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Marine Safety Investigation Unit
MARINE SAFETY INVESTIGATION REPORT
Safety investigation into the grounding of the
Maltese registered general cargo
STELLA
in the Bay Andros Island, Greece
on 26 July 2012
201207/022
MARINE SAFETY INVESTIGATION REPORT NO. 12/2013
FINAL
ii
Investigations into marine casualties are conducted under the provisions of the Merchant
Shipping (Accident and Incident Safety Investigation) Regulations, 2011 and therefore in
accordance with Regulation XI-I/6 of the International Convention for the Safety of Life at
Sea (SOLAS), and Directive 2009/18/EC of the European Parliament and of the Council of 23
April 2009, establishing the fundamental principles governing the investigation of accidents
in the maritime transport sector and amending Council Directive 1999/35/EC and Directive
2002/59/EC of the European Parliament and of the Council.
This safety investigation report is not written, in terms of content and style, with litigation in
mind and pursuant to Regulation 13(7) of the Merchant Shipping (Accident and Incident
Safety Investigation) Regulations, 2011, shall be inadmissible in any judicial proceedings
whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless,
under prescribed conditions, a Court determines otherwise.
The objective of this safety investigation report is precautionary and seeks to avoid a repeat
occurrence through an understanding of the events of 26 July 2012. Its sole purpose is
confined to the promulgation of safety lessons and therefore may be misleading if used for
other purposes.
The findings of the safety investigation are not binding on any party and the conclusions
reached and recommendations made shall in no case create a presumption of liability
(criminal and/or civil) or blame. It should be therefore noted that the content of this safety
investigation report does not constitute legal advice in any way and should not be construed
as such.
© Copyright TM, 2013
This document/publication (excluding the logos) may be re-used free of charge in any format
or medium for education purposes. It may be only re-used accurately and not in a misleading
context. The material must be acknowledged as TM copyright.
The document/publication shall be cited and properly referenced. Where the MSIU would
have identified any third party copyright, permission must be obtained from the copyright
holders concerned.
MARINE SAFETY INVESTIGATION UNIT
Malta Transport Centre
Marsa MRS 1917
Malta
iii
CONTENTS
LIST OF REFERENCES AND SOURCES OF INFORMATION ......................................................... iv
GLOASARY OF TERMS AND ABBREVIATIONS ............................................................................. v
SUMMARY ........................................................................................................................................... vii
1 FACTUAL INFORMATION ........................................................................................................... 1 1.1 Vessel, Voyage and Marine Casualty Particulars ................................................................... 1 1.2 Description of Vessel .............................................................................................................. 2 1.3 The Crew ................................................................................................................................. 4 1.4 Environment ............................................................................................................................ 4 1.5 Navigational Equipment ......................................................................................................... 4 1.6 Narrative ................................................................................................................................. 6
1.6.1 The passage plan ................................................................................................................. 7 1.6.2 The 0000-0400 navigatioanl watch ..................................................................................... 8 1.6.3 The grounding, damages sustained and refloating of the vessel ....................................... 11
2 ANALYSIS .................................................................................................................................... 16 2.1 Aim ....................................................................................................................................... 16 2.2 The Bridge Team and the Absence of a Look-out ................................................................ 16 2.4 Passage Planning, the Use of Navigational Aids and Position Fixing .................................. 18
2.4.1 Passage planning ............................................................................................................... 18 2.4.2 Navigational aids .............................................................................................................. 20 2.4.3 Position fixing ................................................................................................................... 22 2.4.4 Trade-offs and cognitive underload .................................................................................. 23
2.5 Fatigue .................................................................................................................................. 25
3 CONCLUSIONS ............................................................................................................................ 28 3.1 Immediate Safety Factor ....................................................................................................... 28 3.2 Latent Conditions and other Safety Factors .......................................................................... 28 3.3 Other Findings ...................................................................................................................... 28
4 RECOMMENDATIONS ................................................................................................................ 29
iv
LIST OF REFERENCES AND SOURCES OF INFORMATION
Caldwell, J. A. J., & Caldwell, J. L. (2003). Fatigue in aviation: a guide to staying
awake at the stick. Aldershot: Ashgate Publishing Limited.
Cohen, S. (1980). Aftereffects of stress on human performance and social behavior: a
review of research and theory. Psychological Bulletin, 88(1), 82-108.
Hellenic Bureau Marine Casualties Investigation.
International Maritime Organization (2001). MSC/Circ.1014. Guidance on fatigue
mitigation and management. London: Author.
Manager and crew members of MV Stella.
Parker, A. W., Briggs, L., Hubinger, L. M., Folkard, S., Green, S. (1998). The Work
Practices of Marine Pilots: a review. Canberra: Australian Maritime Safety
Authority.
Parker, C. J., Rooney, T. C. (2009). Bridge watchkeeping: a practical guide. London: The
Nautical Institute.
