2/2007. Kvartalsvis Orientering Opklaringsenheden. Quarterly Information. Division for Investigation of Maritime Accidents

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1 2/2007 Kvartalsvis Orientering Opklaringsenheden Quarterly Information Division for Investigation of Maritime Accidents

2 Introduktion Publikationen Kvartalsvis Orientering udgives hvert kvartal for at orientere om de ulykker Opklaringsenheden har afsluttet undersøgelsen af. Denne udgave indeholder også materiale på engelsk. Kvartalsvis Orientering indeholder redegørelser, resuméer af søulykkesrapporter og introduktion til temaundersøgelser, hvis der er udarbejdet sådanne i det pågældende kvartal. En temaundersøgelse er en sammenfatning af en række oplysninger og fakta om en række ulykker, som Opklaringsenheden har undersøgt, inden for et bestemt område tema. I Kvartalsvis Orientering kan man læse en introduktion til de/den temaundersøgelse(r), som er udsendt i det pågældende kvartal. Endelig indeholder Kvartalsvis Orientering en kort beskrivelse af en række ulykker, hvor der ikke er udarbejdet søulykkesrapport eller redegørelse. Disse ulykker, der kaldes statistiksager, er alene indlagt i Opklaringsenhedens ulykkesdatabase og vil indgå som statistisk materiale i Søfartsstyrelsens årlige publikation Ulykker til søs. Kvartalsvis Orientering, søulykkesrapporter, redegørelser og temaundersøgelser findes på Søfartsstyrelsens hjemmeside under Ulykkesopklaring. Introduction The publication Quarterly Information is published to provide information about the investigations of accidents that the Division have completed. Some of the material is in English. The Quarterly Information presents reports (minor), summaries of Marine accident reports together with an introduction to our safety studies, if any. A safety study is a summing up of a number of factual information on several accidents within a specific area a theme. In Quarterly Information, there is an introduction to the safety studies issued in the quarter in question. The Quarterly Information also presents a short description of a number of accidents, which the Division has not made a report on. The cases are called statistical files. The information gathered in connection with these cases is used for statistical purposes only. This information is a part of the statistical material in the yearly publication Accidents at sea published by the Danish Maritime Authority. Please find Quarterly Information, Reports and Safety Studies at the Danish Maritime Authority s homepage under Casualty Investigation. 2

3 Opklaringsenheden Opklaringsenheden har ansvaret for undersøgelse af søulykker og alvorlige personulykker. Formålet med Opklaringsenhedens undersøgelser er at klarlægge, hvad der er sket og hvordan det er sket, sådan at andre kan tage de fornødne forholdsregler for at undgå, at lignende ulykker sker igen. Desuden indsamler Enheden oplysninger til den årlige søulykkesstatistik Formålet er ikke at placere skyld eller ansvar. Opklaringsenheden arbejder som en selvstændig Havarienhed. Enhedens arbejde er adskilt fra alt andet arbejde i Søfartsstyrelsen. Det er vigtigt for undersøgelsen, at Opklaringsenheden snarest underrettes, når der er sket en søulykke eller en alvorlig personulykke. Telefon Telefax (hele døgnet) Opklaringsenheden Vermundsgade 38 C 2100 København Ø The Division for Investigation of Maritime Accidents The Division for Investigation of Maritime Accidents is responsible for investigating accidents and serious occupational accidents on Danish merchant- and fishing ships. The Division also investigates accidents in Danish wastes when foreign ships are involved. The purpose of the investigations is to clarify the actual sequence of events leading to the accident. With this information in hand, others can take measures to prevent similar accidents in the future. The aim of the investigations is not to establish legal or economic liability. The Division s work is separated from other functions and activities of the Danish Maritime Authority. It is important that the Division is advised immediately after the occurrence of an accident at sea. Phone Fax hours a day Division for Investigation of Maritime Accidents Vermundsgade 38 C DK 2100 Copenhagen 3

4 Indholdsfortegnelse - Contents Advarsel udsendt i forbindelse med branden på det færøske skib HERCULES Warning issued as a result of the fire on board the Faroese flagged vessel HERCULES 5 6 Resume af Søulykkesrapporter Summary of Marine Accident Reports Rapport Oljetankfartyget Stoc Regina SGOX- personskada den 27 december 2006 Sjöfartsverket I samarbejde med Opklaringsenheden, DK samt advarsel udsendt I forbindelse med hændelsen Warning issued in connection with the incident. 8 & 9 Occupational accident on board SC BALTIC on 14 September Arbejdsulykke på NINA BRES den 25. november Occupational accident on board NINA BRES on 25 November 2006 full report only in Danish language 12 Redegørelser Reports The grounding of CORONIS on 26 February Kontakt til Radio Medical ved undersøgelse om bord og ved lægebesøg i udland Contact with Radio Medical when examining a crewmember on board and when consulting a doctor abroad Mooring accident FINOLA on 4 January Kollision mellem MISTRAL og K. LARSEN den 28. marts Collision between MISTRAL and K. LARSEN on 28 March Fiskefartøj JANE s forlis den 18. december Statistiksager/Statistical files Liste over statistiksager 42 Listing of statistical files 42 4

5 Advarsel fra Søfartsstyrelsens hjemmeside Den 20. april 2007 udbrød der brand i den færøske fabrikstrawler HERCULES under fiskeri i Det Sydlige Stillehav. Ved branden omkom 11 besætningsmedlemmer, og størstedelen af skibet blev ødelagt. Branden opstod i et lastrum, hvor der blev opbevaret bølgepapemballage m.m. til frosset fisk. Samme dag konstaterede man i HERCULES søsterskib POSEIDON, at flere af skibets nyligt monterede lysstofrørsarmaturer var overopvarmede på grund af lysbuer i armaturernes fatninger med risiko for antændelse af brand. Begge skibe fik få måneder tidligere monteret ny armaturer af samme type i samme lastrum. Opklaringsenheden har sammen med Politiet og Dansk Brandteknisk Institut konstateret, at der kan opstå lysbue i armaturets fatninger på grund af dårlig elektrisk kontakt i lysstofrørsarmaturer af fabrikat: ADVANCE model Centium 1CN-2P32-SC, Instart start Electronic Ballast Armaturerne er samlet i Mexico og forhandlet i Panama. Risikoen for lysbuedannelse øges ved vibrationer. Lysbuerne kan opvarme plastkomponenter i armaturerne og forårsage brand. For yderligere oplysninger kontakt venligst Lars H. Jacobsen på tlf.: eller på 5

