NATIONAL TRANSPORTATION SAFETY COMMITTEE REPUBLIC OF INDONESIA FINAL KNKT.18.06.21.03 Marine Accident Investigation Report The Sinking of SINAR BANGUN 4 Toba Lake, Simalungun North Sumatera Republic of Indonesia 18 June 2018 2018 NATIONAL TRANSPORTATION SAFETY COMMITTEE Sinar Bangun 4, Toba Lake, Simalungun, North Sumatera, 18 June 2018 The report is based upon the investigation carried out by the National Transportation Safety Committee (KNKT) in accordance with IMO Resolution MSC. 255 (84) and Indonesian Shipping Act (UU No.17/2008). Readers are advised that the KNKT investigates for the sole purpose of enhancing Transport safety. Consequently, KNKT reports are confined to matters of safety significance and may be misleading if used for any other purpose. As the KNKT believes that safety information is of greatest value if it is passed on for the use of others, readers are encouraged to copy or reprint for further distribution, acknowledging KNKT as the source. When the KNKT makes recommendations as a result of its investigations or research, safety is its primary consideration. However, the KNKT fully recognizes that the implementation of recommendations arising from its investigations will in some cases incur a cost to the industry. Readers should note that the information in KNKT reports and recommendations is provided to promote transport safety. In no case it is intended to imply blame or liability. The report is based on these rules: 1. Indonesian Shipping Act No. 17 Year of 2008, articles 256 and 257 as well as the explanatory memorandum; 2. Government Regulation No. 62 Year of 2013 on Transport Accident Investigations; 3. Presidential Regulation of the Republic of Indonesia No. 2 Year of 2012 on the National Transportation Safety Committee; 4. 4. IMO Resolution MSC.255 (84) on the Casualty Investigation Code. ISBN: The report is published by the National Transportation Safety Committee (KNKT), Transportation Building, 3rd Fl., Ministry of Transportation, Jln. Medan Merdeka Timur No. 5, JKT 10110, Indonesia, in 2018. i NATIONAL TRANSPORTATION SAFETY COMMITTEE Sinar Bangun 4, Toba Lake, Simalungun, North Sumatera, 18 June 2018 ii NATIONAL TRANSPORTATION SAFETY COMMITTEE Sinar Bangun 4, Toba Lake, Simalungun, North Sumatera, 18 June 2018 iv NATIONAL TRANSPORTATION SAFETY COMMITTEE Sinar Bangun 4, Toba Lake, Simalungun, North Sumatera, 18 June 2018 CONTENTS FOREWORD ................................................................................................................................ iii CONTENTS................................................................................................................................... v TABLE OF FIGURES .................................................................................................................... vii TABLE OF TABLES ....................................................................................................................... ix EXECUTIVE SUMMARY ............................................................................................................... xi GLOSSARY ................................................................................................................................... 1 I. FACTUAL INFORMATION ................................................................................................... 3 I.1. THE ACCIDENT ......................................................................................................... 3 I.2. SEARCH AND RESCUE PROCESS .............................................................................. 5 I.2.1. Search and Rescue (SAR) Operation .......................................................... 6 I.2.2. Extension of the First Phase of Search Operation (Day 8 – 10) .............. 12 I.2.3. Extension of the Second Phase of Operation Search (Day 11 - 13) ........ 14 I.2.4. Extension of the Third Phase of Search Operations (Day 14 - 16) .......... 17 I.3. AFTERMATH .......................................................................................................... 19 I.4. SHIP INFORMATION .............................................................................................. 19 I.4.1. General Information ................................................................................ 19 I.4.2. Ship Construction .................................................................................... 20 I.4.3. Engine and Manoeuvre System ............................................................... 21 I.4.4. Safety Equipment, Navigation and Communication ............................... 21 I.5. SHIP MANNING ..................................................................................................... 22 I.6. HISTORY OF BUILDING, MODIFICATION AND ROUTE ........................................... 23 I.7. WATERS AND WEATHER CONDITION ................................................................... 23 I.8. CARGO INFORMATION .......................................................................................... 25 I.9. REGULATION RELATED TO SAFETY OPERATION OF SHIPS SIMILAR TO SINAR BANGUN 4 ............................................................................................................. 26 I.9.1. Legal Aspect and Operating Permit ......................................................... 26 I.9.2. Oversight of Marine Safety ...................................................................... 26 I.9.3. Oversight of Manning .............................................................................. 27 I.10. MODELING AND SHIP STABILITY CALCULATIONS ................................................. 27 I.10.1. Basic concept of ship stability ................................................................. 27 v NATIONAL TRANSPORTATION SAFETY COMMITTEE Sinar Bangun 4, Toba Lake, Simalungun, North Sumatera, 18 June 2018 I.10.2. Ship Modelling ........................................................................................ 31 I.10.3. The Simulation ........................................................................................ 32 I.10.4. Results of Modeling ................................................................................ 32 II. ANALYSIS ......................................................................................................................... 35 II.1. THE FACTOR OF CAPSIZE ...................................................................................... 35 II.2. TECHNICAL STABILITY ASPECT .............................................................................. 36 II.2.1. The Use of the Deck 3 ............................................................................. 36 II.2.2. The Construction and the Use of Steel ................................................... 36 II.3. THE OVERSIGHT OF LOADING .............................................................................. 37 II.4. TECHNICAL ASPECT ............................................................................................... 37 II.5. IMPACT OF CARGO ON THE PROPULSION SYSTEM .............................................. 38 II.6. SKILL OF THE CREW .............................................................................................. 38 II.7. WEATHER INFORMATION ..................................................................................... 39 II.8. THE CAUSE OF THE LOW NUMBER OF SURVIVORS .............................................. 40 II.9. SAFETY EQUIPMENT ............................................................................................. 40 II.10. EMERGENCY RESPONSE ON BOARD AND EVACUATION OF PASSENGERS .......... 41 II.10.1. Emergency Access ................................................................................... 41 II.10.2. Evacuation Proces ................................................................................... 42 II.10.3. Emergency Telecommunications ............................................................ 43 II.11. THE OVERSIGHT IN TOBA LAKE AREA ................................................................... 43 II.11.1. The Oversight of Ship Worthiness .......................................................... 44 II.11.2. The Oversight of Ship Safety ................................................................... 44 III. CONCLUSION .................................................................................................................. 47 III.1. FINDINGS .............................................................................................................. 47 III.2. CONTRIBUTING FACTORS ..................................................................................... 48 IV. RECOMMENDATIONS ..................................................................................................... 51 IV.1. MINISTRY OF TRANSPORTATION .......................................................................... 51 IV.2. TRANSPORTATION AGENCY OF PROVINCE OF NORTH SUMATRA ....................... 52 IV.3. OPERATOR/OWNER .............................................................................................. 52 IV.4. BUREAU OF METEOROLOGY OF CLIMATOLOGY AND GEOPHYSICS ..................... 53 SOURCES OF INFORMATION .................................................................................................... 55 REGULATIONS .......................................................................................................................... 57 vi NATIONAL TRANSPORTATION SAFETY COMMITTEE Sinar Bangun 4, Toba Lake, Simalungun, North Sumatera,