BRAZILIAN NAVY DIRECTORATE OF PORTS AND COASTS · Code of the International Maritime Organization (IMO), adopted by Resolution MSC.255(84). This Final Report is a technical document

BRAZILIAN NAVY – Directorate of Ports and Coasts Department of Inquiries and Investigations of Navigation Accidents

Fall into the water and death of a crew member of the M/V “LISA” Maritime Safety Investigation Report

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BRAZILIAN NAVY

DIRECTORATE OF PORTS AND COASTS

FALL INTO THE WATER AND DEATH OF A CREW MEMBER OF THE M/V “LISA”

BELEM, PARA – JULY 29, 2014

MARITIME SAFETY INVESTIGATION REPORT

Photo 1: MV "LISA" anchored, at the beginning of the investigation. Reference: Casualty Investigation Code – International Maritime Organization MEPC.3 MSC / Circ.2, June 13, 2008 / Resolution MSC.255 (13)



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TABLE OF CONTENTS

I- LIST OF ABBREVIATIONS........................................................................................3

II- INTRODUCTION.......................................................................................................4

III- SINOPSIS...................................................................................................................4

IV- GENERAL INFORMATION ....................................................................................5

a) MV"LISA"data:”.....................................................................................................5

b) MV “LISA” Documents :........................................................................................6

c) Ferry Tank (BT) "Flexal" Data................................................................................7

d) BT "Flexal" Documents:...............................................................................................8

e) Motor Tug (RM) "Monte Dourado IV" Data:..............................................................8

f) RM "Monte Dourado IV" documents:.....................................................................9

V- DATA OF THE PLACE OF THE ACCIDENT......................................................... 9

VI- HUMAN FACTORS AND CREW .........................................................................14

VII- SEQUENCE OF EVENTS.....................................................................................17

VIII- PROCEDURES AFTER ACCIDENT...................................................................19

IX-CONSEQUENCES OF ACCIDENT …………………………………………..…19

X-EXPERT EXAMINATION.........................................................................................20

XI-ANALYSIS OF DATA COLLECTED AND CAUSAL FACTORS.........................22

XII- LESSONS LEARNED AND PRELIMINARY CONCLUSIONS.........................23

XIII- SAFETY RECOMMENDATIONS ......................................................................23

XIV- ANNEX ................................................................................................................25



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I- LIST OF ABBREVIATIONS AGM - Shipping Agency

AMB - Brazilian Maritime Authority

AP - State of Amapa

BT – Tank Barge

CFM - Chief Engineer

CNPJ- National Register of Legal Entities

Casualty Investigation Code - International Standards and Recommended Practices Code for a

Maritime Safety Accident or Incident Investigation , International Maritime Organization (IMO).

CPAOR - the Port Captaincy of East Amazon

CTS – Minimum Safe Manning

COMTE- Master

DHN - Directorate of Hydrography and Navigation

DPC - Directorate of Ports and Coasts

DPEM - Damage Compulsory Insurance of Personal Injury Caused by Vessels or their Cargo

PA – State of Para

IML - Forensic Institute

IMO - the International Maritime Organization

ISM Code - International Safety Management

IAFN- Administrative Inquire of Navigation Accidents and Facts

MNM - Oiler

MOM - Wiper

MV - Merchant Vessel



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II-INTRODUCTION

For the purpose of accomplishing the collection and the analysis of evidences, the identification

of the causal factors and the elaboration of the recommendations of safety that are necessary, in

order to avoid that in the future occur similar maritime accidents and/or incidents, the Port

Captaincy of East Amazon (CPAOR) carried out the present Safety Investigation of Maritime

Accidents and Incidents (ISAIM) 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 the CPAOR in

relation to the circumstances that contributed or may have contributed to unleash the occurrence and

does not resort to any procedures of proof for verification of civil or criminal responsibility.

Furthermore, it should be emphasized the importance of protecting the person responsible for

the supplying of information related to the occurrence of the accident, for the use of information

included in this report for ends other than the prevention of future similar accidents may lead to

erroneous interpretations and conclusions.

