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REPUBLIC OF CYPRUS MARINE ACCIDENT AND INCIDENT

INVESTIGATION COMMITTEE [Investigation Report No: 106E /2014]

Very Serious Marine Casualty Fatality on Tug-Boat “LAMNALCO LEOPARD” at the port of Pepel – Sierra Leone, on the 3rd of October, 2014

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Foreward

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.

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GLOSSARY OF ABBREVIATIONS AND ACRONYMS

AB - Able Bodied Seaman, an experienced and qualified member of the deck crew BA - Breathing Apparatus C/O – Chief Officer CoC - Certificate of Competency CYCSWP – Cyprus Code of Safe Working Practices for Merchant Seamen DPA - Designated Person Ashore GMT - Greenwich Mean Time GT - Gross Tons ISM Code - International Management Code for the Safe Operation of Ships JHA- Job Hazard Analysis Knots - Speed in nautical miles per hour DBT –Double Bottom Tank DO – Diesel Oil DOT – Diesel Oil Tank ETA - Estimated Time of Arrival DBT – Double Bottom Tank IMO - International Maritime Organization ILO - International Labour Organization LT - Local Time m – metre MT - Metric Ton OOW - Officer of the Watch OS – Ordinary Seaman PTW - Permit to Work RA - Risk Assessment Second Officer (2/O) SMC - Safety Management Certificate SMS - Safety Management System SMD - Minimum Safe Manning Document SOLAS - The International Convention for the Safety of Life at Sea 1974 (as amended) STCW - The International Convention on the Standards of Training, Certification and Watchkeeping for Seafarers 1978 (as amended) SWL – Safe Working Load STS - Ship-to-Ship (STS) transfer operation TBT - Tool Box Talk VHF – Very High Frequency Hand Held Radio (Walky Talky) UTC - Universal Time Co-ordinated ZT - Zone Time

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Contents Glossary of Abbreviations 3 List of Figures 4 List of Annexes 4 1. Summary 5 2. Factual Information 6 2.1. Ship particulars 6 2.2. Voyage particulars 6 2.3. Marine casualty or incident information 6 2.4. Shore authority involvement and emergency response 6 3. Narrative 7 4. Analysis 12 5. Conclusions 18 6. Recommendations 21 List of Figures Figure 1: T/B “Lamnalco Leopard fasted on the port side of M/V “Gypsum Integrity” Figure 2: The displaced fender and a webbing sling lying over it Figure 3: Webbing Sling passing over horizontal bollard Figure 4: Webbing sling passing over Horizontal Bollard and connected to rope with shackle Figure 5: Involved 5 crew members: Captain + C/O + AB1+ AB2+ OS

List of Annexes Annex 1: PPE Matrix Annex 2: Certificate of Death Annex 3: Records of Hours of Work / Rest of Master Annex 4: Automatic Inflatable Lifejacket

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Summary A fatality was investigated in which a Tug-Master was drowned when he fell into the sea. In conducting its investigation, the Marine Accident Investigation Committee (MAIC) reviewed events surrounding the accident, reviewed written statements from the crew members involved and documents provided by the ship’s Management Company and performed analyses to determine the causal factors that contributed to the accident, including any management system deficiencies. Accident Description The accident occurred on 03/10/2014 at approximately 10:50 LT, when the Tug-Boat “Lamnalco Leopard” was secured by its starboard side alongside the port side of the M/V “Gypsum Integrity” in the port of Pepel, Sierra Leone. The crew was re-positioning a Heavy Duty Cylindrical Rubber Fender on the port side of the bow of the Tug-Boat, which had been displaced out of position. To position the fender, webbing connected to a rope was directed to a winch. When under tension, the rope broke/split and hit the Tug-Master. The Tug-Master, who was standing on the external side of the bulwark of the Tug-Boat, fell overboard and disappeared in the water. Search and Rescue operations started immediately but without results. The Tug-Master’s body was found the afternoon of the next day 04/10/2014. The Direct Cause of the accident (death) was Asphyxia due to Massive Pulmonary Oedema due to Drowning (Wet) caused by fall into the water after hit by cut rope. The Contributing Causes

1. Inadequate Planning/Briefing-Failure to complete all preparatory tasks associated with planning/briefing for the job was contributing factor to the accident.

of the accident were:

2. Violation of the safety management system procedures was contributing factor to the accident.

3. It is assumed that a sense of boldness and invulnerability may have made the victim to disregard the

risks associated with the job at hand.

4. Disregard of safety precautions, where work is being carried where there is a risk of falling overboard (PPE: Life –Jacket or floatation device properly secured, and Life-buoy with Line) was contributing factor to the accident.

5. A judgment and decision- making error resulted from faulty evaluation of risks associated with a particular course of action, and wrong choice of place to supervise the operation was contributing factor to the accident.

