republic of cyprus marine accident and incident … · 2020. 6. 19. · to cease the search and...
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REPUBLIC OF CYPRUS
MARINE ACCIDENT AND INCIDENT
INVESTIGATION COMMITTEE
Investigation Report No: 64 Ε / 2019
Very Serious Marine Casualty
Crew Member Disappearance from the M/V “UNITY” on
29/04/2019 off the Western Coast of Philippines
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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.
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Table of Contents
FOREWORD ............................................................................................................................................ II
TABLE OF CONTENTS ........................................................................................................................ III
LIST OF ACRONYMS AND ABBREVIATIONS ............................................................................... IV
1. SUMMARY ............................................................................................................................................ 1
2. FACTUAL INFORMATION................................................................................................................ 2
Ship Particulars .................................................................................................................................. 2 Voyage Particulars.............................................................................................................................. 3 Marine Casualty or Incident Information ........................................................................................... 3 Shore authority involvement and emergency response ....................................................................... 3
3. NARRATIVE ......................................................................................................................................... 5
3.1 SEQUENCE OF EVENTS ......................................................................................................................................... 5
4. ANALYSIS ............................................................................................................................................. 8
4.1 THE SHIP ............................................................................................................................................................. 8 4.1.1 Ship’s Certificates and Surveys .................................................................................................. 8 4.1.2 Ship’s Navigational & Radio Equipment ................................................................................... 8 4.1.3 Passage Plan Analysis ............................................................................................................... 9 4.1.4 Ship’s Condition ....................................................................................................................... 10 4.1.5 The condition of the “A” or Boat deck ..................................................................................... 12 4.1.6 Cargo related factors ............................................................................................................... 13 4.1.7 CCTV – S-VDR ......................................................................................................................... 14
4.2 THE CREW ......................................................................................................................................................... 14 4.2.1 Certification ............................................................................................................................. 14 4.2.2 O/S 1’s Medical Certificate ...................................................................................................... 15 4.2.3 Fatigue ..................................................................................................................................... 15 4.2.4 Working and Living Conditions ............................................................................................... 15 4.2.5 Training .................................................................................................................................... 16 4.2.6 Physiological, Psychological, Psychosocial Condition ........................................................... 16
4.3 THE ENVIRONMENT ................................................................................................................................... 19 External environment: ....................................................................................................................... 19 Internal Environment: ....................................................................................................................... 19
5. CONCLUSIONS .................................................................................................................................. 20
6. RECOMMENDATIONS ..................................................................................................................... 20
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List of Acronyms and Abbreviations
A/B Able Seaman
BAC Blood Alcohol Content
C/E Chief Engineer
C/O Chief Officer
CoC Certificate of Competency
GA General Alarm
CPR Cardio-Pulmonary-Resuscitation
DPA Designated Person Ashore
HSSE Health, Safety, Security and Environment
ISM Code International Management Code for the Safe Operation of Ships
Knots Speed in nautical miles per hour
Lat. Latitude
Long. Longitude
LT Local Time
m Meter
MC Management Company
MT Metric Ton
NM Nautical Mile
O/S Ordinary Seaman
PSN Position
RCC Rescue Coordination Centre
RPM Revolutions per Minute
SAR Search and Rescue operation
2/O Second Officer
SMC ISM Safety Management Certificate
SMM Safety Management Manual
SMS Safety Management System
SOLAS Safety of Life At Sea Convention
STCW95 International Convention on Standards of Training, Certification and Watch
keeping for Seafarers 1978, as amended
S-VDR Simplified -Voyage Data Recorder
VTS Vessel Traffic Services
UTC Universal Time Coordinated
VHF Very High Frequency Radio
ZT Zone Time
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1. Summary
In conducting its investigation, the Marine Accident Investigation Committee (MAIC), reviewed the
events surrounding the incident, documents provided by the Managers of the vessel messrs.
