BRAZILIAN MARITIME AUTHORITY DIRECTORATE OF PORTS … · 2018-09-26 · STCW 78 - International Convention on Standards of Training, ... Certificate of Management of Safety SMS/ISM

BRAZILIAN MARITIME AUTHORITY

DIRECTORATE OF PORTS AND COASTS

COLLISION WITH A FATAL VICTIM BETWEEN THE VESSELS

FAST TITAN AND EVILAZIO

6 of March 2011

MARINE SAFETY INVESTIGATION REPORT

Supply “FAST TITAN” - Courtesy Shipspotting.com

Reference: IMO Casualty Investigation Code - MSC-MEPC.3/Circ.2 13 June 2008/ Resolution MSC.255(84)

Brazilian Maritime Authority - Directorate of Ports and Coasts

Surveys, Naval Inspections and Technical Expertise Management Maritime Casualty Investigation Department (CIPANAVE)

Collision with a fatal victim between the vessels “FAST TITAN” and “EVILÁZIO”

Marine Safety Investigation Report

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INDEX

GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS ........................... 2

I - INTRODUCTION ........................................................................................................ 3

II - SYNOPSIS .................................................................................................................. 3

III – GENERAL INFORMTION ..................................................................................... 4

a) Characteristics of Supply “FAST TITAN” .......................................................... 4

b) Documents of Supply “FAST TITAN” ................................................................. 5

c) Characteristics of Fishing Vessel “EVILÁZIO” ..................................................6

IV – SEQUENCE OF EVENTS ....................................................................................... 7

V – CREW..........................................................................................................................9

VI – DATA OF THE PLACE OF THE ACCIDENT...................................................11

VII - POST-ACCIDENT SURVEY...............................................................................12

VIII - ANALYSIS OF THE DATA GATHERED AND CAUSAL FACTORS.........18

IX - PRELIMINARY LESSONS LEARNT AND CONCLUSIONS.........................20

X - RECOMMENDATIONS........................................................................................21

ANNEXES..........................................................................................................................22





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GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS

2ON – 2nd Officer

AIS – Automatic Identification System

AIT – Certificate of Temporary Registration

AMB - Brazilian Maritime Authority

CIR – Seaman´s book

COLREG - Convention on International Regulations for Preventing Collisions At Sea, 1972

CPRJ - Captaincy of the Ports of Rio de Janeiro

DHN - Directorate of Hydrography and Navigation

DPC – Directorate of Ports and Coasts

FV – Fishing Boat or Fishing Vessel

GPS - Global Positioning System

IMO - International Maritime Organization

ISM Code - International Safety Management Code

MNC – Deck Hand

MOP – Fishing Machinist

PEP – Specialized Professional Fisherman

POP – Professional Fisherman

SMC - Safe Manning Card

STCW 78 - International Convention on Standards of Training, Certification and Watchkeeping of

Seafarer, 1978

TIE – Certificate of Registry





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I - INTRODUCTION

For the purpose of effecting the collection and analysis of evidence, the identification of the

causal factors and the elaboration of safety recommendations that should be necessary, in order to

prevent that in the future occur similar maritime accidents and/or incidents, the Captaincy of the

Ports of Rio de Janeiro (CPRJ) carried out a Marine Safety Investigation, in compliance with that

laid down in the Casualty Investigation Code of the International Maritime Organization (IMO),

adopted by Resolution MSC. 255(84). This Final Report is a technical document that reflects the

result obtained by CPRJ regarding the circumstances that contributed or may have contributed to

trigger the occurrence, and not refers to any proving procedures for determination of civil or crim-

inal liability. Also, one should emphasize the importance of protecting the individuals responsible

for providing information regarding the accident, and the use of information contained in this re-

port for purposes other than the prevention of future similar accidents could lead to erroneous in-

terpretations and conclusions.

II – SYNOPSIS

On the March 6th

, 2011, around 01h10, occurred the collision involving the United States flagged

Supply vessel “FAST TITAN”, IMO 9579937, 55 metres length, 4949 tons gross tonnage, built in

2010, and the fishing vessel (FV) “EVILAZIO”, Brazilian flag, registered in the port of Vitoria

with Nº 3410234675, wooden hull and 18,50 tons gross tonnage, at the coordinates 24º 03’01”S /

042º55’28W, distance 60 nautical miles from the coast of Rio de Janeiro. The supply “FAST TI-

TAN was sailing on autopilot from the Bay of Santos heading Rio de Janeiro. The fishing vessel

“EVILAZIO” had left Jurujuba – Niteroi and was headed to the fishing area when the accident oc-

curred.

