Safer Seas 2013 Bulk Carriers Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Safer Seas 2013 LESSONS LEARNED FROM MARINE ACCIDENT INVESTIGATIONS

NATIONAL TRANSPORTATION SAFETY BOARD www.ntsb.gov NATIONAL TRANSPORTATION SAFETY BOARD www.ntsb.gov

lessons learned from marine accident investigations Safer Seas 2013 LESSONS LEARNED FROM MARINE ACCIDENT INVESTIGATIONS Office of Marine Safety Investigations

MISSION

The National Transportation Safety Board is an independent Federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation – marine, railroad, highway and pipeline. The NTSB determines the probable cause of the accidents and issues safety recommendations aimed at preventing future accidents. In addition, the NTSB carries out special studies concerning transportation safety and coordinates the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. CONTENTS

Message from the Director...... 2 Cargo Vessels...... 4 John D. Leitch...... 4 Mary Ann Hudson...... 6 Alliance Norfolk...... 8 Delta Mariner...... 9 Maersk Wisconsin...... 10 Rickmers Tokyo...... 12

Fishing Vessels...... 14 Chevelle...... 14 Heritage...... 16 Lucky Diamond...... 17 Mary Kay...... 18 Plan B...... 20 Viking II...... 21

Liftboats...... 22 Mako...... 22 Trinity II...... 24

Oil Tankers...... 26 FR8 Pride...... 26 Overseas Reymar...... 28

Passenger Vessels...... 30 Malaspina...... 30 Safari Spirit...... 31

Towing Vessels...... 33 Invader...... 33 Ivory Coast...... 34 Patrice McAllister...... 36

Appendix A: Investigations Completed in 2013...... 38 Appendix B: Investigations Completed in 2012...... 39

1 MESSAGE FROM THE DIRECTOR What Could Go Wrong?

In Safer Seas 2013 we have summarized and compiled marine accident investigations conducted by the NTSB and published in 2013. Our goal, as always, was to determine the cause of each accident, and recommend ways to make marine transportation safer. Hence our title, Safer Seas 2013. Safer Seas 2013 is a “one stop shop,” and is designed to be a quick and easy read. But Safer Seas also contains links to our detailed investigative reports for each of the year’s marine accidents — 21 of them in 2013. Safer Seas is also consolidated by vessel type, so that readers can more easily find reports relevant to their area of interest. We hope that this document gives operators and others such as safety professionals an easy-to-use tool to find the circumstances closest to those they encounter in their own area of interest. At the same time, Safer Seas should serve to inform and remind mariners of lessons learned in all areas, and increase awareness of the safety issues identified. As many of these accident reports demonstrate, But if mariners are not constantly vigilant and if constant vigilance is critical to improving safety. their organization’s culture does not reinforce their Of all the systems on board a vessel, a human respect for marine safety, humans themselves can being is the most complex, and perhaps the most cause incidents, accidents, and even tragedies. difficult one to integrate into a system of safer Whether it’s a fire resulting from a crewmember transportation. So long as human beings serve in ignoring procedures, or a navigational accident marine transportation, however, the human element caused by an error in judgment (such as the loss of is also the only one that can never truly be replaced. the HMS Bounty in Superstorm Sandy), too often people put themselves and others at risk. We hope

2 that by reading and using these reports in the field, The NTSB’s investigators see “What Could Go operators will improve their awareness and learn Wrong” with every accident we investigate. We from others’ misfortunes. hope to provide mariners a tool that they can read at home or at sea, so they can apply the lessons Most of all, we hope that “What Could Go Wrong?” proactively rather than becoming a story for other becomes a literal question on every mariner’s mind, mariners to learn from. not a rhetorical exercise. Flexible formats, including an e-book format, will help make these lessons more available to more mariners. TRACY MURRELL Director, Office of Marine Safety

3 Safer Seas 2013 Cargo Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Collision of Canadian Bulk Carrier John D. Leitch with Law Coast Guard photo of the hull of the John D. Leitch behind the Sheriff’s Office law Enforcement Vessel enforcement vessel shortly after the starboard bow of the bulk carrier contacted the LCSO NBI vessel.

Vessel Identification The John D. Leitch was all secure at the Jonick Dock & Vessel John D. Leitch 350 Challenger Terminal on the east side of the Black River at 0900. Flag Canada United States The vessel began loading coke about an hour later. Construction Steel Fiberglass Coke is a solid carbonaceous material derived from reinforced plastic distillation of bituminous coal used primarily as fuel and in smelting of iron ore. Over the next 30 hours, more Crew complement 5 Moored than 25,877 metric tons of coke was loaded on the bulk carrier.

On October 3, 2012, about 1912, the 730-foot-long After loading, the vessel’s drafts were recorded as Canadian flag bulk carrier John D. Leitch, loaded with 24 feet 3 inches forward, 24 feet 8 inches amidships, furnace coke, was outbound in the Black River at and 24 feet 10 inches aft. The controlling depth at that Lorain, Ohio, when the vessel collided with a 35-foot- section of the Black River channel was reported to be long fiberglass-reinforced plastic law enforcement vessel 27 feet at that time. and piling structure. At 1750, the vessel departed the Jonick Dock & The John D. Leitch departed Hamilton, Ontario, Canada, Terminal bound for Port Cartier, Quebec, Canada. The on October 1, 2012, in ballast condition bound for the vessel’s master was in the wheelhouse and providing Jonick Dock & Terminal on the Black River at Lorain, conning directions to an able-bodied seaman (AB) Ohio. The vessel transited east across Lake Ontario, acting as helmsman. The first mate and third mate were navigated through the eight locks separating Lake on deck providing the master with distances off critical Ontario from Lake Erie, and by afternoon was crossing points and objects using portable VHF radios. The Lake Erie toward Lorain. vessel’s third engineer was on watch and in the engine room. The next morning, the John D. Leitch was upbound in the Black River channel under the control of the The outbound transit required an immediate port master. The master relied heavily upon the vessel’s bow turn from the vessel’s general heading of 356°, and thruster as the waterway narrowed in width from the master then steadied up briefly on a heading of 800 feet to 200 feet and required a series of turns about 292° to pass through the railroad lift bridge. The both port and starboard while passing through three speed of the vessel ranged between 0.4 and 1.2 knots bridges. He also stationed two watch officers on for this segment of the transit. Once the vessel safely deck to act as spotters and to call out distances off cleared the bridge, the master maneuvered starboard critical points and objects using portable VHF (very to a heading of 341° before initiating a second turn to high frequency) radios. The master maneuvered the port to a heading of 284° to allow passage under the vessel almost 3 nautical miles (nm) to the Upper highway bridge. When the master began that port turn, Black River turning basin, swung the bow around, and the vessel’s speed was about 0.6 knots. then proceeded back downstream just over 1 nm and through one of the three bridges to his destination.

4 Safer Seas 2013 Cargo Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

John D. Leitch

As the vessel’s bow cleared the bridge supports on the The allision between the John D. Leitch, the piling system, channel’s east side, the master noticed that the bow and the LCSO’s NBI vessel resulted in the following was not swinging to port as intended, so he applied damages: more engine thrust and pitch to the vessel’s propeller • John D. Leitch: Small scrapes along portions of but with no effect. The master had allowed the stern the forward starboard hull, with no plate inset. of the vessel to transit close enough to the west bank of the channel that the stern was influenced by bank • LCSO NBI vessel: Total damages exceeded suction. As a result, the stern was pulled toward the $500,000. west bank and the vessel’s bow sheered to starboard, No injuries were reported on board the John D. Leitch, toward the east bank where the Lorrain County and the LCSO’s NBI vessel was unmanned at the time Sheriff’s Office (LCSO) law enforcement vessel was of the accident. moored at Coast Guard Station Lorain. At 1912, the forward starboard bow of the John D. Leitch made slight Probable Cause contact with a piling structure and the sheriff’s office vessel. The National Transportation Safety Board determines that the probable cause of the allision was the failure of After contact with the piling structure and the LCSO the master of the John D. Leitch to properly account for NBI (Northern Border Initiative) vessel, the master of bank effect while maneuvering in the confined waters of the John D. Leitch maneuvered the vessel to the retaining the Black River. wall on the west bank of the Black River and moored it. Following the accident, five crewmembers on the John D. Leitch—the master, first mate, third mate, AB, and third engineer—were tested for illegal drugs and alcohol. All test results were negative.

5 Safer Seas 2013 Cargo Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Collision Between Bulk

Carriers Mary Ann Hudson and The Star Grip under way. Visible immediately forward of the superstructure at the stern of the ship are two gray-colored gantry cranes. In this photo, the cranes’ Star Grip cantilever arms are folded inward toward the center of the ship. (Photo by Frank Katzer, available at www.marinetraffic.com)

Vessel Identification was clear, he instructed both tugs to slack their lines Vessel Mary Ann Hudson Star Grip and lie alongside before he ordered slow ahead with Flag United States Norway 20 degrees of port rudder. Once the ship was on centerline in the channel, he eased the port rudder Engine power and 2 Delaval, 7,800 hp 1 Mitsui B&W type diesel, 10,120 hp command. Crew complement 20 N/A Another bulk carrier, Star Grip, was moored port side to at City Dock 23, directly forward of the Mary Ann Hudson. The Star Grip had two gantry cranes on board, On June 6, 2012, at 0530 central daylight time, the and at the time, the cranes’ cantilever arms were underway bulk carrier Mary Ann Hudson collided with extended out over the side of the vessel. The pilot told the moored bulk carrier Star Grip while the Mary Ann investigators that, as the Mary Ann Hudson proceeded Hudson was being moved from City Dock 21 to City down the channel, he felt like the stern of the ship was Dock 29. No one was injured and no pollution resulted drifting toward the Star Grip. from the accident; however, both vessels sustained damage totaling more than $500,000. At 0528, the chief mate on the bow of the Mary Ann Hudson radioed the master and informed him that About 45 minutes earlier, a pilot with the Houston the aft gantry crane on the Star Grip was overlapping Pilots Association boarded the Mary Ann Hudson, the Mary Ann Hudson (the crane’s cantilever arm was moored port side to at City Dock 21 in the Houston passing over the Mary Ann Hudson’s deck). The master Ship Channel. The pilot was on board to shift (relocate) told investigators that he saw the crane arm over his the vessel to City Dock 29, about a half mile down vessel’s deck somewhere between the No. 2 and No. 3 the channel. While awaiting the arrival of assistance cargo hatches. tugboats, the master conducted the master pilot exchange, discussing the vessel particulars and the The pilot ordered 20 degree port rudder and half route. Two tugboats, the Mars and the Andrew K, arrived ahead, and ordered the Andrew K (on the starboard about 0450. The pilot positioned the Mars on the bulk bow) to back easy, intending to lift the vessel away from carrier’s starboard quarter and the Andrew K on the the Star Grip. However, these actions were not enough starboard bow. to move the Mary Ann Hudson clear of the crane. At 0530, the Mary Ann Hudson struck the cantilever arm on On the bridge of the Mary Ann Hudson were the pilot, the Star Grip’s aft crane. As the Mary Ann Hudson passed the master, and a helmsman. The vessel’s chief mate by, its port stores crane and the forward port corner was positioned on the bow of the vessel along with the of the superstructure were damaged, and railings were boatswain and two able-bodied seamen. The weather knocked down. The pilot told investigators that, in his was clear, the winds calm, and darkness prevailed in opinion, the reason the Mary Ann Hudson did not move the early morning hour. At 0521, all lines were in clear of the crane was that the Mars was alongside on and the pilot ordered the tugs to move the Mary Ann the starboard quarter. Hudson away from the dock towards the center of the channel. Once the pilot confirmed that the vessel

6 Safer Seas 2013 Cargo Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

After the collision, the Mary Ann Hudson continued The damage amount to the Mary Ann Hudson and the toward its intended berth. Once docked, at 0601, the Star Grip was estimated to be at least $250,000 for each pilot called the US Coast Guard vessel traffic service bulk carrier. (VTS) to report the collision. The tug masters were unaware that the Mary Ann Hudson had hit the crane on No one was injured on board either vessel, and no the Star Grip until after they had docked the vessel at its pollution or loss of cargo resulted from the accident. new location, and the pilot informed them. Probable Cause Personnel on board the Mary Ann Hudson, including The National Transportation Safety Board determines the pilot, and on board both tugboats held appropriate that the probable cause of the collision between bulk merchant mariner’s credentials issued by the Coast carriers Mary Ann Hudson and Star Grip was the pilot’s Guard for the route, scope of operation, and service ineffective handling of the Mary Ann Hudson and his of each vessel. Following the collision, these personnel ineffective use of the two tugboats to maneuver the were tested for illegal drugs and alcohol. All test results vessel around the Star Grip’s crane arms, which were were negative. extending into the navigable waterway.

