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REPUBLIC OF CYPRUSMARINE ACCIDENT AND INCIDENT

INVESTIGATION COMMITTEE

Investigation Report No: 183A/2016 (Simplified)

Serious Marine Casualty

Contact with berth of the “REGINA MED” in the port of Vasiliko, Cyprus on 24/06/2016

Foreword

The sole objective of the safety investigation under the Marine Accidents and Incidents Investigation Law N. 94 (I)/2012, in investigating an accident, is to determine its causes and circumstances, with the aim of improving the safety of life at sea and the avoidance of accidents in the future.

It is not the purpose to apportion blame or liability.

Under Section 17-(2) of the Law N. 94 (I)/2012 a person is required to provide witness to investigators truthfully. If the contents of this statement were subsequently submitted as evidence in court proceedings, then this would contradict the principle that a person cannot be required to give evidence against themselves.

Therefore, the Marine Accidents and Incidents Investigation Committee, makes this report available to interested parties, on the strict understanding that, it will not be used in any court proceedings anywhere in the world.

This investigation was not carried out as a joint investigation.

Contents

FOREWORD................................................................................................................................................I

LIST OF FIGURES....................................................................................................................................II

LIST OF ANNEXES...................................................................................................................................II

LIST OF ACRONYMS AND ABBREVIATIONS................................................................................III

1. SUMMARY OF THE MARINE CASUALTY.................................................................................1

2. FACTUAL INFORMATION ............................................................................................................3 2.1. REGINA MED...........................................................................................................................................32.1.1. Ship Particulars...................................................................................................................................32.1.2. Voyage Particulars..............................................................................................................................32.1.3. Marine Casualty or Incident Information............................................................................................32.1.4. Shore Involvement and Emergency Response

3. NARRATIVE......................................................................................................................................4

3.1. SEQUENCE OF EVENTS............................................................................................................................5

4. ANALYSIS..........................................................................................................................................8

5. CONCLUSIONS...............................................................................................................................19

6. RECOMMENDATIONS..................................................................................................................21

List of Figures

Figure 1: Nautical chart - Vasiliko portFigure 2: Berthing arrangementFigure 3: Approximate track followed Figure 4: Contact with norh berthFigure 5: Bridge Log-BookFigure 6: Engine Log-BookFigure 7: Engine Bell-BookFigure 8: Bridge Bell-Book

List of AnnexesAnnex 1: Pilot CardAnnex 2: Watches Schedule Annex 3: Hours of Work/RestAnnex 4: Accident/incident reporting form

ii© Marine Accident and Incident Investigation Committee

List of Acronyms and AbbreviationsAB Able SeamanC/E Chief EngineerC/O Chief OfficerCOO Chief Operating OfficerCoC Certificate of CompetencyDPA Designated Person AshoreDO Diesel OilDWT Deadweight TonnageECR Engine Control RoomFPT Fore Peak Tank GT Gross TonnageISM Code International Management Code for the Safe Operation of ShipsKnots Speed in nautical miles per hourLat. LatitudeLong. LongitudeLT Local Timem MeterMC Management CompanyMT Metric TonNM Nautical MilePSC Port State ControlPSN PositionRPM Revolutions per Minute2/E Second Engineer2/O Second Officer SMC ISM Safety Management CertificateSMM Safety Management ManualSMS Safety Management SystemSOLAS Safety of Life At Sea Convention STCW95 International Convention on Standards of Training, Certification andWatch

keeping for Seafarers 1978, as amendedVHF Very High FrequencyVTS Vessel Traffic ServicesUTC Universal Time CoordinatedVHF Very High Frequency Hand Held Radio (Walkie Talkie)ZT Zone Time

iii© Marine Accident and Incident Investigation Committee

1. Summary

The incident occurred on 24/06/2016, at the port of Vasiliko, Cyprus. The Marine Accident Investigation Committee’s (MAIC) only investigator, visited the vessel on her next call at the Vasiliko port, on 29/07/2016, that is about one month after the incident, due to the fact that he was abroad when the accident occurred.

The investigator interviewed only a limited number of witnesses i.e. the Pilot and the Second Officer of the M/V “REGINA MED” (the Master, the Chief Engineer and the Second Engineer who were basic witnesses had in the meantime disembarked). Due to the time lag between the time of accident occurrence and the accident investigation, limitations arise concerning the gathering of available evidence and specifically the following:

1. It wasn’t possible to preserve the incident site in order to obtain undisturbed evidence, not been contaminated or missing, so as to enable logical assessments to be made of what led to the incident.

