REPUBLIC OF CYPRUS
MARINE ACCIDENT AND INCIDENT
INVESTIGATION COMMITTEE
Investigation Report No: 154E
Very Serious Marine Casualty
Crew Member Casualty from the M/V “SWE-CARRIER”
on 24/09/2018 off Liepaja roads
Foreword
The sole objective of the safety investigation under the Marine Accidents and Incidents
Investigation Law N. 94 (I)/2012, in investigating an accident, is to determine its causes and
circumstances, with the aim of improving the safety of life at sea and the avoidance of accidents
in the future.
It is not the purpose to apportion blame or liability.
Under Section 17-(2) of the Law N. 94 (I)/2012 a person is required to provide witness to
investigators truthfully. If the contents of this statement were subsequently submitted as evidence
in court proceedings, then this would contradict the principle that a person cannot be required to
give evidence against themselves.
Therefore, the Marine Accidents and Incidents Investigation Committee, makes this report
available to interested parties, on the strict understanding that, it will not be used in any court
proceedings anywhere in the world.
This investigation was not carried out as a joint investigation.
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Table of Contents FOREWORD ............................................................................................................................................ II TABLE OF CONTENTS ....................................................................................................................... III TYPICAL LIST OF ACRONYMS AND ABBREVIATIONS ............................................................ IV 1. SUMMARY ............................................................................................................................................ 1 2. FACTUAL INFORMATION ............................................................................................................... 3
Ship Particulars .................................................................................................................................. 3
Voyage Particulars ............................................................................................................................. 4 Marine Casualty or Incident Information ........................................................................................... 4
Shore authority involvement and emergency response ....................................................................... 4 3. NARRATIVE ......................................................................................................................................... 6
3.1 SEQUENCE OF EVENTS ........................................................................................................................................ 6 4. ANALYSIS ............................................................................................................................................. 9
4.1 THE SHIP ............................................................................................................................................................. 9
4.1.1 Ship’s Certificates and Surveys .................................................................................................. 9
4.1.2 Ship’s Navigational & Radio Equipment ................................................................................... 9
4.1.3 Passage Plan Analysis ............................................................................................................. 10
4.1.4 Ship’s Condition ....................................................................................................................... 11
4.1.5 Cargo related factors ............................................................................................................... 15
4.1.6 CCTV ........................................................................................................................................ 15 4.2 THE CREW ........................................................................................................................................................ 15
4.2.1 Introduction .............................................................................................................................. 15
4.2.2 Certification ............................................................................................................................. 15
4.2.3 A/B No. 1 Medical Certificate .................................................................................................. 17
4.2.4 Alcohol Testing ........................................................................................................................ 17 4.2.5 Risk Assessment ........................................................................................................................ 17
4.2.6 Fatigue ..................................................................................................................................... 18
4.2.7 Working and Living Conditions ............................................................................................... 18
4.2.8 Training .................................................................................................................................... 18
4.2.9 Physiological, Psychological, Psychosocial Condition ........................................................... 19
4.3 THE ENVIRONMENT .................................................................................................................................... 21 External environment: ....................................................................................................................... 21
Internal Environment: ....................................................................................................................... 22 5. CONCLUSIONS .................................................................................................................................. 23 6. RECOMMENDATIONS ..................................................................................................................... 24
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Typical List of Acronyms and Abbreviations
A/B
BAC
C/E
C/O
CoC
GA
CPR
DPA
HSSE ISM Code
Knots Lat.
Long.
LT
ST
m
MC
MT
NM O/S
PSN
RCC
RPM
SAR
2/O
SMC
SMM
SMS
SOLAS
STCW95
S-VDR
VTS
UTC
VHF ZT
Able Seaman
Blood Alcohol Content
Chief Engineer
Chief Officer
Certificate of Competency
General Alarm
Cardio-Pulmonary-Resuscitation
Designated Person Ashore
Health, Safety, Security and Environment
International Management Code for the Safe Operation of Ships
Speed in nautical miles per hour Latitude
Longitude
Local Time
Ship’s Time
Meter
Management Company
Metric Ton
Nautical Mile Ordinary Seaman
Position
Rescue Coordination Centre
Revolutions per Minute
Search And Rescue
Second Officer
ISM Safety Management Certificate
Safety Management Manual
Safety Management System
Safety of Life At Sea Convention
International Convention on Standards of Training, Certification and Watch
keeping for Seafarers 1978, as amended
Simplified -Voyage Data Recorder
Vessel Traffic Services
Universal Time Coordinated
Very High Frequency Radio Zone Time
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1. Summary
In conducting its investigation, the Marine Accident Investigation Committee (MAIC), reviewed
events surrounding the accident, documents provided by the Managers of the vessel messrs. Rederi AB Swedish Bulk and performed analysis to determine the causal factors that contributed to the accident,
including any management system deficiencies.
Accident Description
The “SWE-CARRIER” is a Cyprus flagged, 2000 built, general cargo ship managed by Rederi AB Swedish Bulk.
