We’ve been asked to re-publish our three-part series on the resignation of Bulgaria’s chief maritime investigator and the enquiries into the losses of MV Vanessa and MV Tolstoy. What Papukchiev has to say is disturbing. He identifies significant shortfall in communications between port state controls, the IMO and flag states, and highlights the challenges faced by maritime investigators in those jurisdictions in which independent investigations are difficult to achieve.
Just one day after being tasked to lead a re-opening of the investigation into the January 2008 sinking of the general cargo ship Vanessa Captain Hristo Papukchiev resigned as chairman of the Commission of Investigation. It was a frustrating end to a mission to enhance safety for seafarers on Bulgarian ships and in Bulgarian waters.
Papukchiev’s story raises issues regarding the country’s commitment to maritime safety, safety investigation, and search and rescue. The issues are not unique to Bulgaria,they are common in those countries where shipping interests wield tremendous political power, power enough to make or break presidents. What makes his story unique is that such tales are usually kept behind well-closed doors but Papukchiev has gone public.
It is probably fair to say that Papukchiev’s frustration, and anger is not aimed at the Bulgarian authorities alone but also at the failure of the international maritime community to give him the support he desperately needed to make change. it was, in particular, a test of the IMO’s commitment to transparency, a test which it failed.
For the first time in Bulgaria’s history, on Papukchiev’s watch, Bulgaria filed an accident report with the IMO, in this case the tragedy of the M/V Tolstoy. He expected a response, he expected action, there was none.
The Tolstoy investigation was the first one completed with Papukchiev as the lead investigator. It identified serious regulatory failings, inadequate vessel monitoring and a serious shortfall in Bulgaria’s SAR capability and in VTS operations. It should have led to a serious enquiry aimed at improving the situation, it did not.
In an interview with the Bulgarian language magazine Klass, he describes his experience in the Tolstoy investigation: “The facts are the investigation into the Tolstoy’s shipwreck was closed and a report was published. During this procedure, different people both working at the Ministry of Transport and members of the Commission were trying to exert pressure on our team. The report was repeatedly being returned on various grounds. However, I think that despite this pressure the report was prepared according to the regulations of the International Maritime Organization and the European Maritime Safety Agency. Recommendations in the final version were addressed to both international organizations and Bulgarian institutions.
“Tolstoy was not built for sailing in the weather conditions she was at the time of the shipwreck. The report concluded on inadequate behaviour by several Bulgarian institutions. They should have not only followed the ship’s itinerary in the Bulgarian territorial waters to trace and rescue her, but should have prevented the disaster, especially when they had identified serious problems.”
Therer were good reasons to raise a red flag and keep watch on Tolstoy. Says Papukchiev: “The fact is there had been no signals of distress from m/v Tolstoy. This should come as no surprise since the ship’s radio-technical equipment had been out of order. In accordance with the existing regulations, m/v Tolstoy should have been watched closely as a potentially risky ship. She has been known for a year to be out of North Korean Maritime Administration’s register. The Bulgarian authorities also received a notification for the imminent deprivation of the ship’s documents and her sale rights. The arrival of this type of vessel into our territory and her behaviour, which was obvious from the surveillance systems, should have been a clear signal for the traffic operators that there was a serious problem. Instead of waiting for the ship to make contact, as it is by the books, they should have used their authority and attempt to reach her. They didn’t. The movement of the ship shows that she has experienced some difficulties that made her lose control at times and change course and speed, which should have rang the alarm bells for the officials on duty.”
Search and rescue efforts were not started until eight to 10 hours after Tolstoy sank. Even though an EPIRB signal was received SAR took some five to six hours to get underway. Without those delays help might have reached Tolstoy before she sank.
