Report on Shipping Casualties (2014,2015 & 2016)

REPORT ON SHIPPING CASUALTIES 2014, 2015 & 2016 DIRECTORATE GENERAL OF SHIPPING, INDIAMkW- ekfyuh fo- 'kadj] Hkk-ç-ls- ukSogu egkfuns'kd ,oa lfpo] Hkkjr ljdkj- Dr. MALINI V. SHANKAR, I.A.S. Director General of Shipping & Secretary to the Govt. of India. FOREWORD Maritime world is transforming at an unprecedented pace. Whether it is the concept of ‘Maritime Autonomous Surface Ships’, opening of polar waters, implementation of MLC, stricter emission controls or lower freight rates for a while, etc., one fundamental principle that has consistently prevailed, through all changes and circumstances, is that shipping should remain safe, secure, energy efficient and environmentally sound. India is committed to the principle and strives for its implementation domestically and globally. As Indian mercantile marine surges ahead, the need for safety enhancement becomes more significant. Indian ships are increasing in numbers, types and in size, our ports, shipyards and waterways are getting busier and we are progressively increasing our contribution in world’s marine manpower pool. While this Directorate assures that the Indian maritime industry progresses at a fast pace, it also has the responsibility to ensure proper regulation. Various new measures have been initiated and existing ones strengthened. These measures range from strengthening of seafarers’ training and employment to measures relating to VTS, reception facilities and navigational safety in Indian ports. Appraisal of NOS-DCP, making the PSC & FSI regimes more rigorous, coordination with stakeholders to enhance navigational safety among fishermen, initiation of implementation of TSS on Indian coast, advancements in LRIT and DGComm center and engaging with relevant authority to ease satellite communication on Indian coast, etc. are other initiatives undertaken. Measures to expedite rehabilitation of and compensation to the affected have been further strengthened. Publication of the summary of casualties is also a step in the same direction. Casualties for the period 2014-16 have been analysed in order to enable the maritime fraternity to devise and adopt corrective and preventive measures. Case studies have been included for readers to identify lessons learnt and to adopt best practices that will promote safety at sea. A total of 39 accidental deaths and 56 accidental injuries in three years within the realm of Indian maritime administration is a reason enough to call for serious introspection and immediate action. A majority of these casualties could have been easily averted by application of basic competencies, proficiencies and/or seamanship. What is of further concern, is the observable inadequacy of ship and shore teams in handling contingencies and their aftermath in many a case. Another notable shortcoming is the discernible break in ‘on- board’ communication and mentorship. This loss in camaraderie and experience transfer has not only added to stress, especially among the young, but has also adversely affected the ‘on-board’ learning. The aforesaid calls for untiring perpetual efforts, as well as novel ideas from all stakeholders in international and Indian maritime domains. Accidents must be eliminated. While the Indian maritime administration remains committed to the cause, maritime industry has to place greater impetus behind safety, security and environment protection, imbibing them as their second nature. We shall remember that ‘safety doesn’t happen by accident’. Be safe. Jai Hind. (Dr. Malini. V. Shankar) ivferkHk dqekj] Hkk-jk-ls- vij ukSogu egkfuns'kd AMITABH KUMAR, I.R.S. Additional Director General of Shipping PREFACE India is ushering on path of an unprecedented growth in the field of Mercantile Marine. Employment of Indian seafarers has soared over the past four years. Movement of ships on the coast of India and through its waters has increased significantly. While this amelioration is laudable, challenges persist. One such challenge is the continued occurrence of casualties involving Indian seafarers, ships and/or facilities. While there is a reduction in their numbers, the condition is still far from satisfactory. A casualty, other than harming life, property and/or environment, can also severely dent the morale of an industry and society. The Indian maritime administration is committed to their cessation. In this direction each casualty, occurring within the realm of Indian administration is investigated exhaustively and trends analysed. Actions, underpinned by proportionate regulation where necessary, are then initiated to avert happening of such casualty in future. Analysis of casualties for the years 2014-16 has been included in this report Learning from the experiences of others is an invaluable quality. Various case studies have therefore also been included in this publication for the stake holders to learn from. Such case studies are also promulgated at regular intervals through the Directorate's website. I hope that lessons of hindsight shall be included into training, education and mentoring to improve risk intuition and aversion. This report also calls for an increased effort on part of Indian ships' and port facilities' owners and operators, some of which may incur costs. However there is an old adage, if you think safety is expensive, try having an accident! I commend the Directorate's team behind this publication and hope that this will contribute towards strengthening of safety culture in the Indian maritime industry. Jai Hind. (Amitabh Kumar) iidIrku ds- ih- t;kdqekj Hkkjr ljdkj ds ukSfVdy lykgdkj ¼dk;ZHkkjh½ Capt. K. P. JAYAKUMAR Nautical Adviser to the Govt. of India (I/c) PROLOGUE The Directorate General of Shipping has brought out the 'Report on Casualties for the period 2014- 16' and I commend the team for their efforts. The report will hopefully bring awareness on various issues related to casualties and contribute in improving industry's preparedness towards safety, security and environment protection. Every casualty, however trivial, poses a challenge. The Indian Maritime Administration while empathising with the ones affected is mandated to examine the casualty to ascertain its root cause, take necessary corrective measures and disseminate the information to all stakeholders to prevent its re-occurrence. This report is a compilation for the industry to learn from. Shipping is a vital component of the international logistics chain. It has always had to deal with challenges due to the sheer diversity of its operation, its operating environment, and hazards encountered. Hence, timely risk identification, assessment, control and mitigation is essential to prevent casualties. Technological changes are now transforming the traditional shipping industry and every change is generally accompanied by its own unique challenges. Despite the advancement in technology, accidents continue to occur with entry into enclosed spaces continuing to remain a major challenge. Similarly, incidents of collision, grounding, explosion, etc., continue to occur and will need to be addressed. India as a fast growing economy needs to play its role in the maritime sector and we remain committed to takes steps to ensure that shipping continues to be a safe, secure, environmentally friendly and efficient means of transportation for mankind. The Indian Maritime Administration reiterates its commitment to take all steps required for enhancing safety, security and environment protection. Be Safe. Jai Hind (Capt. K P Jayakumar) iiiDisclaimer These case studies are for the purpose of disseminating information for the benefit of the public and industry at large. The information is of a general, informational nature but does not constitute legal advice and should not be construed as such. The Directorate General of Shipping has made every effort to ensure the quality of the information available in this document however, before relying on this information, users should carefully evaluate its accuracy, currency, completeness and relevance for their purposes, and should obtain any appropriate professional/legal advice relevant to their particular circumstances. The cases cited herein are for explanation and illustration purposes only. This document is not a substitute for independent professional/ legal advice. The Directorate General of Shipping does not accept any liability for any injury, loss or damage incurred by use of or reliance on the information. The Directorate General of Shipping cannot guarantee and assumes any legal liability or responsibility for the accuracy, currency or completeness of the information. ivCONTENTS I EXECUTIVE SUMMARY …………………………………………………………….. 01 II BRIEF CASE STUDIES ……………………………………………………………. 04 i Death of a seaman due to asphyxiation/ toxicity on a bulk ……………………. 04 carrier. ii Accidental death of two crew members due to asphyxiation. ……………………. 06 iii Explosion in cargo space of a container vessel, resulting in ……………………. 09 death of a seaman. iv Accidental fall into water, while reading ship’s draft & ……………………. 11 subsequent death of 2nd officer. v Injury to deck cadet from a pressurized air hose, while ……………………. 13 working on deck. vi Head injury to seaman while working in engine room. ……………………. 14 vii Injury to finger while shifting ventilation fan on deck. ……………………. 15 viii Collision between vessel and fishing boat, leading to capsizing ……………………. 16 of the fishing boat and death of five fishermen and one more gone missing. ix Contact of vessel with jetty during berthing operations ……………………. 18 resulting in damages, both to the vessel and the jetty. x Passenger jumps overboard from vessel, at anchorage. ……………………. 20 xi Vessel suspected of touching ground, off berth. ……………………. 21 xii Casualty (Death) of a third party worker due to electrocution ……………………. 22 in an enclosed space. xiii Engine crew missing at sea. ……………………. 24 xiv Death of seaman due to medical condition and delay in ……………………. 25 administering proper medical treatment. xv Serious injury to leg of seaman in mooring related accident. ……………………. 27 xvi Damage due to contact with jetty. ……………………. 28 xvii Tug colliding with an oil platform. ……………………. 29 xviii Tug running aground due to heavy weather. ……………………. 31 xix Collision/ contact damage between vessels when approaching ……………………. 32 port. xx Seaman’s right hand’s thumb getting cut during mooring ……………………. 34 operations. xxi Collision of bulk carrier with another vessel at anchor, after ……………………. 36 dragging own anchor. xxii Collision between a bulk carrier and tugboat, resulting in ……………………. 39 damages to both. xxiii Amputation of both wrists of 3rd Engineer in an accident during ……………………. 41 scavenge space inspection. xxiv Death of a seaman due to fall from derrick post onto hatch ……………………. 43 cover. xxv Injury suffered by 2nd engineer while working on incinerator in ……………………. 45 engine room. vxxvi Crushing injury suffered by 4th Engineer while working on ……………………. 47 incinerator, on a LPG vessel. xxvii Severe injury to eye on being hit by manual hoisting handle of ……………………. 49 lifeboat. xxviii Collision between vessels due to miscommunication. ……………………. 51 xxix Head Injury due to falling from height on deck. ……………………. 52 xxx Seaman falling over board, leading to his death. ……………………. 53 xxxi Injury to finger on the left hand of a seaman while adjusting ……………………. 54 gangway. xxxii Loss of part of index finger, while clearing bilges, during hold ……………………. 55 washing xxxiii Injury due to fall. ……………………. 57 xxxiv Vessel running aground due to rough weather. ……………………. 58 xxxv Head Injury due to fall in cargo tank. ……………………. 59 xxxvi Passenger gone missing during the course of voyage. ……………………. 60 xxxvii Injury to left hand of 3rd engineer due to fall. ……………………. 61 xxxviii Damage to port life boat of a ship due to parting of falls. ……………………. 62 xxxix Fire on a diving support vessel. ……………………. 64 xl Collision between a crude oil tanker and general cargo vessel. ……………………. 65 xli Collision between two vessels, while one lay at anchorage. ……………………. 68 xlii Amputation of wrist of first assistant engineer while carrying ……………………. 70 out inspection of main engine’s scavenge space. xliii Injury to left leg of a deck cadet. ……………………. 71 xliv Contact damage between vessel and lock gate. ……………………. 73 xlv Sinking of MSV due to flooding. ……………………. 74 xlvi Fire on MSV leading to its sinking. ……………………. 75 xlvii Sinking of mechanized sailing cargo vessel. ……………………. 76 xlviii Sailing cargo vessel running aground due to cyclone. ……………………. 77 xlix Total loss of mechanized sailing vessel (MSV) due to steering ……………………. 78 failure. III STATISTICS i Summary of casualty events. ……………………. 81 ii Summary of marine accidents, as per severity ……………………. 84 iii Summary of marine accidents, as per type of vessels ……………………. 85 iv Summary of the consequences of various casualties ……………………. 87 v Summary of marine accidents comparing casualties involving ……………………. 89 Indian seafarers on Indian & Foreign flagged ships vi Summary of deaths and injuries due to casualties and of ……………………. 93 missing persons IV TREND ANALYSIS i Collision ……………………. 94 ii Grounding ……………………. 95 iii Contact damage ……………………. 95 iv Fire/Explosion ……………………. 96 v Missing persons ……………………. 97 vi Pollution incidents ……………………. 97 viii Injuries and accidental death ……………………. 98 viREPORT ON SHIPPING CASUALTIES, 2014-16 Executive Summary 1. Article 94 of the United Nation's Convention on Laws of the Sea (UNCLOS) places responsibility on the flag state to carry out inquiry into every marine casualty or incident of navigation on the high seas involving a ship flying its flag and causing loss of life or serious injury to nationals of another State or serious damage to ships or installations of another State or to the marine environment. Also under SOLAS regulation I/21, Load Lines Convention article 23 and MARPOL articles 8 and 12, each Administration undertakes to conduct an investigation into any casualty occurring to ships under its flag. 2. The Indian maritime administration conducts investigations and inquires into marine casualties in accordance with Part XII of the Indian Merchant Shipping Act, 1958 (as amended). 3. Other than investigating marine incidents happening on Indian vessels, the Indian Administration also participates in investigations involving Indian nationals on foreign ships as well as casualties which may not have direct involvement of any Indian seafarer but which happen in Indian waters. 4. Amongst other objectives, one of the primary aims of a marine casualty investigation is to gather information that could be used to prevent future accidents. An investigation may also assist in determining what changes in the present regulations and/or their implementation might be desired. 5. This report covers the incidents which were reported to Indian administration involving Indian vessels, Indian nationals on foreign vessels as well as other maritime casualties in Indian waters over the years 2014, 2015 & 2016. A brief overview is as follows: 1REPORT ON SHIPPING CASUALTIES, 2014-16 6. During the years 2014-16, while the number of Indian seafarers employed worldwide increased by a strong 38.6% the number of casualties reported in relation to them remained nearly the same, rather reduced. While this reduction in number of casualties vis-à-vis number of seafarers employed is a change in positive direction, the nature of casualties remained a cause of concern. As can be observed in the report, various casualties could have been averted by application of basic competencies, proficiencies, skills and/or seamanship which a seafarer is expected to acquire during various pre and post sea competency and modular trainings. Analysis of these casualties led the Directorate to have a closer look at maritime training in India. Strong reforms have been implemented leading to metamorphic amelioration in maritime training in India in past two years. However, improvisation is a continuous process. The existing trainings modules, both pre sea and post sea, are being reviewed with greater emphasis on safety enhancement and in light of contemporary technology and practices in use on board ships. Implementation of centralized exit exams for various modular trainings is being examined at the Directorate, which shall be a major step towards casualty avoidance. 7. Another negative trend which has emerged in the report is the increased involvement of young and inexperienced in causalities. While lack of experience may remain a shortcoming, the trend is also indicative of lack of proper supervision, guidance and above all mentorship from the seniors. Diminishing of mentorship, which has remained a core element of onboard training, is also indicative of break in onboard dialogue and this has also led to increase in psychological stress. Lack of situational awareness also emerged as a major contributing factor in various incidents. 8. No abatement in the number of deaths and missing persons also remains a matter of concern. While implementation of MLC 2006 has certainly improved the ambient working and living conditions on board ships, level of psychological stress remains high. Easing off satellite communication facilities on Indian coast may help seafarers on Indian coast to get relief through communication with their near ones and the Directorate is engaging with relevant authority for the same. 9. India is progressing in the field of mercantile marine. This has led to an increase in maritime traffic on the coast of India as well as in its waters, including ports, rivers and estuaries. 2REPORT ON SHIPPING CASUALTIES, 2014-16 Apart from facilitating such growth, the Directorate has ensured that progress should not go unregulated. Other than reining in substandard shipping through its PSC and FSI regimes, the Directorate has helped other stakeholders, primarily the ports and fisheries, in enhancement of safety standards. Audits under NSPC, conduct of workshops for ports and State maritime boards on VTMS/VTS, conduct of workshops on collision avoidance for fishermen and with States' fisheries departments, participation with IPA in drafting of Recruitment Rules for Pilots, realignment of 'safety fairway' off Mumbai etc. are some of the many steps. Still navigation related incidents have occurred in Indian waters and this calls for continuous, rather enhanced, vigil in this direction. The Directorate has initiated the process for establishment of Traffic Separation Scheme on the coast of India. Timely promulgation of Maritime Safety Information has been strengthened. 10. It has also been noticed that many incidents are not reported to the administration in time. The Directorate has an established DGCOMM center, functioning 24 x 7 to receive such reports and coordinate contingency measures. It is required that DGCOMM centre be informed about any incident at the earliest. Address : Nau Bhavan, DG Commcentre, Nau Bhavan, 3rd Floor, 10, R.K. Kamani Marg, Ballard Estate, Mumbai - 400038 Tel No. : 022-22614646 3REPORT ON SHIPPING CASUALTIES, 2014-16 II - BRIEF CASE STUDIES 2014 Casualty Summary 01 Death of a seaman due to asphyxiation/ toxicity on a bulk carrier 1. What happened? A gearless bulk carrier was discharging coal cargo at an Indian port, when an ordinary seaman (OS) was asked to collect cargo sample from one of the cargo holds. While doing so, the OS, a foreign national, succumbed to the effect of toxic gases that were present in the cargo space, leading to his death. 2. How it happened? A foreign flagged bulk carrier with foreign crew was discharging coal cargo at an Indian port. As per the master many persons boarded the vessel at multiple times, all claiming to be cargo surveyors, and asked the vessel to provide cargo samples. Against one such request, the duty officer instructed an on duty ordinary seaman (OS) to collect cargo sample from one of the cargo An Australian ladder on a bulk carrier, holds. He instructed the OS to take help from however, without the enclosing trunk. another seaman, whoever was working nearby, (Image for illustration purpose only) however did not explicitly identify that seaman Australian ladder on this particular vessel was for him. The OS also somehow decided to do a spiraling type. A steel trunk arrangement was the job alone. This could have been due to the enclosing the ladder. The trunk was fitted to fact that drawing of cargo samples had become provide protection to persons, using the ladder, a sort of routine activity at that port as from falling as well as to protect the ladder multiple persons, all claiming to be cargo against damages from grabs, bulldozers and surveyors, had been asking for the same at other equipment while loading and unloading frequent intervals. of cargo in the hold would be in progress. The duty officer also therefore, neither carried out any risk assessment nor did he fill any The trunk was fully enclosed with just two enclosed space entry permit for the job. openings, one at the entry point at top of the cargo hold and other near the bottom end of The OS decided to climb down into the cargo the vertical ladder. The bottom opening was hold using the Australian ladder. just 2-3 meters above the cargo hold bottom. 4REPORT ON SHIPPING CASUALTIES, 2014-16 There were no other means or openings (iii) Due attention was not paid to the hazards available for ventilation of the trunk space. At associated with the cargo. Coal is known to emit methane, hydrogen sulphide and carbon the time of incident, the cargo hold was 70- monoxide gases but the dangers were not 80% full of coal cargo and therefore the bottom understood by or communicated to the crew. opening got covered with coal. This caused the Probably unaware of the dangers, the OS bottom opening to get blocked shut. Since the entered the space without ensuring that cargo was coal, the trunk space got filled with appropriate precautions were in place. toxic gases. Although gas sampling record was (iv) Ship-shore interface was not effective. No being maintained for the cargo hold, it did not procedures had been established to deal with include the Australian ladder’s trunk space. shore people who boarded the vessel, claiming While climbing down into the hold, the OS was to be cargo surveyors, and asked ship’s crew to provide cargo samples at random. overcome by the toxic gases present in the trunk space and became unconscious. Duty (v) There was a deficiency in the design of officer got suspicious when OS did not return the Australian ladder as no ventilation had with samples for prolonged time and also did been provided in the Australian ladder’s trunk space, other than the openings at top and at not respond to radio calls. Emergency alarm bottom. was raised on board and search party later spotted OS lying unconscious in trunk way. 4. Lessons learnt: He was evacuated from the cargo hold, given (i) ISM procedures, in particular the ‘permit first aid on board and rushed to local hospital to work’ system, must be effectively where he was declared brought dead. implemented and followed by motivation and commitment. 3. Why it happened? (ii) Spaces on board the vessel, which may 3.1 Most proximate cause: fall into the category of ‘Enclosed space’ should Asphyxiation and /or intoxication, due to be identified, recorded and informed to all. This the properties of bulk coal cargo. list must be reviewed and updated regularly. (iii) Independent and exclusive mechanical 3.2 Contributory factors: ventilation, with local operating switch, may (i) There was a total failure of permit to work be considered for the confined Australian system. Enclosed space entry procedures were ladders and booby hatch entrances for ships not followed. Though company’s Safety carrying cargoes which are susceptible to emit Management System had procedure for gases. ‘enclosed space entry’, it was not followed since (iv) Regular training in regards to hazards of the duty officer never expected the ordinary confined spaces must be carried out in addition seaman will enter the Australian ladder space. to the bimonthly ‘Enclosed Space Entry and Besides, as samples were being drawn Rescue Drill’ as required by SOLAS. frequently at the port due to requests from (v) All vessels must carry suitable equipment multiple personnel claiming to be cargo to measure atmosphere in the enclosed spaces, surveyors, the hazardous operation had started prior entry. Such equipment must be being considered ordinary and therefore permit maintained in order. was not drawn. (v) Ship’s staff, in particular the support level staff and trainees, should be trained in (ii) Lack of experience and improper job identifying the hazards stated in Material assignment -The ordinary seaman who died in Safety Data Sheets (MSDS) and Shipper’s the unfortunate incident was earlier working declaration for any particular cargo and the in galley and had been transferred to the deck associated precautionary actions. The MSDS department just two months prior to the should be discussed amongst crew during pre accident. arrival cargo operations meeting. 5REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 02 Accidental death of two crew members due to asphyxiation. 1. What happened? Death of master and electrician in an enclosed space due to asphyxiation. 2. How it happened? A bulk carrier had been undergoing survey throughout the day. Late evening, nearing end of the day, only one survey item had remained pending. This was demonstration of the alarm system, fitted on board to warn the vessel’s Entrance from main deck to stool space staff about any undesired ingress of water into the cargo holds. Such demonstration would (Image for illustration purpose only) require ship’s staff to climb down into the lower stool space of the cargo hold, whosever’s alarm was being tested, and to manually activate the alarm’s sensor fitted therein. Way down to a lower stool space (Image for illustration purpose only) (Image for illustration purpose only) In this regards, an attempt had been made Testing sensor for water ingress alarm previously during the day also, at around 03:00 (Image for illustration purpose only) p.m., to enter stool space of one of the cargo holds.However, the same had to be abandoned Ventilation of the stool space had been as while entering the stool space, personal gas continued ever since, still it was taking detector had sounded warning, indicating low considerable time for O2concentratio level to level of oxygen (O2). improve. 6REPORT ON SHIPPING CASUALTIES, 2014-16 At 09:00 p.m., as only functional test of cargo Master &chief officer rushed to the site with hold water ingress alarm was remaining other crew members. Without taking any pending, the master decided to go ahead with precautions or protective gear, the master the enclosed space entry despite the O reading immediately went down into the lower stool 2 still being only 19.9%. space to rescue the electrician. One AB also followed him, however he was donning a ‘Self Accordingly 2nd officer, along with 2 ABs (Able Contained Breathing Apparatus’ (SCBA) for his seaman), organized man entry into lower stool own safety. The A/B carried with him an space of one of the cargo holds. Gas readings ‘Emergency Escape breathing Device’ (EEBD) of atmosphere in the space were taken by multi also and requested master to don it. But master gas detector. To worsen the situation, the tube remained busy trying to revive the electrician which was lowered into the stool space to draw and ignored his request. He, rather, used the gas sample into the ‘portable gas detecting EEBD to revive the electrician, but did not equipment’ was not long enough to reach till succeed. After some time the master also the bottom of the stool space. Gas succumbed to asphyxia and collapsed besides concentrations were recorded as O =19.9 %, 2 the electrician. H S =0.0, CO=O.O in the enclosed space entry 2 check list. This checklist was further signed The stool space was narrow. The crew first tried by master and chief officer of the vessel. 2nd to take out the unconscious bodies of master officer and 2 ABs stood by on the deck, near and electrician from the space by cutting a hole entry point of the ladder which descended into into the space from cargo hold side but did not the lower stool space, while chief officer succeed. Later, both bodies were lifted out stationed himself on bridge. He remained in through the manhole using ropes. Electrician’s constant communication with 2ndofficer head was found bleeding on the rear and he through walkie talkie. Electrical engineer and was immediately sent to hospital by port electrician entered into the stool space around arranged ambulance. Master was later on taken 09:30 p.m with electrician entering first to hospital by the port vehicle. On arrival at electrical engineer was carrying a personal 0 2 the hospital, both were declared ‘brought in meter with himself, however no personal meter dead condition’. was available with electrician. 3. Why it happened? While both were climbing down the ladder, personal 0 meter with electrical engineer 2 3.1 Most proximate cause: triggered alarm indicating deficiency of oxygen. Soon, the electrical engineer started feeling Probable cause of both the casualties is suffocated also. The electrical engineer stopped asphyxia and/or toxicity. This depletion of descending. However electrician, who was oxygen could also have been due to leakage of lower on the ladder than him, continued to CO /CO gas from the adjacent cargo holds. 2 climb down into the enclosed space. By the time electrical engineer could warn electrician, 3.2 Contributory factors: he observed that electrician, who by this time had reached the last step of the ladder, (i) ‘Permit to work’ system was not effectively suddenly collapsing and falling down. The implemented and appears to have been a mere electrical engineer immediately climbed back paper exercise. Although checklist had been out of the space. Gasping for breath, he used it was not followed in spirit. Master had reported the incident to 2nd officer. 2nd officer decided to go ahead with the enclosed space immediately notified the bridge, chief officer entry despite the O reading still being only 2 and master. 19.9%. 7REPORT ON SHIPPING CASUALTIES, 2014-16 (ii) Equipment used for gas measurement 4. Lessons Learnt: were inadequate. The tube, through which the gas sample was drawn from the stool space (i) Gas testing and other contingency into the ‘portable gas detecting equipment’ was equipment should be ship specific. Their not long enough to reach till the bottom of the suitability should be verified for each particular stool space. O content of the lower stool space ship. Hoses and tubes, which are used for 2 had in fact therefore not been verified at all drawing samples should be long enough to prior to entry. This proved fatal as CO or CO 2 reach the lowest and farthest part of any being heavier may have settled in the lower enclosed space in a single length, without any part displacing oxygen from there. joints. (iii) The stool space, that was entered, was very (ii) Regular training of ship’s staff (bimonthly narrow and possessed a zigzag passage. The in accordance to SOLAS) should be carried out possibility of pockets of toxic gases getting trapped is always present in such in ‘Enclosed Space Entry and Rescue Drill’. constructions, which in this case may have Such drills should be made realistic, without gone unchecked. endangering the ship’s staff and should cover all enclosed spaces, in turns. Efficacy and (iv) Inadequate emergency preparedness. sufficiency of equipment shall be verified during (v) Master’s illogical and rash thinking and such drills. non observance of contingency procedures. The 2nd casualty i.e. of the master himself, could (iii) Filling of an ‘enclosed space entry check have been totally avoided, if the master would list’ should be followed in spirit. Doubts or not have entered in that space under emotional ambiguity, if any, must be clarified by top impulse and had taken precautionary management. Help may be sought from shore measures. based authority. (vi) Fatigue might have set in as the staff was (iv) More awareness of ship’s construction involved in survey since morning. Also haste especially when ventilation and air exchange to complete the job could have clouded the is restricted. situational awareness and rational thinking of the staff. 8REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 03 Explosion in cargo space of a container vessel, resulting in death of a seaman 1. What happened? After about 03 hours, i.e. at around 01:30 p.m., it was observed that smoke from cargo hold A crew member on a foreign flagged container No. 2 had increased. Additional C0 bottles vessel suffered fatal injuries due to fire and 2 were connected to CO line for cargo hold No. explosion in one of the cargo holds, while the 2 2 and C0 was again released into the hold. vessel was at sea. 2 After some time temperatures at various points 2. How it happened? of cargo hold No. 2 were again checked and this time the port and starboard side tunnels A foreign flagged container vessel was en-route measured 40oC. Also the smoke emanating from an Indian port to Colombo. A few hours from the cargo hold was observed to be after its departure from the Indian port i.e. at significantly reduced. At this time, temperature around 10:30 am, an explosion was heard from of hatch cover at bay 10 showed 28oC. cargo hold No. 2 and heavy smoke started emanating from the hold. Late in the afternoon, it was decided that boundary cooling of holds nos. 1, 2 and 3 would Vessel initiated emergency response and be continued throughout the night and also commenced fire fighting procedures. All sprinkler system for cargo hold No. 2 to be kept ventilations flaps and dampers were shut open. Monitoring of temperatures of cargo hold except one vent flap on port side & two flaps No. 2 was also planned to be carried out over on crossway. The same had become night and deck and engine watches were set inaccessible due to heavy smoke. They were shut later by fire fighters donning SCBA. accordingly. Temperature in the port and starboard tunnel spaces of cargo hold No. 2, As one of the measures to extinguish fire, C0 was measured to be 32.5o C at this time, 2 was released in No.1 & No. 2 cargo holds, thereby showing a reduction. consuming all the quantity of C0 that had been 2 provided on board that ship for those two In the evening, around 06:00 p.m., another specific holds. heavy explosion was heard from cargo hold No. 2 which blew apart, hatch cover of 2AP. When Basis various parameters observed, by noon the smoke subsided, also body of a crew time it was assumed that fire in the cargo hold member, an ordinary seaman (OS), was found had subsided. However boundary cooling and hanging on ship’s port side railing. The OS was monitoring of temperatures of areas in and unconscious, with no pulse or breathing and around the two cargo holds were continued. was bleeding through his ears. Vessel, thereafter resumed her voyage and returned to its designated course, from which Efforts were made to revive the OS, including it had altered to minimize wind flow to the seat seeking of ‘radio medical advice’, however of fire. It also started to increase its speed. It without any success. At 08:00 p.m. the OS was was noted that holds’ temperatures were on declared dead by ship’s Master. The vessel was decline. Temperatures in the port and diverted to and anchored at the nearest port. starboard side tunnels of cargo hold No. 2 were There next day morning, it was boarded by a observed to be as 50oC. Small amount of smoke doctor who confirmed death of the OS. was still emanating from hold No.2. 9REPORT ON SHIPPING CASUALTIES, 2014-16 Meanwhile the crew continued fire fighting in (ii) In the absence of proper identification of order to keep the cargo hold and ship’s hull the cargo, requirements with respect to cool. While there were no reports of any damage stowage, segregation and carriage may not have to the environment, the vessel’s water tight been implemented properly. integrity was questionable due to unsecured hatch cover. 3.2 Contributory factors : Experts in salvage and fire fighting were (i) As cargo may have been incorrectly engaged the next day who carried out identified the vessel could not initiate correct containment of heat source in the under deck emergency procedures. cargo. 4. Lessons learnt: 3. Why it happened? The shipping companies/shipper should 3.1 Most proximate cause: ensure that the details of cargo are made available to the Master so that the appropriate (i) Most likely cause of the accident was the stowage can be determined to ensure that such cargo of CALCIUM HYPOCHLORITE or a similar containers are quickly accessed and hazards chemical, stowed in containers, inside hold associated with the cargo, are effectively dealt no.2, which had been incorrectly declared as AQUA CLEANING AGENTS. with in good time. 10REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 04 Accidental fall into water, while reading ship’s draft & subsequent death of 2nd officer 1. What happened? and taken to port facility’s hospital. At the port facility’s hospital, all attempts to revive 2ndOfficer fell overboard, reportedly while 2ndofficer proved futile. He was then shifted to reading ship’s draft, and subsequently died the nearest government hospital, where he was due to drowning. declared ‘brought dead’ on arrival. 2. How it happened? 3. Why it happened? The deceased 2nd Officer had joined the vessel 3.1 Most proximate cause just two hours prior to the fatality. The vessel was starboard side alongside at an Indian port There was evident failure of permit to work and was in the process of discharging coal system. Procedures for ‘working aloft or cargo. Routine familiarization for the in-coming overside’ were not adhered to. Instead of officer had been carried out on the bridge by following established safe procedures and using 3rdOfficer and Master. After the familiarization, proper protective equipment, the 2nd officer may 2ndOfficer went on to deck and was seen taking have tried to cut corners by holding on to the starboard side draft from the jetty. He safely ship’s side rails and lean over the side to read came back on board at around 11:45 a.m. the mid-ship draft and accidently fell Thereafter he was seen crossing over to the overboard. The vessel had high free board at port side, presumably for taking port side draft. that time. He had also not informed anybody nor did he keep a person standby with him. At around 12:00 noon, chief officer, who was on the portside bridge wing, noticed some movement in the sea. Soon he realized it to be a person in water. He directed crew members, who were present on deck, to release life buoys on port side and accordingly two lifebuoys were immediately thrown into the sea. The person, later identified to be the deceased 2nd officer, surfaced from underneath the water. He was called repeatedly, however did not invoke any response and the body was noticed floating motionless. Rescue boat could not be lowered as it was fitted on the starboard side of the vessel, the side on which the vessel was tied up with the jetty. However, lifeboat on the seaward side i.e. port side was somehow also not lowered. Meanwhile the local ship’s agent who was present on board was requested by the master to call for boat and an ambulance. Shore boat arrived at the scene within 8 minutes of request. 2nd officer’s body was lifted from water (Image for illustration purpose only) 11REPORT ON SHIPPING CASUALTIES, 2014-16 3.2 Contributory factors draft(s). Checklist for working over side must be used and all precautions specified therein (i) Starboard lifeboat not lowered to retrieve must be strictly adhered to, including proper 2nd officer from water. This could have saved supervision. critical time that was wasted in waiting for shore boat. (ii) Drills for ‘rescuing persons from water’ should include scenarios of rescuing persons (ii) Since 2nd officer had joined just 2 hours from water while the vessel is alongside and prior it is possible that he may have been when the rescue boat is rendered non- overcome by fatigue due to lack of sleep or launchable due to it being fitted on the time difference due to travel. landward side. 4. Lessons learnt: (iii) Consideration must be given to fatigue level of a new joiner before assigning job or (i) It is imperative to comply with safe transferring responsibility. working practices while working out board or near ship’s side, including when reading ship’s 12REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 05 Injury to deck cadet from a pressurized air hose, while working on deck 01. What happened? 3.2 Contributory factors Deck cadet (apprentice) on board a general (i) Safe working practices not followed while cargo vessel received severe injury to his right working with high pressure pneumatic eye, while air hosing the deck. equipment. (ii) Lack of training and experience. 02. How it happened? (iii) Failure to wear personal protective Deck cadet had been assigned the job of equipment, especially face shield for the cleaning the deck after it had been de-rusted. protection of face and eyes. He was using a pressurized air hose for the same. On completion of the job, cadet just left (iv) Lack of supervision by senior officer(s) on the hose loose and unattended without board. shutting off the air or decoupling the nozzle. The unattended pressurized air hose re- 04. Lessons learnt: bounced and hit him, resulting in severe injury (i) Use of compressed air to clean work place to his right eye. should be discouraged. Cadet was immediately administered first aid (ii) The competence, training level and on board and sent to a hospital ashore for experience of ship’s staff must be taken into further treatment. account prior assignment of any particular task. 3. Why it happened? (iii) Always use proper ‘personal protective 3.1 Most proximate causes equipment’ (PPE) suitable for the work being undertaken. Deck cadet had left the pressurised air hose, unattended, which re-bounced and hit him (iv) Proper supervision is essential to reduce/ under the eye. eliminate accidents. 13REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 06 Head injury to seaman while working in engine room 1. What happened? stays were tied to the piston to control its swinging when the same would be drawn and Third engineer suffered head injury, while would be hanging suspended on the crane. participating in breakdown repairs in engine After securing such ropes, the piston was lifted room of a Liquefied Petroleum Gas (LPG) off the supporting device. carrier. However during one roll of the vessel, the rope 2. How it happened? stays failed to restrain movement of the hanging piston adequately and it went on to Main engine of a foreign flagged LPG carrier hit one of the supports. A plate, which was had to be stopped at sea due to high exhaust supporting the stuffing box, slipped off and fell temperatures. Inspections revealed a broken down on the pipe below it. While falling further bolt on piston crown of one of the engine units. down the plate got deflected towards the The same had to be renewed and this required staircase and landed on the helmet of 3rd stoppage of engine and elaborate work engineer, inflicting injury to his forehead and including extraction of the affected piston. nose. 3rd engineer was taken to the engine control room (ECR) and administered first aid. He was then shifted to hospital wherein he was kept under constant supervision for the next few hours till the bleeding had completely stopped. Skin closure sutures were applied to close the deep cuts on his forehead and nose. Main engine repairs were completed during morning hours of the next day. Vessel was then diverted to a nearby port where the 3rd engineer was transferred to local hospital for further treatment. Piston hanging from crane 3. Why it happened? (Image for illustration purpose only) 3.1 Most proximate cause: (i) Lack of attention and situational Breakdown of main engine had taken place awareness by the 3rd engineer. after the normal working hours. Meeting of engine staff was held and scope of work and (ii) Inadequate securing of the piston as its the risks involved were discussed. movement was not sufficiently restrained. Work commenced at about 07:30 p.m. It was 3.2 Contributory factors? ensured that all had some rest period before commencement of work. It was also planned (i) Vessel rolling, during lifting of piston. to carry out the work in shifts as it was (ii) Conditions which forced the job to be expected to consume extended time. carried out in open sea. As the vessel was in open sea, susceptible to (ii) Lack of supervision by senior officers. rolling and pitching due to waves’ action, rope 14REPORT ON SHIPPING CASUALTIES, 2014-16 Loose objects, including those which had been 3rd engineer could have been alerted of opened/ dismantled during the course of work, approaching danger, by an attentive not secured sufficiently supervisor. 4. Lessons learnt: (iii) Properly rigged and controlled guiding ropes may avoid / minimize the accidents when (i) Detailed ‘risk assessment’ shall be carried lifting heavy weights. out prior undertaking such tasks, including for hazards that may be posed due to the vessel (iv) All loose objects to be properly secured. being in open waters. (v) Additional help from other departments (ii) Proper Supervision is essential to reduce/ need to be considered. In this case a deck hand, eliminate accidents. In this particular case, the such as an AB, would have been useful. Casualty Summary 07 Injury to finger, while shifting ventilation fan on deck 1. What happened? his right hand got caught with the blade of the ventilation fan and got lacerated. Bosun, on a vessel, suffered injury to the middle finger of his right hand while shifting 3. Why it happened? an electrical ventilation fan on deck. 3.1 Most proximate cause: 2. How it happened? The finger getting cut by the fast moving blade Ventilation of top side tanks (TSTs) was in of the heavy duty ventilation fan. progress on a foreign registered bulk carrier. Heavy duty electrical fans were being used for 3.2 Contributory factor the purpose. Not switching off power. Undue haste to close Deck crew had been instructed to shift the work for day. Bosun decided to carry out ventilation fans from top of one TST to another the work alone and did not even switch off the prior to closing work for the day. power. While bosun had full crew at his disposal, he 4. Lessons learnt: decided to shift the fan all alone and also did not switch off the power. The middle finger of Shortcuts should be avoided. 15REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 08 Collision between vessel and fishing boat, leading to capsizing of the fishing boat and death of five fishermen and one more going missing. 1. What happened? As per the Captain’s night orders, the N.O. gave wake-up call to C.O. at 05:00 a.m. and During its sea-trials, a vessel (Vessel 1) collided informed him about the merchant ships in the with a fishing boat resulting in loss of lives of vicinity. He however failed to inform C.O. about six fishermen and sinking of the fishing boat. the fishing vessel that had been sighted right Bodies of 5 fishermen were recovered. However, ahead. body of one fisherman could not be recovered. At about 05:05 a.m. the ‘port lookout’ reported 2. How it happened? to N.O. that the light was opening to red 20° A fishing boat was trying to locate fish in an with a distance of about 3-4 nautical miles. area outside the port. Its crew members had At this time the port lookout also reported their dinner and by 11:00 p.m. all crew went seeing the red light of the vessel but could not to sleep except 1st Tindal, who was steering the make out whether it was the all-round light or vessel. At approximately middle of the night, the side light. The port lookout reported the 1st Tindal handed over steering to 2nd Tindal, sighted light was drawing left and had moved but continued to check for fish till about 01:30 to red 30-40° with a distance of about half a.m. After this, he also went to sleep. At about nautical mile. The port lookout thereafter 04:30 a.m., 2nd Tindal also went to sleep after reported seeing the green light of the target stopping the vessel and switching on all deck vessel, which was also observed by the N.O. lights. No crew member was on watch after that The N.O. therefore concluded that the target time. vessel, which was the fishing boat, had altered course towards its port side as the red light Meanwhile, nearby on ‘Vessel 1’, the Navigating was diminishing and as only the while light Officer (N.O.) came on to the watch at 04:00 and green lights were now visible. a.m. The N.O. had been on the watch earlier also, when the vessel had sailed out of the port At this moment the fishing vessel started the previous night. He had been on the bridge flashing a light towards ‘Vessel 1’ and it started till about 09:30 p.m. He had, thereafter, again moving rapidly to cross ahead of ‘Vessel 1’ from gone to the bridge at around 10:00 p.m. and its port side to the starboard side. The N.O. was later called once more to the bridge, where therefore ordered the course of ‘Vessel 1’ to be he stayed between 01:50-02:45 a.m. the fateful altered to its starboard side, from the existing morning. The later call was due to a 335° to 350° in order to avoid the fishing boat. malfunction in the multi-function display On seeing that the boat was continuing to head (display of radar and ECDIS). towards the ship, N.O. ordered the wheel to be put to starboard 5° and immediately thereafter During the present watch, which he had taken to stardboard10°. over at 04:00 a.m., the N.O. was assisted on the bridge by ‘quarter master’, ‘side boy’, ‘port In spite of the avoiding action taken, the N.O. look out’ and ‘starboard lookout’. In addition, saw the fishing boat going into the shadow zone there was an aft lookout (life buoy sentry). of the forecastle of ‘Vessel 1’ on its port side. Soon a distinct jerk/vibration was felt on the At 04:00 a.m. there were no visible targets on ‘Vessel 1’. either side of the vessel. The N.O. picked up a target on the radar at a Collision between ‘Vessel 1’ and the fishing boat distance of approx. 