Mary Ann Hudson

7 Safer Seas 2013 Cargo Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Fire on Board Vehicle Carrier Alliance Norfolk

Vessel Identification Vehicle carrier Alliance Norfolk. Photo by Jeffrey J. Kunce, http://marinetraffic.com.

Vessel Alliance Norfolk area were secured in preparation for release of the

Flag United States fixed carbon dioxide (CO2) fire extinguishing system, Cars, trucks, motorcycles, boats; which was activated at 1050. Adjoining spaces were industrial and manufacturing monitored for heat or fire, and the master reported Cargo parts and equipment; boxes and that the fire was extinguished at 1250. containers Coast Guard investigators could not determine Crew complement 23 the initial source of ignition. However, the dynamic environment of the vessel rolling in heavy seas and On the morning of March 10, 2012, while transiting shifting cargo in the presence of various flammable between Malta and Sicily, Italy, in the Mediterranean liquids (held within the mixed cargo and containers) Sea, the Alliance Norfolk, a roll on/roll off vehicle carrier, could have produced an ignition source. encountered rough weather and heavy seas resulting in damage to its cargo and a subsequent fire on a cargo The vessel changed course to Piraeus, Greece, as a deck. The fire was extinguished at sea, but 2 days later port of refuge, and anchored there 2 days later at 1200 while in port, the damaged cargo deck was ventilated, on March 12, 2012. A marine chemist boarded the and the fire reflashed, causing further damage to the vessel and at 1700 declared cargo decks 4, 5, and 7 vessel and its cargo. safe for mechanical ventilation. However, at 2000 that The vessel was on a voyage from Jacksonville, Florida, evening, heavy black smoke was seen escaping from the bound for ports in the Arabian Gulf via the Suez Canal ventilation system, indicating that the smoldering fire when it experienced rolls up to 30 to 35 degrees had reflashed when ventilation reintroduced sufficient during its passage through the Mediterranean. While oxygen to feed the fire. The space was again secured, experiencing rough seas, the main engine tripped and the local fire department boarded the vessel and and was subsequently restarted. During this time the brought the fire under control nearly 9 hours later, at crewmembers checked the status of cargo, which 0445 on March 13, 2012. included military containers, commercial vehicles, Following the accident, test results for illegal drugs and motorcycles, small boats, and electrical and other alcohol were negative for Alliance Norfolk crewmembers. equipment. During one of these checks, a crewmember Three crewmembers reported minor injuries. observed large engines, generators, air conditioning chillers, and 20 foot containers adrift on cargo deck 5. Probable Cause Cargo items were shifting with the rolling of the vessel, being thrown against each other and the main deck The National Transportation Safety Board determines supports of the cargo deck. The crew was unable to that the probable cause of the fire on board the safely secure the cargo. Alliance Norfolk was ignition of flammable material by an undetermined ignition source on deck 5 due to At 1030, the fire detection and alarm system activated shifting cargo while the vessel was rolling in heavy seas on cargo deck 5. The chief mate and chief engineer after losing power. Contributing to the severity of the investigated and saw flames and heavy smoke coming damage was the reflash of the smoldering fire when the from the area. Ventilation and boundaries for the vessel was in port.

8 Safer Seas 2013 Cargo Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Allision of Delta Mariner with Eggner’s Ferry Bridge Eggner’s Ferry Bridge with Delta Mariner anchored after striking span E. The stern of the vessel is visible between the piers of the downed span E. Photo by Vessel Identification www.wired2fish.com.

Vessel Delta Mariner was not on watch at the time. The AB was serving as Flag United States lookout. Construction Steel At 2001 local time, the Delta Mariner allided with a 16 crewmembers; 2 pilots, bridge span that provided insufficient vertical clearance Crew complement 2 representatives of cargo owner for the vessel’s passage (the lowest of Eggner’s Ferry Bridge’s four navigable spans). The Delta Mariner

The Delta Mariner, a US flagged roll on/roll off cargo was traveling at a speed of about 11.5 mph when it vessel, departed Decatur, Alabama, on January 25, 2012, struck the bridge and tore away a 322 foot long span, carrying rocket components to Cape Canaveral, Florida. including a portion of US Highway 68. Bridge debris The next day, the vessel allied with Eggner’s Ferry lodged across the bow of the ship. The vessel sustained Bridge on the Tennessee River. minor damage to its bow area, but its cargo was undamaged. Traffic was light on the bridge at the time The ship’s intended route was along the Tennessee of the accident, and vehicles traveling on the highway River to the Ohio River at Paducah, Kentucky, then stopped before reaching the missing span. No injuries south down the Mississippi River to the Southwest Pass were reported on the vessel or on the highway, and no and the Gulf of Mexico to Florida. The voyage typically pollution was reported. took 8 to 10 days. Probable Cause On the day of the accident, the Delta Mariner transited in rain, heavy at times, and reduced visibility. By evening The National Transportation Safety Board determines the rain had subsided, and crewmembers reported that that the probable cause of the allision of the Delta the visibility was good. Mariner with Eggner’s Ferry Bridge was the bridge team’s exclusive reliance on the contract pilot’s Sixteen crewmembers were on board, along with two incorrect navigational direction as the vessel contract pilots and two representatives of United approached the bridge and their failure to use all Launch Alliance (ULA), a space industry manufacturing available navigation tools to verify the safety of the and assembly operation and owner of the cargo. The vessel’s course. Contributing to the accident was Delta Mariner is owned by Foss Maritime Company and Foss Maritime Company’s failure to exercise effective operated by Foss Atlantic. safety oversight of the Delta Mariner’s operations and the failure of the Kentucky Transportation Cabinet to In the pilothouse as the vessel approached the Eggner’s effectively maintain bridge navigation lighting. Ferry Bridge were the master, chief mate, third mate, an able-bodied seaman (AB), and one of the contract pilots. Although the chief mate was the senior officer on watch, he was acting as helmsman at the time of the allision. The third mate was the other deck officer on watch. The master arrived in the pilothouse about 10 minutes before the accident for a routine visit but

9 Safer Seas 2013 Cargo Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Collision between Maersk Wisconsin and Tug and Barge

Unit Ruth M. Reinauer The Maersk Wisconsin at anchor. (Photo by Jeff Byrd, available at www.shipspotting.com) Vessel Identification Radio communications were obtained from voyage Vessel Maersk Ruth M. RTC 102 data recorder audio included in the Coast Guard Wisconsin Reinauer accident investigation report. At 0158, the docking pilot was positioning to make a port turn to shape up Flag United States United States United States for passing under the Bayonne Bridge in Kill Van Kull Type Freight ship Uninspected Double- when he asked the second pilot on board to radio towing vessel hulled tank the Ruth M. Reinauer to request the tug and barge to barge, ocean hold back. The mate of the Ruth M. Reinauer responded service that a flood current off his vessel’s stern prevented Crew 22 crew and 7 Unmanned him from holding back. The Maersk Wisconsin docking complement 2 pilots pilot acknowledged and suggested instead that the tug

and barge stay “tight on the reds,” referring to the red The container ship Maersk Wisconsin, assisted by buoys on the New Jersey side of Kill Van Kull. The mate two tugs, left Port Elizabeth, New Jersey, in the early on board the tug agreed to this port-to-port meeting morning hours of December 5, 2011, to begin its transit arrangement and continued his westbound course at south toward Kill Van Kull, through New York Harbor, 6 knots. and then to sea. At 0213, with fog reducing visibility About 9 minutes later, at 0207, the Maersk Wisconsin to about 0.25 miles, the container ship collided with a docking pilot told the mate of the Ruth M. Reinauer that tug and barge unit in Kill Van Kull channel near Bergen the two vessels would meet on the west side of the Point, New Jersey. bridge and that the Maersk Wisconsin was proceeding The tug Ruth M. Reinauer was pushing barge RTC 102 slowly (about 1–2 knots) and would give the tug and westbound in Kill Van Kull, a narrow, busy waterway barge space to pass. At 0208, the docking pilot radioed connecting New York Harbor Upper Bay to the east the tug to say the Maersk Wisconsin would be “closer to and Newark Bay and Arthur Kill about 3 miles to the reds [red buoys] than we want to be.” He received the west near Bergen Point, New Jersey. The Ruth M. no response from the Ruth M. Reinauer. Reinauer and barge RTC 102 formed an articulated tug At 0211, the docking pilot ordered the Maersk and barge unit—the tug and barge locked together Wisconsin’s engine to slow astern. About the same time, to form one vessel allowing hydrodynamic efficiencies the mate on board the Ruth M. Reinauer radioed the resulting in greater sea speed and sea keeping. docking pilot and said, “You’re turning right into me, About 0120, the Maersk Wisconsin was approximately captain.” The docking pilot responded that the Maersk 1nautical mile from the point at which Newark Bay Wisconsin was all stop. The mate on the Ruth M. Reinauer joins the Kill Van Kull channel. One tug was positioned replied that his tug and barge were right up against the off the starboard bow, the other tug off the port red buoys, and the docking pilot instructed the mate quarter. With fog developing and visibility diminishing, to keep coming and to proceed around the Maersk the docking pilot reduced the speed of the vessel to Wisconsin. Less than a minute later, the Ruth M. Reinauer about 2 knots and sounded the vessel’s fog signal. mate radioed, “Hey captain, have your tugs push you

