republic of cyprus marine accident and incident … · 2020. 6. 19. · smm sms solas stcw95 s-vdr...

REPUBLIC OF CYPRUS

MARINE ACCIDENT AND INCIDENT

INVESTIGATION COMMITTEE

Investigation Report No: 154E

Very Serious Marine Casualty

Crew Member Casualty from the M/V “SWE-CARRIER”

on 24/09/2018 off Liepaja roads

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.

ii

© Marine Accident and Incident Investigation Committee

Table of Contents FOREWORD ............................................................................................................................................ II TABLE OF CONTENTS ....................................................................................................................... III TYPICAL LIST OF ACRONYMS AND ABBREVIATIONS ............................................................ IV 1. SUMMARY ............................................................................................................................................ 1 2. FACTUAL INFORMATION ............................................................................................................... 3

Ship Particulars .................................................................................................................................. 3

Voyage Particulars ............................................................................................................................. 4 Marine Casualty or Incident Information ........................................................................................... 4

Shore authority involvement and emergency response ....................................................................... 4 3. NARRATIVE ......................................................................................................................................... 6

3.1 SEQUENCE OF EVENTS ........................................................................................................................................ 6 4. ANALYSIS ............................................................................................................................................. 9

4.1 THE SHIP ............................................................................................................................................................. 9

4.1.1 Ship’s Certificates and Surveys .................................................................................................. 9

4.1.2 Ship’s Navigational & Radio Equipment ................................................................................... 9

4.1.3 Passage Plan Analysis ............................................................................................................. 10

4.1.4 Ship’s Condition ....................................................................................................................... 11

4.1.5 Cargo related factors ............................................................................................................... 15

4.1.6 CCTV ........................................................................................................................................ 15 4.2 THE CREW ........................................................................................................................................................ 15

4.2.1 Introduction .............................................................................................................................. 15

4.2.2 Certification ............................................................................................................................. 15

4.2.3 A/B No. 1 Medical Certificate .................................................................................................. 17

4.2.4 Alcohol Testing ........................................................................................................................ 17 4.2.5 Risk Assessment ........................................................................................................................ 17

4.2.6 Fatigue ..................................................................................................................................... 18

4.2.7 Working and Living Conditions ............................................................................................... 18

4.2.8 Training .................................................................................................................................... 18

4.2.9 Physiological, Psychological, Psychosocial Condition ........................................................... 19

4.3 THE ENVIRONMENT .................................................................................................................................... 21 External environment: ....................................................................................................................... 21

Internal Environment: ....................................................................................................................... 22 5. CONCLUSIONS .................................................................................................................................. 23 6. RECOMMENDATIONS ..................................................................................................................... 24

iii


Typical List of Acronyms and Abbreviations

A/B

BAC

C/E

C/O

CoC

GA

CPR

DPA

HSSE ISM Code

Knots Lat.

Long.

LT

ST

m

MC

MT

NM O/S

PSN

RCC

RPM

SAR

2/O

SMC

SMM

SMS

SOLAS

STCW95

S-VDR

VTS

UTC

VHF ZT

Able Seaman

Blood Alcohol Content

Chief Engineer

Chief Officer

Certificate of Competency

General Alarm

Cardio-Pulmonary-Resuscitation

Designated Person Ashore

Health, Safety, Security and Environment

International Management Code for the Safe Operation of Ships

Speed in nautical miles per hour Latitude

Longitude

Local Time

Ship’s Time

Meter

Management Company

Metric Ton

Nautical Mile Ordinary Seaman

Position

Rescue Coordination Centre

Revolutions per Minute

Search And Rescue

Second Officer

ISM Safety Management Certificate

Safety Management Manual

Safety Management System

Safety of Life At Sea Convention

International Convention on Standards of Training, Certification and Watch

keeping for Seafarers 1978, as amended

Simplified -Voyage Data Recorder

Vessel Traffic Services

Universal Time Coordinated

Very High Frequency Radio Zone Time

iv


1. Summary

In conducting its investigation, the Marine Accident Investigation Committee (MAIC), reviewed

events surrounding the accident, documents provided by the Managers of the vessel messrs. Rederi AB Swedish Bulk and performed analysis to determine the causal factors that contributed to the accident,

including any management system deficiencies.

Accident Description

The “SWE-CARRIER” is a Cyprus flagged, 2000 built, general cargo ship managed by Rederi AB Swedish Bulk.

This investigation examines the circumstances under which an Able Seaman (from now on described

as “A/B No. 1”) fell overboard while the ship was en route from the port of Liepaja, Latvia to the port

of Gdynia, Poland on 24th September 2018. The crew members last saw A/B No. 1 at 17:20 hrs Ship Time (ST) at the approximate position Lat:

56º27.0’N Long: 019º58.0’E just after the vessel was clearing off the fairway of Liepaja port, and

they realized and confirmed that he was not onboard at 22:30 hrs ST while the vessel was at position

Lat: 55º40.0’N Long: 019º58.0’E, about 55 nmiles south from the port of Liepaja.

At the moment it was realized that the A/B No. 1 was missing, the crew searched thoroughly the ship without any success. As per Master’s report, he decided not to change course back to Liepaja for a search and rescue mission because of the very adverse weather conditions.