6 Warning from the Danish Maritime Authority s homepage On 20 April 2007, a fire broke out on the Faroese flagged factory trawler HER- CULES while fishing in South Pacific Ocean. 11 crewmembers perished and a greater part of the ship was destroyed. The fire broke out in a cargo hold where corrugated cardboard etc. for frozen fish were stored. The same day, it was observed on board HERCULES sister ship, the POSEI- DON, that some of the ship s newly installed fixtures for fluorescent lamps were overheated due to electric arcs in the sockets of the fixtures and that they were at risk of catching fire. A few months earlier new fixtures of the same type were installed in the same cargo hold of both ships. The Division for Investigation of Maritime Accidents has ascertained together with the Danish Police and The Danish Institute of Fire and Security Technology that electric arcs can occur due to poor electric contact in the sockets of fixtures of the make: ADVANCE model Centium 1CN-2P32-SC, Instart start Electronic Ballast The fixtures are assembled in Mexico and purchased in Panama. Vibrations increase the risk of electric arcing. The electric arcs are able to heat plastic components in the fixtures and thereby cause a fire. 6

7 Søulykkesrapporter 2. kvartal 2007 Marine Accident Reports 2 nd quarter 2007 Rapport Oljetankfartyget Stoc Regina -SGOX- personskada den 27 december 2006 Sjöfartsverket. Sammanfattning Oljetankfartyget Stoc Regina låg i Gulfhavn, Danmark för att lossa oljeförorenat vatten som hade lastats i Göteborg. En surveyor ville att prover skulle tas ur tankarna. Fartygets 2:e styrman befann sig på bryggan och bad via radio en matros att göra klart för provtagning och att assistera surveyorn när denne kom ner på däck. Matrosen gick fram till en tankrengöringslucka och började lossa på luckans vingmuttrar. Så snart som muttrarna lossades började det pysa gas ur luckan. Matrosen backade hostande mot en lejdare där han segnade ner och blev sittande mot lejdarens räckverk. En befälselev som befann sig i närheten sprang fram till matrosen. Samtidigt som han försökte skaka liv i matrosen larmade han 2:e styrman via radio. Eleven kände att han blev omtöcknad och lämnade platsen. Han lyckades ta sig upp för en lejdare till poopdäck där han föll ihop och svimmade. 2:e styrman sprang omedelbart ner till däcket och lyckades sedan ta sig fram till luckan som det fortfarande strömmade gas ur. Han drog åt vingmuttrarna som hade lossats med 3 4 gängor. Matrosen flyttades från platsen och gavs syrgas i avvaktan på tillkallad ambulans som förde matrosen och eleven till sjukhus. Sammanfattning av orsaker, faktorer och rekommendationer Utredningen visar att inget säkerhetsdatablad för den aktuella lasten fanns tillgängligt ombord. Besättningen hade fått muntlig information om att lasten bestod av ofarligt processvatten. På Stoc Regina hade utvecklats en kutym att vid provtagning ta prover från lasten via tankrengöringsluckorna i stället för genom det säkra slutna systemet. Matrosen handlade av gammal vana när han öppnade tankrengöringsluckan. Den aktuella tanken var fylld till cirka 75 procent vilket bidrog till att gasbildningen i tanken var större än i de tankar som hade högre fyllnadsgrad. Utredningen visar på vikten av att alltid använda den utrustning och de system som finns tillgängliga på sätt som de är avsedda för. Om befintliga rutiner ska revideras eller nya införas så bör alltid en riskanalys göras. Säkerhetsdatablad ska alltid finnas tillgängligt ombord innan lastning påbörjas. 7

8 ADVARSEL udsendt i forbindelse med hændelsen på STOC REGINA Sejlads med last, der indeholder svovlbrinte. To besætningsmedlemmer på et svensk tankskib mistede bevidstheden på grund af svovlbrintedampe, da de åbnede en lille luge for at tage prøver. Det ene besætningsmedlems tilstand var en overgang kritisk. Skibet var lastet med olieforurenet spildevand, der ifølge informationen indeholdt under 0,1 % svovlbrinte / hydrogensulfid (H 2 S). Efterfølgende undersøgelser af lasten har vist, at trods den forholdsvis lille mængde svovlbrinte, kan der i et lukket rum/tank opbygges en meget stor og livsfarlig koncentration af svovlbrintedampe. Ved små koncentrationer lugter svovlbrinte af rådne æg, men allerede ved 150 ppm lammes lugtesansen. Grænseværdien er 10 ppm. Ved sejlads med laster, der indeholder selv små mængder af svovlbrinte, skal der derfor udvises stor forsigtighed og der skal udarbejdes en arbejdspladsvurdering (APV). Ved åbning af luger skal der anvendes luftforsynet åndedrætsbeskyttelse. Warning issued in connection with the incident on board STOC REGINA Cargo containing hydrogen sulphide Two crewmembers on a Swedish tanker became unconscious due to hydrogen sulphide vapours when they opened a small hatch to take samples. The condition of one of the crewmembers was critical for some days. The ship was carrying oilpolluted wastewater, which, according to the information provided, contained below 0.1 % of hydrogen sulphide (H 2 S). Subsequent examination of the cargo has proven that in closed rooms/tanks with only a comparatively small quantity of hydrogen sulphide, a very large and dangerous quantity of hydrogen sulphide vapours can be formed. A low concentration of hydrogen sulphide smells like bad eggs. In a concentration of 150 ppm, the sense of smell is paralysed. The threshold limit value (TLV) is 10 ppm. Therefore, the crewmembers should be very cautious with regards to cargoes containing even a small quantity of hydrogen sulphide. A risk assessment has to be carried out. When opening hatches, respiratory equipment with air supplies must be used. 8