10 Safer Seas 2013 Cargo Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

away” but received no reply. On the Maersk Wisconsin, level and sustained side shell plate damage and upset of the pilot ordered, “Start thrusters and [engine] full internal framing. Some frame and plate damage was also astern.” The mate of the Ruth M. Reinauer attempted to noted in a cargo tank. The bow of the Maersk Wisconsin use engines to maneuver his vessel to avoid a collision. sustained shell plate damage and was holed about About 0213, the bow of the Maersk Wisconsin contacted 23 feet above the waterline. Internal framing of that the port side midships of the barge RTC 102. At the compartment was also distorted. time of the collision, the speed of the Maersk Wisconsin was less than 1 knot, and the speed of the Ruth M. The initial total estimated damages to the Maersk Reinauer was about 5 knots. Wisconsin and the RTC 102 exceeded $500,000. No one was injured on board either vessel, and no Probable Cause pollution or loss of cargo resulted from the accident. The National Transportation Safety Board determines Following the accident, three crewmembers on the that the probable cause of the collision was the failure Ruth M. Reinauer, nine crewmembers on the Maersk of the docking pilot on board the Maersk Wisconsin Wisconsin, and the docking pilot were tested for illegal to position his vessel according to the meeting drugs and alcohol. All test results were negative. arrangement with the Ruth M. Reinauer to allow Both the container ship Maersk Wisconsin and the barge adequate separation for passage of the tug and barge in RTC 102 were damaged in the collision. On the RTC the navigable channel. 102, two portside ballast tanks were holed at the deck

Maersk Wisconsin

11 Safer Seas 2013 Cargo Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Allision of Container Ship Rickmers Tokyo with Pier II

Vessel Identification The Rickmers Tokyo under way with varied cargo. (Photo by www.rickmers-linie.com)

Vessel Rickmers Tokyo the same time, the second officer heard the master Flag state Marshall Islands command “hard port” over his handheld radio. Construction Steel By 1938 the crew reported to the master that the Crew complement 27 vessel had a large hole at the waterline and had ruptured a ballast tank. The master wanted to anchor, While transiting outbound in the Delaware River north and the river pilot suggested the Marcus Hook of downtown Philadelphia, a river pilot conning the Anchorage below downtown Philadelphia. At 2205, the multipurpose container ship Rickmers Tokyo missed vessel anchored at this location, about 22 miles from the turn in the channel and allided with Pier 11 about the allision, and the river pilot disembarked the vessel. 1909 on December 23, 2011. The pilot, who was not wearing his required corrective eyewear, lost situation The Rickmers Tokyo had centerline cranes forward awareness with regard to the vessel’s location and did of the bridge. To allow for an unobstructed view not use all available navigation equipment to fix its directly forward, the bridge was offset to starboard, position. which partially obstructed the view to port but not to starboard. The bridge console included two radar/ The Rickmers Tokyo arrived in Philadelphia on automatic radar plotting aid (ARPA) displays designated December 22, 2011, and docked port side to the Tioga port and starboard and located directly to each side of Marine Terminal, facing up the Delaware River. On the helm position. The crew reported that from 1859 completion of cargo operations, the vessel got under to the allision, the river pilot remained seated in front way to Antwerp, Belgium. of the port radar display and navigated by looking out the bridge windows and using his personal piloting A river pilot was on board. After he issued several unit (PPU), a laptop computer loaded with navigational rudder commands at 1907 that failed to adjust the software. The pilot said the night was “pitch black and vessel’s heading for the first course change in the moonless” but also commented in an interview that channel, which called for a 17.5° turn to port, the vessel “visibility was perfect.” left the navigation channel to starboard. Noticing a dark shape ahead, the pilot and then the master ordered Neither Pier 11 nor adjacent piers had any installed port rudder commands to move the ship away from the lighting and therefore lacked contrast with the river right bank, but the Rickmers Tokyo struck Pier 11 about and the shore. Additionally, the city lights of downtown 1909. Philadelphia were directly behind this pier set when proceeding downriver, producing background lighting. Prior to and during the allision, both the bosun and the With the exception of the trees on the pier, which the second officer were stationed on the foredeck near the master noticed before taking evasive action, the piers anchors. The bosun commented to the second officer had a relatively low profile against the city lighting. that the vessel was approaching the shore too closely, and when about 50 meters from contact the second After taking the conn and transiting the Harbor Range officer radioed the master with this warning. About at 260.5 degrees, the river pilot issued only course

12 Safer Seas 2013 Cargo Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

changes to 254 degrees before taking action to avoid river pilot’s uncorrected vision was 20/50, not using Pier 11, but a change to at least 243 degrees was his glasses when looking ahead reduced his ability to required to begin the next channel leg. perceive distant visual cues on a dark night. The pilot commented in an interview the day after the According to the vessel operator, the initial repair cost accident that he thought they struck Pier H, which was for damage to the vessel was $546,391. A surveyor’s about 1,200 yards upriver from Pier 11. The pilot’s report estimated the damage to the pier was $121,800. perception that the allision location was about 0.5 nautical mile from the actual accident site indicates Probable Cause a significant error on his part, especially considering The National Transportation Safety Board determines that he was navigating a narrow channel within a that the probable cause of the allision of Rickmers Tokyo constrained river. with Pier 11 in the Delaware River was the river pilot Following the accident, nine Rickmers Tokyo not executing the turn at Port Richmond due to his lack crewmembers, including the bridge and bow teams, and of situation awareness regarding the vessel’s position the river pilot were tested for illegal drugs and alcohol. in the channel and his inadequate use of all available All test results were negative. navigation equipment. Contributing to the allision was the river pilot’s failure to wear his corrective eyewear, Although the river pilot had prescription corrective which was required and would have assisted with lenses for nearsightedness, he did not wear them at distant visual cues on the dark evening. any time during the transit up to the allision. As the

Rickmers Tokyo

13 Safer Seas 2013 Fishing Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Grounding and Loss of the Chevelle

The abandoned fishing vessel Chevelle on the Yaquina Bay entrance north jetty the Vessel Identification day after grounding. (Photo by Ed Chauvaud)

Vessel Chevelle At 1344 on March 10, Coast Guard Station Yaquina Bay Flag United States issued a bar report restricting “all recreational vessels Propulsion type Single engine, 4-blade propeller and uninspected passenger vessels” from operating in Crew complement 4 persons and 1 dog the channel from the middle of the north jetty to the ocean due to hazardous conditions. Although these

The fishing vessel Chevelle was returning to its reports provide all mariners information regarding bar homeport of Newport, Oregon, when a series of conditions, as a commercial fishing vessel, theChevelle large breaking waves on its stern resulted in a loss was not subject to these restrictions. of maneuverability and grounding on the Yaquina Bay Shortly after 1700, the master turned the Chevelle east entrance north jetty on March 10, 2012. The crew to cross the Yaquina Bay bar and lined up the vessel on was hoisted to safety by a US Coast Guard helicopter the center of the entrance channel. He later stated that before the vessel broke apart and sank more than a day although there was some wave and chop on the bar, he later, resulting in an estimated loss of $625,000. No one had crossed it in worse conditions and did not hesitate was injured. to proceed. On the other hand, a crewmember Two days earlier, the Chevelle had completed a indicated that these were the worst conditions in Dungeness crabbing trip near Point Arena, California, which he had attempted to cross a bar. and was heading north to unload its catch in As the vessel began the transit, swells were increasing. Newport, a voyage of about 360 nautical miles. After the accident, at 1906, the Coast Guard expanded On board the vessel were the master and three the bar restriction to include a larger area of the deckhands, accompanied by a dog. The master told channel. investigators that, before the vessel departed Point Arena, he checked all bilge alarms and found them Just before the Chevelle crossed the jetty tips, the vessel to be functional. He estimated that at the time of took a large breaking wave over its starboard quarter, the accident, the vessel had 3,000 to 4,000 gallons of resulting in a severe heel and turning the vessel toward diesel fuel remaining. the north jetty. Another wave over the starboard quarter rolled the vessel again, leaving the Chevelle To reach Newport harbor, vessels must transit from the heeled further over and down by the head, and it did Pacific Ocean into the Yaquina River and Yaquina Bay. As not recover. A witness said crab pots located on the in many coastal northwest harbors, vessels arriving and deck appeared to shift. Such a redistribution of weight, departing Newport must cross a “bar” where the deep along with water on the deck from the breaking wave, waters of the ocean meet the shallower waters near could have contributed to the severity of the heel and a river mouth. North and south jetties 990 feet apart the inability of the vessel to right itself. The wave left protect the 40-foot-deep entrance channel to Yaquina the vessel touching the north jetty boulders bow-first Bay. but the vessel was not hard aground.

14 Safer Seas 2013 Fishing Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

The master initially attempted to back down but was After the accident, the master was tested for both unable to free the vessel as subsequent waves drove alcohol and drugs with negative results. He stated he it further against and up onto the jetty. At 1725, the was very familiar with transiting the Yaquina Bay bar master contacted the Coast Guard for assistance, and and had done so “hundreds” of times. The other three two 47-foot-long motor lifeboats (MLBs), designed for deckhands had from 2 to 20 years of fishing vessel operation in heavy surf, launched to respond. At 1739, experience. the Chevelle lost propulsive power, but its generator continued to operate. By 1948, a hull breach caused Regardless of precautions taken, crossing a bar in large the vessel engine room and forepeak tank to begin swells is inherently hazardous, and mariners should take flooding, and a stream of diesel oil was leaking from the steps to reduce risk. hull. Probable Cause The crew donned survival suits, and the MLBs The National Transportation Safety Board determines attempted to tow the vessel off the jetty. The Coast that the probable cause of the grounding and Guard took the vessel under a 100-foot tow but had subsequent loss of the Chevelle as it crossed the Yaquina to cut the line at 1805 because the vessel was hard Bay bar was the master’s loss of control of the fishing aground and conditions were hazardous. The rough vessel after a series of breaking waves on the stern conditions prevented the MLBs from conducting a heeled the vessel to a severe degree from which it did rescue, and one crewman jumped off the vessel to the not recover. jetty. At 1823, a Coast Guard helicopter arrived, and all four crewmembers and the dog were hoisted to a safe location on the south jetty where they were able to walk ashore. After the Chevelle broke apart and sank, the forward half of the vessel was later located inside the north jetty tip and salvaged in August 2012, but the stern was not located. The monetary loss due to the sinking was estimated to be $625,000.

