republic of cyprus marine accident and incident ......was struck by a mooring line, which he was...

REPUBLIC OF CYPRUS

MARINE ACCIDENT AND INCIDENT

INVESTIGATION COMMITTEE

Investigation Report No: 150E/2016

Very Serious Marine Casualty

Fatal Mooring Accident on the Bulk Carrier “Carme” at

Lagos/Apapa Nigeria on 23/09/2016

Foreword

The sole objective of the safety investigation under the Marine Accidents and Incidents

Investigation Law N. 94 (I)/2012, in investigating an accident, is to determine its causes and

circumstances, with the aim of improving the safety of life at sea and the avoidance of accidents

in the future.

It is not the purpose to apportion blame or liability.

Under Section 17-(2) of the Law N. 94 (I)/2012 a person is required to provide witness to

investigators truthfully. If the contents of this statement were subsequently submitted as evidence

in court proceedings, then this would contradict the principle that a person cannot be required to

give evidence against themselves.

Therefore, the Marine Accidents and Incidents Investigation Committee, makes this report

available to interested parties, on the strict understanding that, it will not be used in any court

proceedings anywhere in the world.

This investigation was not carried out as a joint investigation.

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Marine Accident and Incident Investigation Committee

Contents

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

CONTENTS ............................................................................... ERROR! BOOKMARK NOT DEFINED.

LIST OF ACRONYMS AND ABBREVIATIONS ............................................................................... III

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

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

2.1 CARME .............................................................................................................................................. 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 Response

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

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

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

5. CONCLUSIONS ............................................................................................................................. 16

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

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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

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

ME Main Engine

MT Metric Ton

NM Nautical Mile

OS Ordinary Seaman

OiC Officer in Charge

OOW Officer of the Watch

PSN Position

RPM Revolutions per Minute

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

VDR 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

On September 23, 2016 a fatal mooring accident occurred to the Bosun of the Cyprus registered

Bulk Carrier “Carme”, at Lagos/Apapa Nigeria.

In conducting its investigation, the MAIC, reviewed crew statements and documents provided by

the ship’s Management Company (MC), and performed analyses to determine the causal factors that

contributed to the accident.

Description of the accident:

On September 1, 2016 the Bulk Carrier “Carme” departed from Houston (TX)-USA, loaded with

cargo of corn, bound for Lagos-Nigeria. On September 22, arrived at the port of Lagos. On

September 23, the Bosun was fatally injured during emergency unmooring operation. The Bosun

was struck by a mooring line, which he was handling, while he was standing at the forecastle deck

starboard side in front of a winch drum. The area where the Bosun was standing was within the

snap-back zone of the parted mooring line (Snap-back zones are typically spaces where it is

anticipated a failed mooring line could recoil).

Conclusions

Direct Cause:

1. The Bosun died as a result of (a) Multiple injuries (b) Blunt force trauma.

2. With respect to the manner of death, it was caused by struck by mooring rope.

Contributing Cause(s):

1. The environmental conditions were a factor in the accident (Strong ebb current in conjunction

with inadequate under-keel clearance-Vessel was neither safely afloat nor safely aground).

2. No Specific Risk Assessment and no Tool-Box-Talk for emergency unmooring.

3. The strong ebbing current under the vessel’s flat bottom in conjunction with the vessel’s

grounding, its listing to stbd and trim by the stern, was pushing up the stem causing extreme

tension of the forward mooring lines, resulting in their breaking.

4. Insufficient information given to the Master regarding drafts alongside berth and tidal ebbing

effect.

5. Failure on the part of the Bosun to recognize the danger of coming within snap-back zones of

taut mooring lines.

