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Very Serious Marine Casualty

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Very Serious Marine Casualty VERY SERIOUS MARINE CASUALTY Death of a crew member and injury of three crew members onboard Ro/Pax “HORIZON” due to toxic gas contamination from the sewage tank in ship’s void space, on 7th June 2015 Report date: 17/07/2015 FOREWORD The sole objective of the safety investigation under the Marine Accidents and Incidents Investigation Law N. 94 (I)/2012, in investigating an accident, is to determine its causes and circumstances, with the aim of improving the safety of life at sea and the avoidance of accidents in the future. It is not the purpose to apportion blame or liability. Under Section 17-(2) of the Law N. 94 (I)/2012 a person is required to provide witness to investigators truthfully. If the contents of this statement were subsequently submitted as evidence in court proceedings, then this would contradict the principle that a person cannot be required to give evidence against themselves. Therefore, the Marine Accidents and Incidents Investigation Committee, makes this report available to interested parties, on the strict understanding that, it will not be used in any court proceedings anywhere in the world. (1) GLOSSARY OF ABBREVIATIONS AND ACRONYMS USED IN INVESTIGATION REPORTS AIS - Automatic Identification System AB – Able –Bodied seaman ARPA - Automatic Radar Plotting Aid B/C - Bulk Carrier COLREGS - The Int/nal Regulations for Preventing Collisions at Sea 1972, as amended DO - Diesel Oil DOT - Diesel Oil Tank ECDIS - Electronic Chart Display and Information System ETA - Estimated Time of Arrival ETD - Estimated Time of Departure FO - Fuel Oil FOT - Fuel Oil Tank FPT - Fore Peak Tank DBT - Double Bottom Tank GPS - Global Positioning System IFO - Intermediate Fuel Oil IMO - International Maritime Organization LT - Local Time LOT - Lubricant Oil Tank m - metre MT - Metric Ton NM – Nautical Mile OOW - Officer of the Watch O.S – Ordinary Seaman PSN - Position QM - Quartermaster / Helmsman RPM - Revolutions per Minute SAR - Search And Rescue S.B.E. - Stand By Engine SOLAS - Safety of Life At Sea Convention (2) STCW95 - International Convention on Standards of Training, Certification and Watchkeeping for Seafarers 1978, as amended VDR - Voyage Data Recorder S-VDR - Simplified Voyage Data Recorder VHF - Very High Frequency VTS - Vessel Traffic Services UTC - Universal Time Co-ordinated ZT - Zone Time (3) 1.0 - SUMMARY On 07 June 2015 the Ro/Ro passenger vessel HORIZON sailed in ballast condition from the port of Shengjin, Albania towards a shipyard in Bijela, Montenegro for a scheduled drydock inspection. At around 16:30 LT four crew members were found unconscious inside the ship’s void space no. 3 where the sewage tank is located. Apparently the crew members went inside the void space in order to dismantle and clean the sewage pump suction filter. When the filter cover was dismantled, poisonous toxic gases escaped from the sewage tank line and contaminated the void space causing the death of one crew member by asphyxia and the injury of the other three crew members. The physical and documentary evidence that was gathered during our investigation, lead to the following conclusions. The direct cause of the accident (death) was asphyxia. The contributing causes of the accident were: “Work risk assessment” for entering into enclosed spaces was not performed. The Safety Management System procedures for entering an enclosed space were not followed, nor were any pre-entry form completed and entry permit given. No safety measures were taken before and after the crew entered the void space for work. The void space is suspect of being already contaminated in some degree due to the poor maintenance of the sewage waste discharge pump The following recommendations were made to the Management Company: The Managers to review the casualty within the scope of the SMS and provide a relevant circular to the vessel (4) The Managers should review IMO Resolution A.1050(27) (and SOLAS III, Reg. 19.3.6) and implement to the Company’s SMS the new requirements which entered into force in 01.01.2015. The Managers to arrange for thorough cleaning of the void space floor from any sewage waste contaminants. Managers also to overhaul the sewage discharge pump. The following suggestions were made for consideration by the Department of Merchant Shipping, Cyprus: A permanent mechanical ventilation system to be installed in such enclosed spaces containing sewage tanks or plants. A piping line of permanent backwash with sea water to be installed on sewage filters, which should be used every time before dismantling of the filter cover is to take place. Tank lines to be required to be equipped with a double suction filtering system with isolation valves. The sewage treatment plants to be subjected to annual surveys by the Classification Societies in