6. Recommendations 1. Management Company to issue a fleet circular to draw the attention of its crews of the necessity to implement the Company’s Safety Management system. Also to inform its crews about the accident.

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2. Factual Information 2.1. Ship particulars IMO: 9537422 Name of ship: Lamnalco Leopard Call sign: 5BDM3 MMSI number: 209097000 Flag State: Cyprus Type of ship: Tug-Boat Gross tonnage: 484 Length overall: 32.14m Classification society: BV Registered ship owner: Lamnalco (Cyprus) Ltd. Ship’s Company: Smit Lamnalco Netherlands BV Year of build: 2010 Deadweight: Hull material: Steel Hull construction: Single Hull Propulsion type: Diesel Type of bunkers: IFO Number of crew on ship’s certificate: 7 2.2. Voyage particulars Port of departure: N/A Port of Destination: N/A Type of voyage: N/A Cargo information: N/A Manning: 8 Draft: Fwd= 6,00M Aft= 6,07M 2.3. Marine casualty or incident information Type of marine casualty/incident: Very Serious Marine Casualty Date and time: 03/10/2014 @10:50 LT Position: Lat.: 08 35 N Long.: 013 04 W Location: Port of Pepel, Sierra Leone External and internal environment: Slight sea, Gentle breeze, Partly cloudy, Night, Vis. good Ship operation and voyage segment: In port Place on board: Freeboard Deck (Port side externally of the Bulwark) Human factors: Yes / Human Error /Decision

Consequences Death: 1 2.4. Shore authority involvement and emergency response Search and Rescue operation started immediately. The Tug-Master’s dead body was found the next day early afternoon.

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3. Narrative

3.1 Sequence of Events:

1. On the 2nd of October 2014 the Tug-Boat (T/B) “Lamnalco Leopard” and the T/B “Lamnalco Puma”, participated in an off-shore Ship-to-Ship (STS) transfer operation assisting the M/V ‘Gypsum Integrity”. During the STS operation, the Tug-Master of the T/B “Lamnalco Leopard”, noticed that the aftermost Heavy Duty Cylindrical Rubber Fender on the portside of the bow (shown in Figure 1 below) had been displaced out of position. It was planned for fixing on arrival in the port of Pepel, where prevailed good weather conditions and there was no swell. Both Tug-Boats arrived in the port of Pepel, at approximately 22:00 LT, of the same day.

2. On the 3rd of October 2014 at about 04:30 LT, the M/V ‘Gypsum Integrity”, was un-berthed from a Lay-Over berth and berthed at a Loading berth for loading. T/Bs “Lamnalco Leopard” and “Lamnalco Puma” were in assistance of M/V ‘Gypsum Integrity”.

3. After the operation, both T/Bs, made fast on the port side of the M/V “Gypsum Integrity”. T/B “Lamnalco Leopard” was secured by its starboard side alongside the port side forward of M/V “Gypsum Integrity” and T/B “Lamnalco Puma” was double banked on the portside of T/B “Lamnalco Leopard”.

4. At about 10:30LT, T/B “Lamnalco Puma” casted off from the port side of “Lamnalco Leopard”. Therefore the portside of the “Lamnalco Leopard” became “sea side”.

5. The Chief Officer (C/O) of the T/B “Lamnalco Leopard” instructed two AB’s and one OS for the fender’s repositioning. A chain block and a web-sling were prepared.

6. The Tug-master (Captain) overruled the C/O with another job plan (described below).

Figure 1: T/B “Lamnalco Leopard fasted on the port side of M/V “Gypsum Integrity”

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Figure 2: The red arrow shows the displaced fender and a webbing sling lying over it

Figure 3: Webbing sling passing over Horizontal Bollard

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Figure 4: webbing sling passing over Horizontal Bollard and connected to rope with shackle

Captain AB1 OS AB2

Figure 5: Involved 5 crew members: Captain + C/O + AB1+ AB2+ OS

Captain was positioned on port side externally of the bulwark

Chief Officer was standing on the bow deck (not visible)

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AB 1 was taking instructions from the Captain and transmitting them to the AB2

AB 2 was handling the rope on the capstan

OS was operating the capstan

The purpose of the Captain’s job-plan, was to get the displaced fender back into position by applying tension using a web-sling lying over the fender, connected with a rope and routed to a capstan via two bollards, one bollard located at bow area (visible in the above Figures 3 and 4) and another bollard located amidships port side of the T/B (visible in Figure 5).

