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REPUBLIC OF CYPRUS

MARINE ACCIDENT AND INCIDENT

INVESTIGATION COMMITTEE

Investigation Report No: 56E/2016

Very Serious Marine Casualty

Death of a crew member of the M/V “VASTERBOTTEN” on

14/04/2016 while plying the Baltic Sea

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 carried out as a joint investigation with Sweden (Swedish Accident

Investigation Authority) and Latvia (Transport Accident and Incident Investigation Bureau).

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Marine Accident and Incident Investigation Committee

Contents

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

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

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

LIST OF ACRONYMS AND ABBREVIATIONS ................................................................................ II

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

2. FACTUAL INFORMATION ............................................................................................................2

2.1.VASTERBOTTEN ................................................................................................................................ 2 2.1.1. Ship Particulars ................................................................................................................................. 2 2.1.2. Voyage Particulars ............................................................................................................................ 3 2.1.3. Marine Casualty or Incident Information............................................................................................3

2.1.4. Shore Involvement and Emergency Respons ...................................................................................... 3

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

3.1. SEQUENCE OF EVENTS ........................................................................................................................... 4

4. ANALYSIS ....................................................................................................................................... .9

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

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

List of Figures Figure 1: The “Vasterbotten”

Figure 2: The accommodation’s main deck internal alleyway where the C/E was lying (2 photos)

Figure 3: The accommodation’s internal ladder from where it is assumed that the C/E fell

Figure 4: M/V “Vasterbotten” in the port of Mersrags-Latvia, the day after the incident

Figure 5: Drug and Alcohol warning notice posted

Figure 6: VDR cabinet

Figure 7: VDR Declaration of shore based maintenance

Figure 8: Deck Log-Book extract on 14/04/2016

Figure 9: Photo Deck Log-Book extract 14/04/2016

List of Annexes Annex 1: Record of Hours of Work& Rest

Annex 2: Sea Service

Annex 3: Death Certificate

Annex 4: Company Circular No152 - deck - Alcotester on board

Annex 5: Company Policy on drug and alcohol abuse

Annex 6: Company Procedure on Drug and Alcohol abuse

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List of Acronyms and Abbreviations

AB 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

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

MRCC Marine Rescue Coordination Centre

MT Metric Ton

NM Nautical Mile

OS Ordinary Seaman

PSN Position

RPM Revolutions per Minute

SAR Search And Rescue

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

events surrounding the accident, S-VDR recordings, documents, a forensic autopsy report and

performed analyses to determine the causal factors that contributed to the accident, including any

management system deficiencies.

Accident Description

On the night of the 14th April 2016, the Cyprus flag vessel “Vasterbotten”, was plying the Baltic Sea,

en route from Hallstavic-Sweden to Mersrags-Latvia. At approximately 23:45 hours LT (UTC+1), the

vessel’s Chief Engineer, was found by an Ordinary Seaman, unconscious. He was lying on the floor

of the accommodation’s main deck alleyway, below a ladder and close to the Engine Room’s internal

door.

The General Alarm was raised and the Master was informed. Medical assistance was requested from

the Marine Rescue Coordination Centre-Sweden. Medical advice was given on the telephone. Crew

members provided Cardio Pulmonary Resuscitation. The Chief Engineer was transferred by Helicopter

to Stockholm-Sweden, at Karolinska University Hospital, where he was pronounced dead.

There were no witnesses of the falling down. It is assumed that, as a result of a fall he suffered a

traumatic head injury.

The vessel was registered in Cyprus, the Chief Engineer was Russian and the accident occurred in

international waters but within the Swedish search and rescue area.

Conclusions

Direct Cause:

Fall of the seafarer onto the back of the head which caused extensive cranial injuries.

Contributing Cause(s):

Acute alcohol intoxication may have contributed to the accident.

No implementation of the Management Company’s Procedure on Drug and Alcohol Abuse in the day

of the accident, may have contributed to the accident.

Recommendations

1. The Management Company to take measures to ensure the proper implementation of the Drug and

Alcohol Abuse policy and procedure. The measures may include:

Random Alcohol Checks - (documented results of which to be sent to the Management Company’s

Headquarters).

Alcotest Log-Book placed on the fleet vessels - (which to be sent monthly to the Management

Company’s Headquarters).

Additional items in the ISM Audit Checklist for internal audits, regarding awareness of the Master and

crew on the Management Company’s Drug and Alcohol policy and procedure and on its

implementation. (Within 3 months)

2. The MC to take measures to ensure that the Deck Log-Book is completed in accordance with the

“Matters to be Recorded” and “Instructions for Recording Information in the Official Log-Book”,

printed in the first pages of the Official Log-Book of the Republic of Cyprus. Particularly, to stress the

requirement that entries must be made by the end of each watch as provided by item 17 of the above-

mentioned instructions. (Within 3 months)

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2. Factual Information

2.1. Vasterbotten

Figure 1: The “Vasterbotten”