2. Evidence which relies on the accuracy of human recollection deteriorates with time, therefore the investigation might not be as conclusive as would be if it was performed promptly.

Accident Description

The M/V "REGINA MED” on 24/06/2016, at 09:47LT, during berthing operation in the port of Vasiliko, Cyprus in good weather conditions, no current and very good visibility, came into contact with its berth, bow-on.

On the Navigation Bridge were a Pilot, the Master and the Second Officer (2/O). In the Engine Control Room (ECR), were the Chief Engineer (C/E) and the Second Engineer (2/E).

A fender was completely destroyed and the berth’s concrete construction behind the fender, sustained damage. The vessel suffered damage on the bow and forecastle area and the fore peak tank (FPT) was holed. There was no pollution caused and no-one was injured.

The Port State Control (PSC) of Cyprus, detained the vessel. Temporary repairs were carried out. Condition of Class was imposed by Class Society (RINA).

The vessel was released by PSC, on 30/06/2016 at 18:30 LT, with condition to proceed, (under Class conditions), not later than 05/07/2016, for permanent repairs, directly to a repair yard at Chalkis-Greece.

Conclusions

Direct Cause:

Failure to stop the vessel at suitable distance from its prospective berth in order to commence mooring operation.

Root Cause:

Inadequate coordination and communication (during stand by for berthing-a risk management operation) between the Bridge Team and the Engine Team.

1© Marine Accident and Incident Investigation Committee

Safety Issues:

Vasiliko port’s Pilot boarding position not charted.

Voyage plan not Berth-to-Berth.

Violation of maximum allowable vessel’s length limit for pilotage.

Violation of procedure / practice for pilot’s employment.

Recommendations

The Vessel’s Management Company1. The Vessel’s Management Company to make the necessary arrangements for providing training on Maritime Resources Management to all navigation and engineer officers of its fleet.2. The Vessel’s Management Company to take the necessary measures to ensure that the Voyage plan is planned and executed from Berth-to-Berth.

The STS CompanyThe STS Company to reconsider its policy on assigning pilotage duties to its Chief Operating Officer.

The Cyprus Ports Authority1. The Cyprus Ports Authority to take the necessary action for the charting of the pilot’s

boarding position.2. The Cyprus Ports Authority to stipulate the requirements (qualifications / experience /age

etc.) for maritime pilots taking into consideration the relevant IMO resolution (IMO Assembly Resolution A.960(23) Recommendations on training and certification and operational procedures for maritime pilots other than deep-sea pilots), and prepare relevant legislation (law and regulations) for their employment/hiring and for their continuous professional development.

3. The Cyprus Ports Authority to implement a documented procedure for maritime pilots’ employment.

The “Vasiliko Cement Works”CompanyIn cooperation with the Cyprus Ports Authority to stipulate the requirements for pilots’ employment at Vasiliko port.


2. Factual Information

2.1 Regina Med

2.1.1 Ship Particulars

Name of ship: Regina MedIMO number: 8100777Call sign: 3FGK4 MMSI number: 353822000Flag State: PanamaType of ship: General Cargo/Multipurpose Gross tonnage: 4373 Length overall: 100.20Breadth overall: 17.60Classification society: RINARegistered shipowner: San Nicola Shipmanagment SHPK, AlbaniaShip’s company: San Nicola Shipmanagment S.A., IMO 5290677Year of build: 1982Deadweight: 7988Hull material: SteelHull construction: Single Hull Propulsion type: Internal Combustion Engine 2611KW Type of bunkers: Marine Diesel Number of crew on ship’s certificate: 8

2.1.2 Voyage Particulars

Port of departure: Volos-GreecePort of call: VasilikoType of voyage: InternationalCargo information: N/AManning: 15Number of passengers:0

2.1.3 Marine Casualty or Incident Information

Type of marine casualty/incident: Serious Marine CasualtyDate/Time: 24/06/2016 @ 10:15 Hours LTLocation: PortPosition (Latitude/Longitude): φ = 34° 55'N / λ =033° 38'EExternal and Internal Environment: Sea State Calm /1, Wind NE/1B, Daylight,

Clear, Visibility very goodShip operation and Voyage segment: Normal service – In passage –Ballast Human Factors: Yes/Human ErrorConsequences: Structural Damages/Bulbous Bow

2.1.4 Shore authority involvement and emergency response After contact with the berth, vessel was assisted by the port’s Tug-Boat for mooring starboard side alongside.