A shackle was connected to an eye on the outside hull, underneath the fender. The shackle had a Safe Working Load (SWL) of 3 ¾ tons, and was connected to a web sling with a SWL of 10 tons. The web sling went over the fender and bulwark and was guided over a horizontally placed bollard, welded to the bulwark. From there the web sling was connected to a mooring rope (polypropylene - Minimum Breaking Load of 201 kN) by a shackle of 17 tons SWL. The mooring rope was led to the amidships port side bollard, from where it was guided to the capstan (pull capacity 5 tons). 6. At approximately 10:45 hrs LT, when ready to commence the execution of the job-plan, the Captain went externally of the bulwark on the portside of the vessel, and placed himself at a position facing the fender. From there, he was giving hand signals and verbal instructions to the AB 1 to heave up or slack as appropriate. The AB1 was passing Captain’s instructions to the AB2/rope handler and the OS/capstan operator.

7. The rope began to tension gradually to high tension but the displaced fender was not repositioned.

8. The C/O left from the bow, in order to bring a water hose, to spray water on the displaced fender to lubricate it in order to make easier its repositioning.

9. At approximately 10:50 hrs LT, while applying tension, the rope snapped.

10. The C/O heard the sound of the rope, instinctively turned to see what happened and saw that the Captain had been hit by the snapped rope on his face and fell overboard. According to his statement: “10.50.: When I take the water hose suddenly our rope parted and the rope direct hit captain Patar head. After that he is sinking fall down on the water, and I see capt. Patar sinking directly”. 11. AB1 on hearing the sound of the rope, turned to see the Captain but saw that the Captain was no longer at his previous position. He notified other personnel on deck and rushed towards the position where the Captain was standing, but did not see him.

12. The OS picked up a Life-Buoy and ran to the T/B port bow with the intension of lowering it when the Captain passes by, but the Captain was not seen.

13. At approximately 10:52LT, after further lookout without the Captain in sight, AB1 notified via VHF the Pepel Safety Boat, about the incident.

14. At approximately 10:55 hrs LT, the C/O called the Contract Manager on the telephone (from the T/B Bridge) informing him about the event.

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At the same time the Chief Engineer went to the Bridge and informed other Smit Lamnalco tugs (T/B “Lamnalco Puma” and T/B “Smit Cayman”) who were alongside M/V “Gypsum Centennial”, at the Lay-By berth in Pepel, to keep Man Overboard Look-Out.

15. Both T/Bs, casted off from Lay-By berth and proceeded to the loading berth area. T/B “Lamnalco Puma” searched around the stern of M/V “Gypsum Integrity” and T/B “Smit Cayman” searched on the portside of T/B “Lamnalco Leopard”.

16. Pepel Safety Boat arrived about 10 minutes after the incident and found the Captain’s work-vest, at about 10 meters distance from the vessels bow. The Captain’s work-vest was recovered and delivered on-board the T/B “Lamnalco Leopard”.

17. At 11.05 hrs Lt, the Contract Manager informed the Head Office about the situation and also mobilised the Diving team (Class diving) from Freetown a few minutes later.

18. At approximately 12.00 hrs Lt, Sierra Leone Port Authority, was notified.

19. At approximately 13:50 hrs Lt, the Diving team, the Contract Manager, the Technical Superintendent and the SHE-Q Officer, arrived in order to carry out a preliminary investigation. Statements were taken from all crew.

20. At approximately 14:30LT, AML Marine and Safety team boarded the vessel to assess the situation and carry out investigation.

21. In the meantime the Class Diving Team carried out search in Pepel area to locate the Captain.

22. At approximately 17:30LT, during slack tide, three divers searched the area where the Captain was positioned before the incident and underneath the vessel, without results.

23. Search and rescue resumed on the 4th of October at approximately 10:00 hrs LT, by the Class Diving Team.

24. At approximately 19:30 LT a body had been found on the beach, close to Pepel village. The Chief Officer was called and identified the body, as being the body of the Captain. 25. The Captain’s body was transported to a local Clinic. 26. On the 5th of October the body was transported to the Class Diving Jetty at Freetown where a Coroner carried out post mortem examination. 27. According to the Medical Certificate of Cause of Death issued on 7/10/2014 by the Republic of Sierra Leone – Office of Chief Registration of Births and Deaths: Disease or condition directly leading to death ( A) Asphyxia ( B ) due to (or as a consequence of) Massive Pulmonary Oedema ( C ) due to (or as a consequence of) Drowning (Wet)

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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 draws on documents and written statements from the crew provided by the vessel’s Management Company and an accident investigation report prepared by the ship’s Management Company (as required by ISM Code Section 9).

4.1 The Crew Training and Certification T/B “Lamnalco Leopard” was manned with crew licensed, qualified and medically fit in accordance with the requirements of the International Convention on Standards of Training Certification and Watchkeeping (STCW) Convention as amended. The STCW Basic Safety Training which all seafarers are undergoing as required by the STCW Code as amended: Part A Chapter VI/1, provides for competence to “observe safe working practices” with regards to knowledge, understanding and proficiency in: a) Adhering to safe working practices at all times and, b) Safety and protective devices available to protect against potential hazards aboard ship.

