4/2006. Kvartalsvis Orientering. Quarterly Information Danish Division for Investigation of Maritime Accidents. Opklaringsenheden

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1 4/2006 Kvartalsvis Orientering Opklaringsenheden Quarterly Information Danish Division for Investigation of Maritime Accidents

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3 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

4 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 oke@dma.dk (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 oke@dma.dk hours a day Division for Investigation of Maritime Accidents Vermundsgade 38 C DK 2100 Copenhagen 3

5 Indholdsfortegnelse - Contents Resume af Søulykkesrapporter Summary of Marine Accident Reports MANU arbejdsulykke den 11. marts MINA occupational accident on 27 February Præsentation af temaundersøgelser sendt ud i 4. kvartal af 2006/ Presentation of safety studies issued 4 th quarter of 2006 Temaundersøgelse om skibbrudne fiskeres redning med redningsflåde hvor er kniven 8 Temaundersøgelse om fortøjningsulykker på handelsskibe 9 Safety study on problems with finding the life raft knife brief summary in English full study is only in Danish language Safety study on mooring accidents on board merchant ships Redegørelser Reports Occupational accident on board TOR PETUNIA on 11. July Arbejdsulykke om bord på HAVSKUM den 14. juli Fiskeskibet MICHELLE - kæntring den 31. august CROWN OF SCANDINAVIA kontakt med molehoved den 1. november Grounding of STAR ISMENE on 20 August Grounding of VELOS on 3 September KLEVSTRAND grundstødning den 22. september Statistiksager/Statistical files 41 4

6 Søulykkesrapporter 4. kvartal 2006 Marine Accident Reports 4 th quarter 2006 MANU Arbejdsulykke den 11. marts 2006 Resumé MANU var på fiskeri på Grønlands østkyst. Under en indhivning af trawlen viste det sig, at trawlwirerne havde krydset hinanden. Det var derfor nødvendigt at tage trawlskovlene på dækket for at udrede de tørnede trawlwirer. Bagbord trawlskovl blev hevet til bloks, og trawlbasen (den tilskadekomne) satte en sjækkel i skovlen og gilsonkrogen i sjæklen. Der blev firet lidt på trawlwiren og derefter hevet på gilsonwiren. I dette øjeblik sprang sjæklens bolt, og i samme øjeblik stak trawlbasen hovedet frem for at kontrollere, at gilsonkrogen sad, som den skulle. Boltstumpen ramte trawlbasen midt på den nederste kant af hans beskyttelseshjelm med en sådan kraft, at der blev slået hul i hjelmen, og trawlbasen fik kraniebrud. Trawlbasen, som hele tiden var ved bevidsthed, blev af besætningen behandlet på skibets hospital og blev efter kontakt med Radio Medical og med assistance fra Grønlands Kommando evakueret med helikopter til hospitalet i Godthåb. På tidspunktet for udsendelse af denne rapport er trawlbasen igen på fiskeri. Opklaringsenhedens fotografi af beskyttelseshjelmen Konklusion Ulykken skete fordi sjæklens bolt brast som følge af en bøjepåvirkning af bolten kombineret med, at trawlbasen trådte frem for at kontrollere, at gilsonwirens krog havde rigtig fat i sjæklen. 5

7 Ved at anbringe sjæklen i hullet i trawlskovlen blev den udsat for påvirkninger, som den ikke var beregnet for. Det er ikke muligt at fastslå, hvor stort et træk der var i sjæklen i brudøjeblikket, herunder om vejret og dermed skibets bevægelser har medført øget træk. Planlægningen af arbejdet med udredning af trawlwirerne var ikke tilstrækkelig præcis med hensyn til anvendelse af udstyr og fiskernes sikkerhed. En instruktion / procedure om arbejdsgangen i forbindelse med at bringe en trawlskovl på dækket, om det udstyr, som skulle anvendes hertil, samt om forholdsregler for fiskernes sikkerhed, kunne have bidraget til at undgå ulykken. Beskyttelseshjelmen reddede sandsynligvis trawlbasens liv MINA Occupational accident on 27 February 2006 Summary During the loading in Sandnes, Norway, of paper bales to the tween-deck by the ship s elevators, one paper bale, weighing about 500 kg, tipped off the elevator and fell approximately 4 meters to the deck, where it hit an ordinary seaman, OS, who passed by the elevator. The paper bale came at rest on top of the OS. The able seaman, AB, driving the forklift on the tween-deck removed the paper bale. An ambulance was called for, and the injured OS was brought to the local hospital. The OS had broken the pelvis, had injured his right shoulder and had internal bleedings. Picture by the harbour authority, taken shortly after the accident 6

8 Conclusion Although not verified by any eyewitness the most probable cause for the paper bale to tip over is that the land forklift has loaded the two bales on the elevator in a hard and distorted way with the result that the topmost bale fell to the deck. A slippery ramp due to snow and ice may have interfered the manoeuvring of the forklift. The work of loading was not planned and executed in a safe manner. The OS passed the area under the falling bale, because the work of loading was organized in such a way that he should both operate the elevators and remove empty pallets from the elevator. The Investigation Division is of the opinion that a clear marking on the deck of the danger area and also a written work place evaluation would have raised the attention of the crew to the risks of working close to the elevators. The lack hereof is underlying factors of the accident. The following observations indicate a low safety standard on board: The danger area around the elevator shaft on the tween-deck was not marked. The ship s SMS did not contain work place evaluation and working instructions for the operation of the elevators and cargo handling. 19 days after the accident it had not been discussed in the ship s Safety Board. There is a clear indication that the records of hours of rest are not recording the true picture of the rest periods. 19 days after the accident the injured OS had not been replaced. The OS did not wear a helmet. 7