While Bulgaria has a search and rescue plan lodged with the IMO it has little basis in ground truth. Says Papukchiev: “The content of the plan does not match the version published by the State Gazette. The difference is largely due to neglecting of the work on the national search and rescue plan. During the initial review of the map in 2004, a mistake in the definition of the region has been made… The search and rescue plan ought to be amended and optimized every six months if necessary to take into account all the changes occurring in the meantime. It is puzzling that the IMO documentation does not reflect the boundaries declared in the Bulgarian regulations…”
Papukchiev is certainly not the only one worried about the state of Bulgaria’s commitment to maritime safety, search and rescue and safety investigation. In 2008 Captain Dimitar Dimitrov, head of the Bulgarian Ship Masters Association, BSMA, called for and got a resolution approved by the International Federation of Ship Masters Associations which “Expresses its concern about the apparent failure of the Flag States to properly investigate the loss of these two vessels as required by IMO; Urges the IMO Secretary General to ensure that Flag States carry out their obligations to fully investigate ship losses particular those resulting in the loss of life; Calls upon IFSMA to urge the IMO Secretary General to convey its concerns to the relevant flag and coastal states and to urge a thorough investigation so that the circumstances of these losses are understood and the lessons learnt and most importantly so that the families of the dead seafarers know how their loved ones were lost at sea.”
Of particular interest is the list of similarities Dimitrov found between the sinking of the Cambodian-registered Hera in 2004 and the Vanessa in 2008:
“1. Both ships were more than 20 years old, actually 30 years old;
2. Both ships sank in storm weather;
3. Both ships were loaded with full cargo with minimum free board;
4. Both ships continued their voyages in bad weather neglecting the forecasts;
5. Both ships did not contact the coastal states in time to require assistance;
6. Both ships’ masters did not initiate abandon and evacuation of the crew in time;
7. Both ships did not transmit distress signals and did not require assistance in time;
8. On both ships we suppose some influence from shore based staff to delay transmit of distress to save expenses in case of salvage and in both cases the Masters did not use their overriding authority to save the crew.”
Tolstoy fits the template, too.
In Part 2 MAC takes a closer look at the loss of Tolstoy and Vanessa. In the meantime we’ll leave you with the Klass interview exchange:
“Let me ask you this way – if you were a captain of a ship, would you be relaxed passing through Bulgarian territorial waters?
Frankly, if I was in a disastrous situation, I would rely on other ships nearby, not on the assistance by the Bulgarian Maritime Administration, although its rescue vessels are in Varna and Bourgas.”
Part 2: Vanessa’s Story
In April, 2009 Captain Hristo Papukchiev resigned as head of a team tasked with re-opening the investigation into the sinking of the m/v Vanessa in the Sea of Azov in 2008. Almost exactly a year before, the chairman of the Bulgarian Ship Masters Association, Dimitar Dimitrov, called for an independent investigation into the sinking, as well as that of the 2004 sinking of the Cambodian-registered m/v Hera with the loss of its Bulgarian master and the mainly Ukrainian crew.
To these four casualties, Tolstoy, Vanessa and Hera might be added the Indian-crewed m/v Rezzak, missing in the Black Sea since mid-February 2008. In these four remarkably similar incidents some 60 seafarers were lost, not only without closure for their families but without, as yet, adequate safety investigations to lesson the chances of recurrence.
Papukchiev is one of the rare insiders to talk publicly about the causes of his frustration. Maritime accident investigation must be independent of both regulatory bodies, such as maritime authorities, and enforcement agencies charged with prosecution such as a coastguard. It is an independence that is mandatory in the upcoming SOLAS Chapter XI-1 casualty code amendments. Bulgaria, as well as a many other countries have yet to demonstrate the will for compliance.
Says Papukchiev: “An explicit guarantee of the independence of the investigators and of the investigation entity is not given in the law of Bulgaria.”
Indeed, the need for independent investigation into maritime casualties is ill-understood in the judiciaries of countries with poor safety records. That is a major hill for the IMO to climb if it is to achieve compliance.
The story of the Vanessa investigation, too, is a common one. She sank due to hull failure and literally fell apart in a storm on 3 January 2008. Of 11 people aboard, including a Ukrainian pilot, only one person survived.
