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REPUBLIC OF CYPRUS MARINE ACCIDENT AND INCIDENT

INVESTIGATION COMMITTEE

Investigation Report No: 143E

Very Serious Marine Casualty

M/V “OCEAN CROWN” Fatality on Deck in Heavy Weather on 11/09/2019 in the Arab Sea

ii © Marine Accident and Incident Investigation Committee

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.

iii © Marine Accident and Incident Investigation Committee

Table of Contents

FOREWORD ............................................................................................................................................ II

TABLE OF CONTENTS ........................................................................................................................ III

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 ........................................................................................................................................... 10

4.1 THE SHIP ........................................................................................................................................................... 10 4.1.1 Ship’s Certificates and Surveys ................................................................................................ 10 4.1.2 Ship’s Navigational & Radio Equipment ................................................................................. 10 4.1.3 Passage Plan Analysis ............................................................................................................. 11 4.1.4 Ship’s Condition ....................................................................................................................... 12 4.1.5 Cargo related factors ............................................................................................................... 12 4.1.6 CCTV – VDR ............................................................................................................................ 12

4.2 THE CREW ......................................................................................................................................................... 12 4.2.1 Certification ............................................................................................................................. 12 4.2.2 Bosun’s Medical Certificate ..................................................................................................... 13 4.2.3 Fatigue ..................................................................................................................................... 13 4.2.4 Working and Living Conditions ............................................................................................... 13 4.2.5 Risk Assessment ........................................................................................................................ 13 4.2.6 Hot work permit ....................................................................................................................... 15 4.2.7 Personal Protective Equipment (PPE) ..................................................................................... 16

4.3 THE ENVIRONMENT ................................................................................................................................... 16 External environment: ....................................................................................................................... 16 Internal Environment: ....................................................................................................................... 17

5. CONCLUSIONS .................................................................................................................................. 18

6. RECOMMENDATIONS ..................................................................................................................... 19

iv © Marine Accident and Incident Investigation Committee

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 OOBW Officer Of Bridge Watch 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

1 © Marine Accident and Incident Investigation Committee

1. Summary In conducting this investigation, the Marine Accident Investigation Committee (MAIC), reviewed the events surrounding the incident, documents provided by the Managers of the vessel Messrs. GLOBAL CARRIERS LTD and performed an analysis to determine the causal factors that contributed to the incident, including any management system deficiencies. Incident Description The “OCEAN CROWN” is a Cyprus flagged, 2005 built, bulk carrier managed by Global Carriers Ltd. This investigation examines the circumstances under which the bosun of the vessel was severely injured while the ship was en route from Odessa and Ochakov, Ukraine to Tuticorin, India via the Suez Canal. The position of the ship when the accident occurred was Lat: 12º56.6’N - Long: 062º20.5’E while the vessel was sailing the Arab Sea southeast-bound towards India. On 11th September 2019 the bosun together with other three crewmembers were engaged in the job of covering the grab of no. 2 crane with a tarpaulin while the grab rested on its fittings on the stbd side of the main deck, so that it would be protected from the severe weather conditions and the fitter could make some scheduled welding works on the grab. While in the process of covering the grab with the tarpaulin, a sudden sea wave hit the crew members. Its intensity forced the bosun to and under the grab causing severe injuries to his head and his body. The vessel deviated from its course to Kochi, India for emergency helicopter evacuation of the bosun but he passed away due to his injuries some hours before the vessel could reach the port limits. Conclusion(s)

1. Severe weather conditions were a primary contributing factor to the accident.

2. As per the company’s Safety Management System Manual - chapter 7.9.14.3, during foul weather conditions no person is permitted on the exposed main deck areas unless approved by the Master. This approval in the current situation came through the “Hot Work Permit” and allowed the scheduled job operation to proceed. The permit itself was supported by a “Risk

Assessment form”, the results of which concluded that the risk factors of the operation were small to medium range. It is concluded that the risk assessment form was inadequately filled in as there is no evidence that the adverse weather conditions that were prevailing at that time, were taken into account. Therefore, inadequate risk assessment was a contributing factor to the accident.

