Poor shipboard culture and a questionable decision not to initiate a search are highlighted in the Danish Maritime Authority’s report into the disappearance of a seafarer from Tor Anglia in November 2008.
MAC is publishing the report almost in its entirety. Poor shipboard culture plays a role not only in individual safety, as in this case, but the safety of a vessel and its crew, as in the case of the Bow Mariner.
An AB, 44 years of age and of Polish nationality was on 25 November on watch on the
bridge from 20 to 24 hours.
On his next watch on 26 November at 0800 hours the AB did not show up. He had not been in the mess room for breakfast.
Nobody had observed him since he was relieved from his watch at midnight. He was seen last time, when he was going down the indoor staircase from the bridge.
The position of Tor Anglia was at 08.00 hours 29.01’ N – 015.29’ W approximately 35 nm northeast of Tenerife. The wind was north 10-14 m/s, the wave height was 4-5 metres and the visibility was good.
At 0815 hours a search on board the ship was initiated.
At 0830 hours the general alarm was activated. The crewmembers were mustered, but the missing AB did not show up.
At 0835 hours the designated person of the company was contacted. It was decided to search again and after that to contact the relevant authorities, if the AB was not found.
At 0840 hours a search was initiated according to the ISPS search team plan. The search was ended at 0910 without a positive result.
At 0915 hours MRCC Tenerife was informed by telephone and email. MRCC Tenerife initiated a Search and rescue operation. According to the master of TOR ANGLIA, MRCC Tenerife recommended the ship to proceed to Santa Cruz de Tenerife. Because the sea was rather rough the master agreed to this recommendation. MRCC Tenerife has another explanation on this communication.
At 1105 hours the ship was contacted by MRCC Tenerife. They had a message from the police that Tor Anglia must participate in the search and rescue operation. The ship’s course was altered 180 degree to course 045 degree.
The rescue ship LUZ DE MAR was appointed Onscene Coordination vessel.
At 1830 hours, when it became dark, Luz De Mar ended the search and rescue operation and informed Tor Anglia , that the ship could proceed to Santa Cruz de Tenerife.
Information from MRCC Tenerife
On 26 November at 0920 hours Tor Anglia reported by telephone to MRCC Tenerife that a crewmember was missing from the ship. A rescue helicopter was scrambled and CCS Las Palmas was notified.
Before MRCC Tenerife was asking about the ship’s intentions, Tor Anglia advised that the ship was proceeding on the voyage to Santa Cruz de Tenerife.
At 0927 hours a rescue aircraft was scrambled.
At 0940 and 0948 the rescue vessels Salvamar Tenerife and Luz De Mar were mobilised.
The current in the search area was 0.2-0.4 knots. The sea water temperature was 20-25 deg. C.
At 1057 hours MRCC Tenerife instructed Tor Anglia to participate in the search.
TOR ANGLIA informed on request that all life jackets, life buoys and diver equipment was on board.
All ships passing the search area were requested to maintain an increased lookout for the missing crewmember.
At 1841 hours Luz De Mar ended the search and rescue operation.
At 2055 hours a briefing was held at MRCC Tenerife. It was decided to resume the search the next day by rescue vessel and helicopter.
On 27 November at 0804 hours the search was resumed by rescue vessel and helicopter. Between 0940 hours and 1345 hours also a rescue aircraft participated in the search. The search was continued the rest of the day.
During the masters inspection of the AB cabin two pill boxes were found. There was text in Polish on the boxes. One of them was empty and thrown into the wastebasket.
The impression of the master was that it was a psychoactive drug – a “stesolid” like preparation. The boxes were not saved, but according to the report from the Spanish police the drug was OXAZEPAM. OXAZEPAM is used as a tranquillizer for anxiety and for withdrawal symptoms after alcohol abuse.
A medical certificate for the AB issued in Gdynia on 7 June 2006 had no particularly observations. It was stamped and the text was: ”Mr……..underwent alcohol, neurotic and drug test – negative”.
In the ISM-system of the ship, there was no instruction how the master should act in the actual situation.
Reports from Spanish police
The Spanish police was on board Tor Anglia , when the ship had arrived at Santa Cruz and again approx. a week later, when the ship arrived to Santa Cruz again.
