommunication specifically with             instructions.
BAHAMAS                             handlers on a line handling boat.                  regard to tending first breast line ashore.                 Ship's personnel should be briefed regarding intended vessel mooring operations.
56115                               No other damage, no deaths or pollution            Language barrier prevented a positive confirmation to       Pilots should seek and receive understandable positive confirmation regarding all orders.
UNITED KINGDOM
                                    occurred.                                          the Pilot regarding his intended mooring plan, orders       Bridge resource management principles should be employed before and during all critical
                                                                                       and instructions.                                           vessel operations.
                                                                                       Winch brake excessively applied and failed to render        Poor communication between the Master and Pilot was amplified by language barrier.
                                                                                       prior to mooring line failure.                              Deck crew likely made an error in determining to make fast the breast line.
CONTACT                09/06/1999   Use of a derrick boom shift to compensate a        Failure to consider free-surface effect.                    Always keep in mind that a liquid list must never be compensated by any movement - the
ALGOBAY
BULK CARRIER
                                    liquid list.                                                                                                   result of which is more list on the other side.
CANADA                              Consequence : 5 wharf lights knocked down.
21891
CANADA




GROUNDING              10/08/2000   On 10 August 2000, the ALGOEAST was                1. The Master, initially, did not interpret the lights he   1. The current exemption for vessels does not require an assessment of the pilotage skills
ALGOEAST
OIL TANKER
                                    upbound in the deep-draught portion of the         saw as those of a vessel crossing ahead and delayed his     of Masters and navigation officers, and the absence of evaluation criteria for pilotage
CANADA                              Amherstburg Channel, Ontario, with a cargo of      helm order to port. Consequently, the vessel made           skills increases the risk of a subjective evaluation and an inaccurate assessment.
8545                                Bunker C for Sarnia, Ontario.                      contact with the bottom.                                    2. The current practice of not evaluating the shipboard personnel in the implementation of
CANADA
                                    Between buoys D56 and D57, the shipping            2. Although most of the navigation personnel had            BRM practices has the potential to compromise the safe navigation of vessels, and there
                                    channel changes direction by 17.5 degrees. At      received BRM training, BRM principles were not              was no formal follow-up evaluation of the training to ensure that BRM principles were
                                    this location, the Master delayed altering         applied on the vessel at the time of the occurrence.        integrated into daily operations.
                                    course to port. The delay resulted in the vessel                                                               3. Use of a cellular telephone to report an accident prevents other vessels from the
                                    making contact with the bottom outside the                                                                     opportunity to take immediate precautionary measures.
                                    deep-draught portion of the channel at 2142                                                                    Human factors:
                                    eastern daylight time. The vessel sustained                                                                    1. When the Master saw two large white lights of a vessel further upstream crossing the
                                    damage to its forepeak and double bottoms. No                                                                  channel, he thought the lights could be a range of which he was unaware.
                                    one was injured and there was no release of                                                                    2. There was no exchange of information concerning the lights by the bridge team
                                    pollutants.                                                                                                    members.
Type of Casualty                                                                                                                                                                                                                    Page 3
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                   Issues raised
                          Date of
Reporting State           casualty                    Event                                                 Causes                                                                        Human factor
Second ship (if any)
GROUNDING/STRANDING       14/10/1998   Before dawn, while proceeding across Long          Contributory causes included : the absence of a bridge     There was no formal BRM environment in place on the bridge of the ALGOLAKE, and
ALGOLAKE
BULK CARRIER
                                       Point Bay, Lake Erie, the ALGOLAKE                 resource management environment (BRM), the fact            the responsibilities of those participating in the navigation of the vessel were neither
CANADA                                 experienced heavy vibration and came to a          that the responsibilities of those participating in the    defined nor clear.
22851                                  stop. The vessel had struck and grounded on        navigation of the vessel were neither defined nor clear,   The interval between position fixes was too large to effectively monitor the vessel's
CANADA
                                       shoals near the Nanticoke Channel. The vessel      and the non-use of all available means to monitor the      progress along her intended track.
                                       was reflotated the next day with the assistance    vessel's progress along her intended track.                As the vessel approached a course-alteration point, the Master and First Mate engaged in a
                                       of a lightering vessel and three tugs.                                                                        conversation not related to the navigation of the vessel.
                                                                                                                                                     The Master did not specifically inform the First Mate that he was briefly assuming
                                                                                                                                                     responsibility for navigation and this was not mutually understood or agreed upon.
                                                                                                                                                     After the 06:15 hrs vessel position plot, no further position fix was plotted until the vessel
                                                                                                                                                     ran aground at 06:50 hrs.
GROUNDING                 05/04/1999   While upbound in St. Mary's River and altering     Turn orders given too late.
ALGONTARIO
BULK CARRIER
                                       course into Middle Neebish Channel, the            Squat and bank suction - retarded the initial rate of turn. Implementation of BRM training not optimized.
CANADA                                 vessel overshot the turn and grounded in the       Speed not reduced sufficiently to account for lower         Division of bridge responsibilites not optimized.
18883                                  adjacent shallower channel.                        than usual water levels.                                    Master took on more workload at a critical point.
CANADA
                                       Extensive damage to bottom plating.                                                                            Alertness of bridge team would have been low (at 0443).


FALL OVERBOARD            25/01/2001   ALMA C was hove to about 55 miles off the          - The port aft beam shoe had landed on deck in an          There should be written procedures instructing crew to keep clear of heavy equipment,
ALMA C
FISHING VESSEL (SIDE-T)
                                       coast of Denmark while the crew were stowing       unstable fashion, with its heaviest part uppermost.        wires, nets etc. when not carrying out a task. All personnel employed at sea should be
UNKNOWN                                the fishing gear on deck at night. As the vessel   - The crewman was unable to swim and was not               able to swim. As he was not wearing a buoyancy aid, his chances of survival were
220                                    rolled, a heavy ‘beam shoe’ which had been         wearing a lifejacket or buoyancy aid.                      significantly reduced.
UNITED KINGDOM
                                       resting against the bulwark, fell inboard. A       - The vessel’s searchlight was not working.
                                       crewmember, moving out of its way, was             - No risk assessment had been carried out by the           Crewman was in a dangerous position yet appeared to be unaware of, or not concentrating
                                       leaning over a towing chain which suddenly         vessel’s owners.                                           on, the situation around him.
                                       tensioned, throwing him over the side as it did
                                       so. Being unable to swim, he could not reach
                                       a lifebuoy thrown to him and drowned. His
                                       body was later recovered on board.
Type of Casualty                                                                                                                                                                                                                     Page 4
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                    Issues raised
                       Date of
Reporting State        casualty                    Event                                                   Causes                                                                          Human factor
Second ship (if any)
OTHER                  12/06/2000   The dry deployment of an inflatable liferaft         Crew and service agent were unable to tell at a glance       Contents of the training manual did not cover the type of suspension hook fitted to the
ARATERE
PASSENGER SHIP
                                    was being overseen by a servicing agent using        whether the hook had been properly un-cocked.                liferaft davits.
BAHAMAS                             a demonstration unit on board a passenger            The on-board training manual showed a suspension             The liferaft servicing agent, while familiar with liferafts, had insufficient knowledge of the
12596                               ferry. The liferaft canister was placed in a         hook having a different indication of the cocked and         ship's suspension hooks to operate them correctly.
NEW ZEALAND
                                    cradle next to one of the vessel's liferaft          un-cocked conditions to the hooks in use.                    Ship's staff appeared to assume the servicing agent's knowledge of liferafts extended to
                                    davits. Its lifting ring was attached to the         The difficulty in initiating inflation caused the            suspension hooks and so allowed him a significant role in the operation.
                                    davit's off-load suspension hook and the             incorrect lanyard to be pulled.
                                    liferaft lifted clear of the cradle and swung
                                    outboard. It proved difficult to initiate
                                    inflation. While attempting to pull the liferaft
                                    inboard to investigate the failure to inflate, the
                                    suspension hook's lanyard was inadvertently
                                    pulled by the agent, so cocking the hook. He
                                    made an effort to un-cock the hook but,
                                    because he was not familiar with the
                                    mechanism, did not recognize that he had been
                                    unsuccessful. The liferaft was eventually
                                    inflated while inboard. Its weight was then
                                    partially taken manually to clear the fishplate
                                    before pushing it clear of the side of the
                                    vessel. At this stage, the suspension hook
                                    opened allowing the liferaft to fall to the
                                    adjacent quay. There were no injuries.
COLLISION              24/01/2000   With the container ship making slight                Inadequate response from the tug Master to the               Regular simulator based training on handling foreseen but infrequent situations would be
ARIAKE
CONTAINER SHIP
                                    headway, and both main engines going astern,         developing situation (human error).                          of great benefit.
UNITED KINGDOM                      the tug secured to the ship's port quarter was       Fatigue may have affected the tug Master's perception,       Shifts longer than 8 hours, especially at night, for duties requiring instant reactions in
37286                               washed in under the ship's stern counter.            judgement and response.                                      emergencies would appear to be inadvisable.
AUSTRALIA
REDCLIFFE
                                    Inadequate response from the tug Master                                                                           Reactions to foreseen but infrequent situations requiring instant response should be
TUG                                 resulted in collision between the ship and the                                                                    practiced frequently.
AUSTRALIA                           tug. Both suffered significant damage.
470
GROUNDING/STRANDING    12/11/1999   The ship was one of four (amongst five), which       - Lack of awareness by the Master of the deteriorating       - The vessel had been poorly maintained and subject to adverse port state control reports.
ARVIN
GENERAL CARGO SHIP
                                    grounded on the same day and in the same             weather conditions and need to prepare to avoid              The owner is directly responsible to ensure that the vessel is seaworthy and that
MALTA                               circumstances, after being at anchor waiting to      possible grounding.                                          documentation on board is valid.
2516                                enter the Port-la-Nouvelle, South of France, to      - The vessel had deballasted to enter the port.              - A continuous means of communication between the vessel at anchor and port Authorities
FRANCE
                                    load grain. Like two of the others, the ship         Consequently the lower drafts of the vessel were             enables better exchange of information to enable timely decisions on what action to take in
                                    landed on beaches adjoining the entrance.            unable to counter the effect of wind and sea.                deteriorating weather conditions.
                                    The vessel arrived the day before the                - The propulsive power of the vessel was insufficient to     - The charterer and shipper have a responsibility to assure that the assigned vessel is
                                    grounding. During the period at anchor the           counter wind and sea.                                        suitable for the voyage and trade intended.
                                    weather deteriorated to windforce E to SE            - Lack of information from the port to Master.
                                    force 11 to 12. Consequently, anchors dragged        - Unsuitability of the vessel to operate in the prescribed   Master awareness of the changing conditions that may affect the safety of the vessel is
                                    and anchor chains broke.                             sea trade area.                                              dependent not only on his experience and competence, but on the support of port
                                                                                                                                                      Authorities and owner to ensure that he has sufficient information to enable him to make
                                                                                                                                                      correct and timely decisions.
Type of Casualty                                                                                                                                                                                                                    Page 5
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                   Issues raised
                        Date of
Reporting State         casualty                    Event                                                  Causes                                                                         Human factor
Second ship (if any)
GROUNDING               02/02/2000   Grounding at full speed on a sandy beach just       Human factor : poor planning, bad bridge team              Training, certification, good documentation, good watchkeeping.
ASIAN PARADE
VEHICLE CARRIER
                                     after sailing from Dublin to Rotterdam.             management, poor navigation.                               Importance of adequate ship's position checking - no report to Master (course made good :
PANAMA                                                                                                                                              161 degrees, leeway track : 151 degrees).
55680
PANAMA




CAPSIZING               28/09/2000   On 28 September 2000, ATLANTIC EAGLE                It was spring tides and the tidal stream was at its        A recommendation for the area to be avoided during certain tidal conditions has been
ATLANTIC EAGLE
RIGID INFLATABLE BOAT
                                     capsized during a “white water” adventure trip      maximum. Hydrodynamic forces in the vicinity of            made.
UNITED KINGDOM                       in confused water in the vicinity of Horse          Horse Rock were consequently strong and                    Certifying Authorities should check that all boats operating under codes of practice have
                                     Rock, between Ramsey Island and the                 unpredictable and too severe for the coxswain to           appropriate risk assessments in place.
UNITED KINGDOM
                                     Pembrokeshire coast. On board were 12               maintain control. The boat does not normally operate in    The RIB operator should take measures to improve the overall safety of its RIB operations.
                                     passengers and 2 crew members.                      the vicinity of Horse Rock when the tidal stream is at     The provision of adequate VHF coverage in the vicinity of Ramsey Sound should be
                                     The boat visited The Bitches and different          its maximum.                                               investigated.
                                     locations around the Ramsey Island. On its
                                     return trip the boat, for further adventure, made                                                              The safety brief to the passengers was conducted in a light-hearted manner and did not
                                     manoeuvres in the turbulent waters in the                                                                      include action to be taken in the event of capsize or falling overboard.
                                     vicinity of Horse Rock.                                                                                        Passengers experienced difficulty in orally inflating their lifejackets in the turbulent water,
                                     She started to surf on the front of a wave                                                                     and wet clothing and heavy footwear reduced buoyancy.
                                     during which she was lifted and overturned.
                                     Under rather dramatic circumstances the
                                     passengers and crew were rescued from the
                                     water by a nearby RIB from the same
                                     company.
                                     Several people were injured with abrasions,
                                     bruising and shock. The engine and electrical
                                     equipment was damaged by water immersion.
                                     Rubber tube and hull were damaged during
                                     recovery.
COLLISION               25/09/2000   As the east bound bulk self-unloader was            The detection of the anchored vessel was hampered by       Need for confirmation of successful communication between bridge team and others on
ATLANTIC HURON
BULK CARRIER
                                     approaching a huge light in a narrow and            its proximity to a large light structure and the light's   board the ship.
CANADA                               shallow channel with a speed of 12 knots, the       RACON signal.                                              Formal training in the use of ECS/ECDIS will maximize the opportunity to detect
22746                                course was altered to starboard for a port-to-      Lack of communications between vessels for                 impending dangers.
CANADA
GRIFFON
                                     port passage with an northwest-bound                situational awareness.                                     Training on successful activation/deactivation of safety critical switches.
ICEBREAKER/BUOYTENDER                approaching vessel. Further course alterations      Breach of navigational rule in keeping as close as was
CANADA                               to starboard were made to provide more sea          practicable to the starboard outer limit of the            Made assumption on confirmation bias :
2212
                                     room. In doing so, the bulk self-unloader           recommended route.                                         The detection of the anchored vessel was exacerbated by assumptions of the watch officer
                                     struck the other vessel which was at anchor         Insufficient understanding of ship's speed and squart      of the bulk self-unloader that no vessel would be at anchor, at that location, at night.
                                     near the light.                                     effect.                                                    The bridge team of the anchored vessel assumed that transiting vessels would take
                                     Both vessels were damaged.                                                                                     appropriate action to avoid coming dangerously close to the anchored vessel.
                                     Four people sustained minor injuries on board
                                     the anchored vessel.
Type of Casualty                                                                                                                                                                                                                  Page 6
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                  Issues raised
                         Date of
Reporting State          casualty                    Event                                                  Causes                                                                       Human factor
Second ship (if any)
FALL OVERBOARD           23/11/2000   ATLANTIC PRINCESS was shooting her nets             The crewman had not properly donned his lifejacket.       Lifejackets must be properly donned and securely fastened.
ATLANTIC PRINCESS
FISHING VESSEL (STERN)
                                      at night in the English Channel when a man          There were no guardrails forward of the stern roller.     Beacon-equipped lifejackets should be worn on fishing vessels when shooting nets.
UNITED KINGDOM                        disappeared overboard.                                                                                        Where practicable, guardrails should be fitted forward of the stern roller.
3229                                  The alarm was promptly raised but, although
UNITED KINGDOM
                                      an accurate position was obtained, he was not                                                                 It is evident that the lifejacket had been carelessly fitted.
                                      recovered. His inflated lifejacket was later                                                                  Crewman was in a dangerous position yet appears to have been unaware of, or not
                                      picked up. There was no witness to exactly                                                                    concentrating on, the situation around him and probably got too close to the moving
                                      what had happened, but it is probable that he                                                                 equipment.
                                      was dragged over the stern by the stern roller
                                      as the nets were paying out.
COLLISION                16/05/2000   Both ships in ballast and at anchor in River        (No information on DANIS KOPER, scope of cable,            Provisions of IACS Equipment (IACS Req. 1981/Rev.4 1999) A1.1 A1.2, refers to design
AZURE
BULK CARRIER
                                      Plate strong wind force 7-9. DANIS KOPER            holding ground, draught etc.).                             of anchoring equipment "for temporary mooring of vessel within a harbour or sheltered
PANAMA                                dragged anchor, colliding with AZURE at             Anchor holding power in strong winds when in ballast. area when the vessel is awaiting berth, tide etc." Based on good holding ground, A1.1.4
35243                                 about 08:40 hrs.                                                                                               "The EN formula for anchoring equipment . . . is based on an assumed current speed of
PANAMA
DANIS KOPER
                                      AZURE sustained damage to stem. DANIS                                                                          2.5m/sec, wind speed of 25m/sec and a scope of chain between 6 and 10".
BULK CARRIER                          KOPER apparently damaged more seriously in                                                                     No information from DANIS KOPER on which to make a detailed assessment. Prime
MALTA                                 way of hold No. 5.                                                                                             facie issues such as anchor watchkeeping, engine readiness, scope of cable etc are issues
13807
                                                                                                                                                     to address.
FIRE                     21/04/2000   A fire broke out in the engine room which was       The source of the oil spraying onto the hot surface was Although there was no evidence as to why one of four studs unscrewed, the possible cause
BADER III
LIVESTOCK CARRIER
                                      caused by lubricating oil spraying onto a hot       due to the loosening and final unscrewing of a stud in     may have been an insufficient tightening torque applied.
BAHAMAS                               surface of the engine, probably the poorly          the lubricating oil duplex filter allowing lubrication oil The protective steel cover fitted around the exhaust manifold was ineffective in preventing
36387                                 insulated and exposed exhaust manifold. Fire        to be blown out of the hole.                               the spraying oil reaching the hot manifold.
BAHAMAS
                                      could eventually be extinguished by activation                                                                 Locking devices were fitted on the studs on completion of repairs to prevent a recurrence.
                                      of CO2 fixed fire fighting system.
                                      No injuries to persons.
GROUNDING                04/02/1999   BALTIC CHAMP dragged her anchor and                 Contributory causes included the prevailing weather   A risk of further damage and oil pollution could have been reduced had a tow been
BALTIC CHAMP
GENERAL CARGO SHIP
                                      grounded off Kirkwall in west-south-westerly        conditions, the close proximity of a leeshore, an undue
                                                                                                                                                prepared immediately after the tug's arrival. This would have required, at that time, either
PANAMA                                winds, gusting between 60 and 70 knots. The         reliance on the Officer of the Watch to detect        the tug's Master agreeing to a towing contract or BALTIC CHAMP's Master agreeing to
1660                                  Master, who was alone on watch, failed to           immediately any drift, an inadequate length of cable  Lloyd's Open Form. Had a coastguard emergency towing vessel (ETV) been available, the
UNITED KINGDOM
                                      detect the vessel drifting astern in sufficient     used to anchor the vessel, and inadequate monitoring  coastguard would have been free to negotiate a towing contract.
                                      time to prevent her grounding. Although             of the vessel's position.                             The Master became increasingly confident that the anchor would not drag during the 10
                                      Lloyd's Open Form was eventually agreed with                                                              hours the vessel remained in position. The Master placed undue reliance on the Officer of
                                      the Master of the anchor handling tug,                                                                    the watch to detect immediately any drift and to take effective action to prevent the vessel
                                      BALTIC CHAMP refloated on the next tide                                                                   grounding.
                                      and her Master manoeuvred her clear before a                                                              The length of cable used to anchor the vessel was inadequate.
                                      tow could be established. Damage was                                                                      The Master failed to detect the vessel drifting in sufficient time to prevent her running
                                      sustained to her hull, but there were no injuries                                                         ashore. The Master had probably become complacent with respect to his monitoring of
                                      and no pollution.                                                                                         the vessel's position.
OTHER/UNKNOWN            10/09/2000   For reasons which have not been discovered,         On board testing of the atmosphere in No. 2 hold      No person should enter a confined space without authorization and then only in
BALTIYSKIY-107
GENERAL CARGO SHIP
                                      an experienced Russian seaman left his work         showed very low levels of oxygen and very high levels accordance with a Code of Safe Practice and use of the IMO Maritime Safety Card.
RUSSIAN FEDERATION                    station on deck on the pretext of going to the      of carbon monoxide. Tests in the U.K. taken two days Even when there is no apparent reason why the enclosed space atmosphere should not be
1926                                  toilet but, instead, he made an unauthorized        later showed oxygen levels as low as 0.7% (normal =   safe, observe the above precautions.
UNITED KINGDOM
                                      entry to No. 2 hold containing sawn wood.           20.8%) and carbon monoxide levels as high as 235      Seafarers are aware that many lives have been lost in enclosed spaces but they illogically
                                      Disturbed covers led to his body being              ppm (normal = 0 to 5 ppm).                            believe that they are somehow immune.
                                      discovered at the bottom of the hatchway            Extensive enquiries and investigations revealed no    IMO has issued Resolution A.864(20) on the dangers.
                                      access to the hold.                                 apparent reason for atmospheric conditions.           Only continual reinforcement of the message by senior management will reduce such
                                      His body was retrieved with the aid of a crew                                                             accidents.
                                      member wearing self-contained breathing
                                      apparatus. The seaman was dead.
Type of Casualty                                                                                                                                                                                                                      Page 7
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                    Issues raised
                        Date of
Reporting State         casualty                    Event                                                  Causes                                                                          Human factor
Second ship (if any)
LISTING                 20/03/2001   A chemical carrier carrying sulphuric acid sank    - Collapse of the No. 9 longitudinal bulkhead and
BALU
CHEMICAL TANKER
                                     in heavy weather storm force 8 to 9. In            involuntary cross transfer of cargo of different specific
MALTA                                response to the emergency two merchant ships       gravities between starboard and port No. 9 tanks.             Vigilance in survey care and maintenance of tank air vents.
5795                                 were diverted to rescue all of the 23 crewmen      - Failure of tank air vent to prevent water ingress into
FRANCE
                                     who were on board. 22 crew members                 ballast tanks as freeboard decreases with list.
                                     abandoned ship using the port and starboard        - Loss of buoyancy, which resulted in the foundering,
                                     lifeboats. The Master abandoned the vessel by      was due to water ingress through deck opening and
                                     liferaft.                                          downflooding thereafter.
                                     In response to a progressive list to starboard
                                     ballast was transferred between No. 8 ballast
                                     tanks but without effect: the list continued to
                                     increase to about 7º.
COLLISION               09/02/2000   - Suspected collision between a crude oil          - Lack of effective lookout on both vessels during 30         - Lack of effective radar and/or visual lookout on one or both vessels is the most common
BARENTS SEA
OIL TANKER
                                     tanker and a pleasure craft of length 4.5 metres   minutes prior to the collision.                               cause of collision between ocean-going ships and small craft.
PANAMA                               in position 33º59’20S, 151º21’49E near S.E.        - The pleasure vessel presented a poor radar target. No       - It is usual radar operating practice to regularly suppress the heading line to check for any
57680                                coast of Australia. No one on the crude oil        radar reflector was fitted.                                   targets that may be obscured. In this case there is a good possibility that the OOW may
AUSTRALIA
SEA WASP
                                     tanker became aware of the collision.              - The heading line on the oil tanker’s radar display may      not have performed this operation.
RECREATIONAL VESSEL                  - There were no injuries or pollution. The         have obscured any radar echo from the pleasure vessel.
AUSTRALIA                            crude oil tanker struck the pleasure craft         - In the prevailing weather conditions, the white             - Proper use of radar does not obviate the need for effective visual lookout.
                                     causing structural damage to the starboard side    topsides of the pleasure craft would have made its            - There may be a need to remind mariners that small craft generally present very poor
                                     of the boat’s cabin, and damage to the             visual detection more difficult.                              radar target even at close range.
                                     windscreen and depth sounder. The crude oil
                                     tanker did not sustain any damage.
GROUNDING/STRANDING     09/06/1999   Whilst proceeding on a harbour cruise in           The Master did not avail himself of all of the ship's aid     The chain of command from the Owners to the Master is tenuous, as there are no Standing
BLUENOSE II
MOTOR POWERED SAILING
                                     Halifax harbour under sail and not under           to navigation; did not use the services of all his officers   Orders provided from the Owner to the Master.
VESSEL                               power, the vessel BLUENOSE II grounded on          to advantage; had not prepared a voyage plan nor              The Master had not prepared a voyage plan, nor a more simple arrangement, to identify
CANADA                               Pleasant Shoal. The weather at the time was        identified leading marks or transit bearings to assist        range marks or transit bearings to assist him in the navigation.
191
CANADA
                                     fair, winds south easterly at 15 to 20 knots and   him in monitoring the progress of the vessel; and was         Neither the Master nor the mates were familiar with the concept of Bridge Resource
                                     visibility was unrestricted. There were 53         distracted by the proximity of passengers and the             Management (BRM).
                                     passengers and a crew of 16, including the         background noise of radio communications.                     The Master did not receive a warning from the Marine Communications and Traffic
                                     Master, on board. The vessel suffered minor        The radios, which were designed to facilitate easy            Services (MCTS) Officer that his vessel was standing into danger.
                                     hull damage. No one was injured and there          communication between the Master and the Engineer,            The Master reserved the responsibility for the navigation of the vessel and
                                     was no pollution.                                  did not function as designed.                                 communications to himself.
                                                                                        All the above factors may have led the Master to lose         The Master did not maximize the use of his officers to assist him in the navigation of the
                                                                                        situational awareness.                                        vessel.
Type of Casualty                                                                                                                                                                                                                   Page 8
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                 Issues raised
                        Date of
Reporting State         casualty                    Event                                                Causes                                                                         Human factor
Second ship (if any)
FAILURE OF WATERTIGHT   27/11/1998   On 27 November 1998, a scallop dragger while       Gap between the hatch covers and at least one of the      Whatever fishing vessels modifications, they should be always officially approved and
DOORS/PORTS/ETC
BRIER MIST
                                     crossing Les Escoumins and Rimouski, almost        scuttles on deck was not weathertight.                    controlled.
FISHING VESSEL                       fully loaded, in bad weather, flooded the hold     Absence of water level detector in the fish hold.         Life rafts should have an hydrostatic release and be in a position of easy launching in
CANADA                               by a gap between the hatch covers. The Master      Pumping problems.                                         emergency situations.
46
CANADA
                                     tried to pump the water out but had pumping        Water on deck.
                                     problems. The water on deck was about              Delay in requiring assistance.                            Too many violations and errors.
                                     300mm. The vessel sunk with five persons on        No control of the modifications and how they could
                                     board. During the summer 1998 some                 have affected negatively the vessel's stability and
                                     modifications were done by the owner: he           buoyancy, although required.
                                     installed a crane and a net drum; he added 42      Inspections did not control the weathertight hatch
                                     ingots of 46 kg each in the bottom; he added       cover.
                                     weight to the scallop drag; removed a box of       The life raft was not used because presumably it sunk
                                     stones from the hold. No inspection was            with the vessel.
                                     required to certify the safety of the              The seamen had not been trained in marine emergency
                                     modifications.                                     duties.
                                     The vessel was not equipped with EPIRB,
                                     although required. The life raft was not found
                                     and presumably it was not equipped with a
                                     hydrostatic release unit.
                                     Consequences: two persons drowned, three are
                                     missing and loss of the vessel.
GROUNDING               02/11/2000   While the vessel was operating along the inner  - Watch Officer was distracted from his duties by the        - The dangers of allowing non-watch standers to attend the bridge particularly when a
BUNGA TERATAI SATU
CONTAINER SHIP
                                     route of the Great Barrier Reef on the west     following: 1) Making a personal telephone call while         vessel is operating in pilotage waters.
MALAYSIA                             coast of Australia, the navigational officer wason watch; 2) The presence of his wife on the bridge;         - The importance of good Bridge Resource Management, teamwork and communications.
21339                                distracted from his duties, missed a planned    and, 3) An unspecified issue related to his children’s       - Illustrates the limitations of a VTS and reiterates that navigators should not overly rely
AUSTRALIA
                                     course change waypoint and ran hard aground     care giver ashore that prompted the phone call.              on VTS for ship routing directions.
                                     on a charted reef at approximately 20 knots.    - Lack of adherence to basic Bridge Resource
                                     No injuries, deaths or pollution resulted.      Management principles.                                       - Deck Officer & his wife isolated themselves on the starboard bridge wing due in part to
                                     Vessel was refloated. Extensive damage was      - Deck Officer’s routine delegation of navigational          the noise of the AB vacuuming the bridge.
                                     done to the ship’s bottom and the reef.         duties to the Able Bodied Seaman on watch including          - High volume of spurious or low level alarms serves to desensitize vessel traffic
                                                                                     position fixing & plotting.                                  operator’s to alert messages and alarms.
                                                                                     - Failure of the Able Bodied Seaman to notify the Deck
                                                                                     Officer of the vessel’s position, the course change and
                                                                                     proximity to danger.
                                                                                     - Vessel Traffic Service (VTS) operator’s attention was
                                                                                     diverted due to high volume of vessel activity &
                                                                                     reacquisition of a lost radar target. This distraction
                                                                                     caused the operator to fail to observe a danger notice or
                                                                                     to observe the developing dangerous situation.
                                                                                     - Traffic Information Module’s design failed to
                                                                                     properly alert VTS operator to a developing dangerous
                                                                                     situation.
WORK-RELATED ACCIDENT   13/03/2000   A fisherman slipped in the fish holds and his   - Working alone with unguarded machinery.                    - Slippery surface, pitching vessel and exposed rotating machinery is an attractive cocktail
C-JOY
FISHING VESSEL
                                     trousers dragged his left foot and leg into the - Exposure of propeller shaft well & hem of his rain         of conditions to increase risk of personal injury.
CANADA                               exposed propeller shaft well damaging his leg   pants getting caught up in the shaft.
15                                   which was amputated after medivac to hospital. - Inability to stop the propeller shaft rotation + the tear   - Warning labels on his garment indicating its resistance to tearing could have raised the
CANADA
                                                                                     resistant fabric of his trousers.                            awareness of the fisherman to the danger of exposing himself to unguarded machinery.
                                                                                     - Delay in medical assistance because, being single          - Working around unguarded machinery without a second person monitoring the activity
                                                                                     handed, nobody knew of the accident.                         raises the risk of increasing the severity of injuries since the propeller shaft rotation could
                                                                                                                                                  have been stopped earlier.
Type of Casualty                                                                                                                                                                                                                     Page 9
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                   Issues raised
                       Date of
Reporting State        casualty                    Event                                                    Causes                                                                        Human factor
Second ship (if any)
EXPLOSION              26/03/1999   The single hull oil product tanker was in ballast     The explosion was most probably caused by the
CAM ETINDE
OIL TANKER
                                    with no cargo on board lying at the anchorage         ignition of pockets of gas in No. 1 Centre Tank by        It is recognised that the explosion resulted from a simple failure to observe established and
BAHAMAS                             of a West African port.                               sparks from grinding work on the catwalk immediately      well documented safety procedures in relation to tank cleaning and hot work. The owners
5549                                An Able Seaman and an Ordinary Seaman                 above an open tank cleaning hatch.                        of the vessel are accordingly recommended to take appropriate measures to ensure that all
BAHAMAS
                                    were employed in cleaning No. 1 Centre Tank;          The grinding work on the catwalk while tank cleaning      established safety procedures, particularly in regard to tank cleaning and hot work, are
                                    at the same time a Deck Fitter and another            was in operation was in contravention of the              strictly observed by crews on their vessels.
                                    Ordinary Seaman were working on the catwalk           procedures laid down in the Safety Manual of the
                                    to repair the rail on the catwalk. The site of this   vessel.
                                    repair was directly above the Butterworth hatch       The risk of carrying out hot work on tankers is
                                    in No. 1 Centre Tank and they were equipped           recognized in the procedures in the Safety Manual
                                    with a grinding machine. This work was                which require that:
                                    ordered by the Chief Officer.                         - Permits are required for all hot work;
                                    An explosion occurred in No. 1 Centre Tank at         - Hot work is not to be carried out while tank cleaning
                                    1345 hours (local time). The two men working          is in progress;
                                    in No. 1 Tank were injured and brought to the         - Procedure for hot work is reviewed by those
                                    deck by 1350 by crew who assembled to assist          concerned before beginning.
                                    in dealing with the incident. The two men who
                                    had been working on the catwalk were also
                                    injured and given assistance. All of the injured
                                    seamen were given first aid and then conveyed
                                    to hospital for medical treatment. Later, the
                                    two men who had been working in the tank
                                    died from their severe burn injuries. The vessel
                                    sustained extensive structural damage.
GROUNDING              13/05/1999   In the morning of 13/05/99, CANADIAN                  The vessel came into contact with the bottom because      The owner had requested that buoys be placed early to facilitate the voyage. The
CANADIAN EMPRESS
PASSENGER SHIP
                                    EMPRESS was upbound in Lynch Channel on               the navigation instruments and the technique used by      Canadian Coast Guard had agreed to the request and three buoys were in position before
CANADA                              Lake Saint-Louis in clear weather. The vessel         navigation personnel did not permit precise navigation    the CANADIAN EMPRESS began her first voyage of the season.
463                                 was under the conduct of the Master, with 48          in the restricted channel. The route and waypoint         The vessel's progress along her intended track was not adequately monitored by regularly
CANADA
                                    passengers and 14 crew on board. Shortly after        features of the DGPS were not used to help monitor the    plotting positions on the chart. Key navigational aids, such as DGPS route and waypoint
                                    the vessel rounded the northern end of Dowker         vessel's progress along her intended track. Also, the     features, were not used to their fullest potential to assist in monitoring the vessel's progress.
                                    Island, on a heading of approximately                 water level was unusually low, leaving little room for
                                    southwest by west, an unusual rumbling sound          error. The elimination of the Madore Point range and
                                    was heard. The various compartments were              the absence of buoy AD-38 contributed in reducing the
                                    verified visually and sounded; there was no           situational awareness of the navigation team.
                                    ingress of water. The vessel's keel coolers on
                                    the starboard side had been damaged beyond
                                    repair.
GROUNDING/STRANDING    09/04/1999   The CAPE ACACIA departed Ridley Island                The CAPE ACACIA struck bottom because of a                1. The Master was not fluent in English, and the pilot misunderstood the Master’s
CAPE ACACIA
BULK CARRIER
                                    Coal Dock, Prince Rupert, British Columbia,           delayed decision on the best course of action after       description of the problem.
PANAMA                              on 9 April 1999. When proceeding towards the          experiencing engine problems. Factors contributing to     2. The period of 10 mns to make the decision to return to anchorage placed the vessel in a
87803                               open sea under the conduct of a pilot, the            the occurrence were:                                      position from which it was unsafe to make the turn to starboard.
CANADA
                                    vessel experienced engine problems, which             1. Poor communication between the Master and the          3. Helm and engine movements, while attempting to turn the vessel around to proceed to
                                    required the engine to be run at a reduced            Pilot, which led to an inadequate appreciation of the     the anchorage, were inappropriate and the subsequent decision to abort that turn and
                                    speed. While attempting to turn the vessel            existing situation.                                       proceed outbound is questionable.
                                    around to proceed to anchorage, she struck            2. The inadequate sharing of information among the        Human factors:
                                    bottom on a shoal south of West Kinahan               bridge team.                                              1. Poor communication between the Master and the Pilot.
                                    Island at 0200 local time. The bottom shell           3. A poor appreciation of the vessel’s manoeuvring        2. Knowledge of the vessel’s position, and deep draught, together with limited
                                    plating forward sustained extensive damage.           characteristics.                                          manoeuvring capabilities in the fully-loaded condition and reduced power, would have
                                    There was no pollution as a result of this                                                                      indicated insufficient sea room for the proposed manoeuvres.
                                    striking and no one was injured.
Type of Casualty                                                                                                                                                                                                              Page 10
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                Issues raised
                       Date of
Reporting State        casualty                    Event                                                 Causes                                                                        Human factor
Second ship (if any)
COLLISION              19/03/2000   In darkness and in fog, container ship CELTIC      CELTIC KING - Over-reliance on ARPA and                     Manning of bridge/wheelhouse in adverse conditions.
CELTIC KING
CONTAINER SHIP
                                    KING collided with the trawler DE BOUNTY.          assumption that fishing vessel would maintain course        Over-reliance on electronic aids.
UNITED KINGDOM                                                                         and speed. Single man bridge operation.                     Speed in fog remains an issue.
4015                                                                                   Loss of radar return in clutter.                            Knowledge of COLREG by fishermen.
UNITED KINGDOM
DE BOUNTY
                                                                                       Excessive speed.                                            Fatigue on ships with reduced crew.
FISHING       SIDE/S                                                                   Fatigue.
BELGIUM                                                                                DE BOUNTY - Knowledge of rules relating to vessels
385
                                                                                       navigating in restricted visibility.
                                                                                       No radar plot kept.
                                                                                       Mate alone on bridge, no sound signals.
                                                                                       Trawling close to the termination of a traffic separation
                                                                                       lane, where particular caution was required.
GROUNDING/STRANDING    23/10/1999   Pilot error resulted in vessel grounding with no   The main cause of the grounding was misguided advice
CEMCON
CEMENT CARRIER
                                    major damage, no pollution and no injuries or      given by the Pilot.                                         Latent unsafe condition created by Port Authorities decision not to properly mark Channel.
BAHAMAS                             deaths.                                            Reduced ambient sunlight condition in evening twilight
3875                                                                                   approach and transit.
BAHAMAS
                                                                                       Uncharted and poorly marked buoys that failed to
                                                                                       conform to a recognized buoyage system.

