REPUBLIC OF CYPRUS MARINE ACCIDENT AND INCIDENT … · 2020. 6. 19. · to cease the Search and...

REPUBLIC OF CYPRUS

MARINE ACCIDENT AND INCIDENT

INVESTIGATION COMMITTEE

Investigation Report No: 64 Ε / 2019

Very Serious Marine Casualty

Crew Member Disappearance from the M/V “UNITY” on

29/04/2019 off the Western Coast of Philippines

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© Marine Accident and Incident Investigation Committee

Foreword

The sole objective of the safety investigation under the Marine Accidents and Incidents

Investigation Law N. 94 (I)/2012, in investigating an accident, is to determine its causes and

circumstances, with the aim of improving the safety of life at sea and the avoidance of accidents

in the future.

It is not the purpose to apportion blame or liability.

Under Section 17-(2) of the Law N. 94 (I)/2012 a person is required to provide witness to

investigators truthfully. If the contents of this statement were subsequently submitted as evidence

in court proceedings, then this would contradict the principle that a person cannot be required to

give evidence against themselves.

Therefore, the Marine Accidents and Incidents Investigation Committee, makes this report

available to interested parties, on the strict understanding that, it will not be used in any court

proceedings anywhere in the world.

This investigation was not carried out as a joint investigation.

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Table of Contents

FOREWORD ............................................................................................................................................ II

TABLE OF CONTENTS ........................................................................................................................ III

LIST OF ACRONYMS AND ABBREVIATIONS ............................................................................... IV

1. SUMMARY ............................................................................................................................................ 1

2. FACTUAL INFORMATION................................................................................................................ 2

Ship Particulars .................................................................................................................................. 2 Voyage Particulars.............................................................................................................................. 3 Marine Casualty or Incident Information ........................................................................................... 3 Shore authority involvement and emergency response ....................................................................... 3

3. NARRATIVE ......................................................................................................................................... 5

3.1 SEQUENCE OF EVENTS ......................................................................................................................................... 5

4. ANALYSIS ............................................................................................................................................. 8

4.1 THE SHIP ............................................................................................................................................................. 8 4.1.1 Ship’s Certificates and Surveys .................................................................................................. 8 4.1.2 Ship’s Navigational & Radio Equipment ................................................................................... 8 4.1.3 Passage Plan Analysis ............................................................................................................... 9 4.1.4 Ship’s Condition ....................................................................................................................... 10 4.1.5 The condition of the “A” or Boat deck ..................................................................................... 12 4.1.6 Cargo related factors ............................................................................................................... 13 4.1.7 CCTV – S-VDR ......................................................................................................................... 14

4.2 THE CREW ......................................................................................................................................................... 14 4.2.1 Certification ............................................................................................................................. 14 4.2.2 O/S 1’s Medical Certificate ...................................................................................................... 15 4.2.3 Fatigue ..................................................................................................................................... 15 4.2.4 Working and Living Conditions ............................................................................................... 15 4.2.5 Training .................................................................................................................................... 16 4.2.6 Physiological, Psychological, Psychosocial Condition ........................................................... 16

4.3 THE ENVIRONMENT ................................................................................................................................... 19 External environment: ....................................................................................................................... 19 Internal Environment: ....................................................................................................................... 19

5. CONCLUSIONS .................................................................................................................................. 20

6. RECOMMENDATIONS ..................................................................................................................... 20

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List of Acronyms and Abbreviations

A/B Able Seaman

BAC Blood Alcohol Content

C/E Chief Engineer

C/O Chief Officer

CoC Certificate of Competency

GA General Alarm

CPR Cardio-Pulmonary-Resuscitation

DPA Designated Person Ashore

HSSE Health, Safety, Security and Environment

ISM Code International Management Code for the Safe Operation of Ships

Knots Speed in nautical miles per hour

Lat. Latitude

Long. Longitude

LT Local Time

m Meter

MC Management Company

MT Metric Ton

NM Nautical Mile

O/S Ordinary Seaman

PSN Position

RCC Rescue Coordination Centre

RPM Revolutions per Minute

SAR Search and Rescue operation

2/O Second Officer

SMC ISM Safety Management Certificate

SMM Safety Management Manual

SMS Safety Management System

SOLAS Safety of Life At Sea Convention

STCW95 International Convention on Standards of Training, Certification and Watch

keeping for Seafarers 1978, as amended

S-VDR Simplified -Voyage Data Recorder

VTS Vessel Traffic Services

UTC Universal Time Coordinated

VHF Very High Frequency Radio

ZT Zone Time

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1. Summary

In conducting its investigation, the Marine Accident Investigation Committee (MAIC), reviewed the

events surrounding the incident, documents provided by the Managers of the vessel messrs.