A lack of training and certification was not a contributory factor to the accident. Manning level At the time of the incident, she was manned in excess of the T/B’s Minimum Safe Manning Document (MSMD). She had a crew of 8 although her Minimum Safe Manning Document provides for 7. The Captain, the Chief Officer and the Chief Engineer were Indonesians, the Second Engineer was Ghanaian, three Sailors and one Cook were Sierra Leoneans. A lack of manpower was not a contributory factor to the accident.

Alcohol Impairment There was no evidence to suggest that alcohol or drugs were taken by any of the crew members involved in the accident. Fatigue . Watchkeeping duties are performed by the Captain (06-12) - (18-24) and the C/O (00-06) - (12-18). The Captain had rest the previous day from 12-6 and at 06:00 he woke up and had breakfast. His hours of rest were in accordance with MLC, 2006 and STCW as amended requirements, having rested 6 consecutive hours before his watch commenced. Fatigue was not considered a contributory factor to the accident.

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Organization on board Watchkeeping duties are performed by the Master (06-12) - (18-24) and the C/O (00-06) - (12-18). Three ABs (AB1, AB2, AB3) perform watchkeeping duties AB1 (4-8)-(16-20), AB2 (08-12)-(20-24), AB3 (00-04)-(12-16). At the time of the accident i.e. at about 10:50 hrs LT, on watch were the Captain and AB2. The C/O, AB1 were on overtime. The OS was dayman. The working language on board was English. There was no language barrier between the ABs and OS and their Officers. Their duties corresponded to their qualifications and experience.

There was no evidence to suggest that, the organizational conditions on board were a contributory factor to the accident.

Working and Living Conditions T/B “Lamnalco Leopard” is fully air conditioned and heated accommodation is provided for up to nine persons in three single and three double berth cabins. There is a large mess room, a well equipped galley, sanitary spaces, washing facilities and stores for dry and frozen supplies. The accommodation is constructed with floating floors and insulated linings and ceilings to reduce sound levels to 60-65 dBA throughout, including the wheelhouse. There was no evidence to suggest, that, the working and living conditions was a contributory factor to the accident.

Physiological, Psychological, Psychosocial Condition All crew members were holders of medical certificate for service at sea issued in compliance with the STCW Convention as amended. They were certificated as fit for sea duty without restrictions and 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 on board. There was no evidence to suggest that the crew’s physical, physiological, psychological, or psychosocial condition was such that could have contributed to the accident. They were physically and mentally fit to perform their job.

4.2 The Tug-Boat At the time of the accident, she was classed with the BV (Notation: I+HULL.MACH Escort Tug Unrestricted Navigation AUT UMS Fire Fighting Ship 1 with Water Spray) and had valid certificates, including an ISM certificate, although below Convention size (GT=484 <500 GT), documenting voluntary compliance with SOLAS ’74 as amended

. The DOC of the Company is applicable to this type of ship.

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Design: Damen azimuth stern drive (ASD) Tug 3213 built and fitted out specifically for towing, mooring, escorting and fire fighting operations.

Length Overall 32.14m with a beam of 13.29m, depth 5.50m and draft (aft) of 6.07m.

The hull form features an increased volume forward, a raised forecastle, deep box keel and a pronounced sheer aft increasing freeboard at the open stern. This additional freeboard aft enhances the tugs’ performance while running astern and reduces the ingress of water on deck. The propulsion system comprises a two Bergen C25:33L8P Main Engines, generating a total of 6,530 BHP (4,800 KW) at 1,000 RPM, coupled to Rolls-Royce US 255 CP fully azimuthing propulsion units. The units incorporate controllable pitch bronze propellers, 4 –blades of 2,800mm diameter.