Understanding how the Vanessa’s structure failed is an important part of understanding how to prevent such losses in the future. An underwater survey would provide much-needed information yet, up to 19 months afterwards the casualty no such examination had been done, even though she lays at an estimated 11 metres, shallow enough for her mast to be clearly visible.
It was not, in fact,the first time the vessel had sunk. In 1999, as Vanessa C, her hull failed and she sank in Great Yarmouth harbour, and was recorded as a serious casualty by the International Maritime Organisation.
An official investigation report was prepared by never approved. Says Papukchiev: “ (The) official report on the Vanessa has never been completed. The investigator’s efforts repeatedly being returned on various grounds. The investigation of the Vanessa had sunk (sic) in to the icy shallow Azov sea, after that melted due to summer fresh water inflow accordingly.”
Vanessa traded between the ports of the Azov Sea and her home port of Burgas, Bulgaria carrying steel. When she foundered she was loaded with 937.4 tonnes of steel billets and 2,007.6 tonnes of wire rod coils, from the Port of Berdyansk.
There is no record to show that her cargo lashing was done according to the manual at any time. An obvious scenario is the movement of heavy cargo shifting against a weakened hull in rough seas. However, without the underwater survey we cannot be sure.
In April this year Papukchiev was tasked to complete the investigation into the sinking of Vanessa. He told the Bulgarian language magazine Klass: “the reasons of my resignation are not directly related to the Minister’s order on the Vanessa’s shipwreck investigation, but circumstances are interconnected. When the Commission was appointed to continue and finish the investigation into the incident, a colleague of mine and a member of the Commission asked me how much I was paid to open the cold files of “Vanessa”. I was shocked at first, but then started to ponder on the investigations done so far, the report that had been prepared long before my appointment, although not approved … Well, did this mean that its authors had been paid? Where were they now? These questions were my greatest concern, namely the Vanessa’s case had begun with a false start … Anyway, I was appointed to proceed with independent investigation because the society expected the truth to come to light. These investigations should be done very precisely and objectively, with facts prevailing not hypotheses. When there are no conditions for an unbiased and objective investigation, a true professional is obliged to resign.”
Resign Papukchiev did, yet he has not turned his back on the possibility of completing the investigation. He tells Maritime Accident Casebook: “To be continued… if guarantee of Independence investigation is set up.”
Part 3: Twilight of Tolstoy
Foundered cargo ships Hera, Vanessa, Rezzak and Tolstoy share common characteristics. All were around 30 or more years old, carrying similar cargoes, two are known to have had low freeboard, all sank in the Black Sea/Sea of Azov, all departed in questionable weather, all were very serious casualties, and with one exception, official investigation reports have yet to be published or filed with the IMO.
The exception is M/V Tolstoy, the report of which was filed with the IMO by then chief investigator Captain Hristo Papukchiev shortly before his resignation from the team tasked with investigating the loss of Vanessa.
In a presentation to the Maritime Accident Investigators International Forum held in Budapest a month before his resignation, Papukchiev identified failures in port state control communications and inaction as contributing to the loss of M/V Tolstoy.
Put simply, port state controls that could have prevented the loss of Tolstoy failed to protect the seafarers, their ship or the environment. It calls into question the commitment of port state memoranda of agreement, MOUs, in the region to safety and their ability to collaborate.
No-one Noticed the Red Flag
Tolstoy was 37 years old when her hull snapped in a storm in the Sea of Azov in the morning of 27 September 2008 with the loss of eight of her 10 crew. She should,in fact, have been under arrest.
Built in Soviet-era Romania at the Santierul Navale Oltenita shipyard, Tolstoy was launched in 1971 as Volgo-Don 5028. She was a River-Sea Type, Project 1565, class О vessel. Papukchiev explains: “What that means is that a vessel of this class might be operated in river-sea water spaces with a height of wave up to 2.0 m.”
