MV CN JUMBOS
Transcription
MV CN JUMBOS
Marine Safety Investigation Unit SAFETY INVESTIGATION REPORT 201403/035 The Merchant Shipping (Accident and Incident Safety Investigation) Regulations, 2011 prescribe that the sole objective of marine safety investigations carried out in accordance with the regulations, including analysis, conclusions, and recommendations, which either result from them or are part of the process thereof, shall be the prevention of future marine accidents and incidents through the ascertainment of causes, contributing factors and circumstances. Moreover, it is not the purpose of marine safety investigations carried out in accordance with these regulations to apportion blame or determine civil and criminal liabilities. NOTE This report is not written with litigation in mind and pursuant to Regulation 13(7) of the Merchant Shipping (Accident and Incident Safety Investigation) Regulations, 2011, shall be inadmissible in any judicial proceedings whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless, under prescribed conditions, a Court determines otherwise. The report may therefore be misleading if used for purposes other than the promulgation of safety lessons. REPORT NO.: 07/2015 March 2015 MV CN JUMBOS Collision between the Maltese bulk carrier CN Jumbos and the Liberian registered bulk carrier Anton Topic two nautical miles Northwest of Ko Lin, Thailand 30 March 2014 SUMMARY On 30 March 2014 at 2214, the Malta registered bulk carrier CN Jumbos and the Liberian bulk carrier Anton Topic collided two nautical miles Northwest of Ko Lin, Thailand. CN Jumbos reported hull damage and water ingress in the double bottom tanks and cargo holds. Anton Topic also sustained structural damage on the port bow. No pollution and injuries were reported. only had access to limited data from CN Jumbos and therefore the safety investigation focused on the events which happened on board the Maltese ship. The MSIU identified that a complex and dynamic situation was not fully recognised, leading to the collision. The MSIU has issued one recommendation to the ship managers, addressing the preservation of voyage data recorder data. During the analytical stage of the safety investigation, the MSIU © Copyright TM, 2015. This document/publication (excluding the logos) may be re-used free of charge in any format or medium for education purposes. It may be only reused accurately and not in a misleading context. The material must be acknowledged as TM copyright. The document/publication shall be cited and properly referenced. Where the MSIU would have identified any third party copyright, permission must be obtained from the copyright holders concerned. CN Jumbos MV CN Jumbos 1 201403/035 single, fixed pitch propeller. service speed is 14.0 knots. FACTUAL INFORMATION Vessels CN Jumbos is a 16418gt Maltese registered bulk carrier, fitted with five cargo holds forward of her accommodation superstructure. She is owned by CN Madison Inc., managed by Franco Compania Naviera S.A., of Greece and classed with Nippon Kaiji Kyokai. The vessel was built by Mitsubishi Heavy Industries Ltd., Japan in 1995. The vessel’s The master and the navigational officer of the watch on CN Jumbos CN Jumbos had a crew complement of 23 from Ukraine, Romania, and Myanmar. All crew members had the necessary qualifications in accordance with the relevant requirements of the STCW Convention. The Ukrainian master was 57 years old and held command of similar sized ships for 17 years. Prior to the accident, he has been in employment as master with the present company for about seven years. He joined CN Jumbos on 12 December 2013. His master’s Certificate of Competency was issued by Ukraine. CN Jumbos has a length overall of 165.50 m. Her loaded draught is 9.525 m. Propulsive power is provided by a fivecylinder B&W 5L50MC, two-stroke slow speed direct drive diesel engine, producing 5370 kW at 125 rpm. The engine drives a single, fixed pitch propeller, reaching manoeuvring speed of 10.8 knots and a full sea speed of 15.0 knots in ballast condition. The third mate was 29 years old at the time of the accident and was also from Ukraine. In 2011, he qualified as an OOW on ships of 500gt or more, in accordance with regulation II/1 of the STCW Convention. He was initially employed by the Company as an AB. He joined CN Jumbos as third mate on 12 December 2013. CN Jumbos is equipped with a range of navigational equipment, including a gyro compass, two radar sets (one fitted with automatic radar plotting aid), and two receivers for global navigation satellite system (GPS). The vessel