3. In addition and further to the risk assessment form, working on deck under the weather conditions prevailing at that time, contradicts the safe working practices for seamen under heavy weather conditions as the welding job was not necessary for the safety of the ship, the crew or the safety of life at sea. No seafarers should be permitted on deck during adverse weather conditions unless considered necessary for the safety of the ship, the crew or for the safety of life at sea. Therefore, violation of safe working practices for seamen regarding work on deck under heavy weather conditions to be performed only when considered necessary for the safety of the ship the crew or the safety of life at sea, was a contributing factor to the accident.


4. As per the company’s Safety Management System Manual - chapter 7.9.14.3, during foul weather conditions the Master shall delay any access to the main deck until the vessel’s course

and / or speed have been properly adjusted to provide the safest possible condition. According to the information received the ship’s course and / or speed was not adjusted in order to provide the safest possible condition for the welding operation to take place. Therefore, violation of the SMS’s requirement during foul weather conditions to delay any access to the main deck until the vessel’s course and / or speed have been properly adjusted for providing safety conditions for work on deck, was a contributing factor to the accident.

5. As per the company’s Safety Management System Manual - chapter 7.9.14.3, during foul weather conditions no person is permitted on the exposed main deck areas unless he is properly equipped with safety gear. Seafarers required to go on deck during adverse weather should wear a lifejacket suitable for working in, a safety harness which can be attached to deck lifelines and full personal protective equipment. The bosun (and also the other three crew members) did not wear any lifejackets and safety harness, which could have possibly prevented the injuries of the bosun. Therefore, violation of the SMS’s requirement that no person is permitted during foul weather conditions on the exposed main deck areas without being properly equipped with safety gear, was a contributing factor to the accident.

Recommendations

1. The Manager should review Chapter 7.1 of the “Plans and instructions for key shipboard

operations” manual. The process of performing the risk assessment by the crew should be

clearer in the step-by-step instructions and the prefilled risk assessment forms in the Risk Assessment Library should be reviewed and corrected if necessary. (within three (3) months)

2. The Management Company by way of a circular or other means, to educate its crews, on Risk Assessment and Work Permit System, as well as implementation of Safe Working Practices for Seafarers including proper use of Personal Protective Equipment. (within three (3) months)


2. Factual Information Ship’s Name: OCEAN CROWN

Figure 1: The OCEAN CROWN (ex- Nikolas)

Ship Particulars

Name of ship: OCEAN CROWN (ex- Nikolas) IMO number: 9317107 Call sign: C 4 T Z 2 MMSI number: 212909000 Flag State: Cyprus Classification Society: CLASS NK Type of ship: Bulk carrier (Supramax) Gross tonnage: 30,057 T Length overall: 189.99 m Breadth overall: 32.26 m Registered ship owner: OCEAN PRECIOUS SHIPPING LTD Ship’s company: GLOBAL CARRIERS LTD Year of build: 2005 Deadweight: 52,347 t Hull material: Steel Hull construction: Double Hull Propulsion type: MAN B&W 6S50 MC Type of bunkers: HS HFO/LS MGO Number of crew on ship’s certificate: 17

Grab No. 2 resting on its fittings


Voyage Particulars

Port of loading: Odessa / Ochakov, Ukraine Port of discharging: Tuticorin, India (via Suez Canal passage) Type of voyage: International Cargo information: 49999.083 MT of corn grains in bulk Manning: 25 crew members (including 3 armed guards) Number of passengers: NIL

Marine Casualty or Incident Information

Type of marine casualty/incident: Very Serious Marine Casualty Date/Time: 11/09/2019 08:18 LT / 0418 UTC Location: Main deck, starboard side next to no. 2 grab fitting Position (Latitude/Longitude): Lat 12º56.6’N Long 062º20.5’E (Arab Sea) External and Internal Environment: Wind force & direction: 7 BF, Sea State: very rough,

Swell height: 3-4 mtrs, Current speed & dir: adverse 1 – 1.5 knt, Weather: clear / partly cloudy, Natural light: daylight, Visibility: Good (between 5-25 nm)

Ship operation and Voyage segment: Ship en route in laden condition to discharging port, Speed 11.6 knots

Human Factors: Yes Consequences: Death: 1 (heavily injured and deceased after 2 days)