At the time of the loss Tolstoy was owned by Pegasus Shipping, a Delaware registered company with head offices in the Seychelles and operated by Regina Shipping of Kiev.
For a period until a year before her loss, Tolstoy was flagged under the DPRK, North Korea. On 26 October 2007 the North Korean marine administration sent a note to all members of the Paris, Black Sea, Mediterranean and Indian MOUs informing them that because of discrepancies with standards and other serous omissions, resulting in multiple detentions of the vessel and issues related to the requirements of the DPRK Ship Register, M/V Tolstoy had been excluded from the register.
Indeed, the Equasis database shows a long list of detentions for Tolstoy.
In the same note the DPRK has asked for assistance in seizing the ship documents of Tolstoy. Some 10 days later, the note was sent by the Secretary of the Black Sea Memorandum of Port State Control to administrations of the states of the Black Sea Region for immediate execution.
Despite the notes from the DPRK and the secretary of the Black Sea MOU Tolstoy continued to ply between ports around the Black Sea and Sea of Azov without hindrance.
According to the Equasis database Tolstoy was detained at the Port of Rostov on Don, Russia for nine days in mid-March 2009. Significantly the reasons for detention were structural damage and deformations of longitudinal and transverse sets of her hull; irregularities regarding the operable condition of radio aids for communication in emergency situation, including GMDSS MF/HF, and the provision of navigational charts and manuals.
Port State Control inspectors in Rostov On Don were apparently unaware of the notes from either the DPRK or the Black Sea MOU and she was allowed to sail.
Despite no longer being registered, Tolstoy was still on the IMO database as operating under the North Korean flag.
From 6 November 2007 to her foundering on 27 September 2008 Tolstoy “…navigated, visited ports, conducted cargo handling in violation of the norms, rules and criteria established by International Maritime Organization and European Maritime Safety Agency,” says Papukchiev.
The DPRK and the Black Sea MOU had waved big red warning flags about Tolstoy but nobody took any notice.
Papukchiev wants to see procedures in place to update the IMO database when vessels are deleted from registries and for port state control inspectors to deprive a vessel of its relevant documents after a flag administration has issued a notice of deletion.
On 22 September 2008 M/V Tolstoy departed Rostov on Don Port for Nemrut, Turkey, a voyage she was not designed for or built to carry out. She had 2,568 metric tonnes of metal scrap in her two holds.
Her two lifeboats were unusable and her gyrocompass didn’t work.
She passed out of the Kerch Channel on 22 September at 6 knots. By 1743 on 26 September she was encountering rain and heavy seas with 4 metre waves, twice her design capacity.
Battered by a NNE wind of Force 8 and sea state 5, having been flooded to an extent that stopped her engines at one point, Tolstoy made around 4.5 knots, deviating up to 25 degrees from her course of 245. Then, according to the VTS trace, at 0318 she suddenly deviated from 210 degrees to 171 degrees and her speed fell to 3.5 knots. Her steering had failed.
Over the next 4 minutes she came back around to 217 at 4.2 knots then her speed began to drop again to 2.6 knots. A little after 0335 the hull girder finally failed. At 0339 she vanished from the Varna VTS monitoring screens.
Two crew members who were on deck survived, made it to an automatically inflated liferaft and were rescue by the Belgian registered yacht Mirage.
No distress signals were transmitted during the emergency either by radio or pyrotechnics. It was not until a EPIRB signal was received about 25 minutes after the vessel foundered that it was realised ashore that there was an emergency. It took almost an hour to validate the signal.
In an interview with the Bulgarian magazine Klass, Papukchiev says: “The fact is there had been no signals of distress from m/v ”Tolstoy”. This should come as no surprise since the ship’s radio-technical equipment had been out of order. In accordance with the existing regulations, m/v ”Tolstoy” should have been watched closely as a potentially risky ship. She has been known for a year to be out of North Korean Maritime Administration’s register. The Bulgarian authorities also received a notification for the imminent deprivation of the ship’s documents and her sale rights. The arrival of this type of vessel into our territory and her behaviour, which was obvious from the surveillance systems, should have been a clear signal for the traffic operators that there was a serious problem. Instead of waiting for the ship to make contact, as it is by the books, they should have used their authority and attempt to reach her. They didn’t. The movement of the ship shows that she has experienced some difficulties that made her lose control at times and change course and speed, which should have rang the alarm bells for the officials on duty.”