The body of A/B No. 1 was found and identified on shore 20 km south of Liepaja about 2 weeks after his disappearance.

Conclusion(s)

There were no witnesses to the disappearance. There is no evidence that it was intentional. The

investigation found that the condition of the structure, machinery and equipment of the vessel was satisfactory.

There is strong indication that the weather conditions could have affected the safety of A/B No. 1 as the sea state was 5-6 and the swell height was 3-4 m WNW, while the wind force and direction was 7

Beaufort (from now on abbreviated as bf) NW. The above weather conditions in combination with the heavy rolling of the vessel, the already slippery floor of the Poop deck and the small free height between

the Poop deck and the level of the sea could have contributed to the accidental fall overboard of A/B No. 1.

There was no risk assessment performed for the securing of deck equipment during very adverse

weather conditions and not all necessary safety precautions were taken. These should have included

the following: Permit to work & company checklist completed, rigging lifelines, wearing lifejacket

with safety harness, deck illumination, visual contact from bridge, working in (at least) pairs, water

resistant portable radios for communications with bridge, use of bridge searchlight to determine

predominant wave direction at night, be aware that even in a regular wave pattern “rogue” waves can

exist which can vary in direction and size from the regular wave pattern being experienced.

Fatigue was not considered as a factor to the accident but the Shipowner should consider employing additional crew members on the ship.

1 © Marine Accident and Incident Investigation Committee

Recommendations

1. Proper risk assessment should be done and the required safety measures should be taken for works on the open decks of the ship each time adverse weather conditions are expected or are

present. The Owner should issue a detailed circular for all his vessels and provide same as proof within 3 months.

2. The grades / capacities and numbers of personnel listed in the Minimum Safe Manning

Document indicate the minimum number of persons necessary for the safety of navigation, the

security, the safe operation of the ship and the protection of the environment. The engagement

of additional personnel as maybe considered necessary for cargo handling and control,

maintenance and watchkeeping and as needed for compliance with the required rest periods, is

the responsibility of the owner / manager and the master. The Owner should provide evidence

within 3 months that he has considered the above and advise his decision regarding hiring or

not additional crew members onboard.

3. Flag State to clarify and inform the interested parties whether the Baltic Sea is included in

the definition of “Middle-Distance International Voyages”.


2. Factual Information

Ship’s Name: SWE-CARRIER

Figure 1: The “SWE-CARRIER”

Ship Particulars

Name of ship: SWE-CARRIER

IMO number: 9194048

Call sign: 5BBR4

MMSI number: 212 385 000

Flag State: Cyprus

Classification Society: RINA

Type of ship: General Cargo

Gross tonnage: 3170 t

Length overall: 98.90 m

Breadth overall: 13.80 m Registered ship owner: Brita Shipping Company Ltd

Ship’s management company: Rederi AB Swedish Bulk

Year of build: 2000

Deadweight: 4554.90 t Hull material: Steel

Hull construction: Double Hull

Propulsion power: 2880 kW / 3917 HP

Number of crew on ship’s certificate: 7


Voyage Particulars

Port of departure: Liepaja, Latvia

Port of destination: Gdynia, Poland Type of voyage: International middle-distance voyage

Cargo information: 4153 mts clinker in bulk

Manning: 7 crew members

Number of passengers: NIL

Marine Casualty or Incident Information

Type of marine casualty/incident:

Date/Time:

Location: Position (Latitude/Longitude):

External and Internal Environment:

Ship operation and Voyage segment:

Human Factors:

Consequences:

Very Serious Marine Casualty 24/09/2018 @ 22:30 Hours Ship’s Time (Cyprus Time)

confirmed that seaman was not onboard

Man Overboard / Unknown location on ship φ = 55°40.0'N / λ = 019°58.0'E (Baltic Sea)

Air Temp: 11C

Sea Temp: 12C

Sea State: 5-6

Swell Height & Dir: 3-4 m WNW

Current speed and Dir: to ESE 2-3 kn

Wind Direction: NW

Wind Force: 7 bf

Weather: Clear/partly cloudy/rain

Natural light: Twilight / night

Visibility: Good (until 25 nm)

In passage – displacement mode

Speed 11.0 knots

Yes

Death: 1 (Disappearance from ship – found dead on

shore two weeks later)

Shore authority involvement and emergency response

On 24/09/2018 the Master sent a PAN PAN message to all ships at 22:35 ST on VHF Ch. 16, then at

22:40 hrs ST on MF 2182 kHz without response but at 22:45 hrs ST contact was established with the

Klaipeda Rescue on VHF Ch. 16 and it was reported the missing crew member. The Master informed

that the vessel would continue her passage to Gdynia as due to adverse weather conditions they would

not be able to reach the approaches of Liepaja port in the nearest 5-6 hours in order to perform Search

and Rescue Operations. Strong wind and current would be pushing the vessel towards shallow waters

of Latvian coast, south of Liepaja. The Klaipeda Rescue advised the Master to report the case to Liepaja

Port Control and they also transmitted an All Ships PAN PAN message on VHF Ch. 16.