GROUNDING/STRANDING    08/04/2001   Failure of steering gear while transiting in     Poor voyage planning - Inshore route taken instead of         Importance of developing an appropriate voyage plan for expected conditions and route.
CHERYL C
GENERAL CARGO SHIP
                                    heavy weather led to a loss of vessel control    customary safer offshore route. This resulted in less         Emergency drills and instruction contributed to safe vessel abandonment.
BARBADOS                            and subsequent vessel grounding on a lee shore.  sea room for the vessel to manoeuvre in case of               Specific behavioural antecedents in this case cannot be determined from the information
1636                                Vessel safely abandoned with no injuries, loss   emergency.                                                    found in the casualty report.
BARBADOS
                                    of life and some minor pollution.                Heavy weather.                                                The Master explained that he took the inshore route to avoid (incorrectly so) heavy
                                                                                     Possible contributing factor : prior steering gear failure    weather although that decision discounted the vessel's proximity to a lee shore.
                                                                                     one month before casualty resulted in the overhaul of
                                                                                     both steering gear motors.
STRANDING/GROUNDING    26/03/1997   On the way from Southampton to Belfast, the      CITA's sole Officer of the Watch, had selected a              Organization of work on board on coastal ships.
CITA
GENERAL CARGO SHIP
                                    feeder container ship CITA ran aground on        course to steer that would, unless subsequently               Watchkeeping arrangements during the hours of darkness.
ANTIGUA AND BARBUDA                 26/03/97 off Newfoundland Point (Isles of        changed, lead to her running aground on the Isles of          Use of bridge watch alarm.
3083                                Scilly) while heading westward at 13 knots for Scilly; he fell asleep once he had selected the course to       Sitting accommodation of the Officer of the Watch.
UNITED KINGDOM
                                    the Land's End Traffic Separation Scheme.        steer.                                                        Securing of containers.
                                    The ship was declared a total loss, the          The bridge watch alarm was not on.
                                    containers were scattered and out of 145 only    No written instructions from the Owner concerning
0
                                    90 were recovered.                               watchkeeping arrangements.
                                                                                     Inadequate securing of the containers.
GROUNDING              21/07/2000   COASTAL BAY was on passage from Dublin The ship's Manager did not provide the Master with                      The Chief Officer was fatigued due to a lack of rest. He was alone on the bridge. The
COASTAL BAY
GENERAL CARGO SHIP
                                    to Liverpool. Her planned route was via The      written instructions regarding watchkeeping                   bridge watch alarm was not in use.
ANTIGUA AND BARBUDA                 Skerries Traffic Separation Scheme (TSS).        arrangements and minimum rest periods, the                    Neither Master nor Chief Officer was able to take adequate rest in accordance with STCW
2481                                Shortly before 23:00 hrs on 20/07/2000, the      requirement for an additional bridge lookout to be            95 Section A-VIII/1.
UNITED KINGDOM
                                    Chief Officer relieved the Master on the         posted at night, or the use and testing of the bridge         The lack of written instructions regarding the watchkeeping arrangements was not
                                    bridge; about 30 minutes later he fell asleep. A watch alarm.                                                  detected by the Maritime and Coastguard Agency during the port state control inspection
                                    planned alteration of course taking the vessel                                                                 in January 2000.
                                    into the north-east bound lane of the TSS was                                                                  The Chief Officer had been unable to take adequate rest since joining the ship 84 days
                                    missed, and the vessel ran aground at 00:20 hrs                                                                before the accident.
                                    the next day.                                                                                                  The Master did not inform the ship Manager that the requirements of STCW 95 regarding
                                                                                                                                                   rest periods could not be complied with.
Type of Casualty                                                                                                                                                                                                                 Page 11
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                 Issues raised
                       Date of
Reporting State        casualty                    Event                                                 Causes                                                                         Human factor
Second ship (if any)
COLLISION              09/10/1999   Collision between cargo ship and wooden            Lack of proper lookout on the cargo ship either by           Seafarers working on fishing vessels do not appear to realize that their ability to detect
CRAIG THE PIONEER
WOOD-CHIP CARRIER
                                    prawn trawler in good visibility and moderate      sight or by radar.                                           small lights or poorly illuminated objects is very seriously impaired when working under
LIBERIA                             weather conditions at 01:57 hrs local time on a    No lookout on the trawler.                                   bright flood lights. They may benefit from suitable advice being disseminated to them in
36152                               moonless dark night off Australian coast.          Serious impairment of vision on the trawler from             this regard.
AUSTRALIA
MAY BELL II
                                    The crew on the trawler were engaged in            working under bright lights.                                 Fatigue appears to have been the major cause for the poor lookout on the cargo ship.
FISHING VESSEL                      recovering the nets at the time and no one was     The 2nd mate and the lookout on watch on the cargo
AUSTRALIA                           keeping a lookout. The second mate and the         ship may have been subject to moderate to high levels
                                    AB on duty on the cargo ship at the time did       of fatigue.
                                    not notice the trawler before or after the
                                    collision.
                                    The trawler sustained minor damage on the
                                    bow. The cargo ship did not sustain any
                                    damage.
GROUNDING/STRANDING    12/11/1999   The ship was one of four (amongst five), which     - Lack of awareness by the Master of the deteriorating       - The vessel had been poorly maintained and subject to adverse port state control reports.
DANUBE VOYAGER
GENERAL CARGO SHIP
                                    grounded on the same day and in the same           weather conditions and need to prepare to avoid              The owner is directly responsible to ensure that the vessel is seaworthy and that
UKRAINE                             circumstances, after being at anchor waiting to    possible grounding.                                          documentation on board is valid.
3712                                enter the Port-la-Nouvelle, South of France, to    - The vessel had deballasted to enter the port.              - A continuous means of communication between the vessel at anchor and port Authorities
FRANCE
                                    load grain. Like two of the others, the ship       Consequently the lower drafts of the vessel were             enables better exchange of information to enable timely decisions on what action to take in
                                    landed on beaches adjoining the entrance.          unable to counter the effect of wind and sea.                deteriorating weather conditions.
                                    The vessel arrived the day before the              - The propulsive power of the vessel was insufficient to     - The charterer and shipper have a responsibility to assure that the assigned vessel is
                                    grounding. During the period at anchor the         counter wind and sea.                                        suitable for the voyage and trade intended.
                                    weather deteriorated to windforce E to SE          - Lack of information from the port to Master.
                                    force 11 to 12. Consequently, anchors dragged      - Unsuitability of the vessel to operate in the prescribed   Master awareness of the changing conditions that may affect the safety of the vessel is
                                    and anchor chains broke.                           sea trade area.                                              dependent not only on his experience and competence, but on the support of port
                                                                                                                                                    Authorities and owner to ensure that he has sufficient information to enable him to make
                                                                                                                                                    correct and timely decisions.
MACHINERY DAMAGE       16/07/1999   On 13/05/1999 and again on 16/07/1999, the         In February 1999, the top sheave on the davit, a             Repairs to the davits with parts other than those specified or recommended by the
DEA FIGHTER
TUG/SUPPLY SHIP
                                    lifting wire of the starboard Fast Rescue Craft    420mm diameter Nilatron sheave, was replaced with a          equipment manufacturer.
UNITED KINGDOM                      (FRC) single arm davit parted while the FRC        280mm steel sheave. During launching, the lifting            Need to notify the vessel operators when operating restrictions/limitations related to the
1022                                was being launched.                                wire would slip into the gap between the bosses of the       safety or longevity of the equipment installed aboard their vessels are imposed on newly
UNITED KINGDOM
                                    A total of three persons were injured in the two   new sheave and the side plate. Mechanical damage             constructed equipment of the same type and model.
                                    incidents.                                         and overstressing of the lifting wire occurred and the       Failure to follow manufacturer's maintenance and repair instructions/specifications.
                                                                                       wire subsequently failed. Also, the manufacturer of          (Human error or violation.)
                                                                                       the davit noted that heavy loading of the lifting wire
                                                                                       occurred when the tele-legs were fully compressed.
                                                                                       Operating instructions for new davit arm assemblies
                                                                                       contained conditions under which the tele-legs should
                                                                                       not be fully compressed. These conditions were
                                                                                       subsequently applied to the davits on the DEA
                                                                                       FIGHTER.
STRANDING/GROUNDING    01/11/1997   The vessel ran aground soon after leaving port     The main engine stopped because of the rocker arm            There had been previous problems with rockers arms nuts slacking off in service, problem
DEBORA
GENERAL CARGO SHIP
                                    and dropping off the pilot. In the port, the       supports coming loose on No. 5 cylinder. Spring              which had not been addressed to avoid recurrence.
SWEDEN                              vessel had undergone a main machinery              locking washers had been used rather than flat washers       It is possible that shutting down of the engine could have been avoided until the vessel
2331                                overhaul and survey.                               specified by the engine manufacture. The nuts had not        was in open sea. However there was a reported lack of exchange of information between
SWEDEN
                                                                                       been tightened sufficiently.                                 engine-room and bridge, which contributed to a lack of understanding and realisation of
                                                                                                                                                    the developing dangerous situation.

                                                                                                                                                    Bridge and engine-room resource management to facilitate good quality and timely
                                                                                                                                                    information between engine room and bridge watchkeeping staff.
Type of Casualty                                                                                                                                                                                                             Page 12
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                 Issues raised
                          Date of
Reporting State           casualty                   Event                                                Causes                                                                        Human factor
Second ship (if any)
FAILURE OF WATERTIGHT   02/02/1998     Due to water ingress, the foundering and total   Shifting of the containers which led to the water           No investigation report but a reporting form and Master's report.
DOORS/PORTS/ETC
DELFIN DEL MEDITERRANEO
                                       loss (including one victim) of the container     ingress.
CONTAINER SHIP                         ship DELFIN DEL MEDITERRANEO took
SPAIN (CANARY ISLANDS)                 place on 02/02/98 off Cape St. Vincent in the
4614
SPAIN
                                       Atlantic Ocean. The crew was rescued by a
                                       Royal Navy ship.


OTHER/UNKNOWN             05/04/2000   On 5/04/2000, a team of Army and Navy            Contributory factors were lack of training, absence of      It must always be assumed that every enclosed space is dangerous unless it has been
DIAMOND BULKER
BULK CARRIER
                                       personnel were engaged on a search operation     planning of the operation, lack of supervision in           established that it is safe. Entry into enclosed spaces must be in accordance with a
PHILIPPINES                            under Northern Ireland Emergency Procedures      addition to the fatal mistake of unauthorized entry to an   recognized Code of Practice.
16721                                  on this bulk carrier loaded with coal from       unventilated hold.                                          The Army personnel were untrained in entry procedures. They should not have entered
UNITED KINGDOM
                                       Colombia for discharge at Londonderry.                                                                       the space until instructed to do so.
                                       Two Army sappers entered No. 1 hold without
                                       self-contained breathing apparatus (SCBA) and
                                       got into difficulties. An Army Corporal
                                       entered the hold to assist and also got into
                                       difficulties.
                                       One of the sappers and the Corporal lost their
                                       lives due to oxygen deficiency and excess
                                       carbon dioxide. The second sapper survived.
CONTACT                 07/11/1999     Refrigerated cargo ship, having disembarked      Poor and ineffective Bridge Team Management.                Importance of Bridge Resource Management and clear communication between bridge
DOLE AMERICA
REFRIGERATED CARGO SHIP
                                       Pilot, makes contact with navigation tower.      Time pressures, real or perceived, felt by the Master to    team members. Fatigue management as a routine safety management issue.
LIBERIA                                Extensive damage to ship.                        make up lost time resulted in an alternative ‘quicker’      Mistakes - the misapplication of a plan.
10584                                                                                   route to the east of the navigation tower.                  Fatigue issues and pressures, real or perceived, on Masters.
LIBERIA
                                                                                        Bridge ergonomics and instrument visibility.
                                                                                        Deficiencies in the Company safety.