Aerial view of accident location at entrance jetties to Yaquina Bay near Newport, Oregon. Inset map shows location of Newport in the Pacific Ocean. (Satellite images by Google Earth)

15 Safer Seas 2013 Fishing Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Sinking of the Heritage

Vessel Identification Map of the area in which the Heritage transited Vessel Heritage and sank. Flag United States Year built 1977 The master made a radio distress call, and then he, Construction Steel the crew, and the onboard National Marine Fisheries Service (NMFS) observer donned their immersion suits Gross tonnage 109 and entered the water about 3.5 miles from Lazy Bay. Engine Diesel The master and four of the crewmembers made it into

the vessel’s liferaft and were picked up by the crew The 67-foot-long fishing vessel Heritage was returning of the Tuxedni, with which they were to rendezvous to Lazy Bay to unload a cargo of fish to the fish tender in Lazy Bay. The crew of a US Coast Guard helicopter vessel Tuxedni. The seven-person complement on board rescued the final crewmember and the NMFS observer the Heritage had been fishing south of Sitkinak Island, from the water. about 25 miles south-southeast of Lazy Bay. During Each of the National Weather Service marine forecasts the return, which took place in a storm, ice built up on for the area where the Heritage operated included a the vessel, causing it to list, flood, and sink. The crew “heavy freezing spray warning” beginning at 0400 on abandoned the vessel about 0600 on January 25, 2012. Sunday, January 22, 2012, when the vessel departed Lazy The master stated that, while en route to Lazy Bay, the Bay, to the time of the sinking. Sea spray icing occurs Heritage encountered northwest winds in excess of when cold, wave-generated spray comes in contact with 50 knots and heavy freezing spray. The master stopped exposed surfaces and the air temperature is below the vessel in Russian Harbor, about 12 miles southeast freezing. Higher wave heights produce more sea spray, of the port in Lazy Bay, so the crew could remove ice which results in greater vessel icing. from the vessel. After ice removal and waiting for slack Following the accident, the master was tested for illegal tide, the master resumed the return voyage across drugs. The result was negative. None of the men were Alitak Bay toward Lazy Bay. tested for alcohol. As the vessel transited toward Lazy Bay, the crew continued to remove ice. One of the crewmembers Probable Cause said, “The final time we beat ice we didn’t make a lot The National Transportation Safety Board determines of progress and it seemed like we made ice as fast as that the probable cause of the sinking of fishing vessel we could clear it.” The master said that, while crossing Heritage was the master’s decision to proceed with the Alitak Bay, the vessel experienced 90 mph wind voyage despite known weather conditions that would gusts, 10- to 15-foot seas, snow, and fog. Eventually, adversely affect the safety of his vessel. Specifically, the the crew took a break from ice removal. One of the weather conditions caused icing on the vessel resulting crewmembers told investigators that, about 20 minutes in a loss of stability due to added weight on the decks after the break began the vessel started listing to port. and superstructure. Another crewmember said that after the vessel began to list he saw the engine room fill with water.

16 Safer Seas 2013 Fishing Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Fire on Board and Sinking of the Lucky Diamond The red star indicates the approximate site of the Lucky Diamond fire and sinking. (Background Vessel Identification from NOAA Chart 11340)

Vessel Lucky Diamond cut the mooring lines to the Lucky Diamond, setting Flag United States the vessel adrift. The Lucky Diamond burned for several Construction Steel hours and then sank in about 40 feet of water. 2 Caterpillar 3412 diesels at Engine power and type On May 17, 2012, divers with T & T Bisso, LLC, 600 hp (447 kW) each performed a penetration dive on the hull and remaining Crew complement 4 structure of the Lucky Diamond, which was resting on

its keel and starboard side shell. The divers identified On April 28, 2012, the Lucky Diamond departed its extensive fire and heat damage, including warped steel homeport in Sabine Pass, Texas, for a month-long bulkheads, decks, and a watertight door. They could not shrimping trip. On board the vessel were a master and locate any human remains. three crewmembers. About 1600 on May 10, 2012, the The status of the navigational, mechanical, propulsion, men stopped fishing for the day and moored theLucky steering, and other vital systems on board the Lucky Diamond stern-to-stern with the anchored fishing vessel Diamond at the time of the accident could not Miss Carol, whose master was a friend of the Lucky be determined, but the master stated they were Diamond’s. After a final check of the engine room, the operational before the accident. The investigation could master of the Lucky Diamond confirmed that everything not determine which electrical generation system was looked good. The crew had dinner and went to sleep. energized at the time of the fire’s ignition. Later that night at 2200, the master awoke to the smell of smoke and went to the galley area to investigate. The fire and subsequent sinking of theLucky Diamond He observed heavy smoke in the galley area and in resulted in the total constructive loss of the vessel. In the vicinity of the crew quarters. In addition, he saw addition, oil sheening was observed in the area of the fire coming up through the deck area near the crew Gulf of Mexico where the vessel sank. quarters. The electrical supply cables from one of the vessel’s diesel generators passed directly underneath Probable Cause this area. The National Transportation Safety Board determines The master shouted to alert the crew and opened the that the probable cause of the loss of the uninspected door to the crew accommodation space, but heavy fishing vessel Lucky Diamond was a fire of unknown smoke prevented him from seeing inside. origin in the engine room followed by downflooding of the interior compartments and eventual sinking of the The master tried unsuccessfully to fight the fire with vessel. onboard firefighting equipment. In his effort, the fire lashed back at him and he sustained first-degree burns to his face and eyes. He then abandoned the vessel via the stern where he boarded the Miss Carol. At that time, the entire accommodation space of the Lucky Diamond was engulfed in flames, and the crew of the Miss Carol

17 Safer Seas 2013 Fishing Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Flooding and Sinking of the Mary Kay

Mary Kay during its 2012 shipyard period in Port Townsend, Washington. (Photo by Port Townsend Shipwrights Co-Op) Vessel Identification

Vessel Mary Kay The Mary Kay next visited Sitka, Alaska, on July 9, Flag United States 2012, where the vessel grounded twice on the boat Engine type Diesel launch (made of cement) in Sitka harbor. It is unknown whether these groundings caused any damage to the Crew complement 4 hull, because, like in Bellingham, the incident was never reported and no formal damage inspection completed. On July 26, 2012, about 2300 Alaska daylight time, the Later that same month, on July 22, the Mary Kay was commercial fishing vessel Mary Kay sank as a result of under way and returning to Sitka when water began flooding in the starboard fish hold, the lazarette, and the leaking from the starboard fish hold and lazarette into engine room. The sinking took place in Dixon Entrance, the vessel’s bilges. The helmsman set the vessel on near Cape Chacon, Prince of Wales Island, Alaska. The autopilot, left the pilothouse, and went to the engine four crewmembers safely abandoned the vessel and room to pump the bilges. The autopilot failed, and the were rescued. vessel struck a floating aid to navigation in Saginaw Channel. Any vessel damage is unknown, as this Almost a month earlier, on July 1, 2012, the Mary Kay incident was not reported either. had returned to service following a 3-month shipyard period at Port Townsend, Washington. During this time, On July 26, 2012, at 1800 local time, the Mary Kay extensive modifications were made, which included departed the fuel dock in Ketchikan, Alaska, headed adding a third fish hold, replacing wornout bottom for Craig, Alaska, to offload about 130,000 pounds planking, removing a hydraulic bilge pump, and installing of salmon that the crew had retrieved at a nearby a refrigerated sea water circulation pipe. The addition of cannery. After getting under way, a highlevel alarm the third fish hold nearly doubled the vessel’s capacity sounded and the crew had to pump the bilges. As the and likely changed its center of gravity. voyage continued, the leaks from the lazarette and the starboard fish hold activated the bilge alarm about When the Mary Kay departed the Port Townsend every 45 minutes. About a third of the way to Craig, shipyard facility on July 1, 2012, the vessel returned as the vessel approached Cape Chacon, the Mary Kay to service without a sea trial. After getting under began experiencing large waves and the crew noticed way toward the first scheduled stop of Bellingham, that the bilges were filling with water. The captain Washington, the crew detected a leak on the bottom activated a gasoline-powered 300-gallon-per-minute of the starboard fish hold and another leak in the (gpm) pump, an electric-powered 300-gpm-pump, and a lazarette. On arriving in Bellingham, the Mary Kay lost hydraulic-powered 250-gpm-pump in the engine room. operational control and consequently allided with a dock in port. The damage to the hull of the Mary Kay was not investigated, perhaps because the estimated damage was less than the required reportable amount.

18 Safer Seas 2013 Fishing Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

The captain issued an urgent call (PAN-PAN) for assistance and returned to the engine room a few minutes later to find that the pumps were not keeping up with the water ingress. He then issued a distress call (MAYDAY) and directed his crew to don survival suits and launch the skiff and the liferaft. The crew successfully abandoned the Mary Kay and, moments after the captain as the last person on board left the vessel, it sank bow first. About an hour later, the crew of another fishing vessel rescued theMary Kay crew. The Mary Kay sank in deep water and was a total constructive loss. Its value, together with the 130,000 pounds of salmon lost with the vessel, was estimated as $625,000.

Probable Cause The National Transportation Safety Board determines that the probable cause of the sinking of the Mary Kay was the captain’s failure to identify and correct the source(s) of the through-hull leaks.

Stern of the Mary Kay while under repair to replace planking. (Photo by Port Towsend Shipwrights Co-Op)

19 Safer Seas 2013 Fishing Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Flooding and Sinking of the Plan B

The Plan B listing to port before sinking. (Photo by Coast Guard) Vessel Identification

Vessel Plan B While opening the starboard fish-hold tank valve (located in the main engine room) to dewater the fish Flag United States tank, the pipe broke and allowed seawater to flood into Engine power and type Single-screw marine diesel engine the engine room through the 4-inch pipe. The captain Crew complement 2 attempted to run the vessel’s pumps to remove the

water; however, the pumps could not keep up with On February 21, 2012, the uninspected fishing vessel the ingress of water. He tried to plug the pipes to stop Plan B was in the Gulf of Maine, en route to Gloucester, the flooding, but they failed to hold. About 30 minutes Massachusetts. The captain and deckhand were in the later, when the engine room was flooded about 3 feet process of draining water from the fish tanks when deep, the captain called the US Coast Guard and said a pipe broke, allowing water to flood into the engine that the water had reached “almost to the engine, with room. Attempts to stop the flooding were unsuccessful, secondary alarms starting to sound.” and at 0720, the vessel sank in about 290 feet of water As the flooding increased, the captain was soaked by 10 nautical miles southeast of Kennebunkport, Maine. water and received shocks as electrical panels and The captain and the deckhand were rescued and wires were shorting. The continued flooding and the sustained no injuries. inability of the crew to arrest it led to the eventual About 0430 that morning, the Plan B departed its sinking and total loss of the vessel and equipment. (The berth in Portland, Maine. The crew had returned from loss of a mechanically-propelled vessel of 100 gross a shrimping trip on February 17 and offloaded all tons or more is classified as a major marine casualty.) shrimping gear and nets in preparation for the herring The crew of a nearby good samaritan vessel, the lobster purse seine season. The purse seine gear was located boat Cameron Lee, assisted the captain and the deckhand in Gloucester and would be loaded on board once the as they departed the sinking Plan B. vessel arrived there. The vessel was operated by Plan B Neither the captain nor the deckhand was required Fisheries Inc., Gloucester; the captain owned 49 percent to hold a Coast Guard license or any other mariner of the company. credentials. Both were tested for drugs and alcohol, and The vessel was on a southerly course in the Gulf of all results were negative. Maine, making about 8 knots. Both outriggers were The status of Plan B’s navigational, mechanical, down for the transit, which the captain stated was propulsion, steering, and other vital systems before the standard for operating under way (the vessel’s stability sinking could not be determined, but the captain stated was better when the outriggers were down than when that they were operational at the time of the accident. they were topped, or retracted). The captain also stated that keeping the fish tanks full of water helped to settle Probable Cause the vessel down. However, the captain told investigators that, on this particular transit, he wanted to arrive The National Transportation Safety Board determines earlier in Gloucester. Therefore, he said he intended that the probable cause of the Plan B sinking was the to drain the water from the fish tanks to reduce the inability of the crew to control flooding from the vessel’s weight and increase speed by about 1 knot. broken PVC (polyvinyl chloride) pipe, which was in open communication with the sea.

