Systems to prevent a pilot’s fatigue, an officer of the watch distracted by other duties, an undermanned bridge and uncorrected charts led to the grounding of the Bahamas-flagged Crete Cement on the south-eastern tip of Aspond Island. She was able to continue but flooding due to compromised watertight integrity led to intentional beaching in the Grisebubukta bay off Fagerstrand.
A joint investigation by the Accident Investigation Board of Norway and the Bahamas Maritime Authority says: “In the early morning of 19 November 2008, the Crete Cement was heading for Slemmestad, after having taken on board approximately 5,000 tonnes of cement at Norcem Brevik.
There were 13 crew on board, including a pilot. The bridge was manned by the pilot, the officer of the watch and a lookout. On passing Digerud, the course should have been altered to starboard to pass between Digerud and Aspond Island. This was not done, and the Crete Cement ran aground at the south-eastern tip of Aspond Island at 06.31.
It was initially decided to continue towards Slemmestad. This was soon reconsidered as it was discovered that Crete Cement was taking in a lot of water and large parts of the vessel was about to be flooded as a result of open or leaking hatches and manhole covers. It was decided to beach the vessel in the Grisebubukta bay off Fagerstrand instead. Crete Cement was beached at approximately 06.59. The vessel continued to take in water, and RCC decided to evacuate the crew to ensure their safety.
Evacuation was completed at 08.30 without any personal injuries. Oil-spill response resources were soon in place, and the environmental consequences of the incident were minimal.
Several causes contribute to explaining why the course was not altered when passing Digerud. The pilot had been on duty for a week and, during this period, his work load had been heavy and involved much night work and few opportunities to get enough rest and sleep. The AIBN finds it highly probable that sleepiness, as a result of insufficient sleep and an unfavourable time of day, is an important factor in explaining this incident. Barriers that should have been
in place to handle the problem of the pilot’s sleepiness were weak or absent.
The officer of the watch was required to deal with other tasks which distracted him from his navigational tasks,
without another navigator being added to the bridge crew. In addition, the capacity of the officer of the watch to keep track of the vessel’s exact position was reduced because the navigational aids in the area had been changed and corrections to the charts were not readily available to the crew. When it was discovered that the vessel was heading for the shore, it was too late to avoid running aground.
On the journey from Brevik to Slemmestad, the vessel’s watertight integrity was not satisfactory. A manhole cover in the engine-room floor, which for all practical purposes is a part of the watertight bulkhead, was only fastened with two or three of a total of 24 bolts, and water entering the bow-thruster room was therefore able to flow into the engine room. This meant that the engine room of the Crete Cement would, relatively quickly, have been filled with so much water that the main engine would have stopped and the vessel would eventually have sunk. The decision to beach the vessel meant that this was prevented. Hence the rescue, salvage and oil-spill response actions were of a different nature than they would have been if the Crete Cement had sunk where the water was deep.
The AIBN proposes five safety recommendations in this report. They are addressed to the Norwegian Coastal Administration, which is recommended to implement measures to ensure that pilots have sufficient sleep and rest. It is recommended that the Norwegian Mapping Authority – Norwegian Hydrographic Service endeavour to promote international standards for the presentation of chart corrections in electronic charts.
It is recommended that Bureau Veritas take operational issues into account when construction drawings of watertight
bulkheads are reviewed. It is recommended that the owner, Kristian Gerhard Jebsen Skipsrederi AS, to change or clarify its safety management system to ensure that the bridge is adequately manned in demanding situations. It is also recommended that the owner introduce compensatory measures on vessels where the crew have to pass through watertight bulkheads to carry out maintenance and repair.
Download the full report here.