The police received statements from the master, the chief officer and three Polish crewmembers. In the reports it is stated from one of the Polish crewmembers, that he thought it was suicide, because the missing AB had been very introverted and did not speak much. The Polish crewmembers stated that the missing AB did not communicate much. They were not aware of any problems between the missing AB and other crewmembers. It was the understanding of the master and the chief officer that the AB had committed suicide.
Information collected in 2009
The master of TOR ANGLIA has maintained that it was MRCC Tenerife who recommended TOR ANGLIA to proceed to Santa Cruz de Tenerife. The communication was carried out by satellite telephone. During the communication the master asked MRCC Tenerife to repeat the recommendation that Tor Anglia could continue its voyage.
The master did agree in MRCC’s recommendation about continuing the voyage. The master has informed that the other officers on board also agreed. Just after the communication with MRCC Tenerife the master contacted the designated person of the company. The DP did also agree in the decision.
The reason was that the missing AB had not been observed since midnight, when he was relieved on his watch on the bridge. It was the understanding of the master that the AB must have disappeared around midnight. He was sure, that they would not be able to find the AB alive because of the rough sea with a wave height of 5-6 metres.
The ship was rolling much because of the height and direction of the waves. The master assessed that it would not be possible to recover a deceased person because of the weather conditions.
The missing AB was an experienced seaman with more than 20 years at sea. When the AB was relieved from his watch, he was using the indoor staircase. The waves did not swamp the deck.
Obligations and procedures
Notice B, Chapter V, Regulation 33 – Distress Messages: Obligations and procedures is about those obligations and procedures which must be followed, when persons are in distress at sea.
In the regulation is stated: “The master of a ship at sea which is in a position to be able to provide assistance, on receiving information from any source that persons are in distress at sea, is bound to proceed with all speed to their assistance, if possible informing them or the search and rescue service that the ship is doing so”.
Analyses and conclusion
The decision not to alter course and initiate the search at once
According to the master of Tor Anglia , MRCC Tenerife recommended the ship to proceed to Santa Cruz de Tenerife.
According to the report from MRCC Tenerife, Tor Anglia advised that the ship was proceeding on the voyage to Santa Cruz de Tenerife, before MRCC Tenerife was asking about the ship’s intentions.
According to the E-mails from the ship to the company, the ship informed the company, that MRCC Tenerife recommended the ship to continue the voyage to Tenerife.
The Division for Investigation of Maritime Accidents has not been able to establish, what was recommended or if anything was recommended by MRCC Tenerife.
The Master has told that it was his understanding that the AB must have disappeared around midnight. However, there is no information on when the AB disappeared between midnight and 08 hours in the morning.
It was the understanding of the master that a man over board could not survive under
the present weather conditions. But it is not known when he disappeared and the temperature of the sea was relatively high.
It was the understanding of the master that it would not be possible to recover a deceased person from the sea under the present weather conditions.
It is the assessment of the Division for Investigation of Maritime Accidents that common seamanship prescribe that the ship turn around and initiate a search as soon as it is known that a person is no longer on board.
It is the assessment of the Division for Investigation of Maritime Accidents that the decision to proceed to Santa Cruz after it became clear that the AB was missing was wrong.
It is the assessment of the Division for Investigation of Maritime Accidents that the master should have turned around at once and initiated a search, regardless any recommendation from MRCC or not.
The master informed the company by telephone and e-mail, that the MRCC recommended the ship to proceed and that the ship continued its voyage. The company supported this decision.
It is the assessment of the Division for Investigation of Maritime Accidents that such a decision should not be discussed with the company. The master must take the decision alone. The master is the person with the best knowledge of the situation and the conditions. The company should abstain from statements, which can influence the decision.
The disappearing from the ship
It has not been established, how, when and why the AB disappeared from the ship.
Recommendations and initiatives
Because of this occurrence the Division for Investigation of Maritime Accidents will extend its investigations in all cases, where persons disappear from the ship, while at sea.
The Division for Investigation of Maritime Accidents recommends the company that this report is discussed with the masters of the company.
Two Polish crewmembers have in 2009 in written statements strongly criticised that the master did not turn around at once and initiated the search. According to these crewmembers, the Polish crewmembers were treated with contempt by the Danish officers.
The Division for Investigation of Maritime Accidents recommends the company to consider the statements in order to ensure that a good working environment on board is maintained.