Riggio, R. E. (2010). Chapter 9: Worker stress and negative employee attitudes and
behaviors. Introduction to industrial/organizational psychology. Retrieved 30 May,
2013, from http://www.instruct.tri-c.edu/dhaiduc/PSY%201050/riggio_ppt_ch09.pdf.
v
GLOSSARY OF TERMS AND ABBREVIATIONS
AB Able bodied seaman
ARPA Automatic radar plotting aid
BNWAS Bridge navigational watch alarm system
E East
ECDIS Electronic chart display and information system
DPA Designated person ashore
GPS Global positioning system
IMO International Maritime Organization
GT Gross Tonnage
ISM International Safety Management
kW Kilowatts
LCD Liquid crystal display
LOF Lloyd‟s Open Form
M Metres
MM Millimetre
MSD Merchant Shipping Directorate
MSIU Marine Safety Investigation Unit
MSM Minimum Safe Manning
MV Motor vessel
N North
NAVTEX An international automated direct-printing service for
promulgation of navigational and meteorological warnings and
urgent information to vessels
Nm Nautical miles
No. Number
OOW Officer of the watch
vi
OS Ordinary seaman
RPM Revolutions per minute
SMS Safety Management System
STCW International Convention on Standards of Training,
Certification and Watchkeeping for Seafarers, 1978, as
amended
SW Southwest
UAIS Universal automatic identification system
VDU Visual display unit
VHF Very high frequency
WP Waypoint
vii
SUMMARY
On 26 July 2012, at 02491, the general cargo vessel Stella ran aground and remained
stranded on the southwest (SW) coast of Andros Island, (several nautical miles SW of
the main port of Gayrio). The vessel was in transit, after discharging cargo from
Chalkis, Greece to the port of Galati Romania, for loading.
At 2359 on 25 July 2012, the second mate relieved the master as the officer of the
watch (OOW), but subsequently fell asleep during his watch on the bridge. The
master had been on duty for the 1800-2400 watch. The watch had been handed over
to the second mate after Stella cleared the South Evoikos Kolpos Channel2 and
entered the Kolpos of Petalion open sea area. The safety investigation revealed that
no look-out was posted, and with the duty OOW asleep on the bridge for almost two
hours, the vessel maintained a steady course and crossed two consecutive (planned)
way points (WPs) without altering course (at the Kafireas Strait between the islands of
Andros and Evia) before running hard aground on the SW coast of Andros Island3,
Greece.
Stella remained stranded on a steep rocky shoreline. She sustained ruptures in her double
ballast tanks and the bottom shell plating was also damaged although limited to the
forepeak tank area. No injuries or pollution were reported and local port authorities /
Coast Guard, who were notified by a nearby fishing boat, took immediate actions, and
provided support to crew and vessel. Refloating operations commenced on the same day
and the salvors were able to refloat Stella on 07 August 2012.
As a result of the safety investigation, the MSIU has made two recommendations to
the management company in order to ensure effective implementation of safe
navigational practices.
1 Unless otherwise stated, all times in the safety investigation report are local times.
2 This stretch of water is a narrow channel of water separating the Island of Evia from Viotia
mainland Greece.
3 The area is close to the port of Gayrio.
1
1 FACTUAL INFORMATION
1.1 Vessel, Voyage and Marine Casualty Particulars
Name Stella
Flag Malta
Classification Society Russian Maritime Register of Shipping
IMO Number 8883288
Type General Cargo
Registered Owner Vapur Shipping Ltd.
Managers Transyug Shipping Co., Ukraine
Construction Steel (Double bottom)
Length overall 89.12 m
Registered Length 84.38 m
Gross Tonnage 1857
Minimum Safe Manning 9
Authorised Cargo Bulk
Port of Departure Chalkis, Greece
Port of Arrival Galati, Romania
Type of Voyage International
Cargo Information In ballast
Manning 10
Date and Time 26 July 2012 at 0249 (ship‟s time)
Type of Marine Casualty or Incident Serious Marine Casualty
Location of Occurrence 37° 53.09‟N 024° 42.02‟E
Place on Board Bulbous; Ballast tank
Injuries/Fatalities None
Damage/Environmental Impact None
Ship Operation On passage
Voyage Segment Transit
External & Internal Environment The vessel grounded at night time, in clear weather
with a visibility of around 6 nm. The wind was
blowing at about 23 knots and wave height was
around 0.5 m. The air and sea temperatures were
26°C and 25°C respectively.
Persons on Board 10
2
1.2 Description of Vessel
Stella is a Maltese registered 1,857 GT single deck, general cargo vessel, built by JSC
Volgograd Shipyard, Russia in 1990 (Figure 1). She is owned by Vapur Shipping Co.
Ltd. and managed by Transyug Shipping Co. of Ukraine. The vessel is classed by the
Russian Maritime Register of Shipping. Stella has an overall length of 86.70 m and a
beam of 12.2 m. She is fitted with a double bottom configuration, deck-house
superstructure, with crew areas and bridge situated forward and with the engine-room
located at the aft end beneath the weather deck.
