Exactly why the Eire registered MFV Iúda Naofa suddenly flooded and sank off the Butt of Lewis is unknown, says the Marine Casualty Investigation Board, MCIB. report, but there are still lessons to be learned.
Exactly why the Eire registered MFV Iúda Naofa suddenly flooded and sank off the Butt of Lewis is unknown, says the Marine Casualty Investigation Board, MCIB. report, but there are still lessons to be learned.
Owned by Odfjell Asia, operated by Ceres Hellic Shipping Enterprises and flagged in Singapore, Bow Mariner left New York at 0500 on February 28, 2004, 22 of her cargo tanks empty except for the vapour of Methyl Tert-Butyl Ether. The tanks were not inerted. Six of the ten remaining tanks contained 13.5 million litres of ethanol.
Aboard her were three Greek senior officers: Captain Efstratios Kavouras, Chief Officer Spiridon Melles and Chief Engineer Legantis-Eley Anasthasiou, and 24 Filipino crew, including Third Officer Lugen Ortilano on his first voyage as a licenced officer and second assistant engineer Edimar Aguilar, who joined the ship twenty three days before.
Only four other crewmembers survived the next 14 hours: Electrician James Bactat, Chief Cook Dominador Marentes, Messman Reynaldo Tagle and Able Seaman Ramon Ronquillo.
The three senior officers had created a climate of fear and intimation on the ship. Junior officers were prohibited from eating the the officer’s mess. They were prohibited from reading the Safety Quality and Environmental Protection Management documents, or from carrying the jobs specified in it. Senior officers did not train their subordinates in the technical and administrative skills they needed to operate the vessel safely.
The vessel carried no immersion suits. Fire and lifeboat drills were rare. Safety training records and the minutes of safety committee meetings were little more than fiction.
It was the second to last day of February, it was cold, with the air temperature at 4.4 Celsius, the sea a little more than a degree higher at 5.5 Celsius. There was a two metre sea running east and a 15 knot wind Northwest.
Third Officer Ortilano was officer of the watch from 0800 to 1200. A little before 10.00 hours, Captain Kavouras gave the order that would doom the ship. He told Ortilano to have the crew open the 22 empty tanks that had held MTBE and Ortilano followed that order.
MTBE vapour is heavier than air, it would not simply rise into the air and disperse when the tanks were opened. It can flow along a surface until it finds a point of ignition. It has a flashpoint of -25.6 degrees Celsius, well below the air temperature. The tanks were full of its vapour. As tank cleaning proceeded, those vapours were displaced, emerging onto the deck and collecting in pockets in corners and spaces.
Vapours like MTBE need a certain amount of oxygen in order to ignite. If the amount of vapour is below a certain level, called the Lower Explosive Level or LEL, it won’t explode. If the amount of vapour is above a certain level, called the Upper Explosive Level, UEL, it also won’t explode. Between these two levels it will explode if there’s a source of ignition.
When the tanks were opened, air entered the tanks, diluting the MTBE vapours to somewhere between the LEL and the UEL..
Put simply, when Third Officer Johnny Acuna replaced Ortilano at 11.50 with instruction from Chief Officer Melles for Ortilano to help with tank cleaning at 13.00, the ship was already a floating bomb. There was a strong smell of MTBE vapour on deck All it needed was a spark.
The tanks were not gas-freed, so Boatswain Aquilino Tabilin put on SCBA gear equipped with steel bottles and took an air-operated Wilden Pump into the tanks to remove residual MTBE from the cargo tanks with the help of an Ordinary Seaman and a Deck Cadet. By the time Ortilano arrived, the number nine centre starboard and wing tanks had already been emptied of remaining MTBE and Tabilin was working in the number eight starboard cargo tank.
Boatswain Tabilin’s entry into a cargo tank filled with explosive vapours wearing SCBA followed no known safe procedures to put it mildly.
At 13.30 the Wilden pump failed. Tabilin had it hauled out of the tank. While he was trying to repair it, Captain told him to get the Norclean Eductor, a kind of industrial vacuum cleaner used for draining combustible fluids, from the midship deckhouse.