Recommendations:

Recommendations to the Management Company:

1. Conduct a thorough risk assessment of mooring operations and a review of the mooring

procedures being followed onboard fleet vessels. (Within 3 months)

2. Specific Risk Assessment should be carried out whenever the conditions for which the Generic

Risk Assessment was done, differentiate. (Within 3 months)

3. Seafarers involved with mooring operations should be briefed and reminded (Tool-Box-Talk)

before every operation to pay particular attention to the safety precautions to achieve a safe

mooring operation and ensure proper communications at all times. Tool-Box-Talk should

identify the snap-back zones for the proposed mooring configuration and to ensure that all crew

members are aware of the danger and that experienced seafarers do not become complacent in

their work, putting themselves and others in a dangerous situation. (Within 3 months)

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Recommendations to the Nigerian Ports Authority (NPA):

1. Sufficient information to be provided to the ships Masters regarding drafts alongside berths and

tidal currents in the port of Lagos and other national ports. (Within 3 months)

2. Factual Information

2.1. Carme

M/V “CARME” berthed at ENL Terminal, Berth No 9, Apapa/Lagos/Nigeria

2.1.1 Ship Particulars

Name of ship: Carme

IMO number: 9697961

Call sign: 5BCK4

MMSI number: 212 300000

Flag State: Cyprus

Type of ship: Bulk Carrier

Gross tonnage: 23,433

Length overall: 179.90m

Breadth overall: 30m

Classification society: DNV-GL

Registered shipowner: Don Juan Shipping Ltd-Cyprus

Ship’s company: Navarone S.A. Greece

Year of build: 2014

Deadweight: 35,906

Hull material: Steel

Hull construction: Single Hull

Propulsion type: Diesel

Type of bunkers: Marine Diesel

Number of crew on ship’s certificate: 14

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2.1.2 Voyage Particulars Port of departure: Houston (TX)-USA

Port of call: Lagos Αpapa, Nigeria

Type of voyage: International

Cargo information: Corn in bulk (4,505 MT)

Manning: 18

Number of passengers: 0

2.1.3 Marine Casualty or Incident Information

Type of marine casualty/incident: Very Serious Marine Casualty

Date/Time: 23/09/2016 @ 01:50 Hours LT

Location: Port Lagos Apapa Berth 9

Position (Latitude/Longitude): Lat.: 06°27’ N - Long.:003° 23' E

External and Internal Environment: Sea State SW/3, Wind SSW/3, Ebb current

3-5 knots, Night, Clear weather, Visibility

good Ship operation and Voyage segment: Normal service – Emergency Unmooring

Human Factors: Yes / Human Error

Consequences: Death: 1

2.1.4. Shore authority involvement and emergency

response

After the incident, at about 01:45 Hours LT, first aid was provided by the C/O and the

Motorman. They tried to stop bleeding from head trauma. Master requested medical

assistance and evacuation to Hospital ashore, via the vessel’s Agent.

At 02:35 Hours LT, Pilot boarded and Tugs arrived.

At 03:22 Hours LT, the Bosun was transferred in unconscious condition from the vessel

to the Pilot-Boat. Then, he was transferred to the " Christ Medical Centre”, Lagos-

Apapa. The Master was informed that the Bosun passed away, by the ship’s

Management Company (MC).

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3. Narrative

3.1. Sequence of Events

1. On September 1, 2016 the Bulk Carrier “Carme” departed from Houston (TX)-USA, fully

loaded with 34,505 MT of corn in bulk, bound for Lagos-Nigeria.

2. On September 22, 2016 arrived at the port of destination, Lagos-Nigeria.

3. On September 22, 2016 at 09:50 hours, a Pilot boarded the vessel and with 2 tugs in

attendance proceeded towards ENL Terminal Berth No 9, Apapa/Lagos/Nigeria. The vessel

approached Berth No.9 at around 10:30 hours and the first line ashore was given at 10:35

hours.

4. At 11:15 hours, all fast by port side alongside at ENL terminal No 9, Apapa, by 4 Head Lines

+ 2 Spring Lines forward, and 2 Aft Lines + 1 Breast Line + 2 Spring Lines aft.