3. Narrative

3.1. Sequence of Events

1. According to the schedule of arrivals and departures of ships in Vasiliko port, a Pilot was assigned (the previous day 23/06/2016), for pilotage and mooring of the M/V "REGINA MED" at the North Berth No1.

2. On 24/06/2016 at 09:25 hrs LT, the M/V "REGINA MED" commenced heaving-up anchor. At the same time, the Pilot boarded on the Pilot-Boat and proceeded to the anchorage to board on the M/V "REGINA MED".

3. At 09:30 hrs LT, anchor up. Vessel underway.

4. At 9:35 the Pilot boarded on the M/V "REGINA MED".

5. Pilot was informed by the Master, that navigational instruments RADAR, AIS, GPS, Speed Log, Gyro Compass, Rudder Angle Indicator, were in operation. Main Engine (ME) was on stand-by and the Steering Gear was in working order. Vessel in Ballast Condition. The sea was calm, wind NE/1B.

6. Pilot confirmed that navigational instruments were in working order.

7. The Master gave to the Pilot the “Pilot Card”, signed by him and the Pilot signed it. Then, the Pilot gave to the Master the "Master-Pilot Information Exchange / Passage Plan" form, which the Master signed.

8. The Pilot informed the Master that the ship will be moored starboard (stbd) side alongside North Berth No.1, and to prepare the port anchor, one meter above the sea level (to be stand-by for emergency).

9. When the Pilot boarded the vessel at 09:35hrs LT, the ME was on Dead-Slow-Ahead (according to the Pilot) or Slow Ahead according to the Bridge and Engine Bell-Books) and heading to west direction. During the aforementioned exchange of information, the ship maintained west direction.

10. At 09:37 hrs LT, the Pilot advised the Master to perform Slow Ahead (according to the Pilot or Dead Slow Ahead according to the Bridge and Engine Bell-Books) and gave to the Helmsman steering command 20 ° to starboard (stbd).

(Pilot’s aim was to bring the vessel in line with the entrance channel and the port’s mouth. The entrance channel is marked with two green buoys, which, when they are in alignment are to the stbd of the ship. At the end of the southern breakwater there is a red light and at the end of the eastern breakwater there is a green light).


Figure 1: Nautical chart -Vasiliko port

11. When the vessel’s course came in line with the channel, the Pilot advised the Master to put the ME on Dead-Slow-Ahead (according to the Pilot - it is not written in the Bell-Books).

12. Near the 1st green buoy, the Pilot advised the Master to Stop the Engine so that, when the ship enters the port her speed to not exceed 2.5 knots. (Pilot and 2/O statement)

13. When the vessel’s bow was abeam to the eastern breakwater (red light), [Distance from Berth =300m], and speed was 1.5 -2.0 knots, the Pilot advised the Master to put the rudder Hard-To-Stbd, and simultaneously the ME on Dead-Slow-Ahead, (according to the Pilot -not stated by the 2/O) – it is not written in the Bell-Books) in order to turn to stbd (while entering into the port). After the vessel began to turn to the stbd and the Pilot judged that the turning rate would bring the vessel to a vertical direction to the North Berth, he (the Pilot) advised the Master to Stop the Engine. (According to the 2/O, ME on Stop as from near the 1st green buoy, for 6 minutes).

14. The vessel continued to turn to stbd coming to a vertical direction to the North Berth. At approximate distance 50 - 60m from the North Berth, (according to the Pilot and the 2/O statement) the Pilot advised the Master to order the Engine Dead-Slow-Astern (At 09:44 Bridge Bell-Book: Dead Slow Astern, 09:44 Engine Bell-Book: Dead Slow Ahead).

15. The Pilot noticed that the vessel’s speed was not reduced and advised the Master to order Slow-Astern (09:44 Bridge Bell-Book: Slow Astern, 09:45 Engine Bell-Book: Slow Ahead) and then Half-Astern (09:45 Bridge Bell-Book: Half Astern, 09:45 Engine Bell-Book: Half Ahead).


East Breadkwater

1st Green Buoy

16. At the same time, the Tug Master of the Tug "TRITON" informed the Pilot on the VHF, that the vessel was moving forward instead of astern.