20 Safer Seas 2013 Fishing Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Flooding and Sinking of the Viking II

The Viking II at sea. (Photo provided by the Coast Guard) Vessel Identification

Vessel Viking II got under way from Cape May, New Jersey, with an estimated 4-hour transit time. A second helicopter was Flag United States sent to relieve the first one as its low fuel level required Construction Wood it to return to base. Finally, a C-130 aircraft was also Crew complement 3 dispatched and its crew dropped a second dewatering

pump into the water near the vessel; however, the About 0900 on October 7, 2012, the 64-foot-long Viking II crew was not able to locate and recover it from fishing vesselViking II sank about 75 nautical miles the sea. off Cape May, New Jersey, following several hours of When the onboard bilge pumps failed as the water uncontrollable flooding in the engine room. The three level continued to rise in the engine room, the crew crewmembers on board (a captain and his two sons) attempted to use the dewatering pump provided by the were rescued unharmed. Coast Guard helicopter. After the crew resolved some Early in the morning the previous day, October 6, the technical difficulties with getting the dewatering pump Viking II had departed Point Pleasant, New Jersey, to started and functioning, the pump began pumping, but assist in a cable-laying project. That evening, after having it could not keep up with the incoming seawater, and transited about 75 nautical miles offshore and after the water level in the engine room reached 7 feet. The shutting down the main engine for the night, the three vessel lost all electrical power, and the captain made the crewmembers went to bed. About 2225, they were decision to abandon ship. About 0245, the crew donned awakened by a high bilge level alarm, which had activated survival suits and entered the vessel’s liferaft. Shortly due to flooding in the engine room. The crew used two thereafter, the crew of the nearby Miss Suzanne rescued onboard pumps in an attempt to stem the flooding, but the uninjured men from the liferaft and brought them the rate of water ingress exceeded the pumps’ capacity. on board. The Coast Guard cutter Ibis arrived at 0350, The captain was not able to determine the source of the and at first light about 0530, the rescued crew was flooding and got the vessel under way headed for shore. transferred from the Miss Suzanne to the Ibis. About He radioed the crewmembers of a nearby fishing vessel, 0900, the Viking II capsized and sank. The Ibis returned the Miss Suzanne, advised them of the situation, and the Viking II crew to Cape May, where they arrived later requested that they stand by to assist if needed. that afternoon. During the transit to Cape May, the Coast Guard tested the Viking II crew for alcohol; the About 2330, as the water level in the engine room results were negative. The crew also submitted samples reached the deck plates, the captain radioed the for drug testing, and one of the crewmembers tested Command Center at Coast Guard Sector Delaware positive for tetrahydrocannabinol (the active ingredient Bay that the vessel was taking on water and needed in cannabis); the others had negative results. immediate assistance. The Command Center alerted its air and surface response assets, and at 0016 a rescue Probable Cause helicopter from Air Station Atlantic City was en route The National Transportation Safety Board determines to the scene. On arrival at 0052, the helicopter crew that the probable cause of the sinking of fishing vessel lowered a dewatering pump to the Viking II crew. Viking II was uncontrolled flooding of the engine room About 0142, the 87-foot-long Coast Guard cutter Ibis from an undetermined source.

21 Safer Seas 2013 Liftboats Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Liftboat Mako

Vessel Identification Photo of the fire, taken on January 17, 2012. The charred remains of the Mako are visible in the foreground, to the right of the flames. Photo provided by the US Coast Vessel Mako Guard. Flag United States Engine power and type Diesel reduction that is, the legs did not have sections that slid or passed within one another to extend or contract the legs. Crew complement 28

In the Funiwaw oil field, the Mako was jacked up in About 0503 on January 16, 2012, the US liftboat Mako about 25 feet of water and had a clearance of about caught fire while supporting oil drilling operations 50 feet from the surface of the water. The liftboat was about 6 miles off the coast of Nigeria. No one on board located about 150 feet from the KS Endeavor’s blowout the Mako was injured, but two workers on the nearby preventer (BOP, an inline mechanical safety device drilling rig KS Endeavor died. The Mako was a total loss. with a valve or series of valves designed to secure the flow of oil and gas in the event of an unintended high- The Mako was operating in the Funiwaw oil field off pressure pipeline release from the well being drilled). the coast of Bayelsa State, Nigeria. Beginning November 18, 2011, the Mako was positioned next to About 0500 on January 16, 2012, as the master was the KS Endeavor, a Panama-flagged jackup drilling rig. getting ready to take over the watch from the mate, The Mako had been taking on drill cuttings from the he heard a loud noise. He went to the bridge where KS Endeavor. Drill cuttings are small pieces of rock he observed a spray of mud, oil, and gas coming from created when a well is drilled through rock to reach the KS Endeavor’s BOP. The mixture coated the Mako’s an oil or gas reservoir. The cuttings were pumped into decks and superstructure. The master sounded the containers on the liftboat. Once filled, the containers general alarm and ordered the mate to muster the were lowered to offshore supply vessels and taken to crew and offshore workers at the liferaft muster station shore for disposal. on the lower deck. The master said to abandon ship if the rig caught fire. All personnel mustered with their The crew on board the Mako included a licensed lifejackets. master and a licensed mate, both US citizens. The vessel carried 26 additional personnel including crew and The master stayed on the bridge and began to jack offshore workers, all Nigerian citizens. down the Mako toward the surface of the water. The Mako was limited in how quickly it could get under Similar to other liftboats, the Mako had jacking way from a jacked-up position. The vessel was capable legs designed to rest on the seafloor and raise the of jacking down at a maximum speed of 7 feet per hull above the sea surface to create a stable work minute. Then the legs would have to be raised from the platform. The level of elevation above the surface of seafloor, requiring additional time. As the Mako began the water would depend on the sea state and the type to jack down, gas from the KS Endeavor’s BOP ignited. of work being done. The Mako’s three 175-foot-long When the liftboat was about 10 feet above the water’s legs were arranged in a triangular pattern with two surface, flames melted a hydraulic hose for one of the legs positioned at the forward outboard sides of the forward jacking legs. The system lost hydraulic pressure, hull and a single leg positioned at the stern on the and as a result the master was unable to lower the centerline of the hull. The length of the legs was fixed, vessel further. He then gathered survival equipment, including the global maritime distress and safety system

22 Safer Seas 2013 Liftboats Lessons Learned from Marine ACCIDENT INVESTIGATIONS

(GMDSS) survival craft radio, search and rescue from the water (26 from the Mako and one from the transponder (SART), and the emergency position KS Endeavor). One offshore worker from the Mako was indicating radio beacon (EPIRB), and headed toward the recovered by another vessel. muster station. The Mako was consumed by the fire and eventually The mate and crewmembers launched two liferafts on sank. The fire at the well continued to burn for about the Mako’s port side and one on the starboard side. another month and a half, until March 2, 2012, when a When the fire started on board theKS Endeavor and portion of the well sealed itself. quickly spread to the Mako, the mate gave the order to enter the water, and all personnel did so successfully Probable Cause by lowering themselves using the escape rope. They The National Transportation Safety Board determines did not attempt to fight the fire. Once in the water, that the probable cause of the fire on board and sinking the personnel tried to pull the rafts away from the of the liftboat Mako was a blowout of the wellhead burning rig and vessel, but were unsuccessful. The under the adjacent jackup drilling rig KS Endeavor, which liferafts melted from the heat and became unusable. resulted in an uncontrollable gas fire that rapidly spread While in the water, the crew used the survival craft to the liftboat. radio to call for help. About 0700, the security vessel Janis 1 recovered the master and 27 other personnel

23 Safer Seas 2013 Liftboats Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Personnel Abandonment of Trinity II

Vessel Identification Photo of the adrift Trinity II, taken while Mexican Navy personnel boarded the vessel.

Vessel Trinity II that the Trinity II would stay in its present location. Flag United States On Tuesday morning, September 6, the National Diesel reduction at 800 Engine power and type Hurricane Center (NHC) reported that the surface horsepower (hp) low pressure system would strengthen further due to Crew complement 10 a cold front approaching from the northwest. Using

the vessel’s anemometer, the Trinity II personnel noted On Thursday, September 8, 2011, about 1225 central that the winds increased further and appeared worse daylight time, the 78.5-foot-long liftboat Trinity II, while than the forecast. By noon that day, the vessel could elevated and at work about 15 miles offshore in the Bay no longer be safely moved. On Tuesday evening, the of Campeche, Gulf of Mexico, sustained damage to its weather deteriorated further and the crew jacked up stern jacking leg from severe weather associated with the Trinity II three times to stay clear of the waves. Hurricane Nate. Four US crewmembers and six non-US On Wednesday afternoon, the Trinity II personnel noted contractors were on board the vessel. that the sustained wind speed increased from 40 mph Similar to other liftboats, the Trinity II had jacking legs to more than 50 mph. The weather system was now designed to rest on the seafloor and raise the hull a tropical storm, which the NHC named “Nate.” The above the sea surface to create a stable platform. rough seas were striking the Trinity II’s jacking legs. On Sunday evening, September 4, the personnel The master later told investigators that, on this night, received a report forecasting the possibility of a the stern leg penetrated an additional 6 feet into the surface low pressure system forming nearby. In his seafloor in a matter of minutes, causing the vessel postaccident interview, the Trinity II master stated that to become further trimmed down by the stern. The he discussed the weather forecast with one of the two stern leg’s jacking mechanism had also jammed at this onboard navigators from Geokinetics, the chartering point, which prevented the crew from further elevating organization, who directed the vessel during positioning. the vessel, even though the two forward legs still had Together, the master and the navigator assessed 12 feet of jack-up capability remaining. whether they should move the Trinity II closer to shore. On Thursday morning, September 8, the personnel Jacking down and moving a liftboat can be a complex on board the Trinity II prepared for the possibility of and time-consuming process, commonly taking about abandoning the vessel. The Trinity II carried a variety of 3–6 hours. Moreover, in the Trinity II’s location, the three lifesaving equipment, including two 25-person inflatable jacking legs were penetrating about 10 feet into the liferafts, which were located in cradles on the main deck seafloor. This amount of penetration was substantial on the port and starboard sides. and would make the moving process even more time- consuming. Further, the personnel and the vessel had Due to the chaos, one of the liferafts inflated on deck. operated during low pressure systems before, and the The high winds caught it and took the liferaft out to sea. wave heights predicted for the next day were moderate, The stern jacking leg also began to fail, causing the about 1–4 feet. Therefore, the personnel determined

24 Safer Seas 2013 Liftboats Lessons Learned from Marine ACCIDENT INVESTIGATIONS

vessel to list. The master placed a Mayday call over the transferred to the hospital, where the day navigator radio and ordered everyone on board to abandon ship. later died. A week after the accident, the body of the night navigator was recovered. The survivors told investigators that, after a large wave crashed onto the port liferaft canister, the other liferaft The total damage to the Trinity II was estimated to be inexplicably inflated while still in the cradle, and was $1.5 million. stuck. The vessel’s cook and the “QC 2” (one of two quality control technicians) retrieved a lifefloat from the Probable Cause stowage location. The National Transportation Safety Board determines Throughout Thursday night into Friday, all 10 personnel that the probable cause of the accident was the failure clung to the single lifefloat as it drifted in heavy seas of Trinity Liftboats (the vessel owner/operator) and and high winds. The personnel did not bring any of the Geokinetics (the chartering organization) to adequately provisions they had prepared earlier. About 2330 on plan for the risks associated with a rapidly developing Friday evening, the night navigator drifted away and surface low pressure weather system, which ultimately became permanently separated from the group. On subjected the elevated liftboat to hurricane-force Saturday, the weather improved but the condition of the conditions, causing the stern jacking leg to fail and the personnel began to deteriorate. One crewmember, an onboard personnel to abandon the vessel. Contributing ordinary seaman, was found with his face underwater, to the injuries and fatalities was the failure of the and the other personnel were unable to revive him. Trinity II crewmembers to make effective use of the vessel’s available lifesaving equipment, resulting in the On Sunday, the remaining personnel were rescued personnel’s prolonged exposure to the elements while by assets dispatched to help in the search. They were awaiting rescue.