9 Occupational accident on board SC BALTIC on 14 September 2006 Summary During discharging bales of return paper whilst the ship was moored alongside quay in Skogen, Norway a crewmember who was tidying up the tween-deck was hit by a falling bale of paper. The paper bale weighed approximately 600 kg. The crewmember and the fork-lift truck driver were the only people present on the ship s tween-deck at the time of the accident. The fork-lift truck driver became aware of the accident when he heard shouting from the injured crewmember. He removed the paper bale, and another crewmember fetched the master, who was in his office. The crewmember had sustained fractures on both legs. The master called in an ambulance, and the injured crewmember was taken to a hospital near by. Later he was transferred to a hospital in The Philippines. Conclusion The Division for Investigation of Maritime Accidents considers the accident a result of various factors: There was an obvious risk connected with being on the tween-deck in the vicinity of the row of paper bales during unloading. Any person situated in the vicinity of paper bales not firmly braced would be potentially exposed to be hit by a falling paper bale. The working situation was usual to all persons involved, which might have caused a lack of attention to the risk of falling paper bales. The safety instructions given to the crewmember with regards to potentially falling paper bales was imprecise. The lack of risk assessment was contributing to insufficient instruction, insufficient planning, lack of due awareness and precautions. The Investigation Division is of that opinion that the master did not arrange a planning of the work in accordance with the instruction. Apparently it was also not supervised whether the instruction was observed by the crewmember even though the master was on duty at the time of the accident. The Investigation Division is of that opinion that the master did not sufficiently realize the potential risk of the work. Probably because the work has always been carried out in this way. 9

10 Arbejdsulykke på NINA BRES den 25. november 2006 Resumé NINA BRES var på rejse fra Karlstad til Casablanca med en last papir i lastrummet og træ i bundter som dækslast oven på lugen. Efter Göteborg på vej mod bunkringsstationen Rivön faldt en ubefaren skibsassistent overbord, da han mistede balancen under opsætning af ekstra surring på dækslasten. Det lykkedes for skibsassistenten at svømme ind mod Knippelholmen, hvor han, ca. 15 minutter efter overbordfaldet, blev hjulpet i land af besætningen fra et redningsfartøj. En helikopter bragte skibsassistenten til hospitalet, hvor han blev undersøgt og varmet op. Skibsassistenten blev, i god behold, bragt tilbage ombord i NINA BRES samme aften. Overbordfald Udsnit af svensk søkort nr Konklusion Arbejdet med påsætning af ekstra surring skulle have været tilrettelagt således, at der først blev opsat stræktov, at der var 2 personer om arbejdet, og at der under arbejdet på lugen og dækslasten blev anvendt faldsikring i form af sikkerhedsline eller lignende. (5.1). En risikovurdering for arbejde på lugen og på dækslasten, herunder arbejde med påsætning af surringer, ville have været et godt grundlag for planlægningen og instruktionen af det pågældende arbejde. (5.2). Det kan konstateres, at skibsassistenten ikke havde megen hviletid i dagene op til overbordfaldet kun 14 timer i de sidste 2 døgn. (5.3). 10

11 NINA BRES Occupational Accident on 25 November 2006 full report only in Danish language Summary NINA BRES was on a voyage from Karlstad to Casablanca loaded with paper in the cargo hold and timber bundles on deck and hatch cover. After having passed Göteborg and en route to the bunker station Rivön an ordinary seaman (OS) fell overboard, when he lost balance during the setting of an extra lashing on the deck cargo. The OS succeeded in swimming towards Knippelholmen, where he was helped ashore by the crew from a lifeboat approximately 15 minutes after he fell over board. A helicopter took him to the hospital, where he was examined and heated. The OS was in good condition and he returned to NINA BRES the same evening. The work of setting the extra lashing should have been organized in the way that first a jackstay should have been set up on the hatch cover. Two crewmen should have been designated for the job and a safety line or something similar should have been used as prevention against falling down during the work on the hatch cover and the deck cargo. A risk assessment on the work on the hatch cover and on the deck cargo, including the work of setting lashings, would have been a good basis for the planning and instruction of the actual work. It can be ascertained that the OS did not obtain much rest time in the days prior to the falling overboard only 14 hours during the latest 2 days. Recommendation The owner is recommended to consider a revision of the workplace risk assessment for lashing and in a way so it will include all work on hatch cover and deck cargo. This should be done together with his shipmasters, 11

12 Redegørelser 2. kvartal 2007 Reports 2 nd quarter 2007 Report from the Division for Investigation of Maritime Accidents The grounding of CORONIS on 26 February 2007 Factual information CORONIS, call sign C6VC9 and IMO No , is a bulk carrier of GT and a L.O.A. of 225 mtrs. It is built in 2006 and registered in Nassau, Bahamas. CORONIS is owned by Vesta Commercial S.A. Panama and operated by Diana Shipping Services S.A.. Athens, Greece. CORONIS on ground (picture by the Investigation Division on 26 February) On 26 February at 0001 hours CORONIS grounded in the southern part of the Sound, at the northern entrance to the Drogden Channel, in position N E. After a rearrangement of bunkers and ballast, CORONIS was refloated on 28 February at Following a diver s inspection, which unveiled a 20 x 60cm hole in a DBT, the ship was released at 2320 and proceeded to Gdynia for repair. 12

13 Grounding Position Extract from Danish chart no 133 Narrative The following description of the sequence of events is based on the Investigation Division s visit on board CORONIS on 26 February and interviews of the Captain, the 2 nd and the 3 rd officer and the helmsman. CORONIS was en route to Muuga in Estonia in ballast and with a crew of 19. The three mates on board ran a normal 3 shift bridge watch. The Captain had been master of CORONIS for about 8 month. CORONIS already passed the Drogden on 18 February en route to Muuga. It was the first time the Captain was navigating in the Drogden and there was a pilot on board during this passage. CORONIS arrived at Muuga on 19 February. The ship should have loaded fertilizers, but the conditions of the holds were not accepted. CORONIS departed Muuga on the 21 February for the North Sea for cleaning of the holds at sea. The vessel passed Drogden northbound on 23 February without a pilot and anchored at Copenhagen Road for bunkering. At 1600 hours the bunkering was completed and CORONIS continued northbound in the Sound and in Kattegat. The draught after bunkering was 7.1m. After cleaning the holds, CORONIS returned south in Danish waters en route back to Muuga. The ship passed the Skaw on 25 February at 1230 hours. A voyage plan had been prepared, and the planned track was laid out in the chart. For the southern part of the Sound BA chart 903 was used. 13