The Captaincy of the Ports of Rio de Janeiro (CPRJ) was advised of the accident by means of ra-

dio communication indicating that the Supply “FAST TITAN” was entering the port of Rio de Ja-

neiro with the crewmembers rescued from the another vessel onboard. Naval Inspectors of the

CPRJ went to the place of berthing and verified that the crewmembers rescued belonged to the FV

“EVILAZIO”, that as a result of the collision suffered many damages and was in danger of sinking,

reason for which carried out an operation for its recovers and afterwards towage to the beach of

Jurujuba in Niteroi.





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The present procedure started immediately after the principal interest parties had been formally

notified by the CPRJ (Annex E) in compliance with the provisions of the IMO Casualty Investigati-

on Code. The United States Coastguard (USCG) declared itself as representative of the Substantial-

ly interested State, once the “FAST TITAN” was United States flagged.

III – GENERAL INFORMATION

Characteristics of the vessels involved in the accident

a) Supply “FAST TITAN” (Photo 01)

Name: FAST TITAN

Flag: United States

Gross tonnage: 449 tons

Displacement: 226 tons

Area of Navigation: Open Sea

Maritime Support

Type: Supply Propulsion: Motor

Activity: Transport of Passengers

IMO: 9579937

Length 51.13m

Built: 2010

Call sign:

(IRIN) WDF4842

MMSI 367456420

Port of Registry: Rio de Janeiro (AIT381E007171

Owner: NAUTICAL SOLUTIONS LLC

Operators: Bram Offshore Transportes Marítimos Ltda

Classification Society: American Bureau of Shipping (ABS)

P&I: Assuranceforeningen Skuld – Norway

Crewmembers on the Certificate: 10 Crewmembers onboard: 9

Propulsion: diesel Motor ( 4) CAT 3512 Diesels,1810HP/

1349.71 KW (each)

Bow Thruster: (2) Tunnel Thruster 250 HP

(each)

Builder : Breaux Brothers Enterprizes Inc Place where built: Loreauville, LA – USA

Annex A) has the technical particulars (Ship´s Particulars) of the ship.





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Photo 01 – Supply “FAST TITAN” berthed at the Caju Terminal RJ

b) Documentation of “FAST TITAN”

Title Issuing

Authority

Date of

Validity

Date of

Validity

Radio Certificate Country of Flag 6/10/2010 6/10/2020

International Certificate of Prevention of

Pollution by Oil (IOPP)

ABS

28/10/2010

28/01/2011

Load Line ABS 1/10/2010 30/9/2015

Document of Conformity – DOC/ISM ABS 9/9/2010 4/11/2013

Certificate of Management of Safety

SMS/ISM

ABS

23/10/2010

22/4/2013

Safe Manning Card CPRJ 30/6/2010 22/10/2011

Certificate of International Measurement GL 30/6/2010 -

International Certificate of Protection for

Ships ISPS (Code)

Country of Flag

27/9/2010

21/5/2015

Certificate of Class ABS 1/10/2010 1/3/2011

Certificate of Registry Country of Flag 15/7/2010 31/7/2011





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The Certificate of Class and the International Certificate of Prevention of Pollution by Oil

(IOPP) were expired. The remaining certificates were up to date, as may be verified from the copy o

the Report of Inspection of the Ship carried out on 06 March of 2011, Annex B) of this report.

The crewmembers of the vessel did not present to the investigators, the Safety Management

Manual with the instructions for operation in emergency situations and instructions for night-time

navigation, use of detection electronic equipments and surveillance.

c) Fishing Vessel (FV) “EVILÁZIO” (Photo 02)

Name: EVILAZIO Brazilian Flag Gross tonnage 18.80 tons

Type: Fishing vessel Propulsion: Motor Activity: Fishing

Area of navigation Open Sea No 3410234675 Material the hull: Wood

Classifier IRIN Port of Registry: Vitoria

Breadth 4.38 metres Depth 1.80 metres Length 12.87 metres

Owners: Artur Benedito Motta Vos and Marcelo Nascimento Ayres

Built in 2002. Artisanal building.