17. The Pilot immediately asked the Captain to drop the port anchor (which was already stand-by).

18. The Master ordered the Chief Officer (C/O) who was at the Forecastle to drop anchor. At 09:45 Hrs LT dropped port anchor.

19. According to the Pilot, at the moment of dropping the anchor, the vessel was moving Half-Ahead instead of Half-Astern as he had instructed the Master and the speed was increasing. The Pilot did not mention that he instructed Full Astern. In the Bell-Books is written that 09:45 (09:45 Bridge Bell-Book: Full Astern, 09:45 Engine Bell-Book: Full Ahead).

20. As soon as the anchor fell, the Pilot asked the Master to communicate with the Engine Room to ask what move the propeller was doing and to Stop Engine.

21. The ME did not stop and at 09:47 hrs LT, the vessel came into conduct with the North Berth by her bow, on Half-Ahead and Speed 4,5 knots. Forward movement onto the Berth was continued for about 2 minutes until the ME stopped.

22. The ME stopped after the Master and Chief Engineer spoke on the telephone.

23. At appr. 09:50 hrs LT, forward mooring line was sent and secured on a bollard at the North Berth. (In the Bell-Books writes finish with engine (FWE) at 09:50 hrs LT).

24. At appr. 09:53 hrs LT, commenced heave-up anchor. (according to the Bridge Log-Book)

25. Tug Boat “TRITON” assisted by pushing the aft port side to bring the vessel’s stbd side alongside.

26. At 10:08 hrs LT, “All Fast” (according to the Bridge Log-Book).

27. Due to the collision, a Fender was completely destroyed and cement construction behind the Fender, sustained damage. The ship sustained structural damage: The shell plating of the lower and upper Bow/Forecastle area, was damaged, heavily buckled and holed. The Deck beams and frames inside Bosun’s store found cracked and buckled. The Fore Peak Tank (FPT) was holed and beams and frames inside the FPT cracked and buckled.

28. At 11:10 Hrs LT, the Port State Control (PSC) of Cyprus, boarded. PSC inspected the vessel, and examined the ME which was found working properly. PSC detained the vessel.

29. Temporary repairs were carried out and Condition of Class was imposed by Class Society (RINA).

30. The vessel was released from PSC, on 30/06/2016 at 18:30 LT, under condition to proceed under Class conditions not later than 05/07/2016, for permanent repairs directly to a repair yard at Chalkis-Greece.


Figure 2: Berthing arrangement (There were 2 vessels alongside at north berth. The “TALLIN” 90m and the “TRADER” 86m. The “REGINA MED” was to make fast stbd side alongside, between them)


4. Analysis

(The purpose of the analysis is to determine the contributory causes and circumstances of the accident as a basis for making recommendations to prevent similar accidents occurring in the future).

The Marine Accident Investigation Committee (MAIC), conducted its investigation, about one month after the accident due to the fact that it’s one and only investigator was abroad when the accident occurred.

The following analysis is based on documents, basically the Bridge and Engine Bell-Books and Log-Books and statements taken by the investigator, from the Pilot the Tug Master and the Second Officer. The MAIC investigator interviewed only a limited number of witnesses i.e. the Pilot the Tug-Master and the Second Officer of the M/V “REGINA MED”, (the Master the Chief Engineer and the Second Engineer who were basic witnesses had in the meantime disembarked). It is stressed that due to the fact that the human memory deteriorates with the time and that it wasn’t plausible to preserve the incident site in order to obtain undisturbed evidence, not been contaminated or missing, the analysis has been based on available signs and indications with reservation of their accuracy.

4.1. Human Factors

The Pilot

The Pilot was holder of a Greek Master Mariner Certificate of Competency (STCW II/2) No.00225262. He was a full-time employee by the STS Company as Chief Operating Officer. Pilotage was additional to his COO duties.

The Crew

The vessel was manned with crew licensed and qualified in accordance with the requirements of the International Convention on Standards of raining Certification and Watch keeping (STCW) Convention as amended.

Certification was not considered as a factor to the accident.

Alcohol Impairment

Although no alcohol test was carried out after the incident, there was no evidence that alcohol or drugs were taken by any of the crew members involved.

Drugs and alcohol was not considered as a factor to the accident.

Fatigue

According to the declared work hours forms, those involved in the incident had been rested within the last 24 hours, more than 10 hours.Fatigue was not considered as a factor to the accident.