III-SYNOPSIS

At 20:35 pm on July 25, 2014, the MV "LISA", coming from the port of Santana, State of

Amapa, IMO No. 9384174, Dutch flag, Call Sign PCTI, type general cargo, loaded with wood

chips, draft of seven meters, owned by the shipping company Lisa Shipping BV, anchored in the

geographical coordinates of Latitude 01 ° 27.3 South and longitude 048 ° 31.8 WEST, position

located in the Minas Gerais Channel, Guajara bay, city of Belem, State of Para, near the shore of

the Island of the Jaguars, inland area, average depth of 12 meters (DHN navigation chart nr 320).

After anchoring at 21:37 hours, the convoy made up of the RM "MONTE DOURADO IV" and

BT "Flexal" docked to starboard side of the MV “LISA” to the transfer operation of 155 tons of fuel

oil MF-380 and connect the supply hose . At 23:00 hours was the beginning of the supply operation

being coordinated by the CFM of the MV"LISA". At 01:15 pm on July 26, 2014 ended the supply.

At 01:28 hours the Master of MV "LISA" descended the bridge to the main deck to check the

progress of supply, which found the CFM, his assistants and the representative AGM of

MV”LISA”. At 01:30 hours the CFM was aboard the RM for signature of supply documentation; as



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there was no pad aboard the RM compatible with the stamp of the CFM, he returned on board the

MV. At 01:39 hours was disconnected the supply hose. At 02:10 hours the MV 2OM met with MV

CFM on the main deck near the accommodation.

At 02:15 hours the RM Master was aboard the MV and demand for the CFM, because it had not

returned to sign the documentation. Also at 02:15 hours the Officer on the bridge was called via

VHF and asked if the CFM was on the bridge. At 02:25 hours the MV Master did call through the

intercom asking for CFM's presence on the bridge. The 02:30 hours, not getting the CFM response,

the Master activated the general alarm and ordered the crew to a search on board; as was a not

successful search, he had to call via VHF radio the AGM and the Pilot Station, prompting the

maritime authorities were informed of the CFM disappearance.

At 02:45 hours was lowered the rescue boat and started searching the river near the MV. At

03:34 hours, the rescue boat had machinery problems. At 03:47 hours, the rescue boat moored in

the Island of the Jaguars. At 04:35 hours, was made radio contact with the VHF of the CPAOR

motor boat. At 4:55 pm, the CPAOR motor boat docked the MV "LISA" with the rescue boat. At

06:10 hours, the CPAOR motor boat unmoored, getting the search under the responsibility of the

competent bodies.

On 28 July, the CPAOR received from the 1ºGMAF that a body was found on the shore of the

Island of the Jaguars, in the geographic coordinates: latitude 01°24`, 551 South and longitude 048º

31`, 645 WEST. At 12:00 hours, the CPAOR inspection team arrived at the scene and recognized

the body through a photo. The launch of 1ºGMAF collected the body to the morgue. The Master

and the representative of MV "LISA"AGM were reported to attend the IML to effect the formal

recognition of the body.

IV- GENERAL INFORMATION

Characteristics of vessels involved in the accident:

a) MV"LISA" data:

Name: MV "LISA"

Previous name: MV "HEATER C";

Flag: Netherlands;

Call sign: PCTI;

Port of Registration: Rotterdam;



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IMO: 9384174;

MMSI: 246922000;

Sat-B Telephone: 870773209203;

E-mail: [email protected];

Type: General Cargo Transportation;

Propulsion: Diesel Engine;

Navigation Area: Open Sea;

Gross Tonnage: 5629;

Total length: 108.20 meters;

Beam: 18.20 meters;

Depth: 9.00 meters;

Draft: 7.057 meters;

Hull Material: Steel;

Classification Society: Germanischer Lloyd;

Owner: LISA SHIPPING BV;

Address : Krakau 3 (Vaanpark 3) 2993 LV Barendrecht, The Netherlands;

Operator: Flinter MANAGEMENT B.V .;

Address: Krakau 3 (Vaanpark 3) 2993 LV Barendrecht The Netherlands, PO Box 349, 2990

AH Barendrecht, The Netherlands.