ANGELAKOS (HELLAS) S.A. and performed an analysis to determine the causal factors that

contributed to the incident, including any management system deficiencies.

Incident Description

The “UNITY” is a Cyprus flagged, 2001 built, bulk carrier managed by ANGELAKOS (HELLAS)

S.A.

This investigation examines the circumstances under which an Ordinary Seaman (from now on stated

as O/S 1) disappeared while the ship was en route from the port of Esperance, Australia to the ports of

Huangpu and Ningbo, P.R. China via Hong Kong for bunkering. The position of the ship when the

crew members realized that the O/S was missing was Lat: 18º15.2’N - Long: 117º23.9’E while the

vessel was sailing west of the coast of Philippines northbound to Hong Kong for bunkering.

At the moment it was realized that O/S 1 was missing, the crew searched thoroughly the ship without

any success. At the same time the Master gave command for the ship to change course and commence

a Search and Rescue operation. After a fruitless search mission for 38 hours the vessel received orders

to cease the Search and Rescue operation and resume her original course.

The body of O/S 1 was never found and he is presumed disappeared.

Conclusion(s)

There were no witnesses to the disappearance of the crew member. On the other hand, there are

indications that the crew member may have fallen overboard from the embarkation station of the

starboard side Boat deck.

Evidence gathered during the investigation:

1. His slippers were found on the “B” deck just outside the weathertight door and next to the ladder

leading to the “A” (Boat) deck below.

2. His footprints were found and photographed on the “A” (Boat) deck floor on the lifeboat embarkation

station, which were leading to overboard.

From statements of the other crew members it is referred that O/S 1 told A/B 1 twice that he “would

not go with him anymore to the next port”. O/S 3 also heard O/S 1 telling these words to A/B 1. In

addition, O/S 1 hugged during the dinner time at least three different crew members, an act which was

considered highly unusual for him.

Therefore, it is considered that in the absence of maritime safety related evidence, the O/S 1

disappearance is not related to maritime safety.

Recommendations

There are not any recommendations.

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2. Factual Information

Ship’s Name: UNITY

Figure 1: The UNITY (ex- Gallia Graeca)

Ship Particulars

Name of ship: UNITY (ex- Gallia Graeca)

IMO number: 9221607

Call sign: P3BZ9

MMSI number: 209159000

Flag State: Cyprus

Classification Society: LLOYDS REGISTER OF SHIPPING

Type of ship: Bulk carrier (Panamax)

Gross tonnage: 39,035 T

Length overall: 224.89 m

Breadth overall: 32.20 m

Registered ship owner: APERTIVO SHIPPING COMPANY LIMITED, CYPRUS

Ship’s company: ANGELAKOS (HELLAS) S.A.

Year of build: 2001

Deadweight: 74,133 t

Hull material: Steel

Hull construction: Double Hull

Propulsion type: ICE - B&W 7S50MC-C

Type of bunkers: HS HFO/LS MGO

Number of crew on ship’s certificate: 14

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Voyage Particulars

Port of departure: Esperance, Australia

Port of call: Hong Kong for bunkering, then Huangpu and Ningbo, P.R. China for discharging

Type of voyage: International

Cargo information: 62,365.19 MT of barley in bulk

Manning: 20 crew members

Number of passengers: NIL

Marine Casualty or Incident Information

Type of marine casualty/incident: Very Serious Marine Casualty

Date/Time: Between 28/04/2019 23:30 and 29/04/2019 06:00 LT

Location: Man overboard / most probably from the stbd boat deck

Position (Latitude/Longitude): Between: Lat 16º54.7’N Long 118º10.5’E and Lat

18º11.7’N Long 117º26.1’E (South China Sea, West

coast of Philippines)

