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Ma2011-6 Marine Accident Investigation Report

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Ma2011-6 Marine Accident Investigation Report MA2011-6 MARINE ACCIDENT INVESTIGATION REPORT June 24, 2011 Japan Transport Safety Board The objective of the investigation conducted by the Japan Transport Safety Board in accordance with the Act for Establishment of the Japan Transport Safety Board is to determine the causes of an accident and damage incidental to such an accident, thereby preventing future accidents and reducing damage. It is not the purpose of the investigation to apportion blame or liability. Norihiro Goto Chairman, Japan Transport Safety Board Note: This report is a translation of the Japanese original investigation report. The text in Japanese shall prevail in the interpretation of the report. MARINE ACCIDENT INVESTIGATION REPORT Vessel type and name: Container ship CARINA STAR IMO number: 9172612 Gross tonnage: 7,401 tons Vessel type and name: Destroyer KURAMA Standard displacement: 5,200 tons Accident type: Collision Date and time: 19:56:09/12 hrs, October 27, 2009 (local time, UTC+ 9 hours) Location: Vicinity of Moji Saki, Kanmon Passage, Kanmon Port Around 294° true, 330m from Moji Saki Light House in Kitakyusyu-City, Fukuoka-Prefecture (approximately 33°57’48.2” N, 130°57’ 35.1” E) June 2, 2011 Adopted by the Japan Transport Safety Board Chairman Norihiro Goto Member Tetsuo Yokoyama Member Tetsuya Yamamoto Member Toshiyuki Ishikawa Member Mina Nemoto CONTENTS 1 PROCESS AND PROGRESS OF THE INVESTIGATION ............................................................ 1 1.1 Summary of the Accident ......................................................................................................... 1 1.2 Outline of the Accident Investigation ...................................................................................... 1 1.2.1 Setup of the Investigation ................................................................................................. 1 1.2.2 Collection of Evidence ....................................................................................................... 1 1.2.3 Factual Information in Public…………………….……………………………………………1 1.2.4 Opinions of Parties Relevant to the Cause .......................................................................1 1.2.5 Comments from CARINA STAR’s Owner .........................................................................1 2 FACTUAL INFORMATION ............................................................................................................ 2 2.1 Events Leading to the Accident ............................................................................................... 2 2.1.1 Events Leading to the Accident According to AIS and Other Information ..................... 2 2.1.2 VDR Radar Image Recorded by Ship C ............................................................................ 5 2.1.3 Events Leading to the Accident According to the Statements from the Crew ................ 6 2.1.4 Events Leading to the Accident According to the Statements from Kanmon MARTIS Operators ....................................................................................................................................... 11 2.2 Death, missing and Injuries to Persons .................................................................................15 2.3 Damage to Vessel .................................................................................................................... 15 2.4 Events following the Accident ................................................................................................ 15 2.4.1 Ship A, Ship B and Kanmon MARTIS ............................................................................15 2.4.2 Fire Fighting and Other Activities .................................................................................16 2.5 Crew and Other Information ................................................................................................. 17 2.5.1 Crew Information ............................................................................................................ 17 2.5.2 Information regarding Operators of Kanmon MARTIS .................................................. 18 2.6 Vessel Information .................................................................................................................. 18 2.6.1 Particulars of Vessel ........................................................................................................ 18 2.6.2 Loading Conditions....................................................................................................... ... 20 2.6.3 Navigational Equipment .................................................................................................20 2.6.4 Maneuverability .............................................................................................................. 20 2.7 Situations at Kanmon MARTIS .............................................................................................22 2.8 Weather and Sea Conditions .................................................................................................. 26 2.9 Characteristics of the Accident Area ....................................................................................27 2.9.1 Kanmon Strait ................................................................................................................. 27 2.9.2 Tidal Stream .................................................................................................................... 28 2.10 Safety Guidance to Crew ........................................................................................................ 29 2.10.1 Ship A ............................................................................................................................... 29 2.10.2 Ship B ............................................................................................................................... 30 2.11 Regulations relating to Kanmon MARTIS ............................................................................32 2.11.1 Services Responsibility .................................................................................................... 32 2.11.2 Operation Regulation ...................................................................................................... 33 2.11.3 Operation Procedure ....................................................................................................... 35 2.11.4 Operation Manual ........................................................................................................... 37 i 2.11.5 Service Procedure ............................................................................................................ 40 2.12 Conventions relating to Marine Traffic Services ...................................................................41 2.12.1 Traffic Safety according to SOLAS convention Chapter V .......................................... 41 2.12.2 Guidelines prepared by IMO ...........................................................................................41 2.12.3 IALA / VTS Manual ......................................................................................................... 42 2.12.4 IMO Phrases. ................................................................................................................... 42 2.12.5 Other Regulations ........................................................................................................... 44 2.13 Other Relevant Matters ......................................................................................................... 44 2.13.1 Effects of Tidal Stream on Vessel Movements ...............................................................44 2.13.2 Description of Act on Port Regulations ...........................................................................46 3 ANALYSIS ..................................................................................................................................... 46 3.1 Situation of the Accident Occurrence.....................................................................................46 3.1.1 Course of the Events ....................................................................................................... 46 3.1.2 Time, Date and Location of the Occurrence of the Accident .......................................... 47 3.1.3 Situation of Collision ....................................................................................................... 48 3.2 Causal Factors of the Accident ............................................................................................... 48 3.2.1 Crew ................................................................................................................................. 48 3.2.2 Vessel ................................................................................................................................ 48 3.2.3 Weather and Sea Conditions ...........................................................................................48 3.2.4 Communications among Crew Members ........................................................................ 48 3.2.5 Communications between Ship A and Kanmon MARTIS ............................................... 49 3.2.6 Lookout and Navigation .................................................................................................. 50 3.2.7 Use of AIS ........................................................................................................................ 53 3.2.8 Situations in Kanmon MARTIS ......................................................................................54
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