14 When CORONIS entered the northern entrance to the Sound, the Captain was on the bridge together with the 3 rd officer and a helmsman. Two radars were operated and normal navigation lights were exhibited. The vessel was hand-steered, which was always the case when navigating in narrow waters. The speed was about 13 knots. The wind was southeast, about 4 m/sec., the visibility was poor to moderate and the current was estimated to north about 0.5 knots. At about 2300 the 2 nd officer entered the bridge. From then on he monitored the positions of the ship on the GPS, inserted them in the chart and currently advised the Captain. The 3 rd officer monitored the traffic on the radar, which according to the 3 rd officer was set to the 3-miles range scale. He detected the 3 northbound vessels at a distance of about 3 miles. The Captain was in command. He used the other radar, which according to the 3 rd officer was set to the 1.5- miles range scale. According to the voyage plan the intended track at the northern entrance to the Drogden was between the white light middle-buoy and the red light buoy No 2. On approaching the entrance 3 northbound vessels were approaching CORONIS from the south. In order to give room for a port to port passage between COR- ONIS and the 3 vessels, the Captain decided to pass the white light middle-buoy on CORONIS s port side, between the middle-buoy and the green light buoy No 2. The last of the 3 vessels was passed port to port, when CORONIS was between the entrance buoys. The white light buoy was close on CORONIS s port side and the speed was unaltered, about 13 knots. After the white light middle-buoy the Captain ordered the helmsman to alter course to port, but it was too late to avoid the grounding, which took place at 0001 hours. According to the Captain there was no communication between CORONIS and the 3 northbound vessels. According to the helmsman he took over at the helm at about It was the Captain who gave the helm-orders. At the time of the grounding he steered 183. Pilot CORONIS took a pilot off Middelgrund on 18 February. According to this pilot, the ship had first requested a pilot from Helsingør, but this was later changed. The pilot boarded CORONIS at 0620 hour and took the vessel through the Drogden Channel. He left the vessel at about 0730 hours. According to the pilot the speed during the passage was 8 9 knots. With a draught of about 7m the pilot would never exceed a speed of 10 knots in the Drogden, where the charted depth of water is 8m. 14

15 According to the pilot, CORONIS s Captain was rather surprised and dissatisfied with the price of the pilotage. The Captain did not use a pilot during the north going passage on 23 February and neither during the actual south going passage. The IMO Resolution on the use of pilotage services in the Sound is not applicable to CORONIS. AIS and VHF communication At At Extract of AIS plot from Royal Danish Administration of Navigation and Hydrography s display system According to the AIS plot there is a close red to red passage at about 2342 between CORONIS and a north going general cargo vessel of about 3000 GT. This passage takes place in the northern part of Hollænderdybet. According to the communication on VHF, channel 16, logged by Lyngby Radio, the watch keeper on the north going vessel has experienced the passage as dangerous and has advised CORONIS to take a pilot. The northern most vessel on the plot at is a Ro/Ro vessel of GT. The next one is a general cargo ship of 3800 GT and the last one a general cargo ship of 2700 GT. According to the communication log the southern most vessel calls CORONIS several times from 2352 hours. The two vessels seem to have talked together on channel 6. 15

16 Analysis and conclusion CORONIS s master was not experienced in navigating in the Sound. He did not use a pilot, possibly because he found the price of the pilotage too high. According to CORONIS s voyage plan the planned track was in the east side of the northern entrance to the Drogden Channel, which would normally be the route of the north going traffic. CORONIS met several oncoming, north going, vessels and the Captain decided at a late moment to deviate from the voyage plan in order to pass the vessels port to port. Due to this change CORONIS was on grounding course when passing the entrance buoys. Although CORONIS was navigating in narrow water in dark and in moderate visibility, had encountered several close passages of other vessels, was encountering further close passages in the entrance to the channel, and had executed unplanned course alterations, the speed of CORONIS was kept unchanged at about 13 knots until the grounding. The under keel clearance for CORONIS s planned passage of the Drogden Channel was less than 1m. Under these conditions and with a speed of 13 knots, there is a risk of damage to the bottom of the ship due to the squad effect. During the passage on 18 February, with a pilot, the speed during the passage was 8 9 knots. 3 April 2007 The Division for Investigation of Maritime Accidents 16

17 Redegørelse fra Opklaringsenheden Kontakt til Radio Medical ved undersøgelse om bord og ved lægebesøg i udlandet Opklaringsenheden udsender redegørelse om denne hændelse for at gøre opmærksom på vigtigheden af at kontakte Radio Medical, uanset om den syge eller tilskadekomne vil blive eller er blevet tilset af en læge i udlandet. Da Opklaringsenheden først er blevet gjort opmærksom på hændelsen mere end to år efter ulykken skete, har Opklaringsenheden ikke interviewet de involverede besætningsmedlemmer. Oplysningerne bygger derfor alene på anmeldelsen af arbejdsulykken, Medical Reports, optegnelser i skibsdagbogen, og andre optegnelser om bord. Personfølsomme oplysninger, herunder diagnose, er ikke medtaget i redegørelsen. Hændelsesforløb Den 6. november 2004 skete der en arbejdsulykke på tankskibet TORM GUN- HILD. Kaldesignal OUQA2, BT, byggeår Skibet var på rejse fra New York til Port Said. Der var sydlig vind, vindstyrke 5 beaufort og sø 5 (ca. 2 meter). Ifølge anmeldelsen arbejdede et besætningsmedlem i maskinrummet, da han kl gled han på en lejder og slog sin ryg mod lejderens ståltrin. Som årsag blev angivet, at skibet rullede kraftigt. Den 12. november henvendte besætningsmedlemmet sig til sygdomsbehandleren om bord. Følgende fremgår af skibsdagbogen: NN complaining about sore back, due to slipping on engine ladder a couple of days ago. Treated with mild painkillers monitoring development. Sygdomsbehandleren var i besiddelse af gyldigt sygdomsbehandlerbevis. Sygdomsbehandleren fulgte Radio Medical optegnelsen i sin undersøgelse af patienten og noterede oplysningerne om undersøgelsen i skibets Radio Medical journal. Beskrivelsen af skaden er imidlertid kortfattet. Skibet tog ikke kontakt med Radio Medical i forbindelse med besætningsmedlemmets sygdomsforløb. Den 19. november fremgår følgende af skibsdagbogen: NN still complaining about sore back. Doctor arranged in Port of Suez. 17