P & I insurance: Dutch P & I;

Port of Origin: Santana, State of Amapa;

Destination: Karskar-Sweden;

Load: wood chips;

b) MV “LISA” Documents :

TITLE ISSUING AUTHORITY ISSUE DATE EXPIRY DATE

Registration Certificate – Flag Country 04/17/2014

Indeterminate

International Certificate of Safety Equipment for

Cargo Ship- Germanisher Lloyd 19/08/2013 27/11/2016

International Pollution Prevention Certificate



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For Oil Germanischer Lloyd 03/07/2013 27/11/2016

International Construction Certificate- Germanischer Lloyd 03/07/2013 27/11/2016

Radio International Certificate- Germanischer Lloyd 03/07/2013 27/11/2016

Free Edge International Certificate- Germanischer Lloyd 03/07/2013 27/11/2016

Document of Compliance (ISM)- Bureau Veritas 14/02/2012 03/01/2017

Safety Management Certificate- Bureau Veritas 26/11/2013 16/08/2018

International Air Pollution Prevention Certificate-

Germanischer Lloyd 23/07/2013 27.11.2016

International Protection Certificate for Ships- Bureau Veritas 26/11/2013 08/16/2018

Minimum Safe Manning – Flag Country 29/01/2013 29/01/2018

International Tonnage Certificate- Gemanischer Lloyd 05/21/2013 Indeterminate

Class Certificate- Germanischer Lloyd 05/02/2013 11.27.2016

International Pollution Prevention Certificate Sewage -

Germanischer Lloyd 07.03.2013 27.11.2016

Document of Compliance with Special Requirements

for Ships carrying Dangerous Goods- Germanischer Lloyd 07.03.2013 27.11.2016

Authorization document for the Grain Transportation

- Germanischer Lloyd 19.08.2013 11.27.2016

c) Ferry Tank (BT) "Flexal" Data

Name: "Flexal";

Flag: Brazil;

Port of Registration: Bethlehem;

Description: 021.031939-9;

Built Location: Belém-PA;

Type: Barge Tank;

Propulsion: unpowered;

Navigation Area: inner;

Gross Tonnage: 1076;

Overall length: 65 meters;

Beam: 15 meters;



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Depth: 3.8 meters;

Draft: 3.3 meters;

Hull Material: Steel

Owner: DELIMA TRADE AND NAVIGATION; Address: Rua Judge Cezar do Rego,

number 850, Cologne Antonio Aleixo, CEP 69008-445, Manaus-AM; CNPJ:

05089941000167; Operator: DELIMA TRADE AND NAVIGATION;

d) BT "Flexal" Documents:

TITLE ISSUING - AUTHORITY ISSUE DATE EXPIRY DATE

Registration Certificate- CPAOR 27/08/2010 Indeterminate

Safety Navigation Certificate - Bureau Colombo Ltda. 24/10/2012 26/11/2016

Class certificate - Bureau Colombo Ltda. 26/11/2012 20/11/2016

National Tonnage Certificate - Bureau Colombo Ltda. 24/10/2012 Indeterminate

National Load Lines Certificate - Bureau Colombo Ltda. 24/10/2012 20/11/2016

Insurance DPEM - BRADESCO SA 10/10/2013 10/10/2014

e) Motor Tug Data (RM) "Monte Dourado IV":

Name: GOLDEN HILL IV;

Flag: Brazil;

Port of Registration: Belem;

Description: 021-022654-4;

Call sign: PQ 9769;

Location Built: Belem-PA;

Type: Tugboat / Pusher;

Propulsion: diesel engine;

Navigation Area: Interior;

Gross Tonnage: 146;

Overall length: 18.8 meters;

Beam: 2.5 meters;

Draft: 1.8 meters;

Hull Material: Steel;



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Owner: SION NAVIGATION LTD;

Address: Highway Arthur Bernardes, passing Conception, number 36, telegraph

neighborhood, CEP 66630-505, Belem-PA;

CNPJ: 05018767 // 0001-61;

Operator: Delima TRADE AND NAVIGATION;

Address: Rua Judge Cezar do Rego, number 850, Cologne Antonio Aleixo, CEP 69008-445,

Manaus State of Amazonas (AM);

f) RM "Monte Dourado IV" Documents:

TITLE ISSUING AUTHORITY ISSUE DATE EXPIRY

DATE

Registration Certificate- Maritime Court 04/10/1989 Indeterminate

Security Navigation Certificate –

Colombo Navigation Bureau ltd. 11/05/2013 23/05/2018

Class Certificate - Bureau Colombo ltd. 05.11.2013 23.05.2016

National Tonnage Certificate Bureau Colombo ltd. 11/05/2013 undetermined

Insurance DPEM- BRADESCO SA 05/03/2014 05/03/2015

National Load Line Certificate - CPAOR 06/07/2000 indeterminate

V- DATA OF THE PLACE OF THE ACCIDENT

The MV”LISA” mooring place is inserted in nautical chart number 320, edited by DHN in

2008, in the geographical coordinates of latitude 01 ° 27.3 SOUTH and longitude 048 ° 31.8 WEST,

in the Minas Gerais channel, in Guajara bay, in the port of Belem-PA.

The accident occurred at night with a new moon, sky little cloudy / overcast passing through

overcast with rain showers and isolated thunderstorms occasionally strong. Wind SE / NE, NW

occasionally, with force 1/3 knots with gusts, good visibility reducing to moderate / restricted

during the rains, temperature stable, calm sea with little balance, ebb tide, stream running 2-3 knots.



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Photo 2: Guajara Bay and the city of Belem.

Photo 3: mooring site of the MV “LISA”



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Photo 4: MV “LISA” anchored on the early investigation of the accident.

Photo 5: anchoring position of the MV “LISA” in relation to where the body was found.



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Photo 6: place of the linkage between the RM and BT.

Photo 7: linkage área between the RM and BT – access between vessels is not provided with board, ladder, etc.



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Photo 8: main deck of BT is not provided of a balustrade.

Photo 9: overview of BT without a balustrade.



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VI-HUMAN FACTORS AND CREW

As the documentation noted on board, the composition of the crew was in accordance with the

Minimum Safe Manning Certificate, all crew members were certified, qualified, familiar and given

the expected STCW Convention. The Crew List was comprised of (13) thirteen crew members: 01

Dutch; 03 Russians; 01 of the Sri- Lanka and 08 Philippines. The working language spoken on

board was English. The vessel had good accommodation for all onboard personnel, usually

operated with this effective; hygienic conditions, ventilation, room temperature, lighting, noise and

leisure time for MV "LISA" crew heed what provides the standards.

The CFM, victim of the accident, Mr. Sunil Gamini Senanayake Henakellage, nationality Sri-

Lanka, 62 years old, boarded the MV "LISA" in the port of Santana-AP in 22/07/2014, last port of

call, but had a extensive experience in this role, having embarked on several ships.

The Master, Mr. Martien T. Lan, Dutch nationality, embarked on 07/09/2014, has 05 years of

experience in this function.

The 2ON, Mr. Gabriel John Consigna Turingan, Philippine nationality, embarked on 07/09/2014,

has 04 years of experience in this function.

The 2OM, Mr. Macky June Salinas Lavesores, Philippine nationality, embarked on 09/07/2014,

has 02 years of experience in this function.

MOM, Mr. Young Minerva Ganancial, Philippine nationality, embarked on 29/03/2014, has

01years of experience in this function.

According to the records found aboard, all crew members meet 08-hour work routine with the

rest of 16 hours in any 24 hour period. There were no worked overtime records that might

compromise the rest or create a condition of fatigue to the crew, except the CFM, which is not in

record overtime but there was excessive working hours.

No evidence of alcohol and / or drugs was found. Procedures on the prohibition of alcohol and

drugs and the random test reports of the crew were updated. Work contracts and health certificates

for all crew members were updated and no observations on prescription drug use and / or mental

and emotional behavior.



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Photo 10: IMO crew list of the MV “LISA”



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Photo 11: Work schedule of crew.



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The Safety Management Manual is in use, including familiarization for new crew members,

and has spread to the entire crew. All operational procedures related to the safety of personnel, ship

and environmental, including checklists, training and exercises, written in English, are up to date.