2.1.1. Ship Particulars

Name of ship: Vasterbotten

IMO number: 9436226

Call sign: 5BHU2

MMSI number: 212 838000

Flag State: Cyprus

Type of ship: General cargo with container capacity

Gross tonnage: 5335

Length overall: 119.26m

Breadth overall: 16,5m

Classification society: DNV-GL

Registered shipowner: ms Vasterbotten GmbH & Company KG

Ship’s company: Schiffahrtskontor Tom Worden GmbH & Company KG

Year of build: 2008

Deadweight: 6805

Hull material: Steel

Hull construction: Single Hull

Propulsion type: Diesel

Type of bunkers: Marine Diesel

Number of crew on ship’s certificate: 7

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2.1.2. Voyage Particulars

Port of departure: Hallstavic-Sweden

Port of call: Maersrags-Latvia

Type of voyage: International

Cargo information: N/A - in Ballast condition

Manning: 11

Number of passengers: 0

2.1.3 Marine Casualty or Incident Information

Type of marine casualty/incident: Very Serious Marine Casualty

Date/Time: 14/04/2016 @ 23:45 Hours LT

Location: Coastal

Position (Latitude/Longitude): φ =59° 29'N / λ = 20°06'E

External and Internal Environment: Sea State Slight NE/3, Wind Light breeze / 2, Night,

Clear, Visibility good

Ship operation and Voyage segment: Normal service – In passage –Ballast

Human Factors: Yes / Fall of person

Consequences: Death: 1

2.1.4. Shore authority involvement and emergency response

M/V “Vasterbotten” informed the Marine Rescue Coordination Centre (MRCC) - Sweden and

medical assistance was requested.

Medical advice was provided by phone.

Ship’s crew provided First Aid until MRCC Sweden Search and Rescue (SAR) Helicopter

arrived.

The Chief Engineer (C/E) was evacuated by MRCC Sweden SAR Helicopter to a Hospital in

Stockholm.

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3. Narrative

3.1. Sequence of Events

1. The “Vasterbotten” on 14/04/2016, at 15:30 hrs LT (UTC+1) completed discharging, at

Hallstavik -Sweden

2. At 16:00 pilot on board.

3. At 16:35 cast off- all mooring ropes on board.

4. At 16:40 sailed in ballast condition from Hallstavik -Sweden.

Destination Mersrags-Latvia. ETA 15/04/16 at 16.40 hrs.

5. At 18:40 hrs, Master’s last contact with the C/E by phone immediately after disembarking of

the Pilot at Svartklubben Pilot Station.

6. At about 19:00 the Master had a fast snack in the dining room and returned to the Navigation

Bridge. He did not see the C/E in the dining room. No any other crew member stated that saw

him during dinner.

7. The Motorman stated that the last time he saw the C/E was around 22:00 – 22:20 hrs, in the

Mess-Room, where the C/E was drinking beer, with one crew member who had received

information about the birth of a son and two other crew (newcomers).

8. At approximately 23:45 hrs the C/E was found by the Ordinary Seaman (OS), unconscious. He

was lying on the floor of the accommodation’s main deck alleyway, below a ladder and close

to the Engine Room’s (ER) internal door.

The OS stated:

“I was going downstairs at evening time, somewhat about half past eleven, about that time…

I was planning to put laundry in washing machine, and stepping down on staircase,

I have found the body of Chief Engineer, laying on the floor…I got closer to him, because I did

not understand what happened……his face was located turned on right side ….

I turned the head and saw his one eye to be bloated, like result of a stroke…stroke caused by

staircase’s railing or maybe other parts of surroundings…the face was covered by some kind

of violet spots…no visible signs of life was seen …when I have seen all these…

I have run on my deck up and encountered Cadet, Kaspar….and I said him that it looked totally,

as Chief Engineer is dead, because the face was of blue colour… then both of us went

downstairs again and I tried to feel his pulse, I did not feel it, so I have started to perform

medical emergency activities, such as breast compression ….

Cadet has squeezed the button of fire alarm…. then all have been informed and

reacted…panic…. dismay ….”

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Figure 2: The accommodation’s main deck internal alleyway where the C/E was lying -The

position of the head is noted

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Figure 3: The accommodation’s internal ladder from where it is assumed that the C/E fell

9. The Cadet raised the General Alarm (GA). The Master heard the Alarm and went to the

Navigation Bridge to find out what happened (he did not know what happened and suspected

that fire broke out).

10. The OS rushed to the Navigation Bridge and informed the Master and the C/O, screaming

“Chief Engineer fell down! over there downstairs!”. The Master proceeded to the accident’s

scene. According to the Master’s statement: “so, we understood that something different from

fire has happened and all together we have been running to Chief Engineer…. myself and OS,

we have turned the body, tried to feel pulse and …. there was some stuff from mouth…all his

meal went out like a belch…so I have cleaned out his mouth also…. we have started to do the

breast compression. When doing the cleansing of his mouth by my finger, I have heard the

sound of “snort” …. some kind of sound could be heard (demonstrates sound) …. I did not feel

the pulse, but guys felt it…. Yeeha…. I understood, that help must be requested from

ashore……. I can’t say about the timing of events, because everything has been mixed in my

head…. may be fifteen minutes passed…but I clearly understood the urgent necessity of outer

help to be called …I got on bridge then…”

11. The Second Officer (2/O) also arrived at the scene. The Motorman heard the alarm and went to

the scene, asked what happened and took the pulse of the C/E.