External and Internal Environment: Air Temp: 33C, Sea Temp: 30C, Sea Scale: 2, Wind

Direction: E, Wind Force: 4, Visibility: Good

Ship operation and Voyage segment: Ship en route in laden condition to bunkering port,

Speed 12.3 knots

Human Factors: Yes

Consequences: Death: 1 (Disappearance)

Shore authority involvement and emergency response

28/04 @ 2342Z 29/04 @ 0742LT – Sent DISTRESS CALL ON MF/HF DSC 16804.5 KHz

28/04 @ 2342Z 29/04 @ 0742LT – Broadcasted on VHF CH.16, “Mayday x 3, giving the most

suspected positions, colour of T-Shirt/Short, body built, name of crew & other details”. Above

broadcast continued and urgency call followed and made every hour until SAR concluded. No

message received from other vessels only verbal acknowledgement.

The following vessels rendered assistance in Search and Rescue operation. Their positions were not

taken during their acknowledgment as these vessels joined the SAR right away upon hearing the

emergency call. All messages exchanged were made verbally through VHF 16.

1. MV Nave Cosmos

2. MV Champion Prince

3. MV Yuma

4. MV Okee Alba

5. MV Ilma

6. MV LNG Fukura

7. MV IVS Kingbird

8. MV LNG Almafyar

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9. MV Audrey SW

10. MV New Dragon

11. MV Towada

12. Various fishing vessels (no names taken)

Conducted a parallel search pattern along with other assisting vessels on the two most suspected

positions. At the datum, conducted expanding square & sector search pattern until SAR

concluded.

29/04 @ 0002Z / 0802LT – Received the acknowledgment of the DISTRESS CALL from

HAIPONG RADIO.

29/04 @ 0042Z / 0842LT – Called MRCC MANILA. Verbal reporting giving the incident report,

position, time, details of the missing crew then followed by email message.

29/04 @ 0733Z / 1533LT – Called MRCC Hong Kong. Verbal reporting giving the incident report,

position, time, details of the missing crew then followed by email message.

29/04 @ 0830Z / 1633LT – Received message from MRCC Hong Kong via EGC.

Every 3 hours an update was sent to Hong Kong MRCC and Manila MRCC by email.

29/04 @ 1335Z / 2135LT – Received Phone Call from MRCC Manila. Only asking the status of the

search.

30/04 @ 0125Z / 0925LT – Call from Hong Kong SAR Aircraft.

30/04 @ 1300Z / 2100LT – Concluded the SAR and resumed her voyage bound to Hong Kong.

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3. Narrative

3.1 Sequence of Events

1. The M/V “UNITY” was on a laden voyage from Esperance, Australia to Huangpu and Ningbo, P.R.

China via Hong Kong for bunkering on 28th April 2019, and sailing west of the coast of Philippines

northbound to Hong Kong.

Figure 2: The actual passage of M/V UNITY. North of Manila the SAR area can be seen.

2. At 06:35 LT at the approximate position of Lat: 18º15.2’N Long: 117º23.9’E, the Master, who was

in his cabin at that time, was informed by the ship’s Chief Officer (C/O) that O/S 1 had not reported

yet to the Bosun for the morning job (cleaning of the alleyway) and the Bosun could not locate him.

3. The Master was informed that the C/O had already ordered for a quick search in the gymnasium,

laundry, crew mess, cabin and bathroom but the search party could not find him. After that statement

the Master announced in the PA system for all deck hands to search the vessel and called the Chief

Engineer (C/E) to stand-by the main engine for search and rescue operation. Subsequently he received

reports from each of the search teams with a negative result. One of the search teams reported that they

found some footsteps (naked foot prints on the humid surface of the deck) on the starboard side boat

deck leading overboard (see Figure 10 below).

4. At about 07:00 LT the Master concluded that O/S 1 was missing from onboard and he immediately

manoeuvred the vessel using a Williamson turn in order to head to almost the reciprocal course of the

original course. He asked his officers to send a distress message and broadcast on VHF regarding the

missing crew. Because the footsteps seemed to be recent, he ordered to broadcast on VHF that the most

suspected past vessel positions were between 04:00 – 06:00 LT.

