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Reporting an accident by:

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2013 Safety recommendations from the final report WIM 16/13 – m/v Karsibór III

6. Zalecenia dotyczące bezpieczeństwa

Komisja uznała za uzasadnione skierowanie do Żeglugi Świnoujskiej – armatora promu Karsibór-III zaleceń dotyczących bezpieczeństwa, stanowiących propozycję działań, które mogą przyczynić się do zapobiegnięcia podobnemu wypadkowi w przyszłości. 

Państwowa Komisja Badania Wypadków Morskich zaleca:

1. Przeprowadzenie inspekcji i pomiar luzów zaworu suwakowego rozrządu oleju (przynajmniej demontaż samego suwaka w celu oceny wizualnej i wymiarowej – jeżeli jest możliwy bez demontażu wału wyjściowego przekładni).

2. Zlokalizowanie i usunięcie przecieków oleju.

3. Przegląd (mycie) wszystkich filtrów na rurociągach powietrza sterującego.

4. Badanie oleju przekładni po przepracowaniu ok. 1000 godzin (wziąwszy pod uwagę wiek eksploatowanych urządzeń).

5. Wyprażanie silikażelu w osuszaczach powietrza przynajmniej raz w roku (po sezonie zimowym). 6. Przetestowanie presostatów załączających pompę rezerwową oraz presostatów alarmowych ciśnienia powietrza sterującego.

7. Przeprowadzenie legalizacji manometrów (tych, dla których minął termin ważności).

8. Umieszczanie w raportach z przeglądów/remontów (zwłaszcza dotyczące elementów układu pneumatycznego) więcej informacji dotyczących stanu sprzed remontu i stanu po remoncie (co zrobiono, jakie części zostały wymienione, karty pomiarowe, itp.).

9. Umieszczenie tablic informacyjnych i instrukcji dla kierowców w języku polskim, niemieckim i angielskim, zarówno na promach jak i na przystaniach na obu brzegach przeprawy.

Komisja ponadto rekomenduje Żegludze Świnoujskiej będącej jednocześnie użytkownikiem infrastruktury portowej, z której korzystają jej promy, zainstalowanie efektywniejszych od obecnie zastosowanych pochłaniaczy energii (odbijaczy) dla ochrony nabrzeży po obu stronach przeprawy.

Dodatkowo Komisja poddaje też pod rozwagę armatora dokonanie modyfikacji układu sterowania przez zainstalowanie dodatkowego awaryjnego układu sterowania skokiem śruby z mostka – tzw. sterowanie przyciskowe (jeden przycisk „Naprzód” drugi przycisk „Wstecz”). Układ taki pozwoliłby błyskawicznie przejąć sterowanie skokiem w sytuacji, gdy przestanie działać pneumatyczne sterowanie skokiem.

6. Safety Recommendations

6.1. Harbour Master’s Office in Świnoujście – VTS Service

Main duty of the VTS Service is the control and traffic flow management in the area of their activity and supervision of compliance by vessels with the traffic rules on designates routes.  The control of the speed of vessels in the port entrance area belongs to the crucial tasks of the VTS Services. The devices operated by the VTS duty officers keeping up with the traffic flow enable to automatically detect and identify these vessels that exceed speed limits. Orders given by the VTS duty officer should be carried out by the vessel (the captain). Non-performance of such an order (given by the VTS Services) could be justified only if fulfilling it endangered the vessel or persons aboard. The use of diminutives and abbreviations and acceptance of radio communications (similar to the one quoted above in the footnote on p. 25) is an affront to the dignity of the VTS Service and provokes to disregarding behaviour of the traffic flow participants in the supervised area. The State Commission on Marine Accidents Investigation has recommended the following:

1. The VTS duty officers should maintain radio communication with the vessels according to the requirements of the radio communication regulations for communication in a very high frequency band for sea services and according to procedures included in IALA Vessel Traffic Service Manual based on IMO Standard Marine Communication Phrases (SMCP), as well as according to the knowledge acquired in the course of training for persons applying for a general certificate of the GMDSS operator.

