Accident Investigation » Maritime Accident Casebook

Corrosion Dropped Thomson Majesty Lifeboat – Malta

Accident, Accident Investigation, Cruise ship, davit-launched, lifeboat, lifeboat accidents, lifeboat safety, safety alert, Safety Alerts, seafarer fatalities No Responses »

Feb 272013

Forward Davit Arm Showing Parted Wire. Photo: Maritime Safety Investigation Unit

Malta’s Maritime Safety Investigation Unit has issued a safety alert following the discovery of significant corrosion on inner strands of a fall wire involved in the falling of of a lifeboat on 10 February 2013. Five seafarers died in the incident which occurred aboard Thomson Majesty while berthed alongside in Santa Crux de La Palma.

Says the safety alert: ” The wire rope had parted approximately where it rested over the topmost sheave, when the davit was in a stowed position.

“The fore and aft davit’s falls were replaced on 22 August 2010 and the next scheduled replacement was August 2014.

”The launching appliance had been dynamically tested in May 2012.

“Initial results of the tests carried out on the parted ends of the wire indicate significant corrosion damage to the inner strands of the wire”. Continue reading »

Pirate Queen Grounding – Defective Nav Light, Defective Procedures

Accident, Accident Investigation, Accident report, Ferry, grounding No Responses »

Feb 232013

Roonagh Pier.

Eire’s Marine Casualty Investigation Board says that failure of the leading lights at Roonagh Pier were the main cause of the grounding of the passenger ferry Pirate Queen but further investigations revealed serious weaknesses in the navigational procedures and practices on the company vessels. There appeared to be an over reliance on visual aids to
navigation and a neglect to practice and use the electronic aids on board.

On the evening of 20th December 2011 the inter island passenger ferry Pirate Queen grounded on rocks at the entrance to Roonagh Pier, Co. Mayo. The vessel was refloated shortly afterwards and although not holed, it had sustained severe structural damage. Two of the passengers were taken off the ferry whilst she was on the rocks and transferred to the pier by a rigid inflatable boat. One passenger sustained injuries during the incident. Continue reading »

Is Your Bridge Prepared For Bad Weather?

Accident, Accident Investigation, Accident report, Safety Alerts, safety flash, seafarer fatalities, weather No Responses »

Feb 232013

The third officer on CCNI Guayas was less lucky.

Heavy weather does not have to be extreme to lead to injuries on the bridge – it’s enough to lack handrails and have improperly stowed equipment. The latest example comes from Marine Safety Forum, MSF, in a safety alert.

Recently on a vessel it was reported that a crewman had taken a fall in the bridge during heavy weather. He suffered only minor injuries.

The incident occurred whilst on sea passage as the vessel was in the process of altering course, the weather although heavy could not be described as extreme and the vessel would have encountered similar conditions on a regular basis. Continue reading »

USS Guardian Investigators To Collaborate

Accident, Accident Investigation, grounding No Responses »

Feb 142013

Battered USS Guardian may be first Philippine case under the IMO Code

Newly appointed US Secretary of State John Kerry has assured his opposite number in the Philippine government, Foreign Affairs Secretary Albert F. del Rosario, of “full cooperation in the salvaging of the USS Guardian as well as in the investigation of the grounding incident and that the US stands ready to fully and appropriately provide compensation for all damages” says the country’s information agency. Of particular note is the willingness of the US Navy to collaborate with Philippine investigators which may open the door to IMO compliant casualty investigations in the country.

Joint investigation of criminal charges are covered in the Visiting Forces Agreement, VFA, between the two countries. The entry of the USS Guardian into a restricted area was a breach of Philippine law. Under the VFA crimes committed by off-duty US military personnel in the Philippines come under the jurisdiction of the Philippines while crimes committed by on-duty personnel are under US jurisdiction. However, recent announcements by the Philippine Coast Guard that its investigation will comply with the non-liability provisions of the IMO Casualty Code may have enabled the US Navy to provide Philippine investigators access to shipboard personnel.

It will be the first investigation in the country carried out in compliance with the code.

Says Del Rosario: “One of the first things we discussed was the USS Guardian incident. We had a very frank discussion between friends. We both agreed on the importance of removing the USS Guardian from the reef without causing further damage,” Secretary del Rosario said, adding “Secretary Kerry reiterated the deep regret of the US government over the incident and its readiness to provide full and appropriate compensation.

