“Karukera” and Motor Yacht “Flipper”

51/18

Very serious marine casualty

Sailing yacht “Karukera” and motor yacht “Flipper”

Yachts collision on the Adriatic Sea on 30 July 2018

July 2019 FINAL REPORT

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The investigation of a serious marine casualty, collision between the sailing yacht “Karukera” and motor yacht “Flipper” was conducted under the State Marine Accident Investigation Commission Act of 31 August 2012 (The Journal of Laws item 1068) as well as norms, standards and recommended procedures agreed within the International Maritime Organisation (IMO) and binding the Republic of Poland. The objective of the investigation of a marine accident or incident under the above-mentioned Act is to ascertain its causes and circumstances to prevent future accidents and incidents and improve the state of marine safety. The State Marine Accident Investigation Commission does not determine liability nor apportion blame to persons involved in the marine accident or incident. This report shall be inadmissible in any judicial or other proceedings whose purpose is to attribute blame or liability for the accident referred to in the report (Art. 40.2 of the State Marine Accident Investigation Commission Act).

State Marine Accident Investigation Commission Pl. Stefana Batorego 4, 70-207 Szczecin, POLAND tel. +48 91 44 03 286, mobile: +48 664 987 987 (24 h) e-mail: [email protected] www.pkbwm.gov.pl

www.pkbwm.gov.pl 1

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1. Spis treści 2. Facts ...... 4

3. General information ...... 6

3.1. Yacht particulars ...... 6 3.1.1. Karukera ...... 6 3.1.2. Flipper ...... 6 3.2. Voyage particulars ...... 7 3.2.1. Karukera ...... 7 3.2.2. Flipper ...... 7 3.3. Marine accident information ...... 8 3.4. Information on shore services involved and rescue operation ...... 8 4. Description of marine accident circumstances ...... 13

5. Analysis and comments about factors causing the marine accident with regard to examination results and expert opinions ...... 16

5.1. Human factors (faults and omissions) ...... 20 5.1.1. Manoeuvres prior to the collision ...... 20 5.1.2. The crew and their qualifications ...... 21 5.2. Mechanical factors ...... 22 5.2.1. Mutual visibility of the vessels ...... 22 5.2.2. Rescue equipment ...... 23 5.2.3. Communication and navigation equipment ...... 23 5.3. Organisational factors ...... 24 5.4. The influence of external factors including the marine related ones on the accident 24 6. Description of the investigation results, including safety issues and investigation conclusions ...... 24

7. Safety recommendations ...... 25

8. List of photographs ...... 26

9. List of figures ...... 26

10. List of acronyms ...... 27

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11. Participation of substantially interested states ...... 28

12. Sources of information ...... 28

13. Members of the team investigating the accident ...... 28

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Fig. 1 Accident region on 2018-07-30.

2. Facts

On 30 July 2018 at approx. 11:42 hours CEST in the waters of the Adriatic, approx. 3 NM WSW of the Bay of Trašte (Montenegro), there was a collision between the Flipper motor yacht (Azimut 50 type, British flag (Jersey)) and the Karukera sailing yacht (Bavaria 46 type, Polish flag). At a speed of about 21 kn, Flipper hit the left side of Karukera near the stern. Following the impact, two of the eleven people on board of Karukera were killed. The other persons did not require medical assistance. The Karukera was very badly damaged and was towed to the nearby port of Zelenika. The Flipper suffered minor damage to the hull near the stem and the left side and reached the port of Zelenika on its own. At the moment of the collision, the Karukera mainsail was still hoisted and the yacht’s engine was set to full ahead, while trying to make a sudden turn to the starboard to get off the Flipper course, which was approaching almost directly in the bow direction. For all persons on board of both Flipper and Karukera, the emergence of the other vessel in a situation that directly led to a collision was a surprise or was completely unnoticed (on board of Flipper) until the moment of impact. Karukera started the evasive manoeuvre with emergency engine speed at maximum and a turn hard to starboard a dozen or so seconds before the collision, while Flipper did not change its course or speed until the impact. 4

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The Flipper left the Montenegro Marina (Tivat) earlier that day and was heading from the Bay of Kotor to Budva. The Karukera left the anchorage in the Bay of Trašte (Bigovo) and was tacking into the wind, heading for the SW part of the Luštica Peninsula coastline with the intention to anchor in the vicinity of the caves which are attractive to tourists.

