FINAL INVESTIGATION REPORT No.AD09038303 M/V … DE ACCIDENT… · FINAL INVESTIGATION REPORT No.AD09038303 ... Ship Details ... LO Lube Oil FW Fresh Water SW Sea Water

Gaby Bou Chaaya Sunk - M/V ¨ SUNSHINE¨ Accidents Investigator

Panama Maritime Authority Directorate General of Mercant Marine Marine Casualty Investigation Branch

Panama, Republic of Panama Page 1

FINAL INVESTIGATION REPORT No.AD09038303

M/V “SUNSHINE” – IMO No. 7806180

SUNK OFF LIBYAN COST ON APRIL 22, 2007 R-010-07/DISAM Notice: This investigation report was written to improve safety and prevent possible accidents. The report does not address the possible responsibility or liability caused by the accident. The investigation report should not be used for purposes other than the improvement of safety, according.


Panama Maritime Authority

Directorate General of Mercant Marine Marine Casualty Investigation Branch


CONTENTS

SYNOPSIS ....................................................................................................................... 4

CHAPTER “A”, FACTUAL INFORMATION .....................................................................

1. Glossary and Abbreviations .......................................................................................... 6

2. Accident Summary ........................................................................................................ 7

3. Ship Details ................................................................................................................... 8

4. Hull................................................................................................................................ 9

5. Machinery ..................................................................................................................... 9

6. Bridge Equipment ....................................................................................................... 10

7. Relevant safety equipment ......................................................................................... 11

8. Certificates and inspections ........................................................................................ 12

General Arrangement Plan .......................................................................................... 14

Tank Capacity Plan ..................................................................................................... 14

Capacity Plan .............................................................................................................. 15

9. Working language ....................................................................................................... 16

10. Background ............................................................................................................... 17

10.1 The Ship ................................................................................................................. 17

The M/V “SUNSHINE” .................................................................................................... 17

10.2 Management Company ........................................................................................... 19

10.3 Maintenance ........................................................................................................... 19

10.4 Source of Information and interviews ...................................................................... 19

12. Narrative ................................................................................................................... 20

12.1 The previous voyage ............................................................................................... 20

12.2. The voyage of the accident .................................................................................... 20

12.3 Weather conditions ................................................................................................. 20

12.4 Departing condition of the ship ............................................................................... 21

12.5 Lashing of cargo ..................................................................................................... 22

12.6 Qualification of crew ................................................................................................ 22

12.7 The role of USB ...................................................................................................... 22





12.8 The ISM .................................................................................................................. 23

CHAPTER “B”, ANALYSIS ..............................................................................................

13. The accident ............................................................................................................. 25

14. Actions taken by the crew ......................................................................................... 26

15. The stability and important related matters ............................................................... 26

16. Events failures .......................................................................................................... 27

17. Search and rescue .................................................................................................... 27

CHAPTER “C”, CONCLUSIONS .....................................................................................

18. Conclusions .............................................................................................................. 29

19. Main causes of the accident ..................................................................................... 31

CHAPTER “D”, RECOMMENDATIONS ...................................................................... 34

20. Recommendations at this stage of the investigation ................................................. 35

CHAPTER “E”, PHOTOS ................................................................................................

21. Available photos ....................................................................................................... 37

21.1 Safety Inspection ................................................................................................. 38

21.2 Route/map of accident area ................................................................................ 51





SYNOPSIS

M/V “SUNSHINE” sailed on April 21st, 2007 from the port of Trapani – Sicily, loaded with

2048MT of marble, in blocks, heading to Port Said – Egypt. On April 22, 2007 the vessel was

sailing in weather 5-6B with foremost direction but the weather changed rapidly and she

found in heavy seas about 35nm North to the Libyan coast, as reported by her Master.

During Master’s effort to maintain a reasonable course under the given circumstances, the

vessel took, suddenly, excessive list and capsized within 10 minutes. Elsewhere reported

that the time elapsed for vessel’s capsizing was 20 minutes. However, under the stressed

conditions that the crew experienced is reasonable to have a relative sense of the time

without being able to be absolutely accurate.