This investigation examines the circumstances under which an Able Seaman (from now on described
as “A/B No. 1”) fell overboard while the ship was en route from the port of Liepaja, Latvia to the port
of Gdynia, Poland on 24th September 2018. The crew members last saw A/B No. 1 at 17:20 hrs Ship Time (ST) at the approximate position Lat:
56º27.0’N Long: 019º58.0’E just after the vessel was clearing off the fairway of Liepaja port, and
they realized and confirmed that he was not onboard at 22:30 hrs ST while the vessel was at position
Lat: 55º40.0’N Long: 019º58.0’E, about 55 nmiles south from the port of Liepaja.
At the moment it was realized that the A/B No. 1 was missing, the crew searched thoroughly the ship without any success. As per Master’s report, he decided not to change course back to Liepaja for a search and rescue mission because of the very adverse weather conditions.
The body of A/B No. 1 was found and identified on shore 20 km south of Liepaja about 2 weeks after his disappearance.
Conclusion(s)
There were no witnesses to the disappearance. There is no evidence that it was intentional. The
investigation found that the condition of the structure, machinery and equipment of the vessel was satisfactory.
There is strong indication that the weather conditions could have affected the safety of A/B No. 1 as the sea state was 5-6 and the swell height was 3-4 m WNW, while the wind force and direction was 7
Beaufort (from now on abbreviated as bf) NW. The above weather conditions in combination with the heavy rolling of the vessel, the already slippery floor of the Poop deck and the small free height between
the Poop deck and the level of the sea could have contributed to the accidental fall overboard of A/B No. 1.
There was no risk assessment performed for the securing of deck equipment during very adverse
weather conditions and not all necessary safety precautions were taken. These should have included
the following: Permit to work & company checklist completed, rigging lifelines, wearing lifejacket
with safety harness, deck illumination, visual contact from bridge, working in (at least) pairs, water
resistant portable radios for communications with bridge, use of bridge searchlight to determine
predominant wave direction at night, be aware that even in a regular wave pattern “rogue” waves can
exist which can vary in direction and size from the regular wave pattern being experienced.
Fatigue was not considered as a factor to the accident but the Shipowner should consider employing additional crew members on the ship.
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Recommendations
1. Proper risk assessment should be done and the required safety measures should be taken for works on the open decks of the ship each time adverse weather conditions are expected or are
present. The Owner should issue a detailed circular for all his vessels and provide same as proof within 3 months.
2. The grades / capacities and numbers of personnel listed in the Minimum Safe Manning
Document indicate the minimum number of persons necessary for the safety of navigation, the
security, the safe operation of the ship and the protection of the environment. The engagement
of additional personnel as maybe considered necessary for cargo handling and control,
maintenance and watchkeeping and as needed for compliance with the required rest periods, is
the responsibility of the owner / manager and the master. The Owner should provide evidence
within 3 months that he has considered the above and advise his decision regarding hiring or
not additional crew members onboard.
3. Flag State to clarify and inform the interested parties whether the Baltic Sea is included in
the definition of “Middle-Distance International Voyages”.
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2. Factual Information
Ship’s Name: SWE-CARRIER
Figure 1: The “SWE-CARRIER”
Ship Particulars
Name of ship: SWE-CARRIER
IMO number: 9194048
Call sign: 5BBR4
MMSI number: 212 385 000
Flag State: Cyprus
Classification Society: RINA
Type of ship: General Cargo
Gross tonnage: 3170 t
Length overall: 98.90 m
Breadth overall: 13.80 m Registered ship owner: Brita Shipping Company Ltd
Ship’s management company: Rederi AB Swedish Bulk
Year of build: 2000
Deadweight: 4554.90 t Hull material: Steel
Hull construction: Double Hull
Propulsion power: 2880 kW / 3917 HP
Number of crew on ship’s certificate: 7
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Voyage Particulars
Port of departure: Liepaja, Latvia
Port of destination: Gdynia, Poland Type of voyage: International middle-distance voyage
Cargo information: 4153 mts clinker in bulk
Manning: 7 crew members
Number of passengers: NIL
Marine Casualty or Incident Information
Type of marine casualty/incident:
Date/Time:
Location: Position (Latitude/Longitude):
External and Internal Environment:
Ship operation and Voyage segment:
Human Factors:
Consequences:
Very Serious Marine Casualty 24/09/2018 @ 22:30 Hours Ship’s Time (Cyprus Time)
confirmed that seaman was not onboard
Man Overboard / Unknown location on ship φ = 55°40.0'N / λ = 019°58.0'E (Baltic Sea)
Air Temp: 11C
Sea Temp: 12C
Sea State: 5-6
Swell Height & Dir: 3-4 m WNW
Current speed and Dir: to ESE 2-3 kn
Wind Direction: NW
Wind Force: 7 bf
Weather: Clear/partly cloudy/rain
Natural light: Twilight / night
Visibility: Good (until 25 nm)
In passage – displacement mode
Speed 11.0 knots
Yes
Death: 1 (Disappearance from ship – found dead on
shore two weeks later)
Shore authority involvement and emergency response
On 24/09/2018 the Master sent a PAN PAN message to all ships at 22:35 ST on VHF Ch. 16, then at
22:40 hrs ST on MF 2182 kHz without response but at 22:45 hrs ST contact was established with the
Klaipeda Rescue on VHF Ch. 16 and it was reported the missing crew member. The Master informed
that the vessel would continue her passage to Gdynia as due to adverse weather conditions they would
not be able to reach the approaches of Liepaja port in the nearest 5-6 hours in order to perform Search
and Rescue Operations. Strong wind and current would be pushing the vessel towards shallow waters
of Latvian coast, south of Liepaja. The Klaipeda Rescue advised the Master to report the case to Liepaja
Port Control and they also transmitted an All Ships PAN PAN message on VHF Ch. 16.