18 Den 21. november var besætningsmedlemmet til læge i Port of Suez. Af den Medical Report, som blev udfyldt af lægen i Suez fremgik bl.a.: Fit for duty: Yes Patient recommended to be signed off: No The patient is in need for rest on board for two weeks Af skibsdagbogen og Radio Medical journalen fremgår, at besætningsmedlemmet blev behandlet om bord efter Suez lægens anvisninger den 21. og 27. november. Den 8. december kom besætningsmedlemmet til læge i Singapore. Af den Medical Report, som blev udfyldt af lægen i Singapore fremgår bl.a.: Fit for duty: No Patient recommended to be signed off: Yes Besætningsmedlemmet blev sygeafmønstret den 8. december i Singapore. Efterfølgende undersøgelser viste, at besætningsmedlemmet havde alvorlige problemer med ryggen. Analyse og konklusion Hændelsesforløbet viser vigtigheden af at kontakte Radio Medical så tidligt i sygdomsforløbet, som muligt, samt vigtigheden af, at der laves en grundig primærundersøgelse. Princippet for sygdomsbehandlingen på danske skibe er netop, at sygdomsbehandleren på skibet er Radio Medical lægens øjne, ører og hænder. Det er Radio Medical lægen, der stiller diagnosen. Hvis Radio Medical havde været kontaktet, ville en videre undersøgelse af patienten under vejledning af Radio Medical bl.a. have omfattet: En beskrivelse af ryggen og nervesystemet Misfarvning? Ømhed: på torntappene? På siderne af rygsøjlen? Udstrålende smerter fra ryggen, når benene løftes? Bevægelse af ryggen. Bevægelse, kraft og følesans i benene. Vandladningsproblemer? Har han tidligere haft rygproblemer? Smerter hvor i ryggen? Smerter hvornår? Når han går? Når han løfter? Når han sidder? Når han ligger? Er der smerter eller følelsesforstyrrelser i benene? hvor? En fyldestgørende primær undersøgelse, som her beskrevet, ville allerede på det tidlige tidspunkt have givet Radio Medical mulighed for at vurdere besætningsmedlemmets tilstand og hvilken videre undersøgelse der var behov for, fx røntgen eller scanning. 18

19 Hændelsesforløbet viser også vigtigheden af at kontakte Radio Medical, uanset om den syge eller tilskadekomne vil blive eller er blevet tilset af en læge i udlandet. Efter lægebesøget skulle Radio Medical have været kontaktet igen. Radio Medical lægen er den læge, som skibsledelsen/sygdomsbehandleren om bord skal konsultere, når der skal tages stilling til mulig afmønstring af syge besætningsmedlemmer. Der skal ikke træffes beslutninger alene på grundlag af informationer fra en læge i udlandet, hvor den lægefaglige kultur kan være væsentlig forskellig fra den danske. 2. maj 2007 Opklaringsenheden 19

20 Report by the Division for Investigation of Maritime Accidents Contact with Radio Medical when examining a crewmember on board and when consulting a doctor abroad The Division for Investigation of Maritime Accidents publishes a report on this incident to point out the importance of contacting Radio Medical regardless of the fact that the ill or injured person will be or has been examined by a doctor abroad. The investigation division has not taken statements from the crewmembers involved in the accident because the accident occurred more than two years before it came to our knowledge. The information is thus solely based on the reporting form of the occupational accident, the Medical Reports, recordings in the logbook and other recordings on board the ship. Personal information including the diagnosis is not included in the report. Narratives On 6 November 2004 an occupational accident occurred on board the tanker TORM GUNHILD, call sign OUQA2, 28,909 GT, built in The ship was on voyage from New York to Port Said. The wind was south, 5 Beaufort and sea 5 (approximately 2 metres). According to the report form, a crewmember was working in the engine room when he slipped on a ladder and hit his back on step of the steel ladder. A heavy rolling of the ship was mentioned as the cause of this accident. On 12 November 2004, the crewmember contacted the officer in charge of medical care on board the ship. The following appears from the logbook: NN complaining about sore back, due to slipping on engine ladder a couple of days ago. Treated with mild painkillers monitoring development. The officer in charge of medical care held a valid Medical Care Certificate The officer in charge of medical care followed the Radio Medical recording in his examination of the patient and entered the information on the examination in the ship s Radio Medical journal. However, the description of the injury is short. The ship did not contact Radio Medical in connection with the crewmember s course of disease. On 19 November 2004, the following appears from the logbook: NN still complaining about sore back. Doctor arranged in Port of Suez. 20