Taking in consideration the heavy weather conditions, the very quick and sudden capsizing of

the vessel, the nature of the cargo, and the fact that nothing unusual or unsafe was reported,

so far, during vessel course, we may conclude the shifting of the cargo as the actual cause of

vessel’s capsizing and the consequent sinking.

It was a very fortunate event that the crew reacted very effectively activated a GMDSS alarm,

as reported by her Master and using vessel’s life saving means they manage to embark the

life boats and save their lives, being rescued on 24 April, 2007 by the British warship

Montrose. No deaths occurred nor were injuries reported.

Even that no pollution was officially reported, in fact it should be, even of a minor nature

considering the quantities of diesel and lubricating oil on board. Vessel’s managers reported

that there were on board eighteen (18) metric tons of diesel oil and seven tenth (0.7) metric

tons of lube oil, at the time of her departure from the port of Trapani. It is safely assumed that

these quantities will escape, from the vessel, progressively by the air vents and they shall

disperse with the sea currents. This casualty is rated as a Marine Casualty as per the

definition 4.1.3 of Appendix 5 – Code for Casualty Investigations.





CHAPTER “A”, FACTUAL INFORMATION





1. Glossary and Abbreviations

AIS Automatic Identification System CEC Certificate of Equivalent Competency COC Certificate of Competency DOC Document of Compliance E/R Engine Room GMDSS Global Maritime Distress and Safety System GPS Global Position System GT Gross Tons IMO International Maritime Organization ISM International Safety Management Code for the Safe Operation of Ships ISSC International Ship Security Certificate KW Kilowatts LBP Length between Perpendiculars LT Local Time NM Nautical Miles PSC Port State Control PMA Panama Maritime Authority USB Universal Shipping Bureau PHRS Phoenix Register of Shipping OOW Officer on Watch C/E Chief Engineer C/O Chief Officer 1/E First Engineer 2/O Second Officer 2/E Second Engineer 3/O Third Officer 3/E Third Engineer A/B Able Seaman OS Ordinary Seaman MDO Marine Diesel Oil HFO Heavy Fuel Oil LO Lube Oil FW Fresh Water SW Sea Water RPM Revolution per Minute SMC Safety Management Certificate SMS Safety Management System SOLAS Safety of Life at Sea Convention 1974 STCW International Convention on Standards of Training and Watch keeping for

Seafarers UTC Universal Coordinate Time VDR Voyage Data Recorder VHF Very High Frequency (radio)





