Marinha Do Brasil

BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report

MARINHA DO BRASIL

DIRETORIA DE PORTOS E COSTAS

WATERWAY TRAFFIC SAFETY SUPERINTENDENCY

DEPARTMENT OF INQUIRIES AND INVESTIGATIONS OF NAVIGATION ACCIDENTS FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” JULY 24, 2018

MARITIME SAFETY INVESTIGATION REPORT

Photo 1: M/V SEPETIBA BAY (photo obtained on the Internet)

Reference: Casualty Investigation Code, of the International Maritime Organization (IMO) – MSC-MEPC.3 / Circ.2, 13 June, 2008 / Resolution MSC.255 (84).

1 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report

INDEX 1- LIST OF ABBREVIATIONS ...... 3 2- INTRODUCTION...... 4 3- SYNOPSIS ...... 4 4- GENERAL INFORMATION ...... 4 a) Characteristics of the vessel...... 4 b) Documents and Certificates...... 5 5- ACCIDENT LOCAL DATA ………...... 5 6- HUMAN FACTORS AND CREW ...... 6 7- CHRONOLOGICAL SEQUENCE OF EVENTS ...... 7 8 - PROCEDURES AFTER THE ACCIDENT ...... 7 9 - CONSEQUENCES OF THE ACCIDENT ...... 9 10 - EXPERT EXAMINATIONS ...... ,,,,...... 9 11- ANALYSIS AND CAUSAL FACTORS ...... …...... 9 12 - PRELIMINARY LESSONS LEARNED AND CONCLUSION ...... 16 13- SAFETY RECOMMENDATIONS...... 17

14- ANNEX A – SHIP`S PARTICULARS OF THE M/V “SEPETIBA BAY” ………………18

LIST OF ABBREVIATIONS

BCSN - Bulk Carrier Safety Names CPES - Port Authority of Espírito Santo DDSMA - Safety and Environment Dialogue DNV - Det Norsk Veritas EEBD - Emergency Escape Breathing Device FIBRIA- Fibria Celulose SA Gases: CH4-Methane CO - Carbon Monoxide C02 - Carbon Dioxide H2S - Sulfuric Acid 02 - Oxygen IMO - International Maritime Organization IMSBC Code - International Maritime Solid Bulk Cargoes Code ISAIM - Safety Investigation of Marine Accidents and Incidents ISM Code - International Safety Manegement Code LEL- Lower Explosivity Limit MEPC - Marine Environment Protection Committee MMSI - Maritime Mobile Service ldentity MSC - Maritime Safety Commitee OGMO - Labor Management Body PORTOCEL - Portocel Specialized Terminal of Barra do Riacho SA SCBA- Self-Conteined Breathing Apparatus STCW 78 - International Convention on Standards of Training 1978.

II) INTRODUCTION For the purpose of accomplishing the collection and the analysis of evidences, the identification of the causal factors and the elaboration of the recommendations of safety that are necessary, in order to avoid that in the future occur similar maritime accidents and/or incidents, the Ports Captaincy of Espirito Santo (CPES) carried out the present Safety Investigation of Marine Accidents and Incidents (ISAIM) in compliance with that laid down in the Casualty Investigation Code of the International Maritime Organization (IMO), adopted by Resolution MSC.255(84). This Final Report is a technical document that reflects the result obtained by the CPES in relation to the circumstances that contributed or may have contributed to unleash the occurrence and does not resort to any procedures of proof for verification of civil or criminal responsibility. Furthermore, it should be emphasized the importance of protecting the persons responsible for the supplying of information related to the occurrence of the accident, for the use of information included in this report for ends other than the prevention of future similar accidents may lead to erroneous interpretations and conclusions..

2 - SYNOPSIS The accident occurred on 07/24/2018 aboard the ship SEPETIBA BAY, during the discharge operation of logs, at the Portocel Terminal in Aracruz, ES. In the course of the operation a crane operator reported that a man had fallen to the bottom of Basement # 1, which motivated the entry of three other dockers in the basement, to give relief to the victim. This initiative eventually led to the loss of consciousness of the stevedores, as soon as they reached the bottom of the compartment, resulting in the death of three of them and the malaise of another who, however, survived. No water pollution occurred.