Master’s sketch:

Berth mooring lines arrangement at 11:50 hours 22 September, 2016.

5. About one hour after completion of mooring operation, it was noticed that the vessel was

out of position by 1-1.5m away from its berthing position. As the tide was ebbing the strain

on the 4 head/stern lines and 2 forward and 2 aft springs became excessive. The vessel’s

lines were straining at about 1.5m off the berth.

6. Deck Crew attempted to bring the vessel back to its mooring position using mooring

ropes/winches.

7. Deck Crew’s attempt to reposition the ship was unsuccessful. Vessel remained 1-1,5m away

from berth. Crew remained stand-by forward and aft.

8. At 13:30 hours, due to increasing current’s force (estimated at about 4 - 5 Knots), engine

crew commenced preparation of the Main Engine (ME) for emergency.

9. At 13:55 hours, the aft Spring Line parted off, and sequentially, all lines parted.

10. The ME was ready at 13:58 hours.

11. Vessel’s bow started turning to stbd.

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12. At 14:05 hours, all mooring lines parted.

13. ME started. Vessel proceeding away from its berth.

14. Vessel informed the Port Operation and requested Pilot and Tug assistance.

15. At 14:25 hours, two Tugs arrived and started pushing the vessel on its stbd side.

16. At 14:35 hours, Pilot boarded. Proceeding back to berth.

17. At 15:00 hours, third Tug arrived.

18. At 15:50 hours, vessel was made fast again, at the ENL Terminal No 9, port side alongside,

by 4 Head Lines + 2 Breast Lines + 2 Spring Lines forward and aft. At 15:55 hours, stbd

anchor’s chain one shackle, was lowered into the water.

19. At 15:57 hours, Pilot left.

Master’s sketch:

Re-enforced berth mooring lines arrangement at 15:55 hours 22nd September 2016.

20. Low Water was predicted at 16:39 hours. Therefore, the ebb tide eased, taking the strain

off the mooring lines. The additional breast lines and the stbd anchor dropped, kept the vessel

alongside. The next High Water was predicted to be at around 23:10 hrs.

21. At 21:30 hrs, commenced discharging operation.

22. The next day, September 23, 2016 at around 01:30 hours, the tide was ebbing and there were

signs that the mooring lines were under severe strain. Discharging operation interrupted.

23. At about 01:40 hrs, vessel’s lines started parting again due to strong current 4-5 knots,

coming from forward towards aft along the berth’s direction (ebbing tide). Vessel

commenced emergency unmooring. Master contacted Port Operation and requested Pilot

and Tug assistance.

24. During emergency unmooring, the forward mooring station was manned by the Chief

Officer (C/O), who was the Officer in Charge (OiC), the Bosun, the Motorman (Oiler) and

an Ordinary Seaman (OS).

25. At 01:50 hours, the C/O (who was standing at the forecastle deck port side - at the

embarkation station of the forward Life-Raft), watched the last line’s direction towards the

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berth’s bollard and noticed extreme tension. Next to the C/O was standing the Motorman,

who also noticed extreme tension of the line.

26. The C/O gave order to his team to leave the forward mooring station.

27. The Motorman climbed down from the embarkation platform first. The C/O followed. At

that moment, the last line broken off.

28. The C/O looked towards the main deck and saw the Motorman and the OS but not the Bosun.

29. The C/O asked “Where is the Bosun?” and started calling him loudly. The other crew

members did the same.

30. The C/O looked towards the stbd side of the forecastle and noticed a helmet on the deck

close to the stbd mooring winch.

31. The Bosun was struck on the head by the last parted line. He was lying on the forecastle

deck stbd side, unconscious. His head was bleeding.

Reconstruction of the accident site, showing location of crew

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Accident site, showing place of incident

Parted rope

32. The C/O informed via VHF radio, the Master on the Navigation Bridge that the Bosun was

injured.