9 Temaundersøgelser 4. kvartal 2006 Safety Studies 4 th quarter 2006 Temaundersøgelse om skibbrudne fiskeres redning med redningsflåde I perioden marts 1996 til maj 2006 har Opklaringsenheden behandlet 62 søulykker med fiskeskibe, hvor i alt 167 personer er blevet reddet ved brug af skibets redningsflåde. Ved fem af disse søulykker omkom i alt 7 personer. Søulykkerne er kollisioner, påsejlinger, grundstødninger, brande, lækager og stabilitetssvigt og kæntringer, der i de fleste tilfælde førte til skibets forlis. I nogle tilfælde er skibet ikke forlist, men situationen om bord har været så farlig, at de ombordværende var nødt til at forlade skibet. I 17 tilfælde havde de skibbrudne i redningsflåden problemer med at frigøre redningsflådens udløserline fra det synkende eller brændende skib, fordi man ikke kunne finde (eller i enkelte tilfælde få fat i) den kniv, der hører til redningsflåden, og som er beregnet til at skære udløserlinen fri med. Safety study on problems with finding the life raft knife The Division for Investigation of Maritime Accidents has carried out a safety study on the problems which a number of shipwrecked fishermen have experienced in the life raft, since they could not immediately find the knife that comes with the life raft for cutting the release cord and thereby release the raft from the ship. The study is based on reports and statements about accidents since The purpose of the study is to present factual information on the problem. The study is meant to provide information to people who work with life rafts, the life raft devices, education and training, especially for fishermen and seafarers, who are potential users of the life raft. The safety study is issued in Danish language only, but will be translated into English in near future. 8

10 Temaundersøgelse om fortøjningsulykker på handelsskibe På et fortøjningsdæk er der en latent risiko for ulykker, fordi der opereres med meget store kræfter, som ofte er vanskelige at kontrollere. Undersøgelsen viser, at besætningsmedlemmer oftest kommer til skade, når fortøjninger sprænger eller svirper. Det sker også, at besætningsmedlemmer bliver fanget i et spil. Langt de fleste ulykker sker i normale arbejdssituationer, hvor arbejdet foregår på sædvanlig vis. Kun sjældent er tekniske fejl eller dårligt vejr en medvirkende faktor. Undersøgelsen vil give Det Blå Danmark og internationale maritime institutioner et bedre faktuelt grundlag, når fortøjningsulykker er på dagsordenen. Undersøgelsen indeholder også resumeer og henvisninger til andre undersøgelser af fortøjningsulykker, der er foretaget af udenlandske havarikommissioner. Safety study on mooring accidents on board merchant ships based on 17 accidents There is a latent risk of accidents on a mooring deck, because strong forces are present and often difficult to control. The study shows that crewmembers are often injured because of broken or snatching moorings. Crewmembers are also caught in winches. Most of the accidents occurred in normal working situations, where the work was done in the usual way. Only rarely the accidents occurred because of technical defects or bad weather. It is the purpose of the safety study that it will provide the Blue Denmark and international maritime institutions with factual information, when mooring accidents are on the agenda. Therefore, the safety study also includes summaries and references to investigations of mooring accidents performed by investigation branches outside Denmark. The study is available in English language on 9

11 Redegørelser 4. kvartal 2006 Reports 4 th quarter 2006 Report from the Division for Investigation of Maritime Accidents Two crewmembers injured by burns 11 July 2006 Factual information A minor fire/deflagration occurred in a small space on the Danish flagged Ro-Ro cargo ship TOR PETUNIA of 32,289 GT when in dry-dock in Denmark. Two crewmembers, who were working in the area, suffered burns on their faces, hands and knees. Narrative Repair works had been carried out on electrical equipment in a small space of approx. 1.8 x 2.2 x 2.7 metre near the aft stern thruster. Some contact cleaner had been used, sprayed out from an aerosol can (approx. half of the content of a 500 ml can). The contact cleaner is extremely flammable, and the aerosol can was labelled with relevant symbol and text for that and with precautions etc. in 7 languages (see note). The space was ventilated naturally via the entrance approx. 0.7 x 1.5 m in top and an opening of 0.8 x 1.5 m in the bulkhead, 0.7 m above the bottom. Besides the repair work on the electrical equipment some welding was to be carried out in the same space. One hour later two crew members entered to prepare for the welding. A little earlier, they had smelled some vapours from the contact cleaner. But they did not smell anything when preparing for the welding. When one of the crewmembers was testing the welding equipment, an electric arc was made, and a deflagration occurred. The crewmembers were hit by flames. One crewmember suffered 1 st and 2 nd degree burns on his hands (6 7%), and the other crewmember suffered 1 st and 2 nd degree burns on his face and knees (6 7 %). The injured crewmembers were taken to the engine department s changing room, where they were given first aid, while there was called for ambulances to take them to hospital. 10