“Secretary Kerry said that he himself wants to know and get to the bottom of what truly happened. In this context he said that he wants to be a full partner of the Philippines in finding out what happened and that the U.S. government will cooperate fully with the investigation that the Philippines is conducting,” Secretary del Rosario said, adding that this would include the willingness of the US to accept and answer queries posed by Philippine investigators to key US personnel.

According to Secretary del Rosario, Secretary Kerry is also committed to sharing the findings of the U.S. investigation and to consulting the Philippines and its experts before finalizing its investigation.

“We both agreed that it is important to understand what happened and to take the necessary navigational safety measures to protect the reef and that would prevent other ships from grounding there.”

Currently the Philippines has no official body of trained accident investigators which is complaint with the IMO Casualty Code. The country’s Board of Marine Inquiry, BMI, a quasi-judicial body, considers itself the sole agency authorised to carry out accident enquiries although the board has no professional investigators attached and is primarily concerned with establishing liability. Among potential stumbling blocks is that under current legislation any ‘competent court’ can demand access to data gathered during an investigation, including reports, with a view to establishing blame, which contravenes the IMO Code.

Efforts to establish an IMO compliant investigatory capability Philippines have been hamstrung by a BMI reluctance to have its authority diluted. Efforts to replace the BMI have been consistently blocked despite encouraging reports in 2011. However, the PCG investigation team operating within compliance is hoped to break the deadlock.

Blocked Data Caused DP Wandering While Divers Dived

Accident, Accident Investigation, Accident report, diver, diving, lifejacket, marine safety forum, Safety Alerts No Responses »

Feb 142013

Single fault failures should not be possible in safety critical systems. However, a recent incident in which dynamic positioning failed while divers were underwater show that they can and do happen in ways that, with 20/20 hindsight, are not surprising.

A serious incident occurred in which a diving support vessel’s dynamic positioning (DP) system, designated as IMO class 2, failed resulting in the vessel drifting off position while divers were deployed subsea. Investigations have shown that a probable cause of the DP failure was a single fault which caused blocking of the DP system’s internal data communications. Continue reading »

Nicolai Maersk Fatality: Think Before You Crank

Accident Investigation, Accident report, fatality, maritime safety news No Responses »

Feb 122013

Holding on to something that revolves at high speed is not conducive to a long life but inattention and a lack of safety instincts can result in the sorts of incidents covered in Denmark’s Maritime Accident Investigation report on a fatality aboard the Nicolai Maersk on 26 April 2012.

Nicolai Maersk arrived at Jebel Ali, Dubai, United Arab Emirates. Shortly after arrival at 1515 hours the ship began loading and unloading containers.

During the stay in Jebel Ali, the ship was to receive lubricating oil both in bulk and in drums. The drums were to be hoisted on board by means of the aft stores crane. The lubricating oil in bulk was to arrive by truck and be pumped on board at the bunker station on the upper deck close to the gangway. Continue reading »

Surprising Development in USS Guardian – Philippines To Invoke IMO Casualty Code

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Feb 052013

Battered USS Guardian may be first Philippine case under the IMO Code

In what may be a promising step forward for maritime accident investigation in the Philippines the country’s coast guard is to follow the IMO code of casualty investigation for it’s enquiry into the grounding of the USS Guardian. This will be the first investigation to follow the IMO code and is particularly unusual because it involves a military vessel of a foreign power.

In the Official Gazette, a joint US/Philippine statement says: “The Philippine government stated that the Philippine Coast Guard had commenced its independent inquiry into the grounding of the USS Guardian. Upon receipt of information on the incident, the Philippine Coast Guard formed the Maritime Casualty Investigation Team (MCIT) in accordance with its standard procedures and resolutions of the International Maritime Organization (IMO) on serious maritime incidents to establish the circumstances and causes of the grounding on Tubbataha Reef and to formulate safety measures to prevent a repetition of this incident”.

This will be the first time that a case has been investigated under the IMO casualty code.

No agency in the Philippines is charged with conducting non-liability investigations. Although recent legislation, RA 9993, has been passed which mandates adherence to the IMO code, the regulations and rules have bogged down on the insistence by the Board of Marine Inquiry, BMI, a body established to assess liability, that it alone has the authority to carry investigations although it has no members professionally trained to do so and its aims conflict with the requirements of the IMO Code. Those involved in trying to bring the Philippines in line with international standards have expressed frustration at the slowness and lack of understanding of those tasked with implementing the new code.