is also fitted with an AIS, VHF radio, course recorder, echo sounder, and a NW4000-series simplified VDR. The capsule (HSS) has about 12 hours of storage space after which the voyage data is overwritten with new data. Bridge organisation and safe navigation procedures on CN Jumbos The Company’s SMS Manuals specified that prior to sailing, the master was to determine the composition of the bridge watches for open seas, entering/leaving port, restricted visibility/dense traffic, anchoring, transiting straits and special areas where limitations on manoeuvring apply. The master’s bridge manning order, which was posted on the bridge, also explained who should be called for duty. Anton Topic, a 26,250gt bulk carrier, was built in 1996 and is registered in Monrovia. She is owned by Marlona Navigation Co. Inc., managed by Marfin Management SA of Monaco and is classed with Lloyd’s Register of Shipping. The vessel’s overall length is 185.74 m and her loaded draught is 11.62 m. The SMS manual inter alia stated that: Propulsive power is provided by a sixcylinder B&W 6S50MC, two-stroke slow speed direct drive diesel engine, producing 8561 kW at 127 rpm. The engine drives a MV CN Jumbos “...the Master is personally responsible for the safety of navigation and his primary consideration is the safety of the ship and its personnel. The Master is to be present on the bridge when entering or leaving a port, 2 201403/035 crossing channels, etc., in restricted visibility, in bad weather and whenever he considers it necessary. the keeping of a good lookout, using all available means and strict observance of international regulations for preventing collisions at sea. ...The OOW shall be guided by the contents of international regulations and guidelines, but paying particular attention to the Paramount Clause – The safety of the ship and its personnel is always to be the prime consideration, taking precedence over any other. No consideration of program, convenience or previous instructions justifies taking any risk which may place the ship in danger.” The night orders for 30 March 2014 directed the watch keepers to follow the master’s and Company’s standing orders, and to keep a sharp lookout. The master’s standing orders are signed by the navigational officers of the watch at the commencement of each voyage. Environmental conditions The weather on the evening of 30 March 2014 was overcast. Visibility was reported to be up to 12 nautical miles. The wind was Beaufort Force 2 with a low swell of about 0.50 m from the Southeast. With reference to lookout duties, it was required in the SMS Manual that: “…[i]n maintaining a proper lookout, the following are observed at all times: the lookouts are to pay full attention to their assignment and no other duties are to be undertaken by or assigned to them, which could interfere with their task; and Internal audits The last scheduled quality and SMS internal audit prior to the accident was carried out by the master and the Company’s auditor on 13 June 2013. The audit report indicated that the officers and crew demonstrated a good level of understanding of the Company’s requirements and procedures. No nonconformities with respect to the ISM Code and the safety management system were raised. the duties of the lookout and of the helmsman are separate and, consequently, the helmsman is not considered to act also as a lookout while steering.” The matter is also addressed in Rule 5 of the Collision Regulations (COLREGs). Drug and alcohol policy The Company has a drug and alcohol abuse policy, which is enforced on board to ensure a safe working environment on board. The use or possession of drugs is strictly prohibited and any crew member found in contravention of this policy is subject to immediate dismissal. Consumption of alcohol is only allowed in limited quantities and its consumption is permitted neither during hours of work nor four hours before any scheduled work. Narrative Events on CN Jumbos leading up to the collision1 CN Jumbos departed Anggrek, Indonesia on 25 March 2014. The vessel was in ballast, bound for Ko Si Chang in Thailand. The drafts were 3.72 m forward and 5.78 m aft, thus a 2.06 m trim by the stern. The voyage was uneventful. Master’s standing and night orders The master’s orders specified that watch keepers are responsible for the safety of the ship and their first and foremost duty was MV CN Jumbos 1 3 Unless otherwise stated, all times are ship’s time (UTC+7). 