When it arrived its drum was damaged so Kavouras told Ortilano to get two standard drums and have them adapted to replace the damaged one on the Eductor. The drums were strengthen, but there was no bonding between the drum itself and the lid, a precaution designed to prevent build-up of statical electricity.
The first drum was finished at 15.00 and taken on deck. At 17.05, Ortilano and an Engine cadet carried the replacement drums to the deck. The crew had already gone to eat but the Eductor had been mounted on the first drum, and the suction hose lead through the Butterworth opening near the the number eight starboard cargo tank expansion trunk, but the unit was not in operation.
Ortilano had lunch and at 17.30 went to his cabin to rest in readiness for his next watch.
Meanwhile, Ramon Ronquillo and Pumpman Tomas Ventenilla were blowing down cargo lines with compressed air. They probably weren’t aware that this was a bad idea. Blowing down cargo lines can create a static electrical charge which can spark and ignite any explosive fumes still in the pipe. They should have used an inert gas.
At 1800 the crew reported for overtime and went to work. It was twilight and the deck lights were switched on.
Ortilano, Bactat and Ronquillo were in their rooms, sleeping or resting. Chief Cook Marentes, Messman Reynaldo Tagle and messman Rosello were cleaning the galley. Second Assistant Engineer Aguilar was doing his rounds.
As Aguilar placed his hand on the handle of the engine room door, he heard the first explosion. By the time he reached the interior stairwell on his way to his room, the ship was already listing to starboard. He couldn’t open the door to his room. He went up to the bridge and got a lifejacket from the Pilot room.
In his cabin on the port side, Electrician Bactat heard a noise, the ship moved violently and began to list to starboard. Opening the window blinds he saw orange flame. He grabbed his coveralls and lifejacket struggling against the list, he made his way up to the bridge, where some of the windows were broken. He met with four others and made his way down exteriors ladders to the deck, the list making it hard to climb down.
In the galley, Chief Cook Marentes heard a boom and the ship shook violently. Messman Rosello started to panic. Marentes told him to calm down and get a life jacket, then came another, ear-shattering explosion. He went to his own cabin to get his lifejacket. His lifeboat station was on the port side but because of the list he went down an exterior ladder to the winch deck.
In his cabin, Ortilano head a sudden series of explosions, then a loud boom. Through his forward windows he saw flames. Dashing out into the passageway he saw AB Elmer Manahan who told him to get his lifejacket. Ortilano went back into his cabin, got the lifejacket, and exited the accommodations aft.
In a group were Captain Kavoras and Chief Engineer Anasthasiou, talking in Greek, together with four other crew members, including Messman Tagle who couldn’t understand what they saying. They were waiting for instructions, but none were given.
There was no question of using the lifeboats. Because of the list, the port lifeboat almost certainly could not be launched. The starboard lifeboat seems to have been caught by the explosion and fire. Its bow was damaged by the flames and more damage occurred as it fell from its falls in the blast.
Ortilano asked Captain Kavouras whether a distress signal had been sent. Kavouras did not reply. Ortilano went to the bridge, activated the DSC alarm and sent out a mayday.
He didn’t wait for a response. He went up to the bridge top, activated the EPIRB and cast it overboard.
Meanwhile, Tagle followed Captain Kavaoras, Chief Engineer Anasthasiou and the rest of the group to the winch deck on the starboard side. For a moment he covered his eyes. When he look up, the rest had gone over the side. There was a third explosion and someone called to him in Tagalog to jump. Tagle jumped into the water.
As the ship listed an estimated 30 degrees, Electrician Bactat, with a second group, made his way to the starboard winch deck and simply walked into the water. He found a piece of wood and clung to it.
The ship came back on an even keel, her bow sinking rapidly. Aguilar, Marentes and Ronquillo got to the stern railings and held on, determined not to enter the water until the last possible moment. It wasn’t something they’d be trained to do: They’d remembered the movie Titanic.
Ortilano climbed from the bridge top down to the winch deck. Their were people in the water, the lights of their lifejacket lights shining in the darkness. A life raft floated off starboard, still attached by its painter. Ortilano told the men at the stern railings to wait until the ship sank further. He waited himself, then, from a height of three or four metres jumped into the liferaft.