Search and Rescue area

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5. There were 11 vessels in the vicinity that responded to the MOB distress call and assisted in the

Search and Rescue operation between the two given location coordinates. At about 07:30 LT the Master

called the Port Captain of the Management Company (MC) informing him about the situation and

reported the actions made so far. The Port Captain asked the Master to do all necessary actions and

take all means necessary for the search and rescue operation and report to the closest MRCC station to

obtain assistance.

6. At about 08:00 LT the Master contacted MRCC Manila but could not connect. During the same time

the vessel approached the 06:00 LT past vessel position. The vessel slowed down and commenced the

SAR operations. The 11 vessels that responded to the emergency call were told to slow down when

passing the most suspected two given location coordinates and report for any sighting of the missing

crew.

7. At 08:42 LT the Master was able to connect to MRCC Manila by phone and report the incident.

They advised him that they will do everything to help and will coordinate also with other vessels.

Subsequent reports from assisting SAR vessels received that they had no sighting of the missing crew.

8. At 10:45 LT and after yielding a negative result from the SAR operation until then, the Master

decided to go back to the position where O/S 1 was last seen (previous day at 23:30 LT) and left the

04:00 LT vessel past position. He also asked the other assisting vessels that, after searching the area

with no sighting from the missing crew, they could proceed to their destinations.

9. At 15:33 LT the Master received a telephone call from MRCC Hong Kong. He was inquired about

the situation and reported to them accordingly. They instructed him to stay in the vicinity where the

missing crew was last seen and continue the search. They also advised that they would send a SAR

aircraft to help with the operations.

10. At 16:30 the vessel arrived at the assumed datum position in LAT. 16-54.7N LONG. 118-10.5E

where the missing crew was last seen and commenced expanding square search pattern.

Figure 3: The expanding square search pattern

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At 17:00 LT the Master received a message from the MRCC Hong Kong that the SAR aircraft will

arrive to assist with the SAR operation. Then at 19:00 LT he received a message from the MRCC Hong

Kong stating that the SAR aircraft will arrive the following day morning time weather permitting.

11. On 30th April 09:10 LT the Master asked the MRCC Hong Kong about the status of the SAR aircraft

and received the information that the aircraft had already arrived in the search area at around 08:20 LT

and the SAR operation was ongoing. At 11:12 LT the Master asked again the MRCC Hong Kong about

the status of the operation and they replied that the SAR aircraft had carried out aerial search but was

unable to locate the missing crew. They also advised that they had no further instructions for the Master

and that he may proceed to the next port of destination.

12. The Master decided to continue the SAR operation and at 19:00 LT he ordered to resume the sea

passage though the vessel was still inside the search zone that they created. At 21:00 LT and after

completing the 2nd search with a negative result, the Master decided to cease the SAR operation and

eventually left the datum position. He reported his final report to MRCC Hong Kong and MRCC

Philippines and proceeded to destination.

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4. Analysis

The purpose of the analysis is to determine the contributory causes and circumstances of the accident

as a basis for making recommendations to prevent similar accidents occurring in the future. The

following analysis is based on crew statements and ship’s documents provided by the Managers of the

vessel Angelakos (Hellas) S.A. and additional crew statements taken by the MAIC investigator, when

he conducted an investigation onboard the vessel on 06/06/2019 at Ningbo, P.R. China.

4.1 The Ship

4.1.1 Ship’s Certificates and Surveys

The following certificates were checked and confirmed onboard the ship.

Certificate Description Issued Valid until

Classification Certificate 06/09/2016 05/09/2021

Load Line Certificate 17/07/2016 05/09/2021

Cargo Ship Safety Construction Certificate 03/04/2017 05/09/2021

Cargo Ship Safety Equipment Certificate 26/03/2019 05/09/2021

Cargo Ship Safety Radio Certificate 03/04/2017 05/09/2021

Safety Management Certificate 26/10/2018 24/11/2021

Ship Security Certificate 12/04/2019 11/04/2024

Maritime Labour Certificate 03/04/2017 24/11/2021

International Oil Pollution Prevention Certificate, Type B 29/09/2017 22/06/2022

Sewage Pollution Prevention Certificate 03/04/2017 05/09/2021

Air Pollution Prevention Certificate 03/04/2017 05/09/2021

Energy Efficiency Certificate 18/09/2013 -

International Anti – Fouling System Certificate 13/09/2018 -

Ballast Water Management 06/09/2016 05/09/2021

Certificate for the Carriage of Dangerous Goods N/A N/A

DOC of Management Company 19/04/2018 29/04/2023

All Class and Statutory annual surveys were due on 09/2019 and all Class and Statutory renewal

surveys were due on 09/2021.