The investigation into the loss of M/V Tolstoy identified a number of severe shortfalls in Bulgaria’s SAR capability:
• Varna Maritime Rescue Coordination Centre didn’t possess a suitable premise, equipped for operation of a joint staff of experts and participants in search and rescue operations.
• The technical equipment available is not reliable, there is no software support for forecasting of assumed coordinates of people and objects in distress in the search and rescue controlled area.
• Varna Maritime Rescue Coordination Centre has limited user’s access to VT Explorer software product for observation of Black Sea in real time. The perimeter observed is less the boundaries of Bulgarian Search and Rescue Area of Responsibility.
• The experts and operators at Varna Maritime Rescue Coordination Centre have no authorized full access to International Maritime Organization data base of ships with the necessary data for identification of vessels in distress condition.
”The Commission has established that the aircraft, NF helicopters, have no technical ability to communicate with maritime rescue crafts during the coordinated search and rescue,” says the report.
Says Papukchiev in the Klass interview with Mihail Rangelov: “…the rescue teams could have arrived even before the ship had sunk. Still it is difficult to make any assumptions about what would have happened had the authorities reacted on time. Whenever a ship is in a distress, the efficiency of the help she receives depends on the conditions at the time. What is more worrying is the fact that the rescue efforts did not begin until 5-6 hours after the EPIRB signal had been received. But I can’t make any assessment whether the rescue efforts have been right or not” .
Papukchiev expected the final report on the Tolstoy to result in action, for recommendations to be followed or at least discussed. Instead he found himself under increasing pressure to fall into line and training that was already agreed was denied. He was told ‘Go and Kiss the hand, Man…kiss the hand, and all will be OK’.
He tells MAC: “I was expecting some after thunder storm activities regarding presentation of the m/v Tolstoy twilight story. The investigation report was uploaded in due time to IMO GISIS, hard copies sent to IMO and EMSA head quarters and to all parties concerned as well. So far nothing but silence only.”
On 24 April Papukchiev says: “Exhausted by office combats with the renegades I had a walk on fresh air outside the Ministry of Transport nearby to National Theater park with the fountains. Fresh and cold Friday afternoon.”
He was troubled. Nearby was a placard, “20 years: The Wall” as, from somewhere came the sounds of Pink Floyd’s ‘Brick In The Wall’.
“I have missed 20 years ago to take a part in the breaking the previous (Berlin) wall. For a six months in the office I become to mutate in to a brick of the same…” he says. With his independence in danger of being compromised and little support he knew he had to resign that day: “Yesterday would have been too soon,tomorrow would be too late,” he recalls.
He returned to his office and drafted his letter of resignation. He was not going to become another brick in the wall.
Captain Papukchiev has returned to sea. Despite the checkered past he feels the experience of being an investigator has given him new insight into his job as Master: “I have come to myself again across the lessons learned. The experience gained as leading maritime casualty investigator and this deja-vu as Master of the ship made me some startling discoveries . Now I am able to understand more about marine business, captain’s capacities and why certain problems kept cropping up, regarding the difficulties indirectly linked to certain events and their deepest roots in the marine society as well.”
Would he return to maritime investigation? Yes, provided there was a guarantee of independence.
Hristo Papukchiev’s situation was not unique. There are under-trained, under equipped investigators with compromised independence and subjected to political and commercial pressure in a great number of countries. Most remain silent and unsupported by the international community.
For maritime accident/safety investigation to make seafaring safer investigators must be independent yet that need for independence is not often understood in those administrations which need professional maritime accident investigation.