Shore authority involvement and emergency response There were various e-mail exchanges between the Managers, the Master of the vessel, MRCC Mumbai (Maritime Rescue Coordination Centre Mumbai), CIRM Roma (Centro Internazionale Radio Medico Roma) and the agent at Kochi, India. Herebelow are presented the most significant of them: 11/09 19:08 (Time zone undetermined): Emergency message was sent from the vessel to MRCC Mumbai stating the following: THIS IS OCEAN CROWN C4TZ2 (repeated 3 times) AT 1410 LT (1010 UTC) 11 SEP 2019 IN POSITION LAT 14 44 N / LONG 06332 E VSL CROUSE 100 DEG SPEED 12.3 KTS NEXT PORT GALLE, SRI LANKA REQUEST IMMEDIATE ASSISTANCE FOR EVACUATION OF INJURED CREW DUE TO ACCIDENT HAVING AN OPEN WOUND CUT ON TOP OF THE HEAD / NECK AND SHOULDER PAIN / LOWER NO SENSE OF FEELING. CAUSED OF INJURY DUE TO SEABREAKS AND SPRAY OVER MAIN DECK AND THUMBLE DOWN BUMPED AGAINST VSL STRUCTURE / GRAB FITTING. WAITING FOR YOUR ADVICE AND INSTRUCTION. 11/09 13:15 (Time zone undetermined): Message from MRCC Mumbai asking for various information / documents regarding the injured crew member. 11/09 17:53 (Time zone undetermined): Message from the vessel advising ETA Kochi on 14/09 0300 LT. 11/09 21:51 (Time zone undetermined): Message from CIRM Roma advising the Master to arrange urgent evacuation of the injured crew member as soon as possible.


12/09 12:14 (Time zone undetermined): Message from the vessel to MRCC Mumbai referring to the teleconversation between the two parties and requesting immediate disembarkation of the injured crew member to the nearest medical facilities for x-ray scan check-up and medication. The vessel informs MRCC Mumbai that is proceeding to Agatti and Kavaratti islands, Lakshadweep and asking for helicopter disembarkation. Master gives ETA Agatti 13/09 1200 LT and ETA Kavaratti 13/09 1400 LT. 12/09 11:09 (Time zone undetermined): Message from MRCC Mumbai advising the vessel that due to non-availability of specialty medical facilities at Agatti / Kavaratti islands it is recommended to proceed to Kochi or New Mangalore for emergency evacuation of the injured crew member. 12/09 17:05 (Time zone undetermined): Message from the vessel to MRCC Mumbai asking for arrangement of immediate evacuation of the injured crew member by helicopter to the nearest medical facility. The Master also states the medical condition of the injured crew member as follows: Signs: are still the same and response is slowed down and becoming weaker Blood Pressure: 90/60 Pulse: 56 Temperature: 39 deg C Breath: 26 Given: Paracetamol and ibuprofen / antibiotics as prescribed but body temperature is rising 13/09 14:02 (Time zone undetermined): Message from the vessel informing position, course, speed, giving information regarding the helicopter landing area onboard. 13/09 16:27 (Time zone undetermined): Message from MRCC Mumbai requesting the vessel to proceed with maximum speed to Kochi to facilitate launching of helicopter for winching of the patient in basket. 13/09 16:42 (Time zone undetermined): Message from the vessel to MRCC Mumbai giving structural information of the vessel’s hatch covers, obstructions for helicopter landing, height of cranes etc in preparation for helicopter evacuation. 13/09 19:13 (Time zone undetermined): Message from the vessel to MRCC Mumbai informing about some operational matters regarding the helicopter evacuation of the injured crew member. Also informing that his condition has not improved, he has stomach bulging and requests to insert catheter for urine output. 13/09 23:44 (Time zone undetermined): Message from the vessel to all involved informing them that vessel’s ETA to Kochi is 14/09 0600 LT. 14/09 00:09 (Time zone undetermined): Message from the vessel to all involved informing them that the injured crew member was not breathing. The crew applied CPR but with no response. The Master called the MRCC doctor by phone for advice. 14/09 01:26 (Time zone undetermined): Message from the Master informing MRCC Mumbai and all involved parties the following conditions of the injured crew member: Body temperature – 37 deg C Pulse – negative Blink Response – negative Blood Pressure – negative CPR was applied for 30 minutes with no response and the crew declared that he had passed away.