ANGELAKOS (HELLAS) S.A. and performed an analysis to determine the causal factors that
contributed to the incident, including any management system deficiencies.
Incident Description
The “UNITY” is a Cyprus flagged, 2001 built, bulk carrier managed by ANGELAKOS (HELLAS)
S.A.
This investigation examines the circumstances under which an Ordinary Seaman (from now on stated
as O/S 1) disappeared while the ship was en route from the port of Esperance, Australia to the ports of
Huangpu and Ningbo, P.R. China via Hong Kong for bunkering. The position of the ship when the
crew members realized that the O/S was missing was Lat: 18º15.2’N - Long: 117º23.9’E while the
vessel was sailing west of the coast of Philippines northbound to Hong Kong for bunkering.
At the moment it was realized that O/S 1 was missing, the crew searched thoroughly the ship without
any success. At the same time the Master gave command for the ship to change course and commence
a Search and Rescue operation. After a fruitless search mission for 38 hours the vessel received orders
to cease the Search and Rescue operation and resume her original course.
The body of O/S 1 was never found and he is presumed disappeared.
Conclusion(s)
There were no witnesses to the disappearance of the crew member. On the other hand, there are
indications that the crew member may have fallen overboard from the embarkation station of the
starboard side Boat deck.
Evidence gathered during the investigation:
1. His slippers were found on the “B” deck just outside the weathertight door and next to the ladder
leading to the “A” (Boat) deck below.
2. His footprints were found and photographed on the “A” (Boat) deck floor on the lifeboat embarkation
station, which were leading to overboard.
From statements of the other crew members it is referred that O/S 1 told A/B 1 twice that he “would
not go with him anymore to the next port”. O/S 3 also heard O/S 1 telling these words to A/B 1. In
addition, O/S 1 hugged during the dinner time at least three different crew members, an act which was
considered highly unusual for him.
Therefore, it is considered that in the absence of maritime safety related evidence, the O/S 1
disappearance is not related to maritime safety.
Recommendations
There are not any recommendations.
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2. Factual Information
Ship’s Name: UNITY
Figure 1: The UNITY (ex- Gallia Graeca)
Ship Particulars
Name of ship: UNITY (ex- Gallia Graeca)
IMO number: 9221607
Call sign: P3BZ9
MMSI number: 209159000
Flag State: Cyprus
Classification Society: LLOYDS REGISTER OF SHIPPING
Type of ship: Bulk carrier (Panamax)
Gross tonnage: 39,035 T
Length overall: 224.89 m
Breadth overall: 32.20 m
Registered ship owner: APERTIVO SHIPPING COMPANY LIMITED, CYPRUS
Ship’s company: ANGELAKOS (HELLAS) S.A.
Year of build: 2001
Deadweight: 74,133 t
Hull material: Steel
Hull construction: Double Hull
Propulsion type: ICE - B&W 7S50MC-C
Type of bunkers: HS HFO/LS MGO
Number of crew on ship’s certificate: 14
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Voyage Particulars
Port of departure: Esperance, Australia
Port of call: Hong Kong for bunkering, then Huangpu and Ningbo, P.R. China for discharging
Type of voyage: International
Cargo information: 62,365.19 MT of barley in bulk
Manning: 20 crew members
Number of passengers: NIL
Marine Casualty or Incident Information
Type of marine casualty/incident: Very Serious Marine Casualty
Date/Time: Between 28/04/2019 23:30 and 29/04/2019 06:00 LT
Location: Man overboard / most probably from the stbd boat deck
Position (Latitude/Longitude): Between: Lat 16º54.7’N Long 118º10.5’E and Lat
18º11.7’N Long 117º26.1’E (South China Sea, West
coast of Philippines)
External and Internal Environment: Air Temp: 33C, Sea Temp: 30C, Sea Scale: 2, Wind
Direction: E, Wind Force: 4, Visibility: Good
Ship operation and Voyage segment: Ship en route in laden condition to bunkering port,
Speed 12.3 knots
Human Factors: Yes
Consequences: Death: 1 (Disappearance)
Shore authority involvement and emergency response
28/04 @ 2342Z 29/04 @ 0742LT – Sent DISTRESS CALL ON MF/HF DSC 16804.5 KHz
28/04 @ 2342Z 29/04 @ 0742LT – Broadcasted on VHF CH.16, “Mayday x 3, giving the most
suspected positions, colour of T-Shirt/Short, body built, name of crew & other details”. Above
broadcast continued and urgency call followed and made every hour until SAR concluded. No
message received from other vessels only verbal acknowledgement.