At 23:11 hrs ST the vessel sent the following message by Inmarsat-C

“URGENT URGENT URGENT

good evening

AT 21.30 HRS CREW NOTICED ABSENCE

OF [A/B NO. 1]

LAST SEEN BY [A/B NO. 2]


AT 17.30 HRS (15.30 utc) IN THE

VICINITY OF BUOY A PORT OF LIAPAJA

WHEN SECURING DECK EQUIPMENT

AFTER DEPARTURE FROM PORT OF LIEPAJA AT 16.30 UTC

WE CONTACTED TO KLAIPEDA RESCUE ON VHF CH 16

WE DECIDED TO CONTINUE PASSAGE TO GDYNIA

WEATHER AFTER DEPARTURE NW-LY GALE 7/8

WAVES 3-5 M AND THERE IS A SHALLOW WATER

AROUND PORT OF LIEPAJA

BRGDS [MASTER]”

As per the agent in Liepaja, no commercial ship participated in a Search and Rescue mission. A rescue helicopter and naval ships performed a search of unknown duration but did not find the missing A/B.

When the Master was asked why he did not order the vessel to turn around and conduct a Search and

Rescue mission on the missing A/B he sent the following written statement:

“Please note that decision not to change course back to Liepaja and to perform search and rescue operation at Liepaja Roads or on the way there was taken by me at 22:30 hrs yesterday, when ship’s

search team did not find [A/B No. 1] on board, after short discussion / consultation with Chief Officer

by Safety Reasons.

With weather condition like yesterday afternoon / evening / and all night we were safe to proceed having wind / sea at least slightly behind beam, avoiding or reducing heavy resonance rolling by altering course slightly to port or starboard.

But if we would be trying to proceed to NE towards Liepaja, we would be having wind / sea abeam or

slightly ahead of beam, that would cause heavy resonance rolling, as with our cargo vessel is very stiff and danger of shifting of any machineries from foundation would be existing, that is not safe for crew

and ship.

Also in the vicinity of Fairway to Liepaja depths of water are around 10m and it is danger to navigate outside Fairway with our present draught 6m and heavy swell 3-5 m high.

Also wind did generate strong drift set towards SE 1-2 knots across fairway and along Latvian coast.

That was my professional judgement that it was not safe to proceed back to Liepaja and to commence search and rescue, specially that [A/B No. 1] was last seen by [A/B No. 2] with period of about 5 hours ago, at 17:30 hrs.

Best regards

[Master]”


3. Narrative

3.1 Sequence of Events

The following sequence of events was constructed by using official documents provided by the Master and the Owner of the vessel, as well as from statements from the crew members obtained by the MAIC investigator while he visited onboard the vessel.

1. The M/V “SWE-CARRIER” was bound for a laden voyage from Liepaja, Latvia to Gdynia,

Poland on 24th

September 2018.

Figure 2: The route of the vessel from Liepaja to Gdynia.


Notations on Figure 2:

(A) is the position where A/B No. 1 was last seen onboard.

(B) is the position where the crew confirmed that A/B No. 1 was not onboard the vessel. “X” is the approximate position where the body of A/B No. 1 was found on the shore. Wind notation: NW7

2. While the vessel was still loading cargo at Liepaja, A/B No. 1 was gangway security from 06:00 to 12:00 hrs ST. At 12:00 hrs ST A/B No. 1 went for a quick lunch break and then assisted with the

draught survey, sounding of the ballast tanks and closing of the hatch panels. After 15:00 hrs ST he

washed the decks and superstructure from dust from the clinker cargo after loading.

3. At 16:30 hrs ST the vessel left the port of Liepaja, Latvia with the pilot onboard for destination Gdynia with cargo 4153 mts clinker in bulk. A/B No. 1 and A/B No. 2 secured everything forward and

then at 16:48 hrs ST they assisted with the disembarkation of the pilot still inside the port due to strong wind from NW 6 to 7 bf. The vessel passed the breakwater at 16:50 hrs ST while the two A/Bs were

securing all equipment on the poop deck. The weather was NW force 7-8 bf and the wave height 3-5m. The ship was heavily pitching, rolling and sea water sprays were all over the deck.

4. The vessel passed buoys No. 1 and No. 2 at 17:10 hrs ST and continued with various WSW courses

in order to reduce pitching, rolling and escape from shallow water in the vicinity of Liepaja, and after

crossing the 20m depth line continued to SSW towards Gdynia with general course 211 degrees true.

5. At 17:15 ST A/B No. 1 brought the Latvian flag on the bridge and reported that all equipment was

secured on deck, including anchors and all on the forecastle. The crew was told to have rest and be on

stand-by in their cabins. Then at 17:20 hrs ST A/B No. 1 went again on the poop deck and found A/B

No. 2 while the vessel was passing buoy A at Liepaja approaches. A/B No. 1 continued stowing a

mooring rope on port quarter and the A/B No. 2 went inside the accommodation for resting. Short

afterwards A/B No. 2 heard A/B No. 1 come inside the accommodation and go to the storage room. As

it was noticed afterwards A/B No. 1 brought inside the storage room a starboard side aft lifebuoy so

that it was not taken away by the weather. Then he heard again A/B No. 1 go outside to the poop deck.

That was the last time any of the crew members saw or heard A/B No. 1.