21 On 21 November 2004, the crewmember consulted a doctor in Port of Suez. From the report issued by the doctor the following appears among other things: Fit for duty: Yes Patient recommended to be signed off: No The patient is in need for rest on board for two weeks From the logbook and the Radio Medical recordings it appears that the crewmember was treated on board according to the Suez doctor s instructions on 21 and 27 November On 8 December 2004 the crewmember was examined by a doctor in Singapore. By the Medical Report issued by the doctor in Singapore the following appears among other things: Fit for duty: No Patient recommended to be signed off: Yes The crewmember was signed off due to illness on 8 December 2007 in Singapore. The examination carried out subsequently shows that the crewmember was suffering from severe back problems. Analysis and conclusion The sequence of events proves the importance of contacting Radio Medical at an early stage in a progress of a disease and the importance of conducting the primary treatment thoroughly. The principal rule for medical care on Danish ships is that the officer in charge of medical care acts as the eyes, ears and hands of the medical advisor from Radio Medical. It is the doctor at Radio Medical, who makes the diagnosis. If telemedical consultancy by Radio Medical had been initiated, a careful examination of the patient would have included the following, among other things: A description of the back and the nervous system Discoloration? Soreness: of the spinous process? on the sides of the spine? Radiating pain from the back when the legs are in motion? Motion of the back Motion, power and tactile sense in the legs Bladder dysfunction? Has the patient experienced any back problems previously? Pain in the back and where? When is the patient in pain? When the patient is walking? When the patient is lifting something? When the patient is sitting? When the patient is lying down? Does the patient experience any pain or problems with the tactile sense in the legs where? 21

22 A satisfying primary examination, similar to the one described here, would have made it possible for Radio Medical at an early stage to assess the condition of the crewmember and to determine which further examination would be necessary, for example X-ray or scanning. The incident also proves that it is important to contact Radio Medical irrespective of the fact that the ill or injured person will be or has been examined by a doctor abroad. After the crewmember consulted the doctor, Radio Medical should have been contacted again. The officers or the officer in charge of medical care on board have to consult the doctor at Radio Medical when deciding whether to sign off crewmembers due of illness. This decision cannot be made solely on the basis of a doctor abroad whose medical culture can differ significantly from the Danish medical culture. 2 May 2007 The Division for Investigation of Maritime Accidents 22

23 Report from the Division for Investigation of Maritime Accidents FINOLA Mooring Accident 4 January 2007 While the ship was alongside a swell lifted the ship and caused a mooring line to tighten during the handling of the line. The line hit the arm of the 2 nd officer, who was operating the mooring winch, and he was seriously injured. Factual information FINOLA is a Livestock Carrier with a gross tonnage of 3228, length overall 85,36 meters. The vessel was built in Frederikshavn, Denmark in 1988 and is operated by Corral Line ApS, Denmark. FINOLA is primarily transporting livestock between Mexico and Nicaragua. For the past 17 years the vessel has occasionally been transporting livestock between Kawaihae, Hawaii and Vancouver. The duration of the voyage between the two ports is about 10 days in normal circumstances. This time the vessel had been on this route since December The accident happened on the second voyage to Kawaihae. It was the third time that the 2 nd officer was in Kawaihae. The ship was manned with a crew of 15. The master, the chief officer and the ship s sole engineer was Danish citizens. The other crewmembers were Philippine citizens. At sea the watch is divided between the master, the chief officer and the 2 nd officer. In port the watch is divided between the two officers by six hours watches. Narrative FINOLA arrived at Kawaihae Roads in ballast on 3 January at about 0900 hours and was at anchor until the next morning. FINOLA went alongside in Kawaihae harbour on 4 January at 0530 hours. The loading of 2400 heads of cattle was commenced at approximately 0730 hours. The cattle were taken on board via a ramp direct from lorries and through an opening in the ship s side on the A-deck, which is two decks above the main 23

24 deck. According to the master it was important that the vessel is maintain in the same position during the loading operation and also that the ship is as close to the pier as possible at all times. From the forecastle the vessel was moored with one long spring line and three fore lines - one short and two long fore lines. All lines were hawser-laid ropes and they were made fast on pollards on board see the sketch of the mooring rearrangement in the appendix. There were also four lines aft, which were arranged similar to the lines forward. It was a shore crew who led the cattle from the lorries to the ship s side. The ship s crew then led the cattle to the stable deck. There were 6 ratings occupied during the loading operation. One of the ratings was staying at the gangway at all times as ISPS guard. After a couple of hours of loading, the vessel began to move vertically due to swell in the harbour. According to the master it is a known phenomenon that there can be a rather severe swell or surge in the harbour when the wind has been coming from North West for some time. The chief officer, who had the watch, tightened the lines regularly. There was no wind. The second officer took over the watch at about 1200 hours as usual. Two hours later - at about 1400 hours - two of the lines forward snapped due to the increasing swell. The master, who was at the bridge at that time, saw what happened and he called the 2 nd officer by his portable vhf. The 2 nd officer and an AB came to the forecastle and they began to replace the broken lines. The master went to the ship s office. According to the 2 nd officer they were about to secure the last fore line when a swell suddenly lifted the ship. The AB had put on the stopper on the line and the 2 nd officer was then easing out the line by the mooring winch. Due to the sudden pull on the line, the AB was not able to hold the line by the stopper and line laid around the winch drum was tightened and hit the 2 nd officer on his arm. It all happened very fast. The 2 nd officer went to the ship s office and reported what had happened and the master immediately arranged for transportation to the hospital. Additional information 24

25 The normal mooring operations during arrival and departure are normally performed by two AB s. The 2 nd officer s role during the moorings operations is to attend the communication with the bridge and to lead and supervise. The working language on board is English and according to the master, the risk assessments on board are issued in English. This also includes risk assessment for mooring operations. The day after the accident an extraordinary safety meeting was held on board. It was emphasised at the meeting that the crew should be very cautious during mooring operations. It was also concluded at the meeting that the 2 nd officer s limited practical experience with the operation of the winch might have been a contributory factor to the accident. Analyse and conclusion The mooring arrangement was used in the way that it was constructed for and in the usual manner. There is no indication that there were any technical failures besides the broken lines. The information about the accident indicates that the 2 nd officer either was handling the line or standing in a position close to the winch drum at the time of the accident. It all happened very fast and the 2 nd officer is unsure as to how exactly the line hit him. There is always a latent risk for the crew being hit by a line if positioned in a danger zone. In this case the condition with swell / surge posed a risk out of the ordinary. It is the opinion of the investigation division that both the 2 nd officer and the AB were in a very unsafe position when the situation developed. The strong force on the mooring line caused by the swell / surge was foreseeable and a known factor before the replacement of lines was commenced. At the time of the accident both the 2 nd officer and the AB were occupied with the practical work of making the line fast. None of them were therefore prepared for the sudden force on the line caused by the movement of the ship. The following factors contributed to the accident: Lack of planning of the actual task appropriate to the conditions The 2 nd officer had limited practical experience with the operation of the winch Number of crew allocated for the task. None of the two involved crewmembers were able to keep an eye on the outside of the ship at all times 14 May 2007 The Division for Investigation of Maritime Accidents 25