The following vessels rendered assistance in Search and Rescue operation. Their positions were not
taken during their acknowledgment as these vessels joined the SAR right away upon hearing the
emergency call. All messages exchanged were made verbally through VHF 16.
1. MV Nave Cosmos
2. MV Champion Prince
3. MV Yuma
4. MV Okee Alba
5. MV Ilma
6. MV LNG Fukura
7. MV IVS Kingbird
8. MV LNG Almafyar
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9. MV Audrey SW
10. MV New Dragon
11. MV Towada
12. Various fishing vessels (no names taken)
Conducted a parallel search pattern along with other assisting vessels on the two most suspected
positions. At the datum, conducted expanding square & sector search pattern until SAR
concluded.
29/04 @ 0002Z / 0802LT – Received the acknowledgment of the DISTRESS CALL from
HAIPONG RADIO.
29/04 @ 0042Z / 0842LT – Called MRCC MANILA. Verbal reporting giving the incident report,
position, time, details of the missing crew then followed by email message.
29/04 @ 0733Z / 1533LT – Called MRCC Hong Kong. Verbal reporting giving the incident report,
position, time, details of the missing crew then followed by email message.
29/04 @ 0830Z / 1633LT – Received message from MRCC Hong Kong via EGC.
Every 3 hours an update was sent to Hong Kong MRCC and Manila MRCC by email.
29/04 @ 1335Z / 2135LT – Received Phone Call from MRCC Manila. Only asking the status of the
search.
30/04 @ 0125Z / 0925LT – Call from Hong Kong SAR Aircraft.
30/04 @ 1300Z / 2100LT – Concluded the SAR and resumed her voyage bound to Hong Kong.
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3. Narrative
3.1 Sequence of Events
1. The M/V “UNITY” was on a laden voyage from Esperance, Australia to Huangpu and Ningbo, P.R.
China via Hong Kong for bunkering on 28th April 2019, and sailing west of the coast of Philippines
northbound to Hong Kong.
Figure 2: The actual passage of M/V UNITY. North of Manila the SAR area can be seen.
2. At 06:35 LT at the approximate position of Lat: 18º15.2’N Long: 117º23.9’E, the Master, who was
in his cabin at that time, was informed by the ship’s Chief Officer (C/O) that O/S 1 had not reported
yet to the Bosun for the morning job (cleaning of the alleyway) and the Bosun could not locate him.
3. The Master was informed that the C/O had already ordered for a quick search in the gymnasium,
laundry, crew mess, cabin and bathroom but the search party could not find him. After that statement
the Master announced in the PA system for all deck hands to search the vessel and called the Chief
Engineer (C/E) to stand-by the main engine for search and rescue operation. Subsequently he received
reports from each of the search teams with a negative result. One of the search teams reported that they
found some footsteps (naked foot prints on the humid surface of the deck) on the starboard side boat
deck leading overboard (see Figure 10 below).
4. At about 07:00 LT the Master concluded that O/S 1 was missing from onboard and he immediately
manoeuvred the vessel using a Williamson turn in order to head to almost the reciprocal course of the
original course. He asked his officers to send a distress message and broadcast on VHF regarding the
missing crew. Because the footsteps seemed to be recent, he ordered to broadcast on VHF that the most
suspected past vessel positions were between 04:00 – 06:00 LT.