Visibility from the bridge was considered to be very good with no equipment installed
in a way to obstruct the view4. Aft of the deckhouse is the cargo space, which
consists of a single cargo hold, measuring 41.25 m by 8.9 m and 6.0 m deep. Stella
had a summer draught of 4.10 m and a summer deadweight of 2758 metric tonnes.
The cargo hold had two hatch covers of the Piggy-back type.
Propulsive power was provided by two SKL MOTOR GMBH diesel engines (type
6NVDS 48A-2U), producing a total power of 1030 kW. Each main engine drove a
single fixed pitch propeller. The vessel‟s maximum speed was 9 knots.
Stella followed a typical trading pattern of loading steel products (steel coils, steel
plates, etc.) at the Black sea ports of Nikolaev, Ukraine and Galati, Romania. The
discharge ports were mainly the Greek ports in the Aegean (Thessaloniki, Elefsis,
Tsingeli and Chalkis), Diliskelesi, Turkey and Larnaca, Cyprus.
4 A foremast fitted on the stem was not considered to have obstructed visibility during the course of
the events.
3
Figure 1: MV Stella
4
1.3 The Crew
At the time of the accident, the vessel had 10 crew members on board, comprising of
the master, a chief mate, one second mate, the chief engineer, a second engineer, a
third engineer, an electronic engineer, one ordinary seaman, one AB and a cook. All
crew members were Ukrainian nationals except for the chief engineer and the second
engineer who were Russian. The working language on board was Ukrainian.
Since the master held the navigational watch, the ship was normally on the standard 4-
on 8-off navigational watch system. The master had signed on the vessel 08 June
2012. He had no past employments with the company and a total of 35 years
experience at sea, out of which five years as a master. The OOW had signed-on one
month before the master, i.e. on 08 May 2012. He was described to have limited
experience as OOW but was considered by the master and the chief mate as good,
cautious and accurate on his assigned duties.
1.4 Environment
At the grounding site, the wind was North-northwest, force 4 to 5 on the Beaufort
Scale with good visibility. The current was weak and southbound. During the night
the wind increased to force 6. Evidence did not indicate that the weather conditions
had any direct effect on the dynamics of the accident. However, the area is well
known for strong Northerly winds and seas prevailing year around.
1.5 Navigational Equipment
Stella‟s navigation equipment was of the conventional (Russian) type, including a
typical Furuno radar, with ARPA capabilities (with LG Flatron screen) and with GPS
interface5, one SPR-1400 GPS receiver, a custom made automatic steering control,
and an echo sounder unit.
The GPS receiver was positioned in the chart room (a small area located on port side on
the aft section of the wheel house) and incorporated alarm signals, which would activate
5 It was noticed that the speed data input was over the ground and not through the water.
5
Steering
Echo sounder Telegraph
Furuno Radar
when the vessel reached programmed WPs. However, the audible alarms sound level was
very low and more often than not, it could not be heard from the wheelhouse6.
A McMurdo / Transas MT-1 UAIS transponder system with MT-1 VDU was also
installed on the bridge. Stella did not have ECDIS as part of her navigational
equipment. Figures 2 to 5 provide a general indication of the bridge layout.
Figure 2: Echo sounder, steering and telegraph
Figure 3: Position of the radar on the bridge
6 The GPS audible alarm was tested during the course of the safety investigation and it was
confirmed that the sound level was very weak.
6
GPS NAVTEX
Figure 4: GPS unit and NAVTEX
Figure 5: Pilot chairs in the wheelhouse
1.6 Narrative
Stella departed Chalkis at approximately 1830 on 25 July 2012, after completing the
cargo discharge operations. She followed south-easterly courses through the Gulf of
South Evoikos (Channel) and the Gulf of Petalioi (area that stretches between the east
coast of Attica and the southern tip of the island of Evia). The plan was to
subsequently pass Kafireas Strait (during the first hours of the morning) and proceed
to the Canakkale/Dardanelles Strait, with south-easterly course alterations.
7
1.6.1 The passage plan
Evidence suggested that the passage plan had not been prepared by the second mate in
the customary way followed in other vessel‟s voyages7. The deck officer had been
occupied with the cargo discharge operations in Chalkis, up to the departure and the
disembarkation of the pilot just before the full away on passage.
The passage plan had been prepared only as a draft on a piece of paper (Figure 6). It
was the navigational officer‟s intention to officially prepare the passage plan using the
appropriate template on the bridge and eventually have it approved and endorsed by
the master. The passage plan had not been properly drawn on the navigational charts
used for this particular voyage. In this case also, it was the navigational officer‟s
intention to do the task during his navigational watch on the bridge.