26 Appendix Mooring arrangement Archive photo of FINOLA received from the owners Principle of the mooring arrangement at the time of the accident. 26

27 Redegørelse fra Opklaringsenheden Kollision mellem det tyrkiske tørlastskib MI- STRAL og det danske fiskeskib K. LARSEN den 28. marts 2007 Faktuel information MISTRAL, TCCH, IMO Nr , er et tørlastskib på 5469 BT og en LOA på 126 m. Det er bygget i år 2000 i Rumænien og er under tyrkisk flag. Det ejes og opereres af et shipping firma i Istanbul. K. LARSEN, FN 322, OWUW, er et fiskeskib på 66 BT og en LOA på 19,55 m. Det er bygget i træ i Det er ejet privat af fiskeskipperen. MISTRAL var på rejse fra Antwerpen til Rostock. K. LARSEN havde afsluttet dagens fiskeri og var på vej mod hjemhavnen. Kl (lokal tid) ramte K. LAR- SEN bagbord side af MISTRAL i positionen 57 41,2 N ,3 Ø. Hændelsesforløb MISTRAL Den følgende tekst i dette afsnit er baseret på en skriftlig rapport udfærdiget af MISTRAL s skibsfører samt skibsførerens mundtlige forklaring til Opklaringsenheden i Rostock den 29. marts MISTRAL afsejlede fra Antwerpen den 26. marts kl med en last jernaffald til Rostock. Der var en besætning på 23 inklusive skibsføreren, overstyrmanden, 2. styrmanden og en dæk kadet. En 3-skift brovagt blev delt mellem skibsføreren, overstyrmanden og 2. styrmanden. Skibsføreren overtog vagten på broen fra overstyrmanden kl den 28. marts. Dæk kadetten og en rorgænger var også på broen. Der var ØNØ-lig vind, styrke ca. 3 beaufort, søen ca. 2 og en moderat sigtbarhed, 2 3 sømil. To radarer var i funktion på 6 sømils området, og der var også AIS. Farten var normal forlægningsfart, 10,5 knob. Kl observerede skibsføreren K. LARSEN visuelt foran for tværs om bagbord i en afstand af 2,2 sømil. Han kunne ikke se fiskeskibet på radaren, men han fik oplysningerne fra AIS. K. LARSEN viste en masse dækslys, men skibsføreren så ikke nogen lanterner. MISTRAL styrede 057 med en fart af 10 knob. Skibsføreren kaldte K. LARSEN mange gange på VHF, kanal 16, med uden at få svar. Han brugte også en Aldis lampe og skibsfløjten. Han så ingen kursændringer hos K. LARSEN. 27

28 I sidste øjeblik iværksatte skibsføreren et styrbord drej, men K. LARSEN ramte MISTRAL i bagbord side agten for midtskibs. Kollisionen skete kl i positionen 57 40,5 N ,9 Ø. Kollisionsvinkelen var ca. 30 og K. LARSEN skurede ned langs bagbord side af MISTRAL. Først efter kollisionen så skibsføreren en fisker om bord i K. LARSEN. Kl kaldte skibsføreren Lyngby Radio (LYRA) og blev stillet i forbindelse med RCC. MISTRAL lå og ventede indtil kl , da RCC gav tilladelse til at fortsætte rejsen. MISTRAL fik ikke nogen skader i forbindelse med kollisionen bortset fra nogle få afskrabninger på bagbord side. K. LARSEN Den følgende tekst i dette afsnit er baseret på Opklaringsenhedens interview af K. LARSEN s fiskeskipper i Strandby den 2. april K. LARSEN dagfiskede fra Hirtshals. Der var 2 fiskere om bord, begge med bevis som fiskeskipper af 3. grad. De sejlede fra Hirtshals den 28. marts kl. ca for at fiske hummere sømil nord for Hirtshals. De startede fiskeriet med dobbelt trawl kl. ca I løber af dagen gennemførte de 3 træk, og kl. ca satte de kurs mod Hirtshals. De styrede ca. 170 på selvstyreren, og farten var 5 5,5 knob. Det var fint og klart vejr med god sigtbarhed. Det var blevet mørkt kl. ca Der var to Furuno radarer i funktion. Den ene var helt ny og med ARPA og AIS. Den nye radar var indstillet på 3 sømils området, og den anden radar var indstillet på 1,5 sømils området. På dækket stod en radarmonitor, som var indstillet på 1,5 sømils området. I styrehuset var en VHF indstillet på kanal 16. VHF radioen kunne ikke høres på dækket. Begge fiskere arbejdede på dækket med at sortere og pakke hummerne. Fra dækket er der frit udsyn mod styrbord, og de kunne også se radarmonitoren. Fiskeskipperen gik ind i styrehuset hvert minut for at kontrollere navigationen og situationen i farvandet. Der var ingen trafik foran K. LARSEN. Fiskeskipperen observerede på radaren et andet skib foran for tværs om styrbord i en afstand af ca. 3 sømil. Fra AIS konstaterede han, at det var MISTRAL. Han fik også oplysninger om kurs og fart fra AIS, og han skønnede, at K. LARSEN ville passere agten om MISTRAL. Han gik derfor tilbage på dækket og fortsatte arbejdet med hummerne. 28