2. The VTS duty officers should observe the traffic management procedures ensuring safety of navigation in the area under their supervision and enforce in a determined way orders issued to traffic participants.

6.2. Pilot Station in Szczecin

The knowledge and abilities of a pilot grow with the number of ships they have serviced in and out of the port. In the majority of cases, the experience of the pilot in handling is much greater than that of a captain. Model courses by IMO for captains include only a theory of manoeuvring. Only some shipowners send their captains to additional practical trainings conducted by centres that offer training in ship handling. Therefore, an appropriate risk assessment related to bringing a vessel in the port mostly belongs to the pilot, who apart from a long-term practice in ship handling, knows local conditions.

In the opinion of the Commission, the fact that the pilot ceased to advise the captain how to safely handle the vessel in a narrow and winding fairway is against the principles of seamanship (no analysis of risk resulting from excess speed of the vessel), is a serious mistake which contributed to the accident.

In the course of analysing the cause of the accident as far as the human factor was concerned, the Commission paid attention to routine, in the negative sense of this word, with which the pilot performed his duties. Routine is an inherent component of professional practice gained over the years in the performance of the same, repeated activities. Yet, at the same time, each entry in the port is a unique experience. Schematic repetition of activities or their negligence hoping that nothing wrong would happen, may lead to the accident and loss.

The State Commission on Marine Accidents Investigation has recommended the following:

1. Pilots should maintain radio communication with the VTS duty officers according to the requirements of radio communication regulations for communication in a very high frequency band for sea services and according to procedures included in IALA Vessel Traffic Service Manual based on IMO Standard Marine Communication Phrases (SMCP), as well as according to the knowledge acquired in the course of training for persons applying for a certificate of the VHF radio operator.

2. Every year there should be organized a meeting for all pilots to discuss and analyze marine accidents and incidents that took place during previous year in the area covered by the station. During such meetings, pilots should have the opportunity to exchange information and experience gained in the pilotage, which lead or could lead to difficult situations.

3. At least once a year with the consent of the Main VTS Operator in Świnoujście, all pilots acting as observers should take on a duty at the station together with the VTS duty officers.

6.3. Maritime Administration

The SOLAS convention in the Rule V/12, which came into effect in 2002, imposed on the IMO members states the obligation to appoint VTS in the areas, where traffic intensity or the degree of risk would justify such services. Poland complied both to requirements of the international as well as the EU law , implementing the traffic control on its territorial waters. Three VTS systems were established. The directors of maritime offices were responsible for their organization. It results from the material gathered in the course of investigation that each director organized it in a different way. Also, the directors interpreted and carried out in a different way, the delegation contained in the regulation of the Minister of Transport, Construction and Maritime Economy of 14 December 2012 on the National System of Traffic Flow Control and Transfer of Information  to secure the functioning of the VTS Service and to establish regulations and detailed operating procedures of these services.

Under the Art. 39 sec. 5 of the Marine Territories of the Republic of Poland and Maritime Administration Act of 21 March 1991 (Journal of Laws of 2013 item 934 and 1014), a maritime office – which helps local body of the maritime administration (director of the maritime office) to accomplish their tasks – should be composed of four independent units, i.e. maritime inspection, the VTS Service, harbour master’s, and dock master’s offices, and the shipping defence office. In the course of investigation, the Commission had difficulties in locating the VTS Service in the structure of the Maritime Office in Szczecin. These services were included in the composition of the harbour master’s office, merged with his duty services, and subordinated to the harbour master. From the description of tasks imposed on the VTS Service within the Organizational Regulations of the office it results that they go beyond the objectives ordinarily assigned to that kind of services. The VTS Service should cooperate with a competent harbour master’s office but they cannot perform its tasks. They should report to the director of the maritime office and not to the harbour master. Under Polish law, the VTS Service form a part of a maritime office and not a harbour master’s office. They are equally important as the harbour master’s office. The Act distinctly separates the competence of the maritime office director. With the help of the VTS Service, the director performs their tasks with regard to traffic monitoring and transmission of information, whereas with the help of harbour and dock master’s offices the director exercises their competence in ports and harbours. Therefore, according to the Commission, it is improper to merge the VTS Service and duty services of the harbour master’s office in the context of tasks for which the VTS Service were appointed.