COLLISION                 25/09/2000   EASTFERN being overtaken by KINSALE.             EASTFERN not maintaining watch astern (Officer of           Dangers of :
EASTFERN
GENERAL CARGO SHIP
                                       KINSALE collided with the stern of               the Watch largely sitting at console). Vigilance            - keeping watch from static position,
IRISH REPUBLIC                         EASTFERN.                                        reduced as all traffic proceeding in same direction.        - failing to maintain a watch astern,
1171                                                                                    Sole watchkeeper.                                           - single man bridge operation, and
UNITED KINGDOM
KINSALE
                                                                                        KINSALE sole watchkeeper not keeping a proper               - having equipment, other than navigation/emergency equipment, on the bridge.
BULK CARRIER                                                                            lookout. Hand over at change of watch did not identify      The monotony of bridge watchkeeping.
CYPRUS                                                                                  vessel being overtaken. Masts limited vision forward        Single person watches.
5306
                                                                                        from static position. Reduced vigilance in less dense       The static nature of keeping a watch from a chair.
                                                                                        traffic.                                                    Work/interest priorities on ships with reduced manning.
Type of Casualty                                                                                                                                                                                                                  Page 13
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                   Issues raised
                       Date of
Reporting State        casualty                    Event                                                  Causes                                                                          Human factor
Second ship (if any)
OTHER                  03/05/1999   The vessel was alongside in Southampton and         A subsequent post-mortem found a blood alcohol level         Senior Officers and the Company must control excessive alcohol consumption.
EDINBURGH CASTLE
PASSENGER SHIP
                                    under receivership at the time. There were          of 300mg/100ml, about 3.75 times the legal driving           Proper footwear should be worn at all times when moving about the ship.
UNITED KINGDOM                      about 120 crew on board to maintain the vessel      limit in the UK. A Canadian Study suggested that at          Uncarpeted stairs should not be covered with plastic sheeting.
32753                               including 18-20 Polish crew members. On one         this level, the person is likely to be confused with gross   Crew factors - Management and supervision inadequate.
UNITED KINGDOM
                                    afternoon the staff held a barbecue on board        incoordination.                                              Individual - Health: drugs/alcohol.
                                    from 14:00 hrs. The deceased attended that          The stairs used by the casualty were covered with
                                    until about 16:00 hrs before going ashore with      plastic sheeting.
                                    a friend for a drink. He returned at about 20:30    The footwear worn by the casualty was of the "flip-
                                    hrs and joined his friends in the disco club on     flop" type, one found on the stairs, the other at the
                                    board which was open that evening and               bottom.
                                    dispensing free drinks. At about 23:00 hrs he
                                    left to go to bed. At 23:15 hrs he was found at
                                    the bottom of a flight of stairs. Medical
                                    assistance was called and resuscitation tried but
                                    found to be dead.
FIRE                   06/02/2000   Shortly after commencement of voyage with 3         The cause of the fire and the cause of the flooding in       No organized action to take control of the engine room and fight the fire was carried out
EL CABALLO GRANDE
TUG/SUPPLY SHIP
                                    vessels in tow, the tug experienced a loss of       the engine room could not be established.                    by the crew.
VANUATU                             power. A seaman was sent to the engine room                                                                      The general fire alarm was not activated, the vessel's fire fighting means were not used,
377                                 to locate the problem and noticed there was a                                                                    the main and auxiliary engine fuel supply was not shut off, the engine room vent fan flaps
VANUATU
                                    fire in the engine room. A first attempt to                                                                      were not closed and the engine room access doors at main deck level were not closed.
                                    extinguish the fire rising on the starboard main                                                                 The Chief Engineer declared he ran to the engine room and observed fire on the top and
                                    engine with portable appliances was                                                                              outboard side of the starboard main engine as well as on the starboard generator. He
                                    unsuccessful and the vessel was abandoned;                                                                       managed to shut off the port main engine from the foot of the engine room access ladder
                                    when it was noticed that the fire had weakened                                                                   and the air conditioning system and ventilators from his cabin before he boarded the life
                                    the crew re-boarded and the fire was                                                                             raft. He thinks that the starboard engine stopped by itself but is not sure when it happened.
                                    extinguished. It was then however noticed that                                                                   The first action of the crew was to abandon the vessel without an organized attempt to
                                    the engine room was filling up with water. The                                                                   fight and control the fire. Abandon signal was not activated, so the Chief Engineer and
                                    vessel was abandoned a second time and sank                                                                      Oiler were unaware the vessel was being abandoned and they were the last to board the
                                    about 90 mns after the fire started.                                                                             raft.
                                    No injuries to person.                                                                                           Because the life raft line became entangled and the crew were unable to detach the raft
                                                                                                                                                     from the vessel's side, the Chief Engineer and the Mate later had to re-board the vessel to
                                                                                                                                                     free the line and drag the raft from starboard to port side. During the above efforts, the
                                                                                                                                                     raft was ripped and all the crew had to re-board the vessel.
                                                                                                                                                     When the crew boarded the vessel again and noticed the fire had weakened, portable fire
                                                                                                                                                     extinguishers and water buckets were used to control it. The self-contained breathing
                                                                                                                                                     apparatus was used by the Chief Engineer to access the upper engine room and, assisted
                                                                                                                                                     by other crew members, fight the fire. Once the fire had been extinguished all the engine
                                                                                                                                                     room access doors were opened to ventilate the compartment.
Type of Casualty                                                                                                                                                                                                          Page 14
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                            Issues raised
                       Date of
Reporting State        casualty                    Event                                                 Causes                                                                    Human factor
Second ship (if any)
FIRE AND EXPLOSION     26/11/1999   At 0300 hours on 26 November 1999 the               It is very probable that the simultaneous engine room   Bunker heating media should not be heated outside the normal limits and never be
ELIZA
CONTAINER SHIP
                                    bridge watchkeeper, the Master and the Chief        fire resulted from flames from the ruptured double      admitted to the heating coils of empty tanks.
MARSHALL ISLANDS                    Engineer heard an explosion. The engine room        bottom tanks which protruded 1.5 metres under the
5938                                was filled with smoke and was shut down,            engine room. The resultant smoke led the Chief          In the belief that a temperature (of 280ºC) well in excess of the normal range (180ºC to
MARSHALL ISLANDS
                                    secured and CO2 gas admitted at 0320 hours.         Engineer to assume that the fire was initiated in the   200ºC) would remove assumed water from the boiler heating fluid, heating was applied to
                                    The fire was rapidly extinguished but seawater      engine room and to take the decision not to start the   an empty tank. However, this action appears to result from a lack of knowledge of auto-
                                    was rising above the floor plates. The small        machinery and use the main bilge pumps.                 ignition dangers.
                                    bilge pump powered by the emergency
                                    generator failed to halt the flooding. The Chief
                                    Engineer did not want to restart the generators
                                    until he had discovered the cause of the fire.
                                    Consequently, the main bilge pumps were not
                                    used. Both cargo holds were flooding and, at
                                    0700 hours, the vessel was abandoned. The
                                    vessel was still afloat 13 hours after the
                                    explosion when all the crew were rescued from
                                    the ship's lifeboats. The vessel subsequently
                                    sank.
                                    In an attempt to "remove moisture" from the
                                    thermal oil of the fluid heater, the Chief
                                    Engineer opened the valves to the empty No.10
                                    port and starboard double bottom tanks.
                                    The most probable cause of the loss was this
                                    admission of heating fluid at 280ºC from a
                                    thermal fluid heater to one of these empty
                                    double-bottom tanks which had contained oil
                                    fuel. Paraffin had been used for cleaning these
                                    D.B. tanks prior to hot work in an adjacent
                                    tank. The investigation report suggests that this
                                    paraffin could have been the source of
                                    flammable vapour generated by, and
                                    spontaneously igniting the heating coils.
                                    However, the temperature of 280ºC would be
                                    sufficient to spontaneously ignite vapour
                                    generated by the oil fuel residues in the tank.
                                    Since this is within the auto-ignition
                                    temperature of oil fuel vapours, the probability
                                    of an explosion in the tank was exceptionally
                                    high.
                                    The severity of the explosion would be
                                    sufficient to damage the tank and result in
                                    flooding.
GROUNDING/STRANDING    18/03/1998   On 18/03/1998 at 13:45 hrs the general cargo        Wrong estimate, GPS faulty.
ELVINA
GENERAL CARGO SHIP
                                    ship ELVINA touched bottom while entering           Faulty navigational equipment.                          Human error.
PORTUGAL                            the port of Ribadeo and grounded due to a
1330                                navigational error.
SPAIN
Type of Casualty                                                                                                                                                                                                               Page 15
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                Issues raised
                        Date of
Reporting State         casualty                   Event                                                 Causes                                                                        Human factor
Second ship (if any)
GROUNDING/STRANDING     02/04/1998   Vessel grounded in the St. Lawrence Seaway        One officer piloting, the other was Officer of the
ENERCHEM REFINER
TANKER
                                     after a delay in course alteration.               Watch and both lost situational awareness.                  Informal approach to bridge responsibilities.
CANADA                                                                                 Position of vessel was not properly maintained.             Lack of BRM training.
4502                                                                                                                                               Replacement of officers not ISM compliant.
CANADA
                                                                                                                                                   Possible Officer of the Watch fatigue.


WORK-RELATED ACCIDENT   01/12/2000   The crew was performing maintenance of the        Maintenance manuals did not contain instructions for        Even the best trained and most competent person can have a lapse and make an error or
EUROPEAN HIGHWAY
RORO CARGO/FERRY
                                     suspension hooks on a lifeboat. The process       using the hanging-off pendants to perform suspension        omission that results in a casualty.
UNITED KINGDOM                       involved using the hanging-off pendants to        hook maintenance.                                           Communications between team members so that everyone knows the procedures to be
22986                                support the weight of the lifeboat while the      The equipment was not designed to preclude the              followed and what to expect is essential.
UNITED KINGDOM
                                     suspension hooks were unloaded. The person        incorrect rigging of the hanging-off pendant and none       Another member of the maintenance team should perform an independent verification that
                                     in charge of the operation inadvertently rigged   of the other members of the maintenance team verified       critical steps or processes have been correctly executed.
                                     the hanging-off pendants incorrectly. When        the correctness of the rigging before unloading the         All steps necessary to maintain equipment should clearly be outlined in the maintenance
                                     the suspension hooks were released, the           suspension hooks.                                           plan.
                                     lifeboat fell and struck a walkway support        The person in charge also did not brief the other
                                     column before entering the water. Two of the      members of the maintenance team of the procedures           Errors or omissions by fully qualified and trained personnel can lead to casualties. These
                                     three persons aboard the lifeboat were injured    being used.                                                 types of errors or omissions may be prevented if the maintenance team discusses the
                                     and treated at a hospital. There was also an      Fixed structures below the lifeboat increased the           procedures that are being performed or if a member of the team performs an independent
                                     injury sustained in launching the fast rescue     severity of the casualty.                                   check to ensure that critical procedures have been executed properly.
                                     craft (FRC) for rescue operations and the crew    The SOLAS specification for the FRC davit may not           Modification of components to preclude their interconnection, such as the hanging-off
                                     of the FRC was endangered when raising the        afford sufficient protection against injury for the         pendant with the recovery pendant, can prevent personnel errors that result in casualties.
                                     FRC after rescue operations.                      person lowering the FRC.
COLLISION               16/10/2000   Collision between a ro-ro ferry and a fishing     Sudden large alteration of course to starboard by the       Provision of VDR on the ro-ro ferry was very helpful in the accident investigation.
EUROPEAN TIDEWAY
FERRY
                                     vessel (beam trawler) in position 52º03'.36N,     fishing vessel resulting in close quarters situation with   When other vessels are in vicinity, consequence of a proposed alteration of course and/or
UNITED KINGDOM                       002º30'.73E in the North Sea. The ro-ro ferry     the ro-ro ferry.                                            speed on the CPA and TCPA of the vessels in the vicinity should always be pre-assessed
21162                                sustained serious damage in bow above water       The fishing vessel did not pre-assess the effect of its     before the alteration is carried out.
UNITED KINGDOM
VROUW GRIETJE
                                     level whereas the fishing vessel sustained        large alteration on other vessels before commencing         ARPA radars should always be water stabilized when in use for collision avoidance.
FISHING VESSEL (SIDE)                minor damage on the bow.                          the alteration.                                             When vessels are in sight of one another, visual bearings by compass should be checked to
NETHERLANDS                                                                            Subsequent alteration of course to port by the fishing      assess risk of collision in a crossing situation.
419
                                                                                       vessel further aggravated the situation making the          Watchkeepers, especially relatively inexperienced ones, should be given very precise and
                                                                                       collision unavoidable.                                      clear instructions.
                                                                                       Lack of proper lookout on the fishing vessel.               Watchkeepers should be discouraged from relying on estimation of relative bearings when
                                                                                       Contravention of Rule 15 of the COLREGs by the ro-          deciding whether or not risk of collision exists.
                                                                                       ro ferry when taking avoiding action in a crossing
                                                                                       situation.
                                                                                       The ro-ro ferry had very little time to assess the
                                                                                       situation and take appropriate avoiding action.
WORK-RELATED ACCIDENT   20/11/2000   EVANGELOS CH was at anchor in the river           - Oil on the deck, together with rainfall made for          There should be written procedures for closing the hatch covers and the crew should be
EVANGELOS CH
BULK CARRIER
                                     Thames as the crew were closing the hatch         slippery conditions on deck.                                trained in carrying out these correct procedures.
CYPRUS                               covers after completing hold cleaning. To         - A tripping hazard existed in the form of the remaining
17308                                close them completely required the wire from a    butt of an old welded eye-bolt which had been               The 3rd Officer took a risk by placing himself in a dangerous situation by climbing onto
UNITED KINGDOM
                                     winch to be unshackled manually and moved         removed.                                                    the partially-opened hatch covers.
                                     while the covers were partially open. The 3rd     - There was an area of shadow created by the                An attitude of complacency about the practice had developed over time.
                                     Officer climbed onto the hatch covers to          masthouse.
                                     unshackle the wire, but either tripped or         - He was not wearing either a helmet or safety harness.
                                     slipped and fell into the hold. The fall killed   - There was no anti-skid paint on the hatch covers.
                                     him. There was no witness to exactly what had
                                     happened.
Type of Casualty                                                                                                                                                                                                                 Page 16
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                 Issues raised
                       Date of
Reporting State        casualty                    Event                                                  Causes                                                                        Human factor
Second ship (if any)
CONTACT                12/12/1998   FEDERAL BERGEN, under pilotage,                     Absence of Bridge Resource Management.                    The need for proper Bridge Team Management and response by Pilot’s when questioned
FEDERAL BERGEN
BULK CARRIER
                                    contacted port side navigation mark. Ship           Pilot engaged in multi tasks ordered erroneous course     by ship’s staff.
HONG KONG, CHINA                    holed forward.                                      alteration.                                               Attitude to command and control.
16983                                                                                   When questioned did not react in a timely manner.         Slips or lapses leading to erroneous course settings. Communications between different
CANADA
                                                                                        Ineffective use of navigation aids by Pilot.              cultures.
                                                                                        Poor communications and use of human resources.
                                                                                        Vision obscured by centre line cranes.
GROUNDING/STRANDING    02/08/1998   On 2 August 1998, the Panamanian Bulk               Neither the pilot nor the vessel’s navigating personnel   The 1996 bathymetric survey was conducted for operating purposes; since the shipyard is
FEDERAL FRASER
BULK CARRIER
                                    carrier FEDERAL FRASER was calling at the           had access to a 1996 privately-contracted bathymetric     located in a private sector of the port, there was no obligation to report changes to the local
PANAMA                              Port of Quebec to discharge steel plates. As the    survey which confirmed the presence of silting. The       port authority.
22388                               vessel was initiating its final approach to the     newly formed 3.8m ridge on which the vessel ran           Since the 1996 private bathymetric survey was not subsequent to works, such as
CANADA
                                    shipyard’s Murphy wharf, which is located in a      aground was detected during a post-occurrence             construction, dumping, or excavation, the results were not required to be forwarded to the
                                    private sector of the port, assisted by a tug and   sounding.                                                 Navigable Waters Protection Division and were not available to navigators.
                                    under the conduct of a harbour pilot, it                                                                      At the time of the accident, the mechanisms for the exchange of information between
                                    grounded during high tide on a sand shoal                                                                     Canadian Hydrographic Service and navigators, including pilots, were not generally
                                    southeast of its course.                                                                                      known. The CHS had not been informed of all landmarks used by pilots and thus, it could
                                                                                                                                                  not prioritize the selection of landmarks to be charted in order to facilitate the safe passage
                                                                                                                                                  of vessels in restricted waterways.

                                                                                                                                                  Sound bridge resource management practices were not established between the vessel’s
                                                                                                                                                  navigating personnel and the pilot. Communication between navigating personnel and the
                                                                                                                                                  pilot was interrupted, and position fixing methods, such as radar parallel indexing, were
                                                                                                                                                  not employed to determine the ship’s position.
GROUNDING/STRANDING    02/05/1998   Stranding - hitting submerged wreck.                Human error by crew.                                      Adequacy of high speed craft code - seat design/seat belts.
FLORES
HYDROFOIL FERRY
                                    Ship remained unseaworthy.                          Missing aids to navigation.                               Monitoring of vessel position by crew.
HONG KONG, CHINA                    One dead passenger.                                 Error in judgement                                        Emergency training for crew.
305                                                                                                                                               Human error.
HONG KONG, CHINA