order to promote better maintenance by the shipowners. (5) 2.0 – FACTUAL INFORMATION 2.1 – SHIP’S PARTICULARS The ship’s main particulars are the following: Name of ship : HORIZON IMO no. : 7203637 Call sign : 5 B B V 4 MMSI No. : 210899000 Year of build : 1971, Japan Flag State : Republic of Cyprus Port of registry Limassol Type of ship : RoRo Passenger Gross tonnage : 7707 Net tonnage : 3483 Deadweight : 1433.11 tons Class : Polski Register Registered Owner : Ionisus Maritime Co Ltd, Msida, Malta Ship’s Manager : European Seaways Inc, Athens, Greece Length overall : 112.80 m Breadth : 20.40 m Draught : 5.25 m 4 internal combustion - Nigata Shipbuilding & Main engines : Repair Inc. Crew onboard at the time : 38 of the casualty Crew onboard at the time : 38 of the survey Without passengers: 17 Minimum safe manning : Up to 250 passengers: 24 document More than 250 passengers: 30 Passengers capacity : 758 (6) The Class and Statutory certificates of the vessel are as follows: Class and Statutory Certificates Issued Expiry Class 31.07.2014 15.06.2016 Safety Management System - Safety Management (SMC) 09.02.2015 14.10.2019 - Document of Compliance (DOC) 27.11.2014 20.08.2019 Loadline (ILL) 31.07.2014 15.06.2016 International Oil Pollution Prevention 31.07.2014 15.06.2016 (IOPP) International Air Pollution Prevention 31.07.2014 15.06.2016 (IAPP) International Sewage Pollution 31.07.2014 15.06.2016 Prevention (ISPP) Passenger Ship Safety Certificate 14.06.2015 13.11.2015 2.1.1 – CHARACTERISTICS OF THE INTERNATIONAL SEWAGE POLLUTION PREVENTION CERTIFICATE The ISPP certificate certifies that the ship is equipped with a sewage holding tank and a discharge pipeline in compliance with regulations 9 and 10 of Annex IV of the MARPOL Convention. The holding tank has a total capacity of 14.40 m3 and is located between frames 108 – 120 on the starboard side of the ship. The ship is also equipped with a pipeline for the discharge of sewage to a reception facility, fitted with a standard shore connection. In addition the certificate provides the information that the ship has been surveyed in accordance with regulation 4 of Annex IV of the MARPOL Convention. The survey shows that the structure, equipment, systems, fittings, arrangements and material of the ship and the condition thereof are in all respects satisfactory and that the ship complies with the applicable requirements of Annex IV of the MARPOL Convention. (7) The certificate was issued by the Polski Register on 31 July 2014, was based on a survey carried out on 17 April 2014 and expires on 15 June 2016. 2.2 – VOYAGE PARTICULARS We were informed by the Master that the vessel was laid up for some time before commencing her voyages in early June which were intended to be the liner service between the ports of Shengjin, Albania and Brindisi, Italy. The distance between these two ports is about 102 nmiles. At the time of the casualty the vessel had sailed in ballast from the port of Shengjin to destination Bijela, Montenegro for the purposes of a scheduled drydock inspection in the shipyard of the area. The distance between Shengjin and the shipyard is about 73 nmiles. The vessel was manned with 38 crew members. After the casualty we were informed that the vessel is intended to make the liner service between Vlore, Albania and Brindisi, Italy. The distance between these two ports is about 80 nmiles. 2.3 – MARINE CASUALTY OR INCIDENT INFORMATION Type of marine casualty / incident: Very Serious Marine Casualty – Loss of life of one crew member and injury of three crew members Date and time: 07/06/2015 16:30 LT Position: Not recorded – previous entry on same day at 15:05 LT: Lat.: 41°56’6” N Long.: 019°07’3” E Location: About 6 nmiles off Montenegro coast, Adriatic Sea External and internal environment: Wind direction SW 3, slight sea, day, good visibility (8) Ship operation and voyage segment: Vessel in ballast condition on course to shipyard for scheduled drydock survey Place on board: Inside void space no. 3. Entrance of the void space is from the main garage. Capacity of void space approx. 670 m3 Human factors: Yes / Human Error / Decision Consequences: Death of one (1) crew member, injury of three (3) crew members 2.4 – SHORE AUTHORITY INVOLVENMENT AND EMERGENCY RESPONSE 2.4.1 – Upon dealing with the emergency situation the Master informed the company’s DPA and the local agent in Bijela. The Master tried to contact with the local port authorities but the pilot station responded and gave him information that all parties concerned were informed and asked for immediate assistance. 2.4.2 – A shore medical emergency team carried by a fast rescue boat came onboard the vessel and provided emergency medical assistance to the injured crew members and confirmed the death of the forth crew member. The emergency medical team decided to transfer the three injured members as soon as possible to the hospital.
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