VTS Vessel Traffic System FIOS Free In/Out Stowed

2. Accident Summary

2.1 Name of the vessel : SUNSHINE

2.2 Flag : Panama

2.3 Date of Sinking : 22 April 2007

2.4 Time of Sinking : 17:15 (Libyan local time)

2.5 Position : 35 nm North of Libyan coast

2.6 Total on board : 11

2.7 Total loss of Life : 0

2.8 Rescued alive : 11

2.9 Owners : LAVINIA MARITIME COMPANY

2.10 Management Company : DOGRU DENIZCILIK BROKERLIKLIC.LTD STI

2.11 Classification Society : PHOENIX REGISTER OF SHIPPING S.A.

2.12 Other RO : UNIVERSAL SHIPPING BUREAU INC.

2.13 Pollution : None reported





3. Ship Details 3.1 IMO No. : 7806180

3.2 Former Names : ALMIRA, ILKNUR II, KARAER II

3.3 Service : General cargo

3.4 Owners : LAVINIA MARITIME COMPANY

3.5 Flag : Panama

3.6 Call Sign : HO3769

3.7 Port Registry No. : 32789-PEXT

3.8 Characteristic of Service : Unrestricted Navigation

3.9 Gross Tonnage : 1214

3.10 Net Tonnage : 701

3.11 Overall length : 75.00 m

3.12 LBP : 67.00 m

3.13 Molded breath : 11.00 m

3.14 Freeboard : 852 mm

3.15 Draught : 5.14 m

3.16 Derricks and cranes : 3 derricks

3.17 Electrical plan Gen :

3.18 Speed : 11 knots

3.19 Power in kw : 746





4. Hull 4.1 Builder : Gunsin Shipyards S.A.

4.2 Building Year : Dec., 1985

4.3 Building place : Istanbul, Turkey

5. Machinery

5.1 Number, Type, Designer : One Internal Combustion Diesel Engine, Single screw

5.2 Year of built : 1983

5.3 Manufacturer and place of build : SKL, Germany

5.4 Power in kw : 746

5.5 Characteristics : 6 cylinders





6. Bridge Equipment 6.1 Standard magnetic compass

6.2 Gyro compass

6.3 Gyro compass heading repeater

6.4 Heading control system

6.5 Pelorus

6.6 Radar 9 GHz

6.7 A.I.S.

6.8 Echo sounding

6.9 Speed & distance measuring device

6.10 Rudder, propeller, thrust

6.11 Daylight signaling lamp

6.12 GMDSS Radio Equipment A1, A2

6.13 VHF radio installation

6.14 HF radio in installation

6.15 NAVTEX receiver

6.16 COSPAS-SARSAT

6.17 Radar transponders





7. Relevant safety equipment 7.1 Number of motor lifeboats : 1

7.2 Number of rescue boats : 1

7.3 Number of life rafts : 2

7.4 Number of persons accommodated by them : 20

7.5 Number of lifebuoys : 8

7.6 Number of lifejackets : 15

7.7 Number of immersion suits : 11

7.8 Number of thermal protective aids : 10

7.9 Number of radar transponders : 2

7.10 Number of two-way VHF radiotelephone apparatus : 3





8. Certificates and inspections

Certificate Issued by Issuance Expiration Last

Inspection 8.1 Certificate of Registry PMA -

8.2 Ship Station License PMA 05/072005 04/07/2009 -

8.3 Minimum Safe Manning PMA 22/02/2005 - -

8.4 Continuous Synopsis Record PMA 17/06/2005

8.5 Int’l Tonnage 1969 PMA 10/04/2007 - -

8.6 Crew Accommodation USB 13/06/2005 23/02/2009 -

8.7 Load Line USB 13/06/2005 23/02/2010 30/05/2006

8.8 Safety Construction USB 13/06/2005 23/02/2010 30/05/ 2006

8.9 Safety Equipment USB 01/03/2007 27/07/2007 28/02/2007

8.10 Safety Radio USB 01/03/2007 27/072007 28/02/2007

8.11 IOPP USB 13/07/2005 23/02/2010 30/05/2006

8.12 Document of Compliance USB 13/06/2005 03/05/2010 02/09/2006

8.13 Safety Management USB 13/06/2005 23/02/2010

8.14 Int’l Ship Security PMA 13/06/2005 23/05/2010

8.15 Solid Bulk Cargoes USB 13/06/2005 23/02/2010

8.16 Sewage USB 13/06/2005 23/02/2010

8.17 Class PHRS 13/06/2005 23/02/2010 16/11/2006

8.18 Last Dry dock 23/02/2005 Notes :

PMA : Panama Maritime Authorities

USB : Universal Shipping Bureau

PHRS : Phoenix Register of Shipping





General Arrangement Plan


Panama Maritime Authority Directorate General of Mercant Marine Marine Casualty Investigation Branch


Tank Capacity Plan





Capacity Plan





9. Working language All crew (latest crew list is below) of the M/V “SUNSHINE” was of Turkish nationality and their working language was Turkish.





10. Background 10.1 The Ship

The M/V “SUNSHINE” was built in 1985 in Istanbul, Turkey by GUNSIN SHIPYARDS S.A.,

owned by LAVINIA MARITIME COMPANY and operated by DOGRU DENIZCILIK

BROKERLIK LIC.LTD STI.