Figure 6: Draft passage plan
In order to make up for the incomplete passage plan, the route of arrival to Chalkis,
which was drawn on the previous voyage (indication of courses / distances to be
travelled) was used, with an update of the WPs (numbering/sequence) to be used on
each leg of the route to the Dardanelles Strait. The route, which had to be followed
from the departure from Chalkis until arrival at the Dardanelles Strait and Istanbul
Roads (Route no. 28), had been inserted in the GPS receiver in form of WPs (Figure
7), and communicated to the master (Figure 8).
7 It was the responsibility of the second mate to prepare the passage plan and discuss it with the
master for approval.
8
Figure 7: GPS receiver display indicating Route no. 28
Figure 8: Notes to the master, showing the WPs to be followed
1.6.2 The 0000-0400 navigational watch
The second mate took over the navigational watch from the master on 25 July 2012 at
about midnight (2359). At the time, Stella had already reached WP 184. The vessel
9
WP 177
Location where OOW fell asleep
WP184
Route planned
Route followed
Watch handover WP184
No-Go areas
Not to be used for Navigation
was on a course of 098° and making a speed of about 7.5 knots. Stella‟s GPS position
during the watch handover was 37° 57.1‟N 024° 12.6‟E. The position was recorded
on the deck logbook and the navigational chart8.
The watch handover was carried out without any particular remarks on the vessel‟s
navigation and passage plan. The second mate was cautioned to maintain a
continuous radio watch on VHF Channel 16 for safety purposes and on Rafina Traffic
(VHF Channel 13) for coastal traffic purposes. No look-out was posted on the bridge.
Although the vessel had to transit the Kafireas Strait during the 0000-0400 watch, no
master‟s standing orders were left to notify the master or the chief mate when the
vessel would have reached particular WPs.
It was customary on board to draw „No-Go areas‟ on the chart when passing next to
land masses / islands / rocks at distances of 1.5 nautical miles or less (Figure 9).
Guard zones, radar and echo sounder specific alarms were either consciously not set
or had been overlooked.
Figure 9: Tracked route showing where No-Go areas were drawn on the chart
The navigational watch was practically uneventful. The gyro compass course was
098°, whilst the magnetic compass read 097°, and the vessel‟s speed over the ground
was about 7.5 knots. All available navigational instruments were reported to be in
8 The primary position fixing method was the GPS. Radar conspicuous marks and visual aids were
10
Radar
Steering, Telegraph and
Echo sounder
Position where
OOW claimed
to have fallen
asleep
Entrance to chat room
good working order. There was moderate to low visible traffic between WPs nos.
184-175.
The OOW explained that after assuming duties on the bridge, he was initially active
and was walking around the wheelhouse to perform watchkeeping adequately.
However, he claimed that he felt tired after a while. He went near one of the two
chairs on the bridge, precisely the one on port side next to the chartroom entrance9,
resting his back against the chartroom bulkhead and his right arm on said chair.
The OOW further stated that he fell asleep as he was in a standing position,
approximately two hours after he assumed the navigational watch (at approximately
0145 on 26 July 2012)10 (Figure 10). A fix position had been entered neither on the
chart nor on the deck logbook. The last position was the one entered during the
handover of the watch (at about 2359).
Figure 10: Position where the OOW claimed to have fallen asleep
not regularly used on board Stella even if the vessel navigated coastal waters.
9 The OOW claimed that he had selected this position on purpose because he would be in front of the
radar and at the same time he would have been able to hear the GPS alarm signal at the next WP
(no. 175).
10 The OOW explained that the last thing he could remember was that vessel was approximately
1.75 nautical miles from WP no. 175, where he was to alter course to 073°.
11
The course was maintained at 098° (autopilot) and with constant engine rpm, the
vessel‟s speed varied only slightly, depending on the effects, which the weather
conditions (wind/seas) had on the ship at different geographical positions along the
route.
1.6.3 The grounding, damages sustained and refloating of the vessel
Practically with an unmanned bridge for more than one hour, Stella crossed the
planned WPs nos. 175 and 177 and eventually ran aground and remained stranded a
few minutes before 0300.
Both the chief mate and the master woke up to the noise and violent vibrations and
reached the bridge soon after, finding the OOW in a state of shock. Since the master
and the chief mate could not determine whether the vessel had enough buoyancy to
remain afloat, the main engines were kept running for about 20 minutes in order to
ensure that the vessel‟s position remained stable11.
Following the grounding, the vessel sustained a black out although necessary services
were supplied through the emergency power supply. The Designated Person Ashore
(DPA) was informed of the accident at about 0306. The DPA requested the master to
notify Rafina Traffic, verify that none of the crew members was injured, and to
determine the structural condition of the vessel. The chief mate tried to call Rafina
Traffic at approximately 0315 but reportedly he received no response. In the
meantime, all crew members were mustered to ensure that no one suffered any
injuries. Subsequently, the master ordered the sounding of all the double bottom and
ballast tanks. The investigation by the crew members revealed that nos.1 and 2
forepeak tanks were ruptured and had flooded.