All certificates onboard the ship were found to be in order and valid.

4.1.2 Ship’s Navigational & Radio Equipment

The M/V “UNITY” is equipped with the following Radio and Navigational equipment as verified

onboard the vessel and has the following life – saving appliances.

Radio equipment

a) VHF DSC encoder

b) VHF DSC watch receiver

c) VHF radiotelephony

d) MF/HF DSC encoder

e) MF/HF DSC watch receiver

f) MF/HF radiotelephony

g) MF/HF direct printing telegraphy

h) Secondary means of alerting: Satellite EPIRB

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i) NAVTEX receiver

j) EGC receiver

k) Satellite EPIRB COSPAS – SARSAT

l) Radar search and rescue transponder (SART)

m) Duplication of equipment

n) Shore – based maintenance

Navigational equipment

a) Standard magnetic compass

b) Spare magnetic compass

c) Gyro compass

c) Gyro compass heading and bearing repeaters

d) ECDIS

e) 2nd ECDIS

f) 9 GHz radar

g) 3 GHz radar

h) ARPA

i) AIS system

j) LRIT system

k) S-VDR

l) Bridge navigational watch alarm system (BNWAS)

Life-saving appliances

a) Total number of persons for which life – saving appliances are provided: 25

b) 2 totally enclosed lifeboats of 25 persons each

c) 1 liferaft for total 25 persons

d) 14 lifebuoys

e) 31 lifejackets

f) 31 immersion suits

The “UNITY” at the time of the accident, had valid certificates including an ISM certificate. The

maintenance records indicated that she was maintained in accordance with existing regulations and

approved procedures.

All ship’s navigational, radio and safety equipment were found in order.

4.1.3 Passage Plan Analysis

The passage plan of UNITY for the voyage detailed as follows:

a. The passage plan from Esperance, Australia to Hong Kong was found to be in order and

complete including the charts, manoeuvring data, pilot and port information, tide tables etc.

b. The ship proceeded for the intended voyage until the time the crew realised that O/S 1 was

missing from onboard, after which the ship diverted for the Search and Rescue mission. Later

the next day and after the Search and Rescue mission was terminated, the ship was instructed

to resume her original course.

c. The vessel’s speed was approximately 12.3 knots when the incident took place.

The ship’s passage plan was found to be in order.

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4.1.4 Ship’s Condition

A physical survey onboard the vessel showed the condition of the ship’s superstructure and the path

that O/S 1 presumably took until his fall overboard. The survey showed that the condition of the

structure, machinery and equipment (as many as could be surveyed during the investigator’s time

onboard) was satisfactory and the ship complied with the relevant requirements of chapters II-1 and II-

2 of the SOLAS convention.

The survey also showed that the life – saving appliances and the fully enclosed lifeboats and the liferaft

were provided in accordance with the requirements of the SOLAS convention.

The following schematic shows the “B” deck, where the cabin of O/S 1 is located.

Figure 4: Schematic of the “B” deck

The cabin of O/S 1 is a single cabin composed of a bed, a desk, a couch and a closet and has a common

bathroom with the neighboring cabin of another O/S (from now on stated as O/S 2). The cabin door

can be permanently fixed on the wall by way of a stop. The cabin was left untouched and sealed by the

crew until further notice. It was only opened for the surveyor who investigated the incident on behalf

of the P&I Club on 29th April 2019 and then for the MAIC investigator. After our investigation was

over, it was ordered that the personal belongings of O/S 1 to be packed and sent back to his family.

The cabin was found in order without anything extraordinary to notice. The bed was made even though

the disappearance of O/S 1 took place between 23:30 at night and 06:00 of the next morning. The

Exit to open deck

Ladder to deck

below

O/S 1 cabin

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shared bathroom with O/S 2 did not have anything out of the ordinary and O/S 2 advised that he did

not find anything unusual in their common bathroom after the incident.

