Pl. Stefana Batorego 4, 70-207 Szczecin
The Commission has deemed it expedient to provide Corina vessel’s operator, Żegluga Gdańska Sp. z o.o., with recommendations on safety, which are proposal of action, which could contribute to preventing similar accidents in future. The recommendations pertain to implementation of the ship’s operator’s safety policy related to carriage of hazardous bulk cargoes and access to enclosed spaces on ships.
The State Commission on Maritime Accident Investigation recommends:
1) introducing changes to procedures included in the Safety Management System so that they include up to date requirements included in Regulation 19, Chapter III of SOLAS Convention pertaining to alarms and exercises in entering enclosed spaces and rescuing persons from them;
2) ensuring that enclosed spaces are identified on ships and the level of risk that may occur in them is assessed, depending on their locations on the ship and the way they are used, as well as ensuring that information on these spaces and hazards is displayed in a visible place on board the ship and is accessible to the crew;
3) ensure marking with warning signs of spaces, entry to which in specific operational statuses could pose a hazard to health or life of persons, and that entries to such spaces are secured in a manner prohibiting entry without the consent of a person responsible for safety;
4) before enrolling them on a ship, referring persons designated by the ship’s operator and responsible for implementation of the safety policy on ships (ship’s master, chief officer, chief engineer) to trainings on “entering and rescuing from enclosed spaces” and on “assessment and limitation of the risk of hazards.
The Commission has noted the efforts of Corina vessel’s operator undertaken following the accident, aiming at improvement of the ship’s operator safety management system, including development of new instructions related to enclosed spaces on ships. However the Commission sees the need for further action related both to the substance and quality of documents drafted by the ship’s operator.
Furthermore, the Commission recommends that changed are introduced to instruction I-08-2 (Instructions for procedures in case of a danger), in the scope of names of alarms and alarm signals, in order to make them consistent with the names and signals envisaged in § 13 of the Ordinance of the Minister of Infrastructure of 9 December 2014 on specific conditions of navigation of marine vessels (Journal of Laws, item 48).
State Commission on Maritime Accident Investigation has found it reasonable to formulate safety recommendations, forming the proposal of actions which may contribute to prevention of similar accidents in the future to the following bodies.
State Commission on Maritime Accident Investigation has recommended that the Company TransAtlantic Ship Management AB should:
1) instruct masters to prepare and implement watchkeeping schedules at port and at sea in such a way that, in accordance with the STCW Convention requirements, there was a duty seaman as a lookout on the bridge, apart from a watch officer, at night (in hours of darkness) and not only between 22:00 and 06:00;
2) instruct masters and officers responsible for preparing the voyage plan, when preparing the plan through narrow channels or fairways, to take into account the curvature of a track or passage by a sufficiently frequent changes of the course in order to observe the requirement of the COLREGS Regulation 9(a) to keep to the outer limit of a narrow channel or fairway.
The State Commission on Maritime Accident Investigation has recommended that the Zakład Usług Żeglugowych Sp. o. o. & Co. Sp. K. should:
1) make changes to the scope of responsibilities set out in the work chart of the dispatcher who is responsible for supervising the work of the tug boat crews, allowing the dispatcher to check the condition of the crew members (not only on sobriety), in particular a skipper of a tug boat, before their commencement of towing services;
2) take other measures, in consultation with the JSG – FACH Sp. o. o. company responsible for hiring the crews of tug boats, including control measures, which would prevent bringing and consuming alcoholic beverages on board of owner’s tug boats;
3) carry out systematic trainings and inform crew members of tug boats and, in particular, their skippers, about the consequences of performing their duties after consuming alcohol, including those stipulated in art. 87 § 1 of the Act of 20 May 1971 – the Code of Offences ; or in a state of intoxication, stipulated in art. 178a of the Act of 6 June 1997 – the Criminal Code and art. 108 § 2 of the Act of 26 June 1974 – the Labour Code and in art. 127 § 1 point 7 of the Act of 18 August 2011on Safety at Sea;
4) abandon the practice of taking passengers aboard vessels unfit for that purpose. Moreover, the Commission has submitted for further consideration of the operator the possibility of equipping the vessels in AIS transponders. The introduction of AIS devices, which are compulsory, for example, on small fishing vessels which are smaller than tug boats, would increase safety of navigation in water regions with heavy traffic. The operator’s tug boats could be sooner detected and shown on AIS monitors of the sea going vessels, and the AIS messages received by AIS devices on tug boats.