In the meantime, also at about 0315, the coastal State‟s Coast Guard was informed by
a nearby fishing boat of the grounding. Assistance was immediately deployed to the
area and two cargo vessels navigating in close proximity to the area, were requested to
remain on stand-by. The Coast Guard eventually established contact with Stella at
0450 and was officially informed of the accident by the master, who also reported on
11
Only the forward part of the bottom area of the vessel seemed stranded on the rocky seabed and the
extent of damages e.g. water ingress in ballast tanks could not been assessed at that time.
12
the safe condition of the crew. Later during the morning, a diver from the Coast
Guard inspected the nature and extent of the bottom shell plating damages.
An occasional survey was carried out in the presence of the classification society
surveyor on 26 July 2012 in order to determine the extent of damages to the bottom
shell plating (Figure 11). As a result of the grounding, Stella sustained the following
structural damages:
Port side bottom area Plating bent 3000 mm * 1000 mm at frames 5 to 9;
Crack 200 mm * 60 mm at frame 24; breach in hull
1000 mm * 500 mm at frame 26-28; plating bent
5000 mm * 1500 mm at frame 20-28; plating bent
3000 mm * 2000 mm at frame 29-33.
Centreline bottom area Plating bent 600 mm * 300 mm at frame 28; plating
bent 2000 mm * 2000 mm at Frame 29-33.
Starboard side bottom area Plating bent 500 mm * 500 mm at frame 7 8; plating
bent 4000 mm * 1000 mm at frame 11-19; crack
20 mm * 80 mm; plating bent 1000 mm * 300 mm at
frame 21-23; three platings bent 1000 mm * 500 mm,
1500 mm * 500 mm, 2000 mm * 300 mm. Three
cracks 100 mm * 20 mm, 40 mm * 60 mm and
300 mm * 80 mm at frame 28-31; plating bent
4000 mm * 2000 mm and three cracks
200 mm * 80 mm, 300 mm * 20 mm, 80 mm * 20 mm
at frame 33-36.
13
Figure 11: Sketch of the damages on the bottom plating of the vessel
14
Salvage operations (Figures 12 and 13) were initiated during the morning of 26 July
2012. Two tug boats were deployed to the area and LOF was eventually signed by the
master.
Figure 12: Salvage operation
Figure 13: Booms around the vessel as an anti-pollution measure
Anti-pollution procedures were also initiated as a precautionary measure. The
refloating operation took several days to complete due to unfavourable weather
conditions in the area. The vessel was eventually refloated on 07 August 2012. On
15
08 August 2012, the vessel was allowed to sail to Perama for permanent repairs.
Stella arrived at Perama on 11 August 2012. Repairs were initiated on 17 August
2012 and completed on 06 September 2012.
16
2 ANALYSIS
2.1 Aim
The purpose of a marine safety investigation is to determine the circumstances and
safety factors of the accident as a basis for making recommendations, to prevent
further marine casualties or incidents from occurring in the future.
2.2 The Bridge Team and the Absence of a Look-out
It has been established that the OOW fell asleep during the navigational watch prior to
the ship running aground.
It seemed that it was a customary practice on board Stella that no dedicated look-out
is posted during the navigational watch, including hours of darkness. Although the
watch arrangements (as agreed by the master and chief mate) were posted on a board
(Figure 14), it was evident that practice being followed on board was not accurately
reflecting the Company‟s ISM procedures.
Figure 14: Watch arrangement on board Stella
17
Both the master and the chief mate claimed that due to exigencies on board and the
number of crew members, the OOW had to be the sole look-out even in hours of
darkness. They had also stated that crew members were involved in other
assignments on board and the trading pattern imposed an additional burden on the
crew members. Evidence indicated that the master would only post a look-out on the
bridge in those situations which he perceived to be difficult or hazardous. In this
respect, it was claimed that a look-out was only posted during the passage through
South Evoikos Channel, considered as the only challenging part of the voyage12
.
This appeared to be the master‟s normal operating practice. The master, who was
essentially the latest to join on board, explained that this was the practice (i.e. not
using an AB as a look-out), which he had inherited from his predecessor. Moreover,
he perceived the part of the route which had to be navigated during the 0000-0400
watch as not of real concern vis-à-vis navigational difficulties. Therefore, he
considered the posting of a look-out on the bridge neither as compulsory nor
necessary and that the OOW could handle the watch alone on the bridge.
Whilst it is doubtful as to whether a look-out was actually posted when Stella
departed Chalkis, it may be concluded that no look-out was posted during the hours of
darkness that followed. Further to going against international requirements, Stella
was scheduled to pass in close proximity of hazardous, shallow waters before sailing
through the Strait of Kafireas (between Evia and Andros Islands), a very busy
navigational strait with intense merchant traffic passing through (in both directions)
and associated with difficult passages for low powered vessels because of prevailing
strong sea currents and northerly winds13
. A prima facia, it seems that the particular
hazards of this passage had been underestimated by the master, especially under the
particular voyage circumstances (during hours of darkness and with the least
experienced navigational OOW on watch).