CONTACT                11/01/2000   Vessel was sailing offshore in a ballasted         Investigation concluded that there was a heavy strike to
GRAND ARABELLA
VEHICLE CARRIER
                                    condition when a sudden loud shock was             the vessel aft, starboard side plating by an unknown     Crew safely coordinated the successful evacuation of the vessel.
LIBERIA                             experienced coming from the starboard side         floating or slightly submerged rigid object.
16038                               aft. Vessel experienced uncontrolled flooding
LIBERIA
                                    and sank. All crewmembers safely evacuated
                                    the vessel and were retrieved within a half hour
                                    by a passing vessel. Vessel sank; no deaths,
                                    injuries or pollution resulted from this incident.
Type of Casualty                                                                                                                                                                                                                     Page 17
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                     Issues raised
                           Date of
Reporting State            casualty                    Event                                                 Causes                                                                         Human factor
Second ship (if any)
COLLISION                  18/03/2000   - The pleasure craft was struck at night whilst    - No lookout on the recreational vessel. Both crew          The importance of proper lookout for collision avoidance has been widely and repeatedly
HAI TENG
BULK CARRIER
                                        at anchor in a shipping lane 28 miles East of      members on board were asleep at the material time.          promulgated. It is the most common cause of collisions, especially involving small craft.
CHINA, PEOPLE'S REPUBLIC                Mooloolaba, near N.E. coast of Australia, by a     - The lookout on the bulk carrier was not sufficiently      There appears to be no viable solution to overcome this problem except to continue to
OF                                      ship later identified to be the bulk carrier HAI   effective to detect the small craft.                        bring home this message to the operators of small craft at every opportunity.
22112
AUSTRALIA
                                        TENG.                                              - Anchor light displayed on the pleasure craft did not
CHESTER                                 - The pleasure craft sustained minor structural    comply with COLREGs and had a very low range.
YACHT                                   damage at the port quarter.                        - The visual detection of the light on pleasure craft may
AUSTRALIA
                                        - No pollution or injuries.                        have been affected by the reflection of moonlight from
                                                                                           the water.
                                                                                           - The small pleasure craft with limited visual and radar
                                                                                           conspicuousness, was anchored about 28 miles off the
                                                                                           coast in shipping lanes.
                                                                                           - The size, and possibly the aspect, of the pleasure
                                                                                           craft, as well as existing sea conditions, are likely to
                                                                                           have contributed to the craft not being observed on the
                                                                                           bulk carrier’s radar.
COLLISION                  07/03/1999   Open sea conditions, clear weather, daylight,      Angle of approach about 20 degrees abaft the beam,          Failure of most basic watchkeeping/lookout requirements. No lookout maintained by
HALO CYGNUS
BULK CARRIER
                                        crossing ships on steady course. Vessels           marginal crossing overtaking situation.                     Officer of the Watch at chart table laying off courses.
PANAMA                                  collided, LAS SIERRAS striking HALO                Watckeeping/lookout onboard both vessels, prime             Routine monotony. Violation of basic procedures, routine violation.
38480                                   CYGNUS on starboard side penetrating No.1          facie ineffective. From HALO CYGNUS it is known
PANAMA
LAS SIERRAS
                                        cargo hold.                                        that Officer of the Watch was working for prolonged
BULK CARRIER                            Six crew members from HALO CYGNUS                  periods at chart table. No lookout.
PANAMA                                  killed.                                            No evidence from LAS SIERRAS.
72167
                                                                                           LAS SIERRAS was stand on vessel whether
                                                                                           overtaking or crossing situation but subject to
                                                                                           COLREG Rule 17 (a)(ii) and 17(b).
                                                                                           Deficient watchkeeping/lookout on both ships.
COLLISION                  11/02/1998   In a crossing situation, the west-bound            Each vessel failed to stand a vigilant watch.
HANJIN BARCELONA
CONTAINER SHIP
                                        container ship collided with the northbound        The absence of established minimum CPA guidelines           The officer of the watch on the fishing vessel was fatigued due to insufficient rest and his
PANAMA                                  fishing vessel in a visibility 8~10 at night on    on both ships and operators.                                attention was divided between navigating the vessel and stowing gear in the chartroom.
51754                                   the high waters in the Bering Sea on 11/02/98.     The stand-on container ship violated Rule 7 of the
UNITED STATES
ALASKA I
                                        The 33 crew members on board the fishing           COLREG when taking action to avoid collision.
FACTORY FISHING (STERN)                 vessel donned immersion suits, however, one        The give-way fishing vessel:
UNITED STATES                           crew was unable to put a regular size suit on      Not having a dedicated lookout on watch.
1246
                                        and abandoned ship into the liferafts without      Violation of Rules 8 and 16 of the COLREG when
                                        one on.                                            taking early and substantial action to keep well clear of
                                        All crewmembers were rescued by a nearby           the stand-on container ship.
                                        fishing vessel.
                                        The fishing vessel sunk due to heavy flooding
                                        whereas the container ship sustained minor
                                        damage.
GROUNDING/STRANDING        21/01/2001   Dragging anchorage.                                Anchor heaving too late.                                    Check anchorage and be ready to sail in time.
HAPPY LADY
GAS CARRIER LPG
NORWAY
6107
UNITED KINGDOM
Type of Casualty                                                                                                                                                                                                                    Page 18
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                    Issues raised
                        Date of
Reporting State         casualty                    Event                                                  Causes                                                                          Human factor
Second ship (if any)
GROUNDING               25/12/1999   The HEDLO had loaded a cargo of steel               The Master had several navigational options available       The Master, when on watch, did not plot the positions which he had observed on the
HEDLO
GENERAL CARGO SHIP
                                     products at Duisberg and Rotterdam departing        to him in the passage past the Islands of Utsira, Urter     navigational chart.
BAHAMAS                              from the latter at 22:00 hrs local time (UTC +      and Karmo.                                                  The Master did not keep a written passage plan.
1092                                 1hr) on 23/12/1999 and, at about 22:30 hrs, on                                                                  The Managers of the vessel are requested to review the instructions to Masters regarding
BAHAMAS
                                     25/12/1999, she ran aground on Urter Island,                                                                    safe navigational practices.
                                     about 8 miles west south west of Haugesund,                                                                     As a result of the positions not being plotted and the Master's belief in his familiarity with
                                     Norway. The weather on the passage had been                                                                     the area, the vessel grounded on rocks that formed the perimeter of Urter Island.
                                     poor when the vessel sailed and it deteriorated
                                     to a south westerly severe gale or storm during
                                     24 and 25 December. HEDLO was
                                     subsequently declared to be a Constructive
                                     Total Loss.
FIRE                    05/05/1998   On 5 May 1998, a serious fire followed a burst      The ship's personnel were not adequately trained to         The importance of fitting approved equipment in all relevant instances and fuel lines in
HMAS WESTRALIA
NAVY TANKER
                                     flexible hose failure and impingement on a hot      deal with the ensuing fire and had insufficient             particular was not understood by key personnel.
AUSTRALIA                            surface. Four lives were lost in the machinery      knowledge of (eg) CO2 systems and International
                                     space. The failed hose was newly installed.         Shore Connections.                                          Surprisingly, the basic training and attention to on-board drills seems to have been less
AUSTRALIA
                                     Due to complicated procurement procedures                                                                       rigorous than on comparable merchant vessels.
                                     and personnel failings, the hoses were not
                                     ordered from Lloyds Registers approved list.
GROUNDING/STRANDING     03/06/1999   HOPE I, loaded with 19,016 tons of wheat and        Contributory causes included : the inadequate means of      When the vessel lost electrical power, the emergency generator activated instantly.
HOPE I
BULK CARRIER
                                     under the conduct of a pilot, was proceeding        determining the amount of fuel in the generator service     However, the emergency switchboard was not designed to connect to the steering gear,
MALTA                                downbound in the St. Lawrence Seaway. In            tank from inside the engine room, the inadequate fuel       nor was it required to be. Prior to 1984, SOLAS 1978 did not require that emergency
17152                                the vicinity of Canada Island, the vessel           transfer procedures, the fact that the engine room staff    power be available to steering systems.
CANADA
                                     experienced a loss of electrical power. With        did not transfer fuel to the generator service tank and     Though the low level alarm for the generator service tank activated 12 hours prior to the
                                     no steering control, the vessel left the channel    were unaware of the amount of unpumpable fuel in the        occurrence, the engine room staff did not transfer diesel oil to the tank.
                                     and grounded in front of the wharf at               tank, and the lack of an emergency power supply to the
                                     Morrisburg, Ontario.                                steering gear.
                                     There were no injuries or pollution as a result     There was no appropriate means of determining the
                                     of the grounding.                                   amount of diesel oil in the generator service tank from
                                                                                         inside the engine room.
                                                                                         The engine room staff were not aware that the internal
                                                                                         arrrangement of the generator service tank was such
                                                                                         that the last 1.8 tonnes of fuel could not be pumped out.
GROUNDING/STRANDING     21/10/2000   HORIZONTE CLARO landed her catch in                 The Skipper was unaware that HORIZONTE CLARO                The over-reliance on the video plotter has caused, or contributed to, several accidents at
HORIZONTE CLARO
FISHING VESSEL (SIDE)
                                     Loch Inver, Scotland, on 20/10/2000. She then       was about 400 m north of the intended track and             sea in recent years.
SPAIN                                sailed at about midnight to return to the fishing   heading towards Soyea Island. Heavy rain reduced            It is important to discourage the consumption of alcohol before sailing.
240                                  grounds. Twenty minutes later she ran               visibility and degraded the radar picture. The video        The life-saving equipment was not available for immediate use.
UNITED KINGDOM
                                     aground. Her crew had not detected that she         plotter, primarily used for fishing purposes, was not       The Skipper was totally reliant on the video plotter for the safe navigation of the vessel in
                                     had departed from her intended track to the         adequate for safe navigation. The Skipper was unable        confined waters. The Skipper's assessment of the vessel's position, based upon the video
                                     south of Soyea Island, and she grounded to the      to utilize positional information from the degraded         plotter, was inaccurate. DGPS and GPS positions were not plotted on the paper chart.
                                     east of it. There were no injuries.                 radar picture. The lookouts were not posted outside
                                     HORIZONTE CLARO was re-floated the next             the wheelhouse when visibility was severely reduced.
                                     day by the coastguard tug.
Type of Casualty                                                                                                                                                                                                           Page 19
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                            Issues raised
                       Date of
Reporting State        casualty                    Event                                                 Causes                                                                    Human factor
Second ship (if any)
GROUNDING/STRANDING    12/10/1995   On 12/10/1995 at 18:32 hrs and in poor              Master's mistake due to lack of concentration.
HUAL TROOPER
VEHICLE CARRIER
                                    visibility, the ro-ro HUAL TROOPER carrying         Master alone on the bridge with the Helmsman.
BAHAMAS                             864 vehicles grounded 24 hrs after departure
56164                               from Bremerhaven to Gdynia. The ship
BAHAMAS
                                    grounded S.E. of Drogden lightouse which the
                                    Master had mistakenly assumed to be
                                    Falsterborev lighthouse, right after
                                    disembarkation of the Pilot. The First Mate
                                    who had escorted the Pilot to the pilot ladder
                                    realized the mistake on his return but it was too
                                    late.
COLLISION              29/05/2000   At 13:37 (local time) on 29 May 2000, the           HYUNDAI EMPEROR was overtaking                         The importance to give effect to the rules of COLREG, 1972, particularly: rule 5 -
HYUNDAI EMPEROR
CONTAINER SHIP
                                    container ship HYUNDAI EMPEROR collided             NORDFRAKT.                                             Lookout; 7 - Risk of collision; and 13 - Overtaking.
PANAMA                              with and sank the general cargo ship                OOW failing to maintain proper lookout by all means;
51836                               NORDFRAKT, position 38º 35'.5N, 009º                absence of communications and incorrect judgement of   Unsafe Act and Decision
PANAMA
NORDFRAKT
                                    41'.6W. Both vessels were approaching the           the NORDFRAKT course.                                  - Alone on the bridge near an entrance of traffic lane: Violation - Mistake - Knowledge-
GENERAL CARGO SHIP                  south entrance of the Portuguese Cape Roca          The vessels did not take any action to avoid the       based Routine;
NORWAY                              traffic separation scheme. HYUNDAI                  collision.                                             - Late detection of the NORDFRAKT : Error - Slip - Attention Failure;
1900
                                    EMPEROR course (T) was 345 (22kn) and                                                                      - Absence of communication: Violation - Mistake - Knowledge-based Routine;
                                    NORDFRAKT course (T) was 315 (12kn). At                                                                    - Incorrect judgement of the course of the NORDFRAKT: Error - Slip - Skill-based;
                                    the beginning of the watch the OOW (2nd                                                                    - Bridge not attended in a risk situation of collision: Violation - Mistake - Knowledge-
                                    officer) sent the lookout to work on the                                                                   based Routine;
                                    forward deck being alone at the bridge. The                                                                - No action to avoid the collision: Violation - Mistake - Knowledge-based Routine.
                                    OOW only noticed the NORDFRAKT when
                                    the distance between the two ships was 4 or 5
                                    miles and he did not evaluate either course or
                                    speed, but he said the estimated course was
                                    NW. He then considered his vessel could pass
                                    by the bow of the NORDFRAKT by 0.5 miles
                                    and he went to the radio room asking for the
                                    help of the officer in charge, placing the ship
                                    on automatic pilot. When he returned to the
                                    bridge he felt vibrations on the ship, the
                                    collision had happened.
                                    Consequences:
                                    NORDFRAKT : total loss of the ship and 6
                                    persons dead (all the crew);
                                    HYUNDAI EMPEROR : damages to the
                                    forward side shell P/S and bulbous bow plating
                                    but remaining seaworthy.
Type of Casualty                                                                                                                                                                                                                  Page 20
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                   Issues raised
                        Date of
Reporting State         casualty                    Event                                                   Causes                                                                        Human factor
Second ship (if any)
FAILURE OF WATERTIGHT   30/10/2000   In the early hours of 30/10/2000, the non-cargo      - Progressive flooding of forepeak, nos 1, 2, 3, 4 & 5
DOORS/PORTS/ETC
IEVOLI SUN
                                     bow spaces and compartments of the chemical          ballast tanks and the double bottom tanks;                  Human factors:
CHEMICAL TANKER                      tanker IEVOLI SUN progressively became               - Poor condition of the tank vent valves which failed to    - Reason for electrical fault on ballast pump/cargo/windlass electro-hydraulic system was
ITALY                                flooded while en route from Fawley (Great            prevent water ingress into tanks;                           not diagnosed because of possible lack of knowledge, reinforced by stress of weather, time
4189
FRANCE
                                     Britain) to Berre between Casquets and               - Decision to proceed head into the sea in worsening        pressures and complicated system.
                                     Ouessant.                                            weather conditions;                                         - Lack of awareness of flooding conditions and decision to proceed head into the weather.
                                     Running with a forward trim, the Captain             - Inability to pump out the water through the ballast       - Safety management system and survey regime failed to ensure that tank air vents were
                                     called for a tug's assistance and later evacuated    lines owing to an electrical fault following the flooding   maintained in safe condition.
                                     his crew as the ship had become non-                 of the bow storeroom.                                       - Failure of design whereby single hydraulic failure caused system failure of cargo ballast
                                     manoeuvrable and risked sinking at any time.                                                                     and windlass hydraulic system.
                                     The crew was airlifted by the French Navy Air                                                                    - Common mode electrical failure of components which affected safety and control
                                     Force and the ship was towed from the stern by                                                                   function integrity.
                                     a French salving ship that was en route to a
                                     Norman refuge harbour.
                                     This crossing was not completed and the ship
                                     finally sunk at approximately 9.5 nm north of
                                     Casquets at a water depth of between 60 and
                                     70 m.
WORK-RELATED ACCIDENT   07/07/2000   The pumpman apparently sat on the coaming            Unsafe act of sitting on the coaming of an open hatch       The design of the cargo pumproom and specifically the fact that only one ventilation fan
INGA
OIL TANKER
                                     of an open pumproom hatch and removed his            to the pumproom. This hatch was intended for use            was installed.
LIBERIA                              left boot in an effort to check a blister on his     when hoisting and lowering machinery and equipment.         The practice of lashing the hatch cover, which was designed to be secured except when
18625                                foot. It appears that he lost his balance and fell   Due to design flaws and imprudent operational               being used to raise and lower equipment, in the open position.
UNITED KINGDOM
                                     through the open hatch to the pumproom below.        procedures, the pumproom service hatch was secured          The lack of a grating to prevent personnel and objects from falling into the pumproom.
                                     It was probably in excess of an hour between         in the open position most of the time.                      Need to address the pumproom design flaws so that the pumproom hatch cover can remain
                                     the time of the fall and his being located by        There was no removable grating inside the coaming to        in the closed position except when actually in service.
                                     another member of the crew. He had no pulse          prevent personnel or other objects from falling into the    Human error/unsafe act of sitting on the coaming of an open hatch.
                                     when the rescue party reached him.                   pumproom.
                                                                                          Due to the weight and arrangement of the hatch cover,
                                                                                          it required more than one person to open or secure.
OTHER                   09/11/1998   For the first time in the hands of a new owner,      The centrifugal brakes on the winches had been set up       1. The hook resetting procedure was not described in the on-board manuals.
IOLCOS GRACE
BULK CARRIER
                                     the crew of a bulk carrier was conducting a          to give the desired lowering speed when only lightly        2. Contents of on-board manuals were poor.
PANAMA                               boat drill while at anchor. The lifeboats were       loaded. When the lifeboat was nearly fully loaded, the      3. Wear patterns on the hooks' release mechanism showed they had not been properly reset
38022                                25-person capacity fully enclosed. The               speed was excessive and contributed to the undesirable      for a prolonged period. Clearly previous crews had also been unaware of the proper
CANADA
                                     starboard boat had been lowered, manoeuvred          swing of the boat.                                          procedures.
                                     in the water and recovered to its stowed             Incorrect resetting of the on-load release hooks caused     4. The lifeboats were last lowered during a survey by Class for the SEC (Safety
                                     position. The port boat was then prepared. Six       them to open spontaneously under shock load.                Equipment Certificate), seven months before this accident.
                                     people entered the boat and the winch brake          Poor maintenance and setting of hook release cables         A safety pin on the starboard boat's operating mechanism was missing.
                                     wire was pulled from inside the boat. Initially      enabled the hooks to open without the operating handle
                                     there was no movement. However, the boat             being pulled.
                                     then lowered suddenly, swinging away from            The release mechanism was not fitted with a
                                     the davits before swinging back and striking         hydrostatic interlock able to prevent release before the
                                     the side of the deck. The forward suspension         boat was waterborne.
                                     hook then released allowing the boat to briefly
                                     swing about the aft hook. The aft hook then
                                     released, allowing the boat to fall to the water
                                     and capsize. All six crew were injured, one
                                     fatally.
Type of Casualty                                                                                                                                                                                                                    Page 21
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                     Issues raised
                        Date of
Reporting State         casualty                    Event                                                    Causes                                                                         Human factor
Second ship (if any)
MACHINERY DAMAGE        07/12/1997   During sea trials, domestic steam on the vessel       The rupture was caused by the failure of the safety          The SMS was inadequate. It did not contain adequate procedures to ensure the
ISLAND PRINCESS
PASSENGER CRUISE SHIP
                                     was provided by a temporarily installed oil           valves to prevent over pressurisation of the                 maintenance and safe operation of the steam generating plant, despite previous economiser
UNITED KINGDOM                       fired boiler. The two economisers (waste heat         economiser. The safety valves had not been                   and safety valve problems on the ISLAND PRINCESS and a sister vessel.
20186                                boilers) were filled with water, but, were not        maintained to the manufacturer's specifications and
UNITED KINGDOM
                                     going to be used. The crew intended to vent           they had become seized in the closed position.               Preoccupation of the engineering staff with the shipboard repairs and sea trials may have
                                     the economisers by using the hand easing gear         Long term progressive corrosion and fatigue cracking         resulted in inadequate thought being given to the consequences of not draining the
                                     for the safety valves to lift the valves off their    of the economiser contributed to the failure.                economiser or ensuring that venting was sufficient to prevent a pressure accumulation.
                                     seats. The crew was unaware that the safety           The engineers on watch, after deciding not to drain the
                                     valves on the port economiser were not opened         economiser, failed to monitor economiser pressure to
                                     despite the position of the indicators on the         ensure that it was adequately vented.
                                     easing gear. Both valves were corroded in the         There was a history of economiser fractures and safety
                                     closed position and they did not relieve the          valve seizures on this ship and a sister vessel.
                                     pressure that was building up in the                  The Safety Management System (SMS) did not
                                     economiser. Due to excessive pressure, the            adequately address either of these issues in that there
                                     port economiser ruptured in way of a                  were no procedures for inspection of the economisers
                                     circumferential welded joint. Two persons             or to ensure satisfactory safety valve operation.
                                     died and three others were injured as a result of
                                     the failure.
CAPSIZING               14/01/1993   En route from Swinoujscie to Ystad with 35            The Ferry left Swinoujscie asymmetrically (towards           The Ferry departed Swinoujscie without having fulfilled the safety requirements as to:
JAN HEWELIUSZ
FERRY
                                     passengers and 29 crew members and a cargo            port side) ballasted. The wind pressure and shifting of      1. The emergency stability in Rule 7, Chapter 7, Part II-B of the SOLAS 60 Convention.
POLAND                               of 10 railway waggons and 28 motor vehicles           cargo from the vehicles and the vehicles themselves          2. Keeping the stern gate stream-proof, required by Rule 3.10(b)(iii), Chapter I of the
3015                                 the Ferry capsized and sank subsequent to a           increased the listing to port. The pouring of water,         Load Line Convention of 1966.
POLAND
                                     still increasing list to port during the conditions   flowing overboard on that side from no. 3 ballast tank       3. Fastening of motor vehicles in accordance with good seamanship.
                                     of black night with gusty winds of a force of         and overflowing from no. 10 stb. to port tanks of the
                                     hurricane blowing from the West. The Ferry            rolling compensation system caused the list to increase      Besides see DECISION of 26 January 1999 by The Maritime Chamber of Appeal at the
                                     was a total loss and the 35 passengers and 20         to an angle at which considerable amounts of                 District Court at Gdansk.
                                     crew members lost their lives.                        overboard water commenced penetrating inside the
                                                                                           Ferry through the constructional openings, up to the
                                                                                           moment when she lost the buoyancy. It cannot be
                                                                                           excluded that, during the Ferry’s list to port side the
                                                                                           overboard water penetrating inside, due to her stern
                                                                                           gate getting untight, could well have deepened her list
                                                                                           and speeded up the Ferry’s sinking.
GROUNDING/STRANDING     23/04/1999   Upbound in St. Mary's River, struck bottom in         A deeper and shallower channel are adjacent to each          Company Masters warned to consider effects of shallow water, squat and trim in the area.
JEAN PARISIEN
BULK CARRIER, GREAT
                                     Middle Neebish Channel without grounding.             other.
LAKER SELF                           Shell holed in way of water ballast tank no. 5.       Vessel contacted bottom in the shallow side.
CANADA                                                                                     As vessel approached the shallower side, bank suction
22772
CANADA
                                                                                           and squat were possible.
                                                                                           Considerable stern trim was not adjusted prior to transit.
Type of Casualty                                                                                                                                                                                                            Page 22
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                             Issues raised
                       Date of
Reporting State        casualty                    Event                                                 Causes                                                                     Human factor
Second ship (if any)
COLLISION              07/08/1999   The tug was outbound from Vancouver, at            Effective lookout was not maintained by either vessel.   Importance of comprehensive knowledge of navigation lights.
JOSE NARVAEZ
TUG
                                    night, towing the coal-laden barge on a            Lack of proficiency of pleasure craft operators to       Dedicated lookout should be posted.
CANADA                              towline. The pleasure craft passed between the     identify light configurations on ships.
150                                 tug and the barge. The propellers of the           Tug boat:
CANADA
SUNBOY
                                    pleasure craft became fouled in the towline,       - Sub-standard navigation lights.
PLEASURE CRAFT                      and the pleasure craft was struck by the on-       - Ineffectively monitored company's safety policy.
UNITED STATES                       coming barge, and capsized.                        - The wheelhouse was temporarily left unattended due
17
                                    Of the 14 people on board the pleasure craft,      to the defective intercom.
                                    four drowned, one remains missing and nine
                                    were rescued.
CAPSIZING              14/10/1999   A fishing vessel of 11.2 m in length of open       Vessel was overloaded, deck below the water.             The skippers/operators of small fishing vessels should understand the basic principles of
JOSEPH & SISTERS
FISHING VESSEL
                                    construction, at 0315 on October 14, 1999,         Lobster traps vertical centre of gravity was too high.   stability and should learn safe operating practices and survival techniques.
CANADA                              when proceeded to lay lobster traps was struck     The well deck scuppers plugs retained on board the       The crewmembers of small fishing vessels should learn safe operating practices and
24                                  by three waves, which flooded the well. The        water shipped over the gunwale.                          survival techniques.
CANADA
                                    vessel capsized and one crew member is             Crewmember was not wearing any type of personal          Life rafts should have a hydrostatic release and be in a position of easy launching in
                                    missing. The vessels was carrying 160 lobster      flotation device.                                        emergency situations.
                                    traps (about 12.7MT) with the uppermost tier 2     Skipper/operator was not certified and crewmembers
                                    m above the deck. Five persons were on board,      did not have basic safety training.                      Vessel overloaded and height of the traps centre of gravity: Error - Mistake - Inadequate
                                    2 more than the authorized number. Before                                                                   technical knowledge.
                                    departure, the owner did not listen to the                                                                  Putting in the well deck scuppers plugs: Error - Mistake - Inadequate technical knowledge.
                                    official weather information. He plugged the                                                                Crewmember not wearing personal flotation device: Error - Mistake - lack of perception.
                                    well deck scuppers, because the deck would be                                                               Skipper/operator and crewmembers without certification or basic safety course and
                                    below the waterline due to the overloading.                                                                 training: organizational error - poor regulation, procedures and practices.
                                    The free surface effect of the water inside the
                                    well and the too high traps centre of gravity on
                                    board, caused a situation of instability and the
                                    vessel capsized. The cargo and crew were
                                    thrown into the water. The owner escaped after
                                    the vessel partially righted in a flooded
                                    condition and sunk by the stern first. The
                                    missing crew member was not wearing any
                                    type of personal flotation device and the crew
                                    did not have time to launch the life raft
                                    manually and it did not deploy automatically.
                                    The rescue was done by another fishing vessel.
                                    Consequences: One person missing and total
                                    loss of the vessel.
Type of Casualty                                                                                                                                                                                                                Page 23
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                Issues raised
                       Date of
Reporting State        casualty                    Event                                                 Causes                                                                        Human factor
Second ship (if any)
FALL OVERBOARD         28/12/1999   Two tugs, the SEASPAN PACER and                    The reason why the mate fell overboard was not             See "Causes"
JUNEAU
FREIGHT BARGE
                                    ESCORT EAGLE, were manoeuvring the                 established with any certainty.
UNITED STATES                       barge JUNEAU onto its berth in Seattle. The        However, factors conducive to an accident of this kind
5051                                chief mate from the SEASPAN PACER was on           are the working condition on board the barge, which
CANADA
                                    the barge directing the two skippers of the tugs   comprised inadequately protected walkway on its side,
                                    and three other tug crewmen on the barge.          lack of lighting, obstructions and protrusions located
                                    During the berthing operation, the chief mate      within the walkway, and the dew-covered surface of
                                    fell overboard from the barge becoming             the deck.
                                    trapped between the barge and the dolphin. He      Also safety equipment such as hard hats & head lamp
                                    sustained serious injuries. In spite of a prompt   were not used and the non strapping of the radio to the
                                    response by the crew of the tugs and               coveralls exposed the deckhand to higher-than-normal
                                    emergency units, he did not regain                 risk and reduced his chance of survival in the accident.
                                    consciousness and was declared dead upon
                                    arrival at a local hospital.
GROUNDING/STRANDING    12/11/1999   The ship was one of four (amongst five), which     - Lack of awareness by the Master of the deteriorating     - The vessel had been poorly maintained and subject to adverse port state control reports.
KARAER III
GENERAL CARGO SHIP
                                    grounded on the same day and in the same           weather conditions and need to prepare to avoid            The owner is directly responsible to ensure that the vessel is seaworthy and that
TURKEY                              circumstances, after being at anchor waiting to    possible grounding.                                        documentation on board is valid.
1595                                enter the Port-la-Nouvelle, South of France, to    - The vessel had deballasted to enter the port.            - A continuous means of communication between the vessel at anchor and port Authorities
FRANCE
                                    load grain. The KARAER III grounded on the         Consequently the lower drafts of the vessel were           enables better exchange of information to enable timely decisions on what action to take in
                                    rocky structure of the breakwater south of the     unable to counter the effect of wind and sea.              deteriorating weather conditions.
                                    port entrance.                                     - The propulsive power of the vessel was insufficient to   - The charterer and shipper have a responsibility to assure that the assigned vessel is
                                    The vessel arrived the day before the              counter wind and sea.                                      suitable for the voyage and trade intended.
                                    grounding. During the period at anchor the         - Lack of information from the port to Master.
                                    weather deteriorated to windforce E to SE                                                                     Master awareness of the changing conditions that may affect the safety of the vessel is
                                    force 11 to 12. Consequently, anchors dragged                                                                 dependent not only on his experience and competence, but on the support of port
                                    and anchor chains broke.                                                                                      Authorities and owner to ensure that he has sufficient information to enable him to make
                                                                                                                                                  correct and timely decisions.
GROUNDING/STRANDING    13/12/2000   LAGIK was carrying a cargo of 2250.40 tons         1. The Master taking the helm from the Pilot as the        1. There were no written procedures or instructions for the pilots on the River Nene and no
LAGIK
GENERAL CARGO SHIP
                                    of steel products to be discharged in Port         vessel was about to enter the swinging basin.              formal written risk assessments had been carried out with regard to navigation.
ANTIGUA AND BARBUDA                 Sutton Bridge. The vessel was under pilotage       2. Differing perceptions as to who had conduct of the      2. The tug’s crew were ashore, and it took over 30 minutes to make her ready for use.
1000                                in the River Nene on the last of a spring flood    navigation after the Master took the helm.                 3. Fenland District Council was required to have an OPRC plan for the port but did not
UNITED KINGDOM
                                    tide. As she entered the swinging basin at the     3. Inappropriate manoeuvring for the prevailing            have one.
                                    port, to be swung prior to berthing, she lost      conditions.                                                4. All four pilots at Port Sutton Bridge had not revalidated their certificates of competency.
                                    control and her bow grounded at a distance         4. The Master either ignoring the Pilot’s advice or        Human factors:
                                    from the opposite bank equal to the ship’s         failing to exercise his right to intervene when he         1. It was agreed that a spring would not be used during the turning operation.
                                    length, then her aft grounded within a few         became concerned about the Pilot’s intended                2. There is conflicting evidence with respect to the advice given by the Pilot after the
                                    seconds. The time of the grounding was 19:32       manoeuvre.                                                 Master took over the helm, and the helm, propeller and bow thruster movements carried
                                    UTC on 13 December 2000. She was declared          5. No spring line was used and no tug was standing by      out during the following period.
                                    a constructive total loss and blocked the River    ready for immediate use.
                                    Nene and closed the port of Wisbech for 44         6. No formal written risk assessment had been made
                                    days. No injuries were sustained as a result of    for the turning operation at Port Sutton Bridge.
                                    this accident.
Type of Casualty                                                                                                                                                                                                                   Page 24
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                    Issues raised
                       Date of
Reporting State        casualty                    Event                                                    Causes                                                                         Human factor
Second ship (if any)
CAPSIZING              28/03/2000   At 21:30 (local time) on 28 March 2000, a            At the time of the occurrence, the stability of the vessel   To what extent the loss of one paravane endangers the safety of a vessel.
LORI CATHLYNN
FISHING VESSEL
                                    small fishing vessel heeled, downflooded the         had been reduced because: the vessel had a deck load         The deck integrity should be always guaranteed.
CANADA                              lazarette and holds and capsized to starboard,       of herring spawn, about 4MT, not considered by the           Fishing vessels should undergo an inclining test and should meet the criteria of IMO
37                                  but remained afloat. The vessel suddenly yaw         roll test; the fishing holds were 50% filled with            Resolution A.168(ES.IV).
CANADA
                                    to starboard and heeled to the same side. The        seawater ballast; and the oil fuel and fresh water tanks     Concise and simplified information should be given to the fishing vessels skippers to
                                    skipper reacted by steering to port and the          were slack.                                                  assess the stability of the vessel when the standard conditions of loading and operation are
                                    vessel recovered from the roll but again heeled      It is possible that the excessive heel was influenced by     changed.
                                    rapidly to starboard up to an angle of 50º-60º.      the possible loss of the roll dampening paravanes.
                                    The Mayday call was transmitted and the 5            Deck integrity: the flush deck scuttles covers and the       The flush deck scuttles and the hatch covers not secured: Violation - Mistake - Rule based.
                                    crewmembers were rescued in 5 mins by a              hatch covers of the fishing holds were not properly          Incorrect loading reducing the stability: Error - Mistake - Misapplication of good practices.
                                    nearby fishing vessel. No skiff or inflatable life   secured.                                                     Absence of guidance about the loading, trim and stability conditions for the vessel in
                                    raft were on board.                                  Absence of guidance for the skipper about the loading,       operation: organizational error - poor regulation, procedures and practices.
                                    Consequences: no injury or pollution; only one       trim, and stability conditions of the vessel in operation.   No inflatable life raft or skiff was on board: Violation - Mistake - Rule based.
                                    crewmember received treatment from
                                    hypothermia; the vessel was rendered unfit to
                                    proceed.
COLLISION              21/12/2000   - Tank barge collided with the ro-ro cargo           On the tank barge :                                          - Fitting of watch alarms and provision of lookout man can help to prevent such accidents.
LOVERVAL
RORO CARGO
                                    vessel in River Thames whilst the ro-ro cargo        - The mate suffering from the effects of fatigue caused      - Specific instructions and guidelines with respect to hours of work and rest should be
LUXEMBOURG                          vessel was secured alongside discharging             by long hours of duty and lack of quality rest.              given to the crew with the aim of eliminating fatigue amongst watchkeepers.
10931                               cargo.                                               - The mate had recently consumed alcohol.                    - Consideration should be given to extending suitably modified requirements of ISM Code
UNITED KINGDOM
BRUCE STONE
                                    - LOVERVAL was holed above the waterline             - No additional person on watch during the hours of          to domestic tankers.
OIL TANKER                          on her port side; BRUCE STONE sustained              darkness.
UNITED KINGDOM                      only superficial bow damage. There were no           - The absence of a watch alarm.                              Administrations should consider extending the provision of STCW Convention relating to
357
                                    injuries or pollution.                                                                                            hours of work and rest for watchkeepers, and suitably modified requirements of ISM
                                    - There was potential for a more serious                                                                          Code, to ships on domestic trade.
                                    accident resulting in explosion, serious injury
                                    and pollution.
GROUNDING/STRANDING    17/08/1999   The MANDARIN ARROW was en route from                 The vessel grounded as a result of being set suddenly        The currents in Duncan Bay have been known to cause berthing difficulties in the past. In
MANDARIN ARROW
GENERAL CARGO SHIP
                                    Kitimat to Duncan Bay under the conduct of a         onto a shoal. Contributing to the occurrence was the         March 2000, the Duncan Bay simulation was completed and training commenced for both
BAHAMAS                             British Columbia coast Pilot. During the             fact that, at this stage of the tide, currents in the area   senior and apprentice pilots on the full mission bridge simulator at Star Center in Dania,
35998                               approach to a wharf in Duncan Bay, with two          are unpredictable, the manoeuvres to withdraw the            Florida, USA.
CANADA
                                    tugboats assisting, the vessel grounded              vessel from danger were undertaken too late to have          The abort manoeuvre was initiated too late to have the intended result of withdrawing the
                                    approximately 25 m from the shore. About 55          the intended result, and the assisting tugs were not of a    vessel from danger.
                                    mns later, the vessel re-floated on a rising tide    design well suited to assist in the docking of this large
                                    and was berthed at the wharf without further         vessel.
                                    incident.
                                    No injury or pollution was reported as a result
                                    of this occurrence. However, the MANDARIN
                                    ARROW sustained extensive damage to her
                                    shell plating.
Type of Casualty                                                                                                                                                                                                             Page 25
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                              Issues raised
                        Date of
Reporting State         casualty                    Event                                                   Causes                                                                   Human factor
Second ship (if any)
WORK-RELATED ACCIDENT   10/06/2000   Due to inoperable bilge pumps, a portable           The pump was initially located on the open deck;        Hazards associated with exhaust gases from portable gasoline powered equipment
MARIAMA K
FISHING VESSEL
                                     internal combustion gasoline engine driven          however, the suction head was not sufficient to         operated in enclosed spaces.
UNITED KINGDOM                       pump was used in the engine room to pump the        effectively pump the bilges from this position. When    While at sea, the necessity to keep the emergency escape hatch open for the discharge
                                     bilges. The exhaust gases from the gasoline         located in the engine room, the discharge rate of the   hose of the pump adversely affected the watertight integrity of the vessel and the
UNITED KINGDOM
                                     engine discharged directly into the engine          pump improved.                                          effectiveness of the engine room fixed firefighting system.
                                     room. When the pump was operated in port,           Apparently, no consideration was given to the removal   Logistics of managing and maintaining vessels operating for prolonged periods in remote
                                     without the main or auxiliary equipment or the      from the engine room of the exhaust gases from the      areas away from the home port.
                                     engine room vent fan running, the carbon            engine on the pump nor of the hazards associated with   Fire an explosion hazards associated with the potential leakage of gasoline from the fuel
                                     monoxide levels inside the engine room rose to      carbon monoxide concentrations in enclosed spaces.      tank of the portable pump into the engine room bilges.
                                     dangerously high levels. The engineer in the        (MSC/Circ.827, Internal cause 8.1.1.2).                 Lack of training and/or awareness of carbon monoxide poisoning led to the unsafe act of
                                     engine room was overcome and died of carbon                                                                 locating the portable pump in the engine room.
                                     monoxide poisoning. Personnel attempting to                                                                 Also, consideration was not given to the potential effects of operating the vessel at sea
                                     rescue and revive the engineer also felt the                                                                with the escape trunk to the engine room open. (Human error)
                                     effects of the carbon monoxide concentrations.
WORK-RELATED ACCIDENT   08/09/2000   A cart for carrying pipes to the "iron              The reason why the parking brake was released was       - There was no audible alarm fitted to indicate movement of the cart to warn the crewman
MARINE 700
DRILLING PONTOON
                                     roughneck" runs on a track and is operated by       not established. But the slight trim by the bow and     of the danger.
VANUATU                              rack and pinion. The cart was loaded with a         pitching of the vessel would have influenced            - A single joystick controls the cart’s speed and direction as well as the parking brake.
27386                                long 6 inch pipe and parked with the parking        movement of the cart.                                   Brake is applied or released by simply jogging the joystick. The joystick was not protected
VANUATU
                                     brake engaged. A crewman was working near                                                                   to prevent passers-by accidentally jogging it.
                                     the "roughneck" when the cart inadvertently                                                                 - The information in the cart manual encouraged complacency by stating that the parking
                                     rolled towards him knocking him over to one                                                                 brake was not needed in calm conditions.
                                     side. He was airlifted to hospital but died a few                                                           - The brake seemed to be inoperable since, during post-accident tests, the cart moved with
                                     hours after the accident.                                                                                   the brake set in the on position.