Aguilar jumped for the lifeboat, missed, fell into the water and climbed into the liferaft. Then Ronquillo jumped and climbed in, followed by Marentes.
They found the life raft equipment, cut the painter, and searched for survivors. Ortilano lit flares, hearing cried for help each time. He called out to them to swim towards the flates. Two men, so covere in oil as to be unrecognisable, got close enough to be helped into the life raft, messman Tagle and Electrician Bactat.
At 1937, the Bow Mariner sunk under the waves, her deck lights still shining until almost the last moment.
Top, above side scan sonar images of Bow Mariner on the seafloor, courtesy NOAA. Compare to photo below from Marine Marchande.
Rescue efforts were already underway by the US Coast Guard and two ships that has seen the explosion. A Coast Guard helicopter, CG 6026, arrived at 19.28. There were more than a dozen lifejacket lights floating in the water and spotted the life raft with signs of people aboard.
Battling darkness, fumes, and the heavy fuel oil that covered the survivors, it took half an hour to rescue the six men from the liferaft. They were flown to Norfolk Sentara Hospital. The helicopter was grounded due to contamination.
The only survivors were those in the life raft, Ortillano, Aguilar, Marentes, Ronquillo, Tagle and Bactat.
A second helicopter, CG 6588 located a body in the water. Wearing only a shirt and a gold necklace, it showed evidence of traumatic injuries to the head, legs and arms, perhaps a sign that he had been caught by one of the explosions. It was Chief Officer Melles.
Five other bodies were eventually recovered. Each one dead by drowning associated with hypothermia.
Of the remaining 18 bodies, the sea took them for eternity.
The damaged starboard lifeboat. Fourth engineer Ajoc was found alive, holding onto the boat’s lifelines but died on the way to hospital. USCG photo.
Capsized port lifeboat.
There are so many lessons to be learned from the Bow Mariner incident that it’s hard to know even where to begin.
What sparked the explosion isn’t known and hardly matters. The situation was such that disaster was inevitable.
The senior officers confused arrogance and intolerance with leadership. Educating and training subordinates to work safely is part of leadership.
As we saw in the first series of Maritime Accident Casebook, it isn’t uncommon for senior officers to get complacent about the cargoes their ship carries, to assume they know better than the guys who wrote the safety procedures. It’s a life-threatening assumption.
Make sure your subordinates are aware of safe procedures, make sure they know what’s in the SMS, or in this case, SQEMS.
Encourage them to be safety aware and pro-active to take the initiative if they see what they believe to be an unsafe situation.
Ensure you have a good working relationship with your subordinates, it might save your life.
It might be a good idea, too, that they know how to make a distress call. Lugen Ortilano didn’t give his vessel’s position, which could have led to a delay in response to the emergency. He didn’t wait for a response to his call. Both are understandable since the ship was a bomb, all the same it’s worth ensuring that those who might have to make such a call practice how to speak calmly and clearly and give the ship’s position and its situation. Valuable time could be saved.
But let’s look at survival. Those aboard the life raft survived. Those who did not wore lifejackets that would have kept them afloat. Why didn’t they live?
The water was just 5.5 degrees Celcius. Two things happened when the men jumped into that sea. The first was cold shock. It was difficult to control breathing, their heart rate soared, and their blood pressure went up. It was hard to think clearly. For a few critical minutes, they were totally incapacitated. Cold shock can kill.
Those who survived cold shock were victims of hypothermia. Our bodies need warmth, indeed, they generate warmth. But in a cold sea, the body’s core temperature can fall so far that it can’t be maintained. It induced a fatigue, a fatal desire to sleep. In that situation, sleep is death. With unconsciousness, they drowned.
Aguilar, Marentes and Ronquillo were right to delay entering the water for as long as possible. The sooner you’re in the water, the sooner you die.
Of course, it’s best not to get in the water at all, get a lifeboat if you can.
When in the water, huddle together as much as possible and try and keep others awake.
Depending on the water conditions, some survival techniques commonly taught may not be useable. Dr. Frank Golden, a specialist in survival, gave the following suggestions to Maritime Accident Casebook:
Regardless of the water temperature, be sure wear a lifejacket, especially in cold water.