6.0 nautical mile. This appears to have occurred at about 05:16 a.m. target was the fishing vessel. It also appears that the stem of the vessel 16REPORT ON SHIPPING CASUALTIES, 2014-16 collided with the starboard forecastle area of (iv) Ineffective look out on the fishing vessel the fishing boat. and inappropriate maneuver by the fishing boat who seems to have deliberately proceeded to 3. Why it happened? obstruct the passage of ‘Vessel 1’. 3.1 Most proximate cause: 3.2 Contributory factors: Fatigue: While most of the crew on fishing boat (i) In view of the foregoing, the collision were asleep the N.O. on ‘Vessel 1’ also seems probably occurred as the navigation officer to have been fatigued. This would have (N.O.) of ‘Vessel 1’ did not take early action adversely affected his reflexes and ability of and allowed the situation to develop into a close comprehend the situation. quarter situation despite picking up the fishing boat on radar at a distance of about 6 nautical 4. Lessons Learnt: miles. (i) COLREGs shall be duly complied with, (ii) Action taken by ‘Vessel 1’, to avoid including keeping a proper look out. Early and collision, was also insufficient and in effective. definitive action avoids dangerous situations The vessel which is highly maneuverable from developing. should have opted for a larger alteration of (ii) The on board management shall ensure course. that proper rest is accorded to all. (iii) ‘Vessel 1’ did not draw attention of the (iii) N.O. should have requested for more rest fishing boat by any sound and/or light signals. before coming on watch. 17REPORT ON SHIPPING CASUALTIES, 2014 – 16 _____________________________________________________________________________________________________________________________________________________________________________________________________________ Casualty Summary 09 Contact of vessel with jetty during berthing operations resulting in damage, both to the vessel and the jetty 1. What happened? wherein the pilot specifically asked if there were any problems with the ship’s engines. An Indian container vessel made contact with This was because of the reason that the port, jetty during berthing at an Indian port, in the past, had experienced problems related resulting in damages to both the vessel and to ship’s maneuvering with sister ships of the jetty. the container vessel. Rather, it was because of these problems that certain conditions 2. How it happened? and limitations had been imposed by the The container vessel arrived at ‘pilot boarding port on movement of those sister vessels station’ of the port at around 03:30 a.m.. It when within its port limits. had been allotted a particular berth at the container terminal of the port. Main engine The master assured the pilot that there had been tried out satisfactorily, for ‘ahead' were no problems on that particular and ‘astern’ movements, prior to vessel’s vessel. He however, also informed the pilot arrival at the pilot station. that astern movement should only be given at speed below 4 knots. This container vessel Vessel was not having anchor on its port side also, in past, had instances of failure of as the same had got lost in an earlier incident. main engines to kick start in astern direction. The port authority had been duly informed regarding absence of this anchor. Also, the After embarking its pilot, the container vessel port authority had been requested to berth the commenced its approach through the channel. vessel starboard side alongside so that The engine had been kept on ‘slow ahead’ so replacement anchor could be connected to as to allow sufficient distance between itself vessel’s port side. Due to this request of the and the feeder vessel,which was proceeding vessel, a cut off time of 04:00 a.m. had been ahead of it. This distance was being given for embarking the pilot so as to enable maintained in order to ensure that tugs the vessel to berth with the flood tide. should become available for berthing of the container vessel after berthing the feeder Another coastal feeder container vessel was vessel. VTMS was also keeping the pilot also expected to arrive at the pilot station at informed about progress of berthing of feeder 03:00 a.m. It was decided by the port that the vessel and the pilot on the container vessel feeder vessel will embark its pilot at 03:00 was adjusting vessel’s speed accordingly. a.m, prior to the container vessel under The container vessel transited the approach consideration. channel without any problem, till around 04:47 a.m. At this instant, when the vessel Somehow, the feeder vessel got delayed by half was a little short of its berth, its main engine an hour. However, order of pilots’ boarding was stopped to slow down the vessel. The was kept unchanged and the feeder vessel vessel, however, lost steering and started went on to embark its pilot first, as was swinging to its starboard side. To check the decided. swing a kick ahead, a short start of engine on dead slow ahead, was given with wheel hard Thereafter, the container vessel embarked its over to port side. Though this arrested the pilot at 03:54 a.m. While the pilot was starboard swing, it commenced vessel’s swing climbing up to the bridge of the container to port. Engine was stopped once again. With vessel, its master tried out astern movement engine stopped, the vessel again stopped on the vessel’s main engine. On arriving at the responding to steering and continued swinging bridge, Master/Pilot exchange was carried out, to port, towards the berth. 18REPORT ON SHIPPING CASUALTIES, 2014-16 At this instant the pilot called for astern (ii) Bridge team did not challenge the Pilot’s movement by advising ‘dead slow astern’ actions, nor did they raise concern with the command. However, the main engine did not pilot regarding high approach speed. They also respond. The engine turned on air but did not agreed to go ahead with berthing without kick on fuel. This was attempted twice after availability of tugs. which the pressure in the air bottles had come (iii) Approach angle almost perpendicular to down too low to be able to give any more kicks. the berth. Valves of the air bottles were opened so as to equalize the pressure of the air bottles and (iv) There was failure on part of the Port another kick was given however the engine did management as tug boats were not made not pick up on fuel even then.The vessel, at available for the maneuver despite it being this instant still possessed a speed of approx. known that the vessel was short of one anchor 3.8 knots and was swinging to its port side. To and was proceeding towards the berth with a worsen the situation ‘no’ tugs had been made following tide. fast to the vessel till that time. This, because the tugs had yet not arrived after berthing the (v) Failure of the VTMS to alert the vessel in feeder vessel. time for its approach speed being excessive. The vessel had only one starboard side anchor, 4. Lessons learnt: which was dropped to control forward advance of the vessel. This also did not help as it reduced (i) The berth should be approached at a safe the vessel’s speed only partially and the vessel speed. Due regards shall be had to possible made heavy contact with the jetty at 04:50 a.m. machinery failure(s). Contingency measures should be thought of. While vessel suffered structural damages, two pillars of the terminal also got damaged. (ii) The passage plan and mooring 3. Why it happened? arrangement at the berth should be examined and agreed to by the pilot and vessel’s staff, 3.1 Most proximate cause: prior to the commencement of approach. Such exchange should be detailed and include Machinery failure. Failure of the main engines arrangement of tugs. to go astern when required. Also the air reservoir got exhausted just after three kicks, (iii) The responsibility of the safety of vessel whereas the regulations require 12 consecutive rests with the master, with pilot contributing starts. in an advisory position. If any act of the pilot 3.2 Contributory factors is causing concern challenge must be raised by vessel’s staff. (i) High speed of approach to the jetty, which became more precarious in the absence of tugs. (iv) Port operations and VTMS must also exhibit due diligence in allocating resources to (ii) Failure of the company and vessel’s management. Though the container vessel and different maneuvers ensuring that the its sister ships had been experiencing similar resources, be they the tug boats or mooring problem for some time, sufficient remedial boats or mooring gangs, will be timely and action had not been taken to deal with it. sufficiently available. 19REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 10 Passenger jumps overboard from the vessel, at anchorage 1. What happened? Search operations were carried out by the ship's rescue boat and with the help of fishing A passenger from a passenger vessel jumped boats in proximity. Efforts to find the missing overboard, while the vessel was waiting at the passenger were continued till next day early outer anchorage of a port, awaiting berthing. morning, however the missing passenger could not be traced. 2. How it happened? 3. Why it happened? On arrival at an Indian port, a passenger vessel had been made to wait at anchorage for a day. 3.1 Most proximate cause: Pilot had been scheduled to board the vessel next day morning at 07:00 a.m. to berth the The action of passenger appeared to be case of vessel inside the port. All passengers were suicide. Hand written letter recovered from his informed accordingly. personal belongings revealed that he was depressed. He had resigned from his last As per the routine, evening video cinema was employment and was returning home from his exhibited on the swimming pool deck after place of employment with very minimum dinner and passengers appeared to be in a paraphernalia. relaxed mood. The movie ended at around 11:00 p.m. and the passengers started moving 3.2 Contributory factors towards their respective bunks, when a loud noise of somebody jumping into the sea was The vessel's staff could not detect the signs of heard. Few passengers close to the incident depression and suicidal tendencies in the spot, witnessed a person jumping overboard passenger. and trying to swim away from the ship. 4.0 Lessons learnt: A life buoy was immediately thrown towards the person in water by the on-duty fire patrol, (i) Any abnormality or signs of depression in who also informed the 'officer on watch' (OOW) passenger(s) should be identified and the over portable radio. Emergency procedures passenger referred to counselor. were initiated including alerting VTMS and Pilot station. They were requested to further inform (ii) Welfare officer / Guides should be local 'search and rescue' (SAR) authorities. passenger friendly and be able to identify and Maritime Rescue Coordination Centre (MRCC) counsel the depressed, isolated and was informed over INMARSAT 'C'. traumatized passengers. 20REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 11 Vessel suspected of touching ground, off berth 1. What happened? indicated on the chart were also not conforming with the actual. An Indian cement carrier of approx. 12000 GT suspected of having touched the ground on its The declared depth at the berth was 9.5 m. starboard side, while departing from an Indian With expected prevailing tide of 0.66 m port. added to it, depth available at berth should have been 10.16 m. Accordingly, the depth 2. How it happened? during passage, after casting off from the The vessel, a cement carrier, was departing an berth, should have been a minimum of Indian port under pilotage and with the 10.96 m. However, when measured using assistance of 2 tugs. Around 11:00 a.m., vessel hand lead line it was observed to be only cleared the jetty. As, vessel was heading 9.30 m. outwards at a speed of 0.8 knots, the master and bridge team noticed vessel was losing 3.2 Contributory factor speed. i) Inadequate sounding of the sea bottom At around 11:10 a.m., engines were stopped, by relevant authorities. suspecting that the ship’s bottom may have touched the sea bottom on the vessel’s ii) It could have been that silting near the starboard side. Readings on echo sounder were break water/ south end of the jetty might inconclusive and did not indicate any depth have increased over a period of time, under keel. which went unnoticed. Manual soundings were taken using hand lead 4 Lessons learnt: line. The same indicated lesser depths on starboard side of the vessel, in front of its i) The available depths at berth and in accommodation block. It was suspected that the channel should be confirmed from the vessel may have touched the bottom there. various sources including port authorities From soundings, nature of sea bottom and pilot, particularly when calling at appeared to be that of soft mud. smaller ports. Around 11:20 a.m. the vessel was moved into area of deeper depths with the assistance of ii) Same should form part of Master- Pilot tugs, where it anchored. Checks were carried exchange. out on the vessel and its condition was found satisfactory. iii) If in any doubt, the vessel should verify the actual depths, using various means. 3. Why it happened? iv) Draft used for evaluating under keel 3.1 Most proximate cause: clearance should be dynamic and Incorrect declaration of water depths in the incorporate possible reduction of depths due area lying just off the berth. Depths to formation of sand waves etc. 21REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 12 Casualty (Death) of a third party worker due to electrocution in an enclosed space. 1. What happened? of the other workshop worker, who was inside the tank went ahead to hold the Death of a shore labourer on an Indian lamp and gotelectrocuted. passenger vessel, when the vessel was undergoing repairs/maintenance at an Indian Duty engineer was informed who announced dry-dock. the incident on public address system. Ship staff immediately rushed to the accident site. 2. How it happened? The casualty was given first aid by ship staff and thereafter he was shifted to the hospital An Indian passenger vessel was undergoing where he was declared dead on arrival. repairs at an Indian dry-dock. At the time of the incident, master and chief officer of the 3. Why it happened? vessel were engaged in other activity. 3.1 Most proximate cause: One of the jobs at the dry-dock was cleaning of the vessel’s sewage holding tank. The tank Death due to electrocution was required to be cleaned so that it could be 3.2 Contributory factor surveyed. i) The work had been outsourced to a In the process, the sewage holding tank was subcontracting workshop whose track record opened up and made gas free. The tank being with respect to safety had not been verified. gas free was checked by ship’s staff and As is evident, the workshop personnel were not thereafter handed over to a third party familiar with neither the ‘enclosed space contractor, a workshop, for cleaning. procedures and work environment on board’ This 3rd party contractor further sub contracted nor were they trained in emergency procedures, the work to another entity, a workshop headed including basic first aid. by a local person. However, this workshop ii) The workers were not equipped with wasnot authorized by the vessel’s owners for personal protective equipment and were rather suchkind of work. This workshop deployed working barefoot and half naked. The working sevenpersonnel for working inside the tank. equipment being used by them were also The seven workers were not equipped with unsafe. personal protective equipment and were rather iii) It is likely that the person may been working barefoot and half naked. The working sweating and already exhausted while equipment being used by them were also working inside the tank. This may have unsafe. reduced his resistance. Also the hand held The workshop personnel were also neither lamp was not fitted with a safety glass and once familiar with the ‘enclosed space procedures the body came in contact with a live source of and the work environment’ on board a ship electric current, it may have lead to the nor were they trained in any kind emergency casualty. procedures, including basic first aid. iv) Casual approach of Master/Ship staff During the work a hand held lamp, belonging towards the safety of workshop personnel on to the workshop, was lowered inside the tank board, who missed noticing such lapses in through manhole by workshop’s person. One safety measures. The tank was made gas free 22REPORT ON SHIPPING CASUALTIES, 2014-16 and handed over to the workshop. Henceforth entrance to the enclosed space. These caused no supervision was maintained by the vessel’s delay in evacuating the casualty from the staff. This caused delay in raising of alert and enclosed space to hospital. summoning of help. Also crucial vital seconds, 4. Lessons learnt: in switching off the power were lost. i) Explicit and well defined guidelines must v) Credentials of the workshop had also not be stated in company’s safety management been verified. system with respect to vessel’s responsibility vi) Lack of clarity in the company’s safety towards the safety of shore personnel, management system regarding responsibility including any third party workers. of safety of third party workers when working ii) Ship’s staff, shall maintain situational on board their ship. awareness of activities on board the ship, even vii) Non availability of emergency response though not directly involved with third party equipment such as stretcher and SCBA at workers. 23REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 13 Engine crew missing at sea 1. What happened? 3. Why it happened? An engine crew went missing from a tanker 3.1 Most proximate cause: vessel while the vessel was at sea. The crew member probably jumped from the 2. How it happened? ship, under depression. The engine crew had joined the vessel just a 3.2 Other contributory factors: few days prior to the incident and had been carrying out his duties satisfactorily since then. (i) Despite being aware of the disturbed However on the 18th day after joining, he mindset of the crewmember effective refused to go down to the engine room for counseling was not provided to him by ship’s watch and also demanded immediate staff to help allay his fears and anxiety. His repatriation to his home. kin(s) could have been involved in the process over telephone. The matter was communicated to the company’s office who agreed to relieve the crew (ii) Also no watch was kept on the crew. member on compassionate grounds at the next port. 4. Lessons learnt: Meanwhile, senior officers on the vessel decided i) Officers on vessels should be trained in to keep him off the watch till next port. identifying psychological distress in crew and On the day of the incident, the particular crew to provide ‘First aid counseling’. member was last seen at around 02:00 p.m., ii) Companies should incorporate resting in his cabin. compassionate procedures to handle However, at dinner time his absence was psychologically distressed seaman, if any, on noticed. Search was conducted on the vessel board their ship. but the engine crew could not be found. Man overboard procedures were initiated, including iii) Ship owners/ managers/ operators should informing the nearest ‘Search and Rescue’ evolve psychometric testing methods which (SAR) facility. Search was carried out for the would identify traits that would lead to missing crew member, including using aircraft, suicidal tendencies in marine environment. A but the missing engine crew could not be brief of the findings of the psychometric test, located. should be available with the ship’s master. 24REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 14 Death of seaman due to medical condition and delay in administering proper medical treatment. 1. What happened? At 09:03 a.m., master called up the designated person ashore (DPA) who in turn advised him An Indian seaman was found unconscious to rather seek radio medical advice. while working on deck. He later died. Proper first aid and medical procedures were not Meanwhile, vessel’s staff tried to treat the administered timely. unconscious fitter on board, with automated external defibrillator (AED). Steps as per the 2. How it happened? AED prompts were followed, but the equipment didn’t give any prompt/advice for administering A foreign flagged container vessel with multi shock even after repeated attempts. nationality crew was on a transoceanic voyage. Between 09:10 a.m and 09:17 a.m, master tried On the day of the incident work was allocated, to obtain radio medical advice from two shore as usual, to all crew and tool box meeting held based centers, but in both centers he faced in the morning. At 08:20 a.m, after the tool language barrier as the doctors on the other box meeting, all deck crew proceeded to deck side could not communicate in English. Finally on their allocated jobs. The deceased person, at 09:17 a.m. he managed to converse with a a repair fitter, had been allocated the job of doctor at one of the two centers. On doctor’s renewing deck railings at a particular point. advice Glycerol Tri-nitrate tablet was He had been assigned an ordinary seaman (OS) administered sublingually to the patient. for assistance. Meanwhile, CPR and administration of oxygen At 08:30 a.m, after arranging tools at the was continued on the unconscious fitter as well worksite, the fitter instructed his assistant OS as efforts were continued to provide shocks by to go and switch on certain deck lights. The AED. OS followed suit and left to switch on the lights It was assumed that AED may not be and also to bring some paint with him. The functioning due to ship’s vibrations and fitter, at this time was left behind alone. therefore vessel started reducing RPM at 09:48 The OS returned after approximately 15 a.m. in order to reduce external vibrations. minutes along with Bosun and an able bodied Trials were again made to use the AED seaman (AB) to find the fitter lying on main however the equipment still didn’t give any deck in an unconscious state. The AB prompt/advice for administering shock. immediately informed bridge about the At 10:15 a.m., nearly one and a half hour after situation through hand held radio (walkie first sighting of the fitter in an unconscious talkie). Thereafter the three seamen shifted the state, the fitter was declared dead in unconscious fitter on to upper deck. consultation with the shore based radio The master having come to know of the incident medical advice center. arrived at the upper deck at 08:50 a.m. Chief 3. Why it happened? engineer had already arrived at the site by that time and had commenced administering cardio 3.1 Most proximate cause: pulmonary resuscitation (CPR) to the unconscious fitter. On examination, master Medical casualty, most probably due to heart found vital signs of the fitter missing. ailment. 25REPORT ON SHIPPING CASUALTIES, 2014-16 3.2 Contributory factor 4. Lessons learnt: (i) Time is of greatest essence in case of any (i) Lapses and delays in administration of medical emergency. While effective shore based first aid and appropriate medical treatment. training is the key and therefore requirement Instead of wasting time in shifting the casualty of refresher for medical related courses has to upper deck, the three seamen should have been implemented, it is equally imperative that started administering CPR immediately on the ship’s staff familiarizes themselves well with scene. They should have been instructed the medical equipment available on board. accordingly by the officer on bridge. The master too instead of wasting valuable time in (ii) Procedures to avail radio medical advice communicating with DPA should have shall be readily available with the ship’s staff administered medicine timely or arranged for and form part of passage plan. seeking radio medical advice. (iii) Medical equipment provided on board (ii) The vessel’s staff were not familiar with shall be verified to be fit for use in marine the use of medical equipment available on environment, like in this case it is doubted that board. The AED could not be used till last that the AED may not have operated due to moment. ship’s vibrations. 26REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 15 Serious injury to leg of seaman in mooring related accident. 1. What happened? Second officer immediately switched off electric power and informed bridge. Right foot of an Indian seaman got severed at ankle due to the leg getting entangled in eye of Vessel was anchored off the terminal and a mooring rope. He therefore got pulled on to medical assistance sought. Injured AB was the winch. transferred to shore based medical facility. 2. How it happened? 3. Why it happened? An Indian Liquefied Petroleum Gas (LPG) vessel 3.1 Most proximate cause: was sailing out of an Indian port around noon AB getting pulled on to the storage drum as time. At 12:35 p.m., all ship’s mooring lines his leg got entangled in the eye of a mooring had been cast off from the jetty and the vessel rope. was getting clear of the jetty. 3.2 Contributory factor Forward mooring station was initially being manned by 2nd officer, two able bodied seamen (i) Less staff to man forward station as one (ABs) and one ordinary seaman (OS). However, AB had been called to the bridge. as soon as the last line was cast off from the jetty, one of the two ABs was called up on to (ii) The winch being operated in an auto the bridge of the vessel for steering. The second mode with no emergency stoppage available officer meanwhile, continued to man the with the operator. forward mooring station, now with only one AB & one OS. (iii) Lapse in concentration of the AB when rope got retrieved on board. He may not have They were securing the mooring ropes. 2nd anticipated that the mooring rope would fall officer was working on the starboard winch in his way.. with OS, while AB was working ‘alone’ on the port side winch. The AB was picking up last of 4. Lessons learnt: the head ropes. The port winch at this time (i) Accident avoidance during mooring was being operated in an automatic mode, with operations require continuous training with AB having engaged the port winch lever on auto ship’s specific arrangement. mode on full speed. As soon as the eye, at the end of the rope, got retrieved onboard the AB (ii) Whenever auto mode is used on an showed hurry to stop the winch lever. At this machinery an emergency shut down time, his right leg got entangled with eye of arrangement should be readily available with the rope and the AB got pulled on to the storage the operator. drum along with the rope which was getting hoisted on to the drum in automatic mode. This (iii) Vessels must regularly review man caused right foot of the AB to severe off from power requirements vis-a-vis various his leg, at its ankle joint. activities. 27REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 16 Damage due to contact with Jetty 1. What happened? ii) Parting of rope which had been provided by the dredger to the tug. An Indian dredger vessel suffered damage on its bow due to coming in contact with a jetty 3.2 Contributory factor while being shifted between two berths. i) Lack of experience of tug’s crew. 2. How it happened? ii) Improper seamanship as anchor was not An Indian dredger vessel was being shifted from used to check the swing. one berth to another in an Indian port. Pilot was on board and two tugs were being used, 4. Lessons learnt: one tied to forward part and another to the stern of the dredger. i) Mooring ropes, on board any ship, should be maintained in optimum condition and While the tug boat at stern was made fast using inspected at regular intervals. Attention shall tugboat’s mooring rope the tug boat that was also be paid to the stowage location of the ropes, made fast to the forward part of the dredger in particular if stowed in close proximity to vessel was using the dredger’s mooring rope chemicals, oils and/or exposed to weather and during the shifting movement. sun for prolonged durations. In such cases the ropes may deteriorate significantly, however The movement was going on smoothly till the very few or no visible signs of such deterioration vessel came near to the jetty. Pilot ordered tug may be present. boats to ‘slow pull out’ in order to break the movement of dredger vessel towards the jetty. ii) Breaking strength of ropes, that are used In doing so, the tug boat that was made fast to with the tugs, shall be evaluated vis-à-vis the forward part of the vessel gave a sudden bollard pull of the tugs or the load that the jerk. Because of this jerk, the mooring rope rope is expected to bear during mooring that was making it fast to the dredger parted. operation. It should be considered that the With nothing to check, dredger vessel’s bow ropes may have to bear jerk loads, if sudden went on to hit the jetty. Also, there were no changes in the tug’s pull directions are ordered. fenders at the corner of the jetty. This contact Such jerk loads can be considerably higher left a slight dent on the port bow of the dredger than the static loads. vessel. iii) Use of anchors should be considered as a 3. Why it happened? contingency measure in such cases, with due regards to the presence of any submerged 3.1 Most proximate cause: pipeline, cable or other underwater i) Inappropriate response of the tug. obstructions. 28REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 17 Tug colliding with an oil platform 1. What happened? this time bridge team on the AHT comprised of only the master and the 2nd officer. The route A tugboat collided with a process platform selected by them was not the safest, as it shall incurring damages to both itself and the bring the AHT close to the oil platform. Also process platform approach speed of AHT was excessive. The AHT was not fitted with any current measuring 2. How it happened? device and speed was being measured only from A barge had been engaged in a pipeline project GPS. at an oil field. It was to participate in jacket During its approach two calls were made by face survey at various oil platforms in an Indian the barge’s control station to the AHT, warning off shore area. it for its excessive speed. The barge was being supported by 2 anchor On entering the 500 meter safety zone around handling tugs (AHTs), which when idle would the oil platform, radars on AHT were put on usually tie up to the buoy. standby. On the day of the incident, at 02:25 p.m., one At 03:20 p.m., main engines on the AHT were of the two ‘Anchor Handling Tugs’ (AHT) stopped to confirm from the barge that no received instructions from its controlling barge divers were down. After 2 minutes i.e. at 03:22 to cast off from the buoy and proceed to the p.m. the AHT resumed its approach to the barge to receive potable water and carry out barge. At 03:23 p.m. astern movement was crew transfer. This buoy was situated 2.3 given on the bridge telegraph as the distance nautical miles from the barge. The AHT planned from oil platform was reducing, however, there a course to head straight on to the oil platform was no response for stern movement. Master and then turn the vessel towards the barge in had misjudged the distance. close proximity to the platform. As vessel was still carrying ahead momentum No communication was made with the control and as the engines were not responding to tower of the oil platform in regards to this astern kick, master pressed emergency stop movement. Later on also, no communication to minimize the impact of collision. was made, either by the barge or by the AHT with the control tower of the oil platform. The At 03:25 p.m. the AHT collided with oil platform control tower of the oil platform was not causing damages to both the oil platform and informed even when the AHT was entering into itself. the 500 m safety zone around the oil platform. 3. Why it happened? On receipt of instructions both main engines on the AHT were prepared ready by the duty 3.1 Most proximate cause: engineer. Chief engineer was not informed. This Shortcomings in Navigation. Safest route was reportedly was normal practice on the vessel. not taken and speed was excessive. The AHT The AHT casted off the buoy at 03:10 p.m. and had set a course heading straight on to the commenced proceeding towards the barge. The platform with plan to turn the vessel very close prevailing weather conditions were within the to the platform, which was a dangerous parameters permitted for such operations. At maneuver. 29REPORT ON SHIPPING CASUALTIES, 2014-16 3.2 Contributory factor v) No Risk Assessment was carried out before entering the safety zone of the platform. i) Failure in communication. 4. Lessons learnt: ii) Inadequacy of Bridge team and casual approach of the AHT’s staff. There was no i) The contractors may be advised to prepare a check-list of important Do’s/Don’ts (duly ‘lookout’ and helmsman on the bridge. There reviewed and approved by platform companies) was lack of communication between the 2nd which should be briefed to the crew members. officer and master on the bridge. A very casual approach was made by the AHT’s crew for such ii) All vessels (including barges, supply and critical operation. Absence of chief engineer support vessels etc.) entering into the 500 m from the engine room further corroborates the zone of any installation must intimate the casual approach of crew. control room of the complex and obtain permission from the concerned platform. iii) Use of ‘emergency stop’. Master claimed to have pressed the emergency stop as he did iii) The safety audit of supply vessels to be not get astern movement. Since the speed was carried out on a random basis. too high, the stern movement may not have iv) At the time of deployment of marine come. However, emergency stop shut down the spread in offshore field, particularly when complete main engine and on the concerned barges come to platforms for construction field- AHT it would have taken up to 15-20 minutes activities, the preliminary/preparatory meeting to restore the propulsion power. This caused with the platform/OIM must be attended by the main engines to be not available for Master/senior crew of all boats (AHTs, supply considerable time due to the activation of vessels etc) also, which are attached to the emergency stop. barge for assistance. iv) Lack of awareness of marine procedures. v) The platform should enquire and advise There were several unwarranted departures the vessels about ‘safe approach speed’, while from laid down procedures for vessel to operate permitting the vessels within 500 m zone of in such critical waters. the installation. 30REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 18 Tug running aground due to heavy weather 1. What happened? of hours accompanied with heavy rain and restricted visibility. A tug boat ran aground in an Indian port due to severe weather conditions. The tug under consideration, after pushing the mooring launch towards shallow waters 2. How it happened? resumed maneuvering inside the turning circle. At this time, master of the Tug observed An Indian port was threatened by an another tug, which was also maneuvering approaching Tropical Revolving Storm (TRS) inside the turning basin, crossing its bow at which was expected to pass over the port. As a very close range. He gave wide alteration to precautionary measure the port sent all port to avoid collision. However, in doing so merchant vessels, which were in the port, out the tug boat came under the effect of strong to open sea. The port authority however advised prevalent winds which it could not counter and its tugs to stay within the turning area and the tug got pushed over by strong wind on to not to cross the break waters. Also the tugs the shallow waters making it run aground. were entrusted to take care of the port’s mooring launches. 3. Why it happened? Accordingly, each tug tied up one launch and 3.1 Most proximate cause: anchored inside the break waters. As the wind picked up, the tugs weighed their anchors and Severe weather condition and strong wind started maneuvering inside the turning basin. which had pushed the tugboat to shallow The unmanned mooring launches were being waters. towed by the tugs. After few hours the wind speed increased to nearly 100 knots (approx. 3.2 Contributory factor 185 km/hr) raising heavy waves inside the i) Restricted space available inside the port harbour. Due to this towing rope of one of the for more than one tugs to maneuver. mooring launches parted and the launch started drifting towards the berth at a high ii) Parting of the mooring line that was speed. To safe guard the jetty from collision keeping fast the launch to the tug boat. with the adrift launch, its assisting ‘Tug’ was instructed to push the drifting launch away iii) Underestimation of the drag due to wind from the jetty, towards nearby shallow waters. and waves by the tug’s crew. This was also aimed at avoiding the sinking of the adrift launch within the port’s approach 4. Lessons learnt: channel. i) Impetus be laid behind training of Winds died down when eye of the storm passed navigating officers in handling of vessels in over the port, only to pick up again after couple heavy weather. 31REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 19 Collision/Contact damage between vessels when approaching port 1. What happened? As ‘Vessel 1’ had a fishing vessel on its starboard side it was observing restriction in An Indian bulk carrier of approx 40,000 GT altering to starboard. collided with an outbound tanker vessel when approaching anchorage area at a foreign port. ‘Vessel 1’ tried to draw attention of ‘Vessel 2’ through various means however there was no 2. How it happened? response. An Indian flagged bulk carrier ‘Vessel 1’ was ‘Vessel 2’, the tanker, kept increasing its speed approaching anchorage area ‘A’ at a foreign port to reach about 13 knots. As a result, the CPA on a North Westerly heading. Weather kept decreasing, reducing down to just 0.1 conditions were favourable and visibility was nautical mile. Still no avoiding action was good. apparent from its side. ‘Vessel 1’ had also carried out another All this while ‘Vessel 1’ continued to draw maneuver just a short while back, at outside attention of ‘Vessel 2’ with all available means port limit (OPL) area. After the maneuver it had and also tried to keep itself maximum to again increased its speed to ‘maneuvering full’ starboard while keeping clear of the fishing while approaching the anchorage. vessel which was now on its beam. However, ‘Vessel 1’ somehow did not reduce its speed. While proceeding towards the anchorage, the bulk carrier, ‘Vessel 1’ sighted a fishing vessel on its starboard bow, which it started tracking on its radar. At the same time it observed, visually as well as on radar, a tanker vessel (‘Vessel 2’) on its port bow moving out from ‘Anchorage B’. ‘Vessel 1’ commenced tracking this ‘Vessel 2’ also on its ECDIS and radar. At this time, it appeared that ‘Vessel 2’ would pass clear of ‘Vessel 1’ crossing from behind its stern, from its port side to starboard side. At 11:50 p.m. ‘Vessel 2’ was steering a course of 080 degree and moving at a speed of 6.6 A minute before collision, ‘Vessel 1’, the bulk knots. Closest point of approach (CPA) of ‘Vessel carrier put its wheel hard over to starboard, 2’ to ‘Vessel 1’, was about 0.9 nautical mile. however it was too late. At about 00:02 a.m. However ‘Vessel 2’ was observed increasing its the starboard forward part of the tanker vessel, speed and this was causing a reduction in its ‘Vessel 2’ made contact with port quarter of CPA distance with ‘Vessel 1’. bulk carrier, the ‘Vessel 1’. Suddenly, ‘Vessel 2’ altered its course to port While there was no casualty or pollution, and started steering 070 degree and increased damages occurred to shell plating and its speed to 10.3 knots. CPA with ‘Vessel 1’ associated strengthening members on ‘Vessel 1’. was further reduced to about 0.3 nautical mile. 32REPORT ON SHIPPING CASUALTIES, 2014-16 3. Why it happened? 3.1 Most proximate cause: Non adherence of COLREGS and lack of application of seamanship by both the vessels. 3.2 Contributory factor: i) Approach to ‘Anchorage area A’ area was planned passing very close to the boundary of ‘Anchorage B’ and at an acute angle to it. ii) Poor assessment of the development of close quarters situation by bridge teams of both the vessels. iii) Speed of ‘Vessel 1’ was not reduced by Master as an action to avoid a close quarter situation. iv) Corrective action was delayed. 4. Lessons learnt: i) While planning passage due regards shall be paid to the expected traffic conditions, including converging and crossing traffic. ii) COLREGs and principles of good seamanship shall be adhered to at all times. 33REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 20 Seaman's right hand's thumb getting cut during mooring operations 1. What happened? An able bodied seaman (AB), on a foreign container vessel lost top phalanx of his right hand’s thumb while making fast a tug boat. 2. How it happened? During berthing operations on a container vessel, 2nd officer and AB were instructed to make fast a tugboat on the vessel’s port quarter. (port side stern) This required picking up a heavy rope (tug’s line) from the tug. The tug’s deck, from where the rope had to be picked up, was lower than the vessel’s poop deck, to which the tug’s line had to be lifted to. Therefore, in order to lift the heavy line a smaller size rope (messenger rope), which could be safely handled manually by the two seafarers, was passed on to the tug. As these messenger ropes are small in size, usually varying between 16 mm to 20 mm in diameter, they can be easily wrapped around warping barrels of mechanized winches in order to take load of heavier and thicker tug’s rope when pulling them up from tug’s deck. The tug’s staff connected the heavy tug’s line to this messenger rope. On connection of the tug’s line, ship’s staff first picked up the slack portion of messenger rope manually by hand. As the weight of the tug’s line started coming on to the messenger line they started transferring the messenger line to the mooring winch. At this time, 2nd officer was operating the winch and AB was warping the messenger line on the warping drum. As the weight/tension on the messenger line gradually increased the seaman started taking additional turns on the warping drum to provide more friction and hence better grip. 34REPORT ON SHIPPING CASUALTIES, 2014-16 3.2 Contributory factor i) The winch not stopped in time as soon as the thumb got trapped. ii) Body parts too close to moving machinery. iii) Inadequate man power assigned for the job. The warping drum was continuously rotating at that time. Suddenly, thumb of AB’s right hand got trapped underneath the messenger line, between the line and the warping drum, and got sheared off. 4. Lessons learnt: 3. Why it happened? Effective resource management, including human resources, remains a key element in 3.1 Most proximate cause: accident avoidance. The management level Thumb getting caught in between the officers, on board a ship, should ensure that messenger rope and the warping drum of the all job stations are adequately and winch appropriately manned. 35REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 21 Collision of a bulk carrier with another vessel at anchor, after dragging own anchor 1. What happened: one of the cargo holds into a dumb barge at 05:30 p.m. A tug had also been kept attending An Indian bulk carrier dragged its anchor and at the site. went on to collide with another vessel also at anchor. The bulk carrier was discharging cargo 3rd officer was assigned to watch on the bridge at the anchorage and two seamen were positioned on deck to look after the cargo operations. However one 2. How it happened? of the two seamen was also involved in other tasks which had been assigned to him by chief It had been planned to discharge coal cargo officer towards preparation for impending from a bulk carrier (vessel 1) while the vessel annual surveys at next port. Also 3rd Officer would be at anchor. The cargo discharge was to be carried out using floating crane into was involved in certain tasks, other than watch barges, which would keep coming and going. keeping, at one time or the other throughout his watch on bridge. Such tasks included At the time of its arrival at the anchorage, the corrections of a navigational publication, bulk carrier had been fully loaded and was resetting of a false fire alarm, talking to his drawing a draft of 17.00 m, even keel. The family on mobile phone and making under keel clearance was just 2.8 m. Due to photocopies of an instruction manual in the such substantial underwater volume and radio room which was situated in a reduced under keel clearance the vessel may compartment aft of the chart room. have been experiencing significant drag forces on its hull due to the prevalent current and/ The first barge completed operations and was or tidal stream. cast off at 07:40 p.m. The next barge was made fast at around 09:00 p.m. Starboard anchor was used and the bulk carrier had been brought up to 5 shackles on At around 08:30 p.m., master had written his deck. night orders and also gave some verbal instructions to 3rd Officer. Master had then ‘Finished with engine’ was declared at 04:00 retired to his cabin. p.m. with instructions for engine to be on 30 minutes notice and short notice in case of an At around 10:00 p.m., chief officer also wrote emergency. The bridge watch keepers were his night orders for the duty officers. He had instructed accordingly. left instructions that duty officers should not leave the bridge at any time. He also then The weather at the time of anchoring was retired to his cabin. favourable with slight sea, low swell, wind force 3 on the Beaufort scale and partly cloudy sky. At around 11:00 p.m., master was called by However, the tidal range on that day was 7.8 the 3rd Officer to bridge, stating that another m with a current of about 3 knots. The change vessel was very close to own vessel. The 3rd in tide was expected at 09:30 p.m. Officer also told master that own vessel In the evening, at approx. 05:00 p.m. a floating appeared to be dragging anchor and moving at dumb crane was brought alongside the bulk a speed of 2.0 knots. He also informed master carrier. It was tied up near middle of the vessel that short notice had been given by him to on its port side. Discharging commenced from engine room to get engines ready. 36REPORT ON SHIPPING CASUALTIES, 2014-16 Master immediately rushed to the bridge and took over control of the vessel from 3rd officer. He discovered that own vessel had dragged anchor by nearly 1.8 nautical miles and was now situated precariously close to a tanker vessel which was also at anchor. The bulk carrier’s distance to the tanker vessel at this time was less than 0.1 nm (1 cable). To worsen the situation, the bulk carrier (Vessel 1) was closing on fast on to the tanker vessel on its port beam. A barge, into which the cargo was being discharged, was still made fast to the crane being used for discharging which, in turn was still made fast to the bulk carrier.. The barge was made to cast off and towed away by the tug. Engine got available at around 11:05 p.m.. Master put engine half astern and then full astern to move away from the tanker. Master instructed chief officer and other deck staff to 3.0 What went wrong? proceed forward for anchor stations. 