3. Narrative

3.1 Sequence of Events 1. The M/V “OCEAN CROWN” was on 11th September 2019 on a laden voyage from Odessa and

Ochakov, Ukraine to Tuticorin, India via Suez Canal and sailing southeast-bound the Arab Sea with speed 11.6 knots.

2. The vessel is equipped with four cranes, each of which is fitted with one grab which is used to load or unload bulk cargo during the usual trading operations of the vessel. While the vessel is sailing, those grabs rest on top of special fittings on the main deck starboard side of the vessel. Figure 2: A typical grab while in operation (left), the Ocean’s Crown grab no. 2 (right) was temporarily

rested on the port side of the vessel during our investigation onboard in order not to obstruct the loading operations on the stbd side at Mesaieed, Qatar as it was not required.

3. As per the information gathered by the investigator onboard, the grabs required some repair works

and in specific they required welding in steel plates which had recently been replaced by the fitter, a job which could, according to the C/O, only take place while the vessel was enroute from one port to another and not during stay at port during loading or discharging operations.

Figure 3: The steel plate that was replaced on grab no. 2 and required further welding works by the fitter.

4. During the previous day (10th September 2019) the crew had engaged and completed the same

plate welding works of grab no. 1 and on 11th September they scheduled to proceed to grab no. 2 for similar job.


5. As per the information received during the investigation onboard, the sea state during this day was very rough, the wind force was 7 BF and the swell height was 3-4 meters. The weather was clear / partly cloudy, the natural light was daylight and the visibility was good. The fwd draft of the vessel was 12.15 mtrs and the aft draft was 11.88 mtrs. That left about 5 mtrs of freeboard between the surface of the sea and the main deck where the job was to take place.

6. The Master ordered the C/O to proceed with the covering of grab no. 2 with a tarpaulin in order to protect it from sprays of sea water during the welding works by the fitter that would follow.

Figure 4: Typical tarpaulins (used and new) found inside m/v Ocean Crown

7. The C/O gave the same instructions to the bosun who called for assistance three other crew members (O/S1, O/S2 and A/B). Then the C/O followed the other crew members on the main deck and was on the port side of the main deck preparing to supervise the other crew members on the stbd side where the grab was resting.

8. The crew members were positioned around the grab as follows: The bosun on the fwd stbd side of the grab, the A/B on the fwd port side of the grab, O/S1 on the aft stbd side of the grab and O/S2 on the aft port side of the grab.

Figure 5: The grab no. 2 fittings and the relevant position of the crew members involved in the accident

Grab fitting

Fwd

Aft

Position of Bosun

Position of A/B

Position of O/S2 Position of O/S1


9. The relevant position of the bosun can be also shown in the schematic below.

Figure 6: Schematic of the relevant position of the bosun at the time of the accident

10. At 08:18 LT (04:18 UTC) of the same day and while the four crew members were preparing to cover grab no. 2 with the tarpaulin, a sudden heavy sea swell broke from starboard side over the main deck where the crew members were working. The bosun was hit by the sea spray, he was not able to hold on and was forced to and washed under the grab towards its aft side. During the process his head and body were injured against the grab/grab fitting. In particular his safety helmet was forced out and his head sustained a cut about 10 cm length by 4 mm depth. His neck, shoulder and back were also injured in such extend that he was not able to move after the accident. No further medical evaluation was available.

Figure 7: The injuries on the bosun of m/v Ocean Crown 11. The other three crew members were able to get cover and they only saw the bosun laid down unconscious after the accident. They picked the bosun up, transported him to the port side of the main deck in order to avoid another water spray coming on the main deck stbd side, informed the bridge accordingly and called for immediate assistance. The bosun was put on a stretcher and was transported to sick bay where first aid was applied on his wounds. Due to the severity of the injury the Company asked for medical advice from CIRM Rome. First aid medication was applied temporarily on him with