The Certificate of Registry of craft – TIE no 341-023467, shown in Annex C) provides other

information on the vessel.

Photo 02 –FV “EZILAZIO” grounded on the beach of Jurujuba after the rescue





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According to information provided by the crew, part of the vessel´s documentation was lost on

the occasion of the accident. From copies further obtained and through consultation to the Report of

National Craft, the investigators ascertained that the documentation of the vessel was in order, regu-

larly registered in the Captaincy of the Ports of Espirito Santo with Certificate of Registry (TIE)

number 341-023467, holding a Safe Manning Card (CTS) and a Term of Responsibility of Safety of

Navigation.

According to the Brazilian Maritime Authority Standard to Vessels Employed in Open Sea Na-

vigation (NORMAM-01/DPC), the Certificate of Registry (TIE) is the document proving the regis-

tration of the vessel on the Brazilian Maritime Authority, with the allocation of name and number of

registration. The vessels which are not subject to surveys shall have on board a Term of Responsibi-

lity of Safety of Navigation. In this document the owner or operator take responsibility for compli-

ance with the items allocation and other safety requirements specified for his boat.

IV – SEQUENCE OF THE EVENTS

The information of the occurrence of the accident was received by the CPRJ by means of ra-

dio communication indicating that the Supply “FAST TITAN” was entering the port of Rio de Ja-

neiro carrying the rescued crewmembers of another vessel. A team of investigators immediately at-

tended the vessel in order on gathering as much evidence as possible to build up a clear picture of what

happened, to support the elaborating of the present Report. At the berthing site it was confirmed that

these shipwrecked sailors were the crew of FV “EVILAZIO”.

In accordance with the information obtained and the registers consulted by the investigators,

around 01h10 of March 6th

, the supply vessel “FAST TITAN” was sailing on autopilot on the

programmed course 345o, coming from the Santos Basin towards the port of Rio de Janeiro. Fur-

thermore, in accordance with the testimonies, on the day of the accident, the sea was with waves

of approximately 1.5 to 2m height, the weather was cloudy without rain, 50% visibility and wind

of 10 knots.

The FV “EVILAZIO” had sailed from Jurujuba, Niteroi on March 5th, 2011, around about 12h00

and was sailing towards the fishing area, located around 70 miles distance from the shoreline of Rio de

Janeiro, when occurred the collision. One crewmember was on watch and all the others were sleeping

at the moment of the accident. This sole awake crewmember on the FV “EVILAZIO” died as a result

of the accident, making difficult the collecting of more detailed and precise information by the inves-





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tigators. According to statements, the average speed of the vessel sailing was from4 to 4.5 knots and

the course adopted was between 210º and 220º, but there are no records or information about the cour-

se really employed at the moment of the accident. The vessel was not engaged in fishing.

According to testimonies of crewmembers of the Supply “FAST TITAN” the FV “EVILAZIO”

was was detected visually by the bow to port at approximately 400m distance, but there was not time

to change the course of the autopilot or issue any alert to avoid the accident. The “FAST TITAN” spe-

ed was around 19 or 20 knots and there was an attempt to reduce speed and change the control of the

autopilot to manual, without success. Also according to testimonies given to the investigators the per-

sonnel on watch on the “FAST TITAN” would had seen only the deck lights of the FV “EVILAZIO”

and it was not possible for them to confirm if the navigation lights were on. Up to this sighting no o-

ther surface contact or alarm was detected onboard the “FAST TITAN” that announced any vessel on

a collision course. The investigation ascertained that there was not any type of communication betwe-

en the vessels, alleging that the accident occurred rapidly. The crewmembers of the “FAST TITAN”

could not inform if when sighted, the FV “EVILAZIO” was sailing or was stopped and, if sailing what

was its course.

As the only crewmember awake on the FV “EVILAZIO” died as a result of the accident, it

was not possible for the investigators to ascertain if the Supply “FAST TITAN” was sighted and

accompanied, or if there was an alteration of course of the FV moments before occurred the acci-

dent. According to the information of the crewmembers of the FV, the boat was equipped with a

GPS, VHF radio and SSB radio, which were switched on during the night of the accident, and it

was routine the vessel sail with only one crewmember on watch during nights of calm weather.