Search and Rescue area
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5. There were 11 vessels in the vicinity that responded to the MOB distress call and assisted in the
Search and Rescue operation between the two given location coordinates. At about 07:30 LT the Master
called the Port Captain of the Management Company (MC) informing him about the situation and
reported the actions made so far. The Port Captain asked the Master to do all necessary actions and
take all means necessary for the search and rescue operation and report to the closest MRCC station to
obtain assistance.
6. At about 08:00 LT the Master contacted MRCC Manila but could not connect. During the same time
the vessel approached the 06:00 LT past vessel position. The vessel slowed down and commenced the
SAR operations. The 11 vessels that responded to the emergency call were told to slow down when
passing the most suspected two given location coordinates and report for any sighting of the missing
crew.
7. At 08:42 LT the Master was able to connect to MRCC Manila by phone and report the incident.
They advised him that they will do everything to help and will coordinate also with other vessels.
Subsequent reports from assisting SAR vessels received that they had no sighting of the missing crew.
8. At 10:45 LT and after yielding a negative result from the SAR operation until then, the Master
decided to go back to the position where O/S 1 was last seen (previous day at 23:30 LT) and left the
04:00 LT vessel past position. He also asked the other assisting vessels that, after searching the area
with no sighting from the missing crew, they could proceed to their destinations.
9. At 15:33 LT the Master received a telephone call from MRCC Hong Kong. He was inquired about
the situation and reported to them accordingly. They instructed him to stay in the vicinity where the
missing crew was last seen and continue the search. They also advised that they would send a SAR
aircraft to help with the operations.
10. At 16:30 the vessel arrived at the assumed datum position in LAT. 16-54.7N LONG. 118-10.5E
where the missing crew was last seen and commenced expanding square search pattern.
Figure 3: The expanding square search pattern
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At 17:00 LT the Master received a message from the MRCC Hong Kong that the SAR aircraft will
arrive to assist with the SAR operation. Then at 19:00 LT he received a message from the MRCC Hong
Kong stating that the SAR aircraft will arrive the following day morning time weather permitting.
11. On 30th April 09:10 LT the Master asked the MRCC Hong Kong about the status of the SAR aircraft
and received the information that the aircraft had already arrived in the search area at around 08:20 LT
and the SAR operation was ongoing. At 11:12 LT the Master asked again the MRCC Hong Kong about
the status of the operation and they replied that the SAR aircraft had carried out aerial search but was
unable to locate the missing crew. They also advised that they had no further instructions for the Master
and that he may proceed to the next port of destination.
12. The Master decided to continue the SAR operation and at 19:00 LT he ordered to resume the sea
passage though the vessel was still inside the search zone that they created. At 21:00 LT and after
completing the 2nd search with a negative result, the Master decided to cease the SAR operation and
eventually left the datum position. He reported his final report to MRCC Hong Kong and MRCC
Philippines and proceeded to destination.
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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
following analysis is based on crew statements and ship’s documents provided by the Managers of the
vessel Angelakos (Hellas) S.A. and additional crew statements taken by the MAIC investigator, when
he conducted an investigation onboard the vessel on 06/06/2019 at Ningbo, P.R. China.
4.1 The Ship
4.1.1 Ship’s Certificates and Surveys
The following certificates were checked and confirmed onboard the ship.