O/S1 O/S2

A/B Bosun

Direction of sudden sea wave

Hatch no. 2

Main deck


the available medicines onboard as per the medical advice. But due to the severity of the injury and as per the advice from CIRM Rome it was decided that the injured crew member should be evacuated to the nearest medical port facilities. Thus, the vessel made contact with MRCC Mumbai for immediate assistance. 12. It was decided that the vessel would proceed to Kochi, India for immediate evacuation by helicopter to the nearest medical facilities. During the same day it was discussed that the vessel proceeds to the islands of Agatti or Kavaratti, Lakshadweep which were closer to the course of the vessel but that idea was soon discarded as those tourist islands do not have the necessary medical facilities for such injuries. On 12th September 2019 the injured crew member complained for severe pain and the vessel continued proceeding with full safe speed to Kochi, India. 13. On 13th September 2019 the patient was observed with stomach blood and the crew inserted, after consulting with MRCC Mumbai, a catheter for output of liquid. Thereafter the patient was given compressed air but his condition deteriorated very quickly and at 21:00 LT (15:30 UTC) he was dead. 14. The vessel arrived at Kochi, India on 14th September 2019 at 05:18 LT. The tug “Ocean Elite”

came alongside with the agent and a doctor who checked the patient and found him dead. Thereafter, the deceased body was arranged for disembarkation at Kochi, India under the care of the P&I Club and the agent. All necessary procedures and formalities were carried out in order to repatriate the body to his hometown. At 10:45 LT the body was transferred to the tug “Ocean Elite” accompanied by the

agent and local authorities.


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 Global Carriers Ltd and additional crew statements taken by the MAIC investigator, when he conducted an investigation onboard the vessel on 14/10/2019 at Mesaieed, Qatar.

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 01/06/2015 30/03/2020 Load Line Certificate 27/04/2018 30/03/2020 Cargo Ship Safety Construction Certificate 01/06/2015 30/03/2020 Cargo Ship Safety Equipment Certificate 29/07/2018 30/03/2020 Cargo Ship Safety Radio Certificate 01/06/2015 30/03/2020 Safety Management Certificate 18/08/2017 11/06/2022 Ship Security Certificate 18/08/2017 11/06/2022 Maritime Labour Certificate 12/06/2017 11/06/2022 International Oil Pollution Prevention Certificate 19/06/2017 04/05/2022 Sewage Pollution Prevention Certificate 01/06/2015 30/03/2020 Air Pollution Prevention Certificate 01/06/2015 30/03/2020 Energy Efficiency Certificate 08/07/2013 - International Anti – Fouling System Certificate 29/07/2018 - Ballast Water Management 08/11/2018 30/03/2020 Certificate for the Carriage of Dangerous Goods 01/06/2015 30/03/2020 DOC of Management Company 21/04/2017 21/02/2022

All Class and Statutory annual surveys were last done on 04/2019 and all Class and Statutory renewal surveys were due on 03/2020. All certificates onboard the ship were found to be in order and valid.

4.1.2 Ship’s Navigational & Radio Equipment The M/V “OCEAN CROWN” 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 i) NAVTEX receiver j) EGC receiver


k) HF direct – printing radiotelegraph receiver l) Satellite EPIRB COSPAS – SARSAT m) Radar search and rescue transponder (SART) n) Duplication of equipment o) Shore – based maintenance Navigational equipment a) Standard magnetic compass b) Spare magnetic compass: Gyro compass repeater c) Gyro compass d) Gyro compass heading and bearing repeaters e) ECDIS f) 2nd ECDIS g) 9 GHz radar h) 3 GHz radar i) ARPA j) AIS system k) LRIT system l) VDR m) 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) 2 liferafts for total 50 persons d) 12 lifebuoys e) 35 lifejackets f) 31 immersion suits

The “OCEAN CROWN” 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 OCEAN CROWN for the voyage detailed as follows:

a. The passage plan from Suez, Egypt to Tuticorin, India 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 accident took place on 11th September 2019 0818 LT. From that time onwards the vessel changed course to Kochi, India for emergency disembarkation of the injured crew member.

c. The vessel’s speed was approximately 11.6 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 main deck. 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 liferafts were provided in accordance with the requirements of the SOLAS convention.

The main 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 ship’s condition was found to be in order.

4.1.5 Cargo related factors

The ship was on a laden voyage from Odessa and Ochakov, Ukraine to Tuticorin, India via Suez Canal, carrying 49,999.083 MT of corn grains 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.

4.1.6 CCTV – VDR The ship is not equipped with a CCTV system. The 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 15/01/2018, expires on 14/01/2023 and requires 17 crew members to be onboard the vessel. The crew onboard the vessel at the date of the incident was 25 crew members including three armed guards hired for the passage from Suez, Egypt to Tuticorin, India. It is thereby concluded that the ship at the date of the incident complied and exceeded the MSMD requirements. 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.


4.2.2 Bosun’s Medical Certificate The bosun had a “MEDICAL CERTIFICATE FOR SERVICE AT SEA” issued on 9th February 2019 by Micah Medical Clinic and Diagnostic Laboratory, Manila, Philippines. All his examinations were normal and he was therefore pronounced “Fit for sea duty”. In detail, the medical certificate states that the bosun 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 the bosun 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. The bosun’s 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 the bosun 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.

4.2.5 Risk Assessment The accident took place on 11th September 2019 at 08:18 LT (Ship’s Time). According to the Bridge log book during the same day at 04:00 LT the following weather conditions were observed: “Overcast skies, near gale, very rough sea, vessel rolling and pitching, heavy at time, good visibility, shipping sea spaying over h-covers Nr. 1 & 2” At 08:00 LT, i.e. just before the accident happened, the weather conditions were the following: “Cloudy skies, very rough sea shipping seas, vessel rolling & pitching, due to SSW swell 4.50 mtrs high, sea spraying on cargo holds 1 & 2 stbd side, visibility good”. At 12:00 LT, i.e. after the accident, the weather conditions were the following: “Cloudy sky, strong breeze, very rough sea, SW swell, visibility good, vessel rolling heavily, sea spray at STBD forecastle and STBD main deck”. It is noted that the bridge logbook states that from 04:00 LT to at least 12:00 LT sea sprays were observed on the stbd side of the vessel affecting the area where the accident occurred. The investigator was presented with three documents that were issued on 11th September 2019 08:00 LT:


1. A “Hot Work Permit” that was valid for 11th September from 08:00 hrs to 17:00 hrs for hot works on deck. The permit states that a Risk Assessment had been carried out before issuing the hot work permit, which derived some risk mitigating measures. The job description states “Renew old air pipe

– use electrode and welding machine” – a description which is mistaken. It is also stated that a formal work plan meeting took place before the hot work permit was approved where all the risks were discussed between the participating crew members. 2. A “Risk Assessment Form” for “Covering tarpaulin at grab” which was issued on 11th September 2019 at 08:00 hrs. The risk assessment form identifies as risk-sources the injuries of crew members and the potential consequences being from light to severe injuries. The identification of “injuries” as

being a risk-source is wrong as the C/O who filled in the risk assessment form does not specify what kind of risk he is referring to. The probability for light injuries was judged to be “3” on a scale from 1 to 4 and the probability for severe injuries was judged to be “2” on a scale from 1 to 4. The total risk factor for both light and severe injuries was calculated to be “6”, which meant that the crew may proceed with caution to perform the job, and additional controls were recommended to further reduce the risk level but such measures are not obligatory. The further action that was taken was “Supervision

and guidance awareness, supervision follow up regulations / procedures”. Additional comments on the

form were: “1. Personnel to carry out the work are highly qualified and properly briefed and 2. Personnel to carry out the work are wearing complete and proper PPE”. 3. A “Risk Assessment Form” for “Hot works on deck” which was issued on 11th September 2019 at 08:00 hrs. The risk assessment form identifies as possible risk-sources the injuries of crew members and the potential consequences being light injuries, severe injuries and fatalities. The identification of “injuries” and “fatalities” as being a risk-source is wrong as it does not specify what kind of risk is referred. The probability for light injuries was judged to be “3” on a scale from 1 to 4, the probability for severe injuries was judged to be “2” on a scale from 1 to 4 and the probability for fatalities was judged to be “1” on a scale from 1 to 4. The total risk factor for both light and severe injuries was calculated to be “6”, which meant that the crew may proceed with caution and additional controls were recommended to further reduce the risk level but such measures are not obligatory. The further action that was taken was “Supervision and guidance awareness, supervision and scholastic follow up regulations / procedures”. Additional comments on the form were: “1. Personnel to carry out the work are highly qualified and properly briefed and 2. Personnel to carry out the work are wearing complete and proper PPE”. The total risk factor for fatalities was calculated to be “4” and therefore no further risk mitigating actions were required to be taken. The probability of occurrence of the above risk – sources was estimated to be of small / medium level (“1” for fatalities, “2” for severe injuries and “3” for light injuries on a scale from 1 to 4). The probability is determined by using the Information Sources for Risk Assessment. In particular those Information Sources are: a. Historical data, b. Experience, c. Stakeholder feedback, d. Observation, e. Forecasts, f. Expert judgement. It is concluded that the estimation of the probability of occurrence of the above risk – sources was inadequate. The correct risk-sources are not identified at all, but the consequences of implied risk-sources are provided. In addition, a risk assessment for working on deck under heavy weather conditions was not filled in by the crew. The weather conditions as described in