33. The C/O and the Motorman provided First-Aid and tried to stop bleeding from the Bosun’s

head trauma.

34. Master requested medical assistance and evacuation to Hospital ashore, via the local vessel’s

Agent.

35. At 01:55 hours, vessel dropped stbd anchor and at 02:00 hours dropped port anchor.

36. The vessel drifted onto a shoal near the berth and stopped.

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37. At 02:35 hours, Pilot boarded and Tugs arrived.

38. The port and stbd anchors were lifted-up, at 03:00 and 03:05 hours respectively.

39. At 03:22 hrs, the Bosun was transferred from the vessel to the Pilot-Boat and then he was

transferred to the " Christ Medical Centre”, Lagos/Apapa.

40. Port Operation instructed vessel to proceed to Commodore Pool anchorage.

41. The vessel proceeded to Commodore Pool anchorage at the Harbour’s entrance, where

dropped anchor at 04:50 hours.

42. Pilot disembarked at 05:15 hours.

43. At 05:45 hours, crew completed sounding of all double bottom tanks (DBT). No water

ingress was observed.

44. The vessel remained at anchor awaiting instructions from Port Operation to re-berth.

45. On September 24, 2016 at 13:45 hours, Pilot on board. Tugs in assistance.

46. Vessel re-berthed at ENL Terminal Berth No.9 at around 19:00 hours.

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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 documents provided by the ship’s Management Company, the

Master’s report, and crew witness statements and VDR recordings downloaded from

htpps://drive.google.com/open?id=0BzPssxh9DsklcVpOdWc5VGdVaG8. Statements had been

confirmed by telephone interviews with the crew, after vessel’s sailing due to the fact that the

incident was notified late, 4 days after it happened, and there was no time and resources to carry out

an on-site investigation.

4.1. The Crew

Vessel’s crew consisted of 18, all Ukrainians.

During emergency unmooring the forward mooring station was manned by the C/O who was

the Officer in Charge (OiC), the Bosun, the Motorman and an Ordinary Seaman (OS).

The Bosun (Victim) The Bosun was Ukrainian. He was born at Kazakhstan on 16/04/1958. He was 58 years old.

His height was 1.62m and his weight was 76Kg. He was found fit for service at sea. The Master

reported that his general physical condition was good.

Certification

The Bosun was licensed, qualified in accordance with the requirements of the International

Convention on Standards of Training Certification and Watch keeping (STCW) Convention as

amended. His Certificate of Proficiency was issued by the Government of Ukraine on

22/12/2015 (STCW Reg. II/5/ Able Seafarer Deck & Boatswain-No:14184/2015/07).

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

Drugs and Alcohol

The Master reported that no any signs of intoxication or drug abuse were observed.

There was no evidence to suggest that drugs or alcohol was as a factor to the accident.

Fatigue

On the previous day of the accident according to the Hours of Work/Rest form, the Bosun

worked from 06:00 until 16:00. On the day of the accident, he started work on 00:30 until 01:50

when the accident happened. During the last 24 hours rested for 14 hours and during the last 7

days rested 101 hours. Therefore, fatigue was not considered a contributory factor, due to being

rested the last 24 hours prior to the accident more than 10 hours and during the last 7 days more

than 77 hours.

Fatigue was not considered as a factor to the accident.

Physiological, Psychological, Psychosocial Condition

The Bosun was holder of a Seafarer Medical Certificate for Service at Sea. His Medical

Certificate No 2582 was issued by the “Medical Centre ArchiMed T” in Odessa-Ukraine.

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It was valid from 16/05/2016 until 16/05/2017. He was certificated as fit for duty as Boatswain

worldwide for one year and for meeting the standards of STCW Code Section A-I/9 for hearing

(unaided hearing satisfactory), visual acuity and colour vision. He was not suffering from any

disease likely to be aggravated by service at sea or to render him unfit for such service.