Certificate Description Issued Valid until
Classification Certificate 06/09/2016 05/09/2021
Load Line Certificate 17/07/2016 05/09/2021
Cargo Ship Safety Construction Certificate 03/04/2017 05/09/2021
Cargo Ship Safety Equipment Certificate 26/03/2019 05/09/2021
Cargo Ship Safety Radio Certificate 03/04/2017 05/09/2021
Safety Management Certificate 26/10/2018 24/11/2021
Ship Security Certificate 12/04/2019 11/04/2024
Maritime Labour Certificate 03/04/2017 24/11/2021
International Oil Pollution Prevention Certificate, Type B 29/09/2017 22/06/2022
Sewage Pollution Prevention Certificate 03/04/2017 05/09/2021
Air Pollution Prevention Certificate 03/04/2017 05/09/2021
Energy Efficiency Certificate 18/09/2013 -
International Anti – Fouling System Certificate 13/09/2018 -
Ballast Water Management 06/09/2016 05/09/2021
Certificate for the Carriage of Dangerous Goods N/A N/A
DOC of Management Company 19/04/2018 29/04/2023
All Class and Statutory annual surveys were due on 09/2019 and all Class and Statutory renewal
surveys were due on 09/2021.
All certificates onboard the ship were found to be in order and valid.
4.1.2 Ship’s Navigational & Radio Equipment
The M/V “UNITY” 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 DSC encoder
b) VHF DSC watch receiver
c) VHF radiotelephony
d) MF/HF DSC encoder
e) MF/HF DSC watch receiver
f) MF/HF radiotelephony
g) MF/HF direct printing telegraphy
h) Secondary means of alerting: Satellite EPIRB
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i) NAVTEX receiver
j) EGC receiver
k) Satellite EPIRB COSPAS – SARSAT
l) Radar search and rescue transponder (SART)
m) Duplication of equipment
n) Shore – based maintenance
Navigational equipment
a) Standard magnetic compass
b) Spare magnetic compass
c) Gyro compass
c) Gyro compass heading and bearing repeaters
d) ECDIS
e) 2nd ECDIS
f) 9 GHz radar
g) 3 GHz radar
h) ARPA
i) AIS system
j) LRIT system
k) S-VDR
l) Bridge navigational watch alarm system (BNWAS)
Life-saving appliances
a) Total number of persons for which life – saving appliances are provided: 25
b) 2 totally enclosed lifeboats of 25 persons each
c) 1 liferaft for total 25 persons
d) 14 lifebuoys
e) 31 lifejackets
f) 31 immersion suits
The “UNITY” 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 UNITY for the voyage detailed as follows:
a. The passage plan from Esperance, Australia to Hong Kong was found to be in order and
complete including the charts, manoeuvring data, pilot and port information, tide tables etc.
b. The ship proceeded for the intended voyage until the time the crew realised that O/S 1 was
missing from onboard, after which the ship diverted for the Search and Rescue mission. Later
the next day and after the Search and Rescue mission was terminated, the ship was instructed
to resume her original course.
c. The vessel’s speed was approximately 12.3 knots when the incident took place.
The ship’s passage plan was found to be in order.
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4.1.4 Ship’s Condition
A physical survey onboard the vessel showed the condition of the ship’s superstructure and the path
that O/S 1 presumably took until his 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) 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 fully enclosed lifeboats and the liferaft
were provided in accordance with the requirements of the SOLAS convention.
The following schematic shows the “B” deck, where the cabin of O/S 1 is located.
Figure 4: Schematic of the “B” deck
The cabin of O/S 1 is a single cabin composed of a bed, a desk, a couch and a closet and has a common
bathroom with the neighboring cabin of another O/S (from now on stated as O/S 2). The cabin door
can be permanently fixed on the wall by way of a stop. The cabin was left untouched and sealed by the
crew until further notice. It was only opened for the surveyor who investigated the incident on behalf
of the P&I Club on 29th April 2019 and then for the MAIC investigator. After our investigation was
over, it was ordered that the personal belongings of O/S 1 to be packed and sent back to his family.
The cabin was found in order without anything extraordinary to notice. The bed was made even though
the disappearance of O/S 1 took place between 23:30 at night and 06:00 of the next morning. The
Exit to open deck
Ladder to deck
below
O/S 1 cabin
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shared bathroom with O/S 2 did not have anything out of the ordinary and O/S 2 advised that he did
not find anything unusual in their common bathroom after the incident.