The vessel changed flag from Turkey to Panama in the year 2004. The vessel under the

Panama flag and operated from DOGRU DENIZCILIK BROKERLIK LIC.LTD STI., has

visited ports within Cyprus, Turkey, Romania Gibraltar, Spain, Malta, Israel, Morocco,

Greece, Tunisia, Italy, Slovenia, Portugal, Libya, Mauritania, Syria and Algeria.

Vessel’s previous names are as follows:

Karaer II, until January, 1999 under Turkey flag

IIknur 2, until December, 2004 under Turkey flag

Almira, until February, 2005 under Panama flag









10.2 Management Company

From 2004, the ship was operated by Dogru Denizcilik Brokerlik Ltd, Stl. This company was

certified pursuant ISM Code with a Document of Compliance (DOC) issued by Universal

Shipping Bureau on June 23rd, 2005 and it is valid until May 3rd, 2010. The last Annual

verification was done by Universal Shipping Bureau on August 2nd, 2006. During this audit,

four (4) non-conformities were raised by the Auditor which, and were all closed on

10/30/2006.

10.3 Maintenance Maintenance of the M/V “SUNSHINE”, according to records and interviews, was carried out

at proper intervals with no significant or related outstanding remarks.

Last special survey including dry-dock was done on February 23rd, 2005 at Gibraltar-

Kenitra, Constanta, Romania.

10.4 Source of Information and interviews

The information contained in this report has been collected through interviews to the

managing company’s personnel, vessel’s Class / RO / RSO surveyors-auditors.





12. Narrative

12.1 The previous voyage M/V “SUNSHINE” arrived at the port of Trapani, Italy from Annaba, Algeria.

12.2. The voyage of the accident M/V “SUNSHINE” sailed on April 21st, 2007 from the port of Trapani, Sicily, loaded with

2048MT of marble, in blocks, heading to Port Said, Egypt. The M/V “SUNSHINE”, 35 nm

North from the Libyan cost, suddenly took excessive list and capsized within 10 minutes.

Elsewhere reported that the time elapsed for vessel’s capsizing was 20 minutes.

No deaths occurred nor were injuries reported.

12.3 Weather conditions

According to Master’s report, the sea state was 5-6 B, while the vessel “was taking the sea

from forward,” that means the weather was ahead of the ship with a S-SW direction. This

statement is not very accurate because, usually a qualified/experienced master will not

stress his ship going ahead in weather like this. It would be wiser to maintain a slightly

different course taking the sea from the stem side.

As per the same statement, “35 miles off of the coast side (Libyan coast) the weather

changed and the sea started from every side.”





12.4 Departing condition of the ship

Before departure, the operations were carried out as usual by the ship’s crew. The loading

of 2048MT marble in blocks from Trapani, Italy to Port Said, Egypt were loaded under FIOS

terms. Other details of load are as follows:

Ballast water : Nil

Diesel Oil : 18MT

Fresh water : 12MT

Lubricating oil : 0.7 MT

Provision & constants : 4 MT

Additionally, all of the vessel’s statutory certificates were valid, as required for the intended

voyage.





12.5 Lashing of cargo The vessel has an approved cargo Securing Manual approved by Universal Shipping

Bureau on October 30th, 2006 in compliance with IMO Maritime Safety Committee,

MSC/Circ 745 of June 13th, 1996. Details of the lashing of cargoes as indicated in the

Manual shall be considered as self-explanatory, however, cargo stowage and lashing was

done from charters under the FIOS terms. As per manager’s statement, it is understood that

vessel’s crew was not actually involved into this process.

12.6 Qualification of crew

Vessel’s crew member’s vessels were of Turkish nationality and the vessel was manned

according to the Minimum Safe Manning Certificate. Only a confirmation issued by Panama

Consulate in Barcelona, Spain stating that required documents for the issuance of

Panamanian Endorsement certificate for Mr. Servet Sahin, Master on board, was available.

National diplomas, endorsements, and Panamanian endorsements of the crew were lost at

time of accident. Therefore, we were unable to check crew’s qualifications. Managing

company stated that there were no available copies of said documents on their premises.

12.7 The role of USB Universal Shipping Bureau (USB) is a Recognized Organization and Recognized Security

Organization authorized by the Panama Maritime Administration to issue statutory

certificates.