6. At 21:30 hrs ST A/B No. 2 reported to the Master that he could not find A/B No. 1. The Master

instructed A/B No. 2 and the Motorman to start looking for the A/B No. 1. At 22:00 hrs ST they both

reported to the bridge that A/B No. 1 was not found after all. At 22:05 hrs ST the whole crew was

called up and commenced throughout search of the ship. At 22:30 hrs ST the Chief Officer, as search

team leader, reported to the bridge that A/B No. 1 was not found onboard. By that time the vessel was

in position Lat 55-42N Long 019-59E and about 55 nautical miles (NM) away from the position where

the A/B No. 1 was last seen.

7. The Master sent a PAN PAN message to all ships at 22:35 ST on VHF Ch. 16 that a person was lost

in unknown position after departure from Liepaja on the way to Gdynia, but did not get any answer.

Then he sent a message at 22:40 hrs ST on MF 2182 kHz without response but at 22:45 hrs ST contact

was established with the Klaipeda Rescue on VHF Ch. 16 and it was reported the missing crew

member. The Master informed that the vessel would continue her passage to Gdynia as due to adverse

weather conditions they would not be able to reach the approaches of Liepaja port in the nearest 5-6

hours in order to perform Search and Rescue Operations. Strong wind and current would be pushing

the vessel towards shallow waters of Latvian coast, south of Liepaja. The Klaipeda Rescue advised the

Master to report the case to Liepaja Port Control and they also transmitted an All Ships PAN PAN

message on VHF Ch. 16.

8. At 23:11 hrs ST Ships Owners, Crew Managers, Charterers and Agents in Liepaja and Gdynia

were informed by sending an Inmarsat-C message as there was no phone connection due to far from

coast.


9. At 24:00 hrs ST the S-VDR back up was pressed.

10. According to information received from the Owners of the vessel, the body of a man was found on the sea coast 20 kms south of Liepaja on or around 8th October 2018. The crew members of the vessel identified the body on the photo as the body of the missing A/B No. 1. In addition, the motorman and A/B No. 3 confirmed that A/B No. 1 wore an ear ring as the one shown in the photo of the body that was found. A/B No. 1 was confirmed deceased by the General Consulate of Liepaja, Latvia.


4. Analysis

The purpose of the analysis is to determine the contributory causes and circumstances of the casualty

as a basis for making recommendations to prevent similar incidents occurring in the future. The

following analysis is based on crew statements and ship’s documents provided by the Managers of the

vessel Rederi AB Swedish Bulk and additional crew statements taken by the MAIC investigator, when

he conducted an investigation onboard the vessel on 14/10/2018 at the New Holland Dock, close to

Kingston upon Hull, UK.

4.1 The Ship

4.1.1 Ship’s Certificates and Surveys

At the time of the casualty, the following certificates were valid for the ship.

Certificate Description Issued Valid until

Classification Certificate 28/05/2018 31/01/2020

Load Line Certificate 19/02/2015 31/01/2020

Cargo Ship Safety Construction Certificate 19/02/2015 31/01/2020

Cargo Ship Safety Equipment Certificate 13/06/2018 31/01/2020

Cargo Ship Safety Radio Certificate 19/02/2015 31/01/2020

Safety Management Certificate 23/10/2014 13/10/2019

International Ship Security Certificate 23/10/2014 14/10/2019

Maritime Labour Certificate 23/10/2014 13/10/2019

International Oil Pollution Prevention (IOPP) 19/02/2015 31/01/2020

International Sewage Pollution Prevention Certificate 19/02/2015 31/01/2020

International Air Pollution Prevention Certificate 19/02/2015 31/01/2020

International Energy Efficiency Certificate 11/04/2014 -

International Anti – Fouling System Certificate 11/04/2014 -

Ballast Water Management Statement of Compliance 07/12/2017 31/01/2020

Certificate of Registration 22/03/2018 -

Maritime Labour Certificate 23/10/2014 13/10/2019

Maritime Labour Convention 2006 Part I + Part II 10/04/2014 -

International Tonnage Certificate 08/04/2014 -

Minimum Safe Manning Document 22/03/2018 09/10/2022

DOC of Management Company 31/08/2018 02/09/2023

The Hull and Machinery Annual survey is due on 31/01/2019 and the Hull and Machinery Renewal survey is due on 31/01/2020.

All certificates onboard the ship were found to be in order and valid.

4.1.2 Ship’s Navigational & Radio Equipment

The “SWE-CARRIER” is equipped with the following Radio and Navigational equipment as verified onboard the vessel and has the following life – saving appliances.

Radio equipment

a) VHF receiver / transmitter

b) VHF DSC watch receiver

c) VHF radiotelephony


d) Inmarsat - C

e) MF receiver / transmitter

f) MF DSC watch receiver

g) NAVTEX receiver

h) EGC receiver

i) Satellite EPIRB

j) Radar search and rescue transponder (SART)

Navigational equipment

a) Standard magnetic compass

b) Gyro compass

c) Gyro compass heading and bearing repeaters

d) Magnetic compass bearing device

e) Means of correcting heading and bearings

f) Nautical charts

g) Nautical publications

h) Receiver for a global navigation satellite system i) 9 GHz radar

j) Second radar (9 GHz)

k) Automatic radar plotting aid (ARPA)

l) AIS system

m) LRIT system

n) S-VDR

o) Bridge navigational watch alarm system (BNWAS)

Life-saving appliances

a) 1 free fall lifeboat for 18 persons (which is also davit launched)

c) 2 liferafts for total 24 persons

d) 8 lifebuoys

e) 12 lifejackets

f) 16 immersion suits

The “SWE-CARRIER” at the time of the accident, had valid certificates including an ISM certificate.