201403/035 On 30 March 2014, at 1955, the third mate came on the bridge for his 2000-2400 watch, taking over the navigation watch from the chief mate. At handover, the third mate reportedly found the bridge in order. The vessel was on auto-pilot. The charted course was 000°(T) and speed was about 12.5 knots. BA Chart 1046 was in use. The vessel was expected at waypoint 20 at about 2200 for her final approach to Ko Si Chang pilot station. (provided that both vessels maintained their respective course and speed). A GPS position (12° 47.6’ N 100° 40.4’ E) plotted at 2200 placed CN Jumbos about six cables South Southeast of waypoint 20. The vessel’s speed was gradually dropping after 2202 and the next charted course 026.4°(T) was shortly due. The master judged that after the course alteration, CN Jumbos would safely pass on the port side of Anton Topic. The master recalled that at about 2210, the small cargo ship on CN Jumbos’ starboard quarter had been overtaken and well clear. At 2100, the master came on the bridge. At the time, CN Jumbos was overtaking a small cargo ship about one nautical mile slightly forward of the starboard beam. There were no other vessels in sight. After familiarising himself with the situation, the master called Ko Si Chang Port authorities and exchanged arrival information. The master instructed the third mate to change over to hand steering and steer 026°. The third mate recalled that when the heading was on 026°, the steering was changed to auto-pilot again. He stated that another course alteration was required by the master to 031° because of a fishing vessel which was ahead of CN Jumbos. At 2150, when the vessel was just off waypoint 20 (12° 48’ N 100° 40’ E), the master acquired a radar target. In the meantime, end of sea passage (EOP) was declared at 2200, when the vessel was about 14 nautical miles from the pilotage embarking area. The master recalled that shortly after reaching course 026°, Anton Topic, which was now less than one nautical mile from CN Jumbos’ port bow, was observed rapidly turning to port. The master stated that he tried to contact her on the VHF radio but he received no reply. The master had the con and the third mate was on hand steering. There was no helmsman and no look-out was posted on the bridge. He immediately ordered a hard-over wheel to starboard, with the engine running manoeuvring full ahead. Notwithstanding this manoeuvre, at 2214, CN Jumbos and Anton Topic collided in position 12° 49.05’ N 100° 40.86’ E. CN Jumbos’ port side was struck by Anton Topic (Figure 1) in way of cargo hold nos. 1 and 2, at an angle of 30°. The master visually sighted the radar target against the back drop of shore lights. He stated that the target was bearing 17° on the gyro compass at a distance of 4.7 nautical miles2. The ARPA displayed Anton Topic on a course of 206° and making a speed of about 13 knots. From the ARPA, the AIS information and the visual aspect of Anton Topic, i.e. two mast head white lights and a red side light, the master recalled that he had judged a crossing situation, with CN Jumbos crossing ahead of Anton Topic 2 The master identified the radar target as Anton Topic on the AIS. MV CN Jumbos 4 201403/035 Structural damages to CN Jumbos A damage survey was carried out by Class NK on behalf of the flag State Administration. The port side shell plating, upper deck plating, forecastle space, and supporting structures between the collision bulkhead and aft bulkhead of cargo hold no. 3 were longitudinally torn, distorted, and dented in a number of places (Figure 2). Figure 1: Damages to Anton Topic port bow Post collision events Immediately following the collision, both vessels stopped their main engines. The starboard side of Anton Topic started closing in on the port side of CN Jumbos until the two vessels were almost parallel and stopped in the water. As Anton Topic surged across the bow of CN Jumbos, the master ordered the engines full astern and the two vessels moved apart. Figure 2: Damage to the side shell plating Anton Topic’s anchor and chain were displaced and lodged into the CN Jumbos’ ship side (Figure 3). CN Jumbos’ cargo holds were breached. There was ingress of water and the vessel started taking a list to starboard. The master raised the general alarm, activated the EPIRB, and issued a distress call. The crew were mustered and the lifeboats prepared. The two liferafts were also tethered and launched. Meanwhile, soundings of ballast tanks and hold bilges were taken by the crew members. Figure 3: Anton Topic’s anchor (and chain), which penetrated CN Jumbos side shell plating Eventually, the starboard list settled at 5° and the situation finally stabilised. The emergency actions called by the master were stood down. At 2230, CN Jumbos anchored off Ko Lin in position 12° 49.01’ N 100° 40.69’ E. Anton Topic reportedly anchored at Laem Chabang anchorage. There was neither any pollution nor injuries reported by the two vessels. An underwater inspection of the hull revealed that the shell and bottom plating between the bulbous bow and water ballast tank no. 4 were dented and punctured in three locations (Figure 4). Water ingress was reported in cargo hold nos. 1 and 2. Four sets of bilge keel were ripped off3. 