Regarding identified by the Commission repeated cases of cutting corners in the Świna channel by vessels piloted by pilots from the Station and the practice of piloting vessels contrary to the requirements of the COLREG Convention, the State Commission on Marine Accidents Investigation has recommended:
1) to instruct the pilots of the Station to advise the masters of piloted vessels whose size allows it, to keep as close as possible to the outer limit of the fairway in accordance with the requirements of Rule 9(a) of the COLREG Convention;
2) to encourage the pilots of the Station to use pilot electronic charts bearing the profile of the fairway, with which the pilots of the Station have been provided by the Szczecin Pilot company;
3) to instruct the pilots of the Station about the need of more frequent communication with the vessels navigating in the Świna channel from the opposite direction if they are not certain about the behaviour of a vessel or need to co-ordinate passing manoeuvres.
After analyzing the provisions on alcohol limits (permissible content of alcohol in blood or breath) binding in Polish law, the Commission noticed that in the Article 127 paragraph 1 point 7 of the Act of 18 August, 2011 on Safety at Sea there is a provision about a penalty establishing a fine for navigating a sea-going vessel or performing duties in the field of safety of the vessel, its protection and prevention of pollution of the marine environment, in a state of intoxication.
The provision about the penalty should refer to the order or prohibition expressed in a substantive provision. In other words, the penalty provided for in the act should refer to the violation of the order or prohibition clearly formulated in the Act (or binding international convention). The is no such provision – requiring specific behavior or prohibiting certain behavior – in the Act. The law on maritime safety has not provided for alcohol limits which should be observed by the crews of the sea-going vessels but it has provided for penalties for failure to comply with these limits. Such a solution is incompatible with the rules of legislative technique.
The State Commission on Maritime Accident Investigation has submitted for further consideration of the minister responsible for maritime economy the possibility of supplementing the provisions of the Act on Safety at Sea with substantive provision specifying in accordance with the provisions of the STCW Convention the limits of alcohol for crew members of sea-going vessels while performing their duties on board.
The State Maritime Accident Investigation Commission has deemed it expedient to issue recommendations on safety, which are proposal of action, which could contribute to preventing similar accidents in future, to the following entities:
State Maritime Accident Investigation Commission recommends that the Director of the Maritime Office in Gdynia should amend § 129 of the Standing Order No 5 of the Director of Maritime Office in Gdynia of 20 February 2013 – Port Regulations so that it clearly specified the place of pilot disembarkation for ships of large draught. The Commission recommends that the place should be located at least 5 cable lengths from the G1-G2 buoy pair.
The Commission suggests the following wording of the paragraph: § 129. 1. Ships of length of 60 m and more shall be obliged to use pilotage service.
2. Ships carrying dangerous cargo or ships of draught of more than 9 m shall embark the pilot at GD buoy or at the appropriate anchorage.
3. Ships of smaller draught shall embark the pilot at the fairway before the gate G-1 – G-2 at the latest.
4. Embarkation of the pilot at other places than defined in subparagraph 1 and 2 shall be carried out under the consent of Harbour Master.
5. The pilot may disembark a ship leaving the port after passing gates G-1 – G-2, and in the case of a ship of draught exceeding 9 m – at the distance of at least 0.5 nautical mile east to the gate.
6. Earlier disembarkation of the pilot, justified by the actual weather conditions, may take place under the consent of Harbour Master and the master of pilot vessel.
State Maritime Accident Investigation Commission recommends that Transocean Maritime Agencies should instruct the masters of its ships to comply with good maritime practices and navigate the ships in person in pilot waters, to supervise in person the manoeuvres related to disembarkation of the pilot and to hand over the ship to the watch officer after disembarkation of the pilot to the pilot board and exit of the ship to sailing waters that are safe for navigation.
The State Maritime Accident Investigation Commission has deemed it expedient to issue recommendations on safety, which are proposal of action, which could contribute to preventing similar accidents in future.
Since the Nefryt shipowner repaired the ventilation trunk of the ventilation system, the Commission has decided that there is no need to formulate recommendations in this regard. The Commission considered the actions taken by the shipowner right after the accident and later to be appropriate corrective and preventive measures , but nevertheless deemed them insufficient. The State Maritime Accident Investigation Commission recommends that the owner of Nefryt, i.e. Euroafrica Services Limited, should:
1) develop and add to the list of “ship’s procedure for normal operation and high risk operations” in the Quality and Safety Management Manual a ship’s procedure for cargo fumigation, with checklists for in-transit fumigation of cargo, recommended by the IMO in MSC.1/Circ.1264;
2) add a subparagraph concerning the assessment of technical condition of ventilation trunks and casings on the ship in the checklist on form 01/P-12 “Protocol of superintendent’s inspection” in paragraph 6 “Deck equipment and devices” or in paragraph 3 “Deck cargo holds/tanks”;
3) furnish the ships of its fleet with automated external defibrillators (AED) which analyse the heart rhythm and allow to establish whether the injured needs defibrillation.