At 23:11 hrs ST the vessel sent the following message by Inmarsat-C
“URGENT URGENT URGENT
good evening
AT 21.30 HRS CREW NOTICED ABSENCE
OF [A/B NO. 1]
LAST SEEN BY [A/B NO. 2]
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AT 17.30 HRS (15.30 utc) IN THE
VICINITY OF BUOY A PORT OF LIAPAJA
WHEN SECURING DECK EQUIPMENT
AFTER DEPARTURE FROM PORT OF LIEPAJA AT 16.30 UTC
WE CONTACTED TO KLAIPEDA RESCUE ON VHF CH 16
WE DECIDED TO CONTINUE PASSAGE TO GDYNIA
WEATHER AFTER DEPARTURE NW-LY GALE 7/8
WAVES 3-5 M AND THERE IS A SHALLOW WATER
AROUND PORT OF LIEPAJA
BRGDS [MASTER]”
As per the agent in Liepaja, no commercial ship participated in a Search and Rescue mission. A rescue helicopter and naval ships performed a search of unknown duration but did not find the missing A/B.
When the Master was asked why he did not order the vessel to turn around and conduct a Search and
Rescue mission on the missing A/B he sent the following written statement:
“Please note that decision not to change course back to Liepaja and to perform search and rescue operation at Liepaja Roads or on the way there was taken by me at 22:30 hrs yesterday, when ship’s
search team did not find [A/B No. 1] on board, after short discussion / consultation with Chief Officer
by Safety Reasons.
With weather condition like yesterday afternoon / evening / and all night we were safe to proceed having wind / sea at least slightly behind beam, avoiding or reducing heavy resonance rolling by altering course slightly to port or starboard.
But if we would be trying to proceed to NE towards Liepaja, we would be having wind / sea abeam or
slightly ahead of beam, that would cause heavy resonance rolling, as with our cargo vessel is very stiff and danger of shifting of any machineries from foundation would be existing, that is not safe for crew
and ship.
Also in the vicinity of Fairway to Liepaja depths of water are around 10m and it is danger to navigate outside Fairway with our present draught 6m and heavy swell 3-5 m high.
Also wind did generate strong drift set towards SE 1-2 knots across fairway and along Latvian coast.
That was my professional judgement that it was not safe to proceed back to Liepaja and to commence search and rescue, specially that [A/B No. 1] was last seen by [A/B No. 2] with period of about 5 hours ago, at 17:30 hrs.
Best regards
[Master]”
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3. Narrative
3.1 Sequence of Events
The following sequence of events was constructed by using official documents provided by the Master and the Owner of the vessel, as well as from statements from the crew members obtained by the MAIC investigator while he visited onboard the vessel.
1. The M/V “SWE-CARRIER” was bound for a laden voyage from Liepaja, Latvia to Gdynia,
Poland on 24th
September 2018.
Figure 2: The route of the vessel from Liepaja to Gdynia.
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Notations on Figure 2:
(A) is the position where A/B No. 1 was last seen onboard.
(B) is the position where the crew confirmed that A/B No. 1 was not onboard the vessel. “X” is the approximate position where the body of A/B No. 1 was found on the shore. Wind notation: NW7
2. While the vessel was still loading cargo at Liepaja, A/B No. 1 was gangway security from 06:00 to 12:00 hrs ST. At 12:00 hrs ST A/B No. 1 went for a quick lunch break and then assisted with the
draught survey, sounding of the ballast tanks and closing of the hatch panels. After 15:00 hrs ST he
washed the decks and superstructure from dust from the clinker cargo after loading.
3. At 16:30 hrs ST the vessel left the port of Liepaja, Latvia with the pilot onboard for destination Gdynia with cargo 4153 mts clinker in bulk. A/B No. 1 and A/B No. 2 secured everything forward and
then at 16:48 hrs ST they assisted with the disembarkation of the pilot still inside the port due to strong wind from NW 6 to 7 bf. The vessel passed the breakwater at 16:50 hrs ST while the two A/Bs were
securing all equipment on the poop deck. The weather was NW force 7-8 bf and the wave height 3-5m. The ship was heavily pitching, rolling and sea water sprays were all over the deck.
4. The vessel passed buoys No. 1 and No. 2 at 17:10 hrs ST and continued with various WSW courses
in order to reduce pitching, rolling and escape from shallow water in the vicinity of Liepaja, and after
crossing the 20m depth line continued to SSW towards Gdynia with general course 211 degrees true.
5. At 17:15 ST A/B No. 1 brought the Latvian flag on the bridge and reported that all equipment was
secured on deck, including anchors and all on the forecastle. The crew was told to have rest and be on
stand-by in their cabins. Then at 17:20 hrs ST A/B No. 1 went again on the poop deck and found A/B
No. 2 while the vessel was passing buoy A at Liepaja approaches. A/B No. 1 continued stowing a
mooring rope on port quarter and the A/B No. 2 went inside the accommodation for resting. Short
afterwards A/B No. 2 heard A/B No. 1 come inside the accommodation and go to the storage room. As
it was noticed afterwards A/B No. 1 brought inside the storage room a starboard side aft lifebuoy so
that it was not taken away by the weather. Then he heard again A/B No. 1 go outside to the poop deck.