: Trinity II after the accident.

25 Safer Seas 2013 Oil Tankers Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Collision of FR8 Pride with Rowan EXL I

The FR8 Pride shortly after the collision. Photo provided by the Coast Guard. Vessel Identification the ship’s bow pass astern of the Rowan EXL I. However, Vessel FR8 Pride Rowan EXL I at 0718, about 4 minutes after the engine slowdown Republic of Republic of began, the starboard-side bow of the FR8 Pride collided Flag Marshall Islands Marshall Islands with the portside of the Rowan EXL I at about 8 knots. Oil tanker, Mobile offshore Shortly after the collision, which punctured the FR8 double hull; 15, drilling unit Pride’s hull below the waterline, the ship’s forepeak tank Type 153-hp direct drive flooded and the vessel grounded at its bow. diesel After the collision and within the timeframes required Crew complement 24 crew and 1 pilot 56 by Coast Guard regulations, the FR8 Pride pilot and crew, and the pilot on board the lead tugboat for the On May 2, 2012, at 0718, the oil tanker FR8 Pride Rowan EXL I, were tested for drugs and alcohol. All collided with the mobile offshore drilling unit (MODU) results were negative. Rowan EXL I in Aransas Pass, Corpus Christi, Texas. No The reason for the automatic slowdown of the FR8 one was injured in the collision, but the two vessels Pride’s engine was that the cooling jacket on the engine’s sustained an estimated $16–17 million in damage. cylinder No. 5 had suddenly cracked. Jacket water began Earlier that morning, the 750-foot-long double-hulled oil leaking from the cracked cooling jacket, and the main tanker FR8 Pride got under way from an offshore fairway engine control system—detecting the resulting pressure anchorage, inbound to Corpus Christi. At 0704, about loss in the jacket water cooling system—protected the 14 minutes before the collision, a local pilot boarded engine by reducing its speed. the FR8 Pride to take the ship into port. At 0714, as After cylinder No.5’s cooling jacket failure, which led to the FR8 Pride was increasing to full-ahead speed on a the collision, the crew called on the assistance of the northwesterly course in the Aransas Pass channel, the engine manufacturer’s service engineer, who identified ship’s main propulsion engine suddenly slowed down several possible causes for the cracked cooling jackets. significantly. The slowdown was automatically triggered According to the service engineer’s report, the cracks by the main engine’s electronic control system in order likely resulted from excessive thermal stresses imposed to protect the engine from damage. As a result of the by rapid application of engine load when the ship’s engine slowdown, the FR8 Pride’s steering ability was speed was increased from slow ahead to full ahead. In greatly reduced, and the ship began an unintended swing addition, the cooling jackets were metallurgically tested to starboard, causing it to sheer out of the channel. in an attempt to determine why they had cracked. The Meanwhile, the MODU Rowan EXL I, also inbound to test found no abnormal conditions such as flaws or Corpus Christi, was about 400 feet outside the channel, defects, preexisting cracks, unusual metal composition, on the starboard side and ahead of the approaching corrosion, or manufacturing defect. The metallurgical FR8 Pride. The non-self-propelled Rowan EXL I was being test report did express the opinion that the material towed at 1 to 2 knots by three tugboats at its bow. As used in manufacturing the cooling jackets (gray cast the FR8 Pride began to swing to starboard, the pilot iron) might be inappropriate for this design application. ordered hard starboard rudder in an attempt to make

26 Safer Seas 2013 Oil Tankers Lessons Learned from Marine ACCIDENT INVESTIGATIONS

However, according to the engine manufacturer, there water temperature condition had occurred during had not been an unusual number of failures of this the maneuvering period leading up to the collision. engine component within the population of this model Therefore, the cause of the cracked cooling jackets engine, suggesting that no design deficiency exists. remains undetermined.

During the months before the collision, the engine’s Probable Cause jacket water temperature control valve could not automatically maintain a steady water temperature in The National Transportation Safety Board determines the engine when load changed appreciably. The crew that the probable cause of the collision of oil tanker had, therefore, been manually controlling the jacket FR8 Pride with MODU Rowan EXL I was the failure of water temperature during ship maneuvering. The the FR8 Pride’s main propulsion engine, which resulted crew’s manual control appeared to have been effective in reduced maneuverability of the ship. before the failure of the No.5 cooling jacket; according to the engine alarm system record, no high or low

The extensive damage to the port side of the Rowan EXL I, including its destroyed survival crafts (orange-colored) near the center of the photo. Photo provided by the Coast Guard.

27 Safer Seas 2013 Oil Tankers Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Allision of Overseas Reymar with San Francisco–Oakland Bay Bridge The Overseas Reymar. (Photo by Kamal Wanniarachchi, at www.vesseltracker.com)

At 1044, the pilot reported to VTS that he and the crew were preparing to get the ship under way and that they Vessel Identification would transit through the CD span. At 1054, the master ordered the anchor heaved, and the vessel began its Vessel Overseas Reymar transit shortly thereafter. VTS asked the pilot to report Flag Marshall Islands the visibility, and the pilot responded that it was about Construction Steel half a mile. Meteorological data indicate that visibility at Crew complement 18 crew and 1 pilot the time of the allision was about one-eighth of a mile near the bridge.

The pilot, who was using both visual cues and vessel On January 7, 2013, at 1118 local time, the 752-foot- radar for navigation, soon realized that the return long tanker Overseas Reymar allided with the fendering from the RACON, or RAdar beaCON, on the CD system of the San Francisco–Oakland Bay Bridge’s Echo span was not displaying on the vessel’s radar screens. tower. The vessel was outbound in San Francisco Bay. The RACON, a transponder that responds to radar No one was injured and no pollution was reported. interrogations, identifies the center of the span. Caltrans, Damage to the vessel was estimated at $220,000, and the California state agency that oversees the Bay Bridge, the cost to repair the Echo tower’s fendering system installed three RACONs on the bridge; in addition was estimated at $1.4 million. to the CD span, the Alpha-Bravo (AB) and DE spans That morning, the pilot awoke about 0600 and checked are equipped with RACONs. RACONs have become his duty status with the San Francisco Bar Pilots one of many tools mariners rely on when operating in Association. He learned that he was scheduled to pilot reduced visibility. Caltrans personnel learned after the the tanker Overseas Reymar for an estimated 1100 accident that the CD-span RACON was out of service. departure. He reported to the pilot station about 0930–0945 to allow sufficient time for departure According to the pilot, shortly after he realized that the preparations. The pilot informed the master that he CD span RACON did not display on the vessel’s radar intended to transit through the Charlie-Delta (CD) screens, the visibility decreased further, and he lost span of the San Francisco-Oakland Bay Bridge (“Bay visual sight of the bridge. The pilot told investigators Bridge”), and the master agreed. that he decided to change his path and instead transit through the DE span; its RACON was functioning and The CD span is 1,079 feet wide; the adjacent visible on the vessel’s radar screens. At that point, the Delta-Echo (DE) span is more than twice as wide, 2,210 vessel was about one and a quarter mile south of the feet. Watchstanders with the US Coast Guard’s San bridge on an approximate heading of 010 degrees and Francisco Vessel Traffic Service (VTS) indicated that a speed of about 10 knots. The ebbing tide was about 80–90 percent of vessels transit through the wider 3 knots at the time, pushing the vessel in a northwest DE span. The pilot told investigators that, nevertheless, trajectory toward the bridge. The pilot called for a he typically chose the CD span when departing 015-degree heading, and the vessel began a slight turn Anchorage 9. to starboard, toward the east, to line up for the DE span.

28 Safer Seas 2013 Oil Tankers Lessons Learned from Marine ACCIDENT INVESTIGATIONS

At 1111:02, the pilot ordered full ahead on the main to consider when transiting waterways in challenging engine. The master conducted two separate phone calls conditions. When the nonfunctioning RACON on during this time, both of which involved operations- the DE span did not display, the pilot appears to have related information. The second phone call from his seen no other alternative than to choose another span company was a long conversation that did not end until with a functioning RACON. Yet marine safety depends 2 seconds before the allision. on mariners being sufficiently prepared and “ahead of the vessel” so that the loss of a single navigational aid, At 1117:25, VTS contacted the pilot and informed him despite its criticality, does not jeopardize safety. that the vessel was proceeding directly toward the Echo tower. Seconds later, the vessel’s aft starboard side Probable Cause allided with the Echo tower’s fendering system. The National Transportation Safety Board determines The pilot reported the allision to VTS personnel and that the probable cause of the Overseas Reymar allision said that he would take the vessel to Anchorage 7 just with the San Francisco–Oakland Bay Bridge was the past the bridge. The master declined tug assistance. The pilot’s decision to alter course from the CD span to pilot, the master, the third officer, the helmsman, and the the DE span without sufficient time to avoid alliding VTS supervisor and watchstanders were all tested for with the bridge’s Echo tower and the master’s failure drugs and alcohol. All results were negative. to properly oversee the pilot while engaging in a phone conversation during a critical point in the transit. The pilot initially selected the CD span because he anticipated encountering reduced visibility. Familiarity with a route facilitates a pilot’s ability to recognize deviation from a planned course, an important factor

Allision damage to the Overseas Reymar’s aft starboard side. (Photo provided by the Coast Guard)

29 Safer Seas 2013 Passenger Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Fire on Board Ferry Vessel Malaspina

Vessel Identification The passenger vessel Malaspina under way.