3.1 Most probable cause The carne’s staff was instructed by chief officer The bulk carrier dragged anchor, which to shift the crane towards stern of the bulk remained undetected and the vessel went on carrier from its present position near middle to collide with the tanker. of the ship. This was to keep the crane clear from direct impact of the tanker. The staff of 3.2 Other contributory factors: the crane proceeded to slacken their ropes from own vessel and move astern. i) No heed paid to change of tide and change in the direction of tidal stream. At 11:15 p.m., the bulk carrier made contact with the tanker vessel in vicinity of its No. 1 ii) Under estimation of drag on the ship’s cargo hold on the port side of the vessel. hull due to current and or tidal stream. The Railings, bulwark, fish plate, fair lead rollers, vessel was deep draft with less under keel gooseneck vent, forepeak tank air vent and clearance. Also the scope of the cable was forecastle deck plating on ‘Vessel 1’ in way of insufficient. The drag force generated due to the ship side were damaged. current and/or tidal stream may have caused anchor to loose ground. iii) Improper watch keeping on bridge. The vessel was at anchor and it was required that navigational watch had to be continued in its optimum form and officer designated for the same different from one designated to supervise cargo operations. Rather both the watches were left to only 3rd officer on bridge. He too was involved in certain tasks at some time or the other throughout his watch such as corrections 37REPORT ON SHIPPING CASUALTIES, 2014-16 of a navigational publication, attending to the 4. Lessons learnt resetting of a false fire alarm, communicating i) It is imperative that watch keeping with his family on his mobile phone, as well as during anchorage should be maintained with making photocopies of an instruction manual same efficacy as is maintained when vessel is in the radio room that was situated in a underway. This becomes even more critical if compartment, aft of the chart room. As a result the vessel is involved in cargo transshipment of all these disturbances during his watch, it while at anchor when attention of the watch seems apparent that the 3rd Officer failed to keeper may get distracted to cargo watch. maintain his situational awareness in the circumstances, with respect to the upkeep of ii) All management level nautical officers a good navigational watch, his primary duty must be trained to evaluate the drag due to at that point of time. wind and current on a ship’s hull. They must also be able to evaluate the holding power of iv) No use was made of the tug boat to push various types of anchors vis-à-vis the nature the bulk carrier away from the tanker or at of sea bottom. least hold it in position. iii) Watch keepers should be focused on v) The tanker vessel also did not raise any their jobs and not be assigned other tasks alert or warn the bulk carrier for its reducing which may distract them. distance from it. 38REPORT ON SHIPPING CASUALTIES, 2014-16 2015 Casualty Summary 1 Collision between Bulk Carrier and a Tugboat, resulting in damages to both 1. What happened? in securing the vessel for high seas. This was acceptable in company’s ‘Safety Management An Indian bulk carrier collided with a tug boat System (SMS)’. just after departing the load port, resulting in damages to both the bulk carrier and the tug As a result, the duty officer was left as the sole boat. watch keeper as well as officer of watch on the bridge. Master was moving intermittently 2. How it happened? between bridge and his office, which was two decks below. The other crewwere on deck, An Indian bulk carrier had departed from its securing the vessel for high seas. load port during day hours. As the vessel cleared restricted waters, master handed over After some time the duty officer observed control of the vessel to 3rd Officer, who was on another vessel, a tug boat, on the vessel’s port duty at that time. Prevalent weather conditions side. The tug boat was moving towards the were fine and visibility was good. Other vessels’ coast at a very high speed. Considering high traffic was also very meager. Vessel was set on speed of the tugboat, the duty officer somehow a North Westerly course of 317o and steering self concluded that the tugboat would had been engaged on auto pilot. Both the comfortably cross ahead of the vessel. He radars, X Band and S Band as well as ECDIS therefore neither acquired this vessel on his were in use. X Band radar was operational on radars nor did he track its movement by any a range of 12 nautical miles whereas S Band other means. Also since he felt that the radar was being operated at a range of 24 approaching vessel would clear his vessel’s bow nautical miles. However none of the radar with sufficient margin, he did not even take overlays were on the ECDIS. Automatic target any evasive action nor did he inform the acquisition by the radars, which had been Master. To worsen the situation, the duty switched off during the pilotage time, when the officer somehow stopped paying attention to vessel was moving out of the port, had the tug boat till it collided with his vessel. At somehow not been switched on again after the the time of collision master was also present pilot’s disembarkation. on bridge, however he was stationed on the GMDSS console and was engrossed in paper After being handed over control of the vessel, work. the duty officer noticed two vessels on the horizon on vessel’s starboard side. These vessel The bulk carrier collided with the tug boat on were situated towards the coast. He acquired its port side. both the vessels on his radar and started tracking them. At this time, the duty officer 3. Why it happened? was managing multiple jobs related to navigational watch simultaneously, one of 3.1 Most proximate cause: which included plotting vessel’s positions on the navigational chart at intervals of 5 minutes. International COLREGs and basic principles of navigational watch keeping not followed. Since the visibility was good and as there was no planned alteration of course in immediate 3.2 Contributory factors: future, master instructed the duty helmsman to proceed to deck to help other crew members (i) Dedicated look-out was not deployed. 39REPORT ON SHIPPING CASUALTIES, 2014-16 (ii) Insufficient bridge watch level. The bridge lookout person despite his need being more on watch was reduced to a single person while the bridge. the vessel was still in an area where traffic 4. Lessons learnt: could be encountered. (i) Bridge watch levels for various conditions (iii) In effective use of radars and ARPAs. shall be explicitly defined in company’s SMS (iv) Inexperience of the officer on watch. He manuals and strictly adhered to. lost situational awareness at the time of (ii) IMO’s ‘Recommendation on operational incident. guidance for officers in charge of a navigational (v) Ineffective resource management by the watch’ shall be strictly implemented and Master of the vessel. He had sent down the adhered to. 40RREEPPOORRTT OONN SSHHIIPPPPIINNGG CCAASSUUAALLTTIIEESS,, 22001144 – 16 ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Casualty Summary 02 AAmmppuuttaattiioonn ooff bbootthh wwrriissttss ooff 33rd EEnnggiinneeeerr dduuee ttoo aaacccccciiidddeeennnttt oooccccccuuurrrrrriiinnnggg ddduuurrriiinnnggg ssscccaaavvveeennngggeee ssspppaaaccceee iiinnnssspppeeeccctttiiiooonnn. 1. What happened? By the time 3rd eennggiinneeeerr aarrrriivveedd aatt tthhee llaasstt uunniitt,, ootthheerr eennggiinnee ccrreeww hhaadd ccoommpplleetteedd WWhhiillee iinnssppeeccttiinngg ssccaavveennggee ssppaaccee of main rreemmoovviinngg tthhee cclleeaanniinngg mmaatteerriiaallss aanndd ttoooollss engine, 3rd ennggiinneeeerr mmeett wwiitthh aann aacccciiddeenntt from the scavenge ssppaaccee.. TThheeyy,, iinncclluuddiinngg 22nd which eventually lleedd ttoo aammppuuttaattiioonn ooff bbootthh hhiiss EEnnggiinneeeerr hhaadd ccoommee oouutt ooff tthhee ssccaavveennggee ssppaaccee wrists. aanndd ssttoooodd ssttaanndd bbyy nneeaarr tthhee ‘‘mmaannhhoollee eennttrraannccee ttoo ssccaavveennggee space’, waiting for 3rd 2. How it happened? EEnnggiinneeeerr aallssoo ttoo eexxiitt tthhee ssppaaccee.. AAtt tthhiiss ttiimmee 33rd OOnn tthhee vveesssseell,, ssccaavveennggee ssppaaccee ooff mmaaiinn eennggiinnee eennggiinneeeerr ggoott lleefftt aalloonnee iinn tthhee ssccaavveennggee ssppaaccee.. hhaadd bbeeeenn cclleeaanneedd dduurriinngg tthhee ddaayy.. 33rd engineer hhaadd bbeeeenn aassssiiggnneedd tthhee jjoobb ooff iinnssppeeccttiinngg the 3rd eennggiinneeeerr hhaadd bbeeeenn ttrryyiinngg ttoo cclliicckk space and taking its pphhoottooggrraapphhss. He was also pphhoottooggrraapphhss ooff tthhee uuppppeerr iinnner part of the required to take photographs of inner surfaces ccyylliinnddeerr lliinneerr bbyy ppaassssiinngg bbootthh hhiiss hhaannddss iinnssiiddee of cylinder liners ooff eeaacchh uunniitt ooff tthhee mmaaiinn the lliinneerr tthhrroouugghh tthhee ssccaavveennggee ppoorrttss aanndd engine from scavenge space. TThhiiss hhee wwoouulldd ddoo hhoollddiinngg tthhee ccaammeerraa tthheerreeiinn.. In order to carry bbyy hhoollddiinngg ccaammeerraa tthhrroouugghh tthhee ssccaavveennggee ppoorrttss.. oouutt iinnssppeeccttiioonn iitt wwaass rreeqquuiirreedd tthhaatt ppiissttoonn ooff tthhee uunniitt bbeeiinngg iinnssppeecctteedd,, bbee mmoovveedd uupp oorr down. TTuurrnniinngg ggeeaarr wwaass bbeeiinngg uusseedd for moving the piston iinn aa ccoonnttrroolllleedd mmaannnneerr aanndd aass required. TThhee ‘‘ttuurrnniinngg ggeeaarr’’ss rreemmoottee ccoonnttrroolllleerr’’ was lying oonn tthhee fflloooorr, besides the 3rd engineer.. TThhee rreemmoottee ccoonnttrroolllleerr iiss iinn general ddeessiiggnneedd wwiitthh aa ssaaffeettyy ffeeaattuurree wwhhiicchh rreeqquuiirreess tthhaatt tthhee bbuuttttoonn ffoorr ttuurrnniinngg tthhee eennggiinnee mmuusstt bbee ccoonnttiinnuuoouussllyy ddeepprreesssseedd ttoo get the eennggiinnee ttoo ttuurrnn aanndd oonnccee rreelleeaasseedd iitt wwoouulldd stop. HHoowweevveerr,, tthhee rreemmoottee ccoonnttrroolllleerr oonn tthhiiss vveesssseell wwaass rreeppoorrtteeddllyy ddeeffeeccttiivvee.. Scavenge manifold While 3rd EEnnggiinneeeerr wwaass aabbssoorrbbeedd iinn cclliicckkiinngg pphhoottooss,, tthhee ttuurrnniinngg ggeeaarr ggoott ooppeerraatteedd aanndd Piston ppiissttoonn ooff tthhee uunniitt ssttaarrtteedd mmoovviinngg uuppwwaarrddss.. SSccaavveennggee ppoorrttss tthhrroouugghh wwhhiicchh hhaannddss wweerree ppuutt TThhiiss wwaass nnoott nnoottiicceedd oorr sseennsseedd bbyy 33rd engineer inside liner uunnttiill tthhee ppiissttoonn ccrroowwnn ttoouucchheedd hhiiss hhaannddss.. RReeaalliizziinngg tthhee sseerriioouussnneessss//ccrriittiiccaalliittyy ooff tthhee situation, the 3rd EEnnggiinneeeerr iimmmmeeddiiaatteellyy ttrriieedd ttoo ppuullll oouutt bbootthh hhiiss hhaannddss,, lleeaavviinngg bbeehhiinndd tthhee ccaammeerraa,, bbuutt ssiinnccee ssccaavveennggee ppoorrttss wweerree ssmmaallll iinn ssiizzee hhee ccoouulldd nnoott ppuullll tthheemm oouutt bbeeyyoonndd hhiiss wwrriissttbbaannddss bbeeffoorree tthhee uuppwwaarrdd mmoovviinngg ppiissttoonn trapped them within tthhee ssccaavveenngge ports . Both hhiiss hhaannddss hhaadd nnooww ggoott ssttuucckk aanndd ccrruusshheedd iinn- bbeettwweeeenn tthhee ppiissttoonn aanndd ssccaavveennggee ppoorrttss,, beyond the wrists. 41REPORT ON SHIPPING CASUALTIES, 2014-16 Upon hearing his cry, 2nd Engineer, who was (i) Ship reportedly using defective ‘turning just outside the scavenge space entrance, gear remote controller’ sincetake over of the rushed into the space and operated the vessel by the existing operator. defective ‘turning gear remote controller’ to (iv) The company not providing a functional move the piston downwards. turning gear remote controller, although it However later, at a hospital, both hands of 3rd being communicated about the defects of the engineer had to be amputated beyond the one that was available on board. wrists. (v) Confined and restricted working 3. Why it happened? conditions in the scavenge space. 3.1 Most proximate cause: (vi) Enclosed Space Entry Procedures not followed/executed properly as 3rd Engineer was Use of a defective ‘turning gear remote left alone in the space. controller’, it being the only one available onboard. 4. Lessons Learnt: 3.2 Contributory factors: (i) Ship staff should not use defective equipment or equipment whose safety features (i) Accidental activation of the turning gear’s have been circumvented. remote controller due to it accidentally dropping or due to 3rd Engineer unknowingly (ii) Risk analysis should be detailed, covering stepping on it. every possible eventuality. (ii) Unsafe procedures deployed by 3rd (iii) Use of gadgets like selfie stick which will engineer in taking photographs. The senior not allow any body part to be put inside the management also did not object to or warn him cylinder and such incidence can be easily against the same. avoided. 42REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 03 Death of seaman due to fall from derrick post onto hatch cover 1. What happened? As soon as weight on wire and pin was removed, weight shifted on to the boom causing sudden A seaman suffered death due to fall from top jerk. This shifting of weight and jerk broke the of the derrick post on to the hatch cover below, entire platform, causing the deceased seaman due to the working platform, on which he was to fall down, along with broken railings, on top stationed, breaking off from top of the derrick of the hatch cover of cargo hold below. He got post. grievously hurt. He later succumbed to hisinjuries. 2. How it happened? A general cargo vessel, with derricks, was operating cargo at an Indian port. At around 06:00 p.m., it was informed to the vessel’s staff, that one of the derricks was neither lowering nor hoisting. 3. Why it happened? 3.1 Most proximate cause: On inspection it was observed that derrick’s (i) Death of seaman happened due to runner wire had got stuck with the sheaves of falling from a substantial height. the topping block. (ii) Structural failure of the platform to To free the same, it was decided to clear the which the weight of derrick boom had planned block’s pin. However, the topping block was to be shifted and to which the deceased seaman still under load and in order to work on the had secured himself. same it was required that the weight be eased from the topping block and transferred to some 3.2 Contributory factors: other point. In order to do so, another cargo block was fitted. This block was connected to (i) Poor risk assessment and work the platform on top of the derrick’s samson planning. No analysis had been made of the post. Weight was to be shifted to an additional load bearing capacity of the mast’s platform wire which had been passed through this newly before deciding to transfer weight on to the fitted block. While working, the deceased same. Also due consideration not given to the seaman secured his safety belt to guard rails fact that load during a jerk could be multiple of the same platform on top the mast. times higher than the static weight. 43REPORT ON SHIPPING CASUALTIES, 2014-16 (iii) Poor seamanship, inexperience of deceased seaman and inadequate supervision of work. 4. Lessons Learnt: 4.1 Risk assessment and work planning shall be comprehensive and detailed, incorporating all expected eventualities. Effective use shall be made of ‘working aloft’ permits. 4.2 Experienced personnel shall be deployed to execute the work safely under constant supervision. (ii) Failure of permit to work system. No 4.3 Strength and load bearing capacity of any evidence of use of checklist or permit for structure or fitting be duly evaluated prior ‘working aloft’. putting any load on to it. 44REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 04 Injury suffered by 2nd engineer while working on incinerator in engine room 1. What happened? blocking closure of the sluice door. He decided to remove the obstacle manually. However, the Second engineer on an Indian ship, suffered sluice door of this incinerator was deep cut on his right wrist while using pneumatically operated instead of the common incinerator on board, due to sudden closure of manual operation. Although power supply to the incinerator’s sluice door. the incinerator was turned ‘off’, 2nd engineer 2. How it happened? failed to shut off air supply to the solenoid which controlled operation of the sluice door. Shipboard personnel were initiating routine Also the pneumatic line was not drained/ burning of garbage in the incinerator on a ship, depressurized. when an alarm of ‘sluice door open’ was received. As soon as the blockage was removed the sluice Second engineer, who was in charge of the door closed immediately, trapping second operation, noticed that a wooden piece was engineer’s hand in the process. 45REPORT ON SHIPPING CASUALTIES, 2014-16 3. Why it happened? 4. Lessons learnt? 3.1 Most proximate cause: (i) The task should have been undertaken only after a thorough risk assessment, Haste in completing the task, overlooking considering all likely hazards. safety. Attention was not paid to hazards incidental to such jobs especially in a cramped (ii) Any equipment working on pneumatic workspace, such as an incinerator. or hydraulic power source should be disconnected and adequately drained/ 3.2 Contributory factors depressurized, prior commencement of work (i) Inadequate familiarity of the concerned on such equipment. The use of Personal engineer with procedures and mechanisms Protective Equipment [PPE] at all times is vital involved in the functioning of the equipment. for protection and minimizing the damage Though the power supply to the incinerator was resulting from any oversight or accident. turned ‘off’; air supply to the door operating solenoid was not shut nor the pneumatic line (iii) Familiarisation of ship’s staff with drained/ depressurized. This led the door to ship’s equipment should be detailed and ship close suddenly with an impact, once the specific. Similar looking equipment on different wooden piece was removed, causing grievous ships may have one or more different injury to the second engineer operations mechanisms. 46REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 05 Crushing injury suffered by 4th Engineer while working on incinerator on a LPG vessel 1. What happened? on main deck, in the funnel’s space, between accommodation and engine casing. This area While verifying the functioning of incinerator of the vessel was very rarely transited by the on a LPG vessel, an Indian 4th Engineer ship’s crew and therefore nobody came to know suffered crushing injury to his lower right arm, of the plight of the 4th engineer. consequentially leading to medical amputation of the arm. Whereas, absence of 4th Engineer was noticed during the coffee break, nearly 2 hours after 2. How it happened? the incident, and a call was also made for him through engineer’s call, however no serious One early morning, while the vessel was en- note was taken when he did not turn up as it route at sea, an alarm of ‘Sluice inside gate was assumed that he may have gone up to his open’ was received for the incinerator. 2nd cabin to his wife, who had joined him on that Engineer was informed and the incinerator particular voyage only. stopped to cool it down. It was presumed that some piece of garbage may be obstructing It was only after the coffee break, while making closure of the door. It was planned to remove his supervisory round, that 2nd engineer found such piece, if any, after lunch. the 4th engineer trapped. 4th engineer was immediately got released and brought to the 4th Engineer was assigned the job of removing ship’s hospital and medical procedures the obstruction, however was not provided any followed. assistance. Therefore, after lunch, he went to incinerator room alone. Initially it was suspected to be a fracture. However soon it was realised that there was Standing on a small step, he opened the no flow of blood to the arm, elbow downwards. garbage loading door to check where exactly Treatment was given as per medical advice and the obstruction was stuck. In order to verify the vessel was diverted to the nearest port. further, he opened the sluice gate by activating the push button. When the sluice gate got At hospital, the surgeon confirmed total opened, he found a wooden piece stuck at the obstruction of all blood vessels to hand and opposite end of the garbage loading door. While forearm. Surgery (fasciotomy) was performed he was checking, he accidentally dropped his immediately but to no avail and amputation of torch inside the incinerator door. the forearm could not be averted. In a natural reflex, he tried to grab the torch 3. Why it happened? by putting his hand deeper into the space. Unfortunately the automatic sluice door, which (i) Amputation of the 4th engineer’s arm was had been opened by 4th engineer by activating the result of a medical decision based on (a) push button, had already started closing back the crush injury and (b) delay in release of his at this time due to it being regulated by an arm and (c) delay in providing professional automatic timer. Even before the 4th Engineer medical help to him. could realize and react, the closing sluice door (ii) The injury was due to timer-regulated trapped his arm. 4th Engineer had been working closing of the sluice door when the victim was alone. He yelled for help but nobody heard him. trying to reach for his torch. The incinerator room on this ship was situated 47REPORT ON SHIPPING CASUALTIES, 2014-16 3.2 Contributory factors. of working with a new type of equipment, the senior officers should draw out the (i) The vessel had been recently delivered familarisation checklist. All elements shall be new, and the incinerator was of a very new extensively covered and manufacturer’s type. The vessel’s staff did not have experience manual and guidelines be duly incorporated. in all its nuances. Over riding facilities and emergency stopping (ii) There was a delay in discovering the devices must be clearly identified, including the distressed situation of the engineer due to the time for which such facility remains active. workplace being an isolated location. (ii) Working alone in isolated areas has (iii) The 4th Engineer was assigned to carry out increased risks and should be the subject of a the job all alone. risk analysis. Procedures for regular communication and verification from such (iv) There was delay in the medical evacuation location be established and followed. If of the victim to shore medical services due to practicable, working alone should be avoid. adverse weather conditions and limited medical evacuation facility of the coastal authority. (iii) Safety features of an installation should never be bypassed and procedures be followed. 4. Lessons Learnt: (i) Familiarisation of crew with various ship (iv) The amount of waste fed at any one time specific procedures, equipment and machinery should be in quantities that do not tend to block shall be detailed and comprehensive. In case the incinerator doors. 48REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 06 Severe Injury to Eye 1. What happened? In order to do so, crank handle was fitted to the manually hoisting lever on the boat’s winch An Indian seaman suffered injury to one of his and crew started taking turns in heaving up eyes due to it getting hit by handle of the the boat manually by rotating the handle. hoisting lever of the life boat’s winch. 2. How it happened? Prior arrival to an Indian port, a foreign flagged vessel of approximately 42,000 GT had planned to lower its lifeboats into the sea and maneuver them in water, while the vessel would wait at anchor for its turn for berthing at the port. It is a statutory requirement to lower ship’s lifeboats into the sea and maneuver them in water, at intervals not exceeding certain stipulated time. The vessel had planned accordingly. However on arrival at the port, the scope of exercise was reduced to mere swinging out the boats from their stowed position and not lowering all the way, as the sea condition was observed to be rough and unsafe for lowering. Risk assessment was carried out, precautions taken accordingly and the drill commenced. However, as soon as the brake was released to swing out the boat, the life boat just started running out freely. Subsequent re-application (Images for illustration purpose only) of brake also could not arrest the uncontrolled freefall lowering of the lifeboat and it got As per his turn, the trainee seaman also came lowered all the way into the sea. in to participate in heaving. The moment, he Fearing that boat may get damaged due to the put his hands on the handle, electrical prevalent rough sea, the crew immediately got engineer, who during this time had made some adjustments on the limit switch, pressed into the act of hoisting back the life boat. electrical hoisting switch to check its However, soon it was discovered that the functioning. The electrical hoisting system electrical hoisting mechanism for the lifeboat came live causing the electric motor to rotate. was also not functional. Therefore, it was The manually hoisting lever, which is geared decided to hoist the boat manually while the to the electric motor, also started rotating at high speed causing the crank handle, which electrical engineer trouble shoots the fault at that time was still connected to it, to also within the electrical system. 49REPORT ON SHIPPING CASUALTIES, 2014-16 rotate. Due to the sudden fast automatic iii) Haste due to the emergency situation turning of the crank handle the crew did not that got created. The ship’s staff intended to find opportune time to disconnect it from the hoist the boat at the earliest. However the lever nor could they control the high speed electrical hoisting mechanism did not respond rotation of the crank handle. favourably. Whereas electrical engineer was still trying to rectify the fault, manual hoisting The handle swung freely and moved on to hit was continued with the handle connected. right eye of the trainee seaman inflicting severe iv) Improper communication – Whereas it injury to the eye. He was later transferred was known that activation of electrical hoisting ashore, with the assistance of coast guard. will cause the manual hoisting lever to rotate 3. Why it happened? at high speed, no warning was issued by the electrical engineer prior trying out. 3.1 Most proximate cause: iii) Ignorance or lack of training/ Sudden rotation of crank handle which went familiariation: Vessel’s staff was not trained in on to hit the trainee seaman. the alternate hoisting mechanism and may be ignorant of the fact that the manually hoisting 3.2 Contributory factors: lever is geared to the electrical system. i) Brake of the lifeboat winch not holding 4. Lessons learnt: causing the lifeboat to run down uncontrolled into the water. i) It is important that situational awareness is not lost during emergency ii) Electrical hoisting system not situation and adequate leadership and functioning in the initial stage. supervision be provided. 50REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 07 Collision between vessels 1. What happened? identification and did not make any other efforts for further positive identification of While moving outbound from an Indian port, ‘Vessel 2’. through an area of high traffic density, an Indian registered bulk carrier (‘Vessel 1’) Following path of the navigable channel, the collided with an inbound Indian River Sea two outbound vessels ahead of ‘Vessel 1’ started Vessel (‘Vessel 2’) due to improper identification turning to their starboard one by one. At this of the vessel and incorrect action taken time a bright light was observed by ‘Vessel 1’ therefore. from about 110 of arc, on its starboard wow. This bright light was directed towards ‘Vessel 2. How it happened? 1’ and was impairing the visibility from its bridge. While bridge team on ‘Vessel 1’ was After casting off from the jetty and passing struggling to deal with this bright light focused abreast of a few subsequent berths, ‘Vessel 1’ on to them, within few seconds red side light was caught in a situation where it had two of a vessel emerged from behind the earlier seen outbound vessels ahead of it and another bright focusing light. This was in fact the port outbound vessel moving parallel to itself on its sidelight of ‘Vessel 2’ . port side. All these vessels were moving in the same direction as that of ‘Vessel 1’. On observing the red side light at just one point, i.e. 11o on its starboard bow, ‘Vessel 1’ realised At this time there were two inbound vessels its mistake of having wrongly identified the also coming in from the opposite direction into barge to be ‘Vessel 2’, with which it had been the port, one of which was the River Sea vessel communicating all this while. i.e. ‘Vessel 2’. By this time, ‘Vessel 2’ had already arrived ‘Vessel 1’ over heard ‘Vessel 2’ on VHF precariously close to ‘Vessel 1’. requesting it to pass portside to portside of each other. At this time ‘Vessel 1’ had a vessel As part of evasive actions, ‘Vessel 1’ put its approaching towards it fine on its port bow and wheel hard over to starboard and the main which at that moment was at a distance of engine’s RPM were reduced drastically. The around 9 cables from it. ‘Vessel 1’ assumed it above actions did avert a major incident, to be ‘Vessel 2’, the vessel which had requested however still could not avoid port bow of ‘Vessel it to pass portside to portside on the VHF. In 2’ from touching the port quarter region of such a situation passing port to port appeared ‘Vessel 1’. normal, rather good. It therefore confirmed back passing port to port to ‘Vessel 2’, again 3. Why it happened? over VHF. 3.1 Most proximate cause: However this identification of ‘Vessel 2’ by Incorrect identification of vessels and incorrect ‘Vessel 1’ was grossly incorrect as actually the actions planned therefore. vessel, that it had been assuming to be ‘Vessel 2’, was a barge i.e. the 2nd inbound vessel. 3.2 Contributory factor ‘Vessel 2’, with whom ‘Vessel 1’ had agreed over VHF was in fact coming in behind the barge. i) Over reliance on VHF for collision However, ‘Vessel 1’ continued to believe on its avoidance. 51REPORT ON SHIPPING CASUALTIES, 2014-16 ii) Lack of situational awareness. viii)Improper manoeuvring by ‘Vessel 1’, as reduction of RPM would have adversely effected iii) Due regard not paid to the presence of the turning ability of the vessel background lights. 4. Lessons learnt: iv) Nonutilisation of bridge equipment such as AIS for identification of targets. i) Look out shall be maintained using all available means including effective use of v) Proper lookout not maintained. bridge equipment, such as AIS, ARPA for positive identification of the other vessels. vi) High traffic density ii) Principles of watch keeping to be adhered vii) VTS/VTMS not alerting sufficiently to. Casualty Summary 08 Head Injury 1. What happened? The DTSM decided to crossover from hatch cover of no. 2 hold to that of no. 3 hold. While An Indian trainee seaman suffered head injury, doing so, the DTSM slipped and fell through while working on a foreign general cargo vessel the gap in between, on to the main deck. Rear due to falling in between two cargo hatches. portion of his head and the neck below the protection of helmet went on to hit one bracket 2. How it happened? of the hatch coaming, thereby inflicting injury. It had been a normal working day on a foreign 3. Why it happened? flagged general cargo vessel. The vessel was 3.1 Most proximate cause: out at sea en-route between two ports. The DTSM not being able to station himself It was late evening and ship’s crew, which properly on the walkway. included Indian nationals, were finishing work for the day. The vessel was also rolling and 3.2 Contributory factor pitching due to the prevalent moderate swell. i) Rain, which had been received in Earlier during the day, the vessel had received afternoon. some rain also. ii) Vessel’s movement due to swell. One of the last activities, that was being undertaken for the day was transferring of a 4. Lessons learnt: rope from aft to forward part of the ship. This i) Working aloft permit to be used. rope was being pulled over the top of cargo holds. One deck trainee seamen (DTSM) had ii) Crossing over between heights to be been told to wait on top of hatch cover of no.2 avoided unless the passage between two such hold while bosun and other crew were securing places is served by well identified safe and the deck. secure means/ passageway. 52REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 9 Seaman falling over board, leading to his death 1. What happened? On investigation it was found that the deceased seaman had been assigned the job of de-rusting A seaman fell overboard from an Indian general (chipping) the deck below the cradle of cargo vessel, while the vessel was loading cargo starboard side rescue boat. He was assigned at an Indian port. The seamen could not be to work alone and any supervision had also saved and his mortal remainswas recovered not been deployed. later from the water. This place, where the seaman was assigned to 2. How it happened? work, fell close to the ship’s side and protection of side rails was also not present. Probably the An Indian general cargo vessel was loading seaman lost situational awareness and tripped cargo at an Indian port. over the side falling into the water The vessel was port side alongside. At around 3. Why it happened? 11:20 a.m. a seaman working on the deck heard screams from water over the shipside. 3.1 Most proximate cause: He saw a fellow seaman struggling to stay afloat in the water. He immediately threw the nearest Seaman loosing balance and tripping over the lifebuoy, but seaman in water could not get ship’s side through an area where protection hold of the same and sank in the water. from side rails was also not present. Ship staff immediately lowered rescue boat and 3.2 Contributory factors searched for the overboard seaman but without i) Improper risk assessment and job any success. Port authorities were called in for allocation. The person assigned to work in close assistance.Body of deceased seaman was proximity of ship’s side all alone. recovered later at 01:30 p.m. on the same day. ii) No use of personal protective equipment. 4. Lessons learnt: i) Safety while working over or near the side of a ship depends heavily on an effective permit to work system through which it is ensured that suitable precautions are in place, including donning of appropriate flotation aid(s) and use of fall prevention equipment. ii) Any work, over or near the side of the vessel must be properly supervised. Single person should not be assigned to such jobs. (iii) Temporary railing, which can be dismantled at short notice, be erected at such locations for the duration of work. Workmen Ship side railings not fitted, by design should be informed of limitations of such (Image for illustration only) alternate arrangement. 53REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 10 Injury to a finger on the left hand of a seaman 1. What happened? adjustingthe gangway. The seaman’s left hand finger got crushed seriously. An Indian seaman suffered injury to one finger of his left hand while adjusting the gangway First aid was administered and he was on a foreign flagged vessel. transferred to the local hospital. He was thence repatriated to India for further treatment. 2. How it happened? 3. Why it happened? A foreign flag vessel of about 20,000GT was 3.1 Most proximate cause: alongside berth in a foreign port. Cargo operations were in progress. The seaman acting in duress, thereby circumventing the safety procedures. As there On duty deck crew were engaged in activities existed threat of immediate damage to the required for safe watchkeeping during cargo gangway the seaman tried to rectify the fault operations. One such duty involved timely overlooking safety measures. adjustment of gangway i.e. the access ladder between ship and the jetty. This ladder needs 3.2 Contributory factors to be adjusted at regular intervals to i) The gangway left unattended for a while accommodate for the change in height of ship’s leading to the hazardous situation to develop. deck from the jetty. The change in height happens due to the vessel rising or lowering in ii) Ineffectivewatch keeping in the port. relation to the fixed jetty due to loading/ unloading of cargo and/or other weights on iii) Inadequate supervision by officers who the ship as well as due to rise or fall of tide. also did not timely warn the deck crew about Other than ensuring safe access between ship gangway. and shore, the aforesaid adjustment is also 4. Lessons learnt: necessary to ensure that the gangway does not get stuck up with the jetty or any other i) Ship’s staff should be explained the obstruction leading to its damage. significance of maintaining calm even during stressful situations. During watch on the fateful day, this adjustment of gangway got overlooked by crew ii) In port watch keeping procedures should leading to a situation when the gangway got be strengthened to avoid precarious situations prone to damage. being developed. Attending to gangway remains an important element of port watch keeping In a hurry to safeguard the gangway, the procedures, in particular in ports with very fast seaman bypassed certain safety checks and loading/ unloading rates and/or with large trapped his finger in the system, while tidal range. 54REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 11 Loss of part of index finger, while clearing bilges, during hold washing 1. What happened? An Indian seaman lost index finger of his right hand while clearing the bilge cover, during hold washing. 2. How it happened? Cleaning of cargo holds was in progress on a bulk cargo while the vessel was proceeding at Perforated steel plate sea. At the time of the incident i.e 11:30 a.m., chief officer, cadet and one able bodied seaman Images for illustration only (AB) were engaged in water washing of one of the cargo holds. While chief officer and cadet were busy hosing down port side shell, the AB noticed water getting accumulated at starboard side bilges and therefore decided to clear coal muck from top of the bilge cover. He tried to clear the bilge cover area with shovel, but as water had accumulated to a height about 30 cm above the cover, he preferred clearing the muck using his right hand. In the process, the AB decided to lift the bilge cover by handle. He tore the burlap further. Accidentally his right hand‘s index finger along with the cotton glove, that he was wearing, got stuck up inside one of the lumber holes adjacent to cover’s handle. As there was strong vacuum in the area, due to water getting sucked out, the AB could not clear The bilge well, into which all the wash water his finger. Rather, as he struggled more to free from the hold gets drained and from where it his finger the sharp edges of the bilge cover is subsequently pumped out, was covered with sheared off his right hand’s index finger from protective cover. top to the nail. This cover was a perforated steel plate. The All this while he neither informed nor called perforated steel plate was in addition also chief officer for help and it is only after losing covered with single layer of burlap to prevent the finger that he walked up to the chief officer fine coal muck from entering into the bilge well and reported. which could have clogged the suction box. AB was moved from hold to ship’s hospital and Washing was progressing normal and all the first aid administered. wash water was being pumped out simultaneously through the bilges. However Later while the torn glove was recovered, cut due to the previous cargo being coal, cargo part of the finger could not be recovered. The residues slowly started accumulating on top same had probably got washed away in the the bilge cover. bilge suction. 55REPORT ON SHIPPING CASUALTIES, 2014-16 3. Why it happened? situation going unnoticed. Chief officer’s prime role was to manage the jobs including the risks 3.1 Most proximate cause: that come along with. The finger getting cut due to sharp edges of iv) Ineffective team work. The the bilge cover. The situation getting aggravated communication between team members was due to the accumulation of water and presence ineffective as the chief officer and cadet of strong vacuum. remained unaware of the adverse situation of the AB. 3.2 Other contributory factors: 4. Lessons learnt: i) Proper procedures not being followed and lack of seamanship. Pumping out of the i) Risk assessment or tool meeting or job bilges could have been suspended to avoid planning for such jobs should clearly identify strong suction and/or the washing could have supervisors for each team with their roles suspended to avoid further accumulation of explicitly defined. Such supervisor(s) may water. assist in team’s activities however should not start performing their duties. ii) Hurriedness to complete the job. ii) Crew members should be encouraged iii) Lack of proper supervision. The team to use simple machines and tools such as crow comprised of chief officer, cadet and AB. All bar etc. in carrying out such jobs. Such simple were totally engrossed in the work and nobody machines not only considerably reduce human was supervising the act which caused the AB’s effort but also add to the safety. 56REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 12 Injury due to fall 1. What happened? 3. Why it happened? An assistant engineer on board a foreign ship, 3.1 Most proximate cause: suffered serious injury due to falling in the Injury due to falling. engine room. 3.2 Contributory factor: 2. How it happened? i) Probable haste to complete work A foreign flagged vessel of approximately 43,000 ii) Lack of experience GT, with all Indian crew, was proceeding on a voyage to a foreign port. 4. Lessons learnt: In the morning one day, assistant engineer was i) Ship is a hazardous area to work in, found lying on the bottom platform of the during safety familiarisation, significance of engine room. Blood was flowing out from his maintaining calmness and situational mouth. Medical advice was sought and awareness be explained to all in particular to assistant engineer was later airlifted from inexperienced new joiners. vessel to the nearest port. ii) Adequate supervision shall be provided to inexperienced. As the assistant engineer was not in a position to respond, the reason behind his fall could iii) Good housekeeping should be not be ascertained with certainty. However, the maintained to ensure that sources which may same could be attributed to the engineer act as tripping agents are properly secured and tripping and falling due to him being in haste. stowed. 57REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 13 Vessel running aground due to rough weather 1. What happened? (ii) Unexplained ingress of water in the engine-room. A foreign flagged vessel of approx. 18,000 GT with Indian compliment suffered engine room (iii) Failure to find cause of flooding and in flooding due to heavy weather and taking remedial measures against the same. subsequently ran aground. 2. How it happened? (iv) Failure to pump out the water. A foreign flagged vessel with Indian compliment (v) Failure to restore emergency power. was engaged on a voyage between two foreign ports. (vi) Failure to adjust ship’s heading in such One day during the voyage, it encountered very a manner so that it drifts away from the danger. rough weather with long and high swell. This caused flooding of the engine room leading to (vii) Failure to anchor the vessel in safe stoppage of the engines. With no power depths, prior to vessel drifting on to shallows. available and under the effect of prevailing heavy weather, the vessel slowly drifted 4. Lessons learnt: towards a shallow area and ran aground. (i) All seafarers must be trained to There was no loss of life and no pollution evaluate the effect of heavy weather on ship reported. and therefore the significance of deploying 3. Why it happened? heavy weather precautions in a timely manner. 3.1 Most proximate cause: (ii) Training should be imparted in Heavy weather leads to flooding in engine identifying the drift patterns for different room. headings of the vessel under same environmental conditions as merely changing Loss of power and effect of heavy weather leads to grounding. the heading considerable changes the drift direction. 3.2 Contributory factors: (i) Improper and inadequate precautions (iii) Training must also be imparted in use against heavy weather. Failure to secure the of anchors in similar situations and in rough watertight integrity of the engine-room. weather situations. 58REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 14 Head Injury due to fall in cargo tank 1. What happened? 3.2 Contributory factors A crew member on an Indian ship suffered head i) Rushing after completion of work injury due to falling in a cargo tank. leads to this incident. 2. How it happened? ii) Slippery surfaces in tank, in particular the access ways, including ladders. An Indian flagged vessel was cleaning its cargo tanks, while waiting at anchorage of a foreign iii) Heat exhaustion could also be a port, in preparation for its next loading. probable reason. A seaman was climbing up the ladder in the 4. Lessons learnt: process of exiting one of the cargo tanks after i) Precautions specified in the enclosed cleaning of the tank. space entry checklists should be adhered till He was climbing in a hurry and in doing so his completion of the job, which includes safe exit leg slipped and he fell down in the tank of all personnel from the space and securing sustaining head injury. of space. 3. Why it happened? ii) The access ladders and entry/exits should be clear of obstacles, oil and grease. 3.1 Most proximate cause: iii) While, an enclosed space checklist Slipping and falling from a substantial height covers a wide range of hazards the one due to leading to injury. heat and dehydration shall also be considered. 59REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 16 Passenger gone missing during the course of voyage 1. What happened? 3.2 Contributory factor A passenger went missing from a passenger i) Inadequate fire patrol. On this passenger vessel during the course of its voyage and could vessel although fire patrol was being not be traced. maintained throughout the voyage for 2. How it happened? passengers’ safety & guidance, they could not detect the passenger leaving the vessel. An Indian flagged passenger vessel was en route from an Indian mainland port towards ii) Inadequate entry/ exit control measures. an Indian island port. A day after its departure Doubts were raised that the passenger may not from the mainland port, at around 04:15 p.m., have boarded the vessel in the first place only a senior member from a team of 19 passengers and that members of his group were only reported to the officer on the watch that one of assuming of having seen him. their members had been missing since 05:00 a.m. that morning. Search was initiated 4. Lessons learnt: immediately and continued till late evening, however the missing person could not be traced i) Strict entry/ exit control mechanisms be on board. Coastal state authorities, including implemented for the passengers. Once declared MRCC, were informed. boarded, passengers should not be allowed to As substantial time had elapsed since the last go back on jetty without being duly accounted sighting of the person, during which the vessel for. had travelled nearly 150 nautical miles, it was decided that turning around the vessel may ii) Personnel receiving the passengers at the not help. Passage of the vessel was continued entrance should be trained to identify signs of while search for the missing person on board psychological distress, if any exhibited by a the ship continued. passenger. The search was continued the following day iii) Fire patrols should be more strengthened. also, however the missing passenger could not Members of the patrol should maintain lookout be found till arrival destination port. over the side also. 3. Why it happened? iv) Announcement to be made at regular 3.1 Most proximate cause: intervals in PA system during the passage, Delay in intimation to the vessel’s staff about regarding guidance & safety of passengers. the passenger gone missing. The group in v) CCTV network installation (on which the passenger was travelling should have alerted the vessel’s staff immediately on passenger ships) at strategic locations discovery of the passenger gone missing. scanning over the sides. 60REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 17 Injury to left hand of 3rd engineer, due to fall 1. What happened? 3.2 Contributory factor While overhauling main engine’s exhaust valve, i) Working aloft procedures were not followed third engineer sustained injury to his left hand properly. No evidence were available of any risk due to him falling down from the work platform. assessment having been done and/or any 2. How it happened? permit in this regards issued. No warning notices or signs were put at work place. Overhauling of main engine’s exhaust valve had been planned on an Indian flagged vessel ii) Inadequate Leadership/Supervision. 2nd during the vessel’s stay at a foreign port. Engineer, who was responsible for safety was In preparation of same, a spare exhaust valve not present at the time of incident. He should had been placed on the working platform. have first satisfied that all safety measures/ Guard railing at the platform had been opened controls are in place and only then should have and temporarily removed to transfer the spare gone to fetch the bolts. Moreover if he had exhaust valve to engine room’s workshop. assumed the supervisory role then he should not have got involved in the job and kept an At the time of the incident, 3rd Engineer was oversight. positioned on the working platform next to the spare exhaust valve. A motorman had tried to iii) Lack of situation awareness. The 3rd warn the 3rd Engineer, by shouting, regarding the removed railing however 3rd engineer failed engineer was lacking situational awareness and to take cognizance of the same. alertness about his surrounding. He also did not pay heed to the warning from motorman. While the work was in progress, 2nd engineer left the work site to fetch some bolts. During 4. Lessons learnt: his absence 3rd engineer tripped and fell down through the space where railing had been i) Working aloft procedures should be opened/ removed. He fell from the workshop implemented wherever applicable. platform to main engine’s cylinder head platform, injuring his left hand. ii) The safety railing(s), if removed, be immediately fitted back as soon as the job is 3. Why it happened? completed. Even during such time area shall 3.1 Most proximate cause: be cordoned off with alternate means such as ropes. Guard rails continued to remain absent throughout the work. They should have either iii) Person-in-charge of safety should only been put back in place or an alternate arrangement erected once the spare exhaust assess and monitor at all times and avoid valve had been shifted to the platform. getting involved in the job. 61REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 18 Damage to port life boat on a ship 1. What happened? During a routine abandon ship drill, on board an Indian vessel, wire forming forward falls of the port lifeboat parted, leaving the boat hanging on the aft hook. Further, this sudden transfer of the entire boat’s weight on to the aft hook caused the hook to break open from the boat resulting in the boat falling into the water from height. 