3 – GENERAL INFORMATIONS A) Characteristics of the vessel: Port of Registry: Monrovia Flag: Liberia Ship Type: Bulk Carrier IMO: 9496343 MMSI: 636016208

4 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report

Official Number: 16208 Owner: Norwest Navigation ES Operators: Norsul Navigation Company Classification Society Det Norske Veritas Class Notation: 1A1 Ore Carrier ESP EO Keel Launched: December 2014 Delivery: June 25, 2012 Shipyard: Samjin Shipbuilding Industries Co., Ltd., China Gross tons: 23,426 Net tonnage: 11,082 Overall Length: 180 m Breadth: 30 m Depth: 14.7 m Cranes: 4 x 35 T Mac Gregor1 P & I Club: Assurance Foreningen Gard - Norway Freight: Timber without bark Quantity: 19,052.2 tonnes Port of loading: Rio Grande, Brazil Port of unloading: Portocell - Aracruz, Espírito Santo, Brazil / Embarkation: Fibria Celusose S / A Receiver: Fibria Celulose S / A Company identified in Safety Management Certificate: Anglo EasternShip Management Limited - 23 / F, 248 Queen's Road East Wanchai, Hong Kong. Ship operating under normal conditions prior to the accident, having been inspected at the Port of Salvador on 05/15/2018, without any deficiencies noted. B) Documents M/V "SEPETIBA BAY": All documents were within their validity

4 - . ACCIDENT LOCAL DATA The accident occurred with the ship moored at Pier 102 at the Portocel Terminal in Aracruz, Barra do Riacho, Espirito Santo, Latitude 19°40`SOUTH, Longitude 040º05 WEST.

5 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report

Photo 2: Ship moored to the Cradle 102 of Portocel

Environmental conditions were normal, with no noteworthy observation.

5 – HUMAN FACTORS AND CREW:

The crew met the STCW / 78 requirements in quantity and quality. Records of rest hours did not point to a period of work that could motivate excessive fatigue. The ship's accommodation was in good conditions of comfort, hygiene and lighting. No evidence of illegal substances was found on board. There were records of compliance with the Safety Management Manual, with conducting training and familiarization exercises with abandonment, fire fighting, steering by the steering machine and others. The ship had shíp / shore check Jíst1 for loading and unloading operations, issued by the Company, and presented documentation proving that it had complied with the port administration.

6 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report

The working languages were Hindi and English, spoken by crew members as the ship presented its latest Class Survey Report, where no relevant operational or material deficiencies were recorded.

6 – CHRONOLOGICAL SEQUECE OF EVENTS - The ship docked at berth 102 of the Port Terminal of Portocel, Barra do Riacho, Espírito Santo, around 4:00 pm on July 21, 2018. - The unloading operation began at 9:00 pm on July 21 and continued without abnormalities until July 24, when the following events occurred: 1) From 07:00 a.m. to 7:30 p.m., cargo hold #1 was opened, where the accident occurred, and its atmospheric control was carried out in three different levels, according to the ship's Log Deck Book launches and the information of the Chief Officer, including the upper part . The readings were considered normal (02 to 20.9%, CH4 = 0, H2S = 0 and Lower Explosiveness Limit (LEL) = 0). (2) The unloading operation of the hold was started at 08.00 and occurred without any abnormalities until 12:20 when the ship's seaman heard from the crane operator that a dockworker was lying on the bottom of the hold under the access ladder. 3) When he realized that there was a dockworker at the bottom of the cargo hold, another stevedore, using the access ladder by the switchman, also entered the basement, in an attempt to give relief to what was supposed to be a wounded. He collapsed, then too, lying down in the cargo hold. 4) The crane operator, who had given the signal of the fall of the first crash, also went to the cargo hold, using the same access, and then fainted. 5) Finally, another stevedore, who would make up the other third in the unloading operation, also entered the cargo hold, in an attempt to help the others, and also fainted. 6) After the accident victims were removed from the hold, three of them were dead and one showed signs of recovery.