That was the last time any of the crew members saw or heard A/B No. 1.
6. At 21:30 hrs ST A/B No. 2 reported to the Master that he could not find A/B No. 1. The Master
instructed A/B No. 2 and the Motorman to start looking for the A/B No. 1. At 22:00 hrs ST they both
reported to the bridge that A/B No. 1 was not found after all. At 22:05 hrs ST the whole crew was
called up and commenced throughout search of the ship. At 22:30 hrs ST the Chief Officer, as search
team leader, reported to the bridge that A/B No. 1 was not found onboard. By that time the vessel was
in position Lat 55-42N Long 019-59E and about 55 nautical miles (NM) away from the position where
the A/B No. 1 was last seen.
7. The Master sent a PAN PAN message to all ships at 22:35 ST on VHF Ch. 16 that a person was lost
in unknown position after departure from Liepaja on the way to Gdynia, but did not get any answer.
Then he sent a message at 22:40 hrs ST on MF 2182 kHz without response but at 22:45 hrs ST contact
was established with the Klaipeda Rescue on VHF Ch. 16 and it was reported the missing crew
member. The Master informed that the vessel would continue her passage to Gdynia as due to adverse
weather conditions they would not be able to reach the approaches of Liepaja port in the nearest 5-6
hours in order to perform Search and Rescue Operations. Strong wind and current would be pushing
the vessel towards shallow waters of Latvian coast, south of Liepaja. The Klaipeda Rescue advised the
Master to report the case to Liepaja Port Control and they also transmitted an All Ships PAN PAN
message on VHF Ch. 16.
8. At 23:11 hrs ST Ships Owners, Crew Managers, Charterers and Agents in Liepaja and Gdynia
were informed by sending an Inmarsat-C message as there was no phone connection due to far from
coast.
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9. At 24:00 hrs ST the S-VDR back up was pressed.
10. According to information received from the Owners of the vessel, the body of a man was found on the sea coast 20 kms south of Liepaja on or around 8th October 2018. The crew members of the vessel identified the body on the photo as the body of the missing A/B No. 1. In addition, the motorman and A/B No. 3 confirmed that A/B No. 1 wore an ear ring as the one shown in the photo of the body that was found. A/B No. 1 was confirmed deceased by the General Consulate of Liepaja, Latvia.
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4. Analysis
The purpose of the analysis is to determine the contributory causes and circumstances of the casualty
as a basis for making recommendations to prevent similar incidents occurring in the future. The
following analysis is based on crew statements and ship’s documents provided by the Managers of the
vessel Rederi AB Swedish Bulk and additional crew statements taken by the MAIC investigator, when
he conducted an investigation onboard the vessel on 14/10/2018 at the New Holland Dock, close to
Kingston upon Hull, UK.
4.1 The Ship
4.1.1 Ship’s Certificates and Surveys
At the time of the casualty, the following certificates were valid for the ship.
Certificate Description Issued Valid until
Classification Certificate 28/05/2018 31/01/2020
Load Line Certificate 19/02/2015 31/01/2020
Cargo Ship Safety Construction Certificate 19/02/2015 31/01/2020
Cargo Ship Safety Equipment Certificate 13/06/2018 31/01/2020
Cargo Ship Safety Radio Certificate 19/02/2015 31/01/2020
Safety Management Certificate 23/10/2014 13/10/2019
International Ship Security Certificate 23/10/2014 14/10/2019
Maritime Labour Certificate 23/10/2014 13/10/2019
International Oil Pollution Prevention (IOPP) 19/02/2015 31/01/2020
International Sewage Pollution Prevention Certificate 19/02/2015 31/01/2020
International Air Pollution Prevention Certificate 19/02/2015 31/01/2020
International Energy Efficiency Certificate 11/04/2014 -
International Anti – Fouling System Certificate 11/04/2014 -
Ballast Water Management Statement of Compliance 07/12/2017 31/01/2020
Certificate of Registration 22/03/2018 -
Maritime Labour Certificate 23/10/2014 13/10/2019
Maritime Labour Convention 2006 Part I + Part II 10/04/2014 -
International Tonnage Certificate 08/04/2014 -
Minimum Safe Manning Document 22/03/2018 09/10/2022
DOC of Management Company 31/08/2018 02/09/2023
The Hull and Machinery Annual survey is due on 31/01/2019 and the Hull and Machinery Renewal survey is due on 31/01/2020.
All certificates onboard the ship were found to be in order and valid.
4.1.2 Ship’s Navigational & Radio Equipment
The “SWE-CARRIER” is equipped with the following Radio and Navigational equipment as verified onboard the vessel and has the following life – saving appliances.