USB had been issuing all statutory certificates for the M/V “SUNSHINE” since 2004.





12.8 ISM We have noted that an initial audit was carried out by USB on May 3rd, 2005 and permanent

DOC was issued on 06/13/05 valid until May 3rd, 2010. The last annual audit was carried out

on August 2nd, 2006 with satisfactory results. Four (4) Non-conformities were raised at that

time, but they were rectified / closed on 10/30/2006.

Nature of deficiencies posted by Port State Controls over the last 2 years, Non-conformities

raised by USB Auditor, and the absence of records/copies of the qualification diplomas /

endorsements of the seafarers on board, are proof of slackness of discipline by company

management.





CHAPTER “B”, ANALYSIS





13. The accident On April 22nd, 2007 the vessel was sailing in weather 5-6B with foremost direction, but the

weather changed rapidly and she was found in heavy seas about 35nm North of the Libyan

coast, as reported by her Master.

During Master’s effort to maintain a reasonable course under the given circumstances, the

vessel suddenly took excessive list and capsized within 10 minutes. Elsewhere reported that

the time elapsed for vessel’s capsizing was 20 minutes. However, under the stressed

conditions that the crew experienced, it is reasonable to have a relative sense of the time

without being able to be absolutely accurate.





Taking in consideration the heavy weather conditions, the very quick and sudden capsizing

of the vessel, the nature of the cargo, and the fact that nothing unusual or unsafe was

reported, so far during vessel’s course, we may conclude the shifting of the cargo as the

actual cause of vessel capsize and its consequent sinking.

It was a very fortunate event that the crew reacted very effectively, activated by a GMDSS

alarm, as reported by her Master, and using vessel’s life saving means. They managed to

embark the life boats and to save their lives, being rescued on April 24th, 2007 by the British

warship Montrose.

No deaths occurred nor were any injuries reported.

Even that no pollution was officially reported, in fact it should be even of a minor nature

considering the quantities of diesel and lubricating oil on board. Vessel’s managers reported

that there were on board eighteen (18) metric tons of diesel oil and seven tenths (0.7) metric

tons of lubricating oil, at the time of her departure from the port of Trapani. It is safely

assumed that these quantities will escape from the vessel, progressively by the air vents

and they shall disperse with the sea currents.

14. Actions taken by the crew It was a very fortunate event that the crew reacted very effectively, activated by a GMDSS

alarm, as reported by her Master, and using vessel’s life saving means. They managed to

embark the life boats and to save their lives.

15. The stability and important related matters The vessel has a Trim and Stability booklet approved initially by the Turkish flag

administration, and reviewed / approved by Universal Shipping Bureau under the provisions

of the International Convention on Load Lines 1966, Annex I, Regulations 10.1 and 10.2.





16. Events failures 16.1 Primary cause of failure has been identified by the shifting of a single heavy

block of marble cargo.

16.2 Loading was carried out by stevedores under FIOS terms, and it is obvious that

the Master had no active role during loading.

16.3 The lashing arrangement used for the securing of the single marble block was

provided, most probably, by the stevedores. Managers were unable to give details about the

lashing used and their condition. Therefore, we can only assume that this lashing was failed

permitting the cargo to be shifted during an extreme acceleration force.

16.4 Vessel’s Master was obliged to check and verify proper and adequate lashing

arrangement of the cargo. It was his responsibility to do so, prior to proceed at sea with

safety. From the information collected it is obvious that this check was never done.

17. Search and rescue No other ships were involved into this casualty. The only vessel involved for rescue

purposes, was the British frigate Montrose and transferred to Turkish Naval Ship Tcg

Gokceada taken to the Turkish Naval Base at Aksaz near Marmaris.