The language on board is English and there are no communication problems. Reports of recent

internal and external audits were filed and available for review; them not on discrepancies. The

procedures for corrective actions and equipment maintenance were updated and all deficiencies had

noted actions taken to solve them.

The ship's Security Manual is also in use on board, including familiarization for new crew

members and was released the entire crew. All files procedures, checklists, training and exercises,

written in English, are up to date except the onboard access control procedure that, during the

supply operation, was not updated.

VII- SEQUENCE OF EVENTS

July 23, 2014 - Wednesday:

The MV "LISA" lived the Santana port - AP, loaded with wood chips, in direction of Belem

port, to receive fuel oil.

July 25, 2014- Friday:

At about 18:00, arrival in the Pilot Station of Mosqueiro to receive a Pilot. At about 18:10

hours the Pilot is on board and the MV "LISA" follows for anchoring in the Belem harbor

anchorage ( Photo 2 and 3). The Master began to confer with the CFM if everything was according

to the fuel supply.

At about 20:35 hours the MV anchored in position of coordinates latitude 01 ° 27.3 South and

longitude 048 ° 31.8 WEST, located in the anchorage position of the Minas Gerais channel, Bay of

Guajara, opposite edge of the city of Belem and near the shore of the Jaguar island, inland area,

with an average depth of 12 meters, located on the chart DHN Nr. 320.

At about 21:37 hours, the representative of the AGM Wilson Sons, Mr. Igor Lopes da Silva,

embarked. The convoy formed by RM "Monte Dourado IV" and LV "Flexal" operated by the

company Delima Commerce and Navigation Ltd., moored the MV to starboard, connecting the hose

to supply 155 tons of oil MF-380 fuel.

At about 23:00 hours, after the hose has been connected and the lists of operational security of

the MV and the train had been checked, the supply operation started; security lists were signed by



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the MV”LISA” CFM and train Master. The supply operation was coordinated by CFM and the staff

was also composed by 2OM, the MNM and MOM.

July 26, 2014 - Saturday:

At about 01:15 hours, finished refueling, and started disconnecting the hose.

At about 01:28 hours, the MV Master descended to the main deck, to see how was the supply

operation. In front of the accommodations found the CFM, his assistants and the representative of

MV AGM. After being told that the supply operation had finished and was going all in order, he

returned to the bridge.

At about 01:30 hours, the hose was disconnected. The MV "LISA" CFM was aboard the RM to

check the documentation for supplies, but CFM returned to pick the pad of its stamp because it was

not compatible with existing in the RM.

At about 01:45 hours, the 2OM was making a survey of the fuel tanks of MV and CFM probed

the BT "Flexal" cargo tanks .

At about 02:10 hours, the 2OM met with CFM on the main deck near the accommodation.

Remained at this location and could not say what the fate of CFM.

At about 02:15 hours, the RM Master was aboard the MV looking for CFM. The Deck Officer in

the bridge was called and questioned about his presence there. The Master asked the Officer that as

soon as the CFM was located to attend the bridge. Over time the CFM was not found. Then the

Master went down to the CFM cabin and the engine room but he was not found.

At about 02:25 hours, the Master was renamed the CFM through the internal communication

system, also without success.

At about 02:30 hours, the general alarm was triggered when searches were made by NM "LISA"

and surroundings. On this occasion was also informed the Pilot Station and the AGM, to

communicate other authorities about the disappearance of CFM.

At about 02:45 hours, was lowered the rescue boat, starting the search in the river near the MV.

At about 03:34 hours, the rescue boat had a machinery problem.

At about 03:47 hours, the rescue boat moored in the Onças Island.

At about 04:35 hours, was maintained radio contact VHF with the CPAOR motor boat, being

reported to the CPAOR Officer the sequence of events.

At about 04:55 hours, the CPAOR motor boat docked on board with the rescue boat being

towed.



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At about 06:10 hours, the CPAOR motor boat unmoored, getting the search under the

responsibility of the competent bodies.

July 28, 2014 - Monday.

The CPAOR received an information from the 1ºGMAF that a body was found on the shore of

the island of the Jaguars, geographic coordinates of latitude 01 °24`.551 South and longitude 048º

31`.645 WEST (Photo 5).