Radio equipment
a) VHF receiver / transmitter
b) VHF DSC watch receiver
c) VHF radiotelephony
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d) Inmarsat - C
e) MF receiver / transmitter
f) MF DSC watch receiver
g) NAVTEX receiver
h) EGC receiver
i) Satellite EPIRB
j) Radar search and rescue transponder (SART)
Navigational equipment
a) Standard magnetic compass
b) Gyro compass
c) Gyro compass heading and bearing repeaters
d) Magnetic compass bearing device
e) Means of correcting heading and bearings
f) Nautical charts
g) Nautical publications
h) Receiver for a global navigation satellite system i) 9 GHz radar
j) Second radar (9 GHz)
k) Automatic radar plotting aid (ARPA)
l) AIS system
m) LRIT system
n) S-VDR
o) Bridge navigational watch alarm system (BNWAS)
Life-saving appliances
a) 1 free fall lifeboat for 18 persons (which is also davit launched)
c) 2 liferafts for total 24 persons
d) 8 lifebuoys
e) 12 lifejackets
f) 16 immersion suits
The “SWE-CARRIER” at the time of the accident, had valid certificates including an ISM certificate.
The maintenance records indicated that she was maintained in accordance with existing regulations
and approved procedures.
All ship’s navigational, radio and safety equipment were found in order.
4.1.3 Passage Plan Analysis
The passage plan of SWE-CARRIER for the voyage detailed as follows:
a. The passage plan from Liepaja, Latvia to Gdynia, Poland was found to be in order and
complete including the charts, maneuvering data, pilot and port information, tide tables etc.
b. The ship proceeded for the intended voyage according to the passage plan. After the A/B No.
1 was confirmed missing from onboard the Master decided not to return for a search and rescue
mission but to continue the ship’s course to Gdynia due to very adverse weather conditions (see
chapter 2) c. The vessel’s speed was approximately 11 knots when the incident took place.
The ship’s passage plan was found to be in order.
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4.1.4 Ship’s Condition
A physical survey onboard the vessel showed the condition of the ship’s superstructure and the
circumstances that could have led A/B No. 1 to fall overboard. The survey showed that the condition
of the structure, machinery and equipment (as many as could be surveyed during the investigator’s
time onboard and only in the superstructure of the vessel) was satisfactory and the ship complied with
the relevant requirements of chapters II-1 and II-2 of the SOLAS convention.
The survey also showed that the life – saving appliances and the equipment of the free – fall lifeboat,
the liferafts and the rescue boat were provided in accordance with the requirements of the SOLAS
convention.
4.1.4.1 The condition of the Poop deck
The following schematic shows the Poop deck, where A/B No. 1 was last seen securing some deck
equipment.
(a) Position where A/B No. 1 was last seen
(d) Storage room
(c) Entrance to accommodation
(b) Cabin of A/B No. 2
Figure 3: Schematic of the Poop deck
As per the crew members witness statements that were obtained, at 17:15 ST A/B No. 1 brought the
Latvian flag on the bridge and reported that all equipment was secured on deck, including anchors and
all on the forecastle and the crew was told to have rest and be on stand-by in their cabins. Then at 17:20
hrs ST A/B No. 1 went again on the poop deck and found A/B No. 2 while the vessel was passing buoy
A at Liepaja approaches. A/B No. 1 continued stowing a mooring rope on port quarter [at position (a)
in Figure 3] and the A/B No. 2 went inside the accommodation for resting in his cabin [at position (b)
in Figure 3]. Short afterwards A/B No. 2 heard A/B No. 1 come inside the
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accommodation [at position (c) in Figure 3] and go to the storage room [at position (d) in Figure 3]. As it was noticed afterwards A/B No. 1 brought inside the storage room the starboard side aft lifebuoy
presumably so that it was not taken away by the weather. Then he heard again A/B No. 1 go outside to the poop deck. That was the last time any of the crew members saw or heard A/B No. 1. It is unknown
what exactly the A/B No. 1 was doing when he fell overboard.
The investigation onboard the vessel showed that the Poop deck was in good condition in accordance
to SOLAS regulations. It accommodates 4 double bollards, 1 winch, a deckstore, a painstore, a CO2
room and ladders leading to the Main deck and to the Boat deck. It did not have any structural
discrepancy or any unrepaired damage, it was found in a satisfactory condition structurally and by way
of maintenance.
Figure 4: The Poop deck
It is concluded that one person cannot fall accidentally overboard from the Poop deck due to structural
deficiencies of the vessel, as there was no evidence of any defect or malfunction that could have
contributed to the fall overboard.
4.1.4.2 The condition of the Boat deck
As it can be shown from the Figure 5 below, the Boat deck is located above the Poop deck.
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Bridge deck
Officers deck
Boat deck
Poop deck
Main deck
Figure 5: The decks of the vessel
The equipment on the boat deck was already secured when the vessel sailed from the port of Liepaja
to destination Gdynia and there was no reason for A/B No. 1 to go to that deck or any of the decks
above that, as the equipment that required securing in the aft of the vessel were all on the Poop deck.
The Boat deck was found in a satisfactory condition structurally and by way of maintenance. The hand
rails had a height of 1.20 m, which is above waist height. They were in good condition and satisfied
the relevant SOLAS requirements. The protective chains in way of the life rafts and the rescue boat
were in a slightly rusty but overall satisfactory condition.
Figure 6: The Boat deck
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It is concluded that one person cannot fall accidentally overboard from the Boat deck due to structural
deficiencies of the vessel, as there was no evidence of any defect or malfunction that could have
contributed to the fall overboard.