Only during storms another crewmember used to be employed as lookout.

As a consequence of the collision the fishing boat was seriously damaged with flooding and

partial sinking. The “FAST TITAN” maneuvered immediately after the collision to give assistan-

ce and rescued all the crewmembers of the FV “EVILAZIO”, which was adrift in the area of the

accident until being towed in direction of the beach of Jurujuba. During the rescue of the fishing

boat crewmembers it was found that there were personal accidents, one rescued crewmember with

light corporal injuries and another unconscious. The injured crewmember was transferred to the

platform “CIDADE DE SANTOS” where he received attention and was removed to a hospital by

a helicopter. The other crewmember of the fishing boat, who was unconscious, died during the

rescue. The body of the crew member died and the other four surviving crew members were taken

to the port of Rio de Janeiro by the “FAST TITAN”.





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After the accident the fishing boat was kept afloat, with the use of plastic barrels and towed

afterwards to Jurujuba beach by another fishing vessel which was operating nearby and rendered

assistance (placement of plastic barrels to improve the buoyancy and towing of the damaged bo-

at).

V – CREWS

From the analysis of the data gathered and the documentation presented, it was found that the

navigation was being conducted in routine form and without problems with the two vessels in good

conditions of operation and with all the equipment functioning.

Supply “FAST TITAN”

The investigators found that, on the occasion of the accident, the crew of the Supply “FAST

TITAN” met that foreseen in the STCW 78 Convention ( International Convention on Standards of

Training, Certification and Watchkeeping of Seafarers 1978) and that in the Safe Manning Card

(SMC) as much in quantity as in the qualifications required. The crew of the “FAST TITAN” ac-

cording to the Crew List (Annex D), is made up of 9 seafarers, being 1 North American and 8 Bra-

zilian. The working language onboard is Portuguese.

The ship had good accommodations for all the personnel embarked and operated normally with

this number on board.

The Captain (Officer of the Watch at the time of the accident) is qualified in the category of 2nd

Officer (2ON), with three and a half years of experience in the command of other vessels, having

embarked on Feb 11th

, 2011.

The sailor who was with the Captain at the moment of the accident was qualified as a Deck

Hand. He was onboard for 60 days and had 13 years of experience.

FV “EVILAZIO”

Neither the Crew List or the Seamen´s books were presented to the investigators, with the alle-

gation that they were lost in the accident. However, as discovered by the investigators, the Safe

Manning Card (SMC) of the vessel established a manning of 4 crewmembers, being one Speciali-





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zed Professional Fisherman (PEP) as Captain, one Fishing Machinist (MOP) and two Professional

Fishermen (POP). At the moment of the accident there were onboard 6 crewmembers (5 qualified

in the category of POP and 1 not qualified).

According to the Brazilian Maritime Authority's Standards for Seafarers (NORMAM-13/DPC),

a Fishing Machinist (MOP) belongs to the "Fishermen Group – Engine Section" category

(subordinates category), and is able to pilot small boats.

None of the crewmembers were qualified as Specialized Professional Fisherman (PEP), mini-

mum category stipulated by the SMC to act as Captain of the vessel.

The crewmember who held the function of Captain for the first voyage is qualified in the cate-

gory of Professional Fisherman, has 15 years experience on the sea and was onboard since Feb 2nd

,

2009 in the function of fisherman.

The crewmember that was at the helm and died as a result of the accident also was qualified in

the category of Professional Fisherman, possessed 12 years of experience and was embarked since

June 21st, 2010.





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VI – DATA OF THE PLACE OF THE ACCIDENT

The place of the accident is located at the point of coordinates 24º 03’01”S/ 042º 55’28”W, dis-

tance 60 nautical miles from the coastline of Rio de Janeiro (Nautical Chart DHN 1601 (Photo 03),

edited by the Directorate of Hydrography and Navigation - DHN).

Photo 03 – Extract of the Nautical Chart 1601 – point of the accident (24º03'01"S / 042º55'28"W).