                                                                                                                                                 Given the working conditions of the rig, the design of the brake/cart system did not ensure
                                                                                                                                                 that the parking brake was a primary source to prevent inadvertent movement of the cart.
                                                                                                                                                 A secondary emergency braking system was fitted but its use was discouraged because its
                                                                                                                                                 application affected shutdown of machinery unconnected with the cart. The design and
                                                                                                                                                 the makers remarks in the manual probably diminished awareness on board of the
                                                                                                                                                 importance of the need for an efficient and safe braking system.
COLLISION               18/06/1998   Collision with container ship NEDLLOYD              Failure of propulsion machinery.                        Machinery test procedure adequacy.
MSC KATIE
CONTAINER SHIP
                                     SYDNEY. Ship remained seaworthy.                                                                            Bridge/Engine room communications.
PANAMA
35599
AUSTRALIA
P&O NEDLLOYD SYDNEY
CONTAINER SHIP
NETHERLANDS
31333
COLLISION               29/02/2000   Collision between the Spanish fishing vessel        Breach of rules.                                        Eventually lack of vigilance on board MURRAY but also on board COLOMIN which was
MURRAY
GENERAL CARGO SHIP
                                     while fishing and the Cypriot cargo ship while      Human error.                                            crossing the TSS at an angle of less than 90º.
CYPRUS                               underway within the Traffic Separation              Fatigue.                                                Breach of COLREG regulations and lack of vigilance.
2201                                 Scheme (TSS).
SPAIN
COLOMIN
FISHING VESSEL
SPAIN
40
Type of Casualty                                                                                                                                                                                                                Page 26
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                Issues raised
                       Date of
Reporting State        casualty                    Event                                                 Causes                                                                        Human factor
Second ship (if any)
FIRE                   20/07/1999   The forward fuel oil filter on the port generator   The fire was due to leakage from the fuel oil filter   Unauthorized modifications should not be made.
NANTICOKE
BULK CARRIER
                                    was said to have been tested at 15:00 hrs on        spraying onto the hot cylinder of the generator        Spare gaskets should be carried.
CANADA                              20/07/1999 and the generator inspected at           probably at the indicator cock.                        Shielding, at least, should have been fitted to prevent sprays reaching hot surfaces. (NB :
21870                               15:15 hrs by the Chief Engineer who took over       The leakage was from the improperly modified filter    in 2003, it will be mandatory for hot un-insulated surfaces to be insulated.)
CANADA
                                    the watch whilst the Watchkeeping Engineer          cover through a re-used annealed copper sealing gasket.Watchkeeping should not be confined to observations in and from control rooms. Regular
                                    attended a fire drill.                              Poor watchkeeping meant that the initial outbreak was  circuits of machinery and cargo spaces should be made. Conscientious watchkeeping
                                    Whilst in the control room, the Chief Engineer      not detected.                                          should be the rule.
                                    noted a high cooling water temperature alarm                                                               Adequate spares should be carried.
                                    from the port generator. Investigation revealed                                                            Manufacturers designs should not be changed.
                                    a smoke-filled engine room from the port                                                                   Thorough tests should be made following maintenance.
                                    generator. The fire was eventually                                                                         NB : Nothing new arises from this casualty.
                                    extinguished by the fixed halon installation.                                                              Pipeline regulations may have prevented this casualty if they had been anticipated.
CAPSIZING              07/08/1997   During embarkation of pilots at the pilot station   The MTCS centre instructed the bulk carrier to prepare Use of appropriate and international approved pilot embarkation equipment.
NAVIMAR V
PILOT BOAT
                                    at Quebec, NAVIMAR V came alongside a 68            the starboard accommodation ladder for embarkation     Better control of stability criteria for pilot boats.
CANADA                              775 dwt bulk carrier shortly before 0010. Two       instead of the equipped pilot embarkation facility     Standards or code of practice for pilot transfer arrangements.
12                                  pilots climbed onto the accommodation ladder,       amidships, which is contrary to international
CANADA
                                    but before they could reach the vessel’s deck,      regulations.                                           The pilots were transferred from the after deck of the boat. The Master of the boat
                                    the pilot boat plunged into the sea and             The speed during the embarkation was greater than      therefore had to divide his attention between the approach manoeuvres ahead and the
                                    resurfaced upside down.                             usual.                                                 transfer of the pilots behind him.
                                    The speed of the vessels during the transfer        The pilot boat was manoeuvred onto the crest of a
                                    was about 10 knots.                                 wave generated by the bulk carrier and the boat
                                    The boat’s crew were the Master and the deck-       descended into the trough of the next wave and the
                                    hand. The deck-hand was thrown overboard            bow plunged into the sea. The boat continued to pitch
                                    but succeeded in climbing onto the overturned       until it turned over.
                                    boat. The Master was trapped within the boat        There were shortcomings in the pilot boat’s dynamic
                                    but after a while he could swim to the surface.     trimming characteristics.
                                    Both men were rescued by a Canadian Coast           There was no communication between the pilot boat
                                    Guard vessel.                                       and the vessel before the embarkation.
                                    The superstructure of the boat shattered and
                                    electrical installations were destroyed by water.
                                    Damage included deformation of the rudder
                                    stocks. After the boat was refloated it was,
                                    however, possible to restart both engines.
                                    Damage to the bulk carrier was limited to
                                    deformation of the bottom platform of the
                                    starboard accommodation ladder.
STRANDING/GROUNDING    30/04/1998   The container ship NENUFAR UNO grounded             The Officer of the Watch was alone on the bridge, he      Need to have two persons on the bridge during the hours of darkness.
NENUFAR UNO
CONTAINER SHIP
                                    on 30/04/1998 at 06:10 hrs on the beach of          did not watch radio frequencies and he fell asleep.       Making necessary arrangements to deal with commercial operations.
SPAIN                               Parque Maritimo on her route from Las Palma,                                                                  Installation of bridge watch alarm.
3779                                Gran Canaria to Santa Cruz, Tenerife.                                                                         Ensuring that surveillance installations ashore can intervene in case of 'any malfunctions'.
SPAIN
                                    Refloated after several attempts with the                                                                     Casualty resulting from human error.
                                    assistance of tug boats on 01/05/98. The ship                                                                 (No investigation report.)
                                    which had a water ingress in the fore peak and
                                    in the bow thruster compartment was to be
                                    repaired in Las Palmas.
Type of Casualty                                                                                                                                                                                                                Page 27
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                 Issues raised
                       Date of
Reporting State        casualty                   Event                                                  Causes                                                                         Human factor
Second ship (if any)
GROUNDING/STRANDING    04/02/1999   New Carissa approached Coos Bay on                 As the vessel approached Coos Bay, the Master was           The Master made a poor decision to go to anchorage instead of steaming in safe waters
NEW CARISSA
WOOD-CHIP CARRIER
                                    03/02/1999. At about 17:00 hrs, the vessel was     instructed by the Pilot to wait until the next morning      until the weather abated.
PANAMA                              informed by Coos Bay Pilot that due to heavy       because the weather was very stormy, boisterous with        The Master did not consider steaming all night instead of anchoring.
36571                               weather, they would bring the vessel into port     very high swells; ebbing tides possibly causing a
PANAMA
                                    at about 07:30 hrs on 04/02/1999. At about         localized steepening of the ocean swell.
                                    19:00 hrs, the vessel proceeded to anchor in
                                    one mile north of the position marked for
                                    anchorage on the chart. The port anchor was
                                    used and seven shackles of chain were in the
                                    water. Winds were westerly to south westerly
                                    direction, force 7-8 beaufort scale. On
                                    04/02/1999 at 06:30 hrs, the Pilot informed the
                                    Master that docking was delayed until 09:00
                                    hrs. At about 07:25 hrs, the Chief Mate
                                    informed the Master that the vessel was
                                    dragging anchor. At 07:30 hrs, began heaving
                                    anchor but the vessel was aground at 08:15 hrs.
                                    With about 400,000 gallons of fuel aboard, the
                                    U.S. Navy attempted to set the vessel on fire
                                    with hand grenades to no avail. On
                                    11/02/1999, the vessel was engulfed in flames
                                    after using C-4 plastic explosives and napalm.
                                    Oil was on the beach with cleanup crews
                                    working. There were 59 different
                                    environmental agencies on the scene.
GROUNDING/STRANDING    17/05/1999   The vessel grounded under pilotage in shallow      - When the pilot realized that ship was out of position,    - A conscious understanding of bridge team’s individual roles, requirements and
NEW REACH
GENERAL CARGO SHIP
                                    water en route through the Great Barrier reef.     the ship’s true position was not established to take        responsibilities within the team will increase the chance of a questioning attitude and good
PANAMA                              The pilot had realized that the Heath Reef light   appropriate action.                                         quality and timely flow of information.
13519                               was in the wrong position relative to the ship.    - Pilot’s navigation based on insufficient information,     - Strategies to avoid the onset of fatigue that may effect performance can be developed by
AUSTRALIA
                                    On altering course the vessel grounded. There      faulty analysis and inexperience.                           individuals having knowledge of factors, which can influence its onset.
                                    were no injuries or pollution. Underwater hull     - Judgement and performance affected by fatigue.            - Effective bridge resource management encourages junior watchkeepers with a limited
                                    and internal tank surveys indicated that it was    - Pilot had no strategy to manage or counter inevitable     experience and different cultural background to take a more active and effective role in
                                    safe for the vessel to resume its voyage.          fatigue levels.                                             navigating a vessel safely.
                                                                                       - Communication between pilot and watchkeepers              - A passage plan is incomplete if it does not involve officers of the watch in the pilotage.
                                                                                       minimal.                                                    - Effective briefing and discussion of the passage plan can overcome problems of
                                                                                       - Watchkeeper did not bring to the attention of the pilot   language differences and misunderstanding among the bridge team.
                                                                                       plotted positions.                                          - Attending a bridge resource management training course can be an effective means of
                                                                                       - The watchkeepers lack of concern for relative             achieving successful navigation in confined waters.
                                                                                       position of reef light.
                                                                                       - Lack of bridge resource management.
COLLISION              27/12/2000   In dense fog, the inward bound feeder              No sound signals and excessive speed.                       The owners to provide a specific documented procedure, for adoption by the crew, for the
NORDSEE
GENERAL CARGO SHIP
                                    container vessel collided with the passenger       Lack of any radar plotting.                                 safe operation of their vessels in restricted visibility.
ANTIGUA AND BARBUDA                 vessel on 27/12/2000, in the approaches to         The absence of a dedicated lookout on the feeder            The owners to review the adequacy of the radar.
2579                                Greenock Harbour on the River Clyde, UK.           container vessel.
UNITED KINGDOM
POOLE SCENE
                                    17 of the 41 passengers on board the passenger     The passenger vessel:
PASSENGER SHIP                      vessel were injured.                               - flawed decision making to sail in dense fog;
UNITED KINGDOM                                                                         - inshore route taken instead of safer outbound channel;
119
                                                                                       - deviation into the inward bound channel.
Type of Casualty                                                                                                                                                                                                                 Page 28
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                 Issues raised
                       Date of
Reporting State        casualty                    Event                                                 Causes                                                                         Human factor
Second ship (if any)
HULL FAILURE           21/07/1999   On route from St Helier, Jersey to Granville at    The forces affecting the damage were due to the             Classification Societies need to pay attention to ensuring that the structure of catamarans is
NORMANDIE EXPRESS
FERRY
                                    27 knots with a following sea and swell, a shell   submerging of the two bows into a wave trough and           adequate given the type of vessel and area of operation.
FRANCE                              plate at the forward end of the tunnel             the effect of the following sea. The vessel’s speed was     A motorised pump, if fitted, could have contained the flooding of the forepeaks.
449                                 separating the two hulls bulked and failed at      at the maximum permitted limit given the weather at         One function which limits the safe maximum speed of the vessel is a following sea
FRANCE
                                    the welded joint resulting in flooding of the      the time.                                                   condition, and its speed and direction. The Commission noted that Classification Societies
                                    two forepeak tanks.                                The Commission noted weakness of the forward                need to take this into account when determining the safe speed of catamarans.
                                    With 115 passengers on board the vessel            section which was inadequately stiffened, and
                                    sought safe refuge in Jersey.                      discontinuities in poor quality of plate welds. Access to   A satisfactory quality of welded joint is dependent to some extent on the welder having
                                                                                       the welded joints were poor, a condition which              easy access to the plate joint.
                                                                                       probably influenced the quality of the welds.
COLLISION              24/08/1999   ANALYSIS BASED ON REPORT FROM                      ANALYSIS BASED ON REPORT FROM PANAMA                        ANALYSIS BASED ON REPORT FROM PANAMA (FSI 11) :
NORWEGIAN DREAM
PASSENGER SHIP
                                    PANAMA (FSI 11) :                                  (FSI 11) :                                                  - COLREGS state clearly that collision avoidance can be carried out by using helm and/or
BAHAMAS                             - The two ships collided in the vicinity of F3     - The collision was mainly caused by the failure of the     alteration of speed. There appears to have been marked reluctance to consider a variation
50760                               light buoy in N.E. approaches to the Dover         passenger cruise ship, which was the give way vessel        of speed as an option by the two vessels in this case.
PANAMA/
BAHAMAS
                                    Straits.                                           in a crossing situation, to make sufficient alteration of   - The use of VHF as a collision avoidance tool can be counter-productive. If the
EVER DECENT                         - The container ship suffered substantial          course or speed to avert collision.                         COLREGS are being followed correctly it would not be necessary to use VHF for
CONTAINER SHIP                      damage to her port side that opened No.3 hold      - Collision could also have been averted by reduction       collision avoidance and thus be distracted from the attentiveness in watchkeeping.
PANAMA
52090
                                    to sea. She took an immediate heavy port list,     of speed by the containership.                              - When overtaking another vessel, careful consideration should be given to the side on
                                    but prompt action by the ship’s crew brought it    - The containership limited her ability to act when she     which to overtake. Factors to be taken into account should include available sea room and
                                    under control. A very serious fire broke out in    overtook another vessel from the port side of the other     possible need to take avoiding action in respect of other vessels in the vicinity.
                                    the above deck containers. It was brought          ship thus preventing herself from taking one of the         - Several issues relating to design considerations and dangerous cargo stow on the
                                    sufficiently under control by the ship’s crew      possible avoiding actions viz. a large alteration of        container ship have been raised in the report. Preliminary details of these and other
                                    with help from a salvage team with firefighting    course to starboard.                                        relevant issues were submitted by the flag State and United Kingdom to the Sub-
                                    tugs in 8 days, to allow the ship to proceed to    - The VHF conversation between the two vessels might        Committee on Fire Protection under FP 44/13/1 on 17 December 1999.
                                    Zeebrugge for discharge and damage                 have delayed a sense of urgency from building up in
                                    assessment.                                        the minds of the bridge officers on the two vessels.        ANALYSIS BASED ON REPORT FROM BAHAMAS (FSI 9):
                                    - The passenger cruise ship suffered serious       - Contributory factors to the fire on the containership     Bridge manning in concentrated traffic areas.
                                    damage to her bow but retained watertight          have not been investigated. The main cause of the fire      Radar training and awareness.
                                    integrity and was able to continue to Dover to     however was the collision impact between the two            Situational factors caused by concentration of traffic through Traffic Separation Scheme
                                    land her passengers and assess damage.             ships.                                                      management.
                                    - There were no deaths or injuries to personnel
                                    on either ship.                                    ANALYSIS BASED ON REPORT FROM                               ANALYSIS BASED ON REPORT FROM PANAMA (FSI 11) :
                                                                                       BAHAMAS (FSI 9):                                            Inadequate bridge manning level on the passenger cruise ship - only one officer and one
                                    ANALYSIS BASED ON REPORT FROM                      Distraction and information overload leading to             rating were on the bridge at the time of collision. The Master was not on the bridge. Such
                                    BAHAMAS (FSI 9):                                   confusion.                                                  manning was considered inadequate given the busy traffic in the region and the
                                    Collision in clear weather leading to damage to    Probable confusion of true and relative radar vectors.      requirements for additional tasks to be performed such as reporting of position to
                                    both ships and outbreak of fire in containers      Watch not doubled up - Inadequate bridge manning.           Coastguard.
                                    aboard container vessel.                           Non-optimal use of radar.
                                                                                       Watch not doubled as per owners orders.                     ANALYSIS BASED ON REPORT FROM BAHAMAS (FSI 9):
                                                                                       Situational factors arising out of design of Traffic        Yes. Planned action did not achieve outcome (mistake).
                                                                                       Separation Scheme system.                                   Bridge not properly manned for situation contrary to owners' standing orders (violation).
                                                                                       Volume and concentration of shipping and rapidly
                                                                                       changing situation.
                                                                                       Both ships restrained in their choice of action by other
                                                                                       shipping.
                                                                                       Container ship not crossing Traffic Separation Scheme
                                                                                       at right angles.
                                                                                       Container ship did not take sufficient action to avoid
                                                                                       collision.
Type of Casualty                                                                                                                                                                                                                Page 29
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                Issues raised
                       Date of
Reporting State        casualty                    Event                                                 Causes                                                                        Human factor
Second ship (if any)
HULL FAILURE           11/06/1999   Over a number of days there was a series of        - Water entered the hold through the hatch covers,         - General corrosion affecting integrity of hull structure and poor condition of machinery in
NUMBER ONE
GENERAL CARGO SHIP
                                    main engines breakdowns. While undergoing          which were not watertight due to corrosion and             a vessel in Class and surveyed.
SAINT VINCENT & THE                 repairs, the decks took heavy seas. An             distortion.                                                - Standard of competence and experience for marine consultants responsible for surveying,
GRENADINES                          estimated 1000 tonnes of seawater entered          - Loss of control of the vessel because of main engine     advising and reporting on vessel condition.
4217
FRANCE
                                    number 1 forward hold through the hatch            failure resulting in the hatch covers taking heavy seas.   - Poor condition of radiocommunication equipment.
                                    covers. The forepeak was exposed to the sea        - Poor condition of the main engine, which broke down      - EBIRB had not been registered so that if a signal had been received it would have been
                                    and flooded. Main deck became submerged            on a number of occasions in the period leading up to       difficult to determine which ship was in distress.
                                    and the vessel listed to starboard. Use of VHS     the sinking.
                                    radio and GMDSS failed to transmit the             - Loss of buoyancy and stability due to corrosion and      Organisation and communication issues relating to relationships between classification
                                    mayday message. Finally, the vessel sank. The      loss of watertightness in hull, watertight bulkheads,      society, owners and flag State, and other interested parties limiting contribution to marine
                                    EBIRB did not work. The two liferafts              double bottom intercostals and hatch covers.               safety.
                                    resurfaced. Seven crew members embarked on         - The difficulty with bilge and ballast pumping
                                    one raft and were picked up by the Cambodian       hindering counter measures to pump out the flooded
                                    cargo ship SUN OCEAN 2 days later. 11 of the       compartments and transfer ballast.
                                    18 crew perished.                                  - Deteriorating weather conditions, which were not
                                                                                       unexceptional for that time of year.
OTHER/UNKNOWN          22/03/1998   The vessel, with three passengers and an           Contributory factors in the loss of life were anxiety      Because the passengers suits were fully zipped, they provided thermal protection, delayed
OCEAN THUNDER
PASSENGER SHIP
                                    operator, left for a 3-hour wildlife trip. All     associated with sudden immersion in cold water, the        the onset of hypothermia, and increased the chance of survival.
CANADA                              wore personal flotation device (PFD) suits.        lack of effective radio equipment, and the absence of      The absence of a boarding ladder on small passenger vessels such as this decreases the
                                    After watching whales, the operator took the       emergency medium range radio equipment causing             chance of survival for a person in the water.
CANADA
                                    vessel in towards Plover Reefs. While there,       delay in starting a search.                                Company and Organisation - standing orders inadequate and insufficient.
                                    the boat was swamped and broached by a large                                                                  Crew factors - unsafe working practices.
                                    swell which threw all the occupants into the                                                                  Equipment - equipment badly maintained.
                                    sea. When the boat failed to return, the owner                                                                Individual - poor perception of risk.
                                    raised the alarm and a search began.
                                    Eventually two passengers were rescued after
                                    two hours but the operator and the other
                                    passenger died.
                                    The speed with which the lightly loaded vessel
                                    was swamped in breaking and confused seas
                                    prevented operation of a MayDay
                                    transmission. It was not helped by the fact that
                                    the VHF radiotelephone was not working well
                                    on the day. Although wearing a PFD suit, the
                                    non-swimmer passenger panicked and quickly
                                    drowned. The operator, with a partly open
                                    PFD suit succumbed to hypothermia and
                                    drowned. The operator may not have
                                    appreciated the effect of the large swell on a
                                    lightly loaded vessel and the confused seas
                                    adjacent to the reef itself.
Type of Casualty                                                                                                                                                                                                              Page 30
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                Issues raised
                       Date of
Reporting State        casualty                    Event                                                   Causes                                                                      Human factor
Second ship (if any)
FALL OVERBOARD         23/02/2000   The vessel had sailed from Wick two days             While there are no witnesses to confirm the true facts, Working lifejacket should be worn when working on deck.
OPPORTUNE
FISHING VESSEL
                                    earlier with a crew of 7 for the fishing grounds     it is probable that the crewman mistakenly thought that Keep people informed as to what and where you are working.
UNITED KINGDOM                      50 miles north-east of Wick. She was engaged         the net would be required shortly and therefore untied Individual - violation of procedures and poor perception of risk.
201                                 in shooting her nets, the fifth time that day; the   the net restraining ropes. With vessel movement, part
UNITED KINGDOM
                                    Skipper in the wheelhouse, 3 fishermen in the        of the net fell overboard and the crewman climbed onto
                                    fishroom, and the other 3 on deck. Partway           the net bin to pull it back inboard. In the process he
                                    through the shoot, the 3 from the fishroom           fell overboard.
                                    came on deck although one, the engineer, went        No lifejacket was worn by the fisherman.
                                    below to carry out machinery maintenance.            He had not told anybody what he was doing.
                                    When 8 coils had been shot, the vessel's course
                                    was changed and the work started on shooting
                                    the remaining 5 coils. After 3 coils had been
                                    shot, the engineer came back on deck to find
                                    the cod end and net had fallen over the side.
                                    Calling the others, the net was hauled inboard
                                    and the 2 loose ropes that held the net in the
                                    bin re-tied. The remaining 2 coils were shot
                                    and the net streamed. Only after they had
                                    finished, did they realize that one of the crew
                                    was missing. The alarm was raised, the nets
                                    retrieved and the vessel started on a reciprocal
                                    course search. The body of the fisherman was
                                    recovered later by a Coastguard helicopter.
CONTACT                27/04/2000   P&OSL AQUITAINE left Dover at 0817 BST               1. Port CPP control was lost because rotary vanes of       At the time of impact, many passengers were standing up ready to disembark, while others
P&OSL AQUITAINE
FERRY
                                    on 27 April 2000, bound for Calais, France           main shaft-driven pump were damaged.                       were making their way down on to the car deck. If an appropriate announcement was
UNITED KINGDOM                      with 1241 passengers and 123 crew on board.          2. The engineers were unable to detect the fault in the    made to the passengers before the vessel enters a port, hopefully the number of those
28833                               After she had passed through the Calais port         shaft-driven pump of the port CPP system for the           injured could be minimized.
UNITED KINGDOM
                                    entrance the Master realized he was going            following reasons :
                                    faster than normal. Despite putting the two          - There was no facility for remotely monitoring the        The chief engineer did not report his thoughts about the CPP system to the Master because
                                    combinators to select astern pitch on both           CPP system oil pressure.                                   he thought it was only a minor problem. Having been told of the problem, the Master
                                    propellers, only the starboard propeller actually    - The lack of an audible alarm facility.                   might well have been more aware of the possibility that something could go wrong with
                                    responded to the command. The failure of the         - There was no obvious and convenient way for the          the system.
                                    port propeller to respond was not noted by the       engineers to monitor and compare bridge demand and
                                    bridge team. As a result, the Master was unable      achieved propeller pitch.
                                    to prevent the vessel from striking the berth at     - The system was not designed to give warning of low
                                    a speed of about 7 knots. 180 passengers and         CPP pump delivery pressure.
                                    29 crew were injured. The vessel was taken out       - The operation and maintenance manual written in a
                                    of service and dry docked.                           language none of the engineers understood.
                                                                                         3. Failure of the chief engineer to inform the Master of
                                                                                         the unusual cutting in of the port CPP stand-by pump.
                                                                                         4. Lack of awareness that anything was wrong with the
                                                                                         port CPP system by the Master and first officer
                                                                                         because the response to changes on position of the
                                                                                         combinator control levers was not monitored during
                                                                                         manoeuvring.
Type of Casualty                                                                                                                                                                                                                  Page 31
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                   Issues raised
                          Date of
Reporting State           casualty                    Event                                                 Causes                                                                        Human factor
Second ship (if any)
OTHER/UNKNOWN             22/06/1999   Failure of a one way sprag type self-lifting       An improper grade of lubricating oil with a higher         The need to use the proper type and quantity of lubricating oil.
P&OSL CALAIS
RORO CARGO/FERRY
                                       clutch installed on a lifeboat winch to lock       viscosity than that recommended by the manufacturer        Difficulty in using the manufacturer's maintenance manuals due to the inclusion of data for
UNITED KINGDOM                         when the power to the winch motor was              was used.                                                  several winches.
26433                                  secured. As a result, the lifeboat did not         Overfilling of the oil reservoir may also be a factor in   In addition, the need to develop clear and concise shipboard maintenance procedures.
UNITED KINGDOM
                                       remain in position and was lowered.                this type of failure. (MSC/Circ.827, Internal cause        Failure to follow manufacturer's recommendations.
                                       No injuries resulted from the failure.             8.1.1.2)                                                   Manuals developed by the equipment manufacturer were not user friendly.
                                       (MSC/Circ.827, Casualty type 6.7)
MACHINERY DAMAGE          26/10/2000   A lifeboat with four people on board was being     - Exact reason why the hooks released was not              The hook mechanism is susceptible to failure given small changes in tolerances due to
PAC MONARCH
BULK CARRIER
                                       lowered into the water when the stern on-load      determined.                                                operational wear, and machining deviations during manufacture. The unsafe condition is
BAHAMAS                                release hook released inadvertently. Three of      - Jerking of the lifeboat as the davit landed on its       difficult to detect by seamen during their normal routines and inspection. Seamen need to
38878                                  the four were killed and the fourth was injured.   stoppers combined with the possible condition that the     be constantly vigilant to ensure that they are aware of the complications of on-load release
BAHAMAS
                                                                                          hooks were not located in the reset position resulted in   hook mechanism and that they are assured that the hooks are properly secured and the
                                                                                          its release.                                               release and interlock systems work effectively.
                                                                                          - It was thought that the hook locking mechanism may
                                                                                          have been disarmed when last lifted out of the water.      - The on-load hooks and release mechanism is complicated making it difficult for seamen
                                                                                                                                                     to ensure that it works and is operated and maintained effectively.
                                                                                                                                                     The hook reset procedure is complicated needing three steps using two hands to reset the
                                                                                                                                                     hook.
                                                                                                                                                     - The release mechanism is liable to release inadvertently when the load is off the hook, a
                                                                                                                                                     condition difficult to detect during launch and recovery routines.
                                                                                                                                                     - The indicating interlock lights can give a false impression that the hooks are locked
                                                                                                                                                     when they are not.
                                                                                                                                                     - Given wear on the reset mechanism, reference marks on the hooks to show that the hooks
                                                                                                                                                     have been set properly can give a false impression they are reset when they are not, thus
                                                                                                                                                     giving the user a false sense of security.
COLLISION               12/01/2000     Night time conditions with clear visibility in     Master of PASADENA UNIVERSAL unsure of                     Poor lookout and reluctance to adjust speed are ongoing issues.
PASADENA UNIVERSAL
REFRIGERATED CARGO SHIP
                                       waters in west bound lane off Sandettie Bank,      position relative to shoal water, does not anticipate      Proper position plotting and bridge management in congested waters.
UNITED KINGDOM (CAYMAN                 Dover Strait. PASADENA UNIVERSAL                   course alteration position, did not overtake at safe       Estimates of distance and issues of interaction.
ISLANDS)                               passed astern of NORDHEIM as part of an            distance and check his actions until finally passed and    Mistakes in the form of poorly executed or inappropriate plan.
9273
UNITED KINGDOM
                                       overtaking manoeuvre. Within five minutes of       clear.                                                     Lack of attention.
NORDHEIM                               passing across NORDHEIM’s stern                    NORDHEIM did not maintain a proper lookout, and
BULK CARRIER                           PASADENA UNIVERSAL alters to port for              had not evaluated action of overtaking ship, made
CYPRUS
5306
                                       fishing vessel while in close proximity to         assumptions on scanty information and did not
                                       overtaken ship. NORDHEIM at course                 appreciate speed of overtaking vessel.
                                       alteration point starts to alter to starboard.
                                       Vessels collide.
GROUNDING/STRANDING       05/04/1999   Grounding of the bulk carrier at 05:00 hrs         Delayed manoeuvre to alter course.                         Excess of self-confidence owing to the open waters at this location of the channel and the
PATERSON
BULK CARRIER
                                       while downbound on Lake St. Francis                Officer of the Watch on bridge single-handedly             good visibility.
CANADA                                 (Canada) on the north side of the channel. The     conducted the navigation and radio communications          Imprecision of the buoys system.
20370                                  casualty took place during a manoeuvre of          were non-operational.                                      Presence of only one officer.
CANADA
                                       course alteration.                                 Over-reliance on visual navigational technique.            Efficiency of navigational aid.
                                       Re-floated 4 days later without having caused
                                       any pollution and with minor damage.
Type of Casualty                                                                                                                                                                                                                Page 32
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                 Issues raised
                       Date of
Reporting State        casualty                    Event                                                  Causes                                                                        Human factor
Second ship (if any)
OTHER                  01/07/2000   In raising the starboard rescue boat, an able       The suspension and painter hooks are of the same size      Adequacy of shipboard instructions for raising rescue boats.
PRIDE OF BILBAO
PASSENGER SHIP
                                    seaman (AB) attached the forward suspension         and this permitted the inadvertent connection of the       Flawed design of the rescue boat in that the suspension and painter hooks were the same
UNITED KINGDOM                      ring to the painter release hook rather than the    suspension ring to the painter hook.                       size.
37583                               suspension hook. The resulting misalignment         There were no instructions for raising the rescue boats    Interim measure by vessel operator to require that the painters be attached before the
UNITED KINGDOM
                                    of the lower blocks when the boat was raised        as required by SOLAS III/35.                               suspension rings.
                                    prevented the lower blocks from engaging in                                                                    Need to ensure that operators of vessels equipped with this, or a similar, rescue boat are
                                    the davit horns. The lower blocks slipped from                                                                 made aware of this casualty.
                                    the davit heads and caused the boat to drop                                                                    Human error/lapse on the part of the AB handling the forward suspension ring.
                                    onto the davit trackway and roll.                                                                              Reportedly, all three ABs involved with the raising of the rescue boat were well trained
                                    One of the ABs aboard the boat jumped to the                                                                   and very experienced.
                                    deck of the PRIDE OF BILBAO and the other
                                    two ABs were thrown into the water.
                                    One AB in the water was seriously injured.
                                    The forward painter hook and then the aft
                                    suspension hook were torn from the boat as the
                                    boat fell into the water.
GROUNDING/STRANDING    12/02/1999   Pilot/crew inattention and poor                     Inattention of the Pilot and crew due to the distraction   The importance of situational awareness, voyage planning and crew communications.
PRINCE OF TOKYO
WOOD-CHIP CARRIER
                                    communications led to the grounding of the          caused by the overboard loss of an accommodation           The need for clear transfer of responsibilities during the changing of the watch.
PANAMA                              vessel resulting in no injuries, loss of life or    ladder.                                                    Need for clearly defined watch team duties and responsibilities.
36712                               pollution.                                          Lack of knowledge or training regarding bridge             Casualty attributed to inattention error, specifically omission following an interruption.
PANAMA
                                                                                        resource management principles.                            The Pilot/crew's attention was diverted and the Pilot failed to follow-up on a rudder order.
                                                                                        Poor communications.                                       Pilot and crew's lack of bridge resource management (BRM) training and use.
                                                                                                                                                   Poor communications between Helmsman and Pilot.
                                                                                                                                                   Cultural background and differences hindered crew/Helmsman from challenging Pilot's
                                                                                                                                                   actions or authority.
OTHER/UNKNOWN          17/07/1999   This 10m long open boat was partially               Neither man was wearing a lifejacket.                      The need for more data on wave generation.
PURDY
FISHING VESSEL
                                    swamped by a large wave generated by a              Wave generating mechanism of HSS not fully                 The importance of wearing a lifejacket at all times when in an open boat.
UNKNOWN                             passing HSS.                                        understood.                                                The assumption that lifejackets were not necessary because weather conditions were good
                                    One of the two men on board was washed                                                                         is too common.
UNITED KINGDOM
STENA DISCOVERY
                                    overboard and was lost.
RORO CARGO/FERRY
NETHERLANDS
19638
OTHER                  20/12/2000   The RANDGRID was confirmed to be                    The individual releasing the chain stopper may have        Fatigue related errors by well trained personnel.
RANDGRID
SHUTTLE TANKER
                                    properly secured to the monobuoy before             been suffering from fatigue. He may also have              Ergonomics are a critical element in the design of a control system. Despite different
NORWAY                              discharge operations commenced. At some             believed that prompt corrective actions, if they were      screen colors, the same function keys should not be used for incompatible events.
75273                               time during cargo discharge, the chain stopper      taken, prevented the release of the chain stopper.         Need to review the Safety Management System, and revise as necessary, after a casualty.
UNITED KINGDOM
                                    opened and the chafing chain was released.          The multi-functional screen of the bridge monitor may
                                    The ship was now moored to the buoy by only         have contributed to the casualty. The function that was    Even well trained personnel that are thoroughly familiar with relevant shipboard
                                    the pickup rope which subsequently failed. As       to be performed, securing of the forward hydraulic         procedures can have lapses or make serious mistakes as a result of fatigue.
                                    the ship drifted from the monobuoy, the rail        pump, used the same function key as opening the chain      Ergonomics, in the form of operator-machine interface, is a critical element in shipboard
                                    hoses parted and approximately a 12 tonnes oil      stopper on another screen.                                 safety.
                                    spill occurred. The chain stopper assembly and      The bridge panel mooring tension indicators were not
                                    its control system were found to be fully           fitted with audio or visual alarms.
                                    operational at all times. It is believed that the   Perceived safety concerns precluded visual verification
                                    chain stopper was inadvertently opened by           that the chafing chain was engaged in the stopper;
                                    shipboard personnel using the bridge monitor.       although, this verification was included in the
                                                                                        monitoring routines.
Type of Casualty                                                                                                                                                                                                                   Page 33
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                    Issues raised
                          Date of
Reporting State           casualty                    Event                                                  Causes                                                                        Human factor
Second ship (if any)
GROUNDING/STRANDING       24/09/1997   On its way from Vancouver to Kitimat (British       Fatigue of Pilot.                                            Co-operation between Pilot and crew.
RAVEN ARROW
BULK CARRIER
                                       Columbia) in Johnstone Strait the bulk carrier      Wrong manoeuvring.                                           Management of pilotage operations.
BAHAMAS                                RAVEN ARROW grounded in a fog situation             Inadequate communication between the Pilot and the           Pilots' training.
25063                                  on 24/09/97 when the Pilot did not assess the       Officer of the Watch.                                        Bridge Resource Management (BRM) training program.
CANADA
                                       position and prematurely altered course to          The Officer of the Watch did not pay attention to the        The human element was the main cause of this casualty.
                                       enter Blackney Passage. The Pilot did not           Pilot's radio contacts with services ashore.
                                       request assistance from the crew.
HULL FAILURE/FAILURE OF   25/04/1998   After loading of approximately 1000 tonnes          Through a very extensive investigation, including a          Hold bilge alarms in all single hold vessels.
WATERTIGHT
DOORS/PORTS/ETC
                                       stone chippings, the vessel left Berwick-upon-      ROV survey, many causes of the foundering have been          The introduction of Voyage Data Recorders (VDRs) in all vessels above 100gt to remove
REMA                                   tweed on 24 April at about 1230 and sailed for      explored. The most plausible cause of vessel                 the uncertainties when investigating marine accidents so that the correct recommendations
GENERAL CARGO SHIP                     Terneuzen with a crew of 4. Its departure draft     foundering was found to be the slow flooding of 769          can be made to improve safety at sea and preserve the life of seafares.
BELIZE
748
                                       was about 3,3m. The weather on departure was        tonnes of sea water into the hold. The investigation has
BELIZE/UNITED KINGDOM                  good, the wind south-west, 3-4 and the sea          not been able to identify how, where and over what
                                       slight to moderate.                                 period of time it happened.
                                       At 0321 on 25 April the vessel transmitted an
                                       incomplete MayDay giving her position as
                                       about 22 miles north-east of Whitby on the east
                                       coast of England. Nothing else was heard from
                                       the vessel.
                                       The wreck of REMA was located on 26 April
                                       at 60-65m depth of water.
                                       An underwater survey found the vessel sitting
                                       on the sea bed in an upright position and intact,
                                       but with evidence of soft contact bow damage
                                       due to impact with the sea bed. Her cargo had
                                       shifted forward and forced its way out of the
                                       forward hatches to spill onto the sea bed.
                                       Total loss of the vessel and the loss of life of
                                       the 4 crew members.
FIRE                      16/01/2000   A fire broke out in the engine room that got        The cause of the fire, its seat and the source of ignition   It should be ensured that all crew members are fully aware of the importance of
ROSS ALCEDO
FISHING VESSEL (SIDE-T)
                                       very soon out of control, the CO2 system could      remain in doubt. Although a fire did occur in the upper      maintaining the structural fire protection of machinery spaces by keeping access doors
UNITED KINGDOM                         not be activated as access to the CO2 cabinet       parts of the engine room in the vicinity of the diesel oil   closed; this can be facilitated by fitting self-closing mechanisms to all access doors.
255                                    was prevented by flames.                            tanks at main deck level, it is not clear how or why this    All crew members should be aware of the need to carry out basic fire and emergency drills
UNITED KINGDOM
                                       The vessel had to be abandoned.                     fire spread so rapidly throughout the accommodation.         and the need to regularly test fire detection systems.
                                       Extensive damage to vessel.                         This rapid spread prevented access to the CO2 control
                                       One person slightly injured                         station on the top of the shelter deck.
                                                                                           The engine room door to the accommodation forward
                                                                                           was open when the fire was discovered. The vessel
                                                                                           was fitted with a four-zone fire detection system
                                                                                           covering the accommodation, galley, wheelhouse and
                                                                                           engine room. This system failed to operate or give any
                                                                                           warning of the fire in the engine room.
Type of Casualty                                                                                                                                                                                                                 Page 34
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                  Issues raised
                          Date of
Reporting State           casualty                   Event                                                 Causes                                                                        Human factor
Second ship (if any)
HULL FAILURE              25/11/1999   SALDANHA was on a ballast voyage from             1. Hydraulically-actuated valves in the ballast system     There should be written procedures for transferring ballast and drawings should be
SALDANHA
BULK CARRIER
                                       Spain to Brazil when the engine room was          were closing in less than half the time recommended by     carefully checked.
UNITED KINGDOM (ISLE OF                flooded due to failure of a gate valve on the     the actuator manufacturers causing sudden high             Ship’s crew should know the vessel’s piping systems.
MAN)                                   ballast/bilge system during ballast exchange      pressure waves through the system.                         BRM principles should be observed in engine-room operations.
90312
UNITED KINGDOM (ISLE OF
                                       operations. The cast iron valve body had          2. Possibly, the practice during surveys of pressurizing   Officers’ certificates must be carefully checked by the flag State Administration.
MAN)                                   fractured. Further flooding occurred when         ballast tanks to prove that they were full.
                                       deballasting to adjust the trim. Eventually it    3. Design of the piping system provided no means of        Officers were not familiar with the ship’s systems.
                                       became clear that the water ingress was from      isolating the broken valve in the ballast line.            There was no co-ordinated response to the incident and the Master did not use the
                                       the ballast tanks, not from the sea.              4. Two other ballast valves were also damaged during,      experience of the other officers. There was a lack of communication between the Master
                                       Deballasting was stopped, but the flooding had    or just before, the incident.                              and the Chief Engieer.
                                       caused a loss of all propulsion and auxiliary     5. There were no drawings in the ballast control room,     Insufficient tank soundings were taken.
                                       machinery, resulting in the vessel having to be   only diagrams on several pages of computer screens,
                                       towed by salvors.                                 possibly leading to errors while following lines from
                                                                                         one screen onto the next.
                                                                                         6. The ship’s drawings of the ballast system were
                                                                                         incorrect.
                                                                                         7. There were no established procedures for
                                                                                         transferring ballast.
                                                                                         8. The 2nd Officer and 2rd Engineer had invalid
                                                                                         certificates.
OTHER                     23/04/1999   The vessel had loaded various parcels of          Atmospheres in tanks were not always tested before         Tank entry permits were not always issued, this does not educate crewmembers in the
SAPPHIRE
CHEMICAL TANKER
                                       chemical products in the U.S. to be discharged    entry. While the decision to test or not was made by a     importance of the fact that a tank should not be entered without an entry permit being
UNITED KINGDOM (ISLE OF                in three Mediterranean ports.                     responsible officer the decision was on previous           issued. To sometimes issue one, and at other times not to, depending on experience, gives
MAN)                                   After clearing one discharge port it was          experience of the cargo.                                   confusing signals to crew members.
9914
UNITED KINGDOM (ISLE OF
                                       planned to clean No. 2 Centre Tank, which had     With dangerous cargoes the atmosphere was always           The investigation revealed that there was no definitive policy onboard for the testing of the
MAN)                                   contained Linear Alkyl Benzene, and No. 6         checked for gas and oxygen but for cargoes that were       atmosphere prior to tank entry. There was also no strict observance to the issue and
                                       Centre Tank that had contained HMD                non hazardous, based on past experience, tanks were        observance of the enclosed space entry permit system. The Company has a reliance solely
                                       (Hexamethylenediamine Solid). This was            entered without checking if there had been ventilation.    on the entry permit system even though in the Safety Management System (SMS) they
                                       carried out by the pumpman and three              Although the two men were quickly recovered from the       state that "enclosed space entry permits and work permits do not make in itself safe an
                                       crewmembers from 1645 (local time) until          tank it appears that the basic practice of rescueing a     activity". There is no policy or emphasis on the fact that entry into an enclosed space that
                                       dinner at 1800 when those concerned believed      dummy from a gas free tank, pumproom or enclosed           is not proven gas free or life supporting should be prohibited.
                                       the work was finished for the day.                space is not contained in the safety Management            It is concluded that the Company has failed to meet their statutory duties in respect to
                                       At approx. 1950 the Chief Officer was doing       System (SMS) drill schedule and has never been             proper familiarisation training in accordance with regulations and their own procedures.
                                       his deck rounds and noticed that the tank lid     carried out.                                               Thus the Company must ensure that the onboard training and familiarisation is undertaken
                                       for No.6 Centre was open. On investigation he                                                                by all crewmembers and supernumeraries in line with the Safety Management System.
                                       saw the pumpman and the deck boy lying on
                                       the first platform inside the tank. The alarm                                                                A serious concern regarding tank cleaning practices, which is also related to tank entry
                                       was raised and the bodies recovered by officers                                                              procedures, is with regard to the following dangerous practice that was commented on by
                                       and crew wearing breathing apparatus.                                                                        the Captain, Chief Officer and the Third Officer, who had previously served on the ship as
                                       Unfortunately all attempts to resuscitate the                                                                pumpman.
                                       two men were unsuccessful.                                                                                   On completion of washing often the tank lid would be opened, someone would then go
                                       The reason why the two men entered a tank                                                                    down the ladder far enough to see under the deck head and onto the bulkheads with a torch
                                       that had not been checked as safe for entry                                                                  to check if they were clean. This practice generally required a deep breath to be taken
                                       could not be established.                                                                                    before entry as the atmosphere was not checked.
                                                                                                                                                    It is concluded that for the Master and Chief Officer to talk openly of having seen this
                                                                                                                                                    practice, and not have taken steps to immediately stop it would appear to condone its use
                                                                                                                                                    which is against all tank entry and safety procedures.
Type of Casualty                                                                                                                                                                                                                   Page 35
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                   Issues raised
                          Date of
Reporting State           casualty                    Event                                                 Causes                                                                        Human factor
Second ship (if any)
OTHER                     10/06/1998   The vessel was purpose built for carrying          The rapid accelerations and decelerations experienced At the time of the accident, the Company were studying ways of improving both seat
SAUTE MOUTONS 6
PASSENGER SHIP
                                       passengers through rapids and similar white        by the vessel and the passengers caused the pelvic       design and cushioning. Subsequently a more substantial foam padding has been fitted to
CANADA                                 water areas. It is highly manoeuvrable and can     regions of the three passengers to forcefully strike the the seats.
7                                      reach speeds of 50 knots in calm water. It is      seat bench of the vessel causing vertebrae and back
CANADA
                                       box shaped with a flat bottom. Passengers sit      injuries. The possibility that these passengers may not
                                       on foam covered bench seats with a steel grab      have braced themselves in their seats as instructed may
                                       rail in front of the benches.                      have contributed to their injuries.The cushioning
                                       48 passengers plus 3 crew embarked and a           ability of the seats appears to have been inadequate for
                                       practice run was carried out after the safety      the vessels movements at the time of the accident.
                                       instructions had been explained. The
                                       subsequent trip was uneventful until the vessel
                                       hit a whirlpool near a local feature called
                                       "Devils' Hole". At this point the vessel met
                                       large waves causing rapid fluctuations in
                                       vertical movements. 3 passengers suffered
                                       heavy impacts with the seats as well as being
                                       hit with a wall of water from foreward. Once
                                       clear of the rapids their injuries became known
                                       to the crew and the vessel moved to the nearest
                                       wharf where medical assistance had been
                                       organized. Injuries were sustained to the lower
                                       back of each of the 3 passengers.
LISTING                   21/07/2000   Vessel sailed from Yokahoma at 0948 on             The Tropical storm reported before the departure of the    The importance of reliable weather forecasts.
SCAN OCEANIC
RORO CARGO
                                       20/07/2000 bound for Houston via Panama            vessel turned out to be much more severe and much          The internal securing of cargo (within each lift/container) is important, and ship’s
UNITED KINGDOM (ISLE OF                Canal. A Tropical storm was forecast 340           closer to the vessel’s intended track than forecast.       personnel should be able to check.
MAN)                                   miles south of the intended track, moving north    Very heavy swell caused the cargo to shift and             The importance of protection of cables at the edges of cable slots.
5752
UNITED KINGDOM (ISLE OF
                                       at a rate of 10 knots. At 0100 on 21/07 the        consequently the vessel to list.
MAN)                                   weather worsened with wind force +12, seas         The internal securing (within each heavy lift) was         The vessel was handled with great skill during the engine stop in the typhoon.
                                       18 and waves about 200 metres apart.               inadequate.                                                The decision to lift off non-essential crew was well taken.
                                       During the Tropical storm the cargo shifted        The shipper gave instructions that the lifts were not to
                                       within its units causing the ship to list. Small   be inspected by the ship’s personnel prior to or during
                                       items of cargo moved. The main engine stalled      loading.
                                       at 1910 due to an electrical fault. It was         The engine stop due to cable fault, caused by the
                                       restarted and the ship made its way back to        violent movement of the vessel, created a very
                                       Yokahoma. A MayDay was transmitted at              dangerous situation.
                                       1915 and non-essential crew was taken off by
                                       helicopter at 1400 on 22/07.
                                       The ship arrived back at Yokahoma at 1900 on
                                       23/07.
                                       Damage to cargo and very minor damage to the
                                       ship.
Type of Casualty                                                                                                                                                                                                                 Page 36
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                  Issues raised
                           Date of
Reporting State            casualty                    Event                                                Causes                                                                       Human factor
Second ship (if any)
OTHER/UNKNOWN              06/01/2001   Four pontoons were lashed on deck as cargo.       Severe rolling which could have been reduced with a        Lack of strength continuity of lashing can result in over-loading of fixtures and lashings.
SCOT TRADER
GENERAL CARGO SHIP
                                        In heavy weather the lashings of two of them      change of course.                                          Management need to support Masters in their decision to reject substandard cargo securing
UNITED KINGDOM                          parted causing them to fall overboard. Painted    Use of three incompatible securing arrangements,           arrangement. Management are responsible to ensure that clear written procedures on how
1585                                    black and floating low in the water, the          which had not been secured properly.                       deck cargo ought to be secured are on board, which will raise the confidence of Masters to
SWEDEN
                                        pontoons were difficult to detect by search       Perversity of consignor when contracted to secure          ensure contractors discharge their obligations effectively.
                                        vessels and posed a serious hazard to shipping.   cargo properly.
                                        The pontoons were eventually salvaged                                                                        Seems to have been a lack of knowledge or violation of relevant guidelines and rules for
                                        undamaged.                                                                                                   lashing and securing deck cargo.
                                                                                                                                                     Time pressures contributed to use of non-standard and unsuitable bottle screws, chains and
                                                                                                                                                     webbing.
CONTACT                    15/01/2000   Boom of crane on barge struck the underside of    Air draught of tow not ascertained prior to tow
SEA CAP XII
TUG
                                        Knight Street Bridge, damaging bridge and         commencing.                                                A previous occurrence precipitated verbal procedures.
CANADA                                  causing the crane to slide off the barge and      Lack of clear understanding on tug regarding route to      More formal written procedures now being developed.
51                                      sink in the river.                                be taken.                                                  Tug operators will be given tow parameters.
CANADA
                                                                                          No written operational procedures.