Working and Living Conditions

There was no evidence to suggest, that, the working and living conditions were a contributory factor to the accident.


Physiological, Psychological, Psychosocial Condition

The crew members involved were holders of medical certificate for service at sea. They were certificated as fit for sea duty.

There was no evidence to suggest that their physical, physiological, psychological, or psychosocial condition was such that could have contributed to the accident. They were physically and mentally fit to perform their job.

4.2 The Ship

The M/V “REGINA MED” is a Gearless, Two Hold, General Cargo/Multipurpose vessel, registered in Panama. The vessel was built in 1982.Engines: (1) Diesel FIAT GMT A420.5 - Power: 3500 BHP / 2610 KWDesigned by: Fiat A., Built by: Wartsila NSD Italia SpA, Built at: Trieste (ITA)Single screw propeller, variable pitch, left hand LOA =100.20m, Draft Forward = 3.95m – Draft Aft = 4.45m Breadth Extreme:17.63m, Breadth Moulded:17.6mGMDSS Sea Area: A1+A2+A3Class Society: Registro Italiano Navale (RINA)P&I Club: Shipowners Mutual Protection & Indemnity Association (Luxemburg) The Propulsion Order TelegraphThe Propulsion Order Telegraph, is located on a control console next to the steering wheel. It is not the classical telegraph type with handle, but it is a panel with push-order buttons. It provides push button communication of all standard propulsion orders between Navigation Bridge and Engine Control Room (ECR). In the ECR a panel with push-acknowledge-buttons is installed. An order can be placed from the Navigation Bridge, by pressing a push-order-button, which then flushes in the ECR, where the order is acknowledged by pressing the push-acknowledge-button.

Port State Control (PSC)One hour after the incident, two Port State Control (PSC) Officers from the Cyprus Department of Merchant Shipping boarded the vessel. Also, a Surveyor of the ship’s Class Society boarded. The PSC Officers inspected the Navigation Bridge, Accommodation and Galley, Decks and Forecastle, Engine Room, Steering Room, and the Fore Peak Tank (FPT).All navigational instruments RADAR, AIS, GPS, Speed Log, Gyro Compass, Rudder Angle Indicator, were in good working order. The ME and the Steering Gear were found in good working order.

The PSC Officers and the Class Society (RINA) Surveyor, examined the operation of the Main Engine and found that it was operating properly.

There was no evidence of any defect or malfunction that could have contributed to the accident.


4.3 The Environment The port of Vasiliko is situated in the southern part of Cyprus between Lemesos and Larnaka. Cargoes being handled are animal fodder, wheat, coal, perlite, cement, soil, gravel, scrab iron. The primary export cargo is cement. The port is protected by two breakwaters, the Southern and the Eastern. There are two berths, the northern of 360m length and the western of 125m. It has turning circle of 300m diameter and the water depth is 9m. Maximum length of ship which can berth is 180m of 8.60m draft.

The channel and the port’s entrance: The channel is marked with two green buoys, which, when they are in alignment are to the right of an entering ship. The buoyage system of the port is inaccordance with the IALA "A" system. At the end of the southern breakwater there is a red light and at the end of the eastern breakwater there is a green light. The Pilot Boarding Position, so far it has not been mapped. The practice followed by the port of Vasiliko Pilots is that an hour before a scheduled boarding, contact is made with the ship to be berthed, via VHF Channel 8.

Pilot’s boarding position not charted. (Safety issue)

Figure 3: Approximate track followed

There was no issue with the draft, since the M/V “REGINA MED” was unloaded. The weather conditions at the time of the accident were: Wind Force & Direction NE/1Beaufort, daylight and very good visibility. Weather conditions did not affect the manoeuvre. There was no such intensity current to affect the manoeuvre. There was no evidence that physical environmental factors, such as weather, climate, fog, dust or sand storm, affected the actions of the Pilot, the Master, the 2/O and the Tug Master.

There is no evidence that the weather conditions contributed to the accident.


Figure 4: Contact with norh berth

The port belongs to the Cyprus Ports Authority which leased it to “Vasiliko Cement Works” Company. The Lease Agreement covers a period of 50 years, from 01/01/1984 to 31/12/2033 and concerns all kinds of cargo (imports-exports) for the needs of the “Vasiliko Cement Works”, as well as cargo of other companies who were granted a license by the Cyprus Ports Authority.

