on board planet v during emergency anchoring

DUTCHSAFETY BOARD

Visiting Address Anna van Saksenlaan 50 2593 HT The HagueT +31(0)70 333 70 00 F +31(0)70 333 70 77

Postal Address PO Box 95404 2509 CK The Hague

www.safetyboard.nl

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DUTCHSAFETY BOARD

Fatal accident on board Planet V during emergency anchoring

The Hague, March 2013 (project number M2012ZSV0526-01)

The reports issued by the Dutch Safety Board are open to the public.

All reports are also available on the Safety Board’s website www.safetyboard.nl


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Dutch Safety Board

The aim in the Netherlands is to reduce the risk of accidents and incidents as much as possible. If accidents or near-accidents nevertheless occur, a thorough investigation into the causes of the problem, irrespective of who is to blame for it, may help to prevent similar problems from occurring in the future. It is important to ensure that the investigation is carried out independently from the parties involved. This is why the Dutch Safety Board itself selects the issues it wishes to investigate, mindful of citizens’ position of dependence with respect to public authorities and businesses. In some cases, the Dutch Safety Board is required by law to conduct an investigation.

Dutch Safety BoardChairman: T.H.J. Joustra

E.R. MullerP.L. Meurs

General Secretary: M. Visser

Visiting address: Anna van Saksenlaan 502593 HT The Hague The Netherlands

Postal address: PO Box 954042509 CK The Hague The Netherlands

Telephone: +31 (0)70 333 7000 Fax: +31 (0)70 333 7077

Website: www.safetyboard.nl

This report is published in Dutch and English. In the event of any discrepancy between these versions, the Dutch text shall prevail.

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CONTENT

List of abbreviations �� 4

Consideration �� 5

1� Introduction �� 91.1 Background ............................................................................................................ 91.2 Objective of the investigation ................................................................................ 91.3 Scope of the investigation .................................................................................... 101.4 Reading guide ...................................................................................................... 10

2� Relevant facts and background information ��112.1 Vessels involved.....................................................................................................112.2 Relevant facts of the accident .............................................................................. 152.3 Personal injury and material damage ................................................................... 212.4 Accident location ................................................................................................. 222.5 Meteorological and current information .............................................................. 222.6 Similar incidents ................................................................................................... 23

3� Analysis �� 253.1 Introduction .......................................................................................................... 253.2 Reconstruction ..................................................................................................... 253.3 Failure of the main engine and its consequences ................................................ 303.4 The emergency manoeuvre using the anchor ...................................................... 36

4� Conclusions �� 424.1 The engine failure, blackout and the ship’s manoeuvre ....................................... 424.2 Use of the anchor ................................................................................................. 42

5� Lessons from the accident �� 43

Annex 1� Investigation details �� 44

Annex 2� Responses received following review of the report �� 48

Annex 3� Reference framework ��52

Annex 4� Detailed risk assessment by Planet V shipping company ��58

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LIST OF ABBREVIATIONS

AIS Automatic Identification SystemAB Able-Bodied Seaman

COLREGS International Regulations for Preventing Collisions at Sea

ECS Electronic Chart SystemEMCIP European Marine Casualty Information Platform

GT Gross Tonnage

IACS International Association of Classification Societies IMO International Maritime Organization ISM International Safety Management

KNRM Royal Netherlands Sea Rescue Institution [Koninklijke Nederlandse Redding Maatschappij]

MARIN Maritime Research Institute Netherlands

NCC Netherlands Coastguard Centre [Kustwachtcentrum]NSI Netherlands Shipping Inspectorate of the Human Environment and

Transport Inspectorate

SCC Scheldt Coordination Centre [Schelde Coördinatie Centrum]SMM Safety Management ManualSMS Safety Management System SOLAS International Convention for the Safety of Life at SeaSRW Westerschelde Shipping Regulations [Scheepvaartreglement

Westerschelde]STCW International Convention on Standards of Training, Certification and SVDR Simplified Voyage Data RecorderSVW Shipping Traffic Act [Scheepvaartverkeerswet]

TEU Twenty-foot Equivalent Unit

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CONSIDERATION

The accidentOn 26 May 2012, a fatal accident occurred on the Westerschelde on board the motor vessel Planet V. During an emergency manoeuvre using the anchor to prevent a collision, the anchor chain entirely ran out and broke free of its end attachment in the chain locker. The loose-flying anchor chain then fatally injured a crew member.

On 26 May, the Planet V was departing the port of Flushing with destination St. Petersburg (Russia). The weather was calm and visibility was good. The tug MTS Vantage, towing a pontoon, had left the port just before the departure of the Planet V. When still in port, the pilot of the Planet V contacted the MTS Vantage by VHF-radio. They agreed that the faster Planet V would overtake the tug and tow on the Westerschelde after having passed the port entrance.

While the Planet V was overtaking the pontoon, the Planet V’s main engine suddenly failed. Since the electrical systems on board the vessel were linked to the main engine, the electricity failed as well and for a short period of time the vessel became ‘not under command’. During the blackout, the rudder unexpectedly turned to port, causing the vessel to deviate sharply from its course and resulting in an imminent collision with the tug and tow. In order to prevent a collision, the captain decided to drop the anchor. However, this measure did not have the intended effect. Despite the engine failure, still the Planet V had a speed over ground of 7.5 knots by the time the anchor was dropped. As a result of this high speed, substantial forces were exerted on the anchor gear eventually causing the chain to break free. The loose-flying anchor chain then fatally injured the crew member who was operating the anchor winch brake.

The Planet V collided with the pontoon almost simultaneously with the breaking free of the anchor chain. Both vessels sustained limited damage as a result of the collision.

Focus of the investigationThe chain of events and, more particularly, the fact that it had resulted in a fatality were sufficient reason for the Dutch Safety Board to conduct an investigation into this accident. The investigation has shown that this specific chain of incidents can be regarded as unique: the Dutch Safety Board did not found any similar accidents in national or international databases. This does not alter the fact, however, that power failures on board seagoing vessels are not uncommon.

In its investigation the Dutch Safety Board focused on the risks of a power failure on board and the risks of ‘emergency anchoring’ manoeuvres.

There was a pilot on board both vessels. Pilots are familiar with local conditions and are used to advise ship’s crews while navigating in narrow waters. The pilots did not contribute to the cause or severity of the consequences of this accident.