2. How it happened? During a routine abandon ship drill, on board an Indian flagged vessel, it was planned to move the lifeboats out from their stowed position. This is statutorily required to be done on a weekly basis. The vessel was making way through the water at this time. Port side lifeboat was moved out by about one metre from its stowed position. Checks such as free movement of sheaves, functioning of limit switches etc. were made. After successful checks, the lifeboat was being heaved back. It was at this time that wire of the forward fall suddenly broke leaving the lifeboat hanging on its aft hook. (Parted wire which was fitted as falls) The entire weight of the lifeboat shifted on to the aft hook with a sudden jerk. As a result, the aft hook got sheared off from the lifeboat’s As the boat’s painter was made fast to strong hull resulting in the lifeboat falling freely into point on the ship, the lifeboat started getting the sea underneath. towed in the water. 62REPORT ON SHIPPING CASUALTIES, 2014-16 Evasive maneuvers were carried out immediately to avoid the lifeboat hitting the ship side and vessel was brought to halt. Once the vessel stopped, lifeboat was pulled over to near mid-ship from where it was lifted on to the deck using mid ship crane. 3. Why it happened? 3.1 Most proximate cause: Inadequate inspection maintenance and 3.2 Contributory factor: lubrication of lifeboat’s falls’ wires. i) The dates for renewal of lifeboat falls did not match with dates entered in the Shipboard computerized PMS (Ship Manager). ii) The shipboard PMS (Ship Manager) did not have any records or job description for lubrication of the lifeboats’ wires. The job description included only monthly inspection with no mention of any form of greasing or lubrication. 4. Lessons learnt: i) When the lifeboats is moved from stowed position or lowered to embarkation level during drills, the fall prevention devices should be fitted to the lifeboat. ii) Regular checks and lubrication of falls’ wires, including static parts of the falls, be included in planned maintenance system. iii) Records for the change of fall wires be maintained up to date and be cross verified with certificates for the wires. 63REPORT ON SHIPPING CASUALTIES, 2014-16 2016 Casualty Summary 01 Fire on a Diving Support Vessel 1. What happened? tank top compartment was stopped. C/E somehow assumed that the fire had gone out An Indian diving support vessel caught fire of control and ordered black out. Generators while operating in vicinity of a Single Point were stopped and quick closing valves shut. Mooring (SPM) in Indian waters, endangering Master wanted C0 to be released without safety of the entire oil installation. 2 understanding that it shall be effective in 2. How it happened? machinery space only, whereas fire was in the accommodation. C0 was released in to the After completing diving operations for the day, 2 machinery space. the diving support vessel was moored to one of the SPM buoys. Meanwhile, four other vessels which were operating in the oil field arrived to the At around 06:15 p.m., fire alarm on the vessel assistance of diving support vessel. got triggered, alarming onset of fire at some place on the vessel. The diving support vessel was towed away by two of those vessels, while fire fighting carried A fire had got initiated in a cabin that had been out by the other two. assigned as accommodation to four divers. However, at the time of onset of fire there was Fire was extinguished at 03:45 a.m the next nobody present in the cabin, as all the four day, however nearly 10 hours after its occupants were engaged in work elsewhere on outbreak. the vessel. As a result of the fire major damages were The alarm was acknowledged by master, who caused to inside of the accommodation. rushed to the site to confirm the fire physically. 3. Why it happened? At the same time, other crew members also noticed fire and raised alarm. 3.1 Most proximate cause The vessel was cast off from the SPM. Basis the burnt electrical iron found in the cabin, from where the fire erupted, it is strong One crew member tried to fight the fire with indication that it may be the likely source of fresh water hose, however could not reach the fire triggered by human negligence. The initial seat of fire as the hose fell short in length. He thick black smoke was due to the burning of came back after donning a breathing apparatus mattresses. Subsequent smoke was from (B. A.) set to find captain trying to fight the fire wooden furniture. with portable fire extinguisher. However, 3.2 Other contributory factors. intense heat and dense smoke emanating from the compartment was posing difficulty in (i) Human Factors – Negligence. approaching the seat of fire. (ii) Inadequate and inappropriate fire fighting Meanwhile divers, who were the occupants of techniques deployed. the cabin and who were informed about the 4. Lessons Learnt: fire by mess man, also arrived at the scene and attempted to fight the fire with portable (i) Drying and ironing of clothes should be extinguishers. On opening the door, they carried out at only at designated locations on noticed that one of the mattresses was on fire. a vessel. One diver tried to operate the extinguisher (ii) The contingency plans should be which failed to activate. implemented at the earliest instead of hits and Crew were mustered. Shore authorities trials. Important time lost at earlier stage may informed. Ventilation & electrical supply to aggravate a situation considerably. 64REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 02 Collision between a crude oil tanker and a general cargo vessel 1. What happened? about 100 m long. Its Closest Point of Approach (CPA) at this time was 1.5 nautical miles with An Indian ‘crude oil tanker’ (‘Vessel 1’) collided a negative Bow Crossing Range (BCR) of 1.8 with a foreign ‘general cargo vessel’ (‘Vessel 2’), nautical miles. This indicated that the general when transiting a strait in foreign waters. cargo vessel would pass from behind the bulk carrier. The CPA alarm was set at 0.5 nautical 2. How it happened? miles and the TCPA alarm was set at 12 At 00:00 Hours, an Indian crude oil tanker was minutes as per master’s instructions. navigating through a strait on a course of 193 2nd officer also observed fishing traffic on the degrees (True) at a speed of about 12.5 Knots. port bow, two points on the starboard bow and She was fully loaded with a cargo of crude oil another vessel, right ahead at a range of 13.0 and was drawing an even keel draft of 15.50 nautical miles. 2nd officer made a few minor m. alterations to starboard, on autopilot, to avoid The weather reported at this time was slight traffic and also to return to the original track sea, low swell, wind North-westerly with a force of 207 degrees True. 4 on the Beaufort scale and cloudy sky. The visibility was also reported to be good. 2nd At 01:00 a.m., the tanker vessel was proceeding officer had taken over the watch from additional on a course of 214 degrees True at a speed of 2nd officer (A2/O). The seaman helmsman 12.1 Knots. At this time the general cargo vessel (SHM), who was deployed as dedicated look out, was at a range of 11.0 nautical miles and a had been on the watch since two hours prior bearing of 247 degrees True and now showing i.e.10:00 p.m. the previous night. He had been a CPA of 1.0 nautical miles. The 2nd officer assigned to continue for another two hours. decided to maintain vessel’s course and speed. The 2nd Officer had joined the vessel just 12 Between 01:00 a.m. and 01:23 a.m., the CPA days prior to the incident. He had in the past of the general cargo vessel got further reduced exhibited lack of confidence in operating ECDIS from 1.0 nautical miles to 0.7 nautical miles on board and had requested more time from with a Time to Closest Point of Approach (TCPA) master in familiarizing himself with the same. of 8 minutes. The crude oil tanker altered The Master was also present on the bridge at course to starboard, on autopilot, to 220 00:00 hours. He was taking assessment of the degrees True. At 01:26 a.m., hand steering was situation from A2/O as there were some vessels engaged and altered to starboard 20. 2nd officer and fishing crafts around. Master completed then instructed helmsman to go hard over to writing his night orders, checked with 2ndofficer starboard. CPA with the general cargo vessel if he was comfortable with the watch and then was now 0.4 nautical miles and TCPA was 4 left once 2nd officer responded in the minutes. The crude oil tanker started swinging affirmative, with instructions to call him in case to starboard slowly at first and then quite of any issues on the bridge, including traffic. rapidly as the ‘Rate of Turn’ increased to a maximum of 30 degrees to starboard. Around 00:56 a.m., a general cargo vessel was observed on the X band radar & ARPA by 2nd At about 01:29 a.m., the crude oil tanker was officer at a range of 11.6 nautical miles at a heading about 265 degrees True, with the bearing of 247 degrees True on the starboard general cargo vessel now lying dead ahead and bow of his vessel. The general cargo vessel was showing a CPA of less than 0.1 nautical miles 65REPORT ON SHIPPING CASUALTIES, 2014-16 and a TCPA of 1 minute. 2nd officer ordered helmsman to go hard over to port. However, even though the rudder showed hard over to port, the Rate of Turn indicator still showed 28 to 30 degrees to starboard with no subsequent change of heading. At about 01:30 a.m. the crude oil tanker collided with the general cargo vessel. Initial impact was with forward part of tanker vessel. The general cargo vessel swung to its port due to the impact, came starboard side along-side on the port side of crude oil tanker and made contact on the manifold rail of crude oil tanker with its starboard quarter. Both vessels then moved apart due to the resultant momentum. There were no injuries and no pollution as a result of the collision, however both vessels suffered structural damages. Why it happened? 3.1 Most proximate cause The crude oil tanker did not comply with COLREGs. The general cargo vessel had been detected at an initial range of 11.6 nautical miles and 34 minutes prior to collision. It had been evident right from this time that this was a crossing situation and that the crude oil tanker was the give way vessel. If actions had been taken as per the collision regulations in ample time and to a degree that was clearly evident to the stand on vessel, this incident would never have occurred. 3.2 Contributory factors. (i) Inadequate navigation skills deployed by the bridge team on the crude oil tanker. 66REPORT ON SHIPPING CASUALTIES, 2014-16 (ii) 2nd officer was not familiar with the 4. Lessons Learnt: maneuvering characteristics of his vessel. He kept relying on indications from Rate of Turn (i) Before assigning independent watch it Indicator and not visually observing that the shall be ensured that the concerned level has vessel’s swing had stopped. adequate confidence in the use of all equipment associated with safe watch keeping. (iii) 2ndOfficer did not call master and/or other assistance. (ii) Explicit understanding of the maneuvering characteristics of the vessel by (iv) Lack of situational awareness especially the navigating officers be confirmed by the with respect to the gradual, but master of the vessel. steady reduction in the CPA and TCPA of cargo vessel. 67REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 03 Collision between two vessels, while one lay at anchorage. 1. What happened? An Indian ‘handymax’ bulk carrier (‘Vessel 1’) was hit by a foreign oil/chemical tanker (‘Vessel 2’), when the bulk carrier was at anchor. 2. How it happened? One early morning, ‘Vessel 1’ was preparing to sail out from the anchorage of an Indian port. The vessel had been at anchor for some time, undergoing repairs which it had just completed successfully. At around 03:00 a.m. ‘Vessel 2’, an oil/chemical tanker, which was proceeding to embark its Bent link of the anchor chain pilot landed being very close to ‘Vessel 1’ which was still at anchor. ‘Vessel 2’ had arrived as ‘Vessel 1’ further paid out its port anchor cable close as 0.52 nautical mile to ‘Vessel 1’. up to 10 shackles. In order to hold its position, ‘Vessel 2’ also lowered its starboard anchor upto 9 shackles in water. Attempts were made to clear anchor chain from port anchor’s flukes of ‘Vessel 2’. After about two hours ‘Vessel 2’ informed ‘Vessel 1’ that the anchor chain was now clear and that they are heaving up anchor to move away. After clearing anchor chain from the flukes, it was observed that starboard anchor cable of ‘Vessel 2’ was leading stern while port anchor cable of ‘Vessel 1’ has started leading ahead. This indicated possible fouling of anchor cables of both the vessels. At this moment ‘Vessel 2’ Officer of watch on ‘Vessel 1’ called ‘Vessel 2’ was lying just 15-20 meters ahead of ‘Vessel on VHF requesting wider berth, but ‘Vessel 2’ 2’, on nearly same heading. Heaving up anchor did not reply. It rather kept approaching closer. on any of the two vessels would have resulted ‘Vessel 2’, at this moment was doing a speed in them coming closer again. Therefore both of approx. 04 knots. Officer of watch on ‘Ves- vessels suspended heaving their anchors and sel 1’ called the port control and informed about the situation. The port control also called up maintained distance for each other, using ‘Vessel 2’, however no response was received. engine while waiting for tug boats’ assistance. Eventually ‘Vessel 2’ made contact with ‘Ves- Within one hour tug arrived on scene and sel 1’ on its port bow. In the process, anchor cable of ‘Vessel 1’ got entangled with flukes of heaving up of anchors was commenced. At port anchor of ‘Vessel 2’. approx. 07:00 a.m. the vessels were cleared. 68REPORT ON SHIPPING CASUALTIES, 2014-16 3. Why it happened? (ii) Ineffective monitoring and delayed 3.1 Most proximate cause warning by VTMS. Inadequate navigation skills deployed by the 4. Lessons Learnt: bridge team on ‘Vessel 2’. The effects of current and tidal stream, which are very strong in the (i) Passage planning and execution shall area, were inaccurately estimated and less be comprehensive and realistic, taking into effectively dealt with. account all topographical and environmental 3.2 Contributory factors. influences on ship’s maneuverability. (i) Environmental conditions - Strong tidal (ii) VTMS/ VTS to assume greater roles. stream and current in the area. 69RREEPPOORRTT OONN SSHHIIPPPPIINNGG CCAASSUUAALLTTIIEESS,, 22001144 – 16 ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Casualty Summary 04 AAAmmmpppuuutttaaatttiiiooonnn ooofff wwwrrriiisssttt ooofff fffiiirrrsssttt aaassssssiiissstttaaannnttt eeennngggiiinnneeeeeerrr wwwhhhiiillleee ccaarrrryyiinngg oouutt iinnssppeeccttiioonn ooff main ennggiinnee’’ss ssccaavveennggee ssppaaccee. 1. What happened? SSuucchh iinnssppeeccttiioonn ooff lliinneerr rreeqquuiirreedd eennggiinnee ttoo bbee ttuurrnneedd ssoo tthhaatt tthhee ppiissttoonn ccaann bbee mmoovveedd uupp AAnn IInnddiiaann ffiirrsstt aassssiissttaanntt eennggiinneeeerr ((11st A/E) aanndd ddoowwnn.. SSaammee wwaass bbeeiinngg ccaarrrriieedd oouutt in a ssuuffffeerreedd iinnjjuurryy ttoo hhiiss rriigghhtt hhaanndd dduuee ttoo iitt controlled manner uussiinngg turning gear. ggeettttiinngg ttrraappppeedd bbeettwweeeenn ssccaavveennggee ppoorrtt aanndd ppiissttoonn,, dduurriinngg rroouuttiinnee iinnssppeeccttiioonn ooff mmaaiinn The ‘‘ttuurrnniinngg ggeeaarr’’ss rreemmoottee ccoonnttrroolllleerr’’,, wwaass engine’s (M/E) scavenge space. bbeeiinngg hhaannddlleedd bbyy oonnee ooff tthhee eennggiinnee ccaaddeettss.. 1st A/E was in ccoonnssttaanntt communication with the 2. How it happened? eennggiinnee ccaaddeett,, wwhhoo wwaass ooppeerraattiinngg tthhee ttuurrnniinngg gear. HHoowweevveerr,, ddue to one miss IInnssppeeccttiioonn ooff ssccaavveennggee ssppaaccee ooff mmaaiinn eennggiinnee ccoommmmuunniiccaattiioonn,, tthhee ccaaddeett ccoonnttiinnuueedd ttoo ttuurrnn was being carried out by 1st AA//EE.. HHee wwaass bbeeiinngg tthhee ttuurrnniinngg ggeeaarr wwhhiillee ppiissttoonn wwaass mmoovviinngg aassssiisstteedd bbyy ttwwoo eennggiinnee ccaaddeettss iinn tthhee jjoobb.. upwards. Somehow 1sstt A/E did not sense this Simultaneously, 1st AA//EE wwaass also checking upwarddss mmoovveemmeenntt ooff tthhee ppiissttoonn aanndd hhiiss rriigghhtt and photographing MM//EE’’ss ppiissttoonn rriinnggss aanndd hhaanndd ggoott ttrraappppeedd bbeettwweeeenn tthhee ssccaavveennggee ppoorrtt lliinneerr.. HHee wwaass cclliicckkiinngg pphhoottooggrraapphhss of the inner aanndd tthhee ppiissttoonn.. EEvveennttuuaallllyy hhiiss hhaanndd hhaadd ttoo bbee sides of ccyylliinnddeerr lliinneerrss bbyy hhoollddiinngg ccaammeerraa aammppuuttaatteedd ffrroomm wwrriisstt oonnwwaarrddss.. through the scavenge ports. 3. Why it happened? 33..11 MMoosstt pprrooxxiimmaattee ccaauussee 1st Asssstt.. EEnnggiinneeeerr’’ss hhaanndd ggeettttiinngg ttrraappppeedd bbyy tthhee uuppwwaarrddss mmoovviinngg ppiissttoonn in between the scavenging port. 3.2. CCoonnttrriibbuuttoorryy ffaaccttoorrss.. (i) IImmpprrooppeerr rriisskk aasssseessssmmeenntt. (ii) IInnccoorrrreecctt rreessoouurrccee mmaannaaggeemmeenntt.. TTrraaiinneeeess Scavenge manifold wweerree aassssiiggnneedd tthhee ccrriittiiccaall ttaasskk ooff ccoonnttrroolllliinngg Piston turning ggeeaarr.. NNoo rreessppoonnssiibbllee ppeerrssoonn was SSccaavveennggee ppoorrttss tthhrroouugghh wwhhiicchh hhaannddss wweerree ppuutt deployed ttoo ssuuppeerrvviissee oorr ffoorr ssaaffeettyy llooookk oouutt.. inside liner (iii) There was a laacckk ooff ssiittuuaattiioonnaall aawwaarreenneessss.. 4. Lessons Learnt: (i) TTrraaiinniinngg ttoo bbee iimmppaarrtteedd iinn eeffffeeccttiivvee rreessoouurrccee mmaannaaggeemmeenntt.. JJoobbss sshhaallll bbee aassssiiggnneedd ttoo tteeaamm mmeemmbbeerrss according to their coommppeetteennccyy aanndd eexxppeerriieennccee.. (ii) UUssee ooff ttoooollss ssuucchh aass sseellffiiee ssttiicckkss ttoo bbee ccoonnssiiddeerreedd ffoorr pphhoottooggrraapphhiinngg ssuucchh llooccaattiioonnss.. 70REPORT ON SHIPPING CASUALTIES, 2014 – 16 ___________________________________________________________________________________________________________________________________________________________________________________________________________ Casualty Summary 05 Injury to the left leg of deck cadet 1. What happened? In order to arrive into the cross deck area, the A deck cadet suffered serious injury to his leg cadet had to climb over the small platform of due to shifting of an inadequately secured two steps, built to cross over the pipes on heavy steel plate in heavy weather condition deck. while the vessel was at anchor. The moment deck cadet had stepped off the 2. How it happened? walkway, when his left foot had just landed on the main deck, the plates which were lying flat The Indian bulk carrier was at anchor, off an on the deck suddenly shifted due to vessel’s Indian port, and was experiencing rough roll, pushing his left foot underneath the step. weather. The cadet’s leg was trapped under the walkway by heavy plates. The vessel had received high thickness (25 mm) steel plates at its previous port for carrying out certain repairs. These heavy steel plates had been temporarily stowed on the main deck, in crossing area between two cargo holds. This stowage area was near the steps of a raised platform which was fitted to facilitate safely crossing over the pipelines in the area. On the day of the incident, two seamen were working on a damaged cargo handling grab, which was stowed in the same cross deck area between the two holds. The vessel was rolling slightly due to the Cadet’s leg could be freed with great difficulty prevalent rough seas. using man power. Later cadet was transferred ashore for medical treatment. Deck cadet, meanwhile, happened to proceed to the same cross deck area in order to assist fitters in another task. 71REPORT ON SHIPPING CASUALTIES, 2014-16 3. Why it happened? threat posed by the steel plate lying unsecured on the deck. 3.1 Most proximate cause: 4. Lessons learnt: Improper securing and lack of basic seamanship. While the hazard of shifting of i) Good house keeping, appropriate plates was ever present, no timely mitigating stowage and adequate securing of all loose action was taken for the same. items form key elements of safety at sea. 3.2 Contributory factor ii) Crew shall be motivated to report any situation or practice that may form a possible i) Lack of Situational Awareness: None of hazard. This may be in the form of ‘Stop action’ the ships personnel, who had been in or around card. the cross deck area, noticed the imminent 72REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 05 Contact damage between vessel and lock gate 1. What happened? 3. Why it happened? An Indian bulk carrier made contact with the 3.1 Most proximate cause: lock gate while entering the lock gates at one Sudden outflow of water current causing the of the canals, thereby sustaining hull damage. ship’s bow to swing sharply onto her port side resulting in contact with the lock. 2. How it happened? 3.2 Contributory factor: An Indian flagged bulk carrier was entering lock gates at a canal during transit of the canal. (i) Inadequate ship-shore interface. The The vessel had pilot on board. vessel had not been made aware that such sudden development may occur. While entering the first lock, vessel was (ii) As there was no precedence of such sort maintaining itself in the centre of the canal of contingency it could not be foreseen by the and its speed at that instant was approx. 0.8 vessel’s staff and be prepared for. knots. 4. Lessons learnt: Suddenly, as the vessel arrived near to the lock gate there was a sudden outflow of water which i) Passage planning to be more elaborate and caused the ship’s bow to swing sharply on to take into account all possible exigencies, its port side. This resulted in vessel’s port bow including if any from past experiences and coming into contact with the locks. history. Vessel sustained damages to ship side on the ii) Ship shore interface shall be more port side, due to this contact. detailed. 