29 De så også MISTRAL visuelt. De hørte ingen lydsignaler og så ingen lyssignaler fra MISTRAL. Medens de to fiskere sorterede hummerfangsten, ramte K. LARSEN næsten frontalt og næsten vinkelret på MISTRAL s bagbord side. K. LARSEN gled ned langs den bagbord side af MISTRAL. De to fiskere blev væltet omkuld på dækket og fik adskillige knubs. Da K. LARSEN var kommet fri af MISTRAL, skyndte fiskeskipperen sig ind i styrehuset og kaldte et makkerskib på en VHF arbejdskanal. Makkerskibet satte kurs mod K. LARSEN og underrettede også dansk MRCC (SOK) om kollisionen. Om bord i K. LARSEN blev fiskerne klar over, at skibet havde fået skader i stævnen, og at det var slået læk. De konstaterede, at forlukafet var vandfyldt, og at der også var vand i lastrummet. Det var imidlertid muligt at holde vandstanden konstant med skibets pumpe. K. LARSEN sejlede selv i havn under følgeskab af et redningsfartøj. AIS Uddrag af Farvandsvæsenets AIS plot Ifølge AIS oplysningerne skete kollisionen kl i positionen 57 41,2 N ,3 Ø. 29

30 K. LARSEN er på uændret kurs 170 og med en fart af ca. 8 knob. MISTRAL styrer 057 med en fart af 9,2 knob og drejer til styrbord umiddelbart før kollisionen. Kommunikation på kanal 16 Ifølge LYRA s log over kanal 16 kommunikation kalder MISTRAL første gang K. LARSEN kl og adskillige flere gange indtil kl MISTRAL forsøger også at etablere forbindelse til K. LARSEN efter kollisionen. Kl kontaktes LYRA af et makkerskib, som ligger tæt på K. LARSEN, og bliver informeret om kollisionen. Analyse og konklusion K. LARSEN s fiskeskipper observerede MISTRAL på radaren, lidt om styrbord i en afstand af ca. 3 sømil, og kort efter så han MISTRAL visuelt. Baseret på AIS oplysningerne skønnede han, at K. LARSEN ville passere agten om MISTRAL, og han gik ud på dækket for at arbejde. Det næste der skete var, at K. LARSEN ramte MISTRAL på bagbord side. MISTRAL s skibsfører observerede K. LARSEN visuelt lidt om bagbord i en afstand af 2,2 sømil. Han fortsatte på uændret kurs og fart, medens han forsøgte at påkalde sig K. LARSEN s opmærksomhed ved at kalde det på VHF og ved brug af skibets fløjte og lys. Da K. LARSEN ikke reagerede, beordrede skibsføreren et styrbord drej lige før kollisionen. Begge skibe havde set hinanden minutter før kollisionen. K. LARSEN var vigepligtigt skib Regel 15 i de internationale søvejsregler. Fiskeskipperen skønnede ud fra AIS oplysningerne, at K. LARSEN ville passere agten om MISTRAL, og han holdt ikke MISTRAL under observation, og han gjorde heller ikke brug af radarens plottefaciliteter for at afgøre om der var fare for sammenstød Regel 7. Begge fiskere arbejdede på dækket med fangsten, hvilket forhindrede dem i at opretholde behørig udkig Regel 5. K. LARSEN opfyldt ikke sin pligt som det skib, der skal gå af vejen.. MISTRAL holdt kurs og fart, som det skib, der skal holde kurs og fart Regel 17(a) (i), og benyttede alle midler for at påkalde sig K. LARSEN s opmærksomhed Regel 34. Da dette ikke lykkedes, drejede MISTRAL til styrbord i sidste øjeblik før kollisionen Regel 17 (b). Adskillige minutter før kollisionen må det have stået klart for MISTRAL s skibsfører, at der var fare for sammenstød, og at K. LARSEN ikke så ud til at tage forholdsregler herimod. Alligevel iværksatte han ikke manøvrer på et tidligere tidspunkt for at undgå sammenstød Regel 17 (a) (ii). 30

31 Kollisionen skete, fordi begge K. LARSEN s to fiskere arbejdede på dækket og herved lod styrehuset ubemandet. K. LARSEN holdt ikke behørig udkig, hvorved det ikke var i stand til at opfylde sine forpligtelser som det skib, der skal gå af vejen. Kollisionen kunne højst sandsynligt have været undgået, hvis MISTRAL på et tidligere tidspunkt selv havde manøvreret. 11. maj 2007 Opklaringsenheden 31

32 Report from the Division for Investigation of Maritime Accidents Collision between Turkish cargo ship MISTRAL and Danish fishing vessel K. Larsen on 28 March 2007 Factual information MISTRAL, TCCH, IMO No , is a general cargo ship of 5469 GT and a LOA at 126m. It is built in year 2000 in Romania and flying the flag of Turkey. It is owned and operated by a shipping firm in Istanbul. K. LARSEN, FN 322, OWUW, is a fishing vessel of 66 GT and a LOA at 19.55m. It is built of wood in It is privately owned by the master. MISTRAL was sailing from Antwerp to Rostock. K.LARSEN had finished the fishing of the day and was sailing towards the home port. At 2149 (LT) K. LARSEN hid the port side of MISTRAL in position 57 41,2 N ,3 E. Narrative MISTRAL The following text in this section is based on a written report by the master of MISTRAL and a verbal statement from the master given to the Investigation Division in Rostock on 29 March MISTRAL sailed from Antwerp on 26 March at 1800 hours loaded with scrap iron for Rostock. There was a crew of 23, including the captain, the chief officer, the 2 nd officer and a deck cadet. A three shift bridge watch was divided between the captain, the CO and the 2 nd off. The captain took over the bridge watch from the CO at 2000 on the 28 March. Also on the bridge were the deck cadet and a helmsman. The wind was ENE about 3 beaufort, the sea state about 2 and the visibility moderate, 2 3 miles. Two radars were operated on the 6-mile range scale and there was also AIS. The speed was normal sea speed, 10.5 knots. At 2140 the captain observed K. LARSEN visually on the port bow at a distance of 2.2 miles. He could not detect the vessel by the radar but he got the information from the AIS. K.LARSEN showed a lot of deck lights but the captain did not observe any navigational lights. MISTRAL was steering 057 with a speed of 10 knots. 32

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