Chapter 3 Marine accident and incident investigation

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Chapter 3 Marine accident and incident investigation 1. Summary of major investigation report Summaries of five of the 1,165 investigation reports publicized in are presented below. Marine 1 While a ship
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Chapter 3 Marine accident and incident investigation 1. Summary of major investigation report Summaries of five of the 1,165 investigation reports publicized in are presented below. Marine 1 While a ship was proceeding in the North East Offing of Iriomote Shima, she pitched, and two passengers each suffered a compression fracture in the lumbar spine (Passenger ship AN-EI GO No. 98, Casualties of passengers) [investigated by Tokyo Office] Full text of the investigation report (Japanese text only): 1. Summary of the accident (1) Date and time: At around 09:40 hrs, April 30 (Thursday), 2009 (2) Location: North East Offing of Iriomote Shima, Taketomi Town, Okinawa Prefecture (3) Outline of the accident: Passenger ship AN-EI GO No. 98 (the Ship), owned by limited private company An-ei Kanko (Company A), was boarded by the master with an ordinary seaman, and had 28 passengers on board. While the Ship was proceeding from Iriomote Shima (Iriomote Island), Taketomi Town, Okinawa Prefecture, to Ishigaki Shima (Ishigaki Island), Ishigaki City, two passengers (Passenger A and Passenger B) suffered injuries when the hull pitched at the north east offing of Iriomote Shima. (4) Date of publication: March 25, Hatoma Shima Lighthouse Hatoma Shima About kn Uehara District Hatoma Suido Dike P Iriomote Shima Dotted line: Return course of the first cruise-service Solid line: Return course of the second cruise-service The Ship About kn Location (at around 09:40 hrs on April 30, 2009) Akabanari Shima Reefs in the east offing of Akabanari Shima AN-EI GO No. 98 Passenger A (injured) Passenger C Ordinary seaman A Passenger B Passenger D Master A Wheelhouse Front passenger (injured) room Plots of estimated positions of the Ship Seat positions in the front passenger room of the injured passengers, and other persons 76 2. Findings (1) It is probable as follows: The Ship was proceeding off the regular course east-southeast ward along the reefs in the north east offing of Iriomote Shima, and, near the east offing of Akabanari Shima (Akabanari Island), she was hit by consecutive waves about 1.5 to 2 meters high from east-northeast on the port bow. Just before the occurrence of the accident, the master recognized the high wave approaching; however, the master kept the Ship proceeding at the original speed, so the Ship s bow rode on the wave crest and then fell down onto the wave bottom; at that time, two passengers, sitting in the front passenger room, were lifted up off their seats and then dropped down onto the seats, causing each of them to suffer a compression fracture in the lumbar spine due to the free fall shock. (2) It is probable that, although from Akabanari Shima to the reefs in the east of Akabanari Shima the master had reduced the speed or changed the course in order to reduce the pitch when a big wave approached, the master had proceeded after that at the original speed and with the original course. (3) It is probable that the master, when approaching the point of turn near the reefs in the east of Akabanari Shima at the original speed, looking in the starboard bow direction in order to monitor the Ship s distance to the reefs in the bow and starboard side, failed to recognize the big wave approaching from the port bow direction. (4) It is probable that the master had lost the chance to reduce the speed due to having failed to recognize the approaching wave until just before its arrival. (5) It is somewhat likely that the master took the course for the following two reasons: the master, remembering a suggestion made by other masters of Company A that wave effects are cancelled by the reefs along the courses closer to the reefs in the north east offing of Iriomote Shima, thought that, along a course close to the reefs, the Ship would suffer smaller hull motions by waves than that experienced at the return course of the first cruise-service; the master, having no chance to look into the regular courses shown in the safety management regulations, wrongly thought that the round-trip course of the first cruise-service and the course was the regular course. (6) It is somewhat likely that the following two facts contributed to the occurrence of the accident: the master and the ordinary seaman failed to provide directions or guidance by public address system to the passengers to sit in the rear passenger room because the hull motions would be smaller there; and the master failed to provide the passengers with guidance to wear seat belts. (7) It is somewhat likely that the following fact contributed to the occurrence of the accident: Company A had not provided its crew with proper safety education in accordance with its safety management regulations concerning standard operations and so forth. 77 3. Probable causes It is probable that the accident occurred when the two passengers, sitting in the front passenger room, were lifted up and then dropped onto their seats, each suffering a compression fracture in the lumbar spine due to the free fall shock when the Ship s bow rode on the big wave crest and fell down to the wave bottom, because the master, proceeding east-southeast ward along the reefs in the north east offing of Iriomote Shima while hitting consecutive waves of about 1.5 to 2 meter high from east-northeast on the port bow and failing to recognize the big wave approaching until just before its arrival, kept the Ship proceeding at the original speed. It is probable that the reason why the Ship was proceeding at the original speed is that, although the master tried to reduce the pitch by reducing the speed and changing the course when a big wave was approaching, the master reverted to the original speed when the wave passed the Ship. It is probable that the reason why the master failed to recognize the big wave approaching until just before its arrival is that the master was looking in the starboard bow direction in order to monitor the Ship s distance to the reefs in the bow and starboard side when approaching the point of turn near the reefs in the east of Akabanari Shima. It is somewhat likely that the reason why the master navigated the Ship off the regular course along the reefs in the north east offing of Iriomote Shima is that, remembering a suggestion by other masters of Company A that, along a course closer to the reefs in the north east offing of Iriomote Shima, the reefs cancel wave effects, the master thought that navigating there would reduce the hull motions in comparison with those experienced in the first cruise-service, and that, having no chance to look into the regular courses shown in the safety management regulations, the master wrongly thought that the course was the regular course. It is somewhat likely that the following facts contributed to the occurrence of the accident: the master and the ordinary seaman failed to provide passengers by public address system with directions or guidance to sit in the rear passenger room where hull motions are smaller; and the master failed to advise the passengers to wear seat belts. It is somewhat likely that the following fact contributed to the occurrence of the accident: Company A failed to provide their crew with proper safety education in accordance with its safety management regulations concerning standard operations and so forth. 4. Recommendations, opinions, and remarks The JTSB recommended Company A to provide safety education in accordance with their safety management regulations and so forth, prepare a safety operation manual in heavy weather applicable to the actual situation of their cruise services, and ensure compliance with the manual. (For the details of the recommendations, refer to Chapter 3-2. Summary of recommendations and opinions (Page 97).) 78 The JTSB expressed its opinions to the Minister of Land, Infrastructure, Transport and Tourism with regard to the guidance of the high speed boat passenger transport business operators to prepare passenger-safety measures, such as ship handling in heavy weather. (For the details of the opinions, refer to Chapter 3-2. Summary of recommendations and opinions (Page 98).) The JTSB made its remarks to the Okinawa Passenger Boat Association to guide the passenger boat service operators in Yaeyama Retto (Yaeyama Islands) in order to firmly execute their safety management regulations. (For the details of the remarks, refer to Appendix 28 Remarks made in (Page 56 in Appendixes).) 79 Marine 2 A container ship, while proceeding eastward in Kanmon Passage and trying to overtake a cargo ship proceeding ahead, proceeded ahead of a JMSDF destroyer proceeding westward and collided with it; a fire broke out (Collision of Container ship CARINA STAR and JMSDF Destroyer KURAMA) [Investigated by the Tokyo Office] Full text of the investigation report: 1.Summary of the accident (1) Date and time: 19:56:09-12 hrs, October 27 (Tuesday), 2009 (2) Location: Vicinity of Moji Saki, Kanmon Passage, Kanmon Port (3) Outline of the accident: Container ship CARINA STAR (Ship A), boarded by a master (Master A) with 15 crew members, was proceeding eastward toward Hanshin Port through the Kanmon Passage in Kanmon Port. Destroyer of Japan Maritime Self-Defense Force (JMSDF) KURAMA (Ship B), boarded by a master (Master B) with 295 Situation of Ship A crew members, was proceeding westward through Kanmon Passage toward Sasebo Port, Sasebo City, Nagasaki Prefecture. The ships collided in the vicinity of Moji Saki, Kita-Kyushu City, Fukuoka Prefecture. Ship A sustained a fracture opening on the starboard bow outer-plate shell plate, and Ship B sustained substantial damage on the bow, Situation of Ship B which caused fire to break out on the damaged parts of both ships. Six crew members of Ship B suffered injuries during the fire-fighting operations; however, there were no injuries among the crew of Ship A. (4) Date of publication: June 24, 2.Findings (1) Situations where Ship A, trying to overtake cargo ship QUEEN ORCHID (SHIP C), proceeded ahead of Ship B a. It is probable that Ship A, while navigating eastward in Kanmon Passage, was approaching the starboard side of Ship C thinking that it would be possible to overtake Ship C at the west of Kanmon Bridge due to the speed difference between both ships. b. Ship A received a message from the Kanmon-Kaikyo Vessel Traffic Service Center (Kanmon MARTIS), Overtake on Ship C s port side, Ship C is moving to the starboard side, but 1 mile (M) ahead of you, Ship B is coming. Pay attention. Over, and replied 80 that they were going to overtake on the port side. However, a voice said Do we have to overtake on her port side? A head-on vessel is getting closer to us, which suggests a possibility that they had doubts about the message from Kanmon MARTIS telling them to overtake Ship C on the port side. c. It is somewhat likely that Master A took the message to have enforcement power instead of just provision of information. It is probable that Ship A decided to overtake Ship C on the port side in the situation where Ship A had approached the starboard side of Ship C; reduced the speed to slow ahead in the vicinity of Hayatomo Seto, west of Kanmon Bridge, put the helm 10º to port and then eventually hard to port because Ship A came close to Ship C, and passed about 70 m astern of Ship C. d. It is probable that Ship A, due to the port-swinging inertia of the helm hard-a-port and the port-side rotational moment caused by the tidal stream, swung widely to port, advanced to the center of Kanmon Passage, and proceeded ahead of Ship B. e. It is probable that Master A did not pay attention to the movement of Ship B because he was concentrating on clearing Ship C, and furthermore, Master A made no Overtaking Signals either. f. It is probable that Ship A, which had tried to overtake Ship C in Kanmon Passage, overtook it even though it should not have according to Article 38, Paragraph 2 of the Ordinance for Enforcement of Act on Port Regulations, because the overtaking position was near Kanmon Bridge, the starboard-side clearance of Ship C would decrease as Ship C put the helm to starboard along Kanmon Passage, the port-side clearance would decrease as Ship B was coming on the opposite course, and as a conclusion, it was difficult to overtake Ship C on the starboard side and on the port side. g. It is probable that the safety management of the owner/management company of Ship A (Company A) in navigating Ship A through the Kanmon Strait was improper because the check list for navigation through narrow channels included no specific descriptions of what to be noted, such as measures to follow the Overtaking Rule or to keep close communications with Kanmon MARTIS. (2) Situations in Ship B proceeding at a speed of about 17 knots (kn) until just before the collision a. It is probable that although Ship B s navigation plan for the Kanmon Strait had prescribed the speed through the water at about 12 kn, Ship B, while navigating westward by Kanmon Passage, was navigating at a speed of about 17 kn at the Tanoura Offing due to the effects of the tidal stream, faster than the full speed through the water of about 15 kn, which had been set before entering Kanmon Passage based on the judgment on the situations where there were no vessels on the same course ahead except for a small vessel and also due to the intention to pass through the Kanmon Strait quickly so as to have sufficient time for scheduled work. 81 19:55:14~ 21 Ship B Location Ship B 12 19:55:30~ 34 Ship A Collision (19:56:0~12) 19:59 19:57 19:58 ~ 19:56 19:55:42~ 46 19:56 19:57 19:55 19:54 Ship C 19:53 19:55 Plots of estimated ship positions (overview) Ship A 19:54 Plots of estimated ship positions b. It is probable as follows: Master B, having visual contact with Ship C, judged Ship C as a large vessel on the opposite course proceeding along the Kanmon Passage with its rudder to the starboard; then, having visual contact with Ship A, Master B judged Ship A as a large vessel similar to Ship C proceeding along the passage in a similar way to Ship C; in addition, Officer B thought that vessels would not try to overtake near the Kanmon Bridge. c. It is probable that Master B s decision to maintain the full speed through the water at about 15 kn, which meant that Ship B was navigating at a speed of about 17 kn due to the effects of the tidal stream, was based on his judgment that Ship C would come close to Ship B but pass by it because Ship A was following close behind Ship C, and would also pass Ship B by putting the helm to starboard in a similar manner to Ship C. d. It is probable that the higher commander of Ship B had not provided proper safety management for passing through the Kanmon Strait because the higher commander of Ship B had not provided Ship B with sufficient guidance, including obtaining movements of passing vessels with the Automatic Identification System (AIS), monitoring VHF communication, and using the