4.1.4.3 The condition of the hatch covers and the free passageway on the Main deck
The hatch covers were closed and secured before the departure of the vessel from the port of Liepaja.
The ship was fully loaded with cargo and had a draught of 5.44m fwd and 6.04 m aft (mean draught
5.74m). This is very close to the maximum summer draught (5.754m) and exceeds the winter draught
(5.634m). The summer freeboard of the vessel is 1.673m and was further reduced by the existing
weather conditions and the heavy rolling of the ship. As per information from the Master, the
passageway around the hatch coamings as well as the hatch covers themselves were very dangerous
with tides and spray water falling ontop of them due to the adverse weather conditions.
There was no reason for the A/B No. 1 to walk on the hatch covers or on the passageway around the
hatch coamings. The only reason could be that he wanted to double check some securing. He did not
forget to secure any equipment because (a) he secured everything together with A/B No. 2 and (b) upon arrival at Gdynia, all equipment forward of the Poop deck was already secured.
If the A/B No. 1 tried to walk on the passageway around the hatch coamings during the time of his
disappearance, that would be indeed very dangerous that a wave could hit him and drag him overboard.
In addition, if he tried to walk on the hatch covers for some reason, the Master and the Chief Officer who were on the bridge navigating the vessel would have seen him.
Figure 7: The passageway around the hatch coamings
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4.1.5 Cargo related factors
The ship was on a laden voyage from Liepaja, Latvia to Gdynia, Poland carrying 4153 mt of clinker
with the hatch covers fully closed and secured. The ship, when inspected, was found in satisfactory
condition without any noticeable cargo leakages.
The cargo was not considered as a factor to the accident.
4.1.6 CCTV
The ship is not equipped with a Closed Circuit TV (CCTV) system.
4.2 The Crew
4.2.1 Introduction
The most common human-factor causes of accidents onboard ships are error of judgement by failure
to comply with the relevant regulations. The “human element” as it is often termed in the shipping literature has frequently been cited as a cause of very serious marine accidents and deaths. Merchant
shipping is known to be an occupation with a high rate of fatal injuries caused by organizational and maritime disasters.
Research has illustrated that there are potentially disastrous outcomes from fatigue in terms of poor health and also diminished performance. Despite the introduction of work / rest mandates by the IMO,
there are still occasions where individuals simply have to work for more than 12 hours with a 6-hour break.
Stress has been identified as a contributory factor to the productivity and health costs of an organization as well as to personnel health and welfare. Most seafarers reported occasional to frequent stress at sea (80%).
Research from other domains indicates a positive relationship between health management and safety performance. Although the research on stress and health behaviours establishes a high level factor as
compared with other occupational groups, there is an absence of literature that aims to evaluate the relationship between seafarers health and performance.
4.2.2 Certification
The Minimum Safe Manning Document (MSMD) was issued by the Cyprus Maritime Authority on 22/03/2018 with expiry date 09/10/2022, requires 7 crew members to be onboard the vessel and is shown below.
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Figure 8: The Minimum Safe Manning Document of the vessel
The crew onboard the vessel at the date of the incident was 7 crew members, qualifying for the minimum amount of crew members required to be onboard. All crew members certificates were up-to-
date and valid and in compliance with all relevant regulations.
The trading area allowed for this Minimum Safe Manning Document is: “Between ports in the area
which extends from the North Cape (Norway) to the West towards the Faeroe Islands, the British Isles, and the European Coast of the Atlantic Ocean, the West Coast of Africa down to the Equator.”
That trading area is called according to the Cyprus law “middle-distance international voyages”. It is not clear whether the Baltic Sea where the incident occurred is considered to be included in the description of the allowed trading area or is included only in the “restricted area voyages” trading area.
The ship was manned in accordance with the Minimum Safe Manning Document but the Maritime Administration to clarify whether the Baltic Sea is included in the trading area allowed for the MSMD.
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4.2.3 A/B No. 1 Medical Certificate
The A/B No. 1 had an “MEDICAL CERTIFICATE OF FITNESS” issued on 18/06/2018 from
Onegomed Medical Clinic in Russia. All his examinations were normal and he was therefore pronounced “Fit for duty as seaman” and “in satisfactory physical condition for the specific duty
assignment undertaken and is generally in possession of all body facilities necessary in fulfilling the requirements of the seafaring profession”.
The A/B No. 1’s medical condition prior to embarkation was not considered as a factor to the accident.
4.2.4 Alcohol Testing
The ship owning company keeps very strict rules against the use of alcohol and drugs onboard their
vessels. The A/B No. 1 was tested for alcohol on 18/06/2018 from Onegomed Medical Clinic in Russia, and was found negative on alcohol usage. In addition, the Master stated that there was strictly no
alcohol onboard the vessel.
Alcohol was not considered as a factor to the accident.
4.2.5 Risk Assessment
As per evidence provided, the weather conditions during the passage from Liepaja to Gdynia were very
adverse with the sea state 5-6, swell height and direction 3-4 m WNW and wind force 7-8 bf NW.
According to the Safety and Environmental Protection Manual of the Managers of the vessel, a risk
assessment should be done before any works on deck are planned to be carried out under bad weather.