3 MV CN Jumbos 5 An internal examination of the cargo holds and water ballast tanks could not be carried out at the time of the damage survey. 201403/035 somehow inadvertently overwritten. The VDR data from Anton Topic was not available to the MSIU. The lack of VDR data from both vessels hampered the reconstruction of events leading to the collision. Fatigue Analysis of the documents submitted to the MSIU did not reveal any evidence that the master or the third mate on board CN Jumbos were suffering from fatigue. To this effect, fatigue was not considered to be a contributing factor. Figure 4: Damage to the bottom shell plating ANALYSIS4 Aim The purpose of a marine safety investigation is to determine the circumstances and safety factors of the accident as a basis for making recommendations, and to prevent further marine casualties or incidents from occurring in the future. Drug and alcohol test The last schedule drug and alcohol test on the crew of CN Jumbos was carried out on 31 March 2014. The MSIU was not aware that drug and alcohol tests were carried out following the collision. However, during the course of the analysis of the crew actions, there were no indications that drug and alcohol could have contributed to the accident. Voyage data recovery Voyage data is valuable (factual) information, crucial to help understand the dynamics of events leading to the accident. It gives insight into the conversations amongst the bridge team members and between other ships. AIS and VHF communication Information extracted from the AIS included the destination of Anton Topic, which was Pasir Gudang, Malaysia. Given the close proximity of her position to Ko Lin, an alteration of course to port (to execute her own voyage plan) should have been anticipated by the master of CN Jumbos. The process for saving VDR data is simple and straight forward although it may vary from one ship to another. The voyage data on CN Jumbos covering the period leading to the collision was reportedly to have been irretrievably lost by the crew members. It could not be established whether the crew members failed to save the data (as initially reported), or if the data was saved but 4 Alternately, there were advantages in using VHF radio to determine the approaching vessel’s intended action or to communicate one’s action to avoid misunderstanding or close quarter situations. However, no attempt was made to either communicate or alert Anton Topic until it was too late to avert the collision. During the course of the safety investigation, the MSIU did not have sufficient information on the unfolding events on board Anton Topic. To this extent, the safety investigation report focuses only on the accident dynamics happening on board the Maltese vessel. In this respect, the MSIU was unable to fully determine the direct causes and underlying factors of this collision. MV CN Jumbos 6 201403/035 Standards of bridge manning and watch keeping The duties of, inter alia, the master, navigational officer of the watch and the look-out were specified in the Company’s SMS manuals as follows: Overall control Master OOW Certified deck officer Manual steering Able seaman Lookout Able seaman Radar & ARPA Certified deck officer Assessment of the situation The master arrived on the bridge at 2100. After he acquainted himself with the situation, he did not consider it necessary to complement the bridge team with a look-out and/or helmsman. Meanwhile, the third mate remained responsible for the navigational watch duties until the con was taken over by the master at about 2210. Soon after, he instructed the third mate to go and switch over to hand steering. The vital function of tracking Anton Topic and other vessels was thus abruptly disrupted with the third mate now stationed at the steering console. Inevitably, the workload was now on the master at a time when continuous monitoring of the relative movements of CN Jumbos and Anton Topic had become critical due to sudden drop in speed and alteration of course to starboard. Although CN Jumbos was approaching the restricted waters