On trials achieved a bollard pull towing ahead of 77.1 tons and 70.1 tons towing astern. The performance when running free was almost equal in directions, recording 14.2 knots ahead and 13.7 knots astern. Two hydraulic towing winches are fitted, one combined double drum winch and anchor windlass on the fore deck for escort work and shiphandling, and a single drum winch aft for towing over the stern. The forward winch has a maximum brake holding capacity of 250 tons and each drum can accommodate 130m of 96mm diameter synthetic rope, plus a 20m pennant of 112mm rope. The winch has two speeds, giving a line pull of 60 tons at 27.4m/minute or 44 tons at 54.8m/min. The aft winch has a maximum brake load of 250 tons and the single drum is equipped with spooling gear. This winch also has two speeds, giving a line pull of 50 tons at 10.7m/minute or 15 tons at 30m/min. The drum carries a 1,000m towline of 60mm diameter steel wire rope. Also located on the after deck is a 5 ton electrically powered capstan, a Mampaey quick release tow-hook with a safe working load (SWL) of 100 tons, and in the open stern a 1,200mm diameter, 126 ton SWL stern roller. Mounted on the starboard column of the bitts aft of the winch is a Heila HLM 10-25 hydraulic knuckle-boom crane capable of lifting 1,100kg at a radius of 7.84m. Equipped for fire fighting to Fi Fi 1 standard. The fire fighting system comprises two remotely operated Alco short barrel monitors, each capable of delivering 1,200 cu/m of water/foam per hour, plus self protection spray nozzles and hose connections on deck. Both monitors are mounted on the forward superstructure at bridge deck level. Water pressure is supplied to the system by two Kvaerner fire pumps, one driven from the front end of each main engine via Kumera Norgear step-up gearboxes. Fully air conditioned and heated accommodation is provided for up to nine persons in three single and three double berth cabins. There is also a large mess room, a well equipped galley, sanitary spaces, washing facilities and stores for dry and frozen supplies. The accommodation is constructed with floating floors and insulated linings and ceilings to reduce sound levels to 60-65 dBA throughout, including the wheelhouse. The Wheelhouse has two control stations, one forward and one aft, designed to give the Tug-Master easy access to either from Captain’s chair mounted on a central track. The forward console is built to standard design common to all Damen modern ASD tugs. The Wheelhouse has large windows ensuring good all-round vision.

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A comprehensive outfit of navigational and communications electronics meets the standards for GMDSS Area 3. Included are two radars, a Satellite compass, GPS, Echo sounder, Auto-pilot, speed log, two Inmarsat C terminals, one Fleet broadband terminal, Navtex, two VHF and one single sideband radio.

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

4.3 Environment Atlantic seaport, is located in western Sierra Leone, on Pepel Island, near the mouth of the Sierra Leone River (an estuary formed by the Rokel River and Port Loko Creek). Beginning in 1933 it exported iron ore brought by rail from the Sierra Leone Development Company’s mines at Marampa, 41 miles (66 km) east-northeast. Pepel is the only Sierra Leone’s iron-ore port. Only Pepel and the port of Freetown have docking facilities.

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Weather conditions: Daylight, Overcast, Visibility Good. High temperatures prevailing in tropical climates are a stress factor. Heat Stress impairs performance. It is a factor when the individual is exposed to conditions resulting in compromised performance. Heat Stress could affect crew performance. Nevertheless it is difficult to prove that it was a contributing factor to the accident. 4.4 Safety Management Smit Lamnalco fleet consists of:

• Terminal tugs • Harbour tugs • Offshore support vessels • AHT(S) • Utility crafts and Crew boats

Smit Lamnalco has implemented a management system named “SLIMS” (Smit Lamnalco Integrated Management System) across the entire company: One Company – One System. SLIMS encompasses all activities undertaken and is applicable to all vessels regardless their size/tonnage. SLIMS is integral to the company.

This integrated safety management system has full ISO 9001/14001 and Occupational Health and Safety Assessment Series (OHSAS) 18001 Certification by classification society Bureau Veritas across the entire

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company and fleet. It is certified for ISM, ISPS and MLC, 2006. SLIMS is fully aligned with the 12 elements of the OCIMF’s Offshore Vessel Management and Self Assessment (OVMSA) Guidelines.

Specific client and local requirements are ‘bridged’ for each contract by means of a SLIMS Bridging Plan.

SLIMS Procedures includes Risk Assessment, Job hazard Analysis (JHA), Permit-to-Work System (PtW), Tool Box Talk (TBT), Master Leading by Example, Stop Work Policy etc.

“Lamnalco Leopard” was engaged under the “African minerals contract”, which commenced on September 2011. The “African minerals contract” consists of 6 Tug-Boats providing support to 4 trans-shipper vessels in the transporting of iron ore between Pepel port and an offshore transfer site. The scope of work includes:

• Supervision of barge loading • Offshore barging of bulk ores • Towing of river barges • FOTP and bulk ores transshipment • Berthing and unberthing transshipment vessels and bulk carriers • Positioning and transfer of fenders • Support for ship-to-ship transfer

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Conclusions Although the Captain overruled the Chief Officer, who had different plan to perform the job, it cannot be substantiated that there was Rank/Position Intimidation which is a factor when the differences in rank of the crew caused the task performance capabilities to be degraded. The job to be done wasn’t a usual job. Fender’s displacement does not occur often. According to the company’s Safety Management System “SLIMS”/ PRC-VSL-09-1301 a Job Hazard Analysis must be carried out when a job to be done is unknown and unfamiliar - New jobs should always be assessed on potential or known risks. Nevertheless, the Captain did not carry out a Job Hazard Analysis, did not issue a Work Permit and he did not make a Tool-Box meeting with the involved crew members, in order to properly organise the job to be performed.