In detail, working on deck in heavy weather should be only done with the express permission of the Master. Only work that is absolutely essential should be carried out on deck during heavy weather and
only after a full and complete assessment has been conducted.
In addition, according to good seaman’s practice, if heavy weather is expected, lifelines should be
rigged in appropriate locations on deck. Attention should be given to the dangers of allowing any person out on deck during heavy weather. No seafarers should be on deck during heavy weather unless
it is ABSOLUTELY NECESSARY for the safety of the ship or crew.
Work on deck during heavy weather should be authorised by the master and the bridge watch should be informed. A risk assessment should be undertaken, and a permit to work and company checklist for work on deck in heavy weather completed.
Any persons required to go on deck during heavy weather should wear a suitable life-jacket, waterproof PPE, and be equipped with a portable transceiver. Seafarers should work in pairs or in teams. All seafarers should be under the command of an experienced senior officer.
According to information received, there was no risk assessment performed at the time when not only A/B No. 1, but also A/B No. 2, were on the open decks for securing the ship’s equipment.
There was no risk assessment performed for the securing of deck equipment during very adverse
weather conditions and not all necessary safety precautions were taken. These should have included
the following: Permit to work & company checklist completed, rigging lifelines, wearing lifejacket with
safety harness, deck illumination, visual contact from bridge, working in (at least) pairs, water
resistant portable radios for communications with bridge, use of bridge searchlight to determine
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predominant wave direction at night, be aware that even in a regular wave pattern “rogue” waves
can exist which can vary in direction and size from the regular wave pattern being experienced. 4.2.6 Fatigue
As per the “Monthly Worksheet” report that was provided by the Master of the vessel, A/B No. 1 at the day of the casualty was resting from 00:00 hrs to 06:00 hrs, then from 06:00 hrs until 12:00 hrs he
was gangway watch, from 12:00 hrs to 13:30 hrs he had a break and from, 13:30 hrs until his
disappearance he was working as described in Chapter 2 above.
As per the witness statements from the crew members, the A/B No. 1 had only a quick lunch break
during his rest hours between 12:00 hrs and 13:30 hrs and then assisted with the draught survey,
sounding of the ballast tanks and closing of the hatch panels before commencing works relevant to the
departure of the vessel from the loading port and securing of all equipment in the forecastle and the
poop deck of the vessel.
According to the Master of the vessel, A/B No. 1 was looking slightly tired when he went to the bridge
to commence his watchkeeping duties. The Master instructed him to get some rest and to be on standby
in his cabin. As the Chief Officer was new of the vessel, he stayed on the bridge with the Master for
additional familiarization.
His records of work and rest hours were examined onboard the vessel and showed that they were in
accordance with all relevant MLC and STCW regulations. It is true that due to the limited number of
crew members employed onboard the vessel, sometimes all crew members are obligated to work for
additional hours according to the trading pattern of the vessel. The conclusion that fatigue played an
important role in the casualty is not comprehensive, but the Shipowner should take the work schedule
of the crew members into consideration and employ additional crew members if he thinks that it would
benefit the rest hours of the crew members.
Fatigue was not considered as a factor to the accident, nevertheless the Shipowner should consider employing additional crew members on the ship.
4.2.7 Working and Living Conditions
As far as the working and living conditions onboard the vessel could be examined, it must be said that they were of average standards, considering the type of ship investigated. The crew members seemed
to be in satisfactory condition both physically and psychologically (as many as could be interviewed) and they did not express any concerns or complains. The condition of the accommodation of the ship
was average but without any recommendations.
There was no evidence to suggest, that, the working and living conditions was a contributory factor to the accident.
4.2.8 Training
The training and drills log for months July 2018 – September 2018 was examined and was found in order and in accordance with all ISM requirements. In particular, the “Man Overboard” drill was conducted during on 28 August 2018.
In any way, the Master, due to adverse weather conditions, judged that it was very risky for the ship to turn around and conduct a search and rescue mission on the missing A/B.
Training and the drills record of the crew members did not contribute to the search and rescue mission as it was cancelled by the Master.
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4.2.9 Physiological, Psychological, Psychosocial Condition
The physiological, psychological and psychosocial condition of A/B No. 1 is not easy to determine fully by an investigation of this type and, accordingly, a professional opinion cannot be expressed.
But for the completeness of the investigation the following information should be considered which was retrieved during the investigation onboard the vessel:
(a) A/B No. 1 was single and has often communications with his mother. He had three cell phones
(something common for sailors who wish to minimize their telephone and internet charges) and
a laptop computer which was analysed as far as possible and its contents were mostly movies,
music and photos. His memory card of 16 GB and a portable Samsung hard disk were checked
and nothing of unusual context was discovered. His e-mails could not be retrieved due to lack
of internet access onboard.
In particular, a list of his personal items that were found onboard after his disappearance is shown below.
Figure 9: List of the A/B No. 1’s personal belongings
(b) Four out of the seven crew members had only embarked the vessel during the previous day,
23/09/2018, in Liepaja. According to the Master of the vessel, A/B No. 1 had previous contracts
with ships of the same company and in particular on the SWE-CARRIER he worked from
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20/10/2017 until 07/03/2018. The Master had joined the vessel on 30/12/2017 and hence worked with him for more than two months before the A/B No. 1’s end of contract.