Fig. 21 Routes of the vessels until the moment of collision (on the Croatian map MK- 27)

1 Route of the Flipper m/y according to the AIS data provided by EMSA. Route of Karukera s/y according to VTMIS radar images and the accounts of the accident participants.

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3. General information

3.1. Yacht particulars

3.1.1. Karukera

Name Karukera Flag Polish Owner Piotr M. Classifying institution - Yacht type Bavaria 46 Call sign - IMO identification number None Displacement approx. 12.000 kg Construction year 1998 Engine power built-in engine 44.1 kW Width 4.48 m Total length 13.98 m Hull construction material polyester-glass laminate Minimum crew Not specified

3.1.2. Flipper

Name Flipper Flag British (States of Jersey) Owner Ixia Asset Management Ltd. Classifying institution - Yacht type Azimut 50 Call sign 2IXO2 IMO identification number None

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Displacement (mLDC) 24.850 kg Construction year 2015 Engine power 2 built-in engines 493 kW each Width 4.63 m Total length 15.88 m Hull construction material polyester-glass laminate Minimum crew Not specified

3.2. Voyage particulars

3.2.1. Karukera

Ports of call during the journey Kotor - Tivat - Bigova Port of destination Not specified Navigation type Coastal Crew information 6 adults, 5 children aged between 7 and 10 Passenger information Not specified

3.2.2. Flipper

Ports of call during the journey Tivat Port of destination Budva Navigation type Coastal Crew information 1 person – professional skipper Passenger information 4 adults, 1 child aged 13

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3.3. Marine accident information

Type very serious marine accident Accident date and time 30 July 2018 at approx. 11:42 hours CEST Geographical position during φ = 42° 21’ N, λ = 018° 37’ E the event

Geographical region of the Adriatic Sea event occurrence Water region character Coastal waters Weather during the accident W 1º B wind, sea condition 1-2, very good visibility, cloudless sky

Yachts’ operating condition Flipper m/y – recreational sailing, en route; during the accident Karukera s/y – recreational sailing, en route

Accident effects for the yacht Flipper m/y – slight damage to the stem and side; Karukera s/y – serious damage to the hull and equipment

Accident effects for the people Karukera s/y – the captain and the first officer died immediately or almost immediately after the collision as a result of injuries

3.4. Information on shore services involved and rescue operation

A few minutes after the collision, the skipper (via the VHF radio station) and the ship owner (via telephone) who was on board of Flipper, as well as the skipper from the Mamma s/y (via the VHF radio station) notified of the accident and called for help. The rescue centre in Bar received the notifications and forwarded to the ambulance services, the fire brigade and the police, as well as to the port services in Montenegro and Kotor. A few minutes after the collision, the Mamma sailing yacht (flying Latvian flag), which was nearby, arrived at the scene of the event and helped to take one of the seriously injured person out of the water. The person died shortly afterwards from blood loss suffered in the water. Next, the Mamma skipper helped the persons on board of Karukera to assess the damage to the yacht, stop the engine and prepare for evacuation. The other seriously injured person – Karukera’s captain and owner – died in the collision. The captain’s body, which fell into the water after the collision, was towed by the second officer 8

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and taken on board of the Flipper drifting near the scene of the event after the collision. The Volunteer Fire Brigade from Radovići, a rescue motorboat from Porto Montenegro, a motorboat from the harbour of Zelenika, a MUP helicopter and 3 other small vessels were dispatched to the accident scene. The fire brigade was the first to arrive. After receiving information that two deceased persons could no longer be helped and that the remaining persons did not require any medical evacuation, the helicopter flew to Zelenika. At the request of the police, both vessels involved in the collision and the Mamma yacht sailed to the harbour of Zelenika, where the police and the prosecutor’s office, as well as the maritime administration, set about carrying out formal activities. Flipper and Mamma arrived there on their own while Karukera was towed by one of the motorboats.

Photograph 2 Karukera after the collision Photograph 1Flipper after the collision

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Photograph 3 Damage to the Flipper’s bow2

Photograph 4 Damage to the Flipper’s port side

2 Photographs 1–5 were provided to the Commission by Aleksandar Bozovic.

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Photograph 5 Damage to Karukera (view from on-board)

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Photograph 6 View of the stern area of Karukera’s port side3

3 Photograph’s author – W. Karaś.

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4. Description of marine accident circumstances

On 30 July 2018 at approx. 10:20 hours, the Flipper left the Montenegro Marina and headed for the open sea, initially sailing along Luštica Peninsula coastline to reach the port of Budva. In the waters of the Tivatski Zaliv and Hercegnowski Zaliv bays, Flipper observed the local speed limit of 10 kn for yachts. In the Kumbor Strait, it correctly slowed down to the prescribed speed of 6 kn. After going out to the open sea and passing by the island of Mamula, the Flipper took a course to Budva and started accelerating systematically so that it reached the speed of

21–22 kn at the moment of the collision.

Fig. 3 The Flipper m/y speed ranges registered on the day of the accident.

Along the route between the island of Mamula and the collision site there were yacht’s head adjustments to the left caused by the shape of the coastline. According to the testimony before the prosecutor, the shock caused by Flipper hitting the hull of Karukera was a surprise for everyone on board (except the skipper). None of the persons (including the skipper) knew where the sailing yacht came from under the bow of their motor yacht. The Flipper was controlled by a professional skipper who was operating the yacht on a day-to- day basis on behalf of the Russian ship owner. Apart from the skipper, there were the ship owner

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himself and four members of his family, including two children, on board. On the same day at approx. 10:30 hours, the Karukera sailing yacht left the mooring buoy she spent the night at and entered the waters of the Bay of Trašte with the intention to reach the Zlatna Luka Bay area. It was the third day after the guests for a holiday cruise with children boarded. As the west wind was blowing, sails (foresail and main sail) were set at approx. 11:03 hours after skirting the Cape of Trašte with the engine on. The yacht set its course at 240° and went under sails at a speed of approx. 3–4 kn close–reach on starboard tack. As usual, the captain gave orders to set the sails and the man particular positions. Shortly before 11:39 hours, the first officer noticed that the yacht was disadvantageously moving away from its destination too far into the sea. At the same time, the wind slowed down and the speed of the yacht significantly decreased. The captain ordered lee ho and to douse the sails and continue the cruise with the engine drive. The rudder was taken over by the first officer, an experienced sailor (yacht captain). The tack was performed at approx. 11:39 hours. The captain started the engine at idling speed and the first officer was still at the rudder. The yacht was now on starboard tack. Some other persons took up handling the lines and winches to furl the foresail.

The location of particular persons on board is shown in Fig. 4.

Fig. 4 Location of persons on board of Karukera during the collision.

Immediately after tacking and furling the foresail the first officer at the rudder noticed a motor yacht approaching at high speed in the opposite direction just in front of the bow and gave a warning shout to the others. In the opinion of the persons on board of Karukera the courses of the approaching vessels collided directly and the distance was between 50 and 150 metres in 14

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the subjective opinion of various persons. The emergence of the Flipper at such a short distance was a surprise for everyone on board of Karukera. Earlier, before tacking at 11:39 hours, a motor yacht was spotted at a long distance, but she was not the subject of reports or talks. Within a few seconds, the captain of Karukera immediately ordered to turn starboard and set the engine gear lever to the maximum speed ahead. The rudder was set hard-a-starboard. Without any noticeable change of course the Flipper hit the stern area of the left side of Karukera with its bow and the middle part of its hull brushing against the stern area of Karukera (cf. Fig. 5).

Fig. 5 Location of the vessels at the moment of the collision.

Shortly before the collision two persons who were close to the sides on Karukera, jumped overboard diving to escape from the hull that rammed the yacht (in Fig. 4 these persons are marked as “II” on the left side and “D” on the right side). Two persons on Karukera – the first officer standing at the rudder and the captain sitting next to her (in Fig. 4 these persons are marked as “I” and “K”) – were in the way of the hull of Flipper and were thrown into the sea with severe injuries. The rest of the persons from Karukera were not injured and did not feel the strong pull of the

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hull during the collision. No one fell down or fell overboard following the impact. After the collision two uninjured sailors swimming near Karukera rushed to rescue both severely injured persons and towed them to the vessels in the immediate vicinity – Flipper and Mamma. The body of the deceased captain was taken aboard Flipper and the dying first officer was taken aboard Mamma. The crews of both vessels started providing first aid and resuscitation, but without success. The inability to save both of them was confirmed on the spot by a doctor who participated in the Karukera cruise. Those who jumped out of Karukera in time returned to their yacht, partly with the help of the Mamma yacht, to clean up the main sail and control the rudder and engine failure. Gas cylinders were thrown overboard and the fuel supply was cut off to stop the engine (the engine control panel had been damaged). A member of the Mamma yacht crew helped to do it. All Karukera passengers were evacuated because of a hole in her side through which the she was making water. Flipper, Mamma and the motorboats which had come to the aid with the unmanned Karukera on the tow sailed to the port of Zelenika.

5. Analysis and comments about factors causing the marine accident with regard to examination results and expert opinions

The analysis of the events is based on the AIS and VTMIS electronic data registered by onshore services and on the accounts of the persons who were on board of Karukera and Mamma. The VTMIS images registered in the system are the primary source for indicating detailed vessel movements immediately before the collision. The detailed vessel movement parameters, especially for the Karukera manoeuvring without an AIS transmitter, should not be interpreted literally, but the obtained image allows for the formulation of reasonable conclusion. Fig. 6 shows the situation immediately after tacking at 11:39 hours, about 2 minutes before the collision, when the Karukera crew were furling the foresail. In this figure, the object marked as “Track 1318968” means the Karukera. The fast approaching Flipper had not yet spotted on board of Karukera at that time. Fig. 7 shows the situation at approx. 10:40 after Karukera took its course at approx. 330⁰ at a distance of approx. 700m from Flipper sailing at 131⁰ Figure 8 shows the situation just before the collision. Fig. 9 shows the plotted routes of Flipper and Karukera a few to several seconds before the

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collision, obtained from superimposed successive VTMIS images. In this situation Karukera starts an evasive manoeuvre to the right.

Fig. 6 Situation after Karukera’s manoeuvre at 11:39 CEST.

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Fig. 7 Situation after finishing Karukera’s manoeuvre at 11:40 CEST

Fig. 8 Situation just before the collision.

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Fig. 9 Plot of the vessels’ routes.

It should be noted that the vessels’ routes presented in the VTMIS system are not the records of all previous positions, but a time averaged approximate vector. On Fig. 9 this is clearly visible for manoeuvring Karukera, but is not relevant for the Flipper and Mamma yachts whose courses remain unchanged. It is important to note the discrepancy between the accounts of Karukera crew members and VTMIS records with regard to the speed of the yacht prior to and after rolling up the foresail. According to oral reports, the yacht’s engine was idling, so that the propeller was not powered and the wind had already completely died down. In these conditions Karukera would not have travelled for 2 minutes before the collision with the speed indicated by the VTMIS, i.e. 3.3 kn. This contradiction may be attributed to the fact that relevant parameters were averaged by the VTMIS, or to incorrect assessment of the situation by the persons who gave their accounts.

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5.1. Human factors (faults and omissions)

5.1.1. Manoeuvres prior to the collision

Karukera’s turn initiated at 11:39 hours was probably made without captain being aware of the speed at which the motor yacht was approaching. This manoeuvre was not noticed by the person steering the Flipper motor yacht. Precise movement parameters of Karukera when it made the emergency escape manoeuvre are unknown. Assuming that Karukera’s course was 330⁰ and Flipper’s course was 130⁰, prior to the collision at 11:41 hours, the relative situation of the vessels was as follows. From the observation point of the Flipper’s skipper, the sailing yacht (carrying main sail) which was heading across the motor-boat course from the right to the left was situated ca. 300–400 m and several degrees to the right of the bow. The sail, whose visibility could have been limited for the person steering the Flipper with these courses, would have been plainly visible during Karukera’s emergency right turn. From the observation point of Karukera’s captain, the motor yacht could have been hidden from view during the furling of the foresail, and then obscured by the mast. The first officer was the first to spot the motor-boat – right at the moment when Karukera was crossing the course of the approaching Flipper – and she spotted the vessel heading straight towards her yacht. The right turn ordered about a dozen seconds prior to the collision by Karukera’s captain and made by laying the rudder to starboard and maximising the engine power to full speed ahead caused the course to change by ca. 40–50⁰, with a slight sideways shifting of Karukera’s position away from Flipper’s course. The above-described manoeuvre made by Karukera is not subject to analysis in terms of its correctness, rightness or even effectiveness. The captain of Karukera had only several seconds to assess the situation and did not know whether anyone on Flipper noticed Karukera at all, and even if they did – whether Flipper would alter its course in any way. When Flipper was spotted the final outcome of this situation already depended solely on a complex series of events. The collision might not have happened at all or it could have had even more tragic consequences. Flipper’s skipper spotted the yacht for the first time when it was ca. 300 m ahead of its bow, i.e. ca. 25 s prior to the collision, and he considered that she is heading in the same direction,

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interpreting Karukera’s turn to the starboard as the yacht’s turn to the port which would carry it in front of Flipper’s bow. The person steering the Flipper did not make any manoeuvres based on these observations until the moment of collision.

5.1.2. The crew and their qualifications

Formal lists of the crew and passengers presented and approved during the briefing included only one person each. This meant that only the person responsible for steering the vessel was reported as present on each vessel. The other persons were not reported neither as crew nor as passengers. Karukera was operated by its owner, an experienced sailor, sailing instructor who dealt in sailing courses and organisation of voyages. He was the holder of marine yacht helmsman navigation certificate issued by the Polish Yachting Association (since 03.07.2012) and marine motorboat helmsman navigation certificate (since 15.10.2012). He sailed Karukera on his own from Greece to Kotor, and on 28 July 2018 took additional 10 people who arrived from Poland on a vacation cruise. In the course of the investigation it was not confirmed that the captain and yacht held licences and radio certificates appropriate for the vessel’s equipment. The owner of Karukera navigated these waters previously and was familiar with them well. Among the 10 persons who came on board in Kotor, there were 5 adults and 5 children aged between 7 and 10. Among the adults there were very experienced yacht captain and two marine yacht helmsmen with less experience. Three of the adults have customarily taken over officer functions (I: navigation, II: technical matters; III: supplies/finances), but in view of the fact that no round-the-clock sailing nor long stretches of the route were planned, the system of watches was not established and mates never navigated the vessel at sea on their own. The captain was responsible for taking all the decisions and assigning all the tasks. The captain of Flipper was a professional skipper holding a certificate entitling him to steer yachts up to 100 tonnes gross (Voditelj jahte) since 20124, issued by Kotor harbour office5, and a limited GMDSS operator certificate. He was operating Flipper on a day-to-day basis for the Russian ship owner.

4The entitlement to operate yachts up to 100 tonnes gross (Voditelj jahte) was renewed in 2016. 5 The level of training and examination requirements may be insufficient. When he testified in front of the prosecutor with his lawyer present, the accused Flipper skipper stated that in his opinion even if a sailing boat with raised sails has the right of way at sea, a sailing boat propelled by engine power should give way to a “larger vessel.” 21

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Apart from the skipper, the ship owner and four members of his close family, including two of his children (aged 20 and 13), were also on board.

5.2. Mechanical factors

Both yachts which participated in the collision are professionally designed vessels mass produced in renowned shipyards. Their construction characteristics and nautical parameters did not have an impact on the accident occurrence. The factors which could have had an impact on the accident occurrence include visibility conditions and equipment. Both yachts were CE certified (Flipper – “B” design category, while Karukera – “A” design category). Both yachts held registration certificates of recreational vehicles. Mechanical factors did not have an impact on the accident occurrence.

5.2.1. Mutual visibility of the vessels

The visibility conditions from Karukera’s cockpit provided an unobstructed view on both sides of the ship. Towards the bow, the visibility could have been limited until the raised genoa sail was folded, and obstructed by a pontoon raised and resting against the front part of the superstructure on the fore deck or by persons standing or sitting near the bow (cf. Fig. 5). Sprayhood was not deployed and did not limit visibility ahead. The visibility conditions from Flipper’s bridge (upper control position) were not hampered in any way. On the day of the accident the windows of the lower, internal control position in the lounge were completely covered with non-transparent anti-glare mesh. When they approached one another, both vessels maintained mutual visual contact for at least 10 minutes:  Karukera yacht became visible from Flipper’s bridge about 15 minutes prior to the collision, emerging with its sails raised from behind the Veslo massif. At this point in time, the yacht was following a nearly perpendicular course under both sails which were visible earlier.  Flipper appeared in Karukera’s field of vision about 10 minutes prior to the collision.  The decision to make a 11:39 hours turn was taken on board of Karukera about 3–4 minutes prior to the collision. By then, Flipper was ca. 1.5 NM from Karukera and followed a steady course.

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5.2.2. Rescue equipment

Rescue equipment of the vessels did not play any role during the accident. Prior to the collision, no one on board of Karukera, including children, was wearing a lifejacket, a protective jacket or a safety harness6. After the collision, the persons remaining on board of the yacht put on lifejackets and were wearing them until the end of the evacuation.

5.2.3. Communication and navigation equipment

The interviews with participants of the voyage and the gathered photographic evidence indicated that Karukera yacht was equipped with the following stationary devices installed at the navigation station in the cabin:  stationary UKF radio-telephone with DSC (microtelephone/manipulator was not available from the cockpit);  GPS receiver/Standard Horizon map plotter of CP/CPF series (the display was not visible from the cockpit);  a navigational plotter recently installed in the cabin in 2018. In addition, navigation was carried out by means of the captain’s smartphone capable of visualising the navigational situation to the extent which is currently impossible to determine. The smartphone was held in hand or attached near the helmsman station by means of Velcro fastenings. It drowned in the sea during the accident. The cabin was also equipped with:  binoculars;  a mobile (hand-held) UKF radio-telephone;  an acoustic signalling device using a can with compressed gas (manual fog signal); These items were not present in the cockpit and were not used on the day of the accident. The details and the condition of navigational devices at Flipper’s control positions are unknown. It may be assumed that the vessel was equipped with radar (an antenna is visible on the photographs) and an UKF radio-telephone and was capable of producing sound signals. Hand-held UKF radio-telephone – switched off – was located on the bridge shortly

6 At that point in time the weather was calm with no clouds and wind.

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after the collision.

5.3. Organisational factors

No watch was kept or it was kept to an insufficient extent on both vessels participating in the collision7. Karukera’s control post was not prepared to establish an immediate radio-telephone connection or emitting acoustic signals. To access the radio-telephone, emit an acoustic signal or use the binoculars, someone had to go down into the cabin.

5.4. The influence of external factors including the marine related ones on the accident

External factors did not have any impact on the occurrence of the accident. At the place and time of the accident there was no wind, while the sun was high in the sky (ca. 66° over the horizon) and did not disturb the effective observation of the sea.

6. Description of the investigation results, including safety issues and investigation conclusions

Following the analysis, the Commission established that the reason behind the collision of Karukera sailing yacht and Flipper motor yacht on 30 July 2018 at approx. 11:42 hours in the waters of the Adriatic, approx. 3 NM WSW of the Bay of Trašte, was the absence of constant visual observation8 by the crews of both vessels; in addition, the following factors contributed to the accident:

 failure to observe the safe speed limit9, resulting in inability to detect vessels sailing in the vicinity sufficiently in advance,

7 According to Władysław Rymarz in International maritime right of way – an outline (pol. Międzynarodowe prawo drogi morskiej w zarysie) (TRADEMAR, Gdynia 2015), among the main causes of collisions analysed in 1997–2006 the most common 3 are: inadequate assessment of situation – 24%, inadequate watch or lack of watch – 23% and failure to spot another vessel until the moment of collision – 13%. Source: Capt. H. Gale MNI, Capt. D. Patraiko, FNI, Improving Navigational Safety, Seaways 03.2007. 8 Regulation 5 of the COLREG 72 convention. 9 Regulation 6 of the COLREG 72 convention. 24

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 failure to react to an immediate threat of collision10 at the moment of spotting the sailing yacht on course, insufficient familiarity with the provisions of the COLREG 72 convention11 and incorrect interpretation thereof. The Commission notices the recurring problem of the failure to keep constant watch during the vessel’s journey, especially in very good hydro-meteorological conditions12. The Commission considers that the analysis of navigational situation of vessels only in a situation where they are in each other’s immediate vicinity to be a bad practice. The movement of vessels which are further away from each other has to be analysed and it has to be assumed that such vessels are capable of moving with much greater speed. Based on the experience gained over the years in this respect, it can be stated that with a proper visual observation an experienced navigator is capable of assessing the risk of collision with the observed vessel. In case of any doubt as to the possibility of collision or if the collision seems certain, one has to use all available means of verifying the situation and take appropriate steps in accordance with the Regulations of the COLREG 72 convention. Persons navigating fast-moving vessels are under special obligation to carefully observe the sea by using all available means. Early detection of all possible situations which may pose a threat of collision or which may bring two vessels too close to one another, as well as taking appropriate measures well in advance, is especially important in this context. The Commission considers noticing the vessel and not taking appropriate actions – except for the situation when such a behaviour is intentional – to be equivalent to not conducting any observation at all, since the results are the same.