The maintenance records indicated that she was maintained in accordance with existing regulations

and approved procedures.

All ship’s navigational, radio and safety equipment were found in order.

4.1.3 Passage Plan Analysis

The passage plan of SWE-CARRIER for the voyage detailed as follows:

a. The passage plan from Liepaja, Latvia to Gdynia, Poland was found to be in order and

complete including the charts, maneuvering data, pilot and port information, tide tables etc.

b. The ship proceeded for the intended voyage according to the passage plan. After the A/B No.

1 was confirmed missing from onboard the Master decided not to return for a search and rescue

mission but to continue the ship’s course to Gdynia due to very adverse weather conditions (see

chapter 2) c. The vessel’s speed was approximately 11 knots when the incident took place.

The ship’s passage plan was found to be in order.


4.1.4 Ship’s Condition

A physical survey onboard the vessel showed the condition of the ship’s superstructure and the

circumstances that could have led A/B No. 1 to fall overboard. The survey showed that the condition

of the structure, machinery and equipment (as many as could be surveyed during the investigator’s

time onboard and only in the superstructure of the vessel) was satisfactory and the ship complied with

the relevant requirements of chapters II-1 and II-2 of the SOLAS convention.

The survey also showed that the life – saving appliances and the equipment of the free – fall lifeboat,

the liferafts and the rescue boat were provided in accordance with the requirements of the SOLAS

convention.

4.1.4.1 The condition of the Poop deck

The following schematic shows the Poop deck, where A/B No. 1 was last seen securing some deck

equipment.

(a) Position where A/B No. 1 was last seen

(d) Storage room

(c) Entrance to accommodation

(b) Cabin of A/B No. 2

Figure 3: Schematic of the Poop deck

As per the crew members witness statements that were obtained, at 17:15 ST A/B No. 1 brought the

Latvian flag on the bridge and reported that all equipment was secured on deck, including anchors and

all on the forecastle and the crew was told to have rest and be on stand-by in their cabins. Then at 17:20

hrs ST A/B No. 1 went again on the poop deck and found A/B No. 2 while the vessel was passing buoy

A at Liepaja approaches. A/B No. 1 continued stowing a mooring rope on port quarter [at position (a)

in Figure 3] and the A/B No. 2 went inside the accommodation for resting in his cabin [at position (b)

in Figure 3]. Short afterwards A/B No. 2 heard A/B No. 1 come inside the


accommodation [at position (c) in Figure 3] and go to the storage room [at position (d) in Figure 3]. As it was noticed afterwards A/B No. 1 brought inside the storage room the starboard side aft lifebuoy

presumably so that it was not taken away by the weather. Then he heard again A/B No. 1 go outside to the poop deck. That was the last time any of the crew members saw or heard A/B No. 1. It is unknown

what exactly the A/B No. 1 was doing when he fell overboard.

The investigation onboard the vessel showed that the Poop deck was in good condition in accordance

to SOLAS regulations. It accommodates 4 double bollards, 1 winch, a deckstore, a painstore, a CO2

room and ladders leading to the Main deck and to the Boat deck. It did not have any structural

discrepancy or any unrepaired damage, it was found in a satisfactory condition structurally and by way

of maintenance.

Figure 4: The Poop deck

It is concluded that one person cannot fall accidentally overboard from the Poop deck due to structural

deficiencies of the vessel, as there was no evidence of any defect or malfunction that could have

contributed to the fall overboard.

4.1.4.2 The condition of the Boat deck

As it can be shown from the Figure 5 below, the Boat deck is located above the Poop deck.


Bridge deck

Officers deck

Boat deck

Poop deck

Main deck

Figure 5: The decks of the vessel

The equipment on the boat deck was already secured when the vessel sailed from the port of Liepaja

to destination Gdynia and there was no reason for A/B No. 1 to go to that deck or any of the decks

above that, as the equipment that required securing in the aft of the vessel were all on the Poop deck.

The Boat deck was found in a satisfactory condition structurally and by way of maintenance. The hand

rails had a height of 1.20 m, which is above waist height. They were in good condition and satisfied

the relevant SOLAS requirements. The protective chains in way of the life rafts and the rescue boat

were in a slightly rusty but overall satisfactory condition.

Figure 6: The Boat deck


It is concluded that one person cannot fall accidentally overboard from the Boat deck due to structural

deficiencies of the vessel, as there was no evidence of any defect or malfunction that could have

contributed to the fall overboard.

4.1.4.3 The condition of the hatch covers and the free passageway on the Main deck

The hatch covers were closed and secured before the departure of the vessel from the port of Liepaja.