The above analysis was made in the context of the requirements of the Minimum Safe
Manning Certificate issued by the flag State Administration. The Certificate allowed
12
The OOW stated that no look-out was posted whatsoever during the voyage from Chalkis up to the
accident site.
13 The Strait of Kafireas is one of the two widely used passages; the other one being the Ikario Strait.
The Strait is a well known area for prevailing strong northerly winds and seas, especially during the
period between July and September (winds are known as Meltemia).
18
for two levels of manning, depending on the trading pattern of the vessel. If the
vessel traded within the restricted areas indicated on the Minimum Safe Manning
Certificate, then one navigational OOW could have been omitted. That meant that the
vessel would only be required to have a master and a chief mate and no other
navigational OOW.
The accident happened in part of the restricted areas specified on the Minimum Safe
Manning Certificate and the evidence did not reveal that the ship was to trade outside
the restricted area – at least on this particular voyage. Thus, in terms of the Minimum
Safe Manning Certificate, the vessel had one extra navigational OOW on board.
However, the Certificate also required three deck ratings, whereas at the time of the
accident, the vessel had just two. Therefore, in order to meet the requirements of the
Minimum Safe Manning Certificate, there were at least two options; either the deck
ratings had to work on a 6-on 6-off watch arrangement during the hours of darkness,
or else the extra navigational OOW had to be posted as a look-out.
It did not transpire that any of these options were being applied on board. In fact, the
„extra‟ navigational OOW was part of the watch system, which permitted the vessel to
work on a 4-on 8-off watch system. Thus, with respect to the actual number of crew
members on board, the vessel was in compliance with the Minimum Safe Manning
Certificate. However, the watchkeeping procedure being adopted on board did not
permit operational compliance, given that there was one missing look-out.
2.4 Passage Planning, the Use of Navigational Aids and Position Fixing
2.4.1 Passage planning
The purpose of the passage plan is to ensure positive control over the safe navigation
of the ship at all times. The passage plan is very similar to a risk assessment exercise,
i.e. it requires the crew members involved to think ahead, foresee potential problems
and plan a strategy to minimise risk. Notwithstanding its importance, evidence
indicated that the passage plan had not been prepared and approved in accordance
with the relevant industry procedures.
The officer responsible for the preparation of the passage plan was occupied with
departure formalities and preparations at Chalkis. He was unable to discuss the
19
master‟s requirements for the voyage prior to departure and prepare the plan
accordingly. As already discussed, he had instead presented his notes to the master
(Figure 8), indicating the WPs, which had to be followed during the route from
departure from Chalkis up to North Aegean Sea.
This route had subsequently been entered in the form of WPs in the GPS receiver and
subsequently transferred to the large scale charts which were to be used for the
voyage. It was apparent to the safety investigation, that only the WPs had been
updated on these charts, which were also used during the previous voyage. The same
routes, as laid-out for the previous voyage, had been maintained and followed during
the last voyage prior to the grounding.
A formal passage plan entered on the company‟s standard form, for this particular
voyage was reportedly prepared after the departure from Chalkis but before the
grounding (Figure 15). Based on the available evidence, it was not excluded that the
document may have been prepared post factum.
Figure 15: Passage plan
20
GPS
Chart room
entrance
2.4.2 Navigational aids
In general, Stella had the necessary navigational aids and instruments to provide for
safe coastal navigation passages. Although the available navigational equipment
(radar, echo sounder, GPS) was reportedly fully functional, the available defences (i.e.
alarms and guard zones) provided were ineffective.
The GPS receiver was fitted in the chart room. Although it had an audible alarm
setting, which activated when the vessel reached a designated WP, the signal‟s
audible level was very weak and could not be heard from the wheelhouse. The
navigational OOW claimed that in order to hear the alarm, one had to rest against the
bulkhead between the chart room and the wheelhouse. Figure 16 shows the position
of the GPS receiver inside the chart room. Figure 17 shows the entrance from the
wheelhouse to the chartroom and the claimed position of the OOW before he fell
asleep during the navigational watch.
Figure 16: Position of the GPS receiver in the chart room
21
Position in which the OOW
claimed to have fallen asleep
Chart room
entrance
Figure 17: Entrance to the chart room from the wheelhouse
The MSIU could not verify the operation of the radar, given that at the time of
deployment, the ship was without power supply as a result of the grounding. The
safety investigation was also unable to verify whether other safety defences (e.g.
guard zones and other specific alarms) were installed, given that the equipment was
relatively old. Moreover, both the chief mate and in particular the OOW were unable
to advise whether or not the feature was available on the radar.
The lack of effective availability of alarms, irrespective of the reason, may be
considered from the engineering perspective as a shortcoming in the redundancy
installed within the system14
. Alarms are actually symbolic barriers and in
comparison with other types of barriers, they can be easily suppressed. On the other
hand, there seemed to be a culture which favoured over-reliance on a single means of
position fixing. It was evident that the OOW was well aware as to where he had to
stay in order to hear the GPS receiver alarm15
.