7 – PROCEDURES AFTER THE ACCIDENT After the dissemination of fallen man information inside the basement, the rescue of the ship was mobilized and two crew members carrying protective equipment for 7 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report breathing, went into the cargo hold to provide first aid. As the equipment they carried was for individual use, there was a need to provide additional equipment to meet the injured. These equipment were not in the vicinity of the basement and were brought from their storage location. The following sequence of events is recorded on-board as: g) At 12h27, litter, resuscitator, EEBD and first aid kits were available near the cargo hold. h) At 12h28 two crew members entered the basement, wearing Self-Contained Breathing Apparatus (SCBA). (i) At 12:30 a.m. rescue equipment was introduced into the hold. j) At 12:32 pm one of the accident victims received oxygen and was placed on the stretcher. (k) At 12.35 the land rescue team arrived on board and entered the cargo hold at 12:40 p.m., and the rescue team was removed from the ship. According to information from the first brigade to enter the cargo hold equipped with gas detectors, at the beginning of the descent to attend the event, the sensors alarmed and indicated an oxygen level (0 2 level of 5% and carbon monoxide level of 66 ppm, about 2 meters from the bottom of the basement where the accident victims were. This saturation value of 0 2 is not compatible with the existence of human life. 1) At 13:05 the first accident was taken from the hold and taken to an ambulance. m) At 1:20 pm the second victim was removed from the hold, by the basket, and transferred to another ambulance. n) At 1332 hours the third victim was withdrawn, also by the basket, and transferred to another ambulance. These casualties were taken to the hospital despite no longer showing vital signs. o) The last casualty was removed from the hold, still using the basket, and transferred to an ambulance at 1:56 p.m. The latter had conditions of locomotion and was accompanied to the hospital for observation. p) Between 14h00 and 15h00 the vessel made formal communications to the Anglo-Eastern Ship Management Limited (AESM-HKG) by satellite telephone and forwarded the messages accompanying the event. (q) At this point, the Statement of Facts records that the port security team, in the guise of its security engineers, boarded and verified the cargo holds n 1 and n 2, considering the values found as normal. r) Between 1940 and 2120 the Federal Police remained on board, carrying out their initial 8 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report investigations. When they left, they determined that the hold was closed for atmospheric measurements the next day, but they collected the gas meter used by the ship in the measurement in the morning. Such an initiative prevented the verification of the meters used by the vessel.

8 – CONSEQUECES OF THE ACCIDENT Personal Injury - Three dockworkers came to death. Environmental damage - There were no. Material damage - There was no.

9 – EXPERT EXAMINATIONS All the on-board and terminal documents that were affected by the accident were verified by the investigators of the CPES. Measurements of the atmosphere of cargo hold number 1 were also carried out after the accident but, as was done with meters other than that used by the vessel before that, these measurements were not considered in this report. It can only be affirmed that the measurements made found different values for each measurement of oxygen and C02 in the basements where they were carried out during the experiment. Moreover, in the case of a single cargo hold, the measurements performed at different levels also presented different values. This indicates the fragility of the measurement method used by the ship, which has always shown the same value for all holds in all measurements. The cadaveric examination reports signed by the medical examiner indicate as immediate mortis the pulmonary edema, for the three stevedores who died.

9 – ANALYSIS AND CAUSAL FACTORS Mentioned above, prior to the unloading operation, the ship and the terminal complete a Check List, prepared by the Company, which must be signed by a representative of both. This document contains an item which provides that the monitoring of the bilge atmosphere shall be agreed between the ship and the Terminal. It is compulsory to check a certain amount of oxygen and methane in the holds to allow the entry of the stevedores, but there is no need to detail how this verification should be conducted. The start of the bilge discharge operation follows a procedure adopted by the Terminal, where access to cargo occurs through the entrance of the cargo hold, using a 9 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report aluminum stairs, to allow access of dockworkers to the top of the logs, whose height comes to about 2 meters from the bilge cover. This can be seen in the following photo:

Photo 3: Arrangement of the logs for the beginning of the unloading

The function of the dockworkers in this type of unloading operation is to attach the hook \ of the cranes at the ends of the steel rope slings and chains which are already in the bales of the wood logs. These bales, once caught by the hooks, are lifted by the onboard cranes and unloaded on the docks, on wagons. On July 21, the mechanical ventilation of all the cargo holds began at 22h00. It should be noted that the launching of this event is done, initially, as if the cargo hold ventilation was natural. A correction, however, scratches the word "natural" and inserts the word "mechanica" (mechanical) into the ship's Log Deck Book. It can`t be said that the correction found occurred before or after the signature of the page by the ship's Captain. During the interview the Captain informed that he signed the document already with the correction found. However, his signature on the correction is not included, as would be expected, given the importance of the fact reported and subsequently corrected. At 6:00 p.m. on the 22nd, the mechanical ventilation of all the holds was closed. In this