The ship was fully loaded with cargo and had a draught of 5.44m fwd and 6.04 m aft (mean draught

5.74m). This is very close to the maximum summer draught (5.754m) and exceeds the winter draught

(5.634m). The summer freeboard of the vessel is 1.673m and was further reduced by the existing

weather conditions and the heavy rolling of the ship. As per information from the Master, the

passageway around the hatch coamings as well as the hatch covers themselves were very dangerous

with tides and spray water falling ontop of them due to the adverse weather conditions.

There was no reason for the A/B No. 1 to walk on the hatch covers or on the passageway around the

hatch coamings. The only reason could be that he wanted to double check some securing. He did not

forget to secure any equipment because (a) he secured everything together with A/B No. 2 and (b) upon arrival at Gdynia, all equipment forward of the Poop deck was already secured.

If the A/B No. 1 tried to walk on the passageway around the hatch coamings during the time of his

disappearance, that would be indeed very dangerous that a wave could hit him and drag him overboard.

In addition, if he tried to walk on the hatch covers for some reason, the Master and the Chief Officer who were on the bridge navigating the vessel would have seen him.

Figure 7: The passageway around the hatch coamings

© Marine Accident and Incident Investigation Committee 14

4.1.5 Cargo related factors

The ship was on a laden voyage from Liepaja, Latvia to Gdynia, Poland carrying 4153 mt of clinker

with the hatch covers fully closed and secured. The ship, when inspected, was found in satisfactory

condition without any noticeable cargo leakages.

The cargo was not considered as a factor to the accident.

4.1.6 CCTV

The ship is not equipped with a Closed Circuit TV (CCTV) system.

4.2 The Crew

4.2.1 Introduction

The most common human-factor causes of accidents onboard ships are error of judgement by failure

to comply with the relevant regulations. The “human element” as it is often termed in the shipping literature has frequently been cited as a cause of very serious marine accidents and deaths. Merchant

shipping is known to be an occupation with a high rate of fatal injuries caused by organizational and maritime disasters.

Research has illustrated that there are potentially disastrous outcomes from fatigue in terms of poor health and also diminished performance. Despite the introduction of work / rest mandates by the IMO,

there are still occasions where individuals simply have to work for more than 12 hours with a 6-hour break.

Stress has been identified as a contributory factor to the productivity and health costs of an organization as well as to personnel health and welfare. Most seafarers reported occasional to frequent stress at sea (80%).

Research from other domains indicates a positive relationship between health management and safety performance. Although the research on stress and health behaviours establishes a high level factor as

compared with other occupational groups, there is an absence of literature that aims to evaluate the relationship between seafarers health and performance.

4.2.2 Certification

The Minimum Safe Manning Document (MSMD) was issued by the Cyprus Maritime Authority on 22/03/2018 with expiry date 09/10/2022, requires 7 crew members to be onboard the vessel and is shown below.


Figure 8: The Minimum Safe Manning Document of the vessel

The crew onboard the vessel at the date of the incident was 7 crew members, qualifying for the minimum amount of crew members required to be onboard. All crew members certificates were up-to-

date and valid and in compliance with all relevant regulations.

The trading area allowed for this Minimum Safe Manning Document is: “Between ports in the area

which extends from the North Cape (Norway) to the West towards the Faeroe Islands, the British Isles, and the European Coast of the Atlantic Ocean, the West Coast of Africa down to the Equator.”

That trading area is called according to the Cyprus law “middle-distance international voyages”. It is not clear whether the Baltic Sea where the incident occurred is considered to be included in the description of the allowed trading area or is included only in the “restricted area voyages” trading area.

The ship was manned in accordance with the Minimum Safe Manning Document but the Maritime Administration to clarify whether the Baltic Sea is included in the trading area allowed for the MSMD.


4.2.3 A/B No. 1 Medical Certificate

The A/B No. 1 had an “MEDICAL CERTIFICATE OF FITNESS” issued on 18/06/2018 from

Onegomed Medical Clinic in Russia. All his examinations were normal and he was therefore pronounced “Fit for duty as seaman” and “in satisfactory physical condition for the specific duty

assignment undertaken and is generally in possession of all body facilities necessary in fulfilling the requirements of the seafaring profession”.

The A/B No. 1’s medical condition prior to embarkation was not considered as a factor to the accident.

4.2.4 Alcohol Testing

The ship owning company keeps very strict rules against the use of alcohol and drugs onboard their

vessels. The A/B No. 1 was tested for alcohol on 18/06/2018 from Onegomed Medical Clinic in Russia, and was found negative on alcohol usage. In addition, the Master stated that there was strictly no

alcohol onboard the vessel.

Alcohol was not considered as a factor to the accident.

4.2.5 Risk Assessment

As per evidence provided, the weather conditions during the passage from Liepaja to Gdynia were very

adverse with the sea state 5-6, swell height and direction 3-4 m WNW and wind force 7-8 bf NW.

According to the Safety and Environmental Protection Manual of the Managers of the vessel, a risk

assessment should be done before any works on deck are planned to be carried out under bad weather.

In detail, working on deck in heavy weather should be only done with the express permission of the Master. Only work that is absolutely essential should be carried out on deck during heavy weather and

only after a full and complete assessment has been conducted.