CHAPTER “C”, CONCLUSIONS





18. Conclusions As said earlier in this report, vessel was loaded with full cargo (2048 MT) of marble in

blocks, as it sailed from the port of Trapani, Sicily heading to Port Said, Egypt. As per

managers’ information, this kind of cargo was usual for this ship, so we shall consider that

her crew was familiar with its handling. In any case, the vessel found itself in heavy seas,

close to the Libyan coast (reported to be 35 miles north), and due to sudden shift of cargo

the ship capsized very quickly and sunk. It seems that the cargo had been shifted, so

suddenly, due to inadequate securing or due to failure of its securing equipment.

We found that the ship had an approved Cargo Securing Manual in accordance with SOLAS

Ch.VII, Reg.5 & IMO Res. A.715(17) and MSC/Circ.745. (Appendix 1)

This Cargo Securing Manual was a bilingual document (Turkish & English), which means

that the Turkish crew had no problem to read or understand it, being written in their own

native language. However, the manual’s copy which we traced from vessel’s RO (USB)

does not contain any particular information of the kind, the number, or the condition of the

portable securing equipment available on board. It is possible that the original Manual on

board had endorsed such kind of information. As usual, the copy submitted to RO for

approval does not. In any case, as the portable equipment is subject to maintenance or

replacement / renewal, it is the Master’s responsibility to maintain such list duly updated.

We had not the chance to interview the Master, but as reported by vessel’s managers, the

cargo was loaded in two layers; the second one was crossing the first one, secured by

dunnage. Only one heavy block was separate and lashed on top of the rest of the cargo. We

assume that this single block could be shifted, being the cause of the capsizing.





The vessel at the time of incident had adequate stability. The loading condition was reported

as follows:

1. Cargo Load : 2048MT

2. Ballast Water : NIL

3. Diesel Oil : 18 MT

4. Fresh Water : 12 MT

5. Lubricating Oil : 0.7 MT

6. Provisions & Constants : 4 MT

As there no particular details were not available, such as detailed loads distribution, centers

of gravity etc., it is not possible to carry out an accurate stability calculation due to the fact

that several assumptions would be introduced, thus, canceling any attempt to obtain

accurate results.

Therefore, as the above loading figures being, almost, very close with a typical “full cargo

departure”, we can safely conclude that the vessel had adequate intact stability. According

to the ship’s approved Stability and Grain Stability Information Booklet, for deadweight of

2078 MT, the calculated value of GM is 0.612 m (after free surfaces correction), so we can

conclude that the vessel had a positive GM in her last voyage. Therefore, the only

explanation for vessel’s capsizing could be only the combination of heavy seas and the

severe shifting of cargo in an adverse combination which resulted to cancel vessel’s positive

GM.

Unfortunately, the load of either the heavy lashed block or its exact place in the holds is

unknown. Managers reported that they never got a cargo stowage plan from the stevedores,

while vessel’s Master was unable to provide more details on this specific point. Under this

lack of information it cannot be verified, by means of calculations, how marble block’s

shifting has affected vessel’s intact stability. Also, there is no information nor any details

regarding the marble block’s lashing equipment.





In our opinion, vessel’s Master should have been aware on the lashing and the exact

positioning of this single marble block, which seems to be the cause of vessel’s capsizing.

Bearing in mind that the vessel was often engaged in such cargoes transportation in the

recent past, we may assume from our experience that an increased feel of confidence

would existed among vessel’s officers, believing that stevedores would make the most

suitable loading. This understanding is being supported from vessel’s managers, on the

basis that her chartering was in accordance with FIOS terms (Free In/Out Stowed).

However, even if this is the case, the C/O and the Master would check by themselves the

lashing arrangements of this single block in order to satisfy themselves that it was

adequately secured and vessel’s safety was not jeopardized. Managers were unable to

confirm if Master and C/O had checked the lashing arrangement or not.

19. Main causes of the accident

In principle, the shifting of cargo is being recognized as the cause of vessel’s capsizing. Up

to the time that the vessel was sunk, she had all her certificates valid and she was in a

seaworthy condition without any due / overdue recommendations.