The “B” deck has two external doors that lead to the open deck area, one on the port side and one on

the starboard side. The closest exit to the open deck from the O/S 1 cabin is the door on the starboard

side of the ship, which leads to a small and constrained open deck area and then to a ladder which leads

to the deck below.

Figure 5 – The O/S 1 cabin as found by the investigator

Figure 6: Area on “B” deck leading to the Boat deck

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As it can be shown from Figure 7 below, the “B” deck is connected to the “A” or Boat deck below via

a ladder. Accordingly, the “A” or Boat deck is connected via a ladder to the Main deck of the vessel.

4.1.5 The condition of the “A” or Boat deck

The “A” or Boat deck was found in a satisfactory condition structurally and by way of maintenance.

The hand rails had a height of 1.20 m. They were in good condition and satisfied the relevant SOLAS

requirements. The protective chains in way of the life boat area were in a slightly rusty but overall

satisfactory condition.

Bridge deck

“B” deck

“A” or “Boat” deck

Main deck

Figure 7: The accommodation decks

“C” deck

“D” deck

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The restricted area of the open deck is the ship’s Muster station and confines the access to the

embarkation station of the Boat deck by hand rails and chains as shown in Figure 8. If a person passes

through the restrictive hand rails and chains on purpose then he finds himself on an open and

unprotected area below the life boat which is on purpose the embarkation station of the specific life

boat.

It is concluded that one person cannot fall accidentally overboard from the Boat deck due to structural

deficiencies of the vessel, as there was no evidence of any defect or malfunction that could have

contributed to the accident.

4.1.6 Cargo related factors

The ship was on a laden voyage from Esperance, Australia to Huangpu and Ningbo, P.R. China via

Hong Kong for bunkering, carrying 62,365.19 MT of barley in bulk. The ship, when inspected, was

found in satisfactory condition without anything noticeable relating to the cargo onboard.

The cargo was not considered as a factor to the accident.

Figure 8: The Boat deck area

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4.1.7 CCTV – S-VDR

The ship is not equipped with a CCTV system. The S-VDR was not stopped or saved as the crew did

not think that anything important could have been recorded from the incident.

4.2 The Crew

4.2.1 Certification

The Minimum Safe Manning Document (MSMD) was issued by the Cyprus Maritime Authority on

29/11/2017, expires on 28/11/2022 and requires 14 crew members to be onboard the vessel.

Figure 9: The Minimum Safe Manning document for Unity

The crew onboard the vessel at the date of the incident was 20 crew members. It is thereby concluded

that the ship at the date of the incident complied and exceeded the MSMD requirements by 6 crew

members.

All crew members certificates were up-to-date and valid and in compliance with all relevant

regulations.

The crew certification was not considered as a factor to the accident.

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4.2.2 O/S 1’s Medical Certificate

O/S 1 had a “MEDICAL CERTIFICATE FOR SERVICE AT SEA” issued on 22nd October 2018 by

Ygeia Medical Center, Inc. of Philippines. All his examinations were normal and he was therefore

pronounced “Fit for sea duty”. In detail, the medical certificate states that O/S 1 met the relevant

hearing standards, had a satisfactory unaided hearing, his colour vision met the standards in STCW

Code, Section A-I/9, he was fit for lookout duties and had no limitations or restrictions on fitness. It

also states that O/S 1 was not suffering from any medical condition likely to be aggravated by service

at sea or to render the seafarer unfit for such service or to endanger the health of other persons onboard.

O/S 1 had undergone screening test for HIV/AIDS and was found to be non-reactive based on the

laboratory test. He was also tested negative for Phencyclidine (PCP), Cocaine, Methamphetamine,

Morphine, Tetrahydrocannabinol and alcohol.

Finally, it is stated that he did not have a medical history of head or neck injury, frequent headaches,

frequent dizziness, fainting spells / seizures or other neurological disorder, insomnia or sleep disorders,

depression or other mental disorders, eye problems, deafness, nose or throat disorders, tuberculosis,

other lung diseases, high blood pressure, heart disease and vascular or chest pain, rheumatic fever,

diabetes and other endocrine disorders, cancer or tumor, blood disorders, stomach pain, other abnormal

disorders, kidney or bladder disorder, back injury, joint pain or arthritis, generic, hereditary or family

disorders, sexually transmitted diseases, tropical diseases, asthma, allergies or had any operations.