(c) A/B No. 1 joined the vessel in his current contract in 17/07/2018 and was due to disembark in November 2018. The cook of the vessel joked with him a few times that they were going to
return home together after the completion of their contracts but he did not answer back to this
joke.
(d) His character was quiet and no special. He did not express any extreme emotions and just followed orders. He did not create any problems with the other crew members and there was
nothing strange about him. In addition, he did not drink any alcohol. After his disappearance,
the rest of the crew members checked his cabin but did not find anything special that would show any suicidal tendencies.
(e) The cook, who embarked the vessel on 29/04/2018 and worked with him onboard the vessel
from his embarkation on until his disappearance, did not notice anything unusual about his
behaviour. As usual he did not talk much during his lunch time. The cook did not know him very much as he was very busy with his work and was only going to eat and then leave without
speaking very much. He was quite all the time, never raised his voice and never showed any
aggression.
(f) A/B No. 1 during his disappearance was wearing rubber boots, orange raincoat and orange
trousers. He was also wearing a helmet and carried with him a handheld VHF device. None of this equipment was found onboard the vessel after his disappearance, but also none of this
equipment was found on him when he was discovered two weeks later lying on the beach 20 kms south of Liepaja.
Figure 10: The type of clothes that A/B No.1 was wearing above his
uniform during his disappearance
(g) Various medicines were found in his cabin that are shown in the photo below.
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Figure 11: Medicines that were found in the A/B No. 1’s cabin
The medicines shown in Figure 11 above are relevant to painkillers, vitamins, pancreatic treatment,
blood pressure, various circulation disorders, antiseptic, eye herpes and allergies. The investigator is not qualified in order to judge how receiving or the lack of receiving these medicines could have
affected the physical state of A/B No. 1.
No safe conclusions could be reached from the above-mentioned information for the A/B No. 1’s physical, physiological, psychological, or psychosocial condition which could be correlated with his disappearance.
4.3 The Environment
External environment:
The weather conditions at the time of the accident were as follows.
Air Temp: 11C
Sea Temp: 12C
Sea State: 5-6
Swell Height & Dir: 3-4 m WNW
Current speed and Dir: to ESE 2-3 kn Wind Direction: NW
Wind Force: 7 bf
Weather: Clear/partly cloudy/rain
Natural light: Twilight / night
Visibility: Good (until 25 nm)
A/B No. 1 was on the Poop deck alone securing some final deck equipment and / or mooring ropes
when the vessel cleared the Liepaja fairway and turned to southern course towards Gdynia. The sea
state was 5-6 and the swell height was 3-4 m WNW, while the wind force and direction was 7 bf NW.
The weather conditions in combination with the heavy rolling of the vessel and the already slippery
floor of the Poop deck could have contributed to the accidental fall overboard of A/B No. 1.
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Internal Environment:
It was advised verbally that there was heavy rolling and spraying of sea water on the surfaces of the Poop deck when the vessel cleared the Liepaja fairway and was on course to Gdynia. This would have
made the Poop deck floor very slippery and dangerous due to the small vertical distance between the Poop deck and the level of the sea.
In conclusion, there is strong indication that the environmental conditions were a factor in the accident.
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5. Conclusions
Conclusion(s)
There were no witnesses to the disappearance. There is no evidence that it was intentional. The investigation found that the condition of the structure, machinery and equipment of the vessel was satisfactory.
The weather conditions could have affected the safety of A/B No. 1 as the sea state was 5-6 and the
swell height was 3-4 m WNW, while the wind force and direction was 7 bf NW. The above weather conditions in combination with the heavy rolling of the vessel, the already slippery floor of the Poop
deck and the small distance from Poop deck to the level of the sea could have contributed to accidental fall overboard of A/B No. 1.
There was no risk assessment performed for working on deck during adverse weather conditions and
not all necessary safety precautions were taken. These should have included the following: Permit to
work from Master, rigging lifelines, wearing lifejacket with safety harness, deck illumination, visual
contact from bridge, working in (at least) pairs, water resistant portable radios for communications
with bridge, use of bridge searchlight to determine predominant wave direction at night, be aware that
even in a regular wave pattern “rogue” waves can exist which can vary in direction and size from the
regular wave pattern being experienced.
Fatigue was not considered as a factor to the accident but the Shipowner should consider employing additional crew members on the ship.
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6. Recommendations
1. Proper risk assessment should be done and the required safety measures should be taken for
works on the open decks of the ship each time adverse weather conditions are expected or are present. The Owner should issue a detailed circular for all his vessels and provide same as
proof within 3 months.
2. The grades / capacities and numbers of personnel listed in the Minimum Safe Manning
Document indicate the minimum number of persons necessary for the safety of navigation, the
security, the safe operation of the ship and the protection of the environment. The engagement
of additional personnel as maybe considered necessary for cargo handling and control,
maintenance and watchkeeping and as needed for compliance with the required rest periods, is
the responsibility of the owner / manager and the master. The Owner should provide evidence
within 3 months that he has considered the above and advise his decision regarding hiring or
not additional crew members onboard.
3. Flag State to clarify and inform the interested parties whether the Baltic Sea is included in
the definition of “Middle-Distance International Voyages”.
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