A private jetty has been constructed (VTTV) Oil Storage Terminal, west of the port, and commenced operation in 2014. VTS Company, (the employer of the Pilot), provides marine services to the port of Vasiliko and to the VTTV Oil Terminal Jetty.

Under a license agreement signed with the Cyprus Ports Authority (CPA), VTS provides marine services to the Oil Storage Terminal, i.e., pilotage, towage, mooring and sludge collection services.


REGINA MED

4.4 Safety Management

4.4.1 Port State Control

PSC-Cyprus, detained the vessel due to serious failure or lack/effectiveness of the ISM Code.

PSC-Cyprus imposed that a Safety Management Audit by the Flag Administration (Panama) to be performed before departure from the port of Vasiliko.

PSC-Cyprus imposed that an Internal Safety Audit and corrective actions to be done within 3 months.

PSC-Cyprus found that he Voyage plan was not Berth-to-Berth.

Voyage plan was not Berth-to-Berth (Safety Issue)

4.4.2 Marine Resources Management (MRM)

On the Navigation Bridge

On the Navigation Bridge was the Pilot, the Master and the Quartermaster.

According to the Pilot, the vessel’s movements were recorded in the relevant Bridge Bell-Book. The Pilot did not know whether the Quartermaster was Second Officer (2/0) or sailor. The investigation revealed that the Quartermaster was the 2/0. The Pilot’s advice/instructions to the Master were transferred by the Master to the Quartermaster. The Quartermaster can steer and simultaneously handle the Propulsion Order Telegraph (the Propulsion Order Telegraph’s console is located next to the steering wheel). The Quartermaster was executing the orders he was receiving from the Master for the course by the steering wheel and the speed by the Telegraph. He was also completing the Bridge Bell-Book.

In the Engine Control Room (ECR)

On the Navigation Bridge, the Propulsion Order Telegraph, is located on a control console next to the steering unit/wheel. It is not the classical telegraph type with handle, but it is a panel with push-order -buttons. It provides push button communication of all standard propulsion orders between Navigation Bridge and ECR. In the ECR the same panel with push-acknowledge-buttons is installed. An order can be placed from the Navigation Bridge, by pressing a push-order-button, which then flushes in the ECR, where the order is acknowledged by pressing the push-acknowledge-button. In the ECR during stand-by the practice is to be on duty the C/E and the 2/E. The unwritten procedure (i.e. the usual practice being implemented) is that the 2/E keeps the Engine Bell-Book where he is writing the time of the order and the C/E presses the push-acknowledge-button and then chooses direction (ahead or astern) and propulsion order (i.e. dead slow, slow, half, full). There is no evidence whether both of them were in the ECR and what they were doing when the incident occurred.

On the Tug-Boat


The Tug Master stated that he heard over his VHF Ch.8, the Quay Inspector who said to the Pilot "you are about 60m" and the Pilot replied ' I have Slow Astern and doing Half ". Because he was at the stern of the “REGINA MED”, looked at the propeller which was on Ahead motion and increasing revolutions. Then he called the Pilot on VHF Ch. 8 and said that instead of doing Astern, is doing Ahead. Almost immediately he heard the noise of the anchor chain falling although he could not see it from the position where he was, (when the anchor falls, makes a lot of noise). He heard on VHF Ch. 8 the Pilot saying to switch-off the engine. Then the ship hit the Quay and continued for 1-2 minutes on Ahead motion.

The Engine Log-Book and the Bridge Log-Book

Engine Bell-Book Bridge Bell-Book

Time Propulsion Order Time Propulsion Order

09:30 Slow Ahead 09:30 Slow Ahead

09:37 Dead Slow Ahead 09:37 Dead Slow Ahead

09:38 Stop 09:37 Stop

60m from the North Berth, the Pilot advised the Master to order the Engine Dead-Slow-Astern.

09:44 Dead Slow Ahead 09:44 Dead Slow Astern

09:45 Slow Ahead 09:44 Slow Astern

09:45 Half Ahead 09:45 Half Astern

09:45 Full Ahead 09:45 Full Astern

Contact with north berth

09:47 Stop 09:47 Stop

09:47 Dead Slow Astern 09:47 Dead Slow Astern

09:48 Stop 09:47 Stop

09:50 Finish with Engine 09:50 Finish with Engine

There is contradiction between the Engine’s Bell-Book and the Engine’s Log-Book. When Ahead movements are written in the Bell-Book, at the respective times, Astern movements are written in the Log-Book.