Inadequate Planning/Briefing-Failure to complete all preparatory tasks associated with planning/briefing for the job was contributing factor to the accident. The Captain placed himself in a dangerous position i.e. externally of the bulwark and next to the rope under tension. He was standing at the snap back of the rope. It is basic seamanship to be careful with ropes under tension, to know where to stand to avoid a rope if parted. He did not adequately assessed the risks associated with his job-plan. He did not consider necessary to carry out formal Risk Assessment as required by safety management system (SLIMS). The Captain intentionally violated the safety management system “SLIMS” Procedures, having consciously assessed and honestly determined to be the best course of action, an unofficial procedure/course of action, as necessary for performing the job at hand. Violation of safety management system procedures was contributing factor to the accident. It is assumed that a sense of boldness and invulnerability may have made him to disregard the risks associated with the job at hand. According to the CYCSWP / 4.11 Protection against drowning: Quote “Where work is being carried out over side or in an exposed position where there is a reasonable foreseeable risk of falling or being washed overboard or where work is being carried out in or from a ship’s boat a lifebuoy with sufficient line should be provided. In addition and as appropriate a lifejacket or buoyancy aid should be provided. Where necessary, personnel should be provided with thermal protective clothing to reduce the risks of cold shock”. Unquote

According to the Management Company’s SMS (SLIMS), Flotation devices: “Approved type flotation devices shall be worn on all exposed areas of deck, when working over-side or in a position over water, when crossing gang-ways, transferring between vessels or quaysides, when performing mooring, towing and anchor handling operations, or carrying out any other task that presents any risk whatsoever of falling into water”.

According to SLIMS/SPC-VSL-09-1305-801 - Inflatable Life-Jacket: Duty to Wear: The inflatable lifejackets is safety equipment, not PPE. The inflatable lifejackets shall be worn on top of the standard coverall when engaged in overboard work or in situations where the risk assessment indicates that the

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use of an inflatable lifejackets is required and will increase the personal safety. On deck the ordinary rigid work vests as per SPC-VSL-09-1305-802 shall be worn.

(Note: A Life-Jacket is designed for floatation and turns an unconscious person from face down to face up in the water, allowing him to breathe. A Work-Vest wore by the Captain is designed for flotation and to keep a conscious person’s head out of the water in calm conditions).

According to the CYCSWP: “ as appropriate a lifejacket or buoyancy aid should be provided”, and according to SLIMS : “Approved type flotation devices ( either lifejacket or buoyancy aid) shall be worn in situations where the risk assessment indicates that the use of an inflatable lifejackets is required - On deck the ordinary rigid work vests as per SPC-VSL-09-1305-802 shall be worn”.

Therefore, either a Life-Jacket or the ordinary rigid work vest could be used. Interpretation for “as appropriate”, i.e. for making a choice between a Life-Jacket and a Work-Vest, shall be based on what the Captain knew or was thinking that he knew about the situation, before the incident. He did not carry out Risk Assessment and worn the ordinary rigid work vest.

The Captain did not wear a Life-Jacket. Subsequent to the incident, a Work-Vest was found floating in the water, which might have been the one worn by the Captain. The remains of the Captain were found without any floatation device. The fact that the witnesses stated that they did not see him after falling, and the C/O stated that “I see capt. Patar sinking directly”, leads to the assumption that he lost his consciousness when was powerfully hit by the parted rope and when he fell into the sea, drunk water, his clothes and shoes added to his weight and went directly down. It is assumed that he did not have his Work-Vest fasted and it was taken off when he fell into the sea, subsequently he did not get any floatation.

Also, the requirement of the SPC-VSL-09-1305-901 – Multi-Purpose Harness, to wear safety harnesses in combination with an approved fall arrester when working over the sea was not implemented.

The requirement of the CYCSWP / 4.11 regarding a lifebuoy with sufficient line was not implemented.

Disregard of safety precautions, where work is being carried out where there is a risk of falling overboard (PPE: Life –Jacket or floatation device properly secured, and Life-buoy with Line) was contributing factor to the accident. The Captain made “an honest mistake”: He proceeded as intended, but his plan proved inadequate and inappropriate for the situation. He failed to adequately evaluate the risks associated with a particular course of action (e.q. risk of partition of the rope) and this faulty evaluation leaded to inappropriate decision‐making and subsequent unsafe situation. Also, wrong choice of place to supervise the operation put himself at risk. The position he had chosen, was externally of the bulwark and in the snap back zone of the mooring line. He could be standing on the Bridge wing for having commanding view. Nevertheless, the other crew members placed themselves at safe positions. A judgment and decision- making error resulted from faulty evaluation of risks associated with a particular course of action, and wrong choice of place to supervise the operation was contributing factor to the accident.