14
Further to this, the retroactive requirement for a bridge navigational watch alarm system (BNWAS)
for existing ships within the GT bracket of Stella was only applicable not later after the first survey
after 01 July 2013.
15 Whilst evidence shows that the OOW remained standing up, the MSIU did not exclude that the
OOW actually sat down in one of the chairs shown in figure 17. On the other hand, the managers
did not rule out that the OOW could have even fallen asleep on the sofa in the chart room.
22
This seemed to present a situation on board whereby the navigational OOW was
relying on the GPS, rather than adopting a system of primary and secondary position
fixing at frequent and regular intervals and whenever the circumstances allowed. In
this particular issue, the fact that the OOW fell asleep is almost secondary. The
intention of the OOW to stay close to the GPS receiver was to hear the audible alarm.
That seemed to be the way by which the OOW would have known when the vessel
reached the next WP.
This was not considered to be adequate monitoring of the vessel‟s position and in fact,
it compromised situation awareness16
. In other words, the OOW, even before falling
asleep, was unable to accurately know where the ship was in relation to the land,
dangers to navigation, and the proximity of other traffic.
2.4.3 Position fixing
The main, if not the only, position fixing method used, at least by the duty OOW was
by GPS. The OOW also claimed that from time to time, he used the radar
(range/bearing) for position fixing. However, he relied mostly on the GPS to obtain
vessel‟s position and determine / monitor whether the planned route was being
followed or needed adjustments.
It transpired that compass bearings for position fixing were not used by the bridge
team of Stella, mainly because the vessel was, for instance, neither equipped with
bearing/azimuth circles, nor an alidade on a fixed gyro-compass repeater on the bridge
wings. In general, notwithstanding the fact that vessel was navigating in coastal
waters, fixing was carried out by GPS only.
The lack of consistency in position fixing was observed on the chart in use on the
bridge for the passage from Kolpos of Petalion (after exiting Notios Evvoikos Kolpos)
to Kafireas Strait. There was no evidence that position fixing was being maintained
during the passage. It was noted that only the WPs were marked on the chart; fix
positions had neither been marked on the chart nor recorded in the deck logbook.
16
With the OOW leaning against the bulkhead (or sitting in the chair / sofa), situation awareness
would have been compromised. Situational awareness was only lost when the OOW eventually fell
asleep.
23
2.4.4 Trade-offs and cognitive underload
Whilst the decision of the master to limit the manning on the bridge to the OOW may
be seen as an underestimation of the risk involved, this decision was not taken in
vacuum; rather it was influenced by the prevailing situation on board.
The lack of manning on the bridge and the (subsequent) issues related to the
monitoring of the vessel‟s position seemed to reflect particular trade-offs. Studies
have shown that during their daily activities, people are routinely making choices
between either being effective or thorough, given that it is very unusual to satisfy both
situations simultaneously. There is also a (natural) tendency that in situations of
increased demand (e.g. an increase in the workload with a constant number of
available people), thoroughness is reduced in order to meet the increased demand.
The level of thoroughness depends on one‟s perception of the situation and it would
happen if the person authorising it is confident that the objectives will be met, without
any unwanted „side-effects‟. Therefore, the choice between efficiency and
thoroughness is in reality a way to manage a situation, in terms of workload in that
particular instinct.
The decision to do without a look-out on the bridge may have potentially served to
create what in a systemic domain is known as double-bind, i.e. a situation which led
to the OOW to receive contradictory messages. To this effect, whilst the company‟s
safety management system focussed on safety as a priority (explicit safety policy), in
the case of increased workload, production took over and a decision was taken to
dispense with a look-out, even during the hours of darkness.
Although the OOW felt tired and eventually fell asleep during his navigational watch,
the safety investigation did not exclude the possibility of boredom, or cognitive
underload, as a potential contributing factor to this accident. Boredom may be
defined as “a subjective experience of tedium, produced by the unchanging nature of
minimal task and environmental demands, and usually accompanied by impairments
in attention”.
24
Although the definition was made with specific reference to work underload from the
perspective of a maritime pilot, it may also apply to an OOW as both the duties of a
maritime pilot and of the watchkeeper require:
1. high level of vigilance; and
2. watchkeeping and monitoring.
Academic literature explains that these tasks, which may act as stressors, are typically
conceived as representing work underload for one reason: there is a requirement for
constant attention but as yet provide little stimulation. In this respect, the
consequence is reduction in physiological arousal and boredom, especially if the
subject‟s exposure is prolonged.
Furthermore, work underload has been also linked to fatigue, which would have
resulted from:
1. lack of job challenge;
2. inadequate information processing demands; and
3. low levels of job control.