12 Analyse and conclusion Extremely flammable vapours from the contact cleaner had concentrated in the space because of insufficient ventilation. The space was not ventilated mechanically to evacuate the vapours. A welding arc ignited the vapours. Initiatives/recommendations Because the ship was dry-docked at a Danish shipyard, the Danish Working Environment Authority attended to this accident. The Danish Working Environment Authority enjoined on the master that the crewmembers had to be instructed in handling gasses to avoid accidents and that ventilation must be carried out when flammable liquids have been used. The accident was considered by the ship s safety committee at an extraordinary meeting. The safety committee enjoined the need of ventilating when agents that give off flammable vapours have been used. Note (extract from label text) Toxic to aquatic organisms, may cause long-term adverse effects in the aquatic environment. Repeated exposure may cause skin dryness or cracking. Vapours may cause drowsiness and dizziness. Keep out of the reach of children. Keep away from sources of ignition - No smoking. Do not breathe vapour/spray. Take precautionary measures against static discharges. Use only in well ventilated areas. Avoid release to the environment. Refer to special instructions/safety data sheet. Caution: Pressurized container: Protect from sunlight and do not expose to temperatures exceeding 50 C. Do not puncture or burn, even after use. Do not spray on a naked flame or any incandescent material. Especially for electronic components no deteriorating effect on synthetic materials, plastic and elastomers mild degreasing effect leaves no residue. Observe: Switch off power before use. Do not switch on power before the cleaner is completely evaporated. UN-nr November 2006 The Division for Investigation of Maritime Accidents 11

13 Redegørelse fra Opklaringsenheden Arbejdsulykker med spilkop på båden HAVSKUM, der anvendes til havbrug Snaptun Fisk Export A/S har en række både, der anvendes i forbindelse med drift af havbrug. På båden HAVSKUM skete der en arbejdsulykke den 14. juli 2006, hvor den ombordværende kom alvorligt til skade med den ene hånd ved arbejde med en spilkop. I forbindelse med undersøgelsen kom det frem, at der også et år tidligere den 20. juli 2005 var sket en ulykke med samme spilkop, hvor den ombordværende brækkede en arm. Sidstnævnte ulykke var ikke blevet anmeldt til Søfartsstyrelsen. HAVSKUM, er en Nystedjolle i glasfiber, kaldesignal OU Bygget BT 5,1. Længde over alt 9,58 meter. 12

14 Hændelsesforløb ved ulykken 14. juli 2006 HAVSKUM sejlede fra Snaptun den 14. juli 2006 om morgenen. Det var klart vejr med let VNV-lig vind. Bådføreren var alene om bord, hvilket er det normale, når der fodres og samles døde fisk. Efter fodringen skulle han trække dødesamlerne på nettene i havbruget op. Der var strøm, og båden måtte fortøjes ved hvert bur. Ved bur nr. 15 tog han tovet fra dødesamleren og startede spilkoppen, men fordi båden drev, kunne han ikke trække tovet om spilkoppen. Han lod tovet hænge på styrekloen til tovet. Og gik tilbage til styrehuset for at rette båden ind. Han gik derefter tilbage til spilkoppen og rakte ud efter tovet til dødesamleren. I det samme greb udfodringspiggen fat i hans overalls. Udfodringspiggen var stykke rundjern på 5-7 cm, som var svejst fast på toppen af spilkoppen. Hans overalls blev trukket rundt om spilkoppen, hvorved han selv blev trukket rundt og ud over siden. Da han førsøgte at få fat i afbryderhåndtaget blev hans hånd fanget af selerne til hans overalls og klemt på spilkoppen. Kort efter lykkedes det ham med stor vanskelighed at få fat i håndtaget og stoppet spilkoppen. Hans overalls var på dette tidspunkt flået helt af. Da han tog handsken af, kunne han se at hånden var meget medtaget. Han viklede en bluse om hånden og holdt den over hovedet, hvorefter han påbegyndte indsejlingen til havnen. Under hjemsejladsen ringede han til chefen på Snaptun Fisk Export A/S, og bad ham have en bil klar, når han kom i havn. 13

15 Andre oplysninger Spilkoppen kan ses på ovenstående foto, der blev taget efter ulykken. På dette foto er udfodringspiggen på toppen af spilkoppen fjernet, hvilket blev gjort kort efter ulykken. Start, stop og omløbsretning for hydraulik til spilkoppen blev betjent med ventiler, der sad ved styrehusdøren. Som det ses på fotoet, var der placeret en omløbshane under spilkoppen. Med denne omløbshane reguleredes hastigheden og spilkoppen kunne bringes til stop ved fuld åbning af hanen. Håndtaget på omløbshanen returnerede ikke automatisk til stop stilling, når det blev sluppet. Ifølge regler, som har været gældende siden 2001, skal betjeningshåndtaget automatisk returnere til neutral stilling, når det slippes. Efter den sidste ulykken den 14. juli 2006 holdt Søfartsstyrelsen syn på HAVSKUM og andre både, der anvendes af virksomheden. På HAVSKUM var der ikke VHF-radio eller godkendt medicinkiste. Der var ikke foretaget en arbejdspladsvurdering (APV). Der blev derfor bl.a. stillet krav om installation af VHF-DSC radio, udarbejdelse af APV og godkendt medicinkiste. Efter ulykken er omløbshanen ved spilkoppen blevet udskiftet med en hane, der har fjederbelastet håndtag, så spilkoppen stopper, når håndtaget ikke er påvirket. Håndtaget kan ved en anordning betjenes med foden, så begge hænder er fri under arbejdet. Snaptun Fisk Export A/S har efter ulykken kontaktet Fiskeriets Arbejdsmiljøråd for assistance til udarbejdelse af APV. Der er blevet udarbejdet en skriftlig instruktion, som er blevet ophængt i styrehuset. En bådfører på HAVSKUM skal være i besiddelse af certifikat til betjening af VHF-DSC radio og kursusbevis i anvendelse af den ombordværende medicinkiste. Bådføreren på ulykkestidspunktet var ikke i besiddelse af radiocertifikat eller kursusbevis til medicinkisten. Han var ansat gennem et vikarbureau den 24. april Han havde ikke erhvervsmæssig maritim erfaring, men er ejer af en fritidsbåd på 34 fod. Ved ansættelsen fik bådføreren instruktion i arbejdet, ved at en erfaren bådfører tog med ud på de første ture. Snaptun Fisk Export A/S har anvendt båden, siden den blev bygget i Fodringsarrangementet og udfodringspiggen blev installeret senere. Analyse og konklusion Bådførerens tøj blev fanget af spilkoppen, da han lænede sig ind over denne, fordi der var placeret en udfodringspig, som kørte med rundt, på toppen af spilkoppen. Bådføreren blev trukket med rundt, fordi spilkoppen ikke var indrettet på en sådan måde, at betjeningshåndtaget gik til neutral og spilkoppen stoppede, så snart håndtaget ikke var aktiveret. 14