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Quote from Narrative

9. At approximately 10:50 hrs LT, while applying tension, the rope snapped.

10.The C/O heard the sound of the rope, instinctively turned to see what happened and saw that the Captain had been hit by the snapped rope on his face and fell overboard. According to his statement: 10.50: “When I take the water hose suddenly our rope parted and the rope direct hit captain Patar head. After that he is sinking fall down on the water, and I see capt. Patar sinking directly”. 11. AB1 on hearing the sound of the rope, turned to see the Captain but saw that the Captain was no longer at his previous position. He notified other personnel on deck and rushed towards the position where the Captain was standing, but did not see him.

12. The OS picked up a Life-Buoy and ran to the T/B port bow with the intension of lowering it when the Captain passes by, but the Captain was not seen.

13. At approximately 10:52LT, after further lookout without the Captain in sight, AB1 notified via VHF the Pepel Safety Boat, about the incident.

Un-Quote from Narrative

Based on the crew statements, it is assumed that: As soon as the rope snapped the Captain was hit on the face and fell in the water. The Chief Officer stated that he saw him sinking. The other crew members who were on deck stated that did not see him on the sea surface. The testimonies of the C/O, AB1, and OS are converging and there are no different testimonies to cross-check and comment. It can be assumed that due to the powerful hitting of the rope the Captain lost his consciousness and as soon as he fell into the sea, started drinking water, and going downwards-his body rapidly submerged into the sea, therefore the crew members who were on the deck i.e. the AB1, and the OS, did not see him. He was wearing a Work –Vest which was found after 10 minutes, at about 10 meters distance from the vessels bow. It is assumed that the Work-Vest was not fasted and as he fell into the sea, the Work- Vest was taken-off. A Work-Vest is designed for flotation and to keep a conscious person’s head out of the water. If he had his Work-Vest fasted or if he wore a Life Jacket, he could have refloated on the sea surface.

Ship’s equipment for recovery operations might include: Rescue Boat, Life Boat, Life Raft, Life Buoys with Line. The Tug-Boat availed 2 Life Buoys with Line and a Life Raft. She was exempted from the IACS Recommendation No99 requirement to carry Rescue-Boat or Inflatable –Boat by its Maritime Administration, due to the area of operation being characterised as Protected. Without a Rescue-Boat or Inflatable –Boat an unconscious person could not be recovered with the available equipment i.e. a Life Buoy with Line or a Life Raft. Using a Life-Raft is an option but is cumbersome and difficult to manoeuvre. There are examples of Life-Rafts being used for recovery of persons from the water, but one of the major problems is difficulty of boarding from the water.

In accordance with the Flag Administration's letter ref. RCS 12053, dated 14/12/2012, the subject vessel is 1. exempted from the IACS Recommendation No. 99 requirement for being fitted with a rescue boat, provided that the rest of the LSA are on board and in good working condition. 2. This exemption is valid for the time period subject vessel is engaged in operations within the protected waters/areas of Freeport, Sierra Leone. 3. The exemption will cease to be valid if/when subject vessel resumes international voyages.

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Further to the assumption that the Captain rapidly submerged into the sea it cannot be substantiated that the unavailability of a Rescue Boat or Inflatable –Boat was contributing factor to the accident. Nevertheless, if he was on the sea surface unconscious or even conscious in some distance from the Tug-Boat, the available means i.e. a Marcus net or Inflatable –Boat instead of a Rescue-Boat would not be capable to recover him.

Conclusively:

The Direct Cause of the accident (death) was Asphyxia due to Massive Pulmonary Oedema due to Drowning (Wet) caused by fall into the water after hit by cut rope. The Contributing Causes

5. Inadequate Planning/Briefing-Failure to complete all preparatory tasks associated with planning/briefing for the job was contributing factor to the accident.

of the accident were:

6. Violation of the safety management system procedures was contributing factor to the accident.

7. It is assumed that a sense of boldness and invulnerability may have made the victim to disregard the

risks associated with the job at hand.

8. Disregard of safety precautions, where work is being carried where there is a risk of falling overboard (PPE: Life –Jacket or floatation device properly secured, and Life-buoy with Line) was contributing factor to the accident.

5. A judgment and decision- making error resulted from faulty evaluation of risks associated with a particular course of action, and wrong choice of place to supervise the operation was contributing factor to the accident.

6. Recommendations 1. Working with ropes is logically seen by Tug-Boats’ crews as a routine task but contain dangers that are often underestimated or not realized. Safety Management System procedures should be implemented as required by the Management Company’s SMS. Management Company to issue a fleet circular to draw the attention of its crews of the necessity to implement the Management Company’s Safety Management System. Also to inform its crews about the accident.