According to the Pilot, when the vessel was abeam the 1st green buoy, he instructed STOP Engine and then, Dead Slow Ahead / Wheel: Hard-to-STBD and again Stop Engine. These movements are not written in the both Bell-Books (Bridge & Engine).

According to the Pilot, at the moment of dropping the anchor, the vessel was moving Half-Ahead instead of Half-Astern as he had instructed the Master. Instead, he stated that the vessel collided with the berth on Half Ahead and speed 4.5 knots. The Pilot did not mention that he instructed Full Astern. In the Bell-Books is written that 09:45 (09:45 Bridge Bell-Book: Full Astern, 09:45 Engine Bell-Book: Full Ahead).

As soon as the anchor fell, i.e. at 09:45, the Pilot asked the Master to communicate with the ECR and ask what move the propeller was doing and to Stop Engine. The ME did not stop and the vessel at 09:47, came into conduct with the North Berth by her bow, on Half-Ahead and Speed 4,5 knots. Forward movement onto the Berth was continued for about 2 minutes until the ME stopped.

According to the Bridge and Engine Bell-Books, after 2 minutes from Stop Engine at 09:48, it was given at 09:50 Finish with Engine (FWE). According to the Bridge Log-Book, the vessel hit the berth at 09:47. First line ashore at 09:50, anchor up at 09:53 and all fast at 10:08. FWE should have been given after, or at the same time with all fast i.e. on or after 10:08 and not at 09:50, as it is written in the Bell-Books. At 09:50 the vessel was yet, in contact with the berth. When the ME finally stopped, it was necessary to weigh-up the anchor, to make maneuvering and be pushed by the Tug towards the berth. In addition to send heaving-line and then mooring lines ashore. This whole operation, could not have been done in zero time i.e. at 09:50 FWE, as it is written in the Bell-Books.

The Engineers were questioned by PSC Officers and stated that the orders received in the ECR were for Ahead moves. On the contrary, the Pilot and the 2/O who were interviewed by the investigator, (one month later) insisted that from the Navigation Bridge, were given astern orders.

The discrepancies between the Deck and Engine Bell-Books, as well as, between the Engine Bell-Book and the Engine Log-Book, and in relation with the Bridge Log-Book, and the fact that the Engine was working properly, leads to the assumption that the Bell-Books may have been manipulated.

The Pilot may have done a mistake i.e. may have given wrong instructions. The Master may have done a mistake i.e. in transmitting Pilot’s instructions to the 2/O. The 2/O may have done a mistake i.e. instead of Astern, may had ordered Ahead the Propulsion Order Telegraph.

The C/E may have done a mistake: The 2/E may have written in the Engine Log-Book Astern, but the C/E inadvertently performed the Procedure incorrectly i.e. pushed the ahead button and his wrong action went unnoticed by the 2/E.

Whoever has done a mistake, the direct cause of the accident, was failure to stop the vessel at suitable distance from its prospective berth, in order to send heaving-line and start mooring.

Failure to stop the vessel at suitable distance from its prospective berth in order to commence mooring operation. (Direct cause)


Either the Bridge Team or the Engine Team during stand-by for berthing made a mistake, which probably is attributed to inadequate coordination and communication between the two teams.

Inadequate coordination and communication (during stand by for berthing-a risk management operation), between the Bridge Team and the Engine Team, was the root cause of the accident.

(Root cause)

Figure 5: Bridge Log-Book


Figure 6: Engine Log-Book


Figure 7: Engine Bell-Book


Figure 8: Bridge Bell-Book


5. Conclusions

MechanicalPSC Officers and the Class Society (RINA) Surveyor, examined the operation of the ME immediately after the incident and found that it was operating properly. Therefore, mechanical cause of the incident was precluded.

The PilotThe Pilot was employed by STS Company as Chief Operating Officer (COO). Pilotage was additional to his office duties. According to the IMO A.960(23) Recommendations on training and certification and operational procedures for maritime pilots other than deep-sea pilots - Annex 2/ Para 9 - Fitness for duty: “Pilots should be adequately rested and mentally alert in order to provide undivided attention to pilotage duties for the duration of the passage”.Performing two jobs, that of the COO and that of the Pilot, increases workload as well as the burden of responsibility causing high stress which in turn can trigger mistakes.