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Photo 04 – aerial view of the point where occurred the accident (Google maps)

Environmental conditions: In accordance with the information obtained and records consulted

by the investigators, on the day of the accident the weather conditions were good, despite being

night with closed weather. The sea was with waves of approximately from 1.5m to 2m in height,

cloudy weather without rain, 50% visibility and wind of 10 knots.

VII – POST-ACCIDENT SURVEY

The investigation onboard the supply vessel “FAST TITAN” started right after the berthing of

the vessel at the terminal of Caju – Rio de Janeiro, and it was found that the ship was in a good state

of conservation (Photo 05). On the bow of the vessel were observed marks of the collision with

scratches in the paintwork (Photo 06), but without affecting the hull.





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Photo 05 – Supply Vessel “FAST TITAN” berthed at Caju terminal

Photo 06 – Bow of the Supply Vessel “FAST TITAN”





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The Life-saving appliances were in accordance with the respective Safety Plan. Damages re-

sulting from the collision were not observed, nor related by the crewmembers.

The main engines, diesel generators and the steering system were in good condition. There are

no records of damages before or after the collision, nor were any reported. The navigation lights

were working normally, with a good level of luminosity. The two radars were working normally,

with good image resolution. By the information of the crewmembers, the lights and the radars were

switched on at the time of the accident.

The allocation of the navigation and communications equipment existing is made up by au-

tomatic pilot (autopilot), two Raytheon radars with 8 miles (Port) and 24 miles (Starboard) scale of

sweeping, compass, GPS, AIS, Nautical Charts, collision alarm system (ARPA), VHF radio, SSB

equipment, whistle and searchlight. In accordance with the accounts of the crewmembers, the fol-

lowing equipments were on and functioning properly at the moment of the collision, although there

are no records to confirm the information provided:

a) in navigation: radar, GPS, AIS and automatic pilot; and

b) in the communications: radio, VHF and telephone via satellite

It was not possible for investigators to define whether the anti-collision system “FAST TI-

TAN” worked integrated with the radar and there is no records of faults in the equipment onboard,

because the vessel does not possess a Logbook for entries, as specified in the ISM Code.

The FV “EVILAZIO” was surveyed on the Jurujuba beach - Niteroi, after her towing to the

site by an unidentified vessel. The boat was in a bad state, without crew onboard and presenting

big damages on the stern to starboard which provoked her flooding and partial sinking. In accor-

dance with the posterior statements, the vessel was equipped with a GPS, VHF radio and SSB radio.

Furthermore, in accordance with the witnesses, the damages were caused by the impact of the

bow of the vessel “FAST TITAN” with the boat´s side, causing the breaking of the woodwork and

the displacement of the superstructure to port (Photos 07, 08, 09 and 10). In the photographs we can

observe the blue drums, used to assist the flotation of the craft during her rescue and towage.





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Photo 07 – FV “EVILAZIO” aground on the beach of Jurujuba after the rescue.

Photo 08- FV “EVILAZIO” damages on the stern and on the superstructure.





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Photo 09- FV “EVILAZIO” side to STBD damaged and superstructure displaced to PORT

(view from the stern)

Photo 10 – FV “EVILAZIO” side to STBD damaged and superstructure displaced to PORT

(view from the bow)





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It was not possible for the investigators to carry out tests with the steering and propulsion sys-

tem, as well they were unable to check the working of the navigation lights and the VHF radio due

to the vessel being without energy and partially submerged. The vessel was not equipped with ra-

dar. It was not possible to check if there was life-saving apliances onboard and its condition.

The structure of the vessel is built of wood and was equipped with a small radar reflector

installed on the masthead.

VIII – ANALYSIS OF THE DATA GATHERED AND CAUSAL FACTORS

Observing the navigation area and the sketch of the situation on the chart DHN 1601 (Photo

03 page 12) made by the investigators based on the information supplied by crewmembers of the

two vessels, it is verified that there are divergences difficult to be clarified once that the only

crewmember of the fishing boat that was awake at the moment of the accident, qualified in the

category of Professional Fisherman (POP), died. On the FV there was no equipment which preserve

records of routes and engines (or helm) maneuvers, effectively executed.