The electrocardiogram (ECG) was completed with some findings which was cleared thereafter by a

specialist after performing stress test and stress echo.

The O/S 1 medical condition prior to embarkation was not considered as a factor to the accident.

4.2.3 Fatigue

The record of work and rest hours was examined onboard the vessel. The records regarding O/S 1 show

that all relevant MLC and STCW regulations were kept and hence fatigue was not considered a

contributory factor to the accident.

Fatigue was not considered as a factor to the accident.

4.2.4 Working and Living Conditions

As far as the working and living conditions onboard the vessel could be examined, it must be said that

they were of satisfactory standards. The crew members seemed to be in very satisfactory condition

both physically and psychologically (as many as could be interviewed) and they did not express any

concerns or complains. The condition of the accommodation of the ship was in order without any

recommendations.

There was no evidence to suggest, that, the working and living conditions was a contributory factor to

the accident.

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4.2.5 Training

The training and drills log for months June 2018 – February 2019 was examined and was found in

order and in accordance with all ISM requirements. In particular, the “Man Overboard” drill was

conducted during the following dates:

29 June 2018

27 September 2018

07 November 2018

22 February 2019

which corresponds to four drills during a 9-month period, exceeding the requirement of performing the

drill once in every 6 months.

The booklet “Plans and procedures for recovery of persons from the water” was checked and found in

order.

There was not any lack of training and drills for “Man Overboard” procedures, therefore lack of

training was not a contributory factor to the accident.

4.2.6 Physiological, Psychological, Psychosocial Condition

The physiological, psychological and psychosocial condition of O/S 1 is not easy to determine fully by

an investigation of this type and, accordingly, a professional opinion cannot be expressed.

But for the completeness of the investigation the following information has been gathered:

(a) O/S 1 was a quiet person, a good worker and he was up for a recommendation for a promotion

to an A/B. He was friendly with the other crew members and had never created any trouble or

problems while serving onboard. He had not shared with the other crew members any personal

or family problems.

(b) It was verbally advised by the Master that during the last two days the vessel was close to the

Philippines coast and hence the mobile phones of the crew members had a good signal. Most

of the crew members caught the opportunity to speak on their mobile phones with their families

during those days. Most probably O/S 1 also spoke with his wife on the phone during those

days.

(c) The previous day of the incident (28th April) was a Sunday and there was no work for the crew

except for those on duty. O/S 1 was present on the morning Bible reading that the crew had

between 09:00 – 10:10. Then an environmental training took place between 10:30 – 11:30 in

which O/S 1 was also present. For the rest of the day the crew were resting in their cabins and

some were watching movies in the crew smoking room but nobody observed O/S 1 during the

afternoon except during the dinner time between 17:00 – 18:00.

(d) The C/O stated that O/S 1 was not a talkative person, he was a good listener but did not start a

conversation by himself. He had not mentioned to him any problems that he may had. He was

hard working and in his spare time he went to the bridge for training of steering.

(e) An A/B (from now on stated as A/B 1) mentioned during his interview that between the Bible

reading and the environmental training O/S 1 told him the words “Hindi Na Kita Sasamahan

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Sa Sunod Na Pwerto” which translates into “I will not go with you anymore in the next port”.

That statement was followed up during the dinner time again. A/B 1 thought that O/S 1 was

joking and did not consider that statement worthy of mentioning to anybody else until it was

too late.

(f) Another O/S (from now on stated as O/S 3) stated that during the dinner time of the 28th April

2019 the O/S made him a hug without saying anything. He also heard him telling A/B 1 that he

would not go to the next port for duty with him.

(g) O/S 2 stated that during the dinner time of the 28th April 2019 O/S 1 hugged him for a short

time without saying anything to him. This was very strange as he did not do that normally. The

last time O/S 2 saw O/S 1 was around 23:30 of the same day when he was going from the

laundry to his cabin. Their cabins are adjustment and they shared the same bathroom. O/S 1

was also going to his cabin, maybe closed his door and thereafter was some music heard from

inside his cabin. O/S 2 did not hear any strange noises or telephone talk during that night.