12. Short time later the Master went on the Navigation Bridge and sent the Chief Officer (C/O) (the

C/O was at the time the Officer of the Watch - OOW) to continue first aid.

13. At 00:10 hrs, of 15/04/2016 the Master transmitted on VHF Ch.16 urgency message “PAN /

PAN - PAN / PAN - PAN / PAN” and requested medical assistance.

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14. At 00:12 hrs, MRCC-Sweden answered and the SAR Helicopter procedure started. (It was

understood that it was a serious medical case. Therefore, MRCC arranged to assign Paramedics

on board the SAR Helicopter before take-off. This caused some delay because the Ambulance

Helicopter (another Helicopter) which had medical crew on board, was engaged in another

medical emergency case).

15. Medical assistance was requested by the Master from the MRCC-Sweden.

16. At 00:34 hrs, the MRCC-Sweden advised the Master to obtain Radio Medical Assistance from

a Doctor via telephone.

17. The Master agreed. Telephone contact with a Doctor was established. The Master was passing

the advice given by the Doctor, via the vessel’s internal broadcasting system, to the crew down

in the accommodation’s main deck internal alleyway where the C/E was lying. The Master

informed the Doctor about the situation of the C/E and the Doctor advised to continue all

medical activities and to conduct cardiopulmonary resuscitation (CPR) - [ 30 compressions

cardiopulmonary rescue, followed by 2 for air intake]. Then the Doctor asked the Master several

times, what kind of adrenalin was availed on board, if it was prefilled bottles or not. The Doctor

said “If you have prefilled bottles, you may give an intramuscular injection” The Master was

not able to check what kind of adrenaline existed on board, because he was alone on the bridge

and the crew was conducting CPR, down in the accommodation’s main deck internal alleyway,

where the C/E was lying. The Doctor was continuously asking about the situation regarding

breathing and pulse and the Master was answering.

18. At 00:50 hrs, the Master reported to the Doctor that the C/E had no pulse and that his skin was

becoming dark. The Doctor told the Master, to continue CPR.

19. At 00:51 hrs, the SAR Helicopter took-off with two paramedics on board from Norrtalje-

Sweden. ETA to the vessel 20 minutes.

20. At 00:54 hrs, Radio Medical Assistance via telephone ceased. Crew members continued CPR

until the arrival of the SAR Helicopter.

21. The Master went at the scene and the C/O returned on the Navigation Bridge.

22. At 01:10 hrs, the SAR Helicopter arrived over the vessel. The C/O communicated and made

arrangements for the landing of the SAR Helicopter.

23. At 01:15 hrs the SAR Helicopter put on the “Vasterbotten” two paramedics and then landed on

the deck.

24. Paramedics examined the C/E made emergency manipulations and then put him on stretcher.

25. At 02.05 the SAR Helicopter took-off from the “Vasterbotten” with the two paramedics and

the C/E on board.

26. ETA to Karolinska Hospital in Stockholm-Sweden 26 minutes. CPR was continued during the

flight.

27. The C/E was transferred by the SAR Helicopter to Solna/Stockholm-Sweden, at Karolinska

University Hospital.

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28. The C/E was pronounced dead by Karolinska University Hospital.

Figure 4: M/V “Vasterbotten” in the port of Mersrags-Latvia, the day after the incident - Alcohol tests

to all crew members indicated BAC 0.00 except one who had BAC 0.90

Figure 5: Drug and Alcohol warning notice posted

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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 S-VDR recordings, crew statements and documents provided by

the Latvian Transport Accident and Incident Investigation Bureau (Investigator of which, boarded the

vessel and took statements, documents, photographs and VDR recordings), documents provided by the

ship’s Management Company, and the forensic autopsy report of the Swedish Department of Forensic

Medicine, provided by the Swedish Accident Investigation Authority.

4.1. The Crew

Chief Engineer:

Certification

The C/E was licensed and qualified in accordance with the requirements of the International

Convention on Standards of raining Certification and Watch keeping (STCW-95) Convention as

amended. (Certificate of Competency No.101 5501 302 /Endorsement No. R860173316 - CHIEF

ENGINEER No:1015501302 III/2 - RUS ST PETERSBURG 03.11.2015 – 07/10/2020)

A lack of certification was not a contributory factor to the accident.

Fatigue

On the previous day of the accident according to the Hours of Work/Rest form, the C/E worked from

00:00 - 00.200 and from 08.00 - 12.00 and from 13.00 -17.00. On the day of the accident, he worked

from 08:00 to 12:00, he had a lunch break from 12:00 to 13:00 and continued his normal duty from

13:00 to 19:00.

Fatigue was not considered a contributory factor, due to being rested the last 24 hours prior to the

accident more than 10 hours.

Fatigue was not considered as a factor to the accident.

Working and Living Conditions

The period of his seafarer’s employment agreement (SEA), was 4 months.

He signed on board the vessel on the 2nd of April 2016.

Unfortunately, he passed away 12 days after his embarkation, on the 14th of April 2016.

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

the accident.