The “B” deck has two external doors that lead to the open deck area, one on the port side and one on
the starboard side. The closest exit to the open deck from the O/S 1 cabin is the door on the starboard
side of the ship, which leads to a small and constrained open deck area and then to a ladder which leads
to the deck below.
Figure 5 – The O/S 1 cabin as found by the investigator
Figure 6: Area on “B” deck leading to the Boat deck
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As it can be shown from Figure 7 below, the “B” deck is connected to the “A” or Boat deck below via
a ladder. Accordingly, the “A” or Boat deck is connected via a ladder to the Main deck of the vessel.
4.1.5 The condition of the “A” or Boat deck
The “A” or Boat deck was found in a satisfactory condition structurally and by way of maintenance.
The hand rails had a height of 1.20 m. They were in good condition and satisfied the relevant SOLAS
requirements. The protective chains in way of the life boat area were in a slightly rusty but overall
satisfactory condition.
Bridge deck
“B” deck
“A” or “Boat” deck
Main deck
Figure 7: The accommodation decks
“C” deck
“D” deck
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The restricted area of the open deck is the ship’s Muster station and confines the access to the
embarkation station of the Boat deck by hand rails and chains as shown in Figure 8. If a person passes
through the restrictive hand rails and chains on purpose then he finds himself on an open and
unprotected area below the life boat which is on purpose the embarkation station of the specific life
boat.
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 accident.
4.1.6 Cargo related factors
The ship was on a laden voyage from Esperance, Australia to Huangpu and Ningbo, P.R. China via
Hong Kong for bunkering, carrying 62,365.19 MT of barley in bulk. The ship, when inspected, was
found in satisfactory condition without anything noticeable relating to the cargo onboard.
The cargo was not considered as a factor to the accident.
Figure 8: The Boat deck area
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4.1.7 CCTV – S-VDR
The ship is not equipped with a CCTV system. The S-VDR was not stopped or saved as the crew did
not think that anything important could have been recorded from the incident.
4.2 The Crew
4.2.1 Certification
The Minimum Safe Manning Document (MSMD) was issued by the Cyprus Maritime Authority on
29/11/2017, expires on 28/11/2022 and requires 14 crew members to be onboard the vessel.
Figure 9: The Minimum Safe Manning document for Unity
The crew onboard the vessel at the date of the incident was 20 crew members. It is thereby concluded
that the ship at the date of the incident complied and exceeded the MSMD requirements by 6 crew
members.
All crew members certificates were up-to-date and valid and in compliance with all relevant
regulations.
The crew certification was not considered as a factor to the accident.
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4.2.2 O/S 1’s Medical Certificate
O/S 1 had a “MEDICAL CERTIFICATE FOR SERVICE AT SEA” issued on 22nd October 2018 by
Ygeia Medical Center, Inc. of Philippines. All his examinations were normal and he was therefore
pronounced “Fit for sea duty”. In detail, the medical certificate states that O/S 1 met the relevant
hearing standards, had a satisfactory unaided hearing, his colour vision met the standards in STCW
Code, Section A-I/9, he was fit for lookout duties and had no limitations or restrictions on fitness. It
also states that O/S 1 was not suffering from any medical condition likely to be aggravated by service
at sea or to render the seafarer unfit for such service or to endanger the health of other persons onboard.
O/S 1 had undergone screening test for HIV/AIDS and was found to be non-reactive based on the
laboratory test. He was also tested negative for Phencyclidine (PCP), Cocaine, Methamphetamine,
Morphine, Tetrahydrocannabinol and alcohol.
Finally, it is stated that he did not have a medical history of head or neck injury, frequent headaches,
frequent dizziness, fainting spells / seizures or other neurological disorder, insomnia or sleep disorders,
depression or other mental disorders, eye problems, deafness, nose or throat disorders, tuberculosis,
other lung diseases, high blood pressure, heart disease and vascular or chest pain, rheumatic fever,
diabetes and other endocrine disorders, cancer or tumor, blood disorders, stomach pain, other abnormal
disorders, kidney or bladder disorder, back injury, joint pain or arthritis, generic, hereditary or family
disorders, sexually transmitted diseases, tropical diseases, asthma, allergies or had any operations.