of Ko Si Chang during that evening, the master’s night orders did not contain any specific instructions to the watch keepers to call additional crew for helm or lookout duties. Although the master was not constrained by the Company to call additional crew members on the bridge, he deemed that it was adequately manned with the navigational officer of the watch and himself. Consequently, this changed the CPA, TCPA of Anton Topic and own vessel’s aspect. The appearance of a fishing vessel at close quarter at this critical moment augmented the mental workload. With the sudden turn of events, monitoring and accurate interpretation of the situation became critical; considering also the dynamic situation and the significant amount of information which the master had to look for, interpret, and act upon. Without any additional support, the master’s accuracy of the situation awareness was compromised and inaccurate. Since the master and the third mate had joined CN Jumbos on 12 December 2013, i.e. well after the Company’s internal SMS audit of 13 June 2013, it could not be determined whether the master was familiar with the Company’s procedures on bridge organisation and safe navigation. However, managers confirmed that the master had undergone familiarisation training at their and the manning agents’ offices, through the Company’s standard pre-joining familiarisation material. Interpretation and action The available evidence suggested that the master may not have readily anticipated the developing situation. It appeared that the master’s understanding of the prevailing situation was such that it did not pose any particular risk which would have warranted the implementation of the SMS procedures and to follow the standing orders. In doing so, however, the navigational watch fell short of the standards on watchkeeping arrangements, prescribed in Chapter VIII of the STCW Convention. MV CN Jumbos At 2200, the master rang EOP and visually sighted Anton Topic. He claimed that at the time, she was 4.7 nautical miles on CN Jumbos’ starboard bow5. The master 5 7 During the consultation period, when the draft safety investigation report was forwarded to the substantially interested parties and States, the managers of Anton Topic submitted a series of 201403/035 stated that she was displaying two white mast head lights and a red side light and that if both vessels maintained course and speed CN Jumbos would cross clear ahead of Anton Topic with a CPA margin of 0.8 nautical miles. Conflicting Evidence There were three discrepancies noted in the evidence made available to the MSIU: Both the master and the third mate visually sighted Anton Topic at 2200, which was an acquired target on ARPA at 2150. The master stated that if both vessels maintained course and speed, CN Jumbos would cross clear ahead of Anton Topic. The third mate, however, reported that Anton Topic was crossing well ahead of CN Jumbos. The interpretation given by the master was at variance with that of the third mate; However, the master seemed to have taken no account of the rapidly falling rpm to manoeuvring full speed and the alteration of course of 026°. Both variables changed the CPA and TCPA of Anton Topic6. It is also possible that the accuracy of a radar plot may be lost while altering course and reducing speed. Therefore, the fresh CPA and TCPA may not be immediately detected or readily available to both vessels. The master stated that he ordered the third mate to change to hand steering at 2210. The third mate, however, reported that it was shortly after 2200 that the master had ordered him to engage hand steering and bring the vessel from 000º to 026º. The auto-pilot was re-engaged and at 2206, a GPS position was plotted on the chart. This event was not recorded in the master’s statement; and Once the course alteration was completed with Anton Topic less than one nautical mile from CN Jumbos, the master relied on his experience and he reportedly judged that Anton Topic would pass very close on the port side of CN Jumbos, which assessment may not have been readily perceived on Anton Topic. Shortly after plotting the GPS position at 2206, the master ordered the third mate to take over the wheel a second time and steer 031º. The third mate stated that it was when he was steering 031º to clear a fishing vessel that Anton Topic struck CN Jumbos. This event was not recorded in the master’s statement. Indeed, Anton Topic’s turning to her port (perhaps to execute her own voyage plan) alarmed the master who at the time was reportedly preoccupied to steer clear of the fishing vessel. His immediate reaction was to order the wheel hard over to starboard, with the engine full ahead to avert the collision with Anton Topic. In the absence of data from VDR the MSIU could not verify which of the versions recorded in the two statements was more accurate. one-minute interval AIS screenshots, covering the time between 2155 and 2205. According to these AIS screenshots, the distance between the two ships at 2200, was 5.88 nautical miles. It was also indicative that the bearing of CN Jumbos had not appreciably changed during that period. 