Physiological, Psychological, Psychosocial Condition

The C/E was born in USSR on 10/11/1952. He was 64 years old.

His height was 1.85m and his body weight was105 Kg. His body composition was normal, well-built

and mildly overweight. His hair color was blond and his eyes color blue.

He was holder of medical certificate for service at sea. He was certificated as fit for watchkeeping

duties in the engine room, worldwide for two years and for meeting the standards of STCW Code

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Section A-I/9 for hearing, visual acuity and colour vision. His medical certificate was issued on

20/11/2015 with expiration date 19/11/2017 by a medical practitioner at St. Petersburg-Russia,

recognized by the Dutch Government.

In his cabin were found packs BISOPROLOL medicines. 13pcs of pills were missing, so he probably

took BISOPROLOL medicine since he joined the vessel on 01/04/16.

Bisoprolol is a beta-blocker that affects the heart and circulation (blood flow through arteries and

veins). Bisoprolol is used to treat hypertension (high blood pressure). Bisoprolol, may have reduced

his resistance to the effects of alcohol.

According to the Master the OS and the Cadet, the C/E: “never had any conflicts or quarrels with any

other on board, was absolutely normal, adequate and life loving individual…none any frictions among

crew at all”.

There was no evidence to suggest that the C/E physical, physiological, psychological, or psychosocial

condition was such that could have contributed to the accident. He was physically and mentally fit to

perform his job.

Post Mortem Examination

The Swedish Department of Forensic Medicine in Stockholm, conducted forensic autopsy on the C/E

on 19/04/2016 (post mortem period about 5 days).

According to the report issued, a neuropathological investigation demonstrated that he sustained local

traumatic brain injuries and to have occurred not more than 1-2 hours prior to death.

A forensic chemistry investigation demonstrated 2.27% ethanol (alcohol) in femoral blood and 2.04%

ethanol in urine.

According to the forensic chemistry investigation:

Quote

“The demonstrated concentrations of ethanol equate to high levels that normally lead to an impact on

motor function, alertness and judgement. The appearance of the overall pattern of injuries strongly

points to the injuries having occurred as a result of powerful blunt trauma to the head and may be

consistent with a fall down a flight of stairs involving a head impact. The injuries demonstrated have

an appearance that strongly points to them being fresh and having occurred in close connection to

death”.

With respect to the cause of death, the examination findings strongly point to having died as a result of

extensive cranial injuries.

With respect to the manner of death, the overall picture of the injuries primarily indicates that the cause

of death was caused by an accident (fall onto the back of the head) to which his acute alcohol

intoxication may have contributed”.

Unquote


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4.2 The Ship

Class: DNV-GL ((Ice Classed), P&I Club: Assuranceforeningen Gard

Dry cargo multi-purpose ship, gearless, with two holds, with container capacity (TEU)

Capacity=331- Reefer Plugs=20, DWT=6805, GT=5335, NT=2566, Extreme breadth=16.5m,

Depth=8.3m, Draft=6.28m, Freeboard=2020mm, Length Overall=119.26m. With Bulbous Bow

Construction: Built by Sainty Shipbuilding Corporation Limited, Launched on 24 Jan. 2008

Engines: (1), Type: Diesel, Power=3000KW, Fuel Type: Marine Diesel, Speed 13.5 Knots Boilers

(1) Oil fired, Generators (4) AC 1x270KV, 1x500KV, 2x251KV.

Designed by: MAN (Augsburg), Built by: STX Heavy Industries at Changwon (South Korea)

VDR

VDR maker: Net Wave Systems B.V.

Type: VDR-100 G2S S-VDR (Simplified Voyage Data Recorder)-Serial no: 20107121737. After the

fatal accident, the decoded data from the S-VDR was requested. Records have been saved, but decoding

was not possible on board. A specialist went on board, and downloaded on CD-ROM the last 48 hours.

Figure 6: VDR cabinet

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Figure 7: VDR Declaration of shore based maintenance

The “Vasterbotten” 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.

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

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4.3 The Environment

External environment:

The weather conditions at the time of the accident were: Sea State Slight NE/3, Wind Light breeze /

2, Night, Clear sky, Visibility good. There is no evidence that physical environmental factors, such as

weather, climate, etc., affected the actions of the C/E.

Internal Environment:

There were no any sudden movements of the vessel which could had caused the C/E slipping and

falling from the accommodation’s internal stairs. The condition of the stairs and the alleyway below,

was not wet nor slippery. They were dry.

There was no evidence that the environmental conditions were a factor in the accident.

4.4 Safety Management

Drug and Alcohol policy and procedure

The Management Company (MC) has a Policy on alcohol use, (SD-007: Declaration of Company

Policy on Drug and Alcohol Abuse-released on 01/04/2013), and a Documented Procedure (VA-004:

Drug and Alcohol Abuse released on 12/12/2002). In addition, the MC issued a Deck Circular

addressed to all Masters (No.152: Alcotester on board + Watchkeeping Alarm + TV – on Bridge- dated

10 /10/2005).

According to the “Declaration of Company Policy on Drug and Alcohol Abuse”:

Quote

No seafarers shall have a blood alcohol level greater than 0,5% or 0,25 mg/l alcohol in

breath, or a quantity of alcohol leading to such an alcohol concentration while performing

designated safety, security and marine environmental duties.