The Commission prepared recommendations for the Transport of Malta Merchant Shipping Directorate, representing the flag state administration on the day of accident, concerning the extension of the scope of flag state inspection to enable the flag state inspectors to check also the technical condition of the ship’s ventilation systems, but due to the change of the ship’s country of registration within the period from the accident to the day of drafting the report, the Commission decided to send to the Maltese administration only a copy of this Final Report for information purposes.
The State Marine Accident Investigation Commission has deemed it expedient to provide recommendations, which are proposals of actions which could contribute to preventing similar accidents in the future.
The State Marine Accident Investigation Commission recommends that the operator of the yacht Down North, DIK Mariusz Nawrot company, in case of deciding to return the yacht to service, should select an appropriate register into which the yacht would be entered (flag state) and an appropriate mode of yacht operation, ensuring meeting of the flag state requirements in the scope of safety, construction and equipment.
The State Marine Accident Investigation Commission recommends that the organizer of maritime sail-training cruises, Navigare Yacht Club company, takes all efforts to ensure due diligence in checking that the yachts to be used for cruise purposes hold valid safety documents, in line with obligations made by the organizer in statements included in the agreements signed with the cruise participants.
The State Marine Accident Investigation Commission recommends that the minister competent for maritime economy should implement the amendments in the Act of 11 August 2011 on maritime safety (Journal of Laws of 2016, item 281), which will enable performing the on-board verifications and inspections by controllers of the port state control (PSC) on foreign sea-going yachts mooring in Polish ports, for which the status related to their mode of operation (commercial or recreational) is unknown or raises justified doubts. The Commission proposes implementation of the following amendments to the provisions of the Act:
1) Article 33(1)(5):
a) Clause 5 should have the following wording: “5) commercial yachts chartered for remuneration without manning, subject to Article 110(2a)” or
b) repeal Paragraph 1(5);
2) After Article 35, add Article 35a in the following wording: „Article 35a. 1. Foreign sea-going yachts mooring in the Polish ports may be controlled by the port state carried out by the controlling authority.
2. Foreign sea-going yacht raising justified doubts whether it is a recreational or commercial yacht, is subject to on board verification.
3. When performing the on board verification, the controllers of port state control follow the applicable guidelines of the Paris Memorandum of Understanding”.
In addition, the Commission put under consideration of the minister competent for maritime economy to allocate additional funds for the SAR Service for training of the MRCK and the MPCK inspectors that will allow to increase skills of persons employed in these centres and to complete the necessary courses in specialized foreign centres.
The State Marine Accident Investigation Commission recommends that the SAR Operational Director supervising the Maritime Rescue Coordination Centre in Gdynia should:
1) expedite the development and implementation of the procedure ensuring that the Centre duty inspectors will remember, at each phone report from another MRCC, to request information in writing on the reported event and will use all available sources of information, including publicly available Internet services, to verify the received reports and assess the actual situation (position) of the vessel in distress based on its name and AIS signal;
2) request the entities managing the systems supporting the search and rescue operations (SWIBŻ and SARCASS) to adjust the systems used in the Centre and to provide them with functions facilitating searching of information on the position and particulars of the vessel in distress based on incomplete data within the period of at least 48 hours backwards;
3) promote training the users of the systems supporting the search and rescue operations in techniques of using the functions facilitating checking data and correctness of the position of the vessel in danger, including its navigation history (archive) and from information derived from the radar VTS sensor of the iMARE VTS system of the National Maritime Safety System (KSBM);
4) ensure effective reporting of any deficiencies in the systems supporting the search and rescue operations to their managing and supervising entities to ensure resolving of such deficiencies.
The Commission additionally proposes considering development in the future of a general policy for recruitment of operational inspector candidates (including e.g. initial requirements, preparatory courses), among others to avoid employing at this position persons without due knowledge of English language.
The State Marine Accident Investigation Commission recommends that the Directors of Maritime Offices in Gdynia, Słupsk and Szczecin draw the attention of the subordinated harbour masters, in which the foreign flagged sea-going vessels moor, to the need of more thorough checks of registration and safety documents of yachts by the officers of the harbour master’s office. In the case of finding irregularities or raising justified doubts as to the yacht status (whether it is a commercial or a recreational one), this fact should be reported to the nearest controller of the port state control or the PSC coordinator in Gdynia.
The State Marine Accident Investigation Commission recommends that the Port State Control officers perform the inspection and verify the status of the yacht Down North navigating under the Canadian flag and conducting commercial activity in the Polish territorial waters, at the nearest mooring of the yacht in a Polish port.
The Commission recommends that the PSC inspectors use the right laid down in the Paris MoU guidelines – Eligibility of Yachts to Port State Control – to determine whether the foreign yacht moored in the port is subject to a PSC inspection despite lack of information on the yacht in the THETIS information system.
The Commission recommends that determination of the status of a yacht which is unknown or to which there are justified doubts, should be performed in line with these guidelines and that further proceeding should follow the Paris MoU provisions.
The Commission recommends that a closer cooperation should be established between the PSC and harbour master’s offices in the scope of determining the status of yachts raising justified doubts as to their status (commercial or recreational).
The State Marine Accident Investigation Commission recommends that the Minister competent for physical culture should include into the scope of certification examination for the Yacht Skipper license the issues related to yacht stability in a way ensuring that the skipper will be capable to use typical stability information documents issued for the yacht.
Yachts of length exceeding 15 m may navigate in all maritime waters under command of persons holding the Yacht Skipper license. Such vessels are subject to technical inspection. Upon inspection performed by a recognized organization or an authorized official body, those yachts receive the document confirming the yacht’s technical capacity for sailing. Many yachts, including some commercial yachts, have the ‘Information on Stability’ document on board, containing the stability data related to basic loading conditions and other guidance information for the skipper’s assessment of proper navigation, thus increasing safety of skipper and the crew. The yacht skipper should have basic knowledge and skills sufficient for practical use of information on stability provided by classification societies according to valid standards and common practices.
The State Marine Accident Investigation Commission recommends that the company Escort Sp. z o.o., Szczecin, carrying out the maintenance service of radio communication equipment, follow the recommendations of the Maritime Safety Committee of the International Maritime Organization (IMO) presented in the circular MSC.1/Circ.1040/Rev.1 during performance of annual testing of EPIRBs of the COSPAS-SARSAT system. The Test Protocol Form should include all recommended annual testing items indicated in the circular and duly recorded performance or non-performance of the individual items of the test.
The State Marine Accident Investigation Commission has deemed reasonable to refer to the following entities safety recommendations representing the proposals of measures that may contribute to the prevention of similar accidents in the future.
In relation to the corrective actions taken by the operator of the tug boat Zeus in the period from the occurrence of the fire until the date of the report, as to tug boat fire-fighting equipment and the anti-alcohol policy, which largely fulfil the recommendations made by the Commission during the accident investigation, the Commission decided not to issue any recommendations in these matters. Nevertheless the State Marine Accident Investigation Commission has recommended that the company Zakład Usług Żeglugowych Sp. z o.o. & Co. in Szczecin should:
1) create a mechanism of control of alarm drills organized and carried out by the masters of tug boats, which would ensure verification that the drills are attended by the whole crew regardless of their individual tasks and functions performed on a tug boat;
2) correct the fire control plan of the tug boat “Zeus” as to correctness of the symbols used on it; the Commission found out that there was no manually operated call point installed on board of the tug boat, but the fire control plan contains symbol of such an installation.
The State Marine Accident Investigation Commission has recommended that the Polish Register of Shipping SA should upgrade Part V “Fire Protection” of the “Rules for the Classification and Construction of Sea-going Vessels” by introducing an obligation to make the modernization, involving the installation of the fire detection and alarm systems in the accommodation and working spaces of tug boats flying Polish flag, built before 1986 with more than 5 crew members. The deadline for modernization should be adjusted to the date of the nearest class survey but not later than the end of 2018.
Since Räddningstjänsten Västra Blekinge (Municipal Rescue Service) has taken due action from experience of the rescue operation (see 6.1) SHK refrains from issuing any recommendations.
SOS Alarmcentral Växjö (the alarm dispatch centre) is recommended to ensure that operational personnel at all times are able to handle the equipment needed for their task.
Swedish Civil Contingencies Agency, MSB, in cooperation with SMA, STA and the Coast Guard, is recommended to enhance knowledge within municipal rescue services about the possibility to get in contact with administrations and authorities with shipping knowledge when needed.