In view of the above, the State Commission on Marine Accidents Investigation has recommended the following:

6.3.1. Director of the Maritime Office in Szczecin

 The Commission has recommended to develop and announce the VTS Service regulations according to the delegation contained in §6 p. 3 of the Regulation of the Minister of Transport, Construction and Maritime Economy on the National System of Traffic Flow Control and Transfer of Information. The regulations should define among others, the organizational structure of the VTS Service, subordination in service of operators (on duty), duty system (including rotations and replacements), the period of rest of operators, and procedures of the VTS operators (external and internal operating procedures). The external procedures should include among others, the mode of maintaining correspondence with ships, radio communication bands, emergency procedures for collision, sinking, grounding, falling overboard, environmental pollution, or fire on a vessel in the controlled area, and principles of cooperation with pilots and the pilot station. The internal procedures should include such ones, as e.g. changing of the watch (duty) procedure, as well as internal emergency procedures in the case of e.g. power failure of devices operated by the VTS operator or sudden loss of contact with a vessel led by the operator.  

When creating the regulations, one should consider IALA recommendations resulting from IALA VTS Manual 2012, IALA Recommendation V-127 on Operational Procedures for Vessel Traffic Services, 2nd ed. 2011, as well as resulting guidelines of appendix 1 to the IMO resolution A. 857 (20) Guidelines for Vessel Traffic Services, and the fact that the VTS operators should not be burdened with additional tasks, such as making inspections of vessels and port areas in the scope of port order or cooperating with the City Technical Duty Officer, Voluntary Sea Rescue  or the Governor’s Operating Office. 

6.3.2. Minister in Charge of the Maritime Economy

The Commission has recommended revising the organizational structure of the Maritime Office in Szczecin with regard to complying with the requirements of Art. 39 sec. 5 of the Marine Territories of the Republic of Poland and Maritime Administration Act. Correct position of the VTS Service in the structure of the office shall restore appropriate status to these services.  

The Commission has recommended to oblige the directors of remaining maritime offices to develop and announce the VTS Services regulations according to the delegation contained in the Regulation of the Minister of Transport, Construction and Maritime Economy on the National System of Traffic Flow Control and Transfer of Information. In the majority of documents related to the functioning of the VTS Services, which were analyzed by the Commission in the course of conducted examination, the directors define only the principles of functioning of the Services. Documents lack information on explicit organization of the Services and procedures of operation of the VTS operators.  

Moreover, in relation to discovered irregularities in the manner of communication of the pilot bringing Godafoss into the port of Świnoujście with the VTS Service, the State Commission on Maritime Accident Investigation has recommended to consider the legitimacy of introducing into the training programmes for sea pilots, periodic trainings (best of all at the time of renewing the diploma) in acquaintance with the regulations concerning radio telecommunication contact in the same scope as is required from persons applying for a certificate of a limited GMDSS operator.

6. Safety Recommendations

The State Commission on Marine Accident Investigation has considered reasonable issuing safety recommendations that form a proposal of measures, which may contribute to prevention of similar accidents in future, to the following entities.

6.1. Owner of the Horizon Aphrodite

The Commission has recommended that the shipowner, Horizon Tankers Ltd. SA Greece, should develop such procedures for preparation of the vessel to exit port that would ensure that the vessel would not be able to exit port not fully ballasted and they would allow the captain to conduct ballasting operations regardless of previously adopted operating plans and schedule of voyages.