Before getting into the water, put on as much clothing as possible. and put something on your head, it will reduce heat loss.
If you can, keep your arms as close to the body and legs together to reduce heat loss.
Tighten crotch strop to ensure a near 40° angle of flotation and to help keep the back of head out of the water to reduce heat loss.
Keeping yourself warm, is the best way to keep yourself alive.
Today, Lugen Ortilano has a framed letter in his wall commending him for his heroism that night. Perhaps once in a while he wonders why such heroism should have been necessary in the first place.
US Coast Guard Video
Investigations are underway to establish the cause of the sinking of the Fraserburgh-based trawler Ocean Way some 100 miles east of the Farne Islands in the North Sea on Sunday, 2 November, but already a sadly familiar issue has already surfaced: lifejackets were not worn.
Search and rescue efforts to locate two missing crewmembers have been suspended. Two survivors and the body of the deceased skipper were pulled from the water. Neither survivor, nor the body of the skipper wore lifejackets.
A vessel can come to grief with extraordinary swiftness. There may be little time to launch a liferaft or to find and don lifejackets. Without a flotation device the extra effort needed to keep afloat encourages the onset of hypothermia and prevents seafarers helping each other.
Delaying making permanent repairs to the 40-year old oceanographic vessel Seaprobe, failing to comply with his vessel’s safety management system nor complying with mandatory load limits proved to be a poor decision by the ship’s owner. Fortunately no-one died but one crewmember was seriously injured, two lightlyinjured and the vessel was lost.
Built in 1974 and owned by Fugro-McClelland of Galveston, Texas, according to the Equasis database, US flagged and in class with the American Bureau of Shipping, the 818 tonne Seaprobe was a converted fishing vessel originally named Northern Empire. It was one of two geotechnical drillships operated by Fugro-McClelland in the Gulf of Mexico.
The US National Transportation Safety board adds: “Contributing to the accident was the owner’s failure to comply with the vessel’s safety management system and mandatory load line regulations”.
In a Jones Act law suite it is alleged that “despite the years of notice, Fugro continually failed to properly maintain the vessel which subsequently led to the eventual sinking”. Fugro’s recruitment advertisements say “Fugro has a strong commitment to health, safety and the environment. ”
One may bear those statements in mind while reading the last days of the Seaprobe:
In late December 2012, the Seaprobe departed its oceanographic research operations off the coast of South America, en route to Morgan City, Louisiana. While in transit, the captain and crew noted seawater entering the engine room where the exhaust pipe for the starboard main engine exited through the engine room overhead.
The captain told investigators that he maneuvered the vessel to minimize water on the deck in the area of the water entry. Also, the crew made temporary repairs including fastening thin sheets of metal to the starboard-side exhaust trunk where the original metal was wasted. The exhaust trunk housed exhaust pipes from machinery in the engine room and ran forward horizontally above the deck to the stack, just aft of the deckhouse. To address the flooding, Saprobe diverted the Seaprobe to the Gulf Marine Repair (GMR) shipyard in Tampa, Florida.
On 4vanuary, 2013, the Seaprobe arrived at the GMR shipyard, where the vessel underwent temporary repairs. After the accident, the uS Coast Guard learned that shipyard personnel used doubler plates to temporarily repair the starboard main engine and generator exhaust pipes housed within the exhaust trunk. Portions of the exhaust trunk’s bottom plate were not renewed after this plate, some of its metal wasted, was removed to gain access to damaged sections of the exhaust pipes within the exhaust trunk.
The port engineer―a representative of the vessel owner who was at the GMR shipyard during the repair work―told investigators that he did not direct shipyard personnel to replace the bottom plate because he wanted to allow for further examination of the exhaust pipes during the vessel’s next scheduled drydock.
Shipyard personnel had asked the port engineer if he wanted the exhaust trunk repaired or left open, and, if the latter, the personnel would install a doubler plate over the six starboard-side freeing ports near the bottomless exhaust trunk to protect it from seawater. The port engineer believed, as an interim measure, “if the freeing ports were closed it would improve protection against seawater contact in that area.”
Shipyard personnel installed the doubler plate over the six freeing ports and left the exhaust trunk open to the atmosphere on the bottom.
An accident was now waiting to happen.