16 En bagvedliggende faktor var, at der ikke var udarbejdet risikovurderinger (APV). En APV ville have øget opmærksomheden på risikoen ved arbejdet og ville have bidraget til en sikker planlægning af arbejdet. Dette forhold, samt at bådføreren ikke havde de nødvendige certifikater, at medicinkisten ikke var i orden, at der ikke var VHF radio om bord og at ulykken i 2005 ikke var blevet anmeldt, indikerer, at sikkerhedskulturen omkring driften af båden ikke har været tilstrækkelig god. 14. november 2006 Opklaringsenheden 15

17 Redegørelse fra Opklaringsenheden MICHELLE Kæntring den 31. august 2006 Faktuel information Michelle S20 af Skagen er en lille glasfiber trawlkutter på 2,4 BT og en længde på 6,9m. Den er bygget i Den 31. august, kl. ca , var MICHELLE, med fiskeskipperen alene om bord, på vej ind til Skagen efter endt fiskeri. Det blæste kraftigt fra vest. Pludselig lagde kutteren sig om på styrbord side og blev liggende. Fiskeskipperen fik kaldt hjælp over mobiltelefonen og han blev reddet. Kutteren blev slæbt til Skagen, hvor den kom på land. Fiskeskipperen har duelighedsbevis i sejlads, og han har fisket hele sit liv. Han erhvervede MICHELLE i juni 2005 og fik den ombygget i vinteren 2005 samt ustyret med nye spil og hydraulik. Kutterens stabilitet blev undersøgt, og dens stabilitetsdokumentation blev godkendt af Søfartsstyrelsen i februar

18 Hændelsesforløb MICHELLE afsejlede i godt vejr fra Skagen den 31. august kl. ca med fiskeskipperen alene om bord. Fiskeskipperen foretog 3 træk i Ålbæk Bugt i løbet af formiddagen og først på eftermiddagen. Herefter besluttede han at sejle i havn. Der var en fangst på kg fladfisk, som var placeret i en kurv i bagbord side sammen med kg is. Det var blæst op, og der var nu en vestlig kuling op til m/sek. og ca. 1m høj sø. MICHELLE sejlede med vind og sø agten for tværs om bagbord, ca. 600m fra land. På vejen ind opstod problemer med køling af motoren, hvilket vanskeliggjorde styringen. Kl. ca begyndte MICHELLE at krænge til styrbord. Fiskeskipperen forsøgte at dreje kutteren styrbord over for at få vinden agten ind eller så langt over, at vinden kom ind om styrbord. Det lykkedes ikke, hvorefter fiskeskipperen satte skruen i neutral. Kutteren lagde sig nu med vinden ind tværs om bagbord og krængede mere og mere til styrbord, indtil den lå helt på siden. Det lykkedes fiskeskipperen at komme ud af styrehuset og kravle ud på skroget. Da han kom ud af styrehuset var den styrbords lønning under vand Siddende på skroget ringede han til sin broder via mobiltelefon. Broderen alarmerede redningsstationen, og fiskeskipperen blev reddet ca. 30 minutter senere. Han havde ikke nået at få sig iført redningsvest, men han havde flåden klar til brug. Efter hændelsen er konstateret, at der i styrbord side, på for- og agterkant af manøvrepulten på dækket, er nogle åbninger oppe under lønningsprofilet, som bruges til kabelgennemføringer. Hul under lønningskanten til brug for kabelføringer 17

19 Analyse og konklusion Vinden var tiltaget kraftigt og den begyndende krængning skyldes sandsynligvis kutterens store vindfang med oversejl og støttesejl. Ifølge skipperen kom lønningen under vand og skibet blev tungere i sine bevægelser. Med lønningen under vand, har der kunne løbe vand ned i maskinrummet gennem de ovenfor nævnte huller under lønningskanten. Vand i skibet har skabt fri overfladeeffekt og har forringet stabiliteten med det resultat, at kutteren lagde sig på siden. Manøvreproblemerne på grund af manglende kølevand kan have bidraget til, at fiskeskipperen ikke kunne rette skibet op. 23. november 2006 Opklaringsenheden 18

20 Redegørelse fra Opklaringsenheden CROWN OF SCANDINAVIA s kontakt med molehoved den 1. november 2006 Faktuel information CROWN OF SCANDINAVIA (COS), OXRA6, IMO Nr , er et ro/ro passagerskib på BT og en længde på 189,4m. Det er godkendt til at sejle med 2139 passagerer. Under en orkanagtig storm ved skibets rutinemæssige anløb af København den 1. november om morgenen, blev skibet af vinden presset mod Langliniekajens molehoved. Skibet fik en ca. 2,5m revne i styrbord side ca. 1,8m over vandlinien. Skibsføreren valgte at sejle ud af havnen igen og at afvente vindens aftagen. Kl. ca sejlede COS igen ind i havnen og lagde til på sin normale plads uden problemer. Uddrag af Farvandsvæsenets AIS plot 19