(h) The Bosun stated that during the dinner time of the 28th April 2019 the O/S came to him and

told him “good appetite” then hugged him and smiled.

(i) The 2nd Officer (2/O) stated that after the dinner time O/S 1 came to him and asked for a

cigarette, even though he was not a smoker, and made him a friendly hug. The 2/O was

surprised that he asked him for a cigarette.

(j) On 29th April 2019 at approximately 06:55 and while the crew were searching the vessel for

the missing O/S, the C/O informed the Master that the search party found some footprints in

the “A” or Boat deck starboard side just underneath the lifeboat on the embarkation platform

and a pair of slippers just outside the weather tight door of the “B” deck (exactly as shown on

Figure 6 – second photograph which is a recreation of the original state). The footprints were

leading overboard as it can be seen from the pictures below which were taken at that moment

from the crew members.

There was no evidence to suggest that the physical, physiological, psychological, or psychosocial

condition of the OS1 was such that could have contributed to the accident.

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Figure 10: The footprint leading overboard as they were found by the search paty

(k) The O/S 1 had possession of two mobile phones which were found intact in his cabin. We could

not have access to them as they are protected by a password. The mobile phones were retained

by the Management Company and sent to MAIC Headquarters.

(l) The crew found inside a drawer in his cabin an amount of medicines which are shown in the

figure below.

Figure 11: The medicines found in O/S 1 cabin

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The medicines found in the O/S. 1 possession are the following:

1. Amoxicillin (Antibiotic)

2. Carbocisteine Solmux (medicine for cough, phlegm, bronchitis)

3. Blumea balsamifera sambong (leaf used for common cold and as a diuretic)

4. Ascof forte (cough relief medicine)

5. Mefenamic Acid (pain relief medicine)

6. Dicycloverine HCI (medicine for cramps, stomach pain)

7. Paracetamol (medicine for pain relief and fever)

8. Loperamide hydrochloride (antidiarrheal medicine)

9. Naproxen Sodium (pain relief medicine)

10. Ginkgo Biloba (capsules for alertness and memory)

No psychotropic drugs were found. The medicines found in his cabin were common medicines that

one can buy easily in a drug store with or without prescription.

4.3 The Environment

External environment:

The weather conditions at the time of the accident were as follows.

Air Temperature: 33º C

Sea Temp: 30º C

Sea Scale: 2

Wind Direction: E

Wind Force: 4

Condition: night dawn

Visibility: Good

Sky: Partly cloudy

There is no evidence that physical environmental factors, such as weather, climate, etc., affected the

actions of O/S 1.

Internal Environment:

It was advised verbally that there were no sudden movements of the vessel which could had caused the

O/S 1 slipping and falling from the Boat deck overboard. The condition of the deck floors were not

damaged at the day of the incident, only a morning humidity was present which preserved the footprints

of O/S 1 for the rest of the crew to observe.

In conclusion, there was no evidence that the environmental conditions were a factor in the accident.

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5. Conclusions

Conclusion(s)

There were no witnesses to the disappearance of the crew member. On the other hand, there are

indications that the crew member may have fallen overboard from the embarkation station of the

starboard side Boat deck.

Evidence gathered during the investigation:

1. His slippers were found on the “B” deck just outside the weathertight door and next to the ladder

leading to the “A” (Boat) deck below.

2. His footprints were found and photographed on the “A” (Boat) deck floor on the lifeboat embarkation

station, which were leading to overboard.

From statements of the other crew members it is referred that O/S 1 told A/B 1 twice that he “would

not go with him anymore to the next port”. O/S 3 also heard O/S 1 telling these words to A/B 1. In

addition, O/S 1 hugged during the dinner time at least three different crew members, an act which was

considered highly unusual for him.

Therefore, it is considered that in the absence of maritime safety related evidence, the O/S 1

disappearance is not related to maritime safety.

6. Recommendations

There are not any recommendations.

REPUBLIC OF CYPRUS MARINE ACCIDENT AND INCIDENT … · 2020. 6. 19. · to cease the Search and...

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