Seaprobe left Tampa about 1400 on 16 January, 2013, and continued toward Morgan City. Based on vessel draft estimates provided by the captain, the freeboard near the deck over the engine room measured 0.3 metres to 1 metre.
During the west-northwest transit toward Morgan City on the evening of 17 January, the Seaprobe experienced north winds at 26 knots, with gusts up to 34 knots, and seas of five metres. The high seas and the fact that six of the Seaprobe’s freeing ports were closed caused seawater to collect on deck. This water made its way into the open bottom of the exhaust trunk and downflooded into the engine room.
Seaprobe lost power to its main engines and generators about 2000 that evening. The chief engineer discovered water in the engine fuel and in the starboard-side day tank. He also saw water entering the engine space near the exhaust trunk. Initially he kept up with the flooding by using the oily water separator to pump the water to a holding tank.
About 2030, the chief engineer restored the portside generator and about 2130 brought the portside main engine back online. However, over the next few hours, he noted that the flooding increased and used the bilge pumps to remove the incoming water. One of the deckhands also saw the engine room flooding and told investigators that every time the Seaprobe rolled in the high seas, a large amount of water entered the engine room on the starboard side.
About 0200 the next morning, 18 January, with the Seaprobe listing to starboard and upto metre of water in the engine room, the chief engineer and the captain determined that the bilge pumps could not keep up with the flooding. They then shut the engine room’s watertight doors to prevent progressive flooding of adjacent areas. Shortlylater, they contacted the US Coast Guard.
Two liferafts were launched, the twelve crew boarded hem and were rescued by two USCG helicopters.
About 1800 that evening, the owner reported to the Coast Guard that the aircraft could not locate the vessel. The Seaprobe is presumed to have sunk sometime around 0315 on 18 January.
Although the Seaprobe was not required to undergo US Coast Guard inspection, two other safety strategies were in place: a load line certificate and a safety management system. Says the NTSB: “Because the vessel owner did not adhere to these strategies, they did not prevent the sinking”.
The American Bureau of Shipping (ABS) issued an international load line certificate for Seaprobe on 29 March, 2012. Under the load line regulations in 46 Code of Federal Regulations (CFR) Part 42, the operators of the vessel should have told ABS before they installed doubler plates over the freeing ports and departed port without repairing the bottom of the exhaust trunk. Having a load line is contingent on weathertight integrity of the vessel above the freeboard deck. Blocking the drainage of water from the deck and operating at sea with openings to the engine room were changes to the conditions of the vessel requiring ABS to revisit the vessel and reassess the load line assignment. ABS, after examining the condition of the vessel and the operator’s proposal for permanent repairs, would have decided whether to allow the vessel to depart Tampa in the condition that it was.
CFR 42.07-55 (b) states that load line certificates may be canceled due to conditions such as closed freeing ports and wasted exhaust trunks. requiring ABS to revisit the vessel and reassess the load line assignment. ABS, after examining the condition of the vessel and the operator’s proposal for permanent repairs, would have decided whether to allow the vessel to depart Tampa in the condition that it was. CFR 42.07-55 (b) states that load line certificates may be canceled due to conditions such as closed freeing ports and wasted exhaust trunks.
These mandatory measures were not adhered to.
Seaprobe’s owner owner held a valid International Safety Management Code Document of Compliance and Safety Management Certificate issued by ABS. One of the four objectives of a safety management system is to ensure compliance with the mandatory rules and regulations when developing procedures for the safety management system.
The safety management system requires documents for vessel maintenance procedures, which are used to verify that all company vessels are maintained in conformity with relevant rules and regulations. Seaprobe owner’s failure to discuss the wasted exhaust trunk and closing of the freeing ports with ABS meets the definition of nonconformity under the safety management system.
In its report the US NTSB concludes that the probable cause of the flooding and subsequent sinking of the Seaprobe was the decision of the vessel owner to delay making permanent repairs to the starboard-side exhaust trunk and covering six of the vessel’s freeing ports, leaving the Seaprobe susceptible to downflooding from boarding seas.
Contributing to the accident was the owner’s failure to comply with the vessel’s safety management system and mandatory load line regulations.