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Requirement

Operation

Cov

eral

ls

Safe

ty F

ootw

ear

Hel

met

Bum

p C

ap

Safe

ty E

yew

ear

Grin

ding

Gog

gles

Glo

ves

Butc

her g

love

Self-

infla

tabl

e ve

st

Floa

tatio

n A

id

Ear d

efen

ders

Safe

ty H

arne

ss

Full

Face

Shi

eld

Dus

t or F

ace

Mas

k

Che

mic

al g

love

s

Che

mic

al A

pron

Wel

ding

mas

k

Wel

ding

glo

ves

Wel

ding

Apr

on

All W

eath

er c

oat/s

uit

Imm

ersi

on S

uit

O2

/ Gas

Mon

itor

Perm

it To

Wor

k

Deck / Cargo Operations

Cold weather operations

Banksman / Dogsman

Bunker operations

Crane Operations

Mooring / Unmooring

Anchor handling

Machinery Spaces

Pressure Systems

Batteries

Chemicals / Solvents

Power tools

Welding / Burning

Abrasive wheels

Heights over 2m

Over the side

23

Annex 1: PPE Matrix

24

25

Field Code Changed

Annex 4: Automatic Inflatable Lifejacket

Safety and Rescue Equipment Equipment:

Rescue and Survival Equipment Card Nr.: 801

Standard:

NEN-EN 396

EN 1095

CE, BV0062 SOLAS, MED

Further info:

Supplier: Secumar

This lifejacket has been designed to cope in the toughest of environments offering a high degree of comfort and durability to the user.

The lifejacket is SOLAS and MED approved.

For overboard operations on top of standard PPE Product description: Automatic Inflatable Lifejacket

Description:

• Type of buoyancy/ Method of Inflator: Inflatable/ Automatic inflator

• CO2-cylinder size 2*60gr. • Body weight from 32 kg and over. • Operating temperature range: -15°C to + 70°C • Standard included: whistle, light, buddy line,

donning instructions, d’-ring, zip closure, oral top tubes, retro reflective tape, crotch strap, lifting becket, hood, harness, non-corrosive parts.

Application

• The lifejacket can only be used outside a garment. • Although the outer shell of the lifejacket provide some protection to the interior of the jacket, extreme caution for

wear & tear and penetration by protruding objects should be paid. • The lifejacket is NOT manufactured out of flame retardant fabrics; this jacket shall not be used during welding and

oxy/gas cutting operations. • A lifejacket is an aid to protect from drowning. It does not guarantee rescue or survival.

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• The lifejacket is only suitable for temperatures in excess of -10° C.

Hazards • Never wear the inflatable lifejacket underneath clothing, coverall, safety harness or coat. When lifejacket inflates,

it might choke the wearer to death. • In water, the lifejacket will not immediately turn an unconscious person, who wears it in combination with heavy

waterproof clothing, to a face- up position. • This lifejacket should not be used in situations or locations where the user can be become trapped underwater. • Floatation is dependent on the CO2 cartridge. Regular inspection of the lifejacket and the CO2 cartridge should

safeguard the operability. • Unbuckled lifejackets do not provide any protection. Only a lifejacket, which suits firmly around your body, can

keep you in a stable position on your back in the water. • At temperatures around 0°C a slowed reaction of the automatic inflator is possible. Temperatures down to-10°C

may double the reaction time of the automatic inflator! • When jumping into the water, fold your arms over the lifejacket to avoid injuries and damage. This applies in

particular when the lifejacket is already inflated. Avoid jumps of over 3 m in height. • The lifebelt is only suitable for safeguarding persons on the deck of a vessel. Any use in contradiction to the

recommendations of these instructions can cause mortal injury.

Use • Visual inspection of the jacket prior to use. Reject inflated and damaged jackets for further use. • Avoid mechanical wear and tear. Avoid contact with (hot) liquids. • Avoid contact with high temperatures. • The inflatable lifejacket shall only be worn in combination with suitable PPE. • The inflatable lifejackets shall only be used with the buckle closed and adjusted to the waist of the user. • Store this lifejacket properly after use, and do not leave it unattended on deck, especially in wet/humid

environments.

Duty to Wear

The inflatable lifejackets is safety equipment, not PPE. The inflatable lifejackets shall be worn on top of the standard coverall when engaged in overboard work, work or in situations where the risk assessment indicates that the use of an inflatable lifejackets is required and will increase the personal safety.

On deck the ordinary rigid work vests as per SPC-VSL-09-1305-802 shall be worn.

Training / instruction Employees, who are to wear inflatable lifejackets, are to be instructed regarding the risk’s of the operation and are to be trained in the proper use of the inflatable lifejackets.

Please read the instructions and product information carefully before use.

Expire time

Inflatable lifejackets are subjected to a periodic service and certification scheme and can only be done by recognized

service station.

Maintenance is only possible for lifejackets, which have not exceeded their maximum service lifetime (10 years)