There was no evidence to suggest that the Bosun’s 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

With respect to the cause of death, the medical certificate of cause of death issued by “Lagos

State University Teaching Hospital Ikeja”, writes that the Bosun died as a result of:

(a) Multible injuries

(b) Blunt force trauma.

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 (struck by mooring rope).

4.2 The Ship

The vessel “CARME” - IMO 9697961, is a Handy-Size Bulk Carrier, 5 holds /5 hatches, built

in 2014 and currently sailing under the flag of Cyprus. CARME has 180m length overall and

beam 30m. Her gross tonnage is 23,433 tons.

Classification Society: DNV-GL +100 A5, Bulk Carrier, BC-A, CSR, ESP, Holds No2,4 may

be empty, IW, BWM, HLP, DG, DBC, +MC, E1, AUT, CM-PS

P&I: North of England P & I Association

Main Engine: Diesel (1), Designed by: MAN-B&W-5S50ME-B8.2, 6400KW / 8582HP at

108RPM, Fix Propeller, Built by: Hudong Heavy Machinery Company Limited at Shanghai-

China

4 Electric Generators

2 Boilers

4 Cranes MacGREGOR, Type GLB3026-2/2426gr, SWL 30 MT

4.3 The Environment

Internal Environment:

According to the Master, the condition of the surrounding area i.e. the forecastle deck where

the Bosun and the other crew members were working, was clean and dry.

Pedestals, panama chocks, rollers, bollards, mooring winches, were in good condition.

External environment

Harbour type: River Natural.

The weather conditions when the incident occurred, were: Wind SSW / 3, Night, Clear sky,

Vis. good.

A tidal stream was ebbing to the vessel’s stem at 3-5 knots. There were no other vessels moored

at the berths forward of the vessel.

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The current, was entering between the vessel’s port side and the quay and due to the fact that

the vessel was grounded, caused a wedge effect increasing the pressure exerted on the mooring

ropes, resulting in their breaking.

Tidal Currents

Tidal currents occur in conjunction with the rise and fall of the tide. The vertical motion of the

tides near the shore causes the water to move horizontally, creating currents. When a tidal

current move toward the land and away from the sea, it “floods.” When it moves toward the sea

away from the land, it “ebbs.” These tidal currents that ebb and flood in opposite directions are

called “rectilinear” or “reversing” currents.

Rectilinear tidal currents, which typically are found in coastal rivers and estuaries, experience

a “slack water” period of no velocity as they move from the ebbing to flooding stage, and vice

versa. After a brief slack period, which can range from seconds to several minutes and generally

coincides with high or low tide, the current switches direction and increases in velocity.

As the tides rise and fall, they create flood and ebb currents.

Source: USA National Ocean Service Department of Commerce http://oceanservice.noaa.gov/education/tutorial_currents/02tidal1.html

http://oceanservice.noaa.gov/education/tutorial_currents/02tidal1.html

http://oceanservice.noaa.gov/education/tutorial_currents/media/supp_cur02a.html

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Trapped rainwater mixed with ebbing tide OUTFLOW

OUTFLOW

During the rainy season in Lagos the huge Lagoon is flooding water down to sea and it turns between

the berths 1 to 9. This mass of water is swelled during the rainy season and tries to funnel down

between Lagos Island and Apapa sweeping at maximum velocity against the wall of ENL Terminal

where the “CARME” was fasted.

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Vessel’s Draft vs Berth’s depth

The charterers guaranteed a draft of 11.5 metres.

According to the the Nigerian Ports Authority Notice of Depths which was issued on 2

March 2016 the draft alongside at ENL berth Terminal No.9, Apapa, was advised to be11.2

metres.

The vessel’s draft readings taken after mooring, on 22 September 2016, were 9.63 metres

forward, 10.20 aft amidships and 10.70 metres aft.