6.2. Pilot Station in Gdańsk

The Commission has recommended that pilots should use tugboats and advise captains to use their assistance until the vessel is pulled away to the roadstead – behind the head of the eastern breakwater to the water region with safe depths (for a given draught of a vessel), taking into account weather conditions during the pilotage and manoeuvrability of a vessel.

6.3. Maritime Administration

The Commission has recommended that the Director of the Maritime Office in Gdynia should place – in the Order introducing Port regulations (Part II Chapter I: Additional provisions for the port of Gdańsk) – a provision regulating the release of tugboats from assisting vessels with large windage area (including in particular not fully ballasted vessels) exiting the port channel, not before reaching the roadstead, depending on the existing weather conditions.

6. Safety Recommendations

The State Commission on Maritime Accident Investigation considered reasonable to submit to Inspectis Poland Ltd in Gdynia, the company employing the injured cargo inspector, safety recommendations suggesting steps to be undertaken in order to prevent similar incidents in the future. The Commission has recommended:

1. Developing procedures regulating the entry of the cargo inspectors into the enclosed spaces aboard including the identification, assessment, and control of risks associated with entering and staying in such premises.

2. Developing a list of tasks to be performed or verification activities (checklist) before sampling the hold of the vessel, depending on the type of load to be controlled. Such tasks or activities should include, among others:

a) a review of personal protective equipment (safety shoes, helmet, gloves, respirator, safety harness),

b) checking the state and security of ladders used by inspectors,

c) checking lighting in the sampling places,

d) determining whether the cargo has been fumigated, and if so, whether the holds have been adequately ventilated by the crew,

e) checking the state of atmosphere in the premises where the inspector enters with a certified measuring instrument.

3. Obliging the inspectors to observe the accepted procedures, and use the checklist, and to confirm that the tasks have been performed or checking the activities described in the checklist before entering the hold.

4. Conducting regular trainings for cargo inspectors in respect of safe entry into enclosed spaces aboard.

5. Equipping the controllers with personal gas concentration measuring instruments and providing trainings in the use of such devices.

6. Equipping the inspectors designated to do the sampling of cargo in the holds of a vessel with standard safety harness, which facilitate the evacuation in the event of the loss of consciousness in the hold (the ladder way).

6. Safety Recommendations

The purpose of traffic separation schemes (TSS) at sea is to organize the traffic of vessels and improve safety of navigation. Vessels that decide to use TSS, have limited freedom of choosing a route. As early as back at sea they have to adjust their courses in order to enter the appropriate traffic line. This causes channeling of the shipping routes back at sea many miles before the TSS.


The introduction of a new TSS Slupska Bank by the maritime services without prior ordering to carry out detailed surveys of approach basins from the eastern and western sides by hydrographic services, has created a threat to the safety of navigation, especially for vessels with deep draught, exposing them to the risk of damage to the hull.


The State Commission for the Investigation of Marine Accidents considered reasonable issuing safety recommendations, forming the proposal of actions which may contribute to prevention of similar accidents like the one of the Twinkle Island, in future to the following bodies.

6.1. Maritime Administration

The Commission has recommended to carry out as soon as possible detailed multibeam hydrographic surveys using full sea floor search of the belt of water used for navigation by sea-going vessels from TSS Slupska Bank to the east towards the ports of the Gulf of Gdańsk. The Commission has recommended to intensify the activities associated with the initiative to appoint a new safe track of TSS Slupska Bank, to carry out appropriate surveys and to prepare relevant documents to be submitted to IMO.  

The Commission has recommended to consider the possibility of determining and marking out on nautical charts a “recommended track with maximum recommended draught” – for vessels with deep draught going from the area of the Gulf of Gdańsk along the Polish coast in a westerly direction to the Danish Straits – from exit from the traffic separation schemes in the Gulf (e.g. from the latitude of φ = 54°45.0’N, after leaving the VTS Zatoka controlled area) to the TSS Slupska Bank and from the TSS Slupska Bank to the TSS Adlergrund, along the entire route or some (selected) sections of the route which had been checked in terms of bathymetric conditions.  