21 Hændelsesforløb COS afsejlede som normalt fra Oslo den 31/10 kl Ved afsejlingen var der en nordlig vind ca. 14 m/sek. Der var 760 passagerer, 156 besætningsmedlemmer og 2 reparatører om bord, i alt 918 personer (indført i skibsdagbogen). På vejen mod København, som foregik planmæssigt, øgedes vinden. Skibsføreren kom op i styrehuset kl. ca ud for Kullen. Overstyrmanden havde vagt fra kl til ankomst sammen med en udkig. På vejen syd over i Sundet blæste det til m/sek. fra N NØ. De kontaktede Kbh. havn for at få oplysninger om vindsituationen i havnen. Fra havnen oplystes på intet tidspunkt vindstyrker over 20 m/sek. Skibsføreren fandt det fuldt forsvarligt at gå i havn i betragtning af skibets manøvremuligheder i forhold til vindsituationen. Før indsejling i havnen blev passagererne oplyst om den snarlige ankomst som normalt. Skibsføreren overtog kommandoen inden havnehullet. Overstyrmanden håndstyrede fra centerpulten. På agterdækket var en styrmand og 2 skibsassistenter klar og på bakken bådsmanden og 2 skibsassistenter. De gjorde også luftpistol til kasteline klar. Der er VHF kontakt mellem styrehus, agterdæk og bak. Havnehullet blev passeret lidt tidligere end normalt. Skibsføreren gik ud til manøvrepulten i styrbord brovinge og overtog manøvreringen. Overstyrmanden stod også i styrbord brovinge og holdt øje med molerne og gav oplysninger til skibsføreren. Efter passage af molerne blev et bagbord drej påbegyndt, og manøvren blev afsluttet, således at COS lå længere nordvest i bassinet end normalt for at opnå ekstra højde for vinden under bakmanøvren mod terminalen. Kl. ca tiltog vinden til mellem 22-24m/sek. Ved hjælp af forceret kraft på maskinerne samt bovpropellerne, blev kurs og fart holdt agterover. Umiddelbart efter øgedes vinden til 30-32m/sek, fra nordvest. COS blev af vinden presset over mod Langliniekajen og skibsføreren blev klar over, at han ikke kunne holde skibet og ikke nå at dreje fri af molehovedet. Han koncentrerede sig om at stoppe skibet, så det lå stoppet i kontaktøjeblikket. Skibsføreren fik stoppet skibets drift agterover, og da skibet med styrbord side ramte molehovedet, lå det stille og selve kontakten virkede ikke særlig hård, nærmest som et hårdt lejeanløb. Kort efter flovede vinden, og skibsføreren kunne se, at han kunne vride skibet fri af molehovedet. Han besluttede at sejle ud af havnen igen for at afvente, at vin- 20

22 den lagde sig. Han afviste muligheden for at lægge til ved Langeliniekajen i denne vind og uden trossehold på kajen. COS sejlede igen ud af havnen ca. 5 minutter efter kontakten. Så snart skibet var ude af havnen blev der checket for skader. Fra maskinen blev hurtigt meldt tilbage, at der ikke var konstateret noget unormalt. Overstyrmanden meldte til broen, at der var en revne i skroget ca. 2m over vandlinien mellem spant 143 og spant 145, og at der skvættede vand ind gennem revnen. Der var vand på dørken på dæk 2, som er besætningskamre. Skibsføreren besluttede, at der skulle lukkes vandtæt (lokalt) på dæk 2. Der blev stoppet værk mm. i revnen, og det stoppede vandet. Det indkomne vand blev suget op med en vandstøvsuger. De vandtætte døre blev igen åbnet. Passagererne blev underrettet om, at de var sejlet ud på grund af det dårlige vejr, og at de ville holde gående udenfor havnen, indtil vejrsituationen bedredes. Der var på intet tidspunkt uro blandt passagererne, som blev holdt løbende underrettet om vejrsituationen. Skibsføreren bedømte situationen for at være helt udramatisk uden nogen risiko for passagererne eller skibet. Skibet var fuldt manøvredygtigt, revnen var ca. 2m over vandlinien, og den var stoppet, og de kunne drive / sejle rundt i roligt vand, indtil vinden flovede. Han valgte i denne situation, at undlade at underrette passagererne om revnen i skibet og den mindre vandindtrængen. Han mente, at der kunne opstå en unødvendig ængstelse blandt passagererne, hvis han meldte dette ud. Skibsføreren var på broen det meste af dagen. De lå og holdt gående mellem Ven og Kbh. havn. Der var konstant 2 mand på vagt ved revnen, og vandstøvsuger var klar. Skibsføreren havde også løbende kontakt med DMI om vejrsituationen. Kl. ca ringede havnen og oplyste, at vinden i havnen var mellem 11 og 12 m/sek., så skibsføreren besluttede at sejle mod havnen igen. Det begyndte imidlertid igen at blæse op, fra havnen oplystes nu m/sek., så skibsføreren besluttede at vente lidt endnu. Kl. ca blæste det ca. 20 m/sek. i Sundet og ifølge havnen ca m/sek. i havnen. De 2 sidste hovedmotorer blev startet, og COS sejlede mod havnen. Herunder kom der igen bølgeskvæt gennem revnen og vand på dæk 2. Vandet blev suget op. 21