The succinct records in the Supply “FAST TITAN´s” Deck and Engine Room Logbooks did

not contribute with details that permit to evaluate the conduct of the crewmembers and the relative

movement of the vessels. The ship has radar but according to statements given nothing was detected

and there was no trigger of the anti-collision alarm. The manuals with the technical characteristics

of the radars were not presented, as well as there are no records that permit identifying if they were

switched on and operating normally, which scale was employed and if the adjustments of resolution

were well executed. As there is no images backup system, nor audio and video recording, it was not

possible to analyze and confirm the statements. The navigation on autopilot may have led to the

lack of attention to possible obstacles.

The information of the crewmembers that the supply “FAST TITAN” was sailing on autopilot

toward 345º and the general direction of navigation from the origin to the destination of the vessel

are consistent.

The information of the crewmembers of the FV “EVILAZIO” that the vessel sailed from

Jurujuba to carry out fishing does not permit tracing her precise course. Both the general sailing

course and the eventual manoeuvres carried out by the fishing vessel are not shown in any record. It

is recalled here that the only crewmember who was on duty at the helm when the accident occurred

died without reporting what happened. There is no way of knowing what manoeuvres the

helmsman may have executed with the absence of registering equipment of courses and commands

to the engines.





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The bow of the "FAST TITAN" hit the fishing vessel to starboard, but since that were not set

out the course of the vessels, there is no way to define which one should maneuver when seeing the

other to starboard, to comply with Rule 15 of the International Regulations for Preventing

Collisions at Sea, 1972 (COLREG) as described below:

Rule 15

Crossing situation

When two power-driven vessels are crossing so as to involve risk of

collision, the vessel which has the other on her own starboard side

shall keep out of the way and shall, if the circumstances of the case

admit, avoid crossing ahead of the other vessel.

On the supply “FAST TITAN” there were two crewmembers on watch at the time of the

accident, one of them the Captain himself, in the function of Officer on Watch, qualified in the

category of Second Officer, and one crewmember qualified as Deck Hand in the role of helmsman

and look-out. The vessel was on autopilot and according to the allegations of the crewmembers, the

radars were switched on and working well. Thus, the fishing vessel should have been detected in

time to allow a maneuver in order to avoid the collision.

It also quote Rule 17 of the COLREG establishing that the vessel that has preference may

manoeuvre to avoid a collision when that which is required to maneuver does not do it properly.

Rule 17

Action by stand-on vessel

(a)

[..]

(II) The latter vessel may however take action to avoid collision by

her manoeuvre alone, as soon as it becomes apparent to her that the

vessel required to keep out of the way is not taking appropriate acti-

on in compliance with these Rules. [..]

On the other hand, Rule 5 of the COLREG (Look-out) establishes, “inter alia”

“Every vessel shall at all times maintain a proper look-out by sight

and hearing as well as by all available means appropriate in the pre-

vailing circumstances and conditions so as to make a full appraisal

of the situation and of the risk of collision.”

A Bridge Resource Management (BRM) should efficiently manage all the resources that are

available for the bridge and promote a good communication and work in a team. The accident

occurred due to failure in the surveillance and the failure by both vessels, of the COLREG rules

mentioned. The failure of vigilance on the part of both vessels resulted in delay in taking preventive

measures in a timely manner to avoid the collision.





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Face of all that has been found, it is concluded that the main causal factors of the accident

have originated from operational failures in the maneuvering of the vessels and the delay in

adopting preventive measures in a timely manner to avoid collision, and failure on the part of the

crewmembers on watch.

IX - PRELIMINARY LESSONS LEARNT AND CONCLUSIONS

Investigations into the circumstances of casualties that have occurred have shown that acci-

dents on board ships are in most cases caused by an insufficient knowledge of, or disregard for,

the need to take precautions. Statements by those involved in the accident have been taken into ac-

count in compiling this report. A lot of factors indicate that the safety culture and safety

management on the part of those involved in the accident were not strong. From the findings of

this investigation came up the following lessons and conclusions:

1. The high speed developed by the Supply “FAST TITAN” (20 knots) recommended a

redoubled vigilance by the speed of approach in relation to the other vessel. On the other hand, the

low speed of the fishing vessel also recommended attention to monitoring because of the lower

capacity quick reaction in an emergency.