…………………………………………………………………………………………………

Compliance with the above is ensured by following the attached company circular.

Unquote

According to the Company Procedure on Drug and Alcohol Abuse (Dated 12/12/2002):

Quote

Description of Routines

Preventive and explanatory Measures

A copy of the document SD-007, the "Declaration of Company Policy on Drug and Alcohol Abuse"

will be permanently displayed on land and on board ships for the information of all personnel. New

personnel are to receive a copy before they begin employment.

The articles of agreement used for individual employment agreements are to contain the following

paragraph:

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In order to ensure ship safety on board, no consuming of alcohol or drugs is permitted while on duty.

The same applies to the possession, distribution or sale of drugs and alcohol on own account.

Violations of these rules can lead to instant dismissal from the employment of the Schiffahrtskontor

tom Wörden GmbH & Co. KG. In addition, each member of staff undertakes to come on duty free of

the influence of drugs and alcohol. Any use of medication - including that of permitted drugs - which

influences the ability to perform duty is also not allowed.

Unquote

According to the IMO / STCW Convention-Part B (non-mandatory) Guidance on prevention of drug

and alcohol abuse:

Quote

Drug and alcohol abuse directly affect the fitness and ability of a seafarer to perform watchkeeping

duties. Seafarers found to be under the influence of drugs or alcohol should not be permitted to perform

watchkeeping duties until they are no longer impaired in their ability to perform those duties.

Administrations should consider developing national legislation:

1.prescribing a maximum of 0.08% blood alcohol level (BAC) during watchkeeping duty as a minimum

safety standard on their ships; and

2.prohibiting the consumption of alcohol within 4 hours prior to serving as a member of a watch.

Unquote

The MC advised seafarers of the maximum permissible blood alcohol content (BAC) permitted whilst

on board: “0,5% or 0,25 mg/l in breadth.……. while performing designated safety, security and marine

environmental duties”. According to the MC’s Procedure, “each member of staff undertakes to come

on duty free of the influence of drugs and alcohol. In the seafarers’ employment agreement is stated

that “no consuming of alcohol or drugs is permitted while on duty” and “each member of staff

undertakes to come on duty free of the influence of drugs and alcohol”.

The MC’s Policy and Procedure on alcohol use is in line with the IMO / STCW guidance on alcohol

abuse. The MC’s requirement to go on duty free of the influence of drugs and alcohol is similar to the

IMO/STCW requirement of no consumption of alcohol 4 hours prior of a watch.

Furthermore, the MC issued the Circular No.152-dated 10/10/2005, which provides for regular alcohol

tests of Watchkeeping Officers, Master and Chief Engineer. The Circular No.152 should have been

issued for a reason.

According to the Deck Circular No.152: “Alcotester on board + Watchkeeping Alarm + TV – on

Bridge”:

Quote

Following regular and frequent alcohol-testing procedure herewith declared by company as permanent

affective:

1. Beginning of each watch>> BOTH<< the reliever and the to be relieved officer/master must

undertake at test with said equipment in front of each other

2. The master must undertake always a test in front of duty officer prior he is overtaking command

starting with

a) end of sea voyage

b) Prior every departure

3. The Ch.Eng. to be tested in front of master/officer

a) Prior every departure

b) Prior every end of sea voyage

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c) On every request by master between

4. Other crewmembers undergoing sea watch on request of master if he decide to be necessary.

Unquote

In his e-mail on 09.03.2017, the Master stated that:

Quote

“Please be informed that the alcotest of watchkeepers i.e. myself and AB Mr. Seminenko was done

before beginning of watch at 20.00 , but omitted to be inserted in time in logbook and was done late in

order to comply with Circular.

There were no chance to make alcotest on 14.04.16 prior departure at 16.00 owing short notice by the

agent. VSL was expected to depart at 18.00 lt”

Unquote

In the Photo of the Deck Log-Book (see below Figure 9) for the day of the incident (14/04/2016) there

is no record for the alcotest. The Photo is dated 15/04/2016. The Master explained in his e-mail that

the record in the Log-Book had been done afterwards i.e. after the Photo of the Deck Log-Book was

taken by the Investigator on 15/04/2016 when the ship was in port Mersrags.

As can be seen in Figure 9: Photo Deck Log-Book extract 14/04/2016, and Figure 8: Deck Log-Book

extract on 14/04/2016, in the day of the incident, the C/E was not tested prior to departure.

The Master with his e-mail explained that, “There were no chance to make alcotest on 14.04.16 prior

departure at 16.00 owing short notice by the agent. VSL was expected to depart at 18.00 lt”. Even

though, the fact is that the C/E was not tested. The Master could have checked the C/E after sailing,

i.e. at 20:00 hrs during normal watch change on the Bridge.