Vessel Passenger vessel Malaspina In the sewage treatment room, the fire burned spare Flag United States rubber fan belts and hoses; severely damaged the Construction Steel sodium bisulfate injection system, which protects Gross tonnage 2,928 carbon filters from premature exhaustion; and damaged overhead insulation, sewage piping, and electrical power Engine power and type 8,000 hp / 5,965 kW diesel cabling. The fire also caused smoke and soot damage to

nearby spaces. The passenger vessel Malaspina was in dry dock in Ketchikan, Alaska, for scheduled repairs when a fire The US Coast Guard investigation revealed that the broke out on February 7, 2012, resulting in damage welding curtain the workers had placed over the estimated between $500,000 and $750,000. No one was ventilation duct was intended to be used only on injured. The Malaspina was undergoing duct repair which a vertical plane to shield against sparks. It was not required “hot work”—cutting, grinding, and welding. designed to withstand continuous contact with slag and other hot material as it did when placed horizontally. The fire began in the sewage treatment room, also The hot material burned through the curtain and fell known as the marine sanitation device space, about down the duct into the sewage treatment room below, 1155 local time. A shoreside work crew employed by where it ignited combustible material. Alaska Ship and Drydock (ASD) was on board the Malaspina to repair a ventilation duct located in a Although the curtain was improperly placed, had the crewmember stateroom with fire watch personnel workers remained on site to ensure that the hot present. ASD’s permit to perform the work did not call materials had cooled sufficiently, they could have for the fire watch to remain on scene for any length of detected and quickly extinguished any small flames time once the work was completed. before the fire spread. The sewage treatment room was located directly Probable Cause below the stateroom in which the repair work was The National Transportation Safety Board determines taking place, and the open ventilation duct directly that the probable cause of the fire on board the exposed the rooms to one another. The workers placed passenger vessel Malaspina was the failure of the a welding curtain horizontally at the opening of the shoreside work crew and fire watch to ensure that exposed duct to collect slag, the waste produced during proper cooling had occurred before leaving the area high-temperature metal work, and other hot material where the repair work was conducted. Contributing to keep it from falling into the room below. About to the accident was the work crew’s improper use and noon, after the workers had been cutting away steel application of a welding curtain, placed horizontally as tabs inside the duct, they and the fire watch departed opposed to vertically, which allowed molten material to for lunch. As they were leaving the vessel, shipyard burn through the curtain and fall into the space below. and vessel personnel noticed smoke coming from the sewage treatment room. The local fire department was notified, and the fire was extinguished.

30 Safer Seas 2013 Passenger Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Fire on Board Safari Spirit

Vessel Identification Safari Spirit ablaze at Fisherman’s Terminal in Seattle, Washington. (Photo by Vessel Safari Spirit Joshua Lewis, KOMO News) Flag United States Construction Aluminum on board. The CEO recalled turning on overhead lighting on the aft deck to illuminate a “Do Not Enter” Built 1981 sign that identified the freshly oiled decks. A security camera located in the port captured an unidentified On April 27, 2012, about 0100 local time, a fire broke out person walking on Pier 9 near the Safari Spirit shortly on the aft deck of the passenger vessel Safari Spirit while before the estimated time of the fire’s ignition; however, the vessel was docked at Pier 9 of Fisherman’s Terminal no evidence was found to indicate this person had any in Seattle, Washington. The vessel was off charter but connection with the fire. soon to start its seasonal cruising schedule in Alaska. The fire was estimated to have started about 0100, with Two company personnel, the chief executive officer the Seattle Fire Department arriving shortly thereafter. (CEO)and the vessel’s chief engineer,were on board The bow of the vessel was pointed north and the and asleep at the time of the fire. The CEO stated ignition location was on the aft deck, so the southerly that he awoke to a popping or crackling sound,got up 10-knot wind helped to push the flames forward on the to investigate, and discovered the fire. After escaping vessel. The forensic fire investigation concentrated on the vessel hand-over-hand across the bow lines to the the self-heating of the flammable oil and paint cans left dock,the CEO and chief engineer tried to fight the fire on the aft decks in the area of the freshly oiled decks. with small water hoses located on the pier. They also However, no final determination was made regarding released the mooring lines of nearby vessels to allow the source of ignition of the fire. (See box below for them to float away from the fire engulfing the Safari more information on selfheating and fire ignition.) Spirit. Local fire units arrived on scene within about 10 minutes and extinguished the blaze. The Seattle Fire In an open letter to company personnel, the CEO Department maintained a fire watch with the vessel alerted staff to the circumstances of this accident, until daybreak to monitor hotspots and observe the precautions in dealing with the materials that were in vessel’s structural integrity. use on board the Safari Spirit that day, and the location of the ignition point of the fire. At the time of the fire, The day before the fire, two contract workers were on the Safari Spirit was operated by Inner Sea Discoveries, board to oil the teak deck, located aft on the vessel’s main which managed a fleet of eight passenger vessels, each deck. The workers also painted newly fabricated kayak carrying from 22 to 88 passengers, with total seasonal storage racks further aft and on the deck below. Rags staff ashore and afloat ranging up to 250 personnel. used to apply and clean up the oil from the teak wood treatment were laid across rails to dry. The workers A marine survey estimated the cost of rebuilding the stated they removed all the oiled rags and painting vessel to be $4 million. A prefire fair market value equipment from the vessel at the end of the work day. To survey in January 2011 estimated the value of the vessel their recollection, all paint and oil cans were sealed and at $1.5 million. stowed on the back deck near the completed work. The CEO and the chief engineer returned to the vessel later that night about an hour apart to spend the night

31 Safer Seas 2013 Passenger Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Probable Cause The National Transportation Safety Board determines Self-heating and fire ignition that the fire on board the passenger vessel Safari Spirit Self-heating is a process in which heat is created ignited due to unknown causes and was accelerated by within a material through a biological or the flammable materials stored on the aft portion of chemical process and without the application of the main deck. an external heat source. If self-heating increases the temperature of the material above its ignition point with sufficient oxygen present, self-ignition can occur. Sufficient air must be present to sustain the combustion reaction, but not so much air that the heat is dissipated. Common examples of materials that can self- heat or self-ignite are linseed oil rags, coal dust, hay, wood chips, manure, and latex.

Charred wreckage of the Safari Spirit. (Photo from Bowditch Marine, Inc.)

32 Safer Seas 2013 Towing Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Capsizing of Invader

Vessel Identification

Vessel Invader Flag United States Construction Steel Persons on board None

On March 18, 2012, about 0630 Pacific standard time, the uninspected towing vessel Invader capsized in Port The capsized Invader and Dry Dock #3. (Photo by KCPQ, Seattle, Washington) of Everett, Washington, after the floating Dry Dock #3 on which the vessel was positioned flooded and began continued listing to starboard, water began flooding listing. Both the Invader and Dry Dock #3 initially through the open manholes into Tanks #1 and #7, sank, but were later refloated. The accident happened causing additional listing. As the flooding progressed, while the Invader was undergoing its annual inspection, the Invader fell off its support blocks placed on the dry maintenance, and repair at Vigor Industrial Shipyard at dock’s floor, set heavily against the dry dock’s starboard Port of Everett. wall, and then partially sank. Dry Dock #3 also sank as a result of the flooding; however, both the Invade rand Dry Dock #3 had eight symmetrical ballast tanks, four the dry dock were later refloated. Fuel and liquids were on each side of the centerline, with similar design pumped from both the Invader and Dry Dock #3 during and capacity. Each of these eight tanks had an access salvage operations and pollution was minimal. manhole from the floor of the dry dock pontoon. The tanks were equipped with independent electric The damage to Dry Dock #3 was estimated to be pumps, valves for flooding and discharge, and piping $818,000. The Invader was a total constructive loss at for pumping single or multiple tanks. Each tank had an over $5 million. overboard discharge for the pumps. The discharge line included a cast iron check valve bolted directly to, and Probable Cause inboard of, a manually-operated discharge valve located The National Transportation Safety Board determines about 8 feet above the keel in the dry dock’s side shell. that the probable cause of the capsizing and sinking of During the day on March 17, 2012, pumping activities the towing vessel Invader and Dry Dock #3 was Vigor had taken place on board Dry Dock #3. That evening, Industrial Shipyard’s lack of operational oversight in water leaked past the check valve of Tank #5 on the ensuring that the discharge valves and manholes were dry dock’s starboard side; debris in the check valve closed after use, and its failure to continuously monitor prevented it from closing. In addition, the 4-inch the condition of the dry dock. discharge valve had been left open (even though the dock master told investigators it was customary to close the discharge valves after use), and this allowed ingress of water. The weight of the water gradually caused the dry dock to list to starboard. Further, the cover plates to the access manholes on Tanks #1 and #7 had been left open and unattended. As the dry dock

33 Safer Seas 2013 Towing Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Fire on Board Ivory Coast Location of hot work Vessel Identification

Vessel Ivory Coast Ivory Coast starboard side showing area of hot work for replacement of rub rails. Flag United States (Photo: US Coast Guard) Engine power and 2 main engines, EMD (Electro-Motive) type model 16-567-BC; max. power 1,350 hp (2,354 kW) each A competent person is trained and experienced in Crew complement Docked: 2 crewmembers, 1 shipfitter, and atmospheric sampling and monitoring and qualified 1 supervisor/competent person acting as to apply workplace standards and identify potential fire watch hazards with authority to correct them.

On October 10, 2011, the uninspected US towing vessel The marine chemist certificate stated that hot work Ivory Coast was moored at General Ship Repair (GSR) in to be performed on the Ivory Coast was limited to Baltimore’s Northwest Harbor while undergoing cutting replacement of the rub rail on the starboard side while and welding—or “hot work”—on the starboard-side maintaining a fire watch and ventilation. A competent hull plating in the engine room when a fire ignited and person was required to check the atmosphere daily spread to the main deck galley. Damage to the engine before hot work could begin to confirm that the room, associated machinery, and galley on the main atmosphere was safe. deck was extensive, with repairs estimated to cost Repair work began on Friday, October 7, and continued more than $1 million. Monday, October 10. The repairs planned for Monday The Ivory Coast arrived at the GSR facility 4 days earlier, morning included conducting hot work in the engine on October 6, 2011,to undergo repairs including the space, which involved cutting with an acetylene torch replacement of rub rails, which protect the vessel’s hull along the starboard hull to remove the vessel’s rub rails. when made up to a barge or another vessel. Most of The shipfitter started work at 0740 and secured the crew left the ship, while the engineer and ordinary the cutting torches before taking a break at 1130. A seaman remained on board in a caretaker status. supervisor/competent person acting as fire watch was About 1630 that afternoon, Upper Chesapeake Chemist stationed nearby in the engine room throughout the Co. Inc. issued a marine chemist certificate indicating hot work and was spraying water from a fire hose to that the atmosphere near the port and starboard diesel cool the hull plating. fuel tanks and the engine room space was safe for When the shipfitter and fire watch resumed work, the workers and for limited hot work. When ship repair and vessel’s engineer was working in the engine room on construction may result in fire, explosion, or exposure the exhaust manifold of the starboard generator. Less to toxic vapors or chemicals, a marine chemist is than 2 hours later, the shipfitter felt intense heat on required to ensure that the work can be conducted his safety jacket and pants, removed his face shield, and safely. After initial certification by a marine chemist, realized that a fire had broken out and the fire watch a competent person conducts follow-up routine was spraying water toward the flames with the fire monitoring of the space and adjacent areas. hose, but the water intensified the flames. The shipfitter told Coast Guard investigators he secured the torch, relieved the fire watch of the fire hose, and a short

34 Safer Seas 2013 Towing Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

time later located a portable CO2 fire extinguisher and No injuries were sustained by those on board or the discharged it at the deck plates but with no effect. responding fire department personnel. No alcohol or drug testing was performed on the vessel crew or the The shipfitter, fire watch, and vessel chief engineer GSR workers. realized the fire was out of control, and all personal evacuated the tug; the shipfitter then asked the Although the marine chemist certificate was completed supervisor/fire watch to call 911. The fire was on October 6, 2011, the day the vessel arrived at GSR, extinguished by the Baltimore City Fire Department the Ivory Coast was subsequently moved within the early that afternoon. repair facility after the certificate was issued. National Fire Protection Association standards specify that The chief engineer stated that before starting hot work “the prescribed work [be] carried out at the original he drained and disconnected the diesel oil manifold location within the facility for which the certificate so the shipfitter could gain access for the repairs. He was issued, unless movement is authorized within also said that below the manifold was a wooden tool the facility by the responsible marine chemist....” The box, which over time had become saturated with marine chemist certificate did not authorize vessel diesel oil. This was confirmed by testing of a sample of movement; therefore, the certificate was voided. residue from the wooden box by the Bureau of Alcohol, However, a competent person performed required Tobacco, Firearms, and Explosives (ATF). Therefore, a daily monitoring to ensure that the atmosphere was possible ignition source of the fire could have been a safe for hot work. shipfitter’s spark igniting the unprotected diesel oil– soaked wooden tool box below the area of the hot Probable Cause work. The National Transportation Safety Board determines that the probable cause of the fire on board the uninspected towing vessel Ivory Coast was sparks from welding and cutting repair work conducted with an oxygen-acetylene torch igniting unprotected combustible material in the engine room.