Whether the MCIT will form the basis for an IMO-complaint body in the Philippines remains to be seen. The Philippine Coast Guard is a law-enforcement body so its independence is questionable, and there remains the issue of whether its finding can be passed to a court whose purpose is to establish liability, as required under current Philippine legislation but contrary to the IMO code.

Most importantly, if the IMO code is followed, the resulting report must be publicly available which is not a current requirement in the Philippines.

The international maritime investigation community, many of whom are barred by law from collaborating with a Philippine investigation will be watching closely.

Seastreak Investigation Updates

Accident Investigation, allision, contact, Ferry No Responses »

Jan 262013

NTSB investigator John Lovell and a representative from the U.S. Coastguard document damage to the Seastreak Wall Street. Photo: NTSB

Updates have been released by the US National Transportation Safety Board on the investigation into the 9 January accident in New York City involving the Seastreak Wall Street ferry.

The engine manufacturer has arrived on-scene and investigators were able to download alarm and parametric data stored on engine control modules in each of the two engine compartments. In addition, investigators retrieved video from several onboard cameras. All of this information is being analyzed.

Investigators also tested the vessel’s steering systems and the tests were satisfactory.

The investigative team have started to conduct static testing of the main engines and control systems. Continue reading »

Lessons From The Guardian Grounding – Don’t Trust Charts

Accident, Accident Investigation, GPS, grounding, maritime safety news, US Navy 14 Responses »

Jan 192013

USS Guardian – thought the reef was eight nautical miles away

With a US Navy investigation underway to assess the circumstances surrounding the USS Guardian grounding that occurred in Philippine waters at 02.25 on 17 January local time there are lessons already to be learned: Charts are not infallible even if they are on screen and it is not wise to navigate to fine tolerances with the aid of GPS when the underlying data is less accurate than the GPS.

An inaccurate chart is not a defence – not bumping into bits of ground remains the master’s responsibility.

Much of the Philippine waters have not be surveyed for 50 years or more, an issue highlighted when the Greenpeace ship Rainbow Warrior also grounded on Tubbataha Reef in 2005. The chart in use showed the reef 1.5 miles from where it actually was.

The digital chart aboard USS Guardian, an Avenger-class mine countermeasures vessel, showed a position about eight nautical miles in error. At the time of the grounding the vessel was attempting passage through a channel just half that width.

Many Philippine charts have not been re-surveyed in some 80 years. Transferring this aged data to an electronic chart does not increase its accuracy. The current NGA chart for Tubbataha reef appears to be the 1986 edition, based on Philippine charts of 1975 and earlier.

According to a source in the Philippine Coastguard “With the 1940 or 42 charts by NAMRIA, there might really be a problem with that’s why we are advised to at least have a difference of Three nautical miles from the shoreline, we have to assume that there is one nautical miles changes in the chart already”.

NAMRIA tells Maritime Accident Casebook that the last hydrographic and topographic survey covering Tubbataha Reef was conducted in 2006 using single beam echosounder for the hydrographic data, 2008 is the latest hydrographic survey using multibeam echosounders. The chart was first published last May 2009 and the reef is marked as a restricted area on current charts.

On Friday, 18 January, the US National Geospatial-Intelligence Agency, NGA provided the US Navy with preliminary findings of a review on Digital Nautical Charts (DNC) that contain inaccurate navigation data and may have been a factor in the Guardian grounding.

This followed the realisation by NGA that there might be a potential inaccuracy regarding the Tubbataha Reef digital chart. NGA has reviewed data from more than 150,000 square nautical miles in the surrounding area and found no additional errors.

The incident may also lead to a review of the $30m 2006 joint hydrographic survey agreement between the US Navy and the Philippines after nine years of negotiations. The project was to use advanced sonar technology to map shipping lanes, harbors, and ports throughout the Philippines. However an incident involving a Philippine Maritime Police Patrol vessel firing warning shots against a US Navy survey vessel in January 2008 led to US Navy surveys being restricted to within four nautical miles of the coast.

The project was expected to generate some $300m in commercial value.

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