COLLISION                  29/08/1998   Collision with 4 moored recreational craft in     Failure of electronic steering control system leading to   Section 17.4 of the High Speed Craft Code prescribes Failure Mode Effect Analysis
SEAFLIGHT I
HYDROFOIL FERRY
                                        Niagara River. One recreational craft sank.       rudder swinging hard to port uncommanded.                  (FMEA) for HSC. HSC Code was not applied to SEAFLIGHT I as a condition for
CANADA                                                                                    High speed in confined waters.                             operation.
145                                                                                       Close passage to recreational craft mooring area.          This accident has similarities with HSC APPOLO JET ramming into moored craft after an
CANADA
AWAKIN
                                                                                          No alarm fitted to indicate power failure to the           electronic control system failure in Hong Kong in 1989. That accident had been given
YATCH                                                                                     electronic control system.                                 wide publicity. Lessons learnt from that accident (mainly introduction of FMEA before a
UNITED STATES                                                                                                                                        HSC is allowed operation) would have prevented this accident.
COLLISION                  25/03/2000   Collision between the bulk carrier and the        - Lack of effective visual and radar look out on the       - Smaller craft need to be aware that they may not be sighted by large ships in good time
SILVER BIN
BULK CARRIER
                                        fishing vessel whilst proceeding at end-on        bulk carrier.                                              to avert collision. They should consider warning the larger ships to the developing
LIBERIA                                 courses in the inner route of the Great Barrier   - Both vessels proceeding at unsafe speed and not          collision risk by whatever means possible including light signal, sound signal and radio
24277                                   Reef. The fishing vessel sustained significant    making required sound signals in reduced visibility.       contact.
AUSTRALIA
CHINDERAH STAR
                                        damage to the wheelhouse, the starboard trawl     - The Master of the fishing vessel was aware that a        - Lack of proper lookout on one or both vessels involved is the most common cause of
FISHING VESSEL (TRAWLER)                boom, the bulwark and the hand rail. No           collision risk was developing yet took no action to        collisions between small craft and large ships.
AUSTRALIA                               significant damage to bulk carrier. No injury     avert collision or warn the bulk carrier.
45
                                        and no marine pollution.                          - Fatigue may have played a role in the unsatisfactory Crew fatigue in the fishing industry is very common due to crews usually consisting of
                                                                                          response to the developing circumstances by the        only 2 or 3 and fishing vessels fishing all night and shifting fishing grounds during the
                                                                                          Master of the fishing vessel.                          day. There may be a need to stress proper manning and effective lookout on fishing
                                                                                                                                                 vessels.
GROUNDING/STRANDING        12/11/1999   The ship was one of four (amongst five), which - Lack of awareness by the Master of the deteriorating - The vessel had been poorly maintained and subject to adverse port state control reports.
SIMBA
GENERAL CARGO SHIP
                                        grounded on the same day and in the same        weather conditions and need to prepare to avoid          The owner is directly responsible to ensure that the vessel is seaworthy and that
GEORGIA                                 circumstances, after being at anchor waiting to possible grounding.                                      documentation on board is valid.
2723                                    enter the Port-la-Nouvelle, South of France, to - The vessel had deballasted to enter the port.          - The SIMBA had false insurance documentation and false IMO number.
FRANCE
                                        load grain. Like two of the others, the ship    Consequently the lower drafts of the vessel were         - A continuous means of communication between the vessel at anchor and port Authorities
                                        landed on beaches adjoining the entrance.       unable to counter the effect of wind and sea.            enables better exchange of information to enable timely decisions on what action to take in
                                        The vessel arrived the day before the           - The propulsive power of the vessel was insufficient to deteriorating weather conditions.
                                        grounding. During the period at anchor the      counter wind and sea.                                    - The charterer and shipper have a responsibility to assure that the assigned vessel is
                                        weather deteriorated to windforce E to SE       - Lack of information from the port to Master.           suitable for the voyage and trade intended.
                                        force 11 to 12. Consequently, anchors dragged
                                        and anchor chains broke.                                                                                 Master awareness of the changing conditions that may affect the safety of the vessel is
                                                                                                                                                 dependent not only on his experience and competence, but on the support of port
                                                                                                                                                 Authorities and owner to ensure that he has sufficient information to enable him to make
                                                                                                                                                 correct and timely decisions.
Type of Casualty                                                                                                                                                                                                              Page 37
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                               Issues raised
                       Date of
Reporting State        casualty                    Event                                                  Causes                                                                      Human factor
Second ship (if any)
CONTACT                15/07/1999   While on a Search and Rescue mission at            - Midnight hour, darkness, crosscurrents near jetties,     - The importance of involving ergonomic and human performance experts in the
SIYAY
HOVERCRAFT
                                    night, the vessel attempted a shortcut through a   strong river current, restricted visibility due to water   acquisition, design and testing of these types of craft.
CANADA                              gap in a breakwater jetty. Vessel failed to        spray and vessel design.                                   - The importance of good Bridge Resource Management, teamwork and communications.
70                                  successfully clear the opening, striking the       - Lack of adherence to basic Bridge Resource               - Illustrates the importance of adequate voyage planning and risk assessment.
CANADA
                                    jetty causing significant damage to the vessel.    management principles.
                                    No serious injuries, deaths or pollution.          - Risky behaviour - inappropriate shortcut taken in a      - Multitasking of vessel’s pilot.
                                                                                       non-life threatening situation when less risky             - Poor situational risk assessment resulting in taking a dangerous shortcut.
                                                                                       alternative was readily available.                         - Ergonomic issues: obstructed view due to bow thruster vents, side windows not inclined
                                                                                                                                                  causing nighttime reflection, searchlight used by pilot was designed for two person
                                                                                                                                                  operation (other than the pilot), nighttime reflection of search light beam due to spray.
                                                                                                                                                  Control station issues: no control of navigation equipment illumination, intensity of
                                                                                                                                                  illumination from radar display.
                                                                                                                                                  - Training issues: Pilot had no Bridge Resource Management training, crew training
                                                                                                                                                  program unstructured, not adhered to or not monitored. Primary method employed - self
                                                                                                                                                  taught on the job training. No time dedicated to training. No formal assessment of pilot
                                                                                                                                                  skill proficiency conducted.
                                                                                                                                                  - Management influence - Staffing shortage of qualified personnel. Non compliance with
                                                                                                                                                  fit for duty assessment requirement.
GROUNDING/STRANDING    26/11/1999   While operating at 35 knots along an inshore       - Navigating team (Master & Chief Officer) was             - The potential dangers of high-speed waterborne transportation, especially in confined
SLEIPNER
FERRY, TWIN-HULL
                                    coastal route in foul weather, vessel navigators   momentarily distracted from their duties by making         waterways and the need to reduce speed if in doubt.
NORWAY                              lost situational awareness and the vessel raked    simultaneous adjustments to respective radars.             - The importance of good Bridge Resource Management, teamwork and communications.
375                                 a charted rock outcropping resulting in              At such high speeds and in confined waters, a            - Importance of sound governmental and Class oversight, approval and inspection of
NORWAY
                                    catastrophic hull damage. Vessel quickly           momentary distraction can result in a significant          critical vessel systems.
                                    broke up and sank resulting in 16 persons dead     (dangerous) deviation from the intended course.
                                    or missing.                                        - Lack of adherence to basic Bridge Resource               - Ergonomic issues:
                                                                                       Management principles of good communication and            Poorly mounted or installed navigation tools (dGPS and electronic charting equipment)
                                                                                       teamwork.                                                  difficult to read so not used, life raft deployment instructions very difficult to follow,
                                                                                       - Complacency in navigation due to familiarity with        immersion suits hindered crew’s manipulation of emergency equipment, difficulty of
                                                                                       vessel’s route.                                            passengers to use lifejackets, evacuation plan not designed to reflect expected behaviour
                                                                                       - Failure to plan, discuss or adhere to approved vessel    of passengers in confined/unlit areas, poor communications with passengers during
                                                                                       route.                                                     emergency, Master unfamiliar with radar and rudder controls, armchair steering wheel had
                                                                                       - Operating in seas far in excess of Governmental          no return to centerline function. Compromise to watertight integrity in that the manhole
                                                                                       operational limits. Vessel speed far in excess of Class    covers purposely removed to gain access to lube oil gauge, difficulties in using sectored
                                                                                       operational limits for sea conditions.                     navigational aids when operating high-speed craft, difficulties in seeing the dark colour
                                                                                                                                                  red in sectored navigational aids.
                                                                                                                                                  - Management issues:
                                                                                                                                                  Inadequate training regarding new crew & new navigation equipment. No safety training
                                                                                                                                                  conducted for catering department personnel, no procedures to determine operational
                                                                                                                                                  limitations (high seas), evacuation operating manuals were incomplete, culture not in
                                                                                                                                                  accord with modern safety management methodologies, sailing directions not currently
                                                                                                                                                  corrected.
                                                                                                                                                  - Regulator issues:
                                                                                                                                                  Granting of non-enforceable operational limitation rules, inappropriate evaluation and
                                                                                                                                                  approval of vessel evacuation plan, inappropriate approval of liferaft release system,
                                                                                                                                                  problems interpreting approval drawings and inspections of emergency source of
                                                                                                                                                  transitional power location, blanket type acceptance of inadequate lifejackets, required
                                                                                                                                                  watertight structures found not in compliance.
Type of Casualty                                                                                                                                                                                                                  Page 38
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                  Issues raised
                         Date of
Reporting State          casualty                   Event                                                 Causes                                                                         Human factor
Second ship (if any)
WORK-RELATED ACCIDENT    13/05/2000   At 05:00 hrs on 13/05/2000, the Skipper of this   The man probably lost his footing on the spare trawl       The risk assessment should be as thorough as in other situations and, in particular, the
SOLSTICE II
FISHING VESSEL (STERN)
                                      trawler was controlling all four winches whilst   and was dragged into the winch by his arm whilst           guards around moving parts and cables should be as extensive as would be the case in
UNITED KINGDOM                        shooting the single sweeps. A Trawlerman          trying to prevent his fall.                                factory situations.
611                                   was making his way aft and passed between         The lack of safety guards fitted to the winches, the man   There were failings on both parties i.e. the lack of care on the part of the victim and the
UNITED KINGDOM
                                      the rotating winch drums. He caught his arm       putting himself in danger, and the inability of the        attempts by the Skipper to do too many things at once.
                                      in the space between the supporting upright       Skipper to operate all winches whilst monitoring the       However, it is difficult to see how more legislation or advice can be effective.
                                      and the flange of the rotating drum and was       actions of the crew were contributory factors.
                                      dragged into the winch and fatally injured.
HULL FAILURE             25/12/1999   Water ingress causing capsizing in port           Malfunction of a valve or problem of watertightness of     Nobody on board.
SONSOLES
DREDGER
                                      resulted in pollution.                            engine room or of the hull.                                Problem arising due to human error.
SPAIN
229
SPAIN