The electrocardiogram (ECG) was completed with some findings which was cleared thereafter by a
specialist after performing stress test and stress echo.
The O/S 1 medical condition prior to embarkation was not considered as a factor to the accident.
4.2.3 Fatigue
The record of work and rest hours was examined onboard the vessel. The records regarding O/S 1 show
that all relevant MLC and STCW regulations were kept and hence fatigue was not considered a
contributory factor to the accident.
Fatigue was not considered as a factor to the accident.
4.2.4 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 satisfactory standards. The crew members seemed to be in very 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 in order without any
recommendations.
There was no evidence to suggest, that, the working and living conditions was a contributory factor to
the accident.
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4.2.5 Training
The training and drills log for months June 2018 – February 2019 was examined and was found in
order and in accordance with all ISM requirements. In particular, the “Man Overboard” drill was
conducted during the following dates:
29 June 2018
27 September 2018
07 November 2018
22 February 2019
which corresponds to four drills during a 9-month period, exceeding the requirement of performing the
drill once in every 6 months.
The booklet “Plans and procedures for recovery of persons from the water” was checked and found in
order.
There was not any lack of training and drills for “Man Overboard” procedures, therefore lack of
training was not a contributory factor to the accident.
4.2.6 Physiological, Psychological, Psychosocial Condition
The physiological, psychological and psychosocial condition of O/S 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 has been gathered:
(a) O/S 1 was a quiet person, a good worker and he was up for a recommendation for a promotion
to an A/B. He was friendly with the other crew members and had never created any trouble or
problems while serving onboard. He had not shared with the other crew members any personal
or family problems.
(b) It was verbally advised by the Master that during the last two days the vessel was close to the
Philippines coast and hence the mobile phones of the crew members had a good signal. Most
of the crew members caught the opportunity to speak on their mobile phones with their families
during those days. Most probably O/S 1 also spoke with his wife on the phone during those
days.
(c) The previous day of the incident (28th April) was a Sunday and there was no work for the crew
except for those on duty. O/S 1 was present on the morning Bible reading that the crew had
between 09:00 – 10:10. Then an environmental training took place between 10:30 – 11:30 in
which O/S 1 was also present. For the rest of the day the crew were resting in their cabins and
some were watching movies in the crew smoking room but nobody observed O/S 1 during the
afternoon except during the dinner time between 17:00 – 18:00.
(d) The C/O stated that O/S 1 was not a talkative person, he was a good listener but did not start a
conversation by himself. He had not mentioned to him any problems that he may had. He was
hard working and in his spare time he went to the bridge for training of steering.
(e) An A/B (from now on stated as A/B 1) mentioned during his interview that between the Bible
reading and the environmental training O/S 1 told him the words “Hindi Na Kita Sasamahan
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Sa Sunod Na Pwerto” which translates into “I will not go with you anymore in the next port”.
That statement was followed up during the dinner time again. A/B 1 thought that O/S 1 was
joking and did not consider that statement worthy of mentioning to anybody else until it was
too late.
(f) Another O/S (from now on stated as O/S 3) stated that during the dinner time of the 28th April
2019 the O/S made him a hug without saying anything. He also heard him telling A/B 1 that he
would not go to the next port for duty with him.
(g) O/S 2 stated that during the dinner time of the 28th April 2019 O/S 1 hugged him for a short
time without saying anything to him. This was very strange as he did not do that normally. The
last time O/S 2 saw O/S 1 was around 23:30 of the same day when he was going from the
laundry to his cabin. Their cabins are adjustment and they shared the same bathroom. O/S 1
was also going to his cabin, maybe closed his door and thereafter was some music heard from
inside his cabin. O/S 2 did not hear any strange noises or telephone talk during that night.