As the Master stated in his e-mail, (it is also recorded in the Deck Log-Book) “Please be informed that

the alcotest of watchkeepers i.e. myself and AB Mr….. was done before beginning of watch at 20.00”

Nevertheless, as he stated in his interview he had a fast snack at 19:00 hrs and returned to the Bridge

and released the C/O. He remained on the |Bridge and no watch change happened at 20:00 hrs when

his watch (8-12) normally started. A change of watch between the Master and the C/O must have been

done some time later, because at 23:45 hrs when the Master was informed about the incident, (he) was

in his cabin. Therefore, the record in the Deck Log-Book (Figure 8) that an Alcotest was done at 20:00

hrs is erroneous.

Also, according to the Circular No.152, beginning of each watch, BOTH the reliever and the to be

relieved must be alcotested. The statement of the Master “alcotest of watchkeepers i.e. myself and AB”,

concerns only the “relievers” and does not include the “to be relieved” as required by the Circular

no.152.

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Figure 8: Deck Log-Book extract on 14/04/2016: containing a record for alcotest which was made after

a Photo of the same page was taken by the Investigator on the 15/04/2016.

17

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Figure 9: Photo Deck Log-Book extract 14/04/2016 taken by the Investigator the next day 15/04/2016,

when the ship berthed in Messregs. (There is no alcotest record).

Therefore, it is concluded that the MC’s Procedure on Drug and Alcohol Abuse was not

implemented in the day of the accident.

The C/E was drinking before midnight. He would go for work the next day after about 8 hours rest

including night sleep. He would not go for work within 4 hours. The duration of alcohol effects, depend

upon several factors, including speed of consumption, taking food, body size, genetic factors, drinking

habits etc. It cannot be stated whether the next day would still be under the influence of alcohol.

18

©


5. Conclusions

The vessel was registered in Cyprus, the Chief Engineer was a Russian citizen and the accident was on

international waters but within the Swedish SAR area.

The MRCC-Sweden, assigned Paramedics on board the SAR Helicopter before take-off. This took

some time because the Ambulance Helicopter which had medical crew on board, was engaged in

another case.

There were no eye-witnesses of the incident. There was a social event at about 22:00 hrs in the Mess-

Room where the C/E was seen drinking beers.

The coroner, who performed the autopsy considered necessary a forensic examination of the brain, in

order to determine the cause of death. The forensic examination indicated high concentration of alcohol

in blood (2.27%) and urine (2.04%), that normally lead to an impact on motor function, alertness and

judgement. Medication may have reduced the victim’s resistance to the effects of alcohol.

It is assumed that the victim slept or lost his footing while stepping down the accommodation’s internal

ladder.

Injuries to the head may have been caused, by a fall down from the internal accommodation ladder,

involving a head impact.

The C/E was drinking before midnight. He would go for work the next day after about 8 hours rest

including night sleep. He would not go for work within 4 hours. The duration of alcohol effects, depend

upon several factors, including speed of consumption, taking food, body size, genetic factors, drinking

habits etc. It cannot be stated whether the next day would still be under the influence of alcohol.

The MC has procedure in place for the seafarers to be subject to testing and screening for drugs and

alcohol abuse by means of a routine testing. The MC’s procedure was not implemented in the day of

the accident.

Conclusively

Direct Cause:

(The immediate events or conditions that caused the accident)

Fall of the seafarer onto the back of the head which caused extensive cranial injuries.

Contributing Cause(s):

(An event or condition that collectively with other causes increases the likelihood of an accident but that

individually did not cause the accident)


No implementation of the MC’s Procedure on Drug and Alcohol Abuse in the day of the accident, may

have contributed to the accident.

19

©


6. Recommendations

1. The MC to take measures to ensure the proper implementation of the Drug and Alcohol Abuse

policy and procedure. The measures may include:

Random Alcohol Checks - (documented results of which to be sent to the MC’s Headquarters)

Alcotest Log-Book placed on the fleet vessels - (which to be sent monthly to the MC’s

Headquarters)

Additional items in the MC’s ISM Audit Checklist for internal audits, regarding awareness of

the Master and crew on the MC’s Drug and Alcohol policy and procedure and on its

implementation. (Within 3 months)

2.The MC to take measures to ensure that the Deck Log-Book is completed in accordance with

the “Matters to be Recorded” and “Instructions for Recording Information in the Official Log-

Book”, printed in the first pages of the Official Log-Book of the Republic of Cyprus. Particularly,

to stress the requirement that entries must be made by the end of each watch as provided by item

17 of the above-mentioned instructions. (Within 3 months)

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2402PersNo.

15.04.2016Issue Date

NIKITIN, VLADIMIREmployee Int. Company No.