2. The night sailing of the fishing vessel with only one crewmember on watch at the

helm is a risky situation the prejudices vigilance. Despite not having evidence that prove it, the

crewmember of the fishing boat may have been overcome by fatigue, sudden illness, or distraction,

that could have resulted in a reduction of his vigilance. The fact that it is not formally foreseen that

the fishing vessel has a crewmember to assist in the tasks of surveillance and monitoring of con-

tacts that could offer some obstacle to navigation increases the risks.

3. The “FAST TITAN” radars installed on the bridge are fitted with an alarm for targets

that approach at distances previously selected but, according to the crew, there was no warning

about the approaching of the fishing vessel. As the investigators did not receive the Safety

Management Manual from the crewmembers of the vessel and as there is no records of defects in

the equipments onboard, once that the vessel does possess a Logbook for such records, it is

difficult to prove if indeed the alarm for vessels operated normally on the occasion of the accident.

Likewise it can not be confirmed the existence of adequate instructions for night-time navigation

and surveillance, especially in dense traffic areas.





21

4. There was no report of factors related to adverse meteorological conditions or mecha-

nical failures, and evidence was not produced that could prove fatigue or health problems on the

part of the crewmember of the supply involved in the accident.

5. Regarding the breach of the rules of the International Regulations to Avoid Collisions

at Sea, 1972 (COLREG), as it was not possible for investigators to accurately define the course of

the fishing vessel, it is not possible to evaluate which vessel should have compulsorily maneuvered

to avoid collision, or if the accident would have been the result of some sudden maneuver of some

or of both vessels.

By the evaluation of this accident it may be proved that the elementary lesson of a permanent

and effective surveillance is the best way to prevent accidents at sea. There is no doubt that, even

for vessels equipped with detection equipment, the vigilant posture of the crewmembers on watch

shall be permanent, while for vessels that do not have electronic equipment vigilance should be

redoubled.

Another lesson that may extracted is that the navigation lights should be in a good state and

lit during the nocturnal periods or of low visibility and during the day in bad weather, to enable

the vessel to be sighted at a safe distance.

Once sighted another vessel, maneuvers and safety procedures recommended by COLREG

should be immediately put into practice in order to define the maneuver as soon as possible, using

the phony contact for questions if needed.

XI – RECOMMENDATIONS

First of all, safety recommendations shall in no case create a presumption of blame or liabil-

ity.

The accident investigated pointed out the necessity for an improvement in the objectives of

the Company Safety Management, in conformity with that laid down in the International Safety

Management Code (ISM Code). In the case of the Supply “FAST TITAN” the ISM records rela-

ting to audits, inspections and corrective measures are susceptible to verification and establish the

scope of knowledge assumed by the administration.





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A good Safety Management System should establish and keep procedures to control all do-

cumentation and data that are relevant. The companies (owner of the ship or any other organizati-

on or person such as the manager) must ensure that the importance of effective Bridge Resource

Management (BRM) be reflected in its ISM documentation. The internal auditors should measure

with precision the level of this compliance.

Considering the potential hazards associated with navigation of a vessel that develops high

speeds, transporting passengers and sailing in waters of dense traffic, it is recommended that she

has a redundant surveillance and tracking targets system with the use of electronic, human and

organizational resources. A Bridge Resource Management contributes effectively to eliminate the

risk that a human error can result in a dangerous situation. It is recommended to carry out internal

audit to check the records of non-compliance, and whether adequate monitoring is being held in

situations similar to those reported.

On the other hand, as generally the fishing boats have a reduced speed on the majority of

their courses, their crews should be trained to visually sweep the horizon frequently and increase

the vigilance when not equipped with electronic detection equipment.

LIST OF ANNEXES:

ANNEX A - Characteristics of Supply “FAST TITAN”

ANNEX B & B1 - Report of Inspection of the ship (FORM A and FORM B)

ANNEX C - Certificate of Registry of vessel (FV “EVILAZIO”)

ANNEX D - Crew List (Supply ”FAST TITAN”)

ANNEX E – Copy of Notification about the accident





23

ANNEX A

Characteristics of Supply “FAST TITAN”





24

ANNEX B

Report of Inspection of the ship (FORM A)





25

ANNEX B1

Report of Inspection of the ship (FORM B)





26

ANNEX C

Certificate of Registry of vessel (FV “EVILAZIO”)





27

ANNEX D

Crew List (Supply ”FAST TITAN”)





28

ANNEX E

Copy of Notification about the accident