i. the Bridge logbook ii. the accident reports by the Master (who had disembarked when the investigation took place

onboard the vessel) and iii. the statement from the crew members


were so severe that they should have normally resulted a very high probability of occurrence of all risk – sources which would result at a risk factor of 8 for light injuries, 12 for severe injuries and 16 for fatalities. This would have prevented both the operations of “Covering tarpaulin to continue hot works”

and “Grab welding”. In addition, safe working practices for seamen dictate that no seafarer should be on deck during heavy weather unless it is absolutely necessary for the safety of the ship or the crew. The welding job was not necessary for the safety of the ship or the crew. Examination of the Risk Assessment forms which were issued before the “covering tarpaulin to

continue hot works” and “grab welding” jobs were inadequately filled in and evaluated as the severity of the prevailing weather conditions was not taken into account as it should have been. Furthermore, contradicts the safe working practices for seamen under heavy weather conditions as the welding job was not necessary for the safety of the ship or the crew.

4.2.6 Hot work permit The Risk Assessment forms for “covering tarpaulin to continue hot works” and “grab welding” were created as a consequence of the hot work (i.e. welding of the grab plate) that was planned to take place. Hot work is an exceptionally high-risk task, where failure to observe safe procedures can lead to people’s heavy injury or death and to severe damage of the ship. The Master is primarily responsible for the identification of hazards involved for the work to be performed and the corresponding mitigating measures to be taken. He provides instructions for the safety precautions prior and during the hot work execution. He prepares and calls a work plan meeting prior to work commencement. He gives the authorization for hot work execution, after verifying that all planned precautions are taken and all personnel involved is aware of the work plan and will establish and maintain the safety precautions. He is responsible to safeguard that instructions are understood by the personnel involved and always followed. Both the C/O and the C/E must provide consultation to the Master during the hazards’ identification process. From the hot work permit provided it is determined that a responsible officer for hot work was not present during the formal work plan meeting that took place before the job was to be conducted. It is also observed from the hot work permit that the surrounding area of the hot work (i.e. area around the grab no. 2 on the main deck) was determined to be “safe”. It is obvious that the severe weather

conditions were not taken into account when issuing the hot work permit. Safe working practices dictate that during foul weather, all personnel shall comply with the following safety precautions: No person is permitted on the exposed main deck areas unless:

i. Approved by the Master ii. Properly equipped with safety gear

iii. Properly supervised iv. The Master shall delay any access to main deck until the vessel’s course and/or speed have been

properly adjusted to provide the safest possible condition In addition, when underway in very adverse weather conditions, the Officer Of Bridge Watch (OOBW) shall:

i. Immediately notify the Master ii. Call all personnel being on weather decks inside iii. Alter course and/or speed as required ensuring their safety


iv. No access to main deck shall be allowed whenever waves wash and/or temporarily cover it with seawater

It is evident that the above-mentioned safety precautions were not correctly taken. In particular, the crew members who were ordered to perform the job were i) not properly equipped with safety gear (see chapter 4.2.7 below) and the vessel’s course and / or speed was not adjusted in order to provide the safest possible condition. A proper assessment of the severity of the weather conditions would have prevented the Master from approving the particular hot work permit.