Vessel had recently been inspected on April 2007, at the port of Lavrion in Greece, for

purposes of renewing her safety equipment and safety radio certificates, by a surveyor of

vessel’s RO (USB). Both surveys were carried out with satisfactory results. At that time,

nothing unusual or strange was observed raising additional attention from the surveyor, and

the vessel reported to be in full functional condition regarding her ballasting-deballasting

operation and during this last voyage had adequate stability.

The General Principles of CSS Code - Code of Safe Practice for Cargo Stowage and

Securing are stating that:





• All cargoes should be stowed and secured in such a way that the ship and persons

on board are not put at risk.

• The safe stowage and securing of cargoes depend on proper planning, execution,

and supervision.

• Personnel commissioned to tasks of cargo stowage and securing should be properly

qualified and experienced.

• Personnel planning and supervising the stowage and securing of cargo should have

sound, practical knowledge of the application and content of the Cargo Securing

Manual, if provided.

• In all cases, improper stowage and securing of cargo will be potentially hazardous to

the securing of other cargoes and to the ship itself.

• Decisions taken for measures of stowage and securing cargo should be based on the

most severe weather conditions which may be expected by experience for the

intended voyage.

• Ship-handling decisions taken by the Master, especially in bad weather conditions,

should take into account the type and stowage position of the cargo and the securing

arrangements.

It seems that the vessel’s Master had underestimated the prevailing severe weather

conditions, and he didn’t take adequate precautions in order to minimize the risk to face the

heavy seas. This behavior could be categorized as misjudgment of the situation. If he was

more precautionary, then he could alter vessel’s heading in a more safe way and possibly

the shifting of the cargo could be avoided. Considering that the mechanism of cargo shifting

is the excessive acceleration imposed by the heavy seas, then according to CSS Code -

Code of Safe Practice for Cargo Stowage and Securing Resolution A.714(17)(Amended by

MSC/Circ.664, MSC/Circ.691, MSC/Circ.740, MSC/Circ.812, MSC/Circ.1026) - Chapter 6 -

Actions Which may be Taken in Heavy Weather – the Master was able to proceed to:

• alteration of course or speed or a combination of both;

• early avoidance of areas of adverse weather and sea conditions; and





• timely ballasting or deballasting to improve the ship’s behaviour, taking into

account the actual stability conditions.

The shifting of the cargo resulted due to inadequate securing or due to failure of securing

equipment under the force of excessive accelerations. Under FIOS terms, managers are

claiming that it was shipper’s responsibility to load properly the vessel; however, we are of

the opinion that vessel’s Master is ultimately responsible for the ship’s safe preparation,

prior to commencing a voyage, and therefore, he should have verified that the cargo block

was properly loaded, stowed, and secured, and also he should have checked lashing during

the voyage.

Finally, based on our investigation, we have concluded that lack of proper implementation of

the CSS Code - Code of Safe Practice for Cargo Stowage and Securing was the principle

cause of this casualty.





CHAPTER “D”, RECOMMENDATIONS





20. Recommendations at this stage of the investigation We have recognized that the principle cause of this maritime casualty was the lack of proper

implementation of CSS Code - Code of Safe Practice for Cargo Stowage and Securing.

Bearing in mind that the said Code – being the applicable regulation in this case - has been

well worked all these years, being amended and improved from the gained experience, we

shall recognize, once more, that human factor remains the week link to this casualty also.

Vessel’s Master had the typical qualifications for his position, so a priori we consider him

capable to perform his duties; that means that he was properly trained according to the

requirements of STCW 78/95. However, his misjudgement in the prevailing weather

conditions and consequently the underestimation of the sea condition, in combination with a

possible lack of proper checking on the stowage and lashing arrangements of his cargo,

could have resulted or lead to this marine casualty.





CHAPTER “E”, PHOTOS





21. Available photos

21.1 Safety Inspection From the latest safety inspection at Lavrion, Greece on February 28th, 2007.

























































21.2 Route/map of accident area

Documents

FINAL INVESTIGATION REPORT No.AD09038303 M/V … DE ACCIDENT… · FINAL INVESTIGATION REPORT No.AD09038303 ... Ship Details ... LO Lube Oil FW Fresh Water SW Sea Water