23 Kl var skibet lagt til kaj uden problemer. Så snart skibet, efter kontakten med molehovedet, var kommet ud af havnen, blev rederiet underrettet, og maskinchefen sørgede for at klassen (DNV) blev underrettet. Klassen kom om bord sammen med rederiinspektøren umiddelbart efter ankomsten. Skibsføreren havde på intet tidspunkt overvejet at underrette SOK, da han vurderede, at situationen ikke var alvorlig. Skibsføreren glemte at underrette Opklaringsenheden om kontakten med molehovedet og den skete skade. Analyse og konklusion COS s maskinkraft var for lille til at modstå det tværskibs vindpres, da vinden pludselig øgedes til m/sek. under skibets manøvre mod terminalen. Skibet ramte derfor molehovedet. Skibsføreren bedømte skaden som lille og uden betydning for passagerer og skibs sikkerhed under de pågældende omstændigheder. Skaden var ca. 1,8m over vandlinien, og den var begrænset til ét rum, som kunne lukkes vandtæt. Der var lukket vandtæt i et kort tidsrum, indtil revnen var blevet stoppet midlertidig. Med hensyn til lækstabilitet er COS er et såkaldt 2-rums skib. Det vil sige, at skibet kan flyde med 2 rum fyldt med vand. Det er Opklaringsenhedens vurdering, at skibets sikkerhed på intet tidspunkt var i fare efter kontakten med molehovedet. Opklaringsenheden har ikke bemærkninger til skibsførerens beslutning om at sejle ud og afvente anløb, indtil vejret blev bedre. Skibsføreren/rederiet burde have underrettet Opklaringsenheden snarest muligt efter kontakten med molehovedet. 29. november 2006 Opklaringsenheden 22

24 Report from the Division for Investigation of Maritime Accidents The Grounding of STAR ISMENE 20 August 2006 Factual information STAR ISMENE, IMO No is a General Cargo Ship of 32,628 GT, built in 1999, owned by the Norwegian company Grieg Billabong AS and registered in Norway. The ship was manned with a crew of 21, all Filipino citizens. Normal watch schedule for the deck officers on board was: Ch off: and nd off: and rd off: and The master, the 2 nd officer and the 3 rd officer were on the bridge at the time of the grounding. The master, age 50, had been on board STAR ISMENE for 1 month and 17 days. It was his first time on board. He has been employed by the company since 1987 and he has been in sister ships to STAR ISMENE since This was his 3 rd contract as master. The master has not been to the Port of Aarhus before. The 2nd officer, age 52, signed on 7 December It was his first time on board this ship. He started in the company in 1998 as officer. He has been to the Port of Aarhus once before in The 3rd officer, age 35, signed on 14 May It was his first time on board. The 3 rd officer has been in the company for 6 years. It was his first time as officer. The 3 rd officer has not been in Aarhus before. 23

25 Narrative The following text in this section is based on verbal statements from the master, the 2 nd officer and the 3 rd officer given to the Investigation Division on 21 August STAR ISMENE departed Antwerp almost fully loaded on 18 August 2006 on a voyage to Aarhus, Denmark for loading the remaining cargo to be discharged in ports on the west coast of The USA. The cargo consisted of fertilizer and malt in bulk, steel plats, steel coils, steel pipes, break bulk cargo and containers - a total of 32,257.3 MT. The maximum draught was 10.3 m upon departure from Antwerp. The master had been on the bridge since the departure. He had been resting in a bed situated at the back of the bridge area. In the morning of 20 August, when the 3 rd officer took over the watch at 0800 hours, the master was also present on the bridge. The master took over the command of the bridge at about 1000 hours which he informed the 3 rd officer. At about 1130 hours the master called Aarhus Pilot Station and he was informed to be at the pilot station at 1600 hours. This was later than expected, and the master reduced the speed from approx. 15 knots to 13.5 knots. (RPM from 96 to 80) The master was comfortable with the traffic situation. Apart from some pleasure crafts there were no ships in the vicinity of own ship. The 3 rd officer was taking positions regularly from the GPS and was also checking the ship s position by means of the radar. In addition to the traditional paper charts there was an electronic chart display available in the front of the bridge near the coning position. The wind was south-easterly force 5 and the sea state was 4. The visibility was good more than 5 NM. The 2 nd officer came to the bridge at 1202 hours. The 3 rd officer told him that the master was in command. The ship was steered by hand, and there had been change of helmsman at approx hours. The gyro course was 270º and the ground speed was about 12 knots. 24

26 The 3 rd officer had inserted the ship s position in BA chart 2589 at 1200 hours and was on the request from the master also inserting a position in the chart at 1205 hours. After that time the 2 nd officer relieved the 3 rd officer on the bridge. The 2 nd officer assisted the master and checked the ship s positions. The 2 nd officer saw that the course was changed slightly to the south (to port) after 1205 hours due to a small vessel on starboard side and then altered back to 270º. The master gave the orders to the helmsman. Shortly before 1215 hours both the master and the 2 nd officer felt a vibration in the ship. The 2 nd officer thought this was due to the increase of the speed, which was made by the master at that time. The vessel listed slightly to starboard and the speed went down to about 10 knots. The speed picked up again and the vessel continued on gyro course 270º. The 2 nd officer inserted a position in BA chart 2589 at 1215 hours. The position was north of the course line in the chart enclosure figure 4. At the time of the ground contact the master was talking with the pilot station on the VHF. The 2 nd officer was in the front of the bridge, and the 3 rd officer, who was still on the bridge, was making the final logbook entries. A few minutes after the vibration the vessel started to list to port side. The master told the chief officer to check all ballast tanks. Ballast tank DB # 1 port side was taking in water. The forepeak tank had run almost full. The ship continued and was at the pilot station at 1342 hours. The pilot was on board at 1345 hours. The vessel was alongside in the Port of Aarhus at 1500 hours (all fast) The agent was on board at 1520 hours. The master discussed the situation with the agent, who arranged for divers. Voyage plan and chart information It is the 2 nd officer on board who is in charge of the voyage plan and the chart corrections. The 2 nd officer had inserted the waypoints from the voyage plan - first in the paper charts and then into the Electronic Chart Display. The voyage plan form, which is the checklist, and the voyage plan, had been completed and approved by the master prior to the departure from Antwerp. According to the voyage plan form, all charts prepared for the voyage had been corrected, and expected under-keel clearances in shallow water areas had been 25