VLADIMIRCHIEF ENGINEER MARRIED

Personal ParticularsFamiliy name:

Nationality:

Given name(s):

RUSSIA

Civil Status:Place of Birth: RUSSIA

Rank:

Street:ZIP: City:

Phone: Mobile: Fax:Email: Internet:Manning Ag.:

Body height:Body weight:

Hair Color:Eye Color:

183 CM100 KGBLONDBLUE

NIKITIN

Date of Birth:Country:

10.11.1952

Airport1:Airport2:

ST. PETERSBURG…RUSSIA

Age: 63

26-5 KANONERSKIY STR ST PETERSBURG

+78127148241 [email protected] SKYPE: VLADIMIR.NIKITIN93

MANX NAUTILUS ST. PETERSBURG

Kind of Lic.:

Place of IssueDoc. Number Issue ExpiryTravel Documents Nat.STCWPASSPORT ST PETERSBURG75 0726622 13.02.2015 13.02.2025RUS

NAT. SEAMAN BOOK ST.PETERSBURGMK 0132907 03.10.2012 unlimitRUS

NAT. SEAFARER ID ST.PETERSBURGRUS 0025785 24.09.2012 23.09.2017RUS

BASIC SAFETY TRAINING… ST PETERSBURG0212508 07.10.2015 07.10.2020RUSVI/1

MEDICAL FIRST AID (A-VI/4-1) ST PETERSBURG0077434 14.10.2015 14.10.2020RUSVI/4-1

ADVANCED FIRE FIGHTING… ST PETERSBURG0314730 16.10.2015 16.10.2020RUSVI/3

SURVIVAL CRAFT AND… ST PETERSBURG0315036 26.10.2015 26.10.2020RUSVI/2-1

SHIP SECURITY WITH DESIG… ST.PETERSBURG0363355 09.10.2015 09.10.2020RUSVI/6-2

CYP ENDORSEMENT LIMASSOLRE00173316 26.02.2016 07.10.2020CYP

CYP SBOOK LIMASSOLCY251008 26.02.2016 25.02.2026CYP

IOM ENDORSEMENT DOUGLAS19671 30.05.2006GBR 01.12.2010

SCHENGEN VISA ST.PETERSBURG012588825 07.04.2015 07.04.2017RUS

Licenses / Certificates Place of Issue Issue ExpiryNat.STCWDoc. NumberCHIEF ENGINEER (III/2 OR III/3) ST PETERSBURG1015501302 03.11.2015RUSIII/2 07.10.2020

Medical: Place of Issue Issue ExpiryNat.STCWDoc. NumberMEDICAL FITNESS CERT. ST PETERSBURG 29.09.2015RUS 29.09.2016

VACCINATION - Y/FEVER DUTCH MED.CENTER 29.09.2014RUS 29.09.2024

Sea Services (recent)Vessel GT Begin Contract End ContractEngine KWEmployer Rank

MANX OCEAN GERMANY… VAESTERBOTTEN 5335 3000 CHIEF ENGINEER 01.04.2016 . .

MANX OCEAN GERMANY… ALAND 5679 3920 CHIEF ENGINEER 22.04.2009 07.09.2009

MANX OCEAN GERMANY… FINNLAND 5257 3840 CHIEF ENGINEER 24.09.2008 01.02.2009

MANX OCEAN GERMANY… FINNLAND 5257 3840 CHIEF ENGINEER 27.02.2008 20.07.2008

MANX OCEAN GERMANY… SEELAND 5679 3920 CHIEF ENGINEER 28.07.2007 07.12.2007

MANX OCEAN GERMANY… NORRBOTTEN 4211 2950 CHIEF ENGINEER 01.12.2006 17.04.2007

MANX OCEAN GERMANY… NORRBOTTEN 4211 2950 CHIEF ENGINEER 15.05.2006 11.09.2006

Declaration of CompanyPolicy

Schiffahrbkontor tom WördenGmbH & Co. KG

Wilhelm€chröder€tr. 3D-21726 Oldendorfon Drug and Alcohol Abuse

$chiffahrtskontor tom Wörden GmbH & Co. KG aims to provide and maintain a workplaceenvironment that protects the health and safety of all employees whilst at work. A safe andproductive work environment includes the respectful treatment of others in the workplace. Theuse of drugs and/or alcohol in the workplace may impair the employees' ability to perform theirwork safety and with respect for colleagues and others. The purpose of this Policy is to reducethe likelihood of injury, damage and/or other negative effects resulting from alcohol and/or druguse andlor abuse in the work environment.

. Masters and crew members who have to consume drugs prescribed by a medical doctorinform that doctor of their activities on board äfrip and request the docton to consider this factwhen designing his therapy.

r No seafarer shall take up his duties on board, whether watch keeping or other duties, if hehas consumed alcohol during the four hours prior to taking up those duties.

. No seafarer shall have a blood alcohol level greater thdn 0,5%o, or 0,25 mg/l alcohol inbreath, or a quantity of alcohol leading to such an alcohol concentration, while performingdesignated safety, security and marine environmental duties. To give an idea whichquantities of alcohol consumption may cause a blood alcohol of 0,15%0 please find thefollowing information (without engagement, only as a guideline)

- 250 ml beer or- 100 ml strong beer or- 30 ml Liquor or- 100 ml Wine or- 60 ml $herry

. Compliance with the above is ensured by following the attached company circular.

. No seafarer may use, ingest, inject, smoke, possess, $ell, or otherwise have any dealingswith any illegal drugs at any time and no seafarer may induce any other person to use illegatdrugs in any form at any time.

. Alcohol and/or drug abuse similarly endangers safety at work ashore. These regulationsaccordingly apply by analogy to personnel of the Schiffahrtskontor tom Wörden GmbH & Co.KG shorebased organisation.