Berth 9 ENL

Extract from the Nigerian Ports Authority notice of depths issued on 2 March 2016

The Master raised a Letter of Protest on 29 September 2016, claiming unsafe berth and

quoting depths alongside as below:

Quote

On 29th September during the Low Water we took the soundings around the vessel

(00:10-01:00 hours) and the following soundings found:

FWD Port/Side 9,80mtrs - FWD Stbd/Side 13,50mtrs

MID Port/Side 9,40mtrs - MID Stbd/Side 14,00mtrs

AFT Port/Side 9,60mtrs - AFT Stbd/Side 13,60mtrs

As the vessel was again off the quay fenders about 1,00 meter we took also soundings

from the quay and we found:

FWD 9,50mtrs - MID 9,40mtrs - AFT 9,10mtrs

Unquote

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The soundings carried out on September 29, 2016 indicate that “CARME” was grounded on

her port side when she was berthed port side alongside, on 22 and 23 September 2016.

“CARME” was grounded on mud on the port side as the depth of water was much less than

the predicted depth.

Therefore, the 5 knots current caused a “Wedge Effect”. The current wedged under the vessel

during ebbing tide, as the port side was grounded and the stbd was in deeper water and

trimmed by the stern, with the bow facing the full force of the current flowing onto the

"CARME’s” flat-keel / box sectioned hull, causing it to lift and put pressure on the forward

mooring lines. Any vessel on the ENL terminal during the ebbing tide would be affected by

the ebbing current, but the box-profile of the “CARME’s” hull and her grounding, amplified

the problem.

The environmental conditions were a factor in the accident (Strong ebb current in

conjunction with inadequate under-keel clearance-Vessel was neither safely afloat nor

safely aground).

(Contributing factor)

4.4 Safety Management

The vessel’s Management Company has Quality and Safety Management System (Q&SMS)

which analyses risks. Mooring operations are recognised within the company’s Q&SMS as

operations that require a Risk Assessment. It contains Generic Risk Assessment regarding

mooring operations.

Risk Assessment

The Safety Management Manual (SMM) - F01 Mooring and Unmooring (Page 8) for the

hazard of crew injury during mooring operations, contains a Generic Risk Assessment which

provides for Control measures:

Quote

“When moorings are under strain all personnel in the vicinity remain in positions of safety, i.e.

avoiding all “snap-back” zones. Immediate action is taken to reduce the load should any part

of the system appear is under excessive strain. Care is needed so that ropes or wires will not

jam, when they come under strain so that if necessary they can quickly be slackened off. If there

is no time to slacken off the ropes, mooring team members in danger must go away from

mooring ropes which may brake or hit a mooring member due to a sudden strain/load”

Unquote

It was not reported by crew members involved (in their statements) that a Specific Pre-

Unmooring Risk Assessment was carried out. Also, no Tool-Box-Talk to the mooring teams

was held to identify the snap-back zones and to ensure that all crew members are aware of the

dangers, and no planning meetings held between bridge staff and mooring officers.

No Specific Risk Assessment and no Tool-Box-Talk was a factor in the accident.

(Contributing factor)

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Maintenance

Mooring Ropes

According to the “Monthly Inventory List” (see Annex) of the MC “Navarone S.A.”, dated

31/08/2016 there were 16 ropes on board. 8 of them forward and 8 aft. All, of 8-strand

polypropelene and polyester ropes, Diameter =65mm - Length=200m. Mooring lines had

been assessed by the ship’s crew on 31/08/2016 and were found to be in good condition. There

were additionally two new spare ropes, in order to be used when necessary, i.e. to replace a

torn rope or a parted one. A Test Certificate was issued by DNV-GL on 31/05/2016. The

mooring lines after been parted the first time, had been reused and then parted again.

Surrounding area

Surrounding area-forecastle deck, pedestals, panama chocks, rollers, bollards, mooring

winches were in good condition. The vessel’s mooring equipment was of appropriate

standard for operations being undertaken and housekeeping standards maintained.

A lack of maintenance was not considered as a contributory factor to the accident.