In addition, according to good seaman’s practice, if heavy weather is expected, lifelines should be

rigged in appropriate locations on deck. Attention should be given to the dangers of allowing any person out on deck during heavy weather. No seafarers should be on deck during heavy weather unless

it is ABSOLUTELY NECESSARY for the safety of the ship or crew.

Work on deck during heavy weather should be authorised by the master and the bridge watch should be informed. A risk assessment should be undertaken, and a permit to work and company checklist for work on deck in heavy weather completed.

Any persons required to go on deck during heavy weather should wear a suitable life-jacket, waterproof PPE, and be equipped with a portable transceiver. Seafarers should work in pairs or in teams. All seafarers should be under the command of an experienced senior officer.

According to information received, there was no risk assessment performed at the time when not only A/B No. 1, but also A/B No. 2, were on the open decks for securing the ship’s equipment.

There was no risk assessment performed for the securing of deck equipment during very adverse

weather conditions and not all necessary safety precautions were taken. These should have included

the following: Permit to work & company checklist completed, rigging lifelines, wearing lifejacket with

safety harness, deck illumination, visual contact from bridge, working in (at least) pairs, water

resistant portable radios for communications with bridge, use of bridge searchlight to determine

17


predominant wave direction at night, be aware that even in a regular wave pattern “rogue” waves

can exist which can vary in direction and size from the regular wave pattern being experienced. 4.2.6 Fatigue

As per the “Monthly Worksheet” report that was provided by the Master of the vessel, A/B No. 1 at the day of the casualty was resting from 00:00 hrs to 06:00 hrs, then from 06:00 hrs until 12:00 hrs he

was gangway watch, from 12:00 hrs to 13:30 hrs he had a break and from, 13:30 hrs until his

disappearance he was working as described in Chapter 2 above.

As per the witness statements from the crew members, the A/B No. 1 had only a quick lunch break

during his rest hours between 12:00 hrs and 13:30 hrs and then assisted with the draught survey,

sounding of the ballast tanks and closing of the hatch panels before commencing works relevant to the

departure of the vessel from the loading port and securing of all equipment in the forecastle and the

poop deck of the vessel.

According to the Master of the vessel, A/B No. 1 was looking slightly tired when he went to the bridge

to commence his watchkeeping duties. The Master instructed him to get some rest and to be on standby

in his cabin. As the Chief Officer was new of the vessel, he stayed on the bridge with the Master for

additional familiarization.

His records of work and rest hours were examined onboard the vessel and showed that they were in

accordance with all relevant MLC and STCW regulations. It is true that due to the limited number of

crew members employed onboard the vessel, sometimes all crew members are obligated to work for

additional hours according to the trading pattern of the vessel. The conclusion that fatigue played an

important role in the casualty is not comprehensive, but the Shipowner should take the work schedule

of the crew members into consideration and employ additional crew members if he thinks that it would

benefit the rest hours of the crew members.

Fatigue was not considered as a factor to the accident, nevertheless the Shipowner should consider employing additional crew members on the ship.

4.2.7 Working and Living Conditions

As far as the working and living conditions onboard the vessel could be examined, it must be said that they were of average standards, considering the type of ship investigated. The crew members seemed

to be in satisfactory condition both physically and psychologically (as many as could be interviewed) and they did not express any concerns or complains. The condition of the accommodation of the ship

was average but without any recommendations.

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

4.2.8 Training

The training and drills log for months July 2018 – September 2018 was examined and was found in order and in accordance with all ISM requirements. In particular, the “Man Overboard” drill was conducted during on 28 August 2018.

In any way, the Master, due to adverse weather conditions, judged that it was very risky for the ship to turn around and conduct a search and rescue mission on the missing A/B.

Training and the drills record of the crew members did not contribute to the search and rescue mission as it was cancelled by the Master.


4.2.9 Physiological, Psychological, Psychosocial Condition

The physiological, psychological and psychosocial condition of A/B No. 1 is not easy to determine fully by an investigation of this type and, accordingly, a professional opinion cannot be expressed.

But for the completeness of the investigation the following information should be considered which was retrieved during the investigation onboard the vessel:

(a) A/B No. 1 was single and has often communications with his mother. He had three cell phones

(something common for sailors who wish to minimize their telephone and internet charges) and

a laptop computer which was analysed as far as possible and its contents were mostly movies,

music and photos. His memory card of 16 GB and a portable Samsung hard disk were checked

and nothing of unusual context was discovered. His e-mails could not be retrieved due to lack

of internet access onboard.

In particular, a list of his personal items that were found onboard after his disappearance is shown below.

Figure 9: List of the A/B No. 1’s personal belongings

(b) Four out of the seven crew members had only embarked the vessel during the previous day,

23/09/2018, in Liepaja. According to the Master of the vessel, A/B No. 1 had previous contracts

with ships of the same company and in particular on the SWE-CARRIER he worked from


20/10/2017 until 07/03/2018. The Master had joined the vessel on 30/12/2017 and hence worked with him for more than two months before the A/B No. 1’s end of contract.