The Commission has recommended to local units of the maritime administration, through the Port Captains of Gdańsk and Gdynia and shipping agents, to advise masters of vessels with deep draught, departing from these ports and heading for the Danish Straits, to use the assistance of sea pilots.

Moreover, the Commission has drawn the attention of the minister responsible for the maritime economy to determine with the Minister of National Defense the priorities in conducting surveys of the main shipping routes to Polish ports (including ports of the Gulf of Gdańsk and the external port in Świnoujście prepared for handling LNG, among others) and to increase the use of hydrographic units of the Polish Navy to carry out bathymetric surveys of Polish marine areas for the safety of navigation.

6.2. Hydrographic Office of the Polish Navy (BHMW)

The Commission has recommended to apply to the United Kingdom Hydrographic Office to correct the Admiralty chart no 2369 and to remove the marking of wrecks in the vicinity of shallows of the depth of 14.2 m detected in June 2013 in the entrance area to the TSS Slupska Bank from the eastern side at a level of Stilo lighthouse.  

The Commission has appreciated the initiative taken by the hydrographic service, after the accident of Twinkle Island, of active measures associated with surveying the depth on the shipping route from the ports of the Gulf of Gdańsk to the Danish Straits running to the south of the Slupska Bank, and in particular the fact of accomplishing the survey works to the west of the TSS Slupska Bank towards the traffic separation scheme TSS Adlergrund (east of Rügen). At the same time, the Commission has recommended to prepare, in cooperation with the maritime administration, a detailed plan of survey works, including a schedule specifying dates (months and years) and water basins where such works shall be conducted for the remaining water regions of the Republic of Poland. The activities carried out in accordance with such schedule would ensure the fulfilment of international obligations for Poland arising from the Copenhagen Declaration and would improve the safety of navigation in these areas.

6. Safety Recommendations

The Commission considered reasonable submitting to the Newa Owners, Reederei Erwin Strahlmann, the following safety recommendations forming the proposal of actions which may contribute to prevention of similar accidents in the future.
The State Commission on Maritime Accident Investigation has recommended to:


1) develop and include in the ship’s manager’s Security Management Book the procedures to ensure constant supervision on the part of the technical department of the ship’s manager over the repairs in the shipyard, anticipating, inter alia, situations similar to the case of Newa, when during the renovation several chief engineers have successively been embarked;


2) make systematical controls by technical inspectors of the ship’s manager the conformity of set values in the ME security systems with the technical and motion control documentation; changes of settings of the ME parameters by the crew should be agreed with the technical inspector responsible for the vessel and documented by entries in the engineer’s log book, and the information on the changes should be recorded in the duty transfer form (CL-012) filled in during the exchange of chief engineers;


3) inform the chief engineer regularly of the need to comply with the annual schedule of testing physical and chemical properties of the ME circulating oil, according to the Li-030 procedure contained in the Security Management Book, particularly when the vessel is in the yard undergoing ME repair;


4) include in the Security Management Book the procedures concerning the conduct of the crew when the vessel runs aground, including the obligation to probe depth around the vessel, check the state of the bottom ballast and fuel tanks, bilges in the holds, overboard oil spills, etc.

6. Safety Recommendations

  Many circumstances influenced the accident of Annemieke. Two of them are particularly important according to the Commission. They form the basis for formulating recommendations that can help to prevent similar accidents in the future. It is the routine, in the negative sense of the word, in the behaviour of the pilot navigating the vessel and the lack of due diligence in the fulfillment of their obligations by the operators of VTS Service.