Personnel required for mooring operation

Four (4) crew were forward for the mooring operation. The C/O as OiC/Supervisor, the

Bosun, the Motorman and an OS. This number is considered sufficient for the vessel’s size.

All required personal protective equipment (PPE) worn at the time of the accident.

A lack of manpower was not considered as a contributory factor to the accident.

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5. Conclusions

On September 1, 2016 the Bulk Carrier “Carme” departed from Houston (TX)-USA, fully loaded

with cargo of corn, bound for Lagos-Nigeria. On September 22, 2016 arrived at the port of Lagos.

At 11:15 hours, berthing by port side, alongside berth “Apapa-No 9”, by 4 Head Lines + 2 Spring

Lines forward, and 2 Aft Lines + 1 Breast Line + 2 Spring Lines aft (1st mooring plan).

About one hour after completion of mooring operation:

On commencement of ebbing tide, it was realised that the vessel was out of position by 1-1.5m away

from its berthing position. Deck Crew attempted to bring the vessel back to its mooring position

using mooring ropes/winches. Deck Crew’s attempt to close the ship towards berth, was

unsuccessful. Vessel remained 1-1,5m away from the berth.

About one hour after Deck Crew’s attempt to bring the vessel back to its mooring position:

At 13:30 hours, due to increasing current’s force (ebbing tide), engine crew commenced preparation

of the ME for emergency. At 13:55 hours, a Head Line parted off, and successively, Head Lines and

Spring Lines forward parted. Vessel’s bow started turning to stbd. At 14:05 LT, all mooring lines

parted. ME started. Vessel proceeded away from its berth. Vessel informed the Port Operation and

requested Pilot and Tug assistance. With assistance of three Tugs, and a Pilot, at 15:50 hours, the

vessel was made fast again, at the berth “Apapa-No 9” by port side alongside, by a reinforced

mooring plan consisting of 4 Long Lines + 2 Breast Lines + 2 Spring Lines forward and aft. In

addition, the stbd anchor was lowered by one shackle into the water (2nd mooring plan).

Twelve hours later the ships mooring lines parted for second time:

The next day, early morning of September 23, 2016 at about 01:40 hours, the vessel’s mooring lines

started parting again due to strong current 3-5 knots, coming from forward towards aft, along the

berth’s direction. Vessel commenced emergency unmooring. Master contacted Port Operation and

requested Pilot and Tug assistance.

The vessel had been grounded from the beginning: The charterers guaranteed a draft of 11.5 metres.

According to the “Nigerian Ports Authority Notice of Depths” (which was issued on 2 March 2016),

the draft alongside at ENL berth Terminal No.9, Apapa, was advised to be11.20 metres. The

vessel’s draft readings taken after mooring, on 22 September 2016, were 9.63 metres forward, 10.20

amidships and 10.70 metres aft. The soundings carried out on 29 September 2016, indicated that

the vessel was grounded on the port side when she was berthed port side alongside, on 22 and 23

September 2016, either side of Low Water.

The strong ebbing current was directed from forward to aft directly, as there were no other vessels

moored at the berths forward of the vessel, caused a wedge effect. As the port side was grounded

and the stbd side was in deeper water with the bow facing the full force of the current flowing under

the "CARME’s” flat-keel / box sectioned hull, causing it to lift and put pressure on the forward

mooring lines.

The strong ebbing current under the flat bottom in conjunction with the vessel’s grounding, its

listing to stbd and trim by the stern, was pushing up the stem causing extreme tension of the

forward mooring lines, resulting in their breaking. (Contributing factor)

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Insufficient information given to the Master regarding drafts alongside berth and tidal ebbing effect,

caused the vessel’s grounding and subsequently caused a wedge effect, increasing the pressure to

the mooring ropes resulting to their parting.

(The mooring plan for both times, on the 22nd and 23rd was according to the local Pilot’s advice).