service provided by Kanmon MARTIS or applying a safe speed in accordance with the situation. (3) Collision avoidance maneuvers taken by Ship A and Ship B a. It is probable that, although Master A had cleared the stern of Ship C, put the helm amidships, advanced Ship A to the center of Kanmon Passage, and put the helm hard to 82 starboard being aware of a risk of collision with Ship B, Ship A collided with Ship B before Ship A obtained a rudder effect. b. It is probable that Master A sent no overtaking signal to Ship C when it overtook Ship C on Ship A s port side. c. It is probable as follows: due to Ship A s starboard light that Master B saw and the aspect of Ship A s mast lights, Master B was afraid that Ship A was taking its rudder to port contrary to Master B s expectation that it would pass with its rudder to starboard; however, Master B kept proceeding at about 17kn and took no action of giving warning signals. d. It is probable that the chief officer of Ship B (Officer B), because the attitude of Ship A had not shown changes, wondered why Ship A was not putting the helm to starboard, and upon being warned by Master B that Ship A might have put the helm to port, set both engines to stop and then to full astern. e. It is probable that, although Master B put the helm hard to starboard while the rudder angle was changing to port due to the helm hard-a-port operation of Officer B, Ship B collided with Ship A. (4) Guidance provided by the Kanmon MARTIS a. It is probable that, according to the information obtained through the radar, the operator thought that Ship A proceeding eastward in Kanmon Passage would overtake Ship C in the east of the east side exit of Hayatomo Seto waterway. AIS Console Daiba Console O Seto Console Hesaki Console b. It is probable that the operator, contacting Ship C, Operation room of Kanmon MARTIS which was ahead of Ship A, and Ship A, which was overtaking Ship C, finally told Ship A as a provision of information to overtake Ship C on the port side and pay attention to Ship B coming 1 M ahead in addition to Ship C shifting to the starboard side, and received the reply from Ship A that Ship A would overtake Ship C on the port side. It is somewhat likely that Master A took the messages from the Kanmon MARTIS as not simple information provisions but legally-enforced instructions because they were in an English imperative form and the IMO Standard Communication Phrases, which the Kanmon MARTIS had not regularly used, were not used c. It is probable that the operator was required to guide Ship A in accordance with the Kanmon MARTIS Operation Manual in such a way that Ship A should not overtake Ship 83 C because, while Ship A and Ship C were approaching the Kanmon Bridge, Ship A would catch up with Ship C in the vicinity of Hayatomo Seto, where Ship B was proceeding on the opposite course, and because the operator received the message that Ship A would overtake Ship C. It is probable that the operator did not give such guidance for the following reasons: the operator thought that, because of the tidal current influences on Ship A and Ship B, Ship B would complete passing before Ship A would overtake Ship C, and that the overtaking would occur in the east of the eastern side exit of Hayatomo Seto waterway; in addition, the operator thought that Ship A would never take improper actions before the completion of safety confirmations required for overtaking. d. It is probable that the operator did not fully grasp the situation where Ship A would overtake Ship C or how Ship B would pass that position. e. It is probable that Kanmon MARTIS did not give Ship B guidance to proceed under a speed limit of 15 kn imposed on a large ship or a ferry over a gross tonnage of 10,000 tons for protecting the safety of vessels moored at berths, because Ship B was not included in such category. f. It is probable that the Kanmon MARTIS, for the following reasons, did not inform Ship B that Ship A would overtake Ship C on the port: the Kanmon MARTIS thought that Ship A would catch up with Ship C in the vicinity of Hayatomo Seto, that Ship B would complete passing before Ship A would overtake Ship C, and that the overtaking would occur in the east of the eastern side exit of Hayatomo Seto waterway; Ship A was not taking a course for initiating such overtaking; finally, Ship B was proceeding off-center of Kanmon Passage. 3. Probable causes It is probable that the accident occurred in the vicinity of Hayatomo Seto in Kanmon Passage, at night and under the current condition of about 1.3 to 2.7 kn SW, by the collision of Ship A proceeding eastward and Ship B proceeding westward, in the following situations: Ship A approaching ahead of Ship B proceeding in the right lane of Kanmon Passage, when Ship A tired to overtake Ship C on the port in the situation where Ship A was approaching the starboard side of Ship C proceeding ahead of Ship A. It is somewhat likely that Ship A tried to overtake Ship C on the port side in a situation where Ship A was approaching the starboar
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