7. Safety recommendations

After investigating the collision of Karukera and Flipper, the State Marine Accident Investigation Commission declared that the main reason behind the accident was the absence of constant visual observation on board of the two vessels. Especially in the case of Flipper which was sailing at a high speed – nearly 7-times higher than Karukera – visual observation should have been conducted constantly and with particular care.

10 Regulation 2 of the COLREG 72 convention. 11 See Chapter 4.1.2. 12 See final report No 32/18 concerning collision of Translontano general cargo vessel with Hunter motor yacht (http://pkbwm.gov.pl/images/Raport_koncowy_PKBWM_PL---Translontano-final-28.05.2019.pdf). 25

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A couple of years ago, an experienced MAIB (Marine Accident Investigation Branch) inspector stated that over the course of ten years of investigating ship collisions in 43% of the cases the crew on navigational bridge either did not see the other vessel at all or noticed it too late13. Similarly, the lack of observation was the cause of collision of vessels in two cases investigated by SMAIC in 2018 (Translontano & Hunter and Begonia S & Miętus II). The State Marine Accident Investigation Commission addresses the content of the report to broadly understood sailing community in order to launch the debate on this issue and introduce a system of watches which would ensure diligent observation of the area around the yacht by the designated crew member.

8. List of photographs

Photograph 1. Karukera after the collision ...... 9 Photograph 2. Flipper after the collision...... 9 Photograph 3. Damage to the Flipper’s bow ...... 10 Photograph 4. Damage to the Flipper’s port side ...... 10 Photograph 5. Damage to Karukera (view from on-board) ...... 11 Photograph 6. View of the stern area of Karukera’s port side ...... 12

9. List of figures14

Fig. 1. Accident region on 2018-07-30...... 4 Fig. 2. Routes of the vessels until the moment of collision (on the Croatian map MK-27) ...... 5 Fig. 3. The Flipper m/y speed ranges registered on the day of the accident...... 13 Fig. 4. Location of persons on board of Karukera during the collision...... 14 Fig. 5. Location of the vessels at the moment of the collision...... 15 Fig. 6. Situation after Karukera’s manoeuvre at 11:39 CEST...... 17

13 Source: David Patraiko FNI, All available means – The Navigator, Issue no. 19, (October 2018), The Nautical Institute. 14 The figures use the maps and navigational data visualised by means of navigational software – OpenCPN (www.opencpn.org).

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Fig. 7. Situation after finishing Karukera’s manoeuvre at 11:40 CEST ...... 18 Fig. 8. Situation just before the collision...... 18 Fig. 9. Plot of the vessels’ routes...... 19

10. List of acronyms

AIS – Automatic Identification System CEST – Central European Summer Time COG – Course Over Ground COLREG 72 – Convention on the International Regulations for Preventing Collisions at Sea (COLREG 1972) DSC – Digital Selective Calling EMSA – European Maritime Safety Agency GPS – Global Positioning System IMO – International Maritime Organization cable – cable (0.1 NM) LS – left side MOB – Man Over Board NM – nautical mile MMSI – Maritime Mobile Service Identity IRWL – International Right of Way Law (COLREG 72) MUP – Ministarstvo Unutrašnjih Poslova (Ministry of the Interior of the Republic of Montenegro) RS – right side NW – North-West (wind direction) SAR – Search and Rescue SW – South-West SOG – Speed Over Ground UKF – ultra-short waves (here: maritime band) UTC – Universal Time Coordinated VTMIS – Vessel Traffic Management Information System

FINAL REPORT 23/16

11. Participation of substantially interested states

The United Kingdom (MAIB) as the flag State of Flipper motor yacht

12. Sources of information

Materials gathered during the direct testimony of accident participants from s/y Karukera. Materials from pre-trial proceedings before judicial authorities in the Republic of Montenegro, including photographic documentation. Statement by the captain of Mamma yacht. Archival AUS records of the movement of Flipper motor yacht according to EMSA and vesselfinder.com. VTMIS records of the movements of Karukera, Flipper and Mamma yachts. Expert opinion made by Piotr Carlson – the expert of the SMAIC

13. Members of the team investigating the accident

Team leader – Tadeusz Wojtasik – Chairman of the Commission Member of the team – Monika Hapanionek – Member of the Commission