Around 12:00 hours, the inspection team of the CPAOR arrived and recognized the body through

a photo. A motor boat from 1ºGMAF collected the body to the Forensic Institute (IML). The Master

and the representative of the AGM of the MV "LISA" were reported to make the formal recognition

of the body.

VIII-PROCEDURES AFTER ACCIDENT

The general alarm was triggered and carried out searches at MV and surrounding areas, and on

this occasion also informed the Pilot Station and the AGM to communicate to other authorities

about the disappearance of CFM. The rescue boat of the MV “LISA” was launched into the water,

starting the search in the river near the MV. However, the rescue boat had machinery problems, has

maintained contact by VHF radio with the CPAOR motor boat and informed the sequence of

events to the Officer on duty in CPAOR, getting the search under the responsibility of the

competent bodies.

IX- CONSEQUENCES OF ACCIDENT

a) Personal injury - Death by mechanical asphyxia (drowning): CFM Mr. Sunil Gamini

Senanayake Henakerallage.

b) Property Damage - Do not occurred.

c) Environmental damage - Do not occurred.

X- EXPERT EXAMINATIONS

On July 23, 2014, the MV demanded the Santana port - AP, bound for the port of Belem - PA,

for supply of fuel oil, loaded with wood chips, estimated time arrived on 18:00 pm , July 25 . Inland

navigation was made through the Amazon River and, after the MV demanded the north bar of this



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river, continued the open sea navigation to the south of the Amazon River bar. At 18:00 hours on 25

arrived at the Pilot Station, in Mosqueiro, to receive pilot in that location. At 18:10 hours, the Pilot

boarded the MV. The NM "LISA" followed for anchoring in the anchorage of Guanabara Bay,

Minas Channel. At 20:35 hours anchored in position coordinates Latitude 01 ° 27.3 South and

Longitude 048 ° 31.8 WEST.

The MV was inspected on July 29 by Port State Control Officers.

As for the general and structural aspect, the MV was in good condition, there was no evidence of

non-conformities, it was in normal fluctuation and tightness, with its navigation equipment,

government, communication, propulsion and salvage materials are under normal operating

conditions and according to their class condition.

At the beginning of the safety investigation held on July 29, 2014 in MV "LISA" about the

accident on 26 July, MV remained at anchor in the same location of the accident and the train

formed by RM "MONTE DOURADO IV” and BT "FLEXAL" had unmoored and returned to its

base of operations. To identify the possible causes of the disappearance of the CFM, the MV

“LISA” documents were found such as: Minimum Safe Manning, Crew List, Statutory Certificates

and its Annexes, Journals, Books Records, Personnel Detail, Service and Rest Schedule, hours

worked Extras registration, Crew Certification, Employment Contracts, Health Certificates, Safety

Management Plan, Security Plan and its operating procedures, checks lists, Training and Reporting

Training registration for Emergency chores. A full visual inspection of the vessel was performed.

The investigators were also carried out interviews with people involved in the accident.

The Service and Rest Schedule stated that the CFM meets service from 08:00 hours to 17:00

hours daily, with the MV at sea or in the harbor. The MV came to the Pilot Station at 18:00 hours,

one hour after the CFM to be in rest. Then, received the Pilot and sailed to the anchorage. The train

docked beside to the MV "LISA" shortly after its mooring and started refueling. It was found that

the CFM was supervising these maneuvers since the MV came to the Pilot Station to the time of his

disappearance, totaling 18:00 hours worked with 01:00 hour of rest, indicating a fatigue condition.

In the lists of operational security check of MV and RM, signed by the CFM of MV"LISA" and

by RM Master, included the lighting procedures, surveillance, communication and availability of

safe means of access between vessels were being met . In photographs taken aboard the MV it was



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found that the access plank between MV and BT was not provided with railing and safety net.

Access between the RM and BT was not provided with any safety device.

. Photo 12: List of BT Security Plan.



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Pictures 6 and 7 show the site of linkage with the RM bow to stern transom of the BT in

which the space between the vessels is large due to the thickness of the RM giant. This space was

not provided with safe means of access (plank, ladder or other access). In the interview with the

MOM of the RM stated that this space is very dangerous.