10 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report information release there are no erasures. It is important to emphasize that on July 23, are the first releases regarding inspections inside the holds. The number 4, opened and inspected at 01:03, with atmospheric check with oxygen at 20.9% and absence of other gases, and those of numbers 2, 3 and 5, open and inspected at 18:30, also with oxygen at 20.9% and absence of other gases. It is noteworthy the lack of detail of the atmospheric measurements, pointing out the number and internal levels of the basements in which they were made, only the information that the oxygen level was 20.9% in all four open and inspected basins. These details motivated the previous verification of other entries in the Log Book and it was verified that ALL the atmospheric measurement launches since June 1st, 2018 (first verified release), up to the date of the accident, presented the same value of 20.9% of Oxygen and absence of other gases. The basement number 1 was opened at 07:25 on July 24th and its discharge began at 07:30, according to the launch by the Chief Mate, who also records that the inspection and the atmospheric measurement were carried out. Again, the values of 20.9% oxygen and absence of any other gases appear. There are also no details of the levels at which the measurements were taken. During the interview the Chief Mate stated that he made three measurements, at three different levels, demonstrating the procedure he would have performed. This lack of detail is not compatible with the F / B Carrier Safety Names (BCSN) (document issued by the FIBRIA Logistics Coordination, when the shipment of the wood in the port of Rio Grande, to the consignee (owner) A copy of the document was presented, but with the signature dated 08/17/2018, almost one month after the accident, which does not allow to determine if it was received with the as it should have been, or only after the accident. This document contains the following safety notes: "Hazard

These cargoes are liable to cause oxygen depletion and increase of carbon dioxide in the cargo space and adjacent spaces. These cargoes are non-combustible or have a low fire risk."

And: "Precautions

Entry of personnel into cargo and adjacent confined spaces shall not be 11 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report

permitted until tests have been carried out and it has been established that the oxygen level is 21 %. /f this conditions not met, additional ventilation shall be applied to the cargo hold or adjacent enclosed spaces and remeasuring shall be conducted after a suitable interval."

This information on the hazard of the cargo in question is also contained in the International Maritime Solid Bulk Cargoes Code - IMSBC CODE, which reads on page 361, concerning the loads of wood in general: Hazard These charges are liable to cause oxygen depletion and increase of carbon dioxide in the cargo spaces and adjacent spaces ... ". That is, exactly contained in the BCSN that would have been delivered to the ship's Master. The IMSBC CODE contains the following guidelines: "Therefore, it is essential to obtain from the shipper valid and updated information on the physical and chemical properties of the cargoes presented for shipment which will be shipped. Also in Rule 2 of the same code, cargo information item 1 reads as follows: "The shipper shall provide the master or his representative with appropriate loading information, sufficiently in advance of loading, to to take such precautions as may be necessary for proper stowage and safe transport of cargo. Such information shall be confirmed in writing and by appropriate transport documents before loading of the ship”. In fact, if this information was not provided in time, a very important action was left open. On the other hand, even without this information, the ship could have relied on IMSBC CODE to deal with the risks posed by the cargo. Section 3 of the Code contains the recommendations on personnel and ship safety. Mainly in item 3.2, which deals with the risks of poisoning, corrosion and suffocation. Transcription of the items: "3.1 General requirements 3.1.1 Before and during loading, transport and unloading of a solid bulk cargo, all necessary safety precautions shall be observed. 3.2 Risks of poisoning, corrosion and asphyxiation 12 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report