27 checked and noted in the charts. The expected draught of the ship was according to the voyage plan form: Fwd: m Aft: m. According to the chart, STAR ISMENE passed an extraction area. All depths of 12.5 m or less were carefully marked on BA chart 2589 see enclosure figure 4. In the chart there is a reference to a note: Depths in areas are unreliable due to the extraction of raw materials. Depth reductions must be expected. Consequences of the ground contact STAR ISMENE returned to Antwerp for discharging of approx. 20,000 MT of the cargo and was then dry-docked in Hamburg for repairs. Conclusion The grounding occurred because STAR ISMENE did not follow the planned route. The information about the ship s draught compared with the information of depths in the area where the grounding occurred has shown that the passage was not safely planned. The planned route should have been either north of or south of Marthe Flak as marked on the chart by cardinal buoys. 5 December 2006 The Division for Investigation of Maritime Accidents 26

28 Enclosures Scene of the incident Figure 1: Extract of the sea area - scale 1:

29 AIS information Extract of AIS plots from the Royal Danish Administration of Navigation and Hydrography s display system. The red lines show STAR ISMENE s movements over ground. Figure 2: The AIS extract above shows the ship s position at 1205 local time. According to the AIS, the ground speed is 13.5 knots. The ship s position is 56º N - 010º55.229` E. Figure 3: The AIS extract below shows the ship s position at 1215 local time. According to the AIS the ground speed is 9.9 knots. The ship s position is 56º N - 010º51.478` E. 28

30 Chart information Figure 4: Digital picture taken on board 21 August -Extract of BA chart 2589 showing the ship s position at 1200, 1205 inserted by the 3 rd officer and at 1215 hours inserted by the 2 nd officer. Figure 5: Digital picture taken on board 21 August Electronic Chart Display showing the ship s track (blue line) and the ship s planned route (red line) 29

31 Report from the Division for Investigation of Maritime Accidents The Grounding of VELOS 3 September 2006 Factual information VELOS, IMO No is a bulk carrier of 36,458 GT, built in 1991, owned by a Greek company and registered in Cyprus. VELOS departed Ventspils, Latvia around midnight on 31 August 2006 on a voyage to China with a full load of MT of Muriate of Potash. The maximum draught was 13.16m. The ship was manned with a crew of 25 of mixed nationality. The master was Greek citizen and the chief officer was Romanian citizen, both experienced sailors and long time service as master and chief officer respectively. After an uneventful passage through the Danish waters, VELOS passed the Skaw on the 3 September at 0300 hours local time and continued on a south westerly course in the North Sea. At approximately 0635 hours, according to AIS information, VELOS hid the ground at a speed of approx. 11 knots in position N E without being stuck. After a few minutes it became clear that the ship was damaged in the bottom with several leakages in port ballast tanks. VELOS was anchored at 0725 hours. On 4 September VELOS was escorted to a safe anchorage off the Skaw for divers survey On 7 September VELOS left the anchorage and was escorted to Aabenraa, Denmark, where the entire cargo was discharged. On 18 September VELOS was escorted to Gothenburg, Sweden, for dry-docking and repairs. Narrative The following text in this section is based on verbal statements from the master and the chief officer given to the Investigation Division on 5 September The vessel left Ventspils, Latvia on 31 August and commenced the sea passage on 1 September at 0030 hours on a voyage to China via the Suez Canal. 30

32 The maximum draught upon the time of departure was m (in seawater) The cargo was 63, MT of Muriate of Potash in bulk. VELOS had pilot on board in the Great Belt on 2 September from 0915 to 1252 hours. On the 3 September the master left the bridge after the ship had passed the Skaw at 0300 hours. The port side ARPA radar was on. The chief officer relieved the 2 nd officer on the bridge at 0400 hours. There was an AB on the bridge as lookout. The wind was coming from SW, force 5-6. The visibility was good. There were two vessels oncoming on a north-easterly course on approx. opposite course. Own ships gyro course was 247º. The ground speed was 11.5 knots. After having taken over the watch, the chief officer altered the gyro course to 238º at about 0430 hours. He chose to alter course before having reached the waypoint due to the oncoming traffic. Another ship was closing in on starboard bow. This ship was seen on the AIS receiver for the first time at about 0400 hours, and the chief officer had observed the ship since then on the radar. The ship was sailing in the same direction as VELOS. At about 0600 hours the chief officer decided to overtake the other vessel on its port side and he altered the course a little to port. At approx 0630 the chief officer felt a vibration. After less than 5 minutes, the ship started to list to port. The chief officer sent the AB to notify the master. The positions had been inserted in the chart every 15 minutes. The last position before the ship had ground contact was at 0615 hours. A few minutes before the ground contact occurred, the AB went down for a few minutes to call some crewmembers, and he was not on the bridge when the vessel was in contact with the ground. The ship was on automatic steering and was steering very well. There had not been any technical problems during the chief officer s watch. 31