The photographs 8 and 9 shows that BT is not provided with a balustrade around the main deck

contour.

In all the interviews included the crew involved in the supply operation did not wear lifejackets.

On the Access Procedures in the Security Plan of the MV "LISA" is not in the record to board

the MV "LISA" through the board positioned between MV and BT "FLEXAL". Vigilance in this

area was not being performed and the CFM was not seen leaving or returning to board when he was

aboard the RM to sign supply documents and sound the BT's cargo tanks.

In the RM Master interview states that this vessel has not Logbook or other operations

registration document.

In the RM CFM interview, after disconnecting the hose, the witness went to the engine room and

put the main motors of the RM running. To be a vessel of limited length, the RM peg area with BT

presents a marked degree of noise, it is not possible to have a satisfying sense of hearing.

Not included in documents during refueling that a containment barrier was thrown into the

water around the vessels. This is required when operating at night, when there is fuel transfer, as

determined by item 0408 of NORMAM 08(standards of the Brazilian Maritime Authority).

XI- ANALYSIS AND CAUSAL FACTORS

The human factor from the point of view of bio-psychological aspect contributed to this

accident, because the CFM was in almost uninterrupted activity with just one hour rest in a period

of 1800 hours worked, creating a favorable condition for this crew fatigue.

The equipment used also contributed to the cause of the accident: the access between vessels -

indicated as safe in checks lists and operational procedures - are not correctly installed and was

unsafe for anyone to pass from one vessel to the other; the life jackets were not being used and

therefore any crew falling into the water at night could pose a high risk of life; the containment

barrier has not been released around the vessels and BT was not provided with the balustrade

around the main deck, with severe risk of falling water by a crew member pedestrian on the main

deck during the night.



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Another important factor was about the surveillance situation. It was found that the input control

and the output control of the board people of the MV "LISA" was not being fulfilled in the area of

access between the MV and BT. As the RM-BT train do not have this type of procedure, people

transiting in unsafe areas without being controlled, since the passages between ships was dangerous

and, also, BT had no balustrade around the deck which is a place where activities are performed

continuously during fuel transfer operations. The coupling area between the RM and BT was also

not provided with secure access and there was no control of the people around there when in transit.

In most cases, the investigations into the circumstances of the marine casualties and incidents

have shown that they are caused by non-compliance with established standards.

XII- LESSONS LEARNED AND PRELIMINARY CONCLUSIONS

In view of what was exposed above, it is concluded that the cause of the accident with the

disappearance followed the death by drowning of CFM "NM LISA" was due to the fall in the water

through one of the access between vessels or the edge not provided with the BT balustrade, which

were not properly secured to access or transit. There was failure to comply with safety standards on

secure access means (rigid board with handrails and safety net); nonexistent of access control

between vessels; life jackets were not used by the crew during access to the vessels to carry over

into unsafe areas (not provided of balustrade), these facts aggravated by the CFM fatigue: the CFM

was in almost uninterrupted activity with just one hour rest in a period of 1800 hours worked,

creating a favorable condition for this crew fatigue.

XIII- SAFETY RECOMMENDATIONS

a) The procedures and / or the checks cited in the Safety Management documentation must be

met and / or properly checked by the crew for their services.

b) The set meal times, rest and leisure must be met to a greater prevention of fatigue in crew

members.

c) The crew should be encouraged to not to risk their physical integrity under any

circumstances, especially if they are in a situation of possible fatigue from lack of rest by excessive

working hours.

d) In the passages between vessels should be supervising crew and logging crews in transit or

prohibiting access where there is an unacceptable risk.



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e) Vessels operating in inland navigation shall be provided with operational procedures for the

safety of personnel, navigation and protection of the water environment. In the Amazon region there

is not a safety management culture and procedures used during navigation / operation of these

vessels are insufficient and, when established, are not applied. Thus, measures are needed to

become safer operations.

f) Compounds train Pusher Barge and Ferry must install a secure access device in the linkage

area between vessels.

g) Barges / inland ferries should be provided with balustrades on the main deck and

construction standards must make compulsory the installation of balustrade in this area.

===================================================



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ANNEX – SHIP`S PARTICULARS OF THE MV "LISA"