Work underload results in reduced levels of vigilance and it also carries a component
of stress because it is perceived that workers will need to exert additional efforts to
maintain the high level of vigilance required on the job. The OOW on board a ship is
no exception.
MSC/Circ.1014 (Guidance on Fatigue Mitigation and Management) also specifies that
“fatigue can arise…even from the boredom of watchkeeping in the still of the night,
affecting, inter alia, reduction in motivation, encouraging apathy”. It has also been
reported that it is possible for errors to occur during conditions of work underload,
meaning that there arises the need to regulate the psycho-physical reactions to
maintain the high level of arousal and vigilance.
Naturally, the progress in technology, mainly automation, has contributed to problems
in cognitive and operative procedures, in turn leading to boredom. Boredom has been
recognised as a psychosocial hazard and people may easily commit errors in their
judgement or even become momentarily distracted.
25
Figure 18 depicts the relationship between performance and stress, where at low stress
levels (e.g. job boredom), the performance level is poor.
Figure 18: The relationship between performance and stress
Adopted from Riggio (2010)
2.5 Fatigue
The safety investigation did not find evidence which would have indicated that the
OOW was suffering from chronic sleep deficit, although fatigue could not be
excluded. The OOW believed that the main reason for falling asleep was fatigue from
the previous day‟s workload and lack of adequate sleep time that had eventually
exhausted him. He explained that apart from his duties as an OOW (inter alia, watch
keeping, prepare passage plans, maintains update/corrections of navigational charts
and books, preparation of all the necessary arrival/departure documents), he was
usually also deeply involved with relevant cargo operations.
On the day before the accident, i.e. 25 July 2012, the OOW had slept for five hours
before reporting for the 1200 – 1800 watch at Chalkis. At about 1800 he assisted in
the securing of the hatch covers. Then, after the vessel‟s departure at 1830, he went to
the bridge to assist with the pilot disembarkation procedures. After that he assisted
with the mooring ropes and went to eat at 2030. He subsequently took a shower at
26
2100 and went to sleep some time later, waking up at 2300 to prepare for his watch
and relieve the master at about 2359.
Extensive scientific literature indicates that acute sleep loss is a core psychological
factor known to underlie fatigue. Moreover, one particular scientific review found
that two hours of sleep loss can result in impairment of performance and level of
alertness. Given that the OOW fell asleep, it was concluded that it was very possible
that he found himself in a homeostatic drive for sleep, which is an increase in the need
for sleep. The drive was also affected by other factors, including the quality of sleep
during the night previous to the accident, level of activity on the bridge before the
accident, the comfort of the immediate environment17
and the lighting levels.
17
This relates to the comment in footnote 15, whereby it was stated that the investigation did not
exclude that the OOW was actually asleep in his chair.
27
THE FOLLOWING CONCLUSIONS, SAFETY
ACTIONS AND RECOMMENDATIONS SHALL IN NO
CASE CREATE A PRESUMPTION OF BLAME OR
LIABILITY. NEITHER ARE THEY BINDING NOR
LISTED IN ANY ORDER OF PRIORITY.
28
3 CONCLUSIONS
Findings and safety factors are not listed in any order of priority.
3.1 Immediate Safety Factor
.1 Stella ran aground and remained stranded on the rocky shoreline after an
alteration of course was not carried out.
3.2 Latent Conditions and other Safety Factors
.1 The OOW fell asleep during the navigational watch and lost awareness of the
vessel‟s location;
.2 Due to the work exigencies on board and the number of crew members on
board, the OOW had to be the sole look-out even during the hours of darkness;
.3 The posting of a look-out during the 0000-0400 watch was not considered to
be necessary because it was perceived that the OOW could keep the watch
alone;
.4 The particular hazards of this passage had been underestimated;
.5 The watch system adopted on board could not allow for a look-out to be
posted during all the night watches;
.6 The decision to have watches without a look-out was a trade-off to meet the
work demands on the ship;
.7 The OOW actions were affected by cognitive underload;
.8 The OOW found himself in a homeostatic drive for sleep as he had acute sleep
loss.
3.3 Other Findings
.1 The OOW relied on a single means of position fixing;
.2 The OOW compromised the accuracy of his situation awareness by standing in
one position on the bridge during his watch.
29
4 RECOMMENDATIONS
In view of the conclusions reached and taking into consideration the safety actions
taken during the course of the safety investigation,
Transyung Shipping Co., Ukraine is recommended to:
12/2013_R1 Establish an effective implementation of safe navigational practices by
ensuring that managed vessels have:
i. adequate communication with the company;
ii. clear company instructions on safe navigational practices; and
iii. adequate master‟s standing orders.
12/2013_R2 Revise the navigational policy in order to ensure specific reference to:
i. responsibilities for navigation and allocation of watchkeeping
duties;
ii. the importance of following industry bridge procedures;
iii. bridge watch administration and safe manning;
iv. the preparation and execution of the passage plan; and
v. expanding the scope of company visits / inspections to navigational
practices on board.