 From the materials about the event collected by the Commission and data stored in audio channels in the VDR recorder it results that the pilot of Annemieke after speaking with the VTS operator during the unmooring manoeuvres from the Górnicze Wharf, he failed to maintain further radio contact with the VTS service and did not inform them (contrary to the port regulations) about unmooring and the intention to join the traffic. The pilot behaved like it was his duty not the VTS, to control traffic in the port. He failed to inform the vessel Celine navigating to the port exit, about his intention to join the traffic, believing that a distance of several cables to the approaching vessel was suitable and the maneuver would not create a hazardous situation. The Commission also found that the pilot navigating Annemieke has not used the portable computer, purchased for the purpose of the pilotage by the company Szczecin-Pilot, fitted with an appropriate electronic chart including information about the configuration of the fairway, GPS module and specialized software, but relied solely on his own experience and knowledge about the borders of the fairway.

The experience and knowledge of the pilot proved insufficient for the safe navigation of the vessel from the port. The subsequent increase of speed, when there was already a risk of collision with the ship standing at the wharf, manifests that the pilot has a bad habit of avoiding collisions by increasing the speed. In the opinion of the Commission, such behavior violates the principles of good seamanship.

Making recommendations with the aim of instructing the pilot to perform his duties in a prudent and professional way would be pointless according to the Commission. In this situation, the State Commission on Maritime Accident Investigation decided to send a recommendation to the Head Pilot of the pilot station Szczecin-Pilot, which organizes and coordinates pilot services in the port of Świnoujście, to call the station pilots’ attention to misconduct of the pilot navigating Annemieke on 19 December 2013 during the accident analyzed in the report and to encourage them to use any additional devices at their disposal that may help them manoeuvre and navigate correctly the ships under their care.
The State Commission on Maritime Accident Investigation recommends the VTS Service of the Harbour Master of Świnoujście to conduct a more thorough control of the traffic flow by VTS duty officers over the supervised area which would ensure full safety of navigation, and to react firmly to violation of the port regulations regarding speed limits on individual parts of the fairway by issuing to captains or pilots of vessels which exceed speed limits orders to limit speed and to enforce these orders consistently.

6. Safety Recommendations

The State Commission on Maritime Accident Investigation deemed it appropriate to send the recommendations aimed at improving technical condition of propulsion that had a direct impact on the safety of navigation to the shipowner of “Langballig”, i.e. Brise Bereederung GmbH & Co. KG Kg.

The State Commission on Maritime Accident Investigation has recommended that the shipowner should include in the system of planned overhaul and repair of “Langballig” the oil pump of the adjustable propeller hub, together with the electric motor and keep these devices in good technical condition as well as he should observe the timing of overhaul and repair of all propulsion elements and components to operate that system according to the manufacturer’s instructions.

Furthermore, the Commission deemed it appropriate to draw the attention of the towing company Fairplay Towage Poland     Sp. z o.o Sp. k. that their practice of not accepting orders for towing services from ships’ captains and waiting for information (service request) from ships’ agents  was incompatible with good seamanship. The captain of the ship, just as the ship’s agent is a representative of a shipowner. Calling for the assistance of tug boats by the captain, and particularly by the captain of a ship which is in an emergency situation, such as “Langballig”, should be treated just like an order of a duty officer of the harbour master’s office or the VTS operator. Calling tug boats and ordering to send them to the vessel were aimed at maintaining the safety of navigation on the fairway and preventing the occurrence of an emergency.

6. Safety Recommendations

According to the statistics provided by the classification society of the Amaranth, more than 60% of fires in engine rooms of the sea-going vessels are caused by the spillage of oil or fuel on hot surfaces (hot spots). These fires are much more dangerous and harder to suppress than other fires.  The operator managing a fleet of 20 vessels may expect the fire in the engine room in every range of 10 years of operation of the fleet.  The crews and the fleet managers should make every effort to ensure that such incidents would not occur.

The State Commission on Maritime Accident Investigation deemed reasonable to refer to the operator of the Amaranth safety recommendations, representing a proposal of measures that can help to prevent similar accidents in the future.