(h) The Bosun stated that during the dinner time of the 28th April 2019 the O/S came to him and
told him “good appetite” then hugged him and smiled.
(i) The 2nd Officer (2/O) stated that after the dinner time O/S 1 came to him and asked for a
cigarette, even though he was not a smoker, and made him a friendly hug. The 2/O was
surprised that he asked him for a cigarette.
(j) On 29th April 2019 at approximately 06:55 and while the crew were searching the vessel for
the missing O/S, the C/O informed the Master that the search party found some footprints in
the “A” or Boat deck starboard side just underneath the lifeboat on the embarkation platform
and a pair of slippers just outside the weather tight door of the “B” deck (exactly as shown on
Figure 6 – second photograph which is a recreation of the original state). The footprints were
leading overboard as it can be seen from the pictures below which were taken at that moment
from the crew members.
There was no evidence to suggest that the physical, physiological, psychological, or psychosocial
condition of the OS1 was such that could have contributed to the accident.
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Figure 10: The footprint leading overboard as they were found by the search paty
(k) The O/S 1 had possession of two mobile phones which were found intact in his cabin. We could
not have access to them as they are protected by a password. The mobile phones were retained
by the Management Company and sent to MAIC Headquarters.
(l) The crew found inside a drawer in his cabin an amount of medicines which are shown in the
figure below.
Figure 11: The medicines found in O/S 1 cabin
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The medicines found in the O/S. 1 possession are the following:
1. Amoxicillin (Antibiotic)
2. Carbocisteine Solmux (medicine for cough, phlegm, bronchitis)
3. Blumea balsamifera sambong (leaf used for common cold and as a diuretic)
4. Ascof forte (cough relief medicine)
5. Mefenamic Acid (pain relief medicine)
6. Dicycloverine HCI (medicine for cramps, stomach pain)
7. Paracetamol (medicine for pain relief and fever)
8. Loperamide hydrochloride (antidiarrheal medicine)
9. Naproxen Sodium (pain relief medicine)
10. Ginkgo Biloba (capsules for alertness and memory)
No psychotropic drugs were found. The medicines found in his cabin were common medicines that
one can buy easily in a drug store with or without prescription.
4.3 The Environment
External environment:
The weather conditions at the time of the accident were as follows.
Air Temperature: 33º C
Sea Temp: 30º C
Sea Scale: 2
Wind Direction: E
Wind Force: 4
Condition: night dawn
Visibility: Good
Sky: Partly cloudy
There is no evidence that physical environmental factors, such as weather, climate, etc., affected the
actions of O/S 1.
Internal Environment:
It was advised verbally that there were no sudden movements of the vessel which could had caused the
O/S 1 slipping and falling from the Boat deck overboard. The condition of the deck floors were not
damaged at the day of the incident, only a morning humidity was present which preserved the footprints
of O/S 1 for the rest of the crew to observe.
In conclusion, there was no evidence that the environmental conditions were a factor in the accident.
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5. Conclusions
Conclusion(s)
There were no witnesses to the disappearance of the crew member. On the other hand, there are
indications that the crew member may have fallen overboard from the embarkation station of the
starboard side Boat deck.
Evidence gathered during the investigation:
1. His slippers were found on the “B” deck just outside the weathertight door and next to the ladder
leading to the “A” (Boat) deck below.
2. His footprints were found and photographed on the “A” (Boat) deck floor on the lifeboat embarkation
station, which were leading to overboard.
From statements of the other crew members it is referred that O/S 1 told A/B 1 twice that he “would
not go with him anymore to the next port”. O/S 3 also heard O/S 1 telling these words to A/B 1. In
addition, O/S 1 hugged during the dinner time at least three different crew members, an act which was
considered highly unusual for him.
Therefore, it is considered that in the absence of maritime safety related evidence, the O/S 1
disappearance is not related to maritime safety.
6. Recommendations
There are not any recommendations.