Northwest Harbor General Ship Repair dock

Baltimore Harbor

ExceptExcept from from National National Oceanic Oceanicand Atmospheric and Administration Atmospheric Chart Administration 12281 Chart 12281 showing showing accident site in Baltimore’s Northwest Harbor. (Background by Google accidentmaps) site in Baltimore’s Northwest Harbor. (Background by Google maps)

35 Safer Seas 2013 Towing Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

Fire on Board Patrice McAllister

Vessel Identification The fire-damaged Patrice McAllister after being towed to port. Photo by Vessel Patrice McAllister Transportation Safety Board, Canada. Flag United States

Engine power and Twin 3516B Caterpillar diesels, 16 engine room near the smokestack. Because the ladder type cylinders each, 4,400 hp/3,278 kW was in the path of the oil spray fire, the chief engineer had to exit through the fire, igniting his clothing. He Crew complement 6 collapsed on deck after exiting. The other crewmembers, who had been alerted to the fire moments earlier by On March 27, 2012, at 0229 eastern daylight time, the heat and smoke coming through a galley range hood uninspected towing vessel (UTV) Patrice McAllister, with vent, discovered the chief engineer and extinguished the six crewmembers on board, experienced an engine flames in his clothing. The chief engineer suffered burns room fire. The crew released CO2 from the vessel’s on more than 90 percent of his body. The oil spray fire fire suppression system into the engine room and also ignited combustible material on the fiddley deck. extinguished the fire; however, the fire later reflashed and burned out of control. The vessel’s chief engineer The crewmembers prepared to release the CO2 into was fatally injured, and the five remaining crewmembers the engine room from the vessel’s fixed fire suppression suffered minor injuries. system. They secured the vessel’s centerline passageway by closing its aft watertight door leading to the weather On March 23, 4 days before the accident, the Patrice deck and its forward door leading to the galley. However, McAllister departed the Ironhead Shipyard in Toledo, the crewmembers did not close the watertight door Ohio, where the vessel had undergone a complete onto the fiddley deck, through which the chief engineer overhaul. The accident voyage was to transfer the vessel had escaped, before the master released the CO2. In to McAllister Towing’s fleet in Staten Island. addition, no means existed to mechanically isolate the engine room’s exhaust and supply ventilation. After midnight on March 27, the Patrice McAllister was transiting at 10–12 knots through Canadian territorial On receiving word that the engine room was secured, waters on Lake Ontario. It was powered by the the master released the CO2, which, as expected, vessel’s portside main engine, which was running at caused the portside main engine to shut down, followed about 1,630 rpm at the time; the crew had shut off the by the generator and ventilation system. The vessel lost starboard main engine to repair a leak in the lubrication all power and began drifting in an easterly direction. oil cooler line. At 0346, after observing a noticeable reduction in heat and smoke, the master reported to the Canadian About 0229, a small hairline fracture in the port Coast Guard that the fire was extinguished. During this engine’s prelubrication oil pump discharge line began time, crewmembers opened the doors to the vessel’s spraying lubrication oil into the engine room. The superstructure and began desmoking it. However, this oil spray made contact with the hot portside engine action allowed CO2 to escape and fresh air to enter the manifold and flashed into an oil spray fire. interior of the vessel, which caused the fire to reflash. The chief engineer was in the engine room when the Because the vessel had lost power, crewmembers were fire broke out. The only exit was an accommodation unable to run the main fire pump, and they had already ladder leading to a watertight door onto the fiddley released all of the CO2.The fire also blocked access to deck, a partially raised deck located directly above the the portable fire pump. The crewmembers were unable

36 Safer Seas 2013 Towing Vessels Lessons Learned from Marine ACCIDENT INVESTIGATIONS

to fight the fire, which now raged out of control. It Following the accident, the five surviving Patrice spread into the accommodation space and consumed all McAllister crewmembers and the body of the chief combustible material up through the upper wheelhouse. engineer were tested for illegal drugs and alcohol. All The vessel’s two liferafts, stowed on the bridge deck, test results were negative. were inaccessible because of the flames and intense heat. Unable to abandon ship, the crew huddled in Probable Cause survival suits at the stern of the vessel, waiting to be The National Transportation Safety Board determines rescued. that the probable cause of the engine room fire At 0456, a Canadian Coast Guard rescue helicopter on board the Patrice McAllister was the ignition of evacuated the chief engineer, who later died from his lubricating oil that sprayed from a fatigue-fractured injuries. An hour later, the remaining five crewmembers, fitting on the portside main engine’s prelubrication who sustained minor smoke inhalation injuries, were oil pump onto the hot surface of the portside main evacuated to the Canadian Coast Guard ship Cape engine’s exhaust manifold. Contributing to the extent Hearne. The Patrice McAllister was salvaged later that of the fire damage was the crewmembers’ compromise afternoon by the UTV Bowditch and towed to Clayton, of the fire boundaries when they prematurely began New York. desmoking the vessel’s superstructure, the inability to completely secure the engine room’s fire boundaries, The fire caused extensive damage to the entire vessel. and the abundance of flammable material throughout According to the surveyor’s report, total estimated the vessel. cost for repair and towage to New York was about $3,569,000.

Point Petre

Accident Site Toronto Lake Ontario

Rochester

Lake Ontario, including the location where the Patrice McAllister crew reported the fire. (Background by Google)

37 INVESTIGATIONS COMPLETED IN 2013

Alliance Norfolk – Onboard fire in the Mediterranean Mary Ann Hudson and Star Grip – Collision in S e a , a b o u t 3 0 m i l e s N E o f M a l t a , o n M a r c h 1 0 , 2 0 1 2 Houston Ship Channel, Texas, on June 6, 2012 Published May 10, 2013 Published December 18, 2013 Chevelle – Grounding and loss in Newport, Oregon, Mary Kay – Sinking near Cape Chacon, on March 10, 2012 Prince of Wales Island, Alaska, on July 26, 2012 Published July 18, 2013 Published October 31, 2013 Delta Mariner – Allision with Eggner’s Ferry Bridge, FR8 Pride and Rowan EXL I – Collision Tennessee River, Kentucky, on January 26, 2012 i n C o r p u s C h r i s t i , Te x a s , o n M a y 2 , 2 0 1 2 Published May 14, 2013 Published June 27, 2013 Heritage – Sinking in Alitak Bay, Alaska, on Overseas Reymar – Allision with January 25, 2012 San Francisco–Oakland Bay Bridge in Published February 1, 2013 S a n F r a n c i s c o B a y , C a l i f o r n i a , o n J a n u a r y 7 , 2 0 1 3 Published November 7, 2013 Invader and Dry Dock #3 – Dockside capsizing and sinking in the Vigor Industrial Shipyard, Port of Patrice McAllister – Engine room fire, about 4 miles Everett, Washington, on March 18, 2012 SE of Point Petre, near Prince Edward Point, Ontario, on Published July 16, 2013 March 27, 2012 Published June 6, 2013 Ivory Coast – Onboard fire in Baltimore, M a r y l a n d , o n O c t o b e r 1 0 , 2 0 1 2 Plan B – Sinking about 10 nautical miles SE of Published May 6, 2013 Kennebunkport, Maine, on February 21, 2012 Published May 28, 2013 John D. Leitch – Collision with law enforcement vessel in Black River, Lorain, Ohio, on Rickmers Tokyo – Allision with Pier II at Port Richmond, Philadelphia, Pennsylvania, on October 3, 2012 December 23, 2012 Published May 28, 2013 Published May 28, 2013 Lucky Diamond – Engine room fire and Safari Spirit – Onboard fire in eventual flooding and sinking in the Gulf S e a t t l e , Wa s h i n g t o n , o n A p r i l 2 7 , 2 0 1 2 o f M e x i c o , L o u i s i a n a , o n M a y 1 0 , 2 0 1 2 Published July 3, 2013 Published February 1, 2013 Trinity II – Personnel abandonment of vessel, Maersk Wisconsin – Collision with tug and barge with loss of life, in the Bay of Campeche, u n i t i n K i l l V a n K u l l , N e w J e r s e y , o n D e c e m b e r 5 , 2 0 1 2 G u l f o f M e x i c o, o n S e p t e m b e r 8 , 2 0 1 1 Published April 23, 2013 Published May 9, 2013 Mako – Onboard fire and sinking in the Gulf of Viking II – Sinking in Atlantic Ocean, 75 nautical miles Guinea, Nigeria, on January 16, 2012 S E o f C a p e M a y , N e w J e r s e y , o n O c t o b e r 7 , 2 0 1 2 Published July 16, 2013 Published June 14, 2013 Malaspina – Onboard fire in Ketchikan, Alaska, on February 7, 2012 Published February 1, 2013

38 INVESTIGATIONS COMPLETED IN 2012

Elka Apollon and MSC Nederland – Natures Way Commander/ACBL 3111 and Barge Collision in the Houston Ship Channel, Upper CE-858 – Collision in the Gulf Intracoastal Waterway, Galveston Bay, Texas, on October 2 9 , 2 0 1 1 Port Allen Lock, Louisiana, on February 1, 2012 Published September 25, 2012 Published April 20, 2012 Andrew J. Barberi – Allision with St. George Terminal, Alliance/MMI 3024 and Naticina– Collision Staten Island, New York, on May 8, 2010 in Texas City Channel and Gulf Intracoastal Published May 24, 2012 Waterway, Galveston, Texas, on August 1 7 , 2 0 1 1 Published April 14, 2012

39 INVESTIGATIONS COMPLETED IN 2013

Safer Seas 2013 LESSONS LEARNED FROM MARINE ACCIDENT INVESTIGATIONS