(c) A/B No. 1 joined the vessel in his current contract in 17/07/2018 and was due to disembark in November 2018. The cook of the vessel joked with him a few times that they were going to

return home together after the completion of their contracts but he did not answer back to this

joke.

(d) His character was quiet and no special. He did not express any extreme emotions and just followed orders. He did not create any problems with the other crew members and there was

nothing strange about him. In addition, he did not drink any alcohol. After his disappearance,

the rest of the crew members checked his cabin but did not find anything special that would show any suicidal tendencies.

(e) The cook, who embarked the vessel on 29/04/2018 and worked with him onboard the vessel

from his embarkation on until his disappearance, did not notice anything unusual about his

behaviour. As usual he did not talk much during his lunch time. The cook did not know him very much as he was very busy with his work and was only going to eat and then leave without

speaking very much. He was quite all the time, never raised his voice and never showed any

aggression.

(f) A/B No. 1 during his disappearance was wearing rubber boots, orange raincoat and orange

trousers. He was also wearing a helmet and carried with him a handheld VHF device. None of this equipment was found onboard the vessel after his disappearance, but also none of this

equipment was found on him when he was discovered two weeks later lying on the beach 20 kms south of Liepaja.

Figure 10: The type of clothes that A/B No.1 was wearing above his

uniform during his disappearance

(g) Various medicines were found in his cabin that are shown in the photo below.


Figure 11: Medicines that were found in the A/B No. 1’s cabin

The medicines shown in Figure 11 above are relevant to painkillers, vitamins, pancreatic treatment,

blood pressure, various circulation disorders, antiseptic, eye herpes and allergies. The investigator is not qualified in order to judge how receiving or the lack of receiving these medicines could have

affected the physical state of A/B No. 1.

No safe conclusions could be reached from the above-mentioned information for the A/B No. 1’s physical, physiological, psychological, or psychosocial condition which could be correlated with his disappearance.

4.3 The Environment

External environment:

The weather conditions at the time of the accident were as follows.

Air Temp: 11C

Sea Temp: 12C

Sea State: 5-6

Swell Height & Dir: 3-4 m WNW

Current speed and Dir: to ESE 2-3 kn Wind Direction: NW

Wind Force: 7 bf

Weather: Clear/partly cloudy/rain

Natural light: Twilight / night

Visibility: Good (until 25 nm)

A/B No. 1 was on the Poop deck alone securing some final deck equipment and / or mooring ropes

when the vessel cleared the Liepaja fairway and turned to southern course towards Gdynia. The sea

state was 5-6 and the swell height was 3-4 m WNW, while the wind force and direction was 7 bf NW.

The weather conditions in combination with the heavy rolling of the vessel and the already slippery

floor of the Poop deck could have contributed to the accidental fall overboard of A/B No. 1.


Internal Environment:

It was advised verbally that there was heavy rolling and spraying of sea water on the surfaces of the Poop deck when the vessel cleared the Liepaja fairway and was on course to Gdynia. This would have

made the Poop deck floor very slippery and dangerous due to the small vertical distance between the Poop deck and the level of the sea.

In conclusion, there is strong indication that the environmental conditions were a factor in the accident.


5. Conclusions

Conclusion(s)

There were no witnesses to the disappearance. There is no evidence that it was intentional. The investigation found that the condition of the structure, machinery and equipment of the vessel was satisfactory.

The weather conditions could have affected the safety of A/B No. 1 as the sea state was 5-6 and the

swell height was 3-4 m WNW, while the wind force and direction was 7 bf NW. The above weather conditions in combination with the heavy rolling of the vessel, the already slippery floor of the Poop

deck and the small distance from Poop deck to the level of the sea could have contributed to accidental fall overboard of A/B No. 1.

There was no risk assessment performed for working on deck during adverse weather conditions and

not all necessary safety precautions were taken. These should have included the following: Permit to

work from Master, rigging lifelines, wearing lifejacket with safety harness, deck illumination, visual

contact from bridge, working in (at least) pairs, water resistant portable radios for communications

with bridge, use of bridge searchlight to determine predominant wave direction at night, be aware that

even in a regular wave pattern “rogue” waves can exist which can vary in direction and size from the

regular wave pattern being experienced.

Fatigue was not considered as a factor to the accident but the Shipowner should consider employing additional crew members on the ship.


6. Recommendations

1. Proper risk assessment should be done and the required safety measures should be taken for

works on the open decks of the ship each time adverse weather conditions are expected or are present. The Owner should issue a detailed circular for all his vessels and provide same as

proof within 3 months.

2. The grades / capacities and numbers of personnel listed in the Minimum Safe Manning

Document indicate the minimum number of persons necessary for the safety of navigation, the

security, the safe operation of the ship and the protection of the environment. The engagement

of additional personnel as maybe considered necessary for cargo handling and control,

maintenance and watchkeeping and as needed for compliance with the required rest periods, is

the responsibility of the owner / manager and the master. The Owner should provide evidence

within 3 months that he has considered the above and advise his decision regarding hiring or

not additional crew members onboard.

3. Flag State to clarify and inform the interested parties whether the Baltic Sea is included in

the definition of “Middle-Distance International Voyages”.


republic of cyprus marine accident and incident … · 2020. 6. 19. · smm sms solas stcw95 s-vdr...

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