3.2.1 Some solid bulk cargoes are susceptible to oxidation, which can result in reduced oxygen, toxic fumes or fumes and self-heating. When these loads are transported, due consideration shall be given attention to the protection of personnel and the need for special precautions to be taken prior to loading and after unloading. 3.2.2 Due attention shall be given to the fact that cargo spaces and adjacent spaces may be subject to oxygen reduction or may contain toxic or asphyxiating gases and that an empty cargo space or tank which has remained closed for a certain time may have insufficient oxygen to support life. 3.2.3 Many solid bulk cargoes are likely to cause oxygen reduction in a cargo space or tank. These include, but are not limited to, most plant and forest products, ferrous metals, metal sulphate concentrates, and coal fillers. 3.2.4 Before entering a confined space on board a ship, appropriate procedures shall be followed . It should be taken into account that after a space or tank has been tested and generally considered safe for entry, there may be small areas where oxygen is deficient or toxic fumes are still present. 3.2.5 When transporting solid bulk cargo which is liable to emit toxic gases and / or cause oxygen reduction in the cargo space, the appropriate instrument (s) for measuring gas and oxygen concentration in the cargo space shall be available. 3.2.6 Emergency entry into a cargo space should only be carried out by trained personnel using self-contained respirator and protective clothing and always under the supervision of a responsible official. The observations so far indicated indicate that the prior verification process of the discharge activity raises doubts as to its effectiveness, both due to the fragility of the measurements of the atmospheric conditions of the holds, with repetitions of values incompatible with a real situation, such as compliance with a methodology for the execution of these measurements, since no written guidelines were presented detailing this procedure. It is emphasized that all this process is conducted by the ship, which informs the Terminal that the hold is free to be accessed by the stevedores, as soon as it considers it safe from the atmospheric point of view, without the presence of noxious gases and with percentage of 02 within values compatible with life. On the other hand, the guidelines received by the employees who operated within of the hold during unloading do not include all the risks to which they would be subjected during the activity. During the Safety and Environment 13 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report

Dialogue (DDSMA) conducted by a port terminal worker, workers were not • trained in the oxygen depletion hazards in their workspace, nor in the harmful situations to which, could be submitted. Much less were they oriented to the emergency situation like the one that occurred, which helped that, after the first worker had suffered the fall and remained unconscious in the bottom of the hold, three other workers tried to rescue him, without taking into account any security measure or protection. During the DDSMA, only issues related to the safety of the unloading operation were discussed, such as the use of protective equipment, cargo safety, cargo control and handling in the basement. During his interview, the DDSMA official confirmed that he had not addressed any issues related to the environmental hazards in the basement regarding possible low oxygen content or presence of gases, but merely addressed issues of protection and care relating to cargo handling . He also said that if he was present at the time of the accident, he would have been one of the victims, because he had never heard of the possibility that the environment would be life-threatening for those who did not have respiratory protection. Taking into account the various recommendations contained in the IMSBC, it is clear that, even in the case of a cargo space considered safe, the possibility of small areas with a low oxygen level would require its access only to personnel carrying equipment that would allow the detection of this area situation. Failure to provide them with this information of danger and failure to provide them with the protection and alarm equipment that would enable them to remain safe has greatly increased their vulnerability and made them critical. There was also a lack of equipment for immediate rescue in the event of an accident near the holds. Such equipment was brought by the brigade of first responders who moved from the headquarters of the company (FIBRIA), after the dissemination of the information of the accident. The first crash was reported at 12:22 a.m. Regarding the details of this event, the only report of who could have seen the fall reports that the stevedore had descended through the logs and would have tried to climb the ladder of the switch, but could not have, falling from a height of about 2 meters from bottom of cargo hold. This version has no confirmation, and the hypothesis that the dockworker has fallen directly from the log pile to the bottom of the hold is not ruled out. The position 14 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report in which the crash was found gives credibility to the version of the direct fall, given the distance that the body is from the ladder, as well as the fact that it is positioned more to the side and not below the access to the shooter. In any case, it was not possible to determine whether the crash fell from the ladder or from the pile of logs.

Photo 4: Position of the injured person right after the accident.

The others, who entered the cargo hold in sequence, did so instinctively, disregarding any security procedure, confirming that they had received no guidance for a critical situation, not even the simplest. From what has been said can be enumerated as Causal Factors: (a) the fragility of the method of atmospheric measurement of cargo holds; b) Disinformation of the stevedores on the hazards inherent in the cargo; c) Poor protection of stevedores, in view of the risk of oxygen reduction inside the holds; d) Disinformation of stevedores regarding emergency procedures in case of accidents e) The lack of knowledge of the DDSMA driver regarding the risks inside the holds; and f) The lack of rigor in the conduct of the check list between the ship and the port.