6 No new CPA and TCPA for Anton Topic were reported by the master. MV CN Jumbos 8 201403/035 It was decided that: CONCLUSIONS Additional focus will be made on COLREGs and the Company’s navigational procedures; 1. A close quarter situation was allowed to develop, eventually resulting into a collision. 2. The master on board CN Jumbos did not anticipate that Anton Topic would alter course to port before passing clear of his ship. The Company will analyse the seafarer’s history in more detail before an approval is issued for the embarkation and signing on; 3. The fishing vessel ahead of CN Jumbos added to the complexity and mental workload of the master at a time when the situation with Anton Topic was critical. The importance of a proper lookout performed by all available means will be highlighted to all OOWs; 4. Internal audits and on board visits by Company personnel will specifically focus on familiarisation of crew members with Company’s navigational and emergency procedures; On sighting Anton Topic turning to port, CN Jumbos neither reduced her speed nor stopped / reversed her main engine. 5. The OOW was at the helm and took no further part in navigation or lookout by sight, hearing or by other means available to him on the bridge. 6. The master deemed the bridge was adequately manned and did not consider calling additional crew members for assistance. 7. No VHF communication was exchanged between the two vessels with respect to course and speed alterations after CN Jumbos’ EOP. Continuous training on safe navigational practices will be provided to crew members to ensure that risky situations are addressed in a timely manner to avoid an escalation to an emergency situation; Issues identified during emergency situations are reviewed by Company’s personnel in order to determine whether the Company’s emergency procedures need to be amended; and The safety lessons identified in this particular accident will be disseminated among vessels under the Company’s management. SAFETY ACTIONS TAKEN DURING THE COURSE OF THE SAFETY INVESTIGATION7 RECOMMENDATIONS Franco Compania Naviera S.A. reported that following the accident, an internal investigation was carried out. Taking into consideration the conclusions reached and the actions taken by the managers of CN Jumbos, Franco Compania Naviera S.A. is recommended to: 7 07/2015_R1 ensure that crew members are thoroughly familiar with the procedures to save data from VDR and sVDR units fitted on board ships under its management. Safety actions and recommendations should not create a presumption of blame and / or liability. MV CN Jumbos 9 201403/035 SHIP PARTICULARS Vessel Name: CN Jumbos Anton Topic Flag: Malta Liberia Classification Society: Nippon Kaiji Kyokai Lloyd’s Register of Shipping IMO Number: 9111371 9107679 Type: Bulk carrier Bulk carrier Registered Owner: CN Madison Inc. Marlona Navigation Co. Inc. Managers: Franco Compania Naviera S.A. Marfin Management S.A.M. Construction: Steel Steel Length Overall: 165.5 m 185.74 m Registered Length: 158.60 m 177.08 m Gross Tonnage: 16418 26250 Minimum Safe Manning: 16 13 Authorised Cargo: Dry bulk Dry bulk Port of Departure: Anggrek, Indonesia Ko Si Chang, Thailand Port of Arrival: Ko Si Chang, Thailand Pasir Gudang, Malaysia Type of Voyage: International International Cargo Information: In ballast Dry bulk Manning: 23 21 VOYAGE PARTICULARS MARINE OCCURRENCE INFORMATION Date and Time: 30 March 2014 at 2214 Classification of Occurrence: Serious Marine Casualty Location of Occurrence: 12° 49.05’N 100° 40.86’E Place on Board Cargo hold; Freeboard deck; Forecastle deck; Overside Forecastle Injuries / Fatalities: None None Damage / Environmental Impact: Hull damage Hull damage No environmental damage Ship Operation: On passage On passage Voyage Segment: Arrival Transit External & Internal Environment: Overcast. Visibility was reported to be up to 12 nautical miles. The wind was Beaufort Force 2 with a low swell of about 0.50 m from the Southeast. Persons on board: 23 MV CN Jumbos deck; Overside 21 10 201403/035