FIRE                     26/10/1998   The vessel was loading a cargo of medium          Limited discharge capacity of fire extinguishers. Hold     It is probable that a cigarette end was discarded in the space between the bundles of MDF
SOUTHGATE
GENERAL CARGO SHIP
                                      density fibreboard (MDF) panels in a Canadian was opened too early after first release of CO2 so that        where flames were seen in what was later determined to be the seat of the primary fire.
BAHAMAS                               port which were packed in bundles of about 2,5 CO2 had not sufficient time to smother the fire.              The fire was probably started between the bundles of MDF by a lit cigarette end
12174                                 m3 volume, wrapped in polyethylene film and                                                                  transferring heat by conduction to the cardboard and polyethylene film which wrapped the
CANADA
                                      held in place by metal straps.                                                                               MDF.
                                      During coffee break at about 1403 hours (local                                                               The extinguishers discharged by the crew in the first response had a limited discharge
                                      time) a burning smell was detected in No. 5                                                                  capacity and did not stifle the flames which were spreading amongst the bundles.
                                      hold, then whitish smoke followed by black                                                                   The jet nozzles used by the crew in the first response proved ineffective because the water
                                      smoke and finally flames could be seen                                                                       jet could not be placed directly onto the flames to reduce the heat.
                                      between the bundles of cargo.                                                                                Although the hold was closed and carbon dioxide gas (CO2) released, the hold was re-
                                      The spreading flames were first fought with                                                                  opened before the CO2 had time to smother the fire.
                                      extinguishers by the crew. As this did not                                                                   Further attempts by the crew and professional firefighters to extinguish the fire with a
                                      prove to be efficient and the fire spread, jet                                                               limited supply of foam and by water spray were unsuccessful, and the hold was resealed
                                      nozzles were used to fight the fire and hatches                                                              and a further supply of CO2 discharged.
                                      and the adjacent engine room bulkhead was
                                      cooled by water.The crew was assisted by the                                                                 Smoking was prohibited in the work area but effective enforcement of this rule was
                                      local fire brigade and the hold was closed and                                                               lacking.
                                      carbon dioxide gas (CO2) was released. When
                                      temperatures of the adjacent bulkheads
                                      indicated that the fire had died the hold was re-
                                      opened, this however proved too early to have
                                      enabled the CO2 to smother the fire which
                                      started again. The discharge of foam and water
                                      spray by the fire brigade proved unsuccessful
                                      so the hold was resealed, again CO2 released
                                      and eventually the fire was stifled after five
                                      days.
                                      One person was slightly injured.
Type of Casualty                                                                                                                                                                                                                 Page 39
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                 Issues raised
                        Date of
Reporting State         casualty                    Event                                                 Causes                                                                        Human factor
Second ship (if any)
FIRE                    25/08/2000   A fire broke out in the engine room which was      The source of the lubricating oil that ignited was a       On ships operating a single man engineering watch system, it should be considered
ST. HELENA
PASSENGER/GENERAL
                                     caused by oil leaking from a flexible hose in a    leaking flexible lubricating oil pipe that caused oil to   whether it is made a requirement to have a second person present in the engine room
CARGO SHIP                           rocker box of the starboard main engine and        spray from the rocker box when the box was opened in       during the opening of any enclosure from which flammable gas, vapour or liquid can
UNITED KINGDOM                       igniting after making contact with the exhaust     an attempt to find a leakage which had been detected       escape.
6767
UNITED KINGDOM
                                     duct.                                              earlier.
                                     Fire was extinguished by crew on daywork
                                     using portable appliances.
                                     No injuries to persons.
FAILURE OF WATERTIGHT   16/04/2000   Failure of the ship’s no. 1 hold hatch covers.     Failure of the hatch covers closing arrangements.          The role of the OOW in port:
DOORS/PORTS/ETC
SUN BIRD
                                     The shear strain of the hatch covers provoked a    Cargo stowed over the hold bilge wells.                    - Keeping the bulk cargo clear of the hold bilge wells.
GENERAL CARGO SHIP                   failure of the weathertight seal along port side   Heavy swell 4-6 meters and winds of 6-7 Beaufort           - Identifying any damages in the hatch cover systems and in the hatch coamings during
SAINT VINCENT & THE                  causing the flooding of the hold. The Master       scale.                                                     cargo operations; and
GRENADINES
1886
                                     detected it at 8:10 a.m., on April 14, 2000        Incorrect understanding of the seriousness of the          - Securing and sealing of the hatch covers before departure.
SAINT VINCENT & THE                  because the vessel was listing to port and         situation by the Master, almost 39 hours between the       Periodical inspections of the hatch covers ashore and after fitting them on board tested in
GRENADINES                           trimming by the bow. The crew was unable to        detection of the problem and the distress call.            operation.
                                     close the gap or to pump the hold bilges
                                     because the cargo was stowed over the bilge                                                                   Cargo stowed over the hold bilge wells: error - slip - attention failure.
                                     wells. The solution was cutting in forward                                                                    Failure of the hold hatch covers: unknown.
                                     bulkhead, 10 small holes, and pumping the                                                                     Incorrect understanding of the situation by the Master: error - mistake (lack of situational
                                     water from bow thrusters compartment bilge                                                                    awareness).
                                     suction. At 3:00 p.m. the water was nearly
                                     cleared from the hold. However, at 8:00 a.m.,
                                     on April 15, it was observed that the water had
                                     increased in depth to 60cm. The Master
                                     changed the course to Curacao to repair the
                                     hatches. The water in the hold was still
                                     increasing, at 3:00 p.m. the Master altered the
                                     course to Aruba to shelter from the weather. At
                                     11:00 p.m. the Master notified USCG and
                                     Aruba CG that the vessel was in distress. At
                                     1:00 a.m. on April 16, 2000, the vessel sank in
                                     position 12º 50’N, 70º 00W. Consequences:
                                     total loss of the ship and marine pollution
                                     82,35MT (MGO) and 3000 l (Lub oil).
Type of Casualty                                                                                                                                                                                                                 Page 40
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                  Issues raised
                       Date of
Reporting State        casualty                    Event                                                   Causes                                                                        Human factor
Second ship (if any)
LISTING                21/08/1999   SUN BREEZE loaded a cargo of                         The Master received insufficient information on the        The importance of accurate stability information in the ship stability booklet.
SUN BREEZE
GENERAL CARGO SHIP
                                    approximately 6800 tonnes of packs of timber         cargo, and no stowage plan, which made it impossible       The charterers responsibility to provide exact information on the cargo to be loaded.
PANAMA                              of various sizes in the West Australian port of      to develop a preloading plan and accurate stability at     The importance of exact stability calculations for both departure and arrival condition.
7816                                Bunbury. The cargo was loaded in the lower           departure.                                                 The importance of securing under deck cargo against shifting.
AUSTRALIA
                                    holds, at the tween decks and as deck cargo.         The status of tanks, free surface effects, was uncertain   The importance of properly lashing deck cargo.
                                    After completion of loading the vessel’s GM,         on departure.
                                    after allowing for free surface effects in certain   The stability of the vessel appears to have been           The commercial pressure from the Owner on the Master to load cargoes and expedite
                                    tanks, was calculated to be 47 cm. After             marginal at departure.                                     voyages.
                                    lashing of the deck cargo was completed the          The cargo was not properly secured either under deck
                                    vessel sailed for China. The vessel was upright      or by properly lashing on deck and the shift of cargo
                                    at departure.                                        contributed to the list.
                                    30 minutes after departure the harbour pilot         The Authorities at departure port were not informed
                                    disembarked. The speed was increased to sea          that the vessel would load timber on deck.
                                    speed and the course set to 335°.                    The light ship centre of gravity was uncertain because
                                    There was a north easterly wind, 2 Beaufort,         the inclining experiment at delivery from ship yard did
                                    and a long westerly swell, ¾ m high.                 not meet IMO approved standards.
                                    The steering was changed to autopilot, at            ¾ metres beam swell.
                                    which time the ship started turning to starboard
                                    on its own accord. Steering was changed to
                                    manual steering and during this the ship
                                    seemed to list first to starboard and then to
                                    port. The Master returned to the bridge at
                                    which time the list was 15 - 20° to starboard.
                                    The engine was stopped and the list settled at
                                    about 25 °. Some packs of timber from no. 1
                                    hatch top were lost over the side. Cargo was
                                    heard shifting in the holds. The vessel was
                                    anchored and assistance called for. The Master
                                    corrected the list by ballasting side tanks and
                                    the vessel was tugged back into port. After
                                    restowing and securing the cargo and reducing
                                    the amount of deck cargo the ship sailed again
                                    and arrived safely to the discharge port.
                                    The shift of deck cargo damaged the rails on
                                    starboard side.
Type of Casualty                                                                                                                                                                                                                 Page 41
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                 Issues raised
                       Date of
Reporting State        casualty                    Event                                                  Causes                                                                        Human factor
Second ship (if any)
MACHINERY DAMAGE       20/05/1999   The vessel suffered a power failure at              The fire most probably originated in the main              The condition of the ship, and in particular the auxiliary and propulsion machinery,
SUN VISTA
PASSENGER SHIP
                                    14:32 hrs LT while at sea with 456 passengers       switchboard, following problems with electrical            created the circumstances in which a fire was likely to develop. A closer scrutiny of the
BAHAMAS                             and 632 crew on board. A fire started in the        equipment and circuit breakers which were resolved by      vessel by the Classification Society might have identified the most serious of the
30440                               engine room at or about the same time. Initial      temporary measures, and the vessel sank because of         mechanical failings and required remedial action to be taken.
BAHAMAS
                                    efforts to locate and extinguish the fire were      failure to ensure that a shell door and watertight doors   Some of the safety systems were lacking when required.
                                    unsuccessful. The engine room was sealed off        in machinery spaces were securely closed, leading to       The fire detection system was ineffective in locating the seat of the fire and the fire
                                    and carbon dioxide smothering gas released.         progressive flooding when the vessel heeled under the      dampers allowed the fire to spread when it might have been more successfully smothered.
                                    Auxiliary and emergency sources of electrical       effect of water pumped from one of the assisting           No electrical power was available from the emergency alternator and the emergency
                                    power also failed and the vessel drifted            vessels.                                                   lighting failed to operate.
                                    thereafter without power.                                                                                      The emergency fire pump could not be used because of lack of electrical power.
                                    The engine room skylight and a side shell door                                                                 These factors made the work of the fire fighting team more difficult. Had the condition of
                                    in the engine room were then opened to                                                                         the machinery spaces been recognized by the ship Managers, Owners and Classification
                                    facilitate the clearance of smoke and entry of a                                                               Society, it is possible that the fire might have been more effectively contained.
                                    fire fighting party which also failed to locate                                                                The ease with which fires can spread and intensify is well illustrated in this case.
                                    and extinguish the fire. The fire subsequently                                                                 However, if the watertight doors had been closed, the spread of fire would have been less
                                    spread to the boiler room, where it later burned                                                               rapid, and if the engine room workshop shell door had been kept closed, the vessel would
                                    with great intensity, and into the                                                                             have remained afloat. It would still have been necessary to evacuate passengers and crew
                                    accommodation and service spaces                                                                               but the ship would have survived, though probably extensively damaged by the fire. The
                                    surrounding the engine and boiler room casings.                                                                general condition of the vessel created the circumstances in which the risk of mechanical
                                    Passengers and crew were evacuated to the                                                                      failures and fires increased, and this, compounded with the errors in fire fighting, led to
                                    open decks as a precautionary measure soon                                                                     the loss of the vessel. It is the opening of the engine room workshop shell door and failure
                                    after the power failure and remained there until                                                               to close the engine room watertight doors to limit flooding to the engine room that were
                                    the order was given to proceed to muster                                                                       responsible for the vessel sinking and no acceptable justification for this has been
                                    stations at 18:05 hrs. The order to abandon                                                                    identified.
                                    ship was given at 18:30 hrs. All passengers                                                                    The competence of some of those in charge of lifeboats was inadequate. This was in part
                                    and the majority of the crew had been                                                                          caused by the engagement of some lifeboat commanders on fire fighting and other
                                    evacuated in lifeboats by 18:52 hrs. A small                                                                   supervisory duties related to abandoning ship. Some crew designated to operate lifeboat
                                    operational crew remained on board after the                                                                   engines were also engaged on fire fighting duties and their duties in the lifeboats had to be
                                    main evacuation and were evacuated before the                                                                  performed by other crew. The vessel was however evacuated in daylight hours without
                                    vessel sank.                                                                                                   serious injury to any person as a consequence of the timely commencement of the
                                    Although some problems were experienced in                                                                     procedure and an appreciation by the Master of the problems encountered. Although some
                                    proceeding to muster stations and boarding the                                                                 of the lifeboat commanders lacked the skills and experience required to handle a lifeboat
                                    lifeboats, all passengers and non-essential crew                                                               in an emergency, most of them displayed an acceptable level of seamanship. The lifeboats
                                    were successfully evacuated from the vessel                                                                    were successfully marshalled and remained together in a group. This facilitated the rescue
                                    without any serious injury.                                                                                    from the lifeboats by the three merchants ships which responded to the call for assistance.
                                    A distress signal was transmitted from the                                                                     The crew undoubtedly faced a complex situation in attempting to control the fire. While
                                    vessel and received by a number of merchant                                                                    they had been trained in fire fighting and exercised in regular drills on the vessel, this
                                    ships in the area. It was also forwarded to the                                                                would not have replicated the scale or complexity of the situation which they faced on
                                    Malaysian Search and Rescue Co-ordination                                                                      SUN VISTA. They might have benefited from enhancement of the normal fire fighting
                                    Centre at Port Klang by Falmouth MRCC. An                                                                      training required by the STCW Convention to include specific training for control of
                                    offshore supply tug with fire fighting capability                                                              major fires on large passenger vessels.
                                    and two container vessels responded                                                                            Although the proposal to open the engine room workshop shell door was made by the
                                    immediately to the request for assistance.                                                                     Chief Engineer, the Captain and the members of Sembawang Emergency Response Team
                                    The tug pumped water into the vessel as                                                                        agreed to it without question. This was an error of judgement by all concerned. In view
                                    requested to assist in limiting the spread of the                                                              of the obvious risks of flooding, the opening of this door should have been questioned. It
                                    fire. This resulted in the vessel listing and                                                                  also allowed air to flow into the engine room and diluted the concentration of CO2 in the
                                    flooding of the machinery spaces through a                                                                     engine room, thereby re-activating the fire which until then had been partially controlled.
                                    shell door in the engine room. The door was                                                                    The closing of the workshop shell door was delegated to two engine room ratings working
                                    opened earlier to gain access and was not                                                                      under difficult conditions without supervision. They were expected to perform a task
                                    thereafter closed. Flood water entered the                                                                     which is judged to have been beyond their physical capabilities in the conditions in the
Type of Casualty                                                                                                                                                                                                              Page 42
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                              Issues raised
                       Date of
Reporting State        casualty                    Event                                                 Causes                                                                      Human factor
Second ship (if any)
                                    adjacent machinery spaces culminating in                                                                     workshop. In view of the importance of closing the workshop shell door, it should have
                                    progressive flooding which led to the sinking                                                                been performed under the supervision of a responsible Officer. It is clear from the
                                    of the vessel at 01:22 hrs on 21/05/99.                                                                      photographic evidence that the workshop shell door was not closed, though there is some
                                                                                                                                                 conflict in the evidence as to when this became known to the Captain, Chief Engineer and
                                                                                                                                                 Sembawang Emergency Response Team. The entry in the Sembawang Emergency
                                                                                                                                                 Response Team log gives reason to conclude that all three knew that this door was open
                                                                                                                                                 while the vessel was heeling 5º at 19:20 hrs on 20/05/99, and that steps should have been
                                                                                                                                                 taken to ensure that the watertight doors in the engine room were closed in order to limit
                                                                                                                                                 flooding to the engine room.
                                                                                                                                                 Some confusion and misunderstanding resulted from the inability to give instructions to all
                                                                                                                                                 passengers and crew simultaneoulsy over the PA system, and some disorder resulted from
                                                                                                                                                 undue haste and crushing in making way to the lifeboats. Stricter control of the passage of
                                                                                                                                                 passengers and crew in going from deck 10 to the lifeboat embarkation stations would
                                                                                                                                                 have avoided the disorder in reaching the boarding gates.
GROUNDING              16/07/1999   According to Bahamas report : Pilots's error in     Anyway Pilot did not check the execution of his order.   Review bridge operating procedures.
SUNNY BLOSSOM
CHEMICAL TANKER
                                    steering.                                                                                                    Check Canadian Pilots' competency (Bahamas).
BAHAMAS                             According to Canadian report : Helmsman's
11598                               error in executing Pilot's order.
BAHAMAS/CANADA
                                    Consequence: grounding in St Lawrence
                                    Seaway.