15 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report

9 – PRELIMINARY LESSONS LEARNED AND CONCLUSIONS From what has been ascertained throughout the investigation, some issues related to safety should be the subject of improvement, especially as regards: A. the training of dockworkers for emergency situations; B. the need to provide the worker with all the information related to his work environment C. the need to equip the stand with indicators of atmospheric risk and equipment capable of minimizing or even eliminating such risks; D. the need to develop a culture of prevention that includes all those involved in the operation, not leaving only one of the entities to verify all the risk indicators, without further checking by the others involved; and E. the necessity of to increase the level of supervision during these operations; From the facts and the records found and the interviews carried out can be concluded by the occurrence of a serious accident, in which a set of mistaken decisions and protective measures that were not adopted ended up making it even more damaging. By assigning the descent of the first stevedore on his own initiative, without worrying about the possibility of finding a hostile atmosphere, the thesis of the ignorance of the risks in his work environment gains strength, which could be avoided with a simple lecture before of the beginning of the activity. If we consider that its descent was involuntary, a decrease in the case, the initiative of the others to try for help without waiting for the qualified personnel indicates a flawed training in both subjects: procedure to be adopted in emergency situation and knowledge about the atmospheric risk in the bottom of cargo hold.

The repetitive releases of 02 values and other gases in the holds of the vessel point to the impression that such activity did not receive on board the amount due (in the case of measurements made without method), or even deliberate negligence (in the case of launches made without the occurrence of effective measurement). By working in an atmosphere of recognized hostility from the atmospheric point of view without any protection, either for indication of risk or for their elimination, dockworkers were subjected to a condition of critical vulnerability. In short, the accident occurred in the face of the access of a dockworker, voluntarily or involuntarily, to a space inside the cargo hold where he was not aware of the possibility of an atmosphere incompatible with life and was aggravated by lack of training and knowledge of the others who, in an attempt to help him, entered the basement without protection and 16 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report without waiting for the arrival of the personnel trained for emergencies.

9 – SAFETY RECOMMENDATIONS A) Provide OGMO personnel with atmospheric detection and monitoring equipment, when loading or unloading wood in the holds of vessels carrying this type of cargo (Terminal); B) Conduct risk analysis for the continued use of self-contained breathing apparatus throughout the time that stevedores are in a basement discharging or loading wood, considering the protective advantages in face the limitations of movement resulting from the use of these accessories (Terminal); C) Conduct training with OGMO personnel on the use of these equipment, keeping track of these trainings; D) Before the commencement of these tasks, provide a comprehensive information on the hazards of cargo, not only those relating to their handling and stowage, but also those affecting the atmospheric changes that such cargo may promote (Terminal); E) To improve the Check List of the beginning of operations of loading and unloading of wood, detailing the method of accomplishment of the atmospheric measurements, determining the number of repetitions, in how many levels to be done, its detailed launch in the Log Deck Book and, mainly, determining the double check of the obtained results, through the monitoring of the activity in the ship by personnel of the end, in order to guarantee the correction of the found values (company and Terminal); F) Keep vigilance near the entrance of the holds, by personnel carrying autonomous breathing equipment, for themselves and for a possible accident, with adequate training to attend the emergencies during the operations of loading and unloading of wood. **************************

17 BRAZILIAN NAVY Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY Department of Inquiries and Investigations of Navigation Accidents FATAL ACCIDENT ON BOARD THE M/V “SEPETIBA BAY” Maritime Safety Investigation Report

14 - M/V "SEPETIBA BAY"- SHIP PARTICULARS

Port of Registry: Monrovia Flag: Liberia Ship Type: Bulk Carrier IMO: 9496343 MMSI: 636016208 Official Number: 16208 Owner: Norwest Navigation ES Operators: Norsul Navigation Company Classification Society: Det Norske Veritas Class Notation: 1A1 Ore Carrier ESP EO Keel launched: December 2014 Delivery: June 25, 2012 Shipyard: Samjin Shipbuilding Industries Co., Ltd., China Gross Tonnage: 23,426 Net tonnage: 11,082 Overall Length: 180 m Breadth: 30 m Depth: 14.7 m Cranes: 4 x 35 T Mac Gregor P & I Club: Assurance: Foreningen Gard - Norway