Schiffahrtskontor tom Wörden GmbH & Co. KG manegement declares unequivocally that it witftake all legal measures in terms of industrial law and if neces$ary of criminal law againstpersonnel found in breach of these regulations. For further details, please refer to the relevantdocumented procedure.

This document is to be made known by public notice in the shorebased organisation and onboard every ship. A copy of the document has to be handed to all new personnel prior to actualemployment.

Stade, U.A4,2A13

It

TI)'I

: 0{ S4.2013 : 01.04.20{€--Other Document No.:sD-007

Procedure

Schiffahrtskontor tom Wörden

GmbH & Co. KG Wilhelm-Schröder-Str. 3

D-21726 Oldendorf

VA-004 Revision 0 12.12.2002 Page 1 of 3

Release to Third Parties by Special Authorisation

of Management only

Drug and Alcohol Abuse

1. Purpose

The Management of Schiffahrtskontor tom Wörden GmbH & Co. KG has already made clear, with its "Declaration of Company Policy on Drug and Alcohol Abuse" in Part A of our System Documentation, that drug and alcohol abuse pose a serious threat to ship safety and to work safety in the Shorebased Organisation.

In order to reinforce this policy, the regulations for implementing the above declaration are set out in this Documented Procedure.

2. Application

This Documented Procedure applies to the Shorebased Organisation and on all ships man-aged / operated by Schiffahrtskontor tom Wörden GmbH & Co. KG.

3. Definitions and Abbreviations

3.1 Definitions

• Safety means the safe operation of vessels according to the ISM Code.

• Environmental Protection means the protection of the maritime environment according to the ISM Code.

• Safety and Environmental Protection System (SE System) means the System accord-ing to ISM Code and STCW 95 of Schiffahrtskontor tom Wörden GmbH & Co. KG .

• Safety and Environmental Protection Manual (SE Manual) means the documentation of Schiffahrtskontor tom Wörden GmbH & Co. KG’s SE System.

3.2 Abbreviations

ISM Code International Management Code for the Safe Operation of Ships and for Pollution Prevention (International Safety Management Code), adopted 04.11.1993

STCW 95 International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, as amended in 1995 (STCW Convention)

STCW Code Seafarers' Training, Certification and Watchkeeping Code (STCW Code)

VA Procedure

Procedure



D-21726 Oldendorf


4. Responsibilities

All personnel in supervisory positions with subordinate members of staff are responsible for the observation of the regulations governing the misuse of alcohol and drugs.

For any further measures, the Masters and the Fleet Manager are primarily responsible.

5. Description of Routines

5.1 Preventive and explanatory Measures

A copy of the document SD-007, the "Declaration of Company Policy on Drug and Alcohol Abuse" will be permanently displayed on land and on board ships for the information of all personnel. New personnel are to receive a copy before they begin employment.

The articles of agreement used for individual employment agreements are to contain the following paragraph: In order to ensure ship safety on board, no consuming of alcohol or drugs is permit-ted while on duty. The same applies to the possession, distribution or sale of drugs and alcohol on own account. Violations of these rules can lead to instant dismissal from the employment of the Schiffahrtskontor tom Wörden GmbH & Co. KG . In addition, each member of staff undertakes to come on duty free of the influence of drugs and alcohol. Any use of medication - including that of permitted drugs - which influences the ability to perform duty is also not allowed. Existing articles of agreement which do not contain this paragraph are to be supplemented by adding an appropriate appendix.

5.2 Measures to be adopted in the case of violations

Where there is suspicion of drunkenness or intoxication from drugs, at least one further per-son should always be called as a witness.

The Master, Fleet Manager is to suspend the affected person immediately from further work. On board ship, the incident is registered in the Deck Log Book and a copy is forwarded to the Fleet Manager, while in the case the shorebased organisation is involved, an informal notice is to be written down in the personnel file. The member of staff involved also receives a copy of the Deck Log Book entry / notice.

The offending member of staff is given the opportunity of proving that he was not under the influence of alcohol or drugs by producing a doctor's certificate (e.g. the result of a blood test) to that effect.

The offending member of staff is to be given a comprehensive dressing down by the Master, Fleet Manager on returning to duty in a sober state.

Where justified, especially in the case of serious threats to ship's and work safety, or for re-peated offences, the offending member of staff is to be given notice of dismissal.

Procedure



D-21726 Oldendorf


6. References and Remarks

6.1 Reference Documents

• SD-007 Declaration of Company Policy on Drug and Alcohol Abuse

• HB-003 Company Responsibilities and Authority

• Seemannsgesetz

• Accident Prevention Regulations

• Articles of Agreement

6.2 Bibliography

• Drug Trafficking and Drug Abuse, ICS, 1994

• Guidelines for the Control of Drugs and Alcohol onboard Ship, OCIMF, 1990

6.3 Remarks

The Management of Schiffahrtskontor tom Wörden GmbH & Co. KG reserves the right, where justified, to prosecute the offender and to claim compensation for damages.

7. Documentation

• Articles of Agreement

• Deck Log Book

• Warning

• Notice of Dismissal

• Personnel File

8. Revision of Documents

Party responsible for the editorial revision of this procedure:

Designated Person

9. Distribution

All Safety Management Manuals

Additional Copies:

• none

10. Attachments

• none