33 The master, who was sleeping, felt the vibration shortly before the AB came down to his bedroom to tell him that something was wrong. At first the master thought that there had been a collision When the master came to the bridge, the ship had already started to list to port and he saw seawater coming from the air vents to the DB tanks No 1, 2 and 3 and later No 4 in port side. The master stopped the vessel and sounded general alarm. A few minutes later he called MAYDAY to Lyngby Radio. According to the master, it turned out that there was not any danger to the ship and the master decided to drop the anchor, which was done at 0725 hours local time on position: 57º N 010º E. A sounding of the DB tanks and the forepeak tank confirmed that the tanks had run full, and that there also was a leakage to BD No 5. The ship was listing about 4 deg. to port. The master do not remember the exact time when he felt the vibration but after having time to look into the charts he is in the opinion that the ship had contact with the ground between 0630 and 0640 hours. The master contacted the Danish Admiral Fleet and the Marine Assistance who coordinated the assistance to ship. Voyage plan, chart and AIS information The navigation was done by traditional paper charts. The 2 nd officer, who is in charge of the correction of charts and voyage planning, had prepared and completed the voyage plan and the plan had been approved by the master prior to the departure from Ventspils. According to the voyage plan, all charts prepared for the voyage had been corrected. The expected draught of the ship was according to the voyage plan: Fwd: 13.10m Aft: m. According to the passage plan and the chart information, the planned leg from waypoint (#42) North West of Hirtshals to waypoint (#43) West of Hanstholm is passing trough an area which is bounded by a 20 meter curve. Within the area depths of 14 and 15 meter are indicated the area is shown on figure 3 to the left of the red arrow. In BA chart 1402, which was the chart in use at the time of the ground contact, the waypoints and courses for this voyage was inserted. The chart also contained information, waypoints and courses, from a previous voyage, the course line passes close by the sea area where the ground contact occurred see enclosure 32

34 figure 3 and 4. On the previous voyage the ship was in ballast and had a draught of approx. 10 m. The positions inserted on the chart shows that the ship deviated from the planned route. According to the charts the ground contact was 2.7 NM southeast of the planned route see enclosure figure 4. The position where the ship had ground contact was marked with WK as wreck and with a clearance of 13 meters. According to the AIS information the ship passed the area with the WK mark at approx hours local time. The position of the WK mark is 57º 30 N - 009º30 E. Analyses and conclusion According to the used chart it was planned to pass trough a relatively large area which is bounded by a 20 meter curve. Within this area depths of 14 and 15 meter are indicated. When comparing the information about depths in the chart with the information of the ship s draught, speed and route planning from WP 42 off Hirtshals southwest to WP 43, it is the opinion of the Investigation Division that the passage plan was not properly planned appropriate to the overall conditions when navigating in open sea. At the time of the grounding the vessel was sailing on a parallel course approximately 2.7 NM from the planned route. The OOW chose to alter course to port due to oncoming traffic about two hours before the grounding. The ship was not brought back to the planned route and was therefore passing closer to the shore. According to the OOW he altered the course further to port about half an hour before the grounding occurred in order to overtake a ship which was ahead of VELOS. The used chart contained course information and waypoints from a previous voyage in ballast which was not relevant for the present voyage. It is the opinion of the Investigation Division that this could have created an unnecessary confusion as to where the ship could navigate safely. It is likely that the course line from the previous voyage, which was passing close to the WK mark, had an influence on the chief officer s alertness. 33

35 Hydrographic survey initiated after the grounding The Royal Danish Administration of Navigation and Hydrography, who was informed about the findings from the diving survey which indicated that VELOS had been in contact with solid ground, decided to make a hydrographic survey of the area. The result of the survey has not been completed by the issuing of this report. 5 December 2006 The Division for Investigation of Maritime Accidents Enclosures Scene of the incident Figure 1: Extract of the sea area - scale 1:

36 AIS information Extract of AIS plots from the Royal Danish Administration of Navigation and Hydrography s display system. The red line shows VELOS movements over ground. Figure 2: The AIS extract above shows the ship s position at12:35:28 local time. According to the AIS the ground speed is 10.9 knots. The ship s position is 57º 30.1 N - 009º30.0` E. 35

37 Chart information Figure 3: Digital picture taken on board on 5 September - Extract of BA chart 1402 showing two routes the lower route is from a previous voyage to Aarhus in ballast. The lower route passes just south of the WK mark see red arrows. The upper route is the one planned for this voyage. Figure 4: Close up of the above chart extract. Positions at 0545, 0600 and 0615 inserted by the chief officer indicates the thru direction of VELOS and that it is leading towards the WK mark. The measured distance between the planed route (the upper line) and line of positions (the blue arrow) is approximately 2.7 NM 36

38 Redegørelse fra Opklaringsenheden KLEVSTRAND s grundstødning den 22. september 2006 Faktuel information Den 22. september 2006, kl grundstødte KLEVSTRAND på klipperne Skåre-Trebåen lidt nord for Haugesund i Norge. KLEVSTRAND var på rejse fra Kambo I Oslo Fjorden til Vaksdal, nord for Bergen med en last på 854 ton gødning. AIS fra Kystverket i Norge KLEVSTRAND, OWFM6, IMO nr , er et palleskib på 1194 BT og en længde på 71m. Det er bygget i 1970 og er hjemhørende i Nørresundby. Hændelsesforløb Nedenstående beskrivelse af hændelsesforløbet er baseret på Opklaringsenhedens interview af skibsføreren og styrmanden den 27. september om bord under skibets ophold i Esbjerg og på materiale modtaget fra Sjøfartsdirektoratet i Norge samt fra politiet i Haugesund. KLEVSTRAND afsejlede fra Kambo i Oslofjorden den 20. september kl mod Vaksdal, nord for Bergen, med en last på 854 tons gødning. Ballasttankene var tomme, og dybgangen for var 3.30m og agter 3,45m. KLEVSTRAND er udstyret med 2 radarer og elektronisk søkort system, hvori ruteplanen var indlagt fra en tidligere rejse. Desuden er skibet udstyret med en 37