Insufficient information given to the Master as regards drafts alongside berth and tidal ebbing

effect, was a contributing factor to the accident. (Contributing factor)

“CARME’s” forward mooring party during emergency unmooring: comprised a C/O, who was the

OiC, the Bosun, the Motorman and an OS. The conditions of the surrounding area, were clean and

dry. All required personal protective equipment (PPE) worn at the time of the accident.

The general physical condition of the Bosun was good, and there were no indications of fatigue,

intoxication or drug abuse.

At 01:50 hrs LT, the C/O (who was standing at the forecastle deck port side - at the embarkation

station of the forward life-raft, when the last mooring line parted, watched for the line’s direction

towards the berth bollard. Next to the C/O was standing the Motorman. Both of them noticed

extreme tension of the line. The C/O ordered his team to leave the forward mooring station.

The Motorman climbed down from the embarkation platform first. The C/O followed. At that

moment the last line broken off. The C/O looked towards the main deck and saw the Motorman and

the OS but not the Bosun.

The Bosun was struck on the head by the last parted line. He was lying on the forecastle deck stbd

side next to the windlass drum, unconscious. His head was bleeding. His helmet was on the deck

close to the stbd mooring winch.

The Bosun of the forward mooring party was injured because he was standing in the snap-back zone

of the line he was handling when it parted. The area where he was standing was designated as a

snap-back zone. Qualified seafarers are aware of the fact that snapback zones exist when a mooring

line is under tension. The Bosun did not comply with the Company’s guide on safe mooring

operations and Generic Risk Assessment to be away from the Snap-Back-Zone. Also, he did not

leave the accident scene on time despite the C/O’s instructions since there was no time to slacken

off the ropes. The Bosun may had become complacent in his work; putting himself in a dangerous

situation.

Failure on the part of the Bosun to recognise the danger of coming within snap-back zones of

taut mooring lines was a factor in the accident. (Contributing factor)

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Conclusively

Direct Cause:

1. The Bosun died as a result of (a) Multiple injuries (b) Blunt force trauma.

2. With respect to the manner of death, it was caused by struck by mooring rope.

Contributing Causes:

1. The environmental conditions were a factor in the accident (Strong ebb current in conjunction

with inadequate under-keel clearance-Vessel was neither safely afloat nor safely aground).

2. No Specific Risk Assessment and no Tool-Box-Talk was a factor in the accident.

3. The strong ebbing current under the flat bottom in conjunction with the vessel’s grounding, its

listing to stbd and trim by the stern, was pushing up the stem causing extreme tension of the

forward mooring lines, resulting in their breaking.

4. Insufficient information given to the Master as regards drafts alongside berth and tidal ebbing

effect, was a contributing factor to the accident.

5. Failure on the part of the Bosun to recognize the danger of coming within snap-back zones of

taut mooring lines was a factor in the accident.

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6. Recommendations

Recommendations to the Management Company:

1. Conduct a thorough risk assessment of mooring operations and a review of the mooring

procedures being followed onboard fleet vessels. (Within 3 months)

2. Specific Risk Assessment should be carried out whenever the conditions for which the

Generic Risk Assessment was done, differentiate. (Within 3 months)

3. Seafarers involved with mooring operations should be briefed and reminded (Tool-Box-

Talk) before every operation to pay particular attention to the safety precautions to

achieve a safe mooring operation and ensure proper communications at all times. Tool-

Box-Talk should identify the snap-back zones for the proposed mooring configuration

and to ensure that all crew members are aware of the danger and that experienced

seafarers do not become complacent in their work, putting themselves and others in a

dangerous situation. (Within 3 months)

Recommendations to the Nigerian Ports Authority (NPA)

1. Sufficient information to be provided to the ships Masters regarding drafts alongside

berths and tidal currents in the port of Lagos and other national ports.

republic of cyprus marine accident and incident ......was struck by a mooring line, which he was...

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