4.2.7 Personal Protective Equipment (PPE) As it was understood by the crew statements all four crew members who participated in the job of covering the grab no. 2 with a tarpaulin were wearing the following Personal Protective Equipment (PPE):

a. Safety helmet b. Gloves c. Overalls (not high visibility) d. Three of them safety boots, one of them safety shoes

The crew members did not wear the following PPE:

a. Life jackets b. Safety harness

Due to the severity of the strength of the wave that hit the vessel on the stbd side, the bosun’s safety

helmet and left safety boot were washed away and lost. It cannot be concluded if the bosun had fully insured his safety helmet before commencing the job but it can be assumed that the hit and pull by the sea wave and the following driving of the bosun under the grab was so severe that the safety helmet was forced out of his head. Applying a safety harness which can be attached to deck lifelines could have probably prevented the severe injuries to the crew member.

4.3 The Environment

External environment: As already mentioned above, the weather conditions at the time of the accident were as follows. Wind force: 7 BF Sea State: very rough Swell height: SW to SSW 3-4 mtrs to 4.5 mtrs Current speed & dir: adverse 1 – 1.5 knt Weather: clear / partly cloudy Natural light: daylight Visibility: Good (between 5-25 nm) Vessel condition: vessel rolling and pitching heavy at time, sea spaying over hatch covers Nr. 1 & 2 stbd side and stbd forecastle and main deck There is evidence, that the severe weather conditions were a primary contributing factor to the accident.


Internal Environment: The condition of the deck floors was not observed to be slippery or damaged. There was no evidence that the internal environmental conditions were a factor in the accident.


5. Conclusions

1. Severe weather conditions were a primary contributing factor to the accident.

2. As per the company’s Safety Management System Manual - chapter 7.9.14.3, during foul weather conditions no person is permitted on the exposed main deck areas unless approved by the Master. This approval in the current situation came through the “Hot Work Permit” and allowed the scheduled job operation to proceed. The permit itself was supported by a “Risk

Assessment form”, the results of which concluded that the risk factors of the operation were small to medium range. It is concluded that the risk assessment form was inadequately filled in as there is no evidence that the adverse weather conditions that were prevailing at that time, were taken into account. Therefore, inadequate risk assessment was a contributing factor to the accident.

3. In addition and further to the risk assessment form, working on deck under the weather conditions prevailing at that time, contradicts the safe working practices for seamen under heavy weather conditions as the welding job was not necessary for the safety of the ship, the crew or the safety of life at sea. No seafarers should be permitted on deck during adverse weather conditions unless considered necessary for the safety of the ship, the crew or for the safety of life at sea. Therefore, violation of safe working practices for seamen regarding work on deck under heavy weather conditions to be performed only when considered necessary for the safety of the ship the crew or the safety of life at sea, was a contributing factor to the accident.

4. As per the company’s Safety Management System Manual - chapter 7.9.14.3, during foul

weather conditions the Master shall delay any access to the main deck until the vessel’s course

and / or speed have been properly adjusted to provide the safest possible condition. According to the information received the ship’s course and / or speed was not adjusted in order to provide the safest possible condition for the welding operation to take place. Therefore, violation of the SMS’s requirement during foul weather conditions to delay any

access to the main deck until the vessel’s course and / or speed have been properly adjusted for providing safety conditions for work on deck, was a contributing factor to the accident.

5. As per the company’s Safety Management System Manual - chapter 7.9.14.3, during foul weather conditions no person is permitted on the exposed main deck areas unless he is properly equipped with safety gear. Seafarers required to go on deck during adverse weather should wear a lifejacket suitable for working in, a safety harness which can be attached to deck lifelines and full personal protective equipment. The bosun (and also the other three crew members) did not wear any lifejackets and safety harness, which could have possibly prevented the injuries of the bosun. Therefore, violation of the SMS’s requirement that no person is permitted during foul weather conditions on the exposed main deck areas without being properly equipped with safety gear, was a contributing factor to the accident.


6. Recommendations

1. The Manager should review Chapter 7.1 of the “Plans and instructions for key shipboard

operations” manual. The process of performing the risk assessment by the crew should be clearer

in the step-by-step instructions and the prefilled risk assessment forms in the Risk Assessment Library should be reviewed and corrected if necessary. (within three (3) months)

2. The Management Company by way of a circular or other means, to educate its crews, on Risk Assessment and Work Permit System, as well as implementation of Safe Working Practices for Seafarers including proper use of Personal Protective Equipment. (within three (3) months)

republic of cyprus marine accident and incident ... › 2020 › 03 › ...the “ocean crown” is...

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