73REPORT ON SHIPPING CASUALTIES, 2014 – 16 ___________________________________________________________________________________________________________________________________________________________________________________________________________ Mechanised Sailing Vessels (MSVs) Casualty Summary 01 Sinking of MSV due to flooding in heavy weather 1. What happened? By next day noon water ingress increased An Indian mechanised sailing vessel (MSV) substantially submerging MSV’s main sank at sea, while carrying a cargo of engine. Main engine’s cooling water pump construction material, due to bad weather. stopped, causing the main engine to trip shut. The MSV consequently lost propulsion and 2. How it happened? started sinking. A 42 years old Indian MSV was on a voyage At around 05:00 p.m., the crew were rescued from a foreign port in Indian ocean to an by a fishing vessel, passing close by while the Indian port. The vessel was carrying cargo of vessel is assumed to have sank to bottom of construction material. The MSV sailed out the sea. from its loading port at around 10:00 p.m. At the time of its departure weather conditions 3. Why it happened? were normal. However, no weather forecast 3.1 Most proximate cause: was obtained for the passage by the vessel’s crew. The MSV was also not fitted with any Heavy weather caused hull failure which lead equipment for receiving such information to water ingress and loss of stability while at sea. Besides, when the vessel’s owner 3.2 Contributory factors had communicated with the vessel’s staff through phone, a day before the vessel’s i) Vessel’s age, as the MSV was 42 years old. departure from its load port, he also did not apprise the crew about expected weather ii) No weather reports considered prior during the forthcoming voyage commencement of the sea passage. Even the vessel’s owner did not inform vessel about weather forecast. Right from early in the morning, the very next day after its departure from the loadport, the iii) The vessel continued on its voyage despite MSV starting experiencing rough weather. having started experiencing adverse weather. Even though the vessel had an option of turning back to safety of its departure port, iv) The vessel could not seek assistance from tindal of the vessel opted to continue on the coastal authorities as it was not fitted with radio based communication equipment. passage. Soon weather worsened, and vessel started rolling and pitching heavily. v) MSV’s crew could not identify the location of ingress of water and therefore could not Later around, 03:00 p.m., ingress of water was take any corrective action for same. observed in forward part of the MSV from 4. Lessons learnt: bottom side of its hull. Crew started removing this water using mechanical pumps. Location i) MSVs should be provided with minimum of water ingress however could not be equipment and/or arrangement to receive ascertained. As water ingress did not appear weather forecasts prior commencement and to be excessive, the vessel continued on its during the course of voyage. voyage through the prevalent adverse weather ii) MSV crew should ensure that Maritime condition. Meanwhile, MSV’s crew could not safety information, including weather seek assistance from coastal authorities as the forecasts, is obtained prior to commencement MSV was also not fitted with communication of voyage and be duly acted upon. equipment for the same. 74REPORT ON SHIPPING CASUALTIES, 2014 – 16 ___________________________________________________________________________________________________________________________________________________________________________________________________________ Casualty Summary 02 Fire on MSV leading to its sinking 1. What happened? Despite fighting of fire for next couple of hours An Indian mechanised sailing vessel (MSV) of by port’s fire fighting service, the situation about 850 GT caught fire, when alongside at a appeared to be only getting worse. Fire was foreign port. As the fire could not be now getting beyond control and appeared controlled, the vessel was towed out of the endangering safety of nearby jetties and port. While being towed out of the port, the infrastructure. The port authority therefore MSV grounded and eventually sank. decided to tow the vessel out of the port to its outside anchorage. 2. How it happened? During being towed, at around 01:00 p.m., the An Indian MSV of approx. 850 Gross Tonnage, MSV ran aground and sank about 10 nautical had loaded miscellaneous general cargoes and miles from the port leading to total loss of the was preparing to sail out from a foreign port. MSV. This MSV was being manned by 15 crew members. 3. Why it happened? In the morning at around 07:30 a.m., while 3.1 Most proximate cause: the MSV was still alongside jetty, smoke was noticed coming out from top of its engine Probable cause could be a short circuit in room opening. Crew members immediately electrical wiring in MSV’s engine room. rushed to the engine room and found that there was smoke concentrated near forward 3.2 Contributory factor part of the engine room. Nearby fire extinguisher was used in an attempt to i) MSV not being maintained as required by extinguish fire, but fire could not be statutes. Its certificate of annual inspection extinguished. Rather the smoke continued to had already expired. rise and started spreading towards the vessel’s cargo compartment. Crew used all portable fire ii) Non fitment of fire detection and fixed fire extinguishers, fitted on board, in an attempt fighting system in the MSV. MSVs are non to extinguish fire but no favourable results conventional vessels and not required to be could be achieved. equipped with such equipment. Also structural fire protection not available to At around 10:00 a.m., nearly two and a half restrict the spread of fire within engine room hours after onset of the fire, port’s fire only. service was called in by the port’s authority. Crew members were asked to evacuate the iv) No mention of use of water initially by vessel, while port’s fire service commenced MSV’s crew in fighting fire. fighting fire from top of the vessel’s engine room. The crew, however, also continued their 4. Lessons learnt: efforts by unloading cargo so that fire could also be dealt with from top of the vessel’s More effective use shall be made of fire cargo hold. extinguishing equipment. _ _ _ _ _ _ _ _ _ _ _ 75REPORT ON SHIPPING CASUALTIES, 2014 – 16 ___________________________________________________________________________________________________________________________________________________________________________________________________________ Casualty Summary 03 Sinking of mechanized sailing cargo vessel due to hull failure in heavy weather 1. What happened? ingress of water and water level continued to increase in engine room. Soon there was An Indian MSV suffered hull failure due to power failure (black out) on the MSV, probably heavy weather and subsequently sank. when sea water touched electrical wiring terminal in the engine room. 2. How it happened? At approx. 11:30 p.m. crew abandoned the ill An Indian MSV had sailed out from a port in fated MSV on a fibre glass rescue boat, while Gulf of Aden to another, after having loaded the MSV sank to bottom of the sea in darkness 450 metric tonnes of cargo such as wheat of the night. flour and pasta. The vessel had sailed out at 06:00 a.m. and weather conditions at that 3. Why it happened? time were fine, with slight sea. The MSV had 3.1 Most proximate cause: on board multi national crew, including 04 Indians. Breach in MSV’s hull due to heavy weather. Approximately 09 hours into the voyage, at 3.2 Contributory factor about 03:00 p.m., the MSV's engine room crew observed ingress of water in its engine room i) As MSVs are non conventional vessels, the bilges. Both engine driven bilge pumps were MSV may not have been built to the strength, started to pump out water. In the mean time, and stability (both intact and damage) sea outside grew choppy coupled with high requirements. swell of around 5 to 6 feet height. The sea and swell were breaking on MSV’s deck. Wind was ii) Weather forecast was not considered prior growing stronger. to departure from port. iii) Even though the MSV’s certificate of In next few hours, when the MSV was nearly inspection was valid, however the annual 100 nautical miles from the nearest coast, inspection and endorsement period for the weather worsened causing the MSV to roll, same had got expired 6 months prior to the pitch and its bow to pound heavily. Tindal of incident. the MSV tried to steer the vessel so as to reduce effects of weather but did not succeed. iv) Precious time was wasted by MSV’s crew before it was identified that water was entering Meanwhile, water ingress in MSV’s engine into the ship from cargo hold area. room had increased. All 4 standby bilge pumps were also put into use to pump out the v) Effective efforts were not to restrict ingress water. of water into the cargo hold. Soon, it was realised that water was ingressing 4. Lessons learnt: from forward part of the engine room i.e. from cargo hold of the MSV. This could have been i) Maritime safety information, including due to breach of hull in way of cargo hold but weather forecasts, should be obtained prior to the exact location could not be identified due commencement of voyage and be duly acted to presence of cargo in the hold. upon. By around 09:00 p.m., even the 06 bilge ii) The MSV’s should undergo inspections and pumps were not being able to cope up with the surveys at stipulated times and intervals. 76REPORT ON SHIPPING CASUALTIES, 2014-16 Casualty Summary 04 Sailing cargo vessel running aground due to cyclone 1. What happened? While the crew was rescued, the MSV could not be salvaged and went on to be a total loss. There was a total loss of an Indian MSV, due to it running aground because of heavy weather 3. Why it happened? conditions. 3.1 Most proximate cause: 2. How it happened? Vessel running aground due to heavy weather. An Indian mechanized sailing vessel (MSV) had 3.2 Contributory factor sailed out from a foreign port with approx. 750 metric tonnes of coal cargo. The MSV was being i) Ingress of water in engine room of the MSV manned by 15 (fifteen) crew members. On departure from its load port, the MSV ii) The MSV being non conventional vessel received a cyclone warning on its passage. As may not have been strengthened and equipped a safety measure, MSV was anchored in the to bear cyclonic weather conditions. shelter of a nearby island. iii) Weather forecast was not considered prior to departure from load port. However, as the weather worsened there was an ingress of water in engine room of the MSV. 4. Lessons learnt: The crew tried to pump out the water. The crew also tried to heave up the anchor however the Maritime Safety Information, including weather anchor rope parted and the MSV, under the forecasts, should be obtained prior to influence of prevailing weather conditions, commencement of voyage and be duly acted drifted on to run aground on nearby coast upon. 77REPORT ON SHIPPING CASUALTIES, 2014 – 16 ___________________________________________________________________________________________________________________________________________________________________________________________________________ Casualty Summary 05 Total loss of mechanized sailing vessel (MSV) due to steering failure 1. What happened? It got too late before the vessel’s staff could realize their oversight and initiate actions to An Indian mechanised sailing vessel (MSV), on check drift of the MSV, which, in absence of a voyage from an Indian island port to the any check or control, as per the crew, Indian mainland, sank 6 miles off its drifted on to hit an unknown and destination due to failure in its steering gear. unnoticed wreck. The MSV’s hull got breached. At least three planks were seen separated from the vessel and sea water 2. How it happened? started gushing into the vessel. Crew tried to pump out the sea water but in vain. The MSV The MSV was on its way back from a port on took a list due to flooding of its cargo space an Indian island, to a port on main land of and started sinking. India. It had unloaded some general cargo at the island’s port. During this return passage, Crew reportedly, called Coast Guard on VHF the MSV was being manned by seven crew channel 16, however no response was received members, including a certified Tindal. Vessel from anyone in the vicinity. had valid certificates on board including Sensing danger to their personal safety, crew certificate of inspection. It is reported that the abandoned the stricken vessel. Within minutes vessel's engines, communication system and of abandoning the vessel, at around 10:30 other equipment had been checked by the p.m., the crew witnessed sinking of the vessel. Tindal and crew, prior to commencement of this return voyage, and same had been found All seven crew members survived by holding to be in good working order. on to the wooden planks till morning when they were noticed by a small fishing boat, After about 22 hours of sea passage, when the which picked them up and safely transported vessel was just 6 miles short of its destination to their port of destination. port, a noise was heard by vessel’s staff which 3. Why it happened? had emanated from gear box of the vessel’s steering system. Inspection of gear box 3.1 Most proximate cause revealed a broken chain, rendering the steering system unavailable. Poor situational awareness and failure of teamwork and contingency management. Just one exigency and there was a total failure of The crew lost situational awareness and organizational setup. All simultaneously got somehow all of them got involved in repair of involved in repairing the steering gear chain the steering chain. Nobody was left to watch with nobody left to monitor the vessel’s the vessel, despite the fact that its engines position which continued drifting unattended, were still running at slow speed. The MSV proceeding on to hit the reportedly unnoticed continued to drift unwatched, unattended and and unknown wreck. uncontrolled under the combined effects of slowly running engine, sea current, rough sea 3.2 Contributory factors condition and an off shore wind, all of i) Loss of control due to machinery failure i.e. which reportedly, the vessel was experiencing failure of the steering gear system. at that time. 78REPORT ON SHIPPING CASUALTIES, 2014-16 ii) Lack of seamanship as anchors were not 4. Lessons learnt: used to check or stop the drift of the vessel. i) Vessel should not be left, at any time iii) The MSV being non conventional vessel without proper watch-keeping, even when not may not be equipped with charts and under command. publications, as required. Therefore they may ii) Use anchors / engines to check not be aware of navigational hazards which may uncontrolled drifting of vessel. lie outside its conventional route as was in this case as the vessel drifted off its intended path. 79REPORT ON SHIPPING CASUALTIES, 2014-16 III - STATISTICS 1. Summary of all casualty events reported ................................................. 81 2. Summary of Marine accidents as per Severity.......................................... 84 3. Summary of Marine accidents as per type of vessels ................................ 85 4. Summary of the consequences of various casualties ................................ 87 5. Summary of Marine accidents comparing casualties involving Indian seafarers on Indian & Foreign flagged Ships.................................. 89 6. Summary of deaths and injuries due to casualties and of missing persons.................................................................................................... 93 80REPORT ON SHIPPING CASUALTIES, 2014-16 Statistics 1 Casualty Event (Nature of Casualty) 81REPORT ON SHIPPING CASUALTIES, 2014-16 82REPORT ON SHIPPING CASUALTIES, 2014-16 83REPORT ON SHIPPING CASUALTIES, 2014-16 Statistics 2 Severity of Casualty 84REPORT ON SHIPPING CASUALTIES, 2014–16 Statistics 3 Type of vessels involved Sr. Type of vessels Year No. 2014 2015 2016 Total General cargo & 1 18 33 23 74 Bulk carrier 2 Container vessel 11 3 5 19 RO-RO/Vehicle/Car 3 1 3 1 5 Carrier 4 Crude Oil Tanker 8 4 2 14 Chemical/Oil 5 8 7 9 24 Product Tanker Liquefied Gas 6 3 4 1 8 Carrier 7 Passenger vessel 4 1 2 7 Other vessels (AHTS, OSV, Tugs, Tows, Barges, 8 13 7 8 28 drillship, Survey and research vessel, dredger) Total 66 62 51 179 85RRREEEPPPOOORRRTTT OOONNN SSSHHHIIIPPPPPPIIINNNGGG CCCAAASSSUUUAAALLLTTTIIIEEESSS,,, 222000111444–––111666 General cargo & Bulk Container vessel RROO--RROO//VVeehhiiccllee//CCaarr carrier CCaarrrriieerr 40 20 33 22 10 20 11 0 0 00 2014 2015 2016 2014 2015 2016 2014 2015 2016 Crude Oil Tanker Chemical/Oil Product LLiiqquueeffiieedd GGaass CCaarrrriieerr Tanker 8 10 4 6 4 2 5 2 0 0 0 22001144 22001155 22001166 2014 2015 2016 2014 2015 2016 OOtthheerr vveesssseellss PPaasssseennggeerr vveesssseell ((AAHHTTSS,, OOSSVV,, TTuuggss,, TToowwss,, BBaarrggeess,, ddrriillllsshhiipp,, SSuurrvveeyy aanndd rreesseeaarrcchh 4 vveesssseell,, ddrreeddggeerr)) 20 2 10 0 0 22001144 22001155 22001166 2014 2015 2016 888666REPORT ON SHIPPING CASUALTIES, 2014-16 Statistics 4 Consequences due to casualties 87REPORT ON SHIPPING CASUALTIES, 2014-16 88REPORT ON SHIPPING CASUALTIES, 2014-16 Statistics 5 Comparison of casualty events and consequences involving (a) Indian seafarers on Indian ships, (b) Indian seafarers on foreign ships and (c) casualties occurring in Indian waters, other than those involving Indian ships or Indian seafarers. 89REPORT ON SHIPPING CASUALTIES, 2014-16 Comparison of casualty events and consequences involving (a) Indian seafarers on Indian ships, (b) Indian seafarers on foreign ships and (c) casualties occurring in Indian waters, other than those involving Indian ships or Indian seafarers 90REPORT ON SHIPPING CASUALTIES, 2014-16 Comparison of casualty events and consequences involving (a) Indian seafarers on Indian ships, (b) Indian seafarers on foreign ships and (c) casualties occurring in Indian waters, other than those involving Indian ships or Indian seafarers 91REPORT ON SHIPPING CASUALTIES, 2014-16 Comparison of casualty events and consequences involving (a) Indian seafarers on Indian ships, (b) Indian seafarers on foreign ships and (c) casualties occurring in Indian waters, other than those involving Indian ships or Indian seafarers 92REPORT ON SHIPPING CASUALTIES, 2014-16 IV – TRENDS’ ANALYSIS 1. Trend Analysis - collision 1.1 After a brief decline in collision collisions took place during berthing, STS incidents in 2014 there was a noticeable operation or when vessels were approaching / increase in 2015. leaving ports. These trends indicate towards inadequate familiarity of the navigating staff 1.2 Non-adherence to COLREGs, delay in with ship's manoeuvring characteristics and taking appropriate actions and lack of effect of weather, environmental, topographical situational awareness remained major causes and other conditions, including interaction, on behind collisions, which involved junior manoeuvring of the vessel. navigating officers. Collisions have also occurred when the vessels were under the 1.3 Inadequate passage planning has also direct con of master or senior officers. Such contributed to collision incidents. 94REPORT ON SHIPPING CASUALTIES, 2014-16 1.3 A vessel's turning behaviour may 1.4 Inadequate and inappropriate bridge vary considerably due to factors such as watch levels have also contributed to such accidents. Reduction in the number of persons wind, available depth etc. Understanding deployed on bridge as well as deploying watch this limitation is critical for every keepers in duties other than watch keeping navigating officer, as in a few cases it has have acted as prime factors in certain cases. been observed that actions to avoid close This calls for greater impetus behind effective quarters situation with small crafts, such bridge resource management. as fishing boat, were delayed significantly. 1.5 VTS/ VTMS could have assumed By the time actions were initiated, there was greater role in the avoidance of a couple of left insufficient time for the vessels to act collision incidents. Strengthening of such as desired. services may be considered. 2. Trend Analysis - Grounding 2.1 While improper manoeuvring and available with the vessel. Maritime underestimation of the effects of weather safety information in this regards had and currents by the bridge team not been timely promulgated. The remained prime causes behind various Directorate is strengthening inspections grounding incidents, there has been an of ports under NSPC, to avoid any such incident where correct depths were not recurrence. 3. Trend Analysis -Contact Damage 95REPORT ON SHIPPING CASUALTIES, 2014-16 3.1 Errors in navigation again appeared as 3.3 Not keeping safety margins and not prime factors in contact damages. having ready a back up plan in case of failure of any equipment also contributed in a few 3.2 However other than navigational errors, incidents. contact damages also occurred due to hardware failures such as parting of tug's lines etc. 4. Trend Analysis -Fire/ Explosion 4.1 There was a reduction in the number of 4.4 There was an explosion in cargo hold of a fire accidents, in particular those involving container vessel reportedly due to incorrect declaration of cargo stowed in containers. Indian seafarers, in the past three years Appropriate stowage and carriage requirements however the incidents continued to happen. therefore could not be followed. Also due to lack of correct information about the cargo, correct 4.2 Such fire incidents were spread through contingency measures could not be deployed. different locations on ships, varying from deck Stricter implementation of regulations in to engine room to accommodation. The causes regards to declaration of cargoes may therefore behind such fires were also varied, varying from be considered. basic negligence, wherein an iron used for ironing clothes was supposedly left unattended 4.5 While the number of fire incidents was on the bed to major failures in safety reduced, a worrisome factor that has emerged is the way in which some of these fires, in procedures such as explosion in a cargo tank particular on coastal vessels and MSVs, were during dry docking. dealt with. The fire fighting techniques deployed by vessel's staff in such cases, were 4.3 Fire incidents in engine room continue to not in accordance with the established raise concerns contingency plans. 96REPORT ON SHIPPING CASUALTIES, 2014-16 5. Trend Analysis -Missing Persons 5.1 There is an increase in the number of unspecified/ unknown in many other missing Indian seafarers and passengers who went persons' cases. missing from ships In between 2014 to 2016. 5.2 Psychological distress can be one of While accidentally falling overboard remained such unknown factors wherein the missing prime cause, the reasons remained person may have taken suicidal steps. 6. Trend Analysis -Pollution Incidents 6.1 Other than keeping a check on sub various stakeholders to eliminate operational standard ships from plying in Indian waters and deliberate pollution. Reception facilities through PSC and FSI, the Directorate is at various ports are being reviewed and taking strong measures in coordination with strengthened. 97REPORT ON SHIPPING CASUALTIES, 2014-16 7. Trend Analysis -Injuries and Accidental deaths 7.1 There is a noticeable increase in the 7.3 Majority of injuries and deaths involved number of injuries, which is worrisome. young seafarers with lesser on job experience. Although the number of accidental deaths This indicates lack of guidance, mentorship and declined, still it remains unacceptable. friendly dialogue from seniors. These have remained strong elements of on board training. 7.2 Various casualties could have been easily averted by application of basic 7.4 Lack of situational awareness and haste competencies, proficiencies, skills and/or have been major factors. It is observed that seamanship which a seafarer is expected to safety measures were circumvented in cases acquire during various pre and post sea in hurry to complete a job or to achieve competency and modular trainings. commercial deadlines. 98REPORT ON SHIPPING CASUALTIES, 2014-16 7.5 Ineffective resource management 7.9 Casualties in enclosed spaces remained a major cause as personnel deployed continued unabated during the three years. for a particular task may not have been This despite the fact that IMO had come out with circular in this regards and most of the competent and sufficiently experienced for such PSCs ran a concentrated campaign on the job. Besides nobody was deployed for issue. The casualties indicate that efforts supervision and safety monitoring in many cannot be relented in this direction. critical operations. In some cases, crew were left to work alone in isolated and high risk 7.10 Injuries while working with incinerator areas. Poor resource management also led to and while trying to take photographs of inner fatigued seafarers getting assigned for jobs liner surface from scavenge space have emerged prime from those in engine room. when their alertness and decision making is already adversely affected. 7.11 Injuries, in particular burn injuries, have been sustained while working on 7.6 Assigning lesser crew than what may equipment which were not cleaned free of have been required for safe conduct of a job combustible material, ventilated and isolated also acted as a major contributing factor, in again indicating inadequate risk analysis. particular in mooring related incidents. 7.12 Slips, trips, incorrect lifting postures, 7.7 Any form of formal risk assessment was use of improper tools, incorrect use of observed missing in various cases. Basic safety pneumatic and hydraulic high pressure equipment, tripping body parts in moving measures such as arranging temporary guard machinery etc. have all led to various injuries. rails, display of warning notices etc. is also A majority of such casualties could have been observed missing. avoided by good housekeeping, proper securing 7.8 Casualties have continued to happen of loose gear, effective guarding of moving parts of machinery and application of basic with persons falling from height be it in tanks, seamanship. in engine room or overboard, into water. Other than training seafarers in working aloft and 7.13 A few fatalities could have been avoided, over side procedures this also calls for ensuring had timely medical assistance from ship or from quality of access ladders as well as availability shore been provided to the deceased. In view of personal protective equipment and floatation of the above augmentation of medical devices for working aloft and over side. evacuation arrangements may be considered. 99