He was trained since October 2015 in pilotage in the port of Vasiliko by an experienced Pilot (ex Senior Pilot of the Cyprus Ports Authority). He was examined by the Deputy Director of the Port of Larnaca, (Senior Pilot of the Cyprus Ports Authority), who allowed him to handle vessels up to 100m.

The Cyprus Ports Authority did not issue to the Pilot a “Licence”. Instead, with a letter dated 19 May, 2016 informed the Director of the “Vasiliko Cement Factory”, that “after an assessment made by the Deputy Director of the Port of Larnaca, the Pilot can perform pilotage of ships not exceeding 100 m total length”.

Nevertheless, according to the schedule of arrivals and departures of ships in Vasiliko port, the Pilot was assigned for pilotage and mooring of the M/V "REGINA MED" which exceeded 100 m in total length, being 100.20m.

The total length of the vessel 100.20m, is slightly greater than the maximum allowed (100.00m). Although it does not make any substantial difference, typically it is a violation. The violation was condoned by “Vasiliko Cement Works” management (assigned the subject Pilot, the previous day 23/06/2016 for pilotage and mooring of the M/V "REGINA MED" at the North Berth No1. Greater violations of maximum allowed length may have been attempted.

Violation of maximum allowable length limit for pilotage. (Safety issue)

The Cyprus Port Authority Law Article 2 stipulates that:“Pilot’ means any person in the employment of the Authority and/or license permit holder and/or authorized and/or otherwise nominated by the Authority and who without belonging to a ship undertakes to advise the captain of the ship who enters into or departs from a port of the Authority’s jurisdiction, without replacing him of his rights and obligations in connection with the safety of the ship”

Although Article 2 does not stipulate qualifications, experience, etc., the requirements and procedure for the employment of pilots, which the Cyprus Port Authority implemented for many years, was to issue a public notice for vacancies stating the required qualifications, experience for pilots and organize interviews for selection of the most suitable candidates. Also, if required, (for appointment


in the public service is required very good knowledge of the English language) written examinations in the English language. For the employment of this case’s Pilot, the usual practice was not followed. Therefore, it is considered as a violation by the Cyprus Ports Authority of its own (unwritten) procedure/practice.

Violation of procedure / practice for pilots’ employment. (Safety issue)

Conclusively

Direct Cause: Failure to stop the vessel at suitable distance from its prospective berth in order to commence mooring operation.

Root Cause:Inadequate coordination and communication (during stand by for berthing-a risk management operation), between the Bridge Team and the Engine Team, was the root cause of the accident

Safety Issues:Vasiliko port’s Pilot boarding position not charted.Voyage plan not Berth-to-Berth Violation of maximum allowable length limit for pilotage. Violation of procedure / practice for pilots’ employment.


6. Recommendations

The Vessel’s Management Company

1. The Vessel’s Management Company to make the necessary arrangements for providing training on Maritime Resources Management to all navigation and engineer officers (within 6 months).2. The Vessel’s Management Company to take the necessary measures to ensure that the Voyage plan is planned and executed from Berth-to-Berth (within 1 month).

The STS Company

The STS Company to reconsider its policy on assigning pilotage duties to its Chief Operating Officer.

The Cyprus Ports Authority

1. The Cyprus Ports Authority to take the necessary action for the charting of the pilot’s boarding position (within 3 months).

2. The Cyprus Ports Authority to stipulate the requirements (qualifications / experience /age etc.) for maritime pilots taking into consideration the relevant IMO resolution (IMO Assembly Resolution A.960(23) Recommendations on training and certification and operational procedures for maritime pilots other than deep-sea pilots), and prepare relevant legislation (law and regulations) for their employment /hiring and for their continuous professional development (within 6 months). 3. The Cyprus Ports Authority to implement a documented procedure for maritime pilots’ employment (6 months). “Vasiliko Cement Works” CompanyIn cooperation with the Cyprus Ports Authority to stipulate the requirements for pilots’employment at Vasiliko port (within 6 months).


Annex1: Pilot Card (page 1)


Annex1:Pilot Card (page 2)


Annex2: Watches schedule


Annex3: Hours of Work/Rest – Master

Annex3: Hours of Work/Rest – Chief Officer


Annex3: Hours of Work/Rest – Second Officer

Annex3: Hours of Work/Rest – AB1


Annex4: Management Company’s form for accident/incident reporting.


foreword - marine accident and incident investigation ... · web viewthe pilot was holder of a...

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