HULL FAILURE           05/05/1999   At 23:10, on 5 May 1999 a leakage of water          Inadequate survey programme of hull inspections.         The need to control the pitting corrosion and to repair the corroded area, not only because
SVITZER MERCATOR
RESEARCH SHIP
                                    into the engine room was discovered. A hole of      Absence of a doubling plate below the bilge suction      these are areas of deep penetrations into shell plating or main structural elements, but
BAHAMAS                             20mm in the bottom shell plating due to the         pipe.                                                    because they are also points for corrosion fatigue and stress corrosion failure.
1538                                corrosive action during sea passage of agitated,    Pitting corrosion.                                       Adequate periodical thickness measurements of shell plating to control both general and
BAHAMAS
                                    aerated water through the internal suction of       Poor maintenance.                                        local corrosions, taking special care at critical or suspect areas.
                                    the engine room oily water separator. The hole
                                    was immediately below the internal suction of                                                                Inadequate survey programme - organizational errors - mistake.
                                    the engine room separator, bilge suction pipe.                                                               Poor maintenance - organizational errors - mistake.
                                    The crew controlled the water level with
                                    pumps and after 3 hours a rubber plug
                                    restricted the water ingress. The Master made a
                                    precautionary distress call. The vessel arrived
                                    in Cork where temporary repairs were made.
                                    The vessel went to Falmouth for dry-docking
                                    to complete the repairing. At the dry dock the
                                    ultrasonic measurements of the shell plate
                                    thickness identified several areas of substantial
                                    corrosion.
Type of Casualty                                                                                                                                                                                                                Page 43
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                  Issues raised
                       Date of
Reporting State        casualty                    Event                                                   Causes                                                                        Human factor
Second ship (if any)
EXPLOSION              17/02/2000   After 8 days at sea carrying a cargo of about        The cause of the explosion in the hold was most             Zinc skimmings is included in IMO's IMDG Code under class 4.3 - UN No. 1435, and
THOR EMILIE
GENERAL CARGO SHIP
                                    2033 metric tons of Zinc skimmings (UN No.           probably the fact that the cargo of Zinc Skimmings,         according to the Code it can give off hydrogen when in contact with moisture or water. A
DENMARK                             1435) a great explosion occurred on the              during a period of about 8 days, had generated so much      special approval, special equipment and precautions on board are required for
1655                                vessel. The Master who was in his bathroom at        hydrogen that, in reaction with oxygen in the air, it       transportation of the material.
DENMARK
                                    the time, managed to make his way to the boat        formed a very explosive atmosphere which was ignited        For the safe transportation of dangerous goods and dangerous materials/products, it is a
                                    deck when he realized that the vessel was            by electrical tools used during maintenance work on         precondition that the goods or the material/product, in all the links of the chain of
                                    already sinking. He then found himself in the        deck.                                                       transportation, is documented and properly described by using the proper shipping name
                                    water with a life raft container close by. He        From the investigation, it appears furthermore that an      and the associated UN Number. No appropriate cargo documentation was provided.
                                    managed to enter the raft and, except for some       underlying cause was that the charter party was agreed      The cargo was first described as "Oxyde Zinc Ore in bulk" and the Master was given a
                                    debris, no trace of the vessel or of surviving       on a false basis, due to the fact that the Shipper of the   declaration on 08/02/00 when loading that "there is no risk of toxic vapours from the Zinc
                                    crew members was left; he was eventually             cargo gave a false description of the cargo.                skimmings although they have been wet by rain". However, it appears that he did not
                                    rescued after about 9 hours by a passing cargo                                                                   notice that the cargo description had changed. Had the cargo documentation been
                                    ship.                                                                                                            provided in accordance with the SOLAS regulations, the chartering Manager as well as the
                                    Loss of lives : 6 crew members; Master slightly                                                                  Master would have been in a position to check the provisions of the IMDG Code to learn
                                    injured.                                                                                                         about the properties of the cargo and the applicable regulations and precautions for
                                                                                                                                                     transport.
OTHER                  13/12/2000   The vessel had entered a lock and was                The ship's ISM Manual required an officer to be             The vessel's ISM Manual must be available at all times and in a language readily
TOR SCANDIA
RORO CARGO
                                    stationery. The first bow line was ashore, the       present during mooring but no officer was present.          understood by the crew.
SWEDEN                              vessel was 2-3 metres from the quay, and the         The hawser should have been secured to the drum by          Personnel safety equipment must be worn when undertaking any mooring operations.
33652                               main engines were stopped. The first bow line        means of two U-bolts. At the time of the accident, it       An officer must be present on the forecastle during mooring operations.
SWEDEN
                                    had been reeled and made fast on the fixed           was held by threaded cordage using the two U-bolts          Any rope or hawser must be secured to the winch drum by the method stated by the winch
                                    drum of the winch. Once secured, the bosun           holes in the drum.                                          manufacturer.
                                    ordered the winch drum brake to be locked and        The normal procedure in locks was for any                   Company and Organisation - Company standing orders inadequate.
                                    the drum dis-engaged. A second bow line was          manoeuvring to be done by operating the winches with        Crew factors - Management and supervision inadequate.
                                    then taken and a start made on taking up the         the drums engaged.                                          Equipment - Equipment misused.
                                    slack. One seaman was operating the winch            It was also normal practice for staff to wear personal      Individual - Violation of procedures, Perception of risk.
                                    controls, another was taking the slack from the      safety equipment, including a safety helmet, during
                                    second bow line off the winch cam while the          mooring - nobody was at the time of the accident.
                                    bosun was standing by the forecastle. It was         The vessel's ISM Manual was in Swedish although the
                                    noticed that the first bow line was taking heavy     crew did not speak or read that language.
                                    tension so the bosun went to ease the brake
                                    drum. However when he eased the brake, the
                                    drum ran away causing the end of the hawser
                                    to pull free. As it did so, it struck the bosun on
                                    the head, killing him instantly. The bosun (a
                                    Philippine national) had worked on this type of
                                    vessel before and had previously served with
                                    the company.
Type of Casualty                                                                                                                                                                                                                  Page 44
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                   Issues raised
                          Date of
Reporting State           casualty                    Event                                                 Causes                                                                        Human factor
Second ship (if any)
GROUNDING/STRANDING       29/01/2000   While deviating from the intended passage          - Environment - sea ice, poor weather and heavy vessel      - Importance & value of a voyage plan and the need to update the plan accordingly when
TRANSMAR
GENERAL CARGO SHIP
                                       plan to avoid sea ice and seek more sheltered      rolls due to large seas prompted diversions from            deviations & adjustments are made.
UNITED KINGDOM (ISLE OF                waters in heavy weather, the TRANSMAR’s            original passage plan.                                      - Importance of good communications - either verbal or written between the captain and
MAN)                                   watch officer failed to properly adjust the        - Failure of Master to issue written standing orders.       all navigational watch standers.
2820
UNITED KINGDOM (ISLE OF
                                       ship's course and allow for set and drift while    - Failure of 1st Officer to promptly notify Master of the   - Value of monitoring and recording a ship’s progress by frequently charting positions and
MAN)                                   operating near shoal waters. Subsequently, the     developing dangerous situation.                             projecting a dead reckoning track line.
                                       vessel contacted a charted shoal, which            - Failure of 1st Officer to adequately plot the vessel’s    - The need of ship’s officers to call the ship’s captain if in any doubt or as soon as a
                                       rendered the vessel’s steering gear inoperative.   position, monitor its progress or make allowances for       dangerous situation is first recognized.
                                       Vessel required tug assistance to make port.       set/drift on the chart used.
                                                                                          - Chart used - British Admiralty chart used showed          Navigational Officer’s over reliance on GPS and the need to cross check navigational
                                                                                          greater depths in the shoal area than did the Finnish       information with all available means.
                                                                                          chart for the same shoal area.
                                                                                          - Failure of navigation officers to check and document
                                                                                          compass error.
                                                                                          - One-man navigational watch.
                                                                                          - Lack of an established Safety Management System.
FAILURE OF WATERTIGHT     16/06/2000   On 16 June 2000, while returning to                The return of the group at a certain time was arranged      The importance of free flow through scuppers.
DOORS/PORTS/ETC
TRUE NORTH II
                                       Tobermory, Ontario, from Flowerpot Island,         and no communication between the Master and the             Operational limitations of a vessel should be stated in clear and unambiguous writing.
PASSENGER SHIP                         Georgian Bay, in moderate sea and weather          group was arranged for eventual change of return trip.      Annual inspections of Maritime Authority Inspectors should provide an accurate safety
CANADA                                 conditions, the vessel was swamped by a series     The Master decided to sail irrespectively of                audit of vessel’s current condition and should not be based on past annual inspections.
6
CANADA
                                       of waves which stove in the vessel’s bridge        unfavourable weather forecast.                              The importance of Safety Briefings in passenger vessels.
                                       front door, flooded the main deck and              After loading at Flowerpot Island the vessel was
                                       downflooded into the hull. The vessel sank         steered toward Tobermory, into the wind and waves,          Lack of communication possibilities between the Master and the group pressed the Master
                                       rapidly in 15 metres of water approximately        and large waves were shipped over the bow.                  to carry out the return trip regardless of unfavourable weather conditions.
                                       200 metres off Flowerpot Island at about 1030      The superstructure of the vessel was in a bad condition     Lack of Safety Briefing led to the passengers not being aware of the location of the
                                       local time. Of 20 people on board, 1 crew, 13      and the waves stove in the bridge front door and            lifejackets or the use of buoyant apparatus and the life raft.
                                       school children and 6 adults, 18 drifted ashore    window.
                                       on two buoyant apparatus. 2 school children        Several of the scuppers were locked or blocked and the
                                       drowned.                                           remaining allowed only the draining of a minor part of
                                                                                          the water on deck. The water therefore flowed over the
                                                                                          main deck.
                                                                                          Several non-watertight hatch covers and other
                                                                                          openings in the main deck caused a continuous
                                                                                          downflooding into the underdeck compartment, and the
                                                                                          vessel lost all reserve buoyancy and sank by the stern.
                                                                                          Under the circumstances the life raft could not be
                                                                                          released, no hydrostatic release fitted.
                                                                                          No safety instructions were given by the Master. The
                                                                                          passengers did not know where the lifejackets were
                                                                                          stowed and they were not easily accessible.
                                                                                          The regular inspection and control by the TCMS did
                                                                                          not disclose the unsafe feature of the vessel, the crew
                                                                                          (the lack of a second crew member) and life-saving
                                                                                          equipment.
Type of Casualty                                                                                                                                                                                                               Page 45
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                               Issues raised
                       Date of
Reporting State        casualty                    Event                                                  Causes                                                                      Human factor
Second ship (if any)
MACHINERY DAMAGE       22/10/1998   In the morning, on 22 October 1998, the motor       Poor maintenance of the outboard motor.                  When fully swamped, open deck fishing vessels should have enough reserve of buoyancy
UNNAMED
FISHING VESSEL
                                    of an open outboard-motor powered harvesting        Insufficient reserve of buoyancy.                        to support the mass of : its full equipment, motor, persons on board and fuel.
CANADA                              punt failed when it was returning to port, with     The persons on board were not wearing any type of        Anyone who works on board fishing vessels should have knowledge of minimum basic
                                    a full load of mussels. The punt drifted            personal flotation device.                               safety practices and procedures, even though they are very small vessels.
CANADA
                                    broadside to the waves, shipping water and          No distress signal was made.
                                    capsized. The two occupants were thrown into        Persons on board did not have basic safety training.     Maintenance of the outboard motor: Error - Mistake - Poor maintenance.
                                    the water and drowned. The two persons were                                                                  Insufficient reserve of buoyancy : organizational - error - poor regulation.
                                    wearing heavy rubber pants, a jacket and boots,                                                              The persons on board were not wearing any type of flotation device: Violation - Mistake -
                                    neither was wearing a life jacket or any                                                                     Rule based.
                                    flotation device because there were not on                                                                   No distress signal was made: Error - Mistake - lack of perception.
                                    board. No distress call was made. The motor of                                                               Persons on board did not have basic safety training : organizational error - poor regulation,
                                    the punt had a history of intermittent                                                                       procedures and practices.
                                    mechanical problems.
                                    Consequences: Two persons died, and total
                                    loss of the punt.
MACHINERY DAMAGE       14/02/1999   A fully enclosed lifeboat on a general cargo        The hook release lever was in a position where it could Although there is no evidence that the release lever was mistaken for the engine gear
WADDENS
GENERAL CARGO SHIP
                                    vessel was put into the water for a routine         interfere with free access through the forward hatch.   lever, the proximity of the lever to the engine controls increased the possibility of
ANTIGUA AND BARBUDA                 exercise with a crew of two. On completion, it      Its location meant that, if unlocked, it might be moved accidental release.
3784                                was positioned beneath the falls, the hooks         accidentally to a position at which the hooks could
AUSTRALIA
                                    connected and raised. It had reached the point      release.
                                    where the tricing pennants could be reattached
                                    when the hooks released allowing the boat to
                                    fall to the water. One of its crew was seriously
                                    injured.
                                    No fault was found with the hook mechanism.
                                    It was concluded that the locking devices of the
                                    hook operating lever had not been engaged and
                                    it had been moved by one of the crew while
                                    sitting in the forward hatch coiling a rope.
MACHINERY DAMAGE       10/11/1999   The ship, laden with a cargo of fly ash,            The failure to maintain the rope locker hatch securing   The lack of bilge pumping capability for the rope locker. The vessel arrangement resulted
WARDEN POINT
BULK CARRIER
                                    encountered prolonged heavy seas which              devices resulted in the loss of weathertight integrity   in approximately 7 tonnes of sea water accumulating in the rope locker before it
AUSTRALIA                           caused submergence of the aft rope locker           and the flooding of compartments.                        overflowed into the steering gear compartment where the bilge pump suction was located.
3894                                access lid. Due to poor maintenance, sea water      The non-tight integrity of the bulkhead between the      Early warning of the flooding could have been obtained by the installation of bilge water
AUSTRALIA
                                    leaked past the poor access lid gasket and          rope locker and steering gear compartment permitted      alarms in the rope locker and/or steering gear flat.
                                    flooded the rope locker. The bulkhead               progressive flooding of the steering gear flat.          Failure of the crew to perform stability calculations before departure and after the flooding
                                    between the rope locker and steering gear flat      Sea water contamination resulting from the failure to    and cargo shift.
                                    was non-tight and there was progressive             properly maintain the fuel oil service tank breathers.   Uncertainty in the stowage factor and angle of repose for the fly ash cargo aboard the
                                    flooding of the steering gear compartment.          The port list caused by the shifting of cargo further    vessel.
                                    The sea water rose to the level of the steering     threatened the safety of the vessel.                     Concerns over the adequacy of the last load line survey.
                                    gear motors and caused the failure of both
                                    motors with subsequent loss of steering. The                                                                 Failure of the crew to use safety harnesses and lifelines when attempting to secure the rope
                                    breathers on the fuel oil service tanks were also                                                            locker hatch lid.
                                    not properly maintained and they permitted sea                                                               Outstanding performance of the crew during the emergency procedures to secure the rope
                                    water to contaminate the fuel.This caused one                                                                locker hatch and perform temporary steering gear repairs, and bring the ship safely into
                                    of the generators to trip off line and increased                                                             port.
                                    the potential for a blackout. Further
                                    complications developed from a port list that
                                    was caused by shifting of cargo.
Type of Casualty                                                                                                                                                                                                                 Page 46
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                Issues raised
                       Date of
Reporting State        casualty                   Event                                                 Causes                                                                         Human factor
Second ship (if any)
MACHINERY DAMAGE       28/11/2000   On 28 November 2000, this loaded tanker was       The Officer of the Watch and the pilot were unaware        The navigating Bridge Watch should be kept informed of potential problems in the
WESTCHESTER
OIL TANKER
                                    under pilotage in the Mississippi when            of the engine problems until the engine had to be          machinery space.
BAHAMAS                             instruments indicated the possibility of a        stopped.
49754                               crankcase explosion. Soon afterwards, at 1801,                                                               The standing orders should contain an instruction that the bridge watchkeepers are kept
BAHAMAS
                                    an explosion occurred and at 1802 the bridge                                                                 informed of potential propulsion problems and these orders should be followed.
                                    was informed that the engine had to be
                                    stopped. Despite attempts to anchor the vessel,
                                    it grounded at 1820 and caused serious
                                    pollution.
LISTING                01/03/1999   In rough seas seawater shipped on deck,           The initial starboard list was caused by seawater          The flush-fitting deck scuttle securing mechanism has been modified. Marine inspectors
WESTISLE
FISHING VESSEL
                                    downflooded past an improperly secured            entering the cargo tank through an improperly secured      are instructed to check that scuttle covers are permanently secured to the vessel.
CANADA                              aluminium fish-loading flush-deck scuttle         scuttle cover. The cover locking mechanism tended to
99                                  cover leading to the forward starboard tank,      jam against the under-deck framework. The scuttle          Although the crew was new to the vessel, emergency drills were not conducted. The
CANADA
                                    causing a starboard list. Downflooding into the   cover was not secured and subsequently dislodged. The      vessel’s lifejackets and immersion suits were not tried; in fact they did not fit six out of
                                    compartment increased when the cover became       list increased when the unsecured deck cargo shifted to    seven crew members because of their above-average build.
                                    dislodged. When the unsecured deck cargo          starboard and the free surface effects progressively
                                    shifted suddenly to starboard the vessel healed   increased.
                                    to an angle of about 70°. By ballasting and
                                    moving weights, the crew was able to return
                                    the vessel to a near upright position. The main
                                    engine stopped due to seawater entering the
                                    fuel system through the air vent of the
                                    starboard fuel tank. The vessel was towed to
                                    port. Damage to vessel was limited to seawater
                                    contamination of the main engine fuel injectors
                                    and fuel system.
CAPSIZING              01/12/1999   Whilst engaged in replacing oyster shells,        A non professional designed platform deck had been      Being under 15 gross tons, an inspection by Transport Canada was not required.
WET N' WILD II
FISHING VESSEL
                                    oysters, mud and gravel the platform deck on      fitted to the vessel. No new stability calculations had Irrespectively of vessel size a major conversion as this one should require inspection and
CANADA                              which the load had been stowed collapsed,         been made. The platform collapsed under the weight of approval by relevant Authorities.
15                                  causing the vessel to develop a list. The         the cargo and the vessel’s sea motions. The scuppers
CANADA
                                    skipper, in an attempt to reach a wharf turned    were plugged, waters shipped onto the well deck was
                                    the vessel and presented the lower side of the    retained; the resulting free surface effect and weight
                                    vessel to the weather.                            further reduced vessel stability.
                                    In a freshening breeze and choppy seas the
                                    listing vessel shipped water and capsized. One
                                    of the 5 persons on board drowned.
COLLISION              09/11/2000   The cargo ship was on passage in the narrow       Possible Causes                                            To the Owner :
WIGHTSTONE
GENERAL CARGO SHIP
                                    channel of the River Medina from Newport to       - The steering gear power failure when the engine          Either fit a freshwater cooler bypass controller to the main engine to enable a higher
UNITED KINGDOM                      Southampton, UK. When the Master pulled           stopped.                                                   temperature to be achieved more quickly; or issue specific instructions to engineers to
439                                 back the fuel control lever in an effort to       - The small amount of port helm that existed at the time   warm the main engine to near operation temperature before departure.
UNITED KINGDOM
ROSE RYAL
                                    reduce the speed, the engine stopped, power       to steer the port curve in the narrow channel.             Consider fitting an additional electrically-driven hydraulic pump into the steering system
YACHT                               steering failed, and the cargo ship suddenly                                                                 to enable the vessel to be steered without interruption in the event of main engine failure,
                                    veered to port and hit the moored yacht.                                                                     during confined river passages.
                                    The unoccupied yacht sustained significant                                                                   Issue instructions to Masters regarding the procedures for aborting passage after an
                                    damage to her bow.                                                                                           incident, until the extent of any injuries or damage has been established.
Type of Casualty                                                                                                                                                                                                                Page 47
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                                 Issues raised
                          Date of
Reporting State           casualty                   Event                                                 Causes                                                                       Human factor
Second ship (if any)
COLLISION               13/06/2000     At about 02:09 hrs (UTC) on 13/06/2000, the       WINTERTIDE's Officer of the Watch (OOW) rigidly           Importance of proceeding at safe speed, making appropriate sound signals, and
WINTERTIDE
REFRIGERATED CARGO SHIP
                                       Panamanian-registered container ship MSC          adhering to the planned navigation track.                 maintaining proper radar, aural and visual lookout in restricted visibility.
UNITED KINGDOM                         SABRINA collided with the Netherlands-            The inaccurate radar plotting and monitoring of MSC       Importance of proper bridge manning, especially in restricted visibility.
5084                                   registered fishing vessel CONCORDIA.              SABRINA by WINTERTIDE's OOW.                              When other vessels are in vicinity, consequence of a proposed alteration of course and/or
UNITED KINGDOM
MSC SABRINA
                                       Fifteen minutes later, MSC SABRINA collided       MSC SABRINA's OOW failing to maintain a proper            speed on the CPA and TCPA of the vessels in the vicinity should always be pre-assessed
CONTAINER SHIP                         with the UK-registered refrigerated cargo ship    radar lookout.                                            before the alteration is carried out.
PANAMA                                 WINTERTIDE at the junction of the Off             MSC SABRINA's speed was considered to have been           MSC SABRINA did not stop to investigate and assist after collision with the fishing
35598
                                       Vlieland and Off Texel TSS off the                excessive given the prevailing visibility.                vessel CONCORDIA.
                                       Netherlands. WINTERTIDE and MSC                   Neither Master was called, nor were additional            Standing orders should be precise with regard to bridge manning and other instructions in
                                       SABRINA were heading south-south-west in a        lookouts posted, when the vessels entered restricted      restricted visibility.
                                       traffic lane in restricted visibility. MSC        visibility.
                                       SABRINA was overtaking WINTERTIDE
                                       with a speed advantage of about 5 knots.
                                       CONCORDIA was on passage from Den
                                       Helder to her fishing grounds and was crossing
                                       the traffic lane from the south-east. The
                                       collision between WINTERTIDE and MSC
                                       SABRINA occurred after WINTERTIDE
                                       altered course to follow her planned track into
                                       the Off Texel TSS which put the vessels on a
                                       collision course. Visibility at the time of
                                       collision was about 2 cables.
                                       As a consequence of the collision,
                                       WINTERTIDE suffered minor damage on the
                                       starboard bow and MSC SABRINA suffered
                                       minor damage on the port quarter. Damage
                                       was well above water level on both ships.
FIRE AND EXPLOSION        26/12/1997   This small product tanker was loading             Established safety procedures were not followed. The      Personnel should be fully trained and certificated in oil tanker procedures. Correct
WOOJIN
OIL TANKER
                                       kerosene into No.2 port cargo tank on 26          end of the inlet pipe was not submerged and kerosene      operating procedures should be followed including loading rates.
KOREA, REPUBLIC OF                     December 1997. This tank had previously been      was projected upwards through its "U" bend and then
287                                    loaded with gasoline and had been "gas freed"     fell. The crew had no relevant tanker safety training.    The operators did not appear to realize the potential dangers inherent in handling
KOREA, REPUBLIC OF
                                       during the short return journey only by natural                                                             dangerous cargoes. Their interest laid elsewhere in (eg) purchasing a phone card,
                                       ventilation. At about 0955, an explosion                                                                    ascertaining the condition of hawsers or in the bathroom.
                                       occurred in No.2 port cargo tank due to static
                                       electricity which injured four crew members.
LISTING                   29/06/1998   WOOYANG HONEY was carrying 6000 tons              The cargo had been soaked by rain before loading,         Shipowners, Masters and crews need to have a thorough knowledge of the characteristics
WOOYANG HONEY
GENERAL CARGO SHIP
                                       of wet pyrites concentrate from China to Korea    however no moisture tests were carried out before         of cargoes carried. If a cargo is subject to liquefaction (listed in the BC Code) the TML
KOREA, REPUBLIC OF                     when liquefaction of the cargo created a free     loading.                                                  must be provided and moisture tests carried out as close as possible to the time of loading,
3959                                   surface causing a heavy list to starboard. In     No information on the TML (Transportable Moisture         particularly if the cargo has been rained upon. Full documentation relating to the cargo
KOREA, REPUBLIC OF
                                       spite of repeated ballasting/deballasting         Limit) or other information on the cargo had been         must be provided and the cargo should be inspected before loading.
                                       operations by the crew, the vessel eventually     provided to the Master or shipowner, neither had it       When ballasting to correct a list caused by a free surface (loll) this must be carefully
                                       capsized and sank.                                been requested.                                           carried out in accordance with the established procedures, starting with ballasting the low
                                                                                         The ship did not carry a copy of the BC Code.             side, not the high side as was done in this incident.
                                                                                         When the ship started to experience stability problems,
                                                                                         the Master did not seek a port or beach the vessel but,   The shipowner concluded the charter contract without ascertaining the characteristics of
                                                                                         by incorrectly ballasting, exacerbated the problem.       the cargo. Neither the Master nor Mate appeared aware of the hazard of cargo
                                                                                                                                                   liquefaction. They also lacked awareness of how to ballast correctly to correct a list
                                                                                                                                                   caused by a free surface.
Type of Casualty                                                                                                                                                                                                Page 48
Ship's name
Type of ship
Flag Authority
Tonnage                                                                                                                                                                      Issues raised
                       Date of
Reporting State        casualty                     Event                                                   Causes                                                           Human factor
Second ship (if any)
OTHER                  24/04/1999   Following sea water infiltration in the sugar it      Poor condition of ship.                         Standard of ships selected by charterers.
ZAHARI STOIANOV
GENERAL CARGO SHIP
                                    was carrying as cargo, the Bulgarian vessel           Water ingress.                                  The handling of substandard ships by Port and Maritime Authorities.
BULGARIA                            ZAHARI STOIANOV had the cargo refused                 Previous bad repairs.                           The loading of cargo that is liable to shift.
5926                                by the buyer. The shifting of cargo resulted in       Cargo liable to shift after improper loading.
FRANCE
                                    a list of 12º and later of 25º in front of the port
                                    of Marseille. The Master decided to ground
                                    the ship which was later towed, unloaded and
                                    authorized to leave the port, and proceeded to
                                    Variya where it had to be scrapped.
                                                                                                                  _______

								
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