6.1. The Operator of the Amaranth

State Commission on Maritime Accident Investigation has recommended that the operator Unibaltic Ltd should:

1) use flat, reinforced graphite or graphite filled spiral gaskets on ships for flanged connections for thermal oil piping system as optimum ones for safety and tightness reliability reasons;

2) oblige the engineer officers on ships to make regular checks of vibration and temperature of bearings of the circulator pumps of the thermal oil system in order to eliminate a fire hazard associated with excessively hot surfaces;

3) train ships’ crew members (mostly masters and deck officers) in the preservation of information in VDR or S-VDR recorders installed on ships, after the accident;

4) amend the existing on-board muster lists on the Amaranth and adapt them to current international requirements.

Moreover, the Commission has recommended to the ship’s operator to consider, in consultation with the classification society, the use of appropriate, approved by the regulations, portable foam fire extinguishers in the vicinity of the system of thermal oil circulator pumps in order to improve fire safety of the Amaranth.

The Commission has also formulated a recommendation for the operator to elaborate instructions for the engineer officers for proper operational supervision, maintenance, and repair as well as ordering original spare parts and materials for the thermal oil system, according to the requirements and specifications of the manufacturer, taking into account specific working conditions of the thermal oil system, which are high temperature, pressure and maintaining the tightness of the system. Since the technical department and quality management department of the Amaranth’s operator had issued such recommendations for the crews of all the ships in its fleet in the bulletin No. 4/2014, prior to the publication of this report, the Commission has refrained from placing this recommendation in the final report.

The Commission positively assessed the measures taken by the shipowner of the Amaranth after the fire on 12 February 2014, and in particular a professionally prepared internal operator’s report of the investigation of this accident.

In connection with irregularities in muster lists of the Amaranth, which were found by the Commission during the investigation of the fire on board, the Commission shall make further recommendations to the following entities.

6.2. Port State Control (PSC)

The State Commission on Maritime Accident Investigation recommends to the inspectors of PSC in Szczecin to pay attention during their inspections on the seagoing vessels of foreign nationality calling at the port of Szczecin to the correctness of their muster lists and in particular the compliance of the general emergency alarm with the applicable international requirements.

6.3. The Classification Society of the Amaranth

The State Commission on Maritime Accident Investigation recommends to the DNV GL classification society, authorized by the flag State (Vanuatu) to issue on their behalf ship’s safety documents, to check in the course of next inspection carried on the Amaranth the validity of the Safety Equipment Certificate or to make an audit related to the functioning of the safety management system, muster lists used o-board and in the case of irregularities to ask the master or the ship’s operator to rectify them in accordance with international requirements in this regard.

6. Safety Recommendations

The Commission has received from the “Marichristina” operator information indicating that after the accident, the operator carried out a survey and analyzed the causes of the incident . Because the actions of the operator, in particular their commitment to carry out until 30 June 2016 the training for masters and deck officers on issues falling within the scope of the training course in Bridge Resource Management  fulfill the expectations of the Commission in relation to activities that may contribute to the prevention of similar maritime accidents in the future, the State Commission on Maritime Accident Investigation refrained from making safety recommendations in relation to the operator (Company).

However, the Commission draws the operator’s attention to the disparities within the meaning of the terms “accident” and “incident” used by the operator in a document prepared by the post-accident team and definitions in the SMM  and in the documents of the International Maritime Organization (IMO) regarding the investigation of marine accidents, in particular in the Casualty Investigation Code  and circulars of the IMO Maritime Safety Committee (MSC) regarding the reporting of marine casualties and incidents .

According to the Commission, the grounding of the vessel which caused its immobilization and inability to continue the journey (even for a short period of time) cannot be classified as an incident, and limiting the definition of an accident to mere cases of uncontrollable events resulting in death or injury of a mariner, damage to the environment or property, excessively narrows this notion.