Seaprobe was subject to regulations found in 46 Code of Federal Regulations Part 3, which require the vessel owner to verify in writing every 2 years that the vessel operates as an oceanographic research vessel and is therefore not subject to inspection as a passenger, freight, or offshore supply vessel. An oceanographic research vessel of less than 300 gross tons does not require inspection.
As is all too often the case teh drive to minimise costs and maximise profits put seafarer’s lives on the line.
Fortunately no lives were lost when the 24 metre motor yacht Isamar struck the charted the Grand écueil d’Olmeto shoal but poor seamanship sank the rather pretty vessel. One suspects that each of the actions or inactions that led to the casualty seemed like a good idea at the time even if they conflicted with good advice at the time.
That the UK-registered vessel had its radar switched off might not have contributed to the loss but the fact that the echosounder – fathomometer for American readers – was switched on but had no shallow water alarm set might well have done.
It might not have mattered that the Electronic Chart System, ECS, had not been updated for 10 years, while indicating a certain laxity with regard to safe navigation, but the fact that it was used for primary navigation when paper charts are advised when using such a system, and set to a scale that did not reveal that there was a reef in the way, certainly did.
No waypoints or course marks were set on the ECS. After all, the captain had a pair of mark one eyeballs.
There are good reasons why an ECS is not recommended for primary navigation. In Isamar‘s case even at the scale which showed the shoal there were no depth indications.
Perhaps there are times to save money on hiring a pilot in unfamiliar waters but this was not one of them. The master of the Greek-registered tug Christos XXII had little experience in tidal waters and his company procedures were of little help when he decided to save on pilotage by anchoring in the tidal waters outside Tor Bay to investigate a dangerous list in the towed vessel Emsstrom, to judge by the UK Marine Accident Investigation Board report on the subsequent collision between tug and tow.
The result of the money-saving measurese and lack of appropriate company procedures was the sinking of the Emsstrom and the holing and flooding of Christos XXII. And a lot more expense.
Britain’s Marine Accident Investigation Branch, MAIB, has warned that roll-tests may give a misleading assessment of vessel stability in its accident investigation report on the capsize of the fishing vessel Heather Anne. It has also called for the Maritime and Coast Guard Agency to determine what behavioural changes are needed to ensure that fisherman wearing lifejackets on deck.
At about 2200 on 20 December 2011, the UK registered fishing vessel Heather Anne capsized and foundered in Gerrans Bay, Cornwall. The skipper and his crewman were soon recovered from the water by a nearby fishing vessel. Neither the skipper nor the crewman was wearing a lifejacket; the crewman had drowned. There was no significant pollution.
Two interim reports have been issued by the UK’s Marine Accident Investigation Branch giving factual data on the foundering of the MV Swanland in the Irish Sea in November 2011 and the collision between the ACX Hibiscus and Hyundai Discovery in the eastern approaches to te Singapore Strait the following month.
Six lives were lost when the Swanland suffered structural failure an sank in rough seas.
The interim report descries the event: “Swanland was in the Irish Sea making good a course of 206° at a speed of around 5 knots over the ground (Figure 4). The vessel was heading into a south-westerly gale force wind with gusts of about 50 knots. The predicted tidal stream was south-south-west at a rate of 2.2 knots, and the sea was rough or very rough, with a significant wave height of approximately 4m. Swanland was pitching into the oncoming seas, but she was not slamming. She was also occasionally rolling up to an angle of approximately 6° and yawing between 10° and 15° of her intended heading.
Eire’s Marine Casualty Investigation Board has released reports on two separate incidents of note: A fatal accident in which a fisherman became separated from his lifejacket after his small boat came to grief in Lough Corrib, County Galway and the sinking of MFV Jeanette Roberta off Glandore Harbour, County Cork.
In the first case on 19th March 2012 two men, who were both wearing life jackets, went angling in an 18ft open boat on Lough Corrib. During the afternoon the boat was struck by a large wave and both men were thrown into the water and were separated from the boat. One man swam to an island and eventually raised the alarm. The other man became separated from his lifejacket.
Both men were airlifted to Galway University Hospital by helicopter, one man was pronounced dead at the hospital and the other was reported suffering from hypothermia.