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The investigation did demonstrate, however, that the crew members had not provided the pilot with all relevant information about earlier problems with the main engine. Nor was the pilot aware of the choice made by the crew to switch the entire ship’s electrical power supply to the shaft generator. For these reasons, the Dutch Safety Board, in response to this accident, calls attention to the cooperation and communication between pilots and crew. In this connection, the Safety Board believes it is important to ensure that the crew and the pilot maintain effective communication at all times about all issues that affect safe navigation, and that a systematic protocol is in place for the transfer of information between these parties. This should include attention both for the characteristics of the waterway and the vessel. These matters should be addressed in education and training of pilots and crew.

Following the blackout the ship made a sharp turn to port. The investigation has revealed that this sudden deviation from the ship’s course can only be explained by a deflection of the rudder to port without the intervention of the crew. The Safety Board finds it remarkable that the rudder could have deflected in this way after the blackout, but has not been able to find any further explanation for this.

Failure of the main engine and the electrical systemDue to the insufficient main engine revolutions caused by the defective regulator, the number of revolutions of the propeller shaft reduced and the supply to the main generator became insufficient. In order to prevent damage to the installations, the safety system disconnected the main generator from the ship’s electrical system. This automatically activated the stand-by auxiliary engine to provide electrical power on board via a stand-alone generator. This process of failure, starting up in response, reaching full revolutions and supplying the ship’s electrical systems took several tens of seconds, causing a total blackout.

A blackout in narrow waters (such as a harbour or river) can be dangerous, because the margins available for correcting the ship’s course are small and the risk of a collision or grounding increase. Pursuant to international regulations, ships built after 1998 are required to have a back-up system to ensure that essential equipment is supplied with electrical power in the event of a blackout. This means that an alternative generator will be available in case the main generator fails. The Planet V was built in 1994. The ship was originally fitted with such a back-up system when it was built. However, it was common practice on board the Planet V not to use that system in view of the additional fuel and maintenance costs involved. So while a potential safety provision was available it was not used for reasons of economy. According to the Dutch Safety Board, ships should use all available back-up systems in areas where accurate navigation is essential, and in any case in narrow waterways, in order to ensure that manoeuvrability is maintained in the event of a blackout.

According to the safety management system (SMS) of the Planet V, a blackout of only a few seconds can have severe consequences in narrow waterways. According to the Dutch Safety Board, sailing in narrow waters on two generators parallel connected with each having sufficient power to supply the ship’s network is a sign of good seamanship. Nevertheless, the same SMS allows the Planet V to sail on just one generator in narrow waters without any stand-by resources being available.

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The crew’s decision to use just one generator, therefore, was backed up by the SMS. The Safety Board nevertheless believes it is desirable for crews to critically assess the regulations in the SMS. The SMS serves to support and aid in the regulation of operational management on board the ship. The crew should highlight cases where the SMS is in conflict with good seamanship and take alternative measures as necessary.

Figure 1: The Planet V and the pontoon moments before the collision. Photo taken from the tug wheelhouse.

(Source: Crew of MTS Vantage)

Emergency manoeuvre using the anchorThe captain decided to use the anchor to prevent a collision with the tug and tow as he saw no other opportunities to prevent the collision. Although regular anchoring is part of the routine procedures on a ship, emergency anchoring seldom occurs in practice. According to the safety regulations of the owner of the Planet V (as incorporated into the safety management system), anchoring is a potential emergency measure in the event of an engine failure in narrow waters. The procedure does not stipulate how and when the anchors can be used. However, it is almost impossible to prescribe such specific procedures and recommendations, because numerous variables have to be considered during the process, such as sailing speed, current, water depth, type of seabed and the amount of decision time available.

At low speeds emergency anchoring can be an effective measure to prevent the ship from colliding or from grounding, provided that it is performed in a controlled manner. However, at a speed over ground of 7.5 knots emergency anchoring is a highly unusual and extremely risky procedure. Firstly, because it is unlikely to be effective, and secondly because of the extremely high risks attached to it. In addition to the risk of the anchor chain breaking and causing damage, crew members in the vicinity could be hit by the chain. The Dutch Safety Board’s investigation shows that the forces exerted in an emergency manoeuvre using the anchor can be substantial.

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However, the crew on board the Planet V were not aware of these considerable forces and the associated risks, as a result of which the manoeuvre was carried out without any safety measures.

Lessons for the shipping industrySailing in narrow waters entails more risks due to the smaller margins available for correcting a ship’s course and the increased risk of the ship colliding or grounding. Therefore, prior to commencing a passage in narrow waters, a risk analysis should be carried out as part of the SMS in order to verify that back-up systems are instantly available. For example, uninterrupted power supply is essential in order to guarantee a ship’s manoeuvrability.

Anchors are designed to moor a ship in a harbour or sheltered area. An anchor is expressly not designed to slow down a ship. Anchoring at high speed is an extremely risky operation that may result in fatal injuries to crew members and serious damage to the ship. This is why such a manoeuvre should only be considered in an extreme emergency. In such a case the captain, in consultation with the bridge team, should assess whether the potential benefits of an effective manoeuvre outweigh the substantial risks for his crew and ship.

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1 INTRODUCTION

1�1 Background

On 26 May 2012 a fatal accident occurred on board general cargo vessel Planet V. The accident occurred at 17.51 hrs1 during the execution of an emergency manoeuvre using the anchor on the Westerschelde near Flushing. Prior to the accident, the main engine and subsequently the ship’s electrical power supply failed. As a result, the vessel became ‘not under command’. In order to prevent a collision with a tug and tow, comprising of the tug MTS Vantage and the pontoon E3505, the captain decided to use the anchor in an attempt to slow down the Planet V and to fasten the turn of the vessel. While doing so the entire anchor chain ran out and broke free of its end attachment in the chain locker. The loose-flying anchor chain then fatally injured a crew member. At around the same time the Planet V collided with the pontoon under tow.

The Dutch Safety Board started an investigation immediately after the accident. On 27 May the Safety Board reported the accident to the flag state2 of the Planet V, Antigua and Barbuda.

The accident took place in Dutch territorial waters. According to the Casualty Investigation Code of the International Maritime Organization (IMO) and EU Directive 2009/18/EC the accident was a very serious casualty and, as a coastal state, the Netherlands is required to ensure that an investigation is carried out. This duty to investigate is laid down in the Dutch Safety Board Decree [Besluit Onderzoeksraad voor Veiligheid]. The Netherlands has acted as lead-investigative state. Antigua & Barbuda has participated in the investigation as substantially interested state in accordance with the IMO Casualty Investigation Code.

1�2 Objective of the investigation

The objective of this investigation is to identify the causes of the accident in order to learn lessons that will help prevent similar incidents from occurring in the future and/or minimise their consequences. The Dutch Safety Board also wants the investigation to provide the shipping industry with insight into the forces exerted on a ship when an anchor is used at high speed, and the associated risks for the crew and the ship.

1 All the times in this report are local times (UTC+2), unless stated otherwise. 2 The flag state is the country whose flag the ship is entitled to carry.

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To this end the following questions were formulated:

1. Why did the failure of the Planet V’s propulsion system result in the ship becoming unmanoeuvrable and experiencing an undesirable course change? How did the parties involved manage the risks of the undesirable consequences of failure of the propulsion and electricity systems?

2. What were the risks of the emergency manoeuvre carried out using the anchor for the Planet V and its crew? How did the parties involved manage these risks?

1�3 Scope of the investigation

The investigation does not include a detailed examination of the preparations for, and execution of, the overtaking manoeuvre between the ships. The investigation has shown that the manoeuvre by both ships was carried out in correspondence with the ordinary practice of seamen and that adequate communication took place regarding the manoeuvre.

Both vessels carried a pilot on board. During the investigation it was established that the pilots did not contribute to the cause of the accident. Also, it was determined that, in relative terms, very little time was available for the captain of the Planet V to involve the crew or the pilot in the (crisis) decision-making. He therefore made the decision to carry out the emergency manoeuvre using the anchor independently, within a few seconds. Therefore, aspects relating to the pilot service or the cooperation between the crew members themselves and with the pilot (the so-called ‘Bridge Resource Management’) were not investigated any further.

The emergency response was initiated immediately after the accident. Members of medical aid services were brought on board by the Royal Netherlands Sea Rescue Institution (KNRM). The injured crew member of the Planet V died shortly after the anchor chain had broken free and before the arrival of the first members of the emergency services. The Safety Board found no reason to investigate the emergency response in further detail.

1�4 Reading guide

Chapter 2 presents the factual information regarding the accident and some background information on the ships involved. Chapter 3 contains the analysis of the engine failure of the Planet V and the emergency manoeuvre with the anchor. Chapter 4 contains the conclusions to the investigation. Chapter 5 formulates lessons that can be learned from the accident.

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2 RELEVANT FACTS AND BACKGROUND INFORMATION

2�1 Vessels involved

2.1.1 Planet VThe Planet V is owned by the shipping company Gerdau3, a family business in Germany which owns one other vessel. At the time of the accident both technical and safety management are assigned to a large German shipping company, Peter Döhle Schiffarts-KG, which in total operates around 450 vessels. In the spring of 2012 the ship sailed on the route St. Petersburg – Newport – Flushing – St. Petersburg.

Part of the crew, including the captain, the chief engineer4 and the fatally injured crew member, were permanent employees of the shipowner and had sailed together consistently as crew for around seven years. The other crew members, who joined the company later, had contracts with the crew management of Bernhard Schulte Shipmanagement Ltd.

Figure 2: Planet V. (Source: Martin Witte Schiffs-foto’s)

3 Reedereigesellschaft MS ‘PLANET’ Henry Gerdau KG (GmbH & Co.)4 The chief engineer is responsible for all technical systems on board a ship.

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The minimum required safe manning5 of the Planet V is nine persons. At the time of the accident there were ten crew members on board. Besides the minimum required crew members there was an additional Schiffsmechaniker6 on board. All crew members held the required certificates of competency.

The official language on board was English. The crew comprised of three Germans, a Russian, two Ghanaians and four Filipinos.

The Planet V and the shipping company (Peter Döhle) have a safety management system (SMS) that is certified according to the International Safety Management (ISM) Code.7 Among other things the SMS contains emergency procedures in the event of the failure of the propulsion system, navigation equipment and blackout. The last audit of this SMS on board took place on 5 March 2012. The shipping company also has an inventory of potential hazardous activities and procedures. As in the case of the SMS this risk inventory was drawn up on the basis of cooperation between the owner of the Planet V and the Peter Döhle shipping company. The inventory defines the risks for the ship, the crew and the environment and the necessary risk management measures.

Both documents contain procedures and estimates of the risks associated with anchoring the ship. There is no description of using the anchor in an emergency manoeuvre to slow down the ship at high speed.

The Planet V was equipped with two anchors: one on port side and one on starboard side of the bow.

5 The minimum safe manning certificate indicates the minimum safe manning required by the flag state. 6 A Schiffsmechaniker is a regular crew member on board German ships (or ships under German management). The

position is comparable with the position of the ship’s technician who used to sail on Dutch ships. The job combines the work of sailor and motorman.

7 On board this was known as the Safety Management Manual (SMM). Otherwise the report refers to SMS.

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Planet V ship’s details

Call sign: V2FS3

IMO number: 9087532

Flag state: Antigua and Barbuda

Home port: St. John’s

Ship type: General cargo with container capacity

ISM manager: Peter Döhle Schiffahrts-KG

Classification society: Germanischer Lloyd

Year of built: 1994

Yard: Peterswerf, Wewelsfleth, Germany

Length over all: 116.4 m

Length between perpendiculars: 107.8 m

Width: 19.2 m

Freeboard draught: 7.05 m

Actual draught: 6.8 m. (forward), 6.8 m. (aft)

GT: 4984

Engines: Man B&W 9L32/40

Propulsion: 1 propeller – controllable pitch8 - turning counter clockwise

Maximum propulsion power: 3,960 kW

Shaft generator capacity: 760 kVA

Auxiliary generators’ capacity: 2 x 287.5 kVA

Rudder: Semi-balance rudder

Anchor type: SPEK anchor, 4030 kg

Container capacity: 532 TEU

Reefer capacity: 80 containers

Maximum speed: 15 knots

Statutory certificates: All valid

Electronic (registration) equipment: Electronic Chart System (ECS) and Simplified Voyage Data Recorder (SVDR)

Table 1: Planet V ship’s details.8

2.1.2 MTS Vantage and the pontoon E3505Global Ship Leasing is the owner of the tug MTS Vantage. The crew is employed by Seacontractors in Flushing. The ship is mainly used for offshore activities off the Dutch coast. At the time of the collision the tug was chartered by Smit Internationale N.V. in Rotterdam.

The minimum required safe manning of the MTS Vantage is five persons. At the time of the accident there were five crew members on board. All crew members held the required certificates of competency.

The official language on board was English. The crew members had various nationalities, namely two Dutch, one Russian and two Filipinos.

8 The Planet V has a controllable pitch propeller with which the pitch (the position of the propeller blades relative to the hub) can be changed. This makes it possible to alter the speed of the ship while keeping the shaft at a constant number of revolutions.

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The pontoon E3505 is owned by Smit Internationale N.V. and is used for offshore activities off the Dutch coast. At the time of the accident the pontoon was not loaded.

Figure 3: The tug MTS Vantage and the pontoon E3505. (Source: Coster Maritieme Fotografie)

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MTS Vantage ship’s details

Call sign: PCNE

IMO number: 9585264

Flag state: The Netherlands

Home port: Terneuzen

Ship type: Tug

ISM manager9: none

Classification society: Bureau Veritas

Year of built: 2011

Yard: Damen Scheepswerf Gorinchem , The Netherlands

Length over all: 27 m

Width: 9.2 m

Maximum draught: 2.8 m

Actual draught: 2.7 m

GT: 221

Engines: 2 Caterpillar

Propulsion: 2 fixed propellers out-turning

Maximum propulsion power: 1,118 kW

Maximum speed: 11 knots

Statutory Certificates: All valid

Electronic (registration) equipment: Electronic Chart System (ECS)

Table 2: MTS Vantage ship’s details.

Pontoon E3505 ship’s details

Flag state: The Netherlands

Ship type: Ocean-going flat top barge

Classification society: Lloyd’s Register

Year of built: 2000

Length over all: 66.0 m

Width: 23.0 m

Maximum draught: 3.21 m

Actual draught: 0.75 m

GT: 1599

Table 3: Pontoon E3505 ship’s details.9

2�2 Relevant facts of the accident

2.2.1 Prior to the accident - Planet VThe Planet V departed from Newport (United Kingdom) on 21 May 2012 with destination Flushing. During the voyage to Flushing there were serious problems with the main engine as a consequence of contaminated fuel (heavy fuel oil10).

9 The SOLAS Convention requires passenger ships larger than 100 GT and cargo ships larger than 500 GT to adhere to the ISM Code. The tug MTS Vantage is therefore not subject to this requirement.

10 Merchant ships are generally powered by diesel engines. These can be run on various kinds of fuel oil with varying viscosities.

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The vessel had bunkered this fuel previously in St. Petersburg.11 During the approach to Flushing via the Westerschelde the Planet V was running on gas oil.12

On Wednesday 23 May 2012 the Planet V arrived in the Sloehaven at Flushing. When in port, the crew carried out repairs to the main engine fuel system. This involved all of the vessels’ nine fuel pumps being replaced and the fuel pipes being cleaned. The crew also isolated the contaminated fuel in a separate fuel tank. The ship would not use this fuel until further notice. On Friday night, the vessel was bunkered with new heavy fuel oil in Flushing.

After the repairs the main engine, while running on gas oil, was tested in the afternoon of Saturday 26 May 2012. This test lasted approximately 30 minutes.13 The main engine was stopped again pending departure later that day.

During the stay in Flushing the ship’s hold was loaded with potatoes and onions. In addition, 56 refrigerated and deep freeze containers (so-called ‘reefers’) were placed on deck at set temperatures varying from -21 °C to +6 °C.14

In preparation of the forthcoming departure the chief officer carried out a routine check of the navigation systems on the bridge at 16.30 hrs. Nothing unusual was observed. Voyage preparations were also made, using a Voyage Plan.15

The captain, the chief officer and the pilot were on the bridge during the ship’s departure. The engine room was also manned and the deck crew were present on the forecastle and aft deck in order to haul in the mooring lines. The main engine was started at 17.18 hrs. During departure the ship was running on gas oil, as during its arrival in Flushing. The two auxiliary engines for the auxiliary generators were running to supply the electrical systems. The shaft generator16 was also running. This generator provided power to the bow thruster only.17 The ship departed at 17.24 hrs.

When the ship sailed out of the Sloehaven, the captain informed the engine room crew that the bow thruster was no longer required. This was a sign for the chief engineer to switch the ship’s entire operational electricity supply from the two auxiliary engines to the shaft generator. After that, the chief engineer stopped the auxiliary engines for the generators. Once the shaft generator solely provided the ship’s electricity and the bow thruster was switched off, there was sufficient power available to feed the reefers. In response the chief officer ordered the crew to start the cooling systems on the reefers. According to the chief engineer, the total power needed after the reefers had been engaged was approximately 600 kW.

11 Fuel loaded on 5 May 2012, type Heavy Fuel Oil (HFO).12 To enhance manoeuvrability, some ships sail using lighter fuel (gas oil).13 According to the alarm table in the engineroom.14 The Planet V has capacity for 80 reefers.15 Before departing for sea, the captain has to draw up a voyage preparation document, which is referred to as a

Voyage Plan.16 A shaft generator is a generator which is driven by the main engine via a gearbox. The use of a shaft generator

saves fuel and reduces maintenance for the auxiliary engines.17 The bow thruster has a maximum power of 353 kW.

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2.2.2 Prior to the accident - MTS VantageOn Saturday 26 May 2012 the tug MTS Vantage was moored in the Sloehaven in Flushing. When the vessel and the pontoon were ready to depart, the pilot who was to assist the tug and tow during its departure arrived. The tug and tow intended to set to sea through the Oostgat. The pilot would disembark the vessel at Flushing roadstead.

The tug and tow left at 17.10 hrs with destination IJmuiden. The length of the towing cable between the tug and the pontoon was approximately thirty metres. During departure the captain and the pilot were present in the wheelhouse. A second tug assisted the MTS Vantage at the rear of the pontoon during unmooring. The second tug disengaged before the tug and tow passed the harbour entrance.

2.2.3 The accidentThe different sailing speeds meant that the Planet V would pass the tug and tow in the waterway of the Westerschelde. Before the MTS Vantage passed the harbour entrance the pilot contacted the pilot of the Planet V by VHF to inform him of the tug’s intentions. They agreed to discuss the overtaking manoeuvre after both ships had passed the harbour entrance.

The MTS Vantage passed the Sloehaven harbour entrance at 17.41 hrs. The tug was sailing at a speed of around 6 knots.18 Planet V passed the harbour entrance at 17.45 hrs. The Planet V was sailing at a speed of around 11 knots. As soon as the tug and tow had passed the harbour entrance, the captain navigated to the centre of the waterway. At that moment there was no other shipping in the vicinity.

The pilots of the Planet V and the MTS Vantage both discussed the upcoming overtaking manoeuvre with the captain. Using the VHF the pilots then agreed that the Planet V would pass the tug on its starboard side.

18 A knot is one nautical mile per hour. A nautical mile is defined as 1,852 metres. A knot is therefore a speed of 1,852 km/hour. Unless stated otherwise, all speeds referred to in this report are speeds over ground. Speed over ground is the speed sailed if corrections are made for current and wind.

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Collision location

Harbour entrance

Sloehaven

Figure 4: Ships and collision location (green line shows course of Planet V, red line shows course of MTS

Vantage). (Source: Coastguard Centre)

When the Planet V entered the Westerschelde waterway, the captain switched over from manual steering to the autopilot and the vessel started its overtaking manoeuvre. At 17.48 hrs the Planet V was on the starboard side alongside the pontoon. The MTS Vantage was sailing at a speed of around 5 knots. The Planet V was sailing at a speed of around 9 knots.

At 17.48:23 the Planet V’s main engine failed. Almost immediately the electrical power supply on board also failed. After the main engine failure the Planet V turned to port (towards the tug and tow). The crew and the pilot stated that the rudder angle indicator showed a starboard rudder angle. The pilot of the Planet V informed the MTS Vantage about the problems on board and requested the pilot of the tug to go ’full speed ahead‘ to prevent a collision. The pilot also informed Scheldt Coordination Centre (SCC) about the situation that had arisen.

The engine room alarms sounded on the bridge of the Planet V. The captain stated that, shortly after he heard the alarm, he knew that it related to a problem with the main engine. At 17.48:39 the Planet V captain instructed the AB and the seaman at the pilot ladder to return to the forecastle and prepare the anchor. At 17.49:34 the captain ordered the anchor to be dropped by VHF. The pilot was not consulted about this emergency control measure. Next, the anchor windlass brake on the forecastle was released allowing the anchor to fall.

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The captain later stated that the anchor manoeuvre was intended to slow down the ship and accelerate its turn to port in an attempt to pass the tug and tow at its stern.

The tug, which was already sailing at near-full speed, further increased speed and turned to port in an attempt to increase its distance from the Planet V. The tug captain then allowed the pilot to take navigational control of the vessel, and positioned himself at the towing cable controls. This allowed him to quickly release the towing cable if necessary. After all, there was a risk that the Planet V would end up between the tug and the pontoon.

After the captain of the Planet V had ordered the anchor chain to be ran out no further, the AB tightened the anchor winch brake.19 Despite this, the anchor chain continued to run out at high speed. To apply more force to the brake control lever, the AB climbed onto the electric motor of the anchor winch (see Figure 5).

The collision between the Planet V and the pontoon occurred at 17.50:05. The Planet V hit the pontoon amidships on its starboard side.

After the collision the Planet V moved down along the pontoon while the anchor chain continued to run out. The Planet V had nine shackles20 attached to its port side anchor. The last link of the anchor chain, which was attached to the ship via the bitter end connection21 in the chain locker, broke loose after the nine shackles had ran out. The loose bitter end of the chain flew out of the spurling pipe and fell overboard. The AB on the electric motor, who was positioned over the spurling pipe, was hit and fatally injured by the anchor chain.

19 A strap brake is a steel band with a non-flammable brake lining around the shaft of the cable wheel. The function of the strap brake is to stop, by means of friction, the rotating movement of the cable wheel via which the anchor chain is let out.

20 A shackle is 15 fathoms, or approximately 27.45 metres.21 The bitter end connection is a steel pin which attaches the end of the anchor chain to the ship. It is the weakest link

in the anchor gear. The International Association of Classification Societies (IACS) prescribes that the breaking strength of the bitter end should equal between 15% and 30% of the strength of the anchor chain.

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Brake control lever

Strap brake

Cable wheel

Hawspipe (overboard)

Anchor chain

Brake control lever

Strap brake

Figure 5: (Starboard) anchor winch

on board the Planet V and

simulated position of the victim

on the electric motor of the

anchor winch.

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2.2.4 After the accidentShortly after the accident the pilot informed the SCC about the medical emergency. At 17.54 hrs the SCC warned the Royal Netherlands Sea Rescue Institution (KNRM) in Breskens and the Netherlands Coastguard Centre (KWC) in Den Helder.

Once detached from the pontoon, the Planet V floated adrift. The pilot advised the captain to wait for the vessel to drift outside the fairway before dropping starboard anchor. At 17.58 hrs the Planet V was anchored close to buoy 5 outside waterway De Honte’s line of buoys.

At 18.36 hrs the medical team that was brought on board by the KNRM established that the AB had died of his injuries.

Shortly after the collision the MTS Vantage decided to return to port so that the pontoon could be inspected, and moored there at around 18.55 hrs. After permission from the port authorities the Planet V too weighed anchor and returned to the Sloehaven accompanied by a tug. At 19.28 hrs the Planet V passed harbour entrance after which the ship moored in the Sloehaven at around 20.00 hrs.

2�3 Personal injury and material damage

The AB on board the Planet V died as a result of the accident. The accident did not result in any physical injury to other crew members.

The accident caused a hole in the bulbous bow and a dent in the bow of the Planet V. Several days after the accident the anchor and the anchor chain were dredged from the sea bed and refitted on board. A number of components of the towing gear on the MTS Vantage were damaged and no longer usable. The E3505 pontoon was holed on starboard side in a tank below the waterline. A few bitts on the deck were dislocated.

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2�4 Accident location

The accident occurred on the Westerschelde in waterway De Honte near the Sloehaven. In the Scheldemond, northbound shipping uses the Oostgat, draught and meteorological conditions permitting. The Oostgat is a stretch of water along the southwestern coast of Walcheren. At the accident location this waterway is 800 metres wide but it is funnel shaped with the narrowest part being 540 metres wide. The blackout took place approximately 1,000 metres to the west of the Sloehaven at the geographical position 52˚26.5N, 003˚39.4E. The charted depth at the accident location varies between 16.6 m and 27 m.

Steenbank pilot station

Oostgat

SloehavenAccident

Figure 6: Overview of Scheldemond with the intended tracks of the two ships. (Source: NL Chart 1803)

2�5 Meteorological and current information

At the time of the accident there were no clouds nor was there any precipitation. The wind was moderate (4 Bft) and came from the east. At the time of the accident no coastal warnings were in force.

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26 May was three days after spring tide.22 At 17.50 there was an incoming current in the waterway De Honte of the Westerschelde. The current was approximately 2.0 knots.

Weather conditions at the accident location 26 May - 17.5023

Outside temperature: 24 °C

Humidity: 35%

Water temperature: 13 °C

Air pressure: 1025 hPa

Visibility: +25 km

Light conditions: Day

Clouds: Clear sky

Wind (direction/strength): Easterly 4 Bft24 (5.5 – 7.9 m/s)

Current (direction/strength): 074° – 2.0 knots (incoming)

High tide Flushing: 18.18 – 4.4 m. LAT25

Low tide Flushing: 12.15 – 0.9 m. LAT

Water level: 4.2 m

Table 4: Weather conditions. (Source: Royal Netherlands Meteorological Institute [Koninklijk Nederlands

Meteorologisch Instituut] (KNMI) and Netherlands Hydrographic Service [Nederlandse Dienst der

Hydrografie])232425

2�6 Similar incidents

Within the framework of this investigation the Dutch Safety Board looked for similar cases of the anchor being used to slow down a ship in an emergency situation. One of the steps the Safety Board took was to request information from sister organisations abroad.26 At international level no cases are known whereby a crew tried to stop a ship sailing at a considerable speed using its anchor.

The investigation showed that instances are known where crew members of disabled ships (e.g. as a consequence of failure of the main engine and/or blackout) used the anchor to try and prevent a ship from grounding by dropping the anchor to stop it while drifting. In all these cases the ships’ speeds were limited. Some of these attempts were successful, others were not. The outcome was influenced by, amongst others, meteorological conditions (e.g. wind speed and wave heights), the position of the ship in the water and the composition of the local seabed.

22 Spring tide is the period during which the difference between low and high tides is the greatest.23 The data is derived from measurements at the closest KNMI stations and precipitation images from the KNMI

weather radar.24 According to the KNMI the wind force for Beaufort scale 4 is ‘moderate’.25 LAT - Lowest Astronomical Tide. The lowest tidal level that can be predicted in average meteorological conditions

and in any combination of astronomic conditions.26 The sister organisations the Dutch Safety Board contacted include those in Canada, Malta, Norway, the United

Kingdom, the United States and Sweden.

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The Dutch Pilots’ Corporation has indicated being aware of a number of occurrences where, at a relatively high speed, the anchor dropped spontaneously or as a result of erroneous handling, and the vessel was stopped. These cases have not been registered in an accident investigation database and therefore cannot be analyzed or verified by the Dutch Safety Board.

The EMCIP international casualty database27 shows that, in the two years prior to the accident, five incidents occurred on the Westerschelde in which an engine malfunction led to a grounding or collision. None of the ships involved used its anchor to slow down or stop.

27 EU Member States record casualty data from maritime casualties in a database called EMCIP (European Marine Casualty Information Platform).

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3 ANALYSIS

3�1 Introduction

The analysis starts with a detailed reconstruction of the accident. Paragraph 3.3 then analyses the failure of the main engine and its consequences. Paragraph 3.4 looks at the use of the anchor and the conditions in which this occurred.

3�2 Reconstruction

The Planet V is equipped with a Simplified Voyage Data Recorder (SVDR). Among other things this device records the ship’s position, course, speed, radar images and communication data. Furthermore, engine room alarms were recorded. In addition, both the Planet V and the MTS Vantage are equipped with an electronic chart system (ECS). These systems recorded the position, speed and chart display of each ship. The blackout on board the Planet V meant a large part of the navigation equipment failed, as a result of which data which would have been relevant to the investigation was not recorded.28

The Netherlands Coastguard Centre registered the Automatic Identification System29 (AIS) signals from the Planet V and the MTS Vantage. The Scheldt Coordination Centre (SCC) in Flushing registered radar images and the VHF communication involving the Planet V, MTS Vantage and other shipping.

MADAS (Marine Accident Data Analysis Suite) software was used for the reconstruction of the collision between the Planet V and the MTS Vantage. Using this software, data from various sources was combined to reconstruct the accident.

Figure 7 shows an overview of the tracks of the Planet V and the MTS Vantage.

28 Although communication was recorded during the power failure, the audibility of the recording on the SVDR is limited at certain points in time. This is clarified in more detail in Annex 1.

29 AIS transponders automatically transmit information specific to the ship and its voyage, including position and speed data.

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Figure 7: Tracks of the Planet V (red) and the MTS Vantage (blue). The black square indicates the location of the

collision.

The following is a chronological list of the most important events leading up to the collision, with the speed, course and distance between the two ships being recorded at each moment in time.30, 31

17.48:23 Planet V blackoutThe blackout of the Planet V occurs.

Planet V32 MTS Vantage33

Speed over ground (knots) 9.6 5.1

Course over ground (degrees) 249 246

Distance between vessels (m) 279

30 The distance between vessels was calculated on the basis of the GPS antenna positions of the two ships. These are not exactly measured values.

31 The Rate of Turn (RoT) of the Planet V was not included in the reconstruction. The RoT was calculated by MARIN. The MARIN-reports are available on www.safetyboard.nl.

32 The Planet V data is based on the SVDR of the Planet V and the radar images of the SCC. Until 17.49:00 the SVDR recorded the speed over ground and course over ground per second. After this point in time the values of the SCC were used (rounded off by the SCC to half a knot).

33 The MTS Vantage data is based on the ECS of the MTS Vantage. The ECS recorded the speed over ground and course over ground per sixty-second time interval. The values shown were calculated by means of linear interpolation between the preceding and subsequent recorded values.

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17.48:39 Captain’s order to ’stand by anchor’The captain of the Planet V gives the order to prepare the anchor so that it can be dropped at a moment’s notice after the captain’s order.

Planet V MTS Vantage




17.49:14 Planet V pilot’s call to MTS Vantage pilotThe pilot of the Planet V informed the pilot of the MTS Vantage by VHF that a blackout had occurred and asked him to go ‘full speed ahead’.





17.49:24 Planet V pilot’s call to Scheldt Coordination CentreThe pilot of the Planet V reports the blackout by VHF to the SCC.





17.49:34 Captain’s order to drop the Planet V’s anchorThe captain of the Planet V gives the order to drop the anchor.





Figure 8 shows the positions of the Planet V and the MTS Vantage shortly before the collision.

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Figure 8: Radar image of the Planet V and the MTS Vantage shortly before the collision. (Source: SCC)

17.50:05 Collision between the Planet V and the pontoon of the tug and towThe Planet V collides with the pontoon of the tug and tow.





17.51:10–17.51:2534 Crew member is fatally injured due to the anchor chainThe Planet V’s anchor chain breaks loose and a crew member is fatally injured.

The above table shows that the distance between the GPS antennas of the two ships at the time of the collision was around 135 metres. This distance can be explained using Figure 9. The longitudinal distance between the two GPS antennas is 90 up to 95 metres. The lateral distance is 95 up to 105 metres.

34 The time at which the anchor chain broke loose could not be exactly determined on the basis of the available data. The time was therefore estimated on the basis of photos taken shortly after the collision from the MTS Vantage. In these photos a dust cloud is visible on the forecastle of the Planet V, which was most likely caused by the running out/breaking loose of the anchor chain. The time was verified by calculating the time it took for the anchor chain to run out, within which calculation the distance covered by the Planet V was compared to the length of the anchor chain.

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From this it can be concluded that the total distance between the two GPS antennas was 130 up to 145 metres, which corresponds to the estimated value of 135 metres.35

MTS Vantage

Planet V

Ponton

20 30

11 - 12

85 - 90130 - 1

45

40 - 45

Figure 9: Distance between the GPS antennas (red dots) of the two ships at the time of the collision.

Figures 10 and 11 show the speed and course over ground of the two ships.

4

5

6

7

8

9

10

MTS Vantage ECSPlanet V SCCPlanet V SVDR

Time

Spee

d (k

nots

)

17:50:0017:49:3017:49:0017:48:3017:48:0017:47:3017:47:00

Speed over ground (knots)

Figure 10: Speed over ground of Planet V and MTS Vantage.

35 Figure 9 shows a simplified diagram of the positions of the ships at the time of the collision. It is simplified because, among other things, the position of the pontoon, the length of the towing line, the heading of both ships and the pontoon and the angle of collision between the Planet V and the pontoon could not be determined exactly.

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170180190200210220230240250260270

MTS Vantage ECSPlanet V SCCPlanet V SVDR

Time

Co

urse

(deg

rees

)

17:50:0017:49:3017:49:0017:48:3017:48:0017:47:3017:47:00

Course over ground (knots)

Figure 11: Course over ground of Planet V and MTS Vantage.

3�3 Failure of the main engine and its consequences

3.3.1 Failure of main engine The problems with the main engine that occurred during the voyage from Newport (United Kingdom) to Flushing were caused by poor quality fuel which did not meet the set requirements.36 The Planet V engine room alarm registration shows that, during this voyage (excessive) differences in the exhaust gas temperature between the different cylinders were observed. To prevent damage, the power-output supplied by the main engine was therefore reduced repeatedly and automatically, i.e. without crew involvement. The fuel analysis report37 and corresponding statement show that, in conjunction with comparable excessive values of certain chemical substances in the fuel, other ships also experienced problems with and/or damage to the fuel system.

The alarms associated with the main engine failure registered on the safety system print-out after departure from Flushing on 26 May do not correspond to the previously observed problems with the fuel. No alarm was registered in the half hour before the blackout. The first two alarms registered were ‘Failure Unessential Consumers’ and ‘Failure Speed Regler’. The first alarm indicates the switching off of the non-essential systems. The second alarm indicates a defective main engine regulator. After the defective regulator was replaced by the chief engineer (shortly after the accident), the main engine operated normally again. A later investigation by the manufacturer confirmed that the (electronic) regulator exhibited defects. After the ship had departed Flushing again on 31 May (using the fuel bunkered in Flushing), the problem did not recur.

36 Fuel used on board seagoing vessels must comply with MARPOL Annex VI, EU Directive 1999/32 and ISO 8217.37 Issued by classification society Det Norske Veritas

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Conclusion:The investigation did not indicate any relationship between the main engine failure on the day of the accident and the earlier fuel problems. The engine malfunction was caused by a defective main engine regulator.

3.3.2 Failure of electrical installationDue to the insufficient main engine revolutions caused by the defective regulator, the number of revolutions of the propeller shaft reduced. This caused a drop in the alternating current frequency supplied by the shaft generator to the ship’s electrical systems. First the safety system tried to prevent the shaft generator from switching off automatically by disconnecting non-essential38 users. However, this did not have the desired result and the frequency dropped even further. This was registered by an ’Under frequency’ alarm. In order to prevent damage to the generator, gearboxes and electrical systems, the safety system disconnected the shaft generator from the ship’s electrical system. Because the auxiliary generators were not running yet, a blackout occurred.

Conclusion:Because the full electrical power supply on board was provided by the shaft generator, the main engine failure resulted in a total blackout.

Several seconds after the shaft generator had switched off, the stand-by auxiliary engine started automatically to provide electrical power on board via a stand-alone generator. This process of starting up, reaching full revolutions and supplying the ship’s electrical systems takes several tens of seconds. Before all the essential ship’s systems are available again, several minutes may pass.

3.3.3 Risk management in the event of propulsion failureAccording to the flag state and the classification society, the technical systems of the Planet V meet the requirements of international legislation and regulations. This was verified prior to the accident by the flag state and the classification society within the required periods. The shipowner had assigned the Planet V to a large shipping company (Peter Döhle Schiffarts-KG) so that the (technical) expertise of this company could be used as well as its safety management system. However, the owner itself crewed the vessel and had a preference for experienced, permanently contracted crew members.

38 Provisions such as air conditioning, ventilation of the accommodation and electrical supply to the reefer containers on deck are not essential for a safe voyage. Excessive power demands cause the number of revolutions of the generator to decrease too far. The safety system will respond by disconnecting non-essential users from the electrical system. This will enable all the available electrical power to be supplied to those users that are essential for a safe voyage. In this case, however, the problem was not that too much power was needed, but that too little electrical power was generated. However, the automatic safety system responds in the same manner.

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The captain, chief engineer and the AB had all been employed by the shipping company for some time and, as such, were very familiar with the procedures on board the Planet V. The shipping company had permanently assigned a ‘Schiffmechaniker’ on board for preventive maintenance, in addition to the required minimum safe manning.

Conclusion:The ship complied with (inter)national rules and regulations relating to the technical systems and crew.

The SMS of the Planet V includes various procedures on how to act in the event of on board system failures. In one of the procedures (Emergency Plan- Main Engine Failure), the use of anchors in the event of an engine malfunction is referred to as a possible measure:

In case of an unexpected failure of the main engine, the following measures should be observed:

• alert engine department• inform master• state position of the vessel, seastate, wind direction and strength, current

direction and force• in case drifting ashore, state depth of water• alert helmsman• prepare anchors to be ready for action• prepare and hoist respective signals for vessel not under command• alert traffic in vicinity by all possible means• if time and location permits, respectively as might be required by present

situation of the vessel, drop anchors• obtain information from chief engineer on duration of necessary repairs• if situation requires, check possibilities of foreign assistance• inform owner’s / operator’s office immediately

Table 5: Emergency Plan - Main Engine Failure Planet V – SMS Planet V.

The procedure does not stipulate how and when the anchors can be used. However, it is (almost) impossible to prescribe such specific procedures and recommendations because numerous variables have to be considered during the process, such as sailing speed, current, water depth, type of seabed and the amount of decision time available. Moreover, the need for such a manoeuvre cannot be determined in advance.

For these reasons the decision to use the anchor in an emergency situation is left to the captain, as the procedure indicates. During the consideration process the pilot can advise (on request or of his own accord) on the local conditions and (im)possible options.

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Conclusion:Generic procedures were available on board the Planet V for use in the event of an engine failure. These procedures provided the crew with a certain degree of freedom to respond adequately in various emergency situations.

3.3.4 Risk management in the event of blackoutThe requirements of the International Association of Classification Societies (IACS)39 stipulate that seagoing vessels must have back-up systems so that, in the event of a blackout, power can still be provided to essential equipment. Among other things this means that, should a generator fail, a back-up generator with sufficient power should be available for the electrical system during normal operations (referred to as sea operations). Such a generator may be linked to the propulsion system (shaft generator). Generators can also be driven by auxiliary engines. The benefit of using a shaft generator is that savings can be made on maintenance and fuel.40 A disadvantage of using a shaft generator is that failure of the propulsion system will also terminate the electrical power supply, since the shaft generator is connected to the main engine via a gearbox.

During the departure from the port on 26 May, electrical power on board was supplied by the two stand-alone generators. These both had a maximum power of 247 kW. The total power output of these two generators was insufficient to cool the 56 reefers on board during the voyage. The crew therefore switched to the shaft generator after the ship had passed the harbour entrance and as soon as the bow thruster was switched off. After that, the deck crew started switching on the reefers on board and the stand-alone generators in the engine room were stopped. From that moment on, the entire electrical power supply in the narrow waters of the Westerschelde was dependent on the propulsion system.

According to the safety management system (SMS) of the Planet V, a blackout of only a few seconds can have huge consequences in narrow waterways (see table 6). According to the Dutch Safety Board, sailing in narrow waters on two generators connected in parallel with each having sufficient power to supply the ship’s network is regarded as the ordinary practice of seaman. Nevertheless, the same SMS allows the Planet V to sail on just one generator in narrow waters without any stand-by resources being available. The crew’s decision to use just one generator, therefore, was backed up by the SMS. The Safety Board nevertheless believes it is desirable for crews to critically assess the regulations in the SMS. The SMS serves to support and aid in the regulation of operational management on board the ship. The crew should highlight cases where the SMS is in conflict with good seamanship and take alternative measures as necessary.

39 The International Association of Classification Societies (IACS) is a coordinating organisation of thirteen classification societies. Its members’ classified vessels amount to approximately 90% of the global fleet. IACS members have to meet the requirements under the IACS Quality System Certification Scheme.

40 The auxiliary engines on board the Planet V each consume approximately 1.2 ton of fuel per day.

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Preamble(...) the sudden failure of an auxiliary engine might cause a blackout of the power supply for essential consumers for a number of seconds only. However in shallow or narrow waters or in dense traffic these seconds can be disastrous. (...)

Description of measuresIf the vessel is proceeding in shallow or narrow waters or areas with dense traffic, at least two generators should be engaged or the shaft generator is in operation. In case of failure of one of such installations, it only takes a few seconds to get a sound machine in operation and to supply necessary electrical power to essential consumers (...).

Table 6 – Emergency Plan - Failure of Auxiliary Engines – SMS Planet V.

Conclusion:Despite the fact that in the SMS of the Planet V a blackout in narrow waters was identified as a major risk, no alternative safety measures were in place.

Both the shipowner and the crew declared that the decision to switch from the auxiliary generators to the shaft generator was taken for reasons of economy. The two auxiliary engines were not switched on to save fuel and maintenance. As a consequence, the main engine failure directly resulted in a blackout. Although a potential safety provision was available it was not used for reasons of economy.

Conclusion:The two auxiliary engines were not switched on to save fuel and maintenance. As a consequence, the main engine failure directly resulted in a blackout.

3.3.5 Manoeuvrability of the ship

The Maritime Research Institute Netherlands (MARIN) carried out an analysis of the ship’s considerable change in course to port after the blackout.41 The analysis revealed that the Planet V is a course-stable ship and that substantial forces are therefore required to cause it to deviate from its course.

41 The MARIN-reports are available on www.safetyboard.nl.

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The anchor was dropped around 80 seconds after the blackout. The collision occurred approximately 30 seconds later. The MARIN report shows that before the anchor was dropped and could have had any effect the ship’s maximum rate of turn had already been reached. Therefore, the anchor did not contribute to the turn to port or the speed reduction of the Planet V.

Conclusion:The anchor manoeuvre did not contribute to the prevention of the collision or the mitigation of its consequences.

According to the calculations made by MARIN, the Planet V’s sudden course change to port can only be explained by a force exerted by the ship’s rudder. Forces exerted on the ship, such as wind and current, cannot have caused this turn. Simulations have shown that the observed rate of turn can only be achieved by a port rudder angle of 45°.42

Conclusion:The turn to port can only have been caused by a significant rudder deflection.

Prior to the blackout the ship was sailing on the autopilot.43 The crew stated that they did not operate the rudder after the blackout. They also stated that, after the blackout, the rudder angle indicator indicated a starboard rudder angle, which, however, they did not constantly monitor. The investigation could not provide any explanation for the difference between the stated position of the rudder angle indicator on the bridge and the actual position of the rudder which was required for the actual course change to port. This occurrence shows that after a blackout the crew can no longer automatically rely on the accuracy of the ship’s sensors.

Due to the blackout after the main engine failure the crew was unable to operate the rudder from the bridge and influence the course of the ship. Given the short time between the blackout and the collision, there was also no time for the crew to man the emergency conning position in the engine room in order to stop the turn to port towards the tug and tow. As a result, the ship became ’not under command’ after the failure of the main engine and the blackout.

42 In combination with a stopping propeller (referred to as ‘wind milling’) and a 50% position of the propeller pitch.43 Based on the SVDR recorded data and crew members’ statements.

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If the electrical power supply had not failed, the crew would still have been able to operate the rudder after the main engine failure . However, in that case, the rudder would have become less effective due to the ship’s decreasing speed and the limited flow of water over the rudder.

Conclusion: The blackout meant that the crew was unable to correct the turn to port by using the rudder.

3�4 The emergency manoeuvre using the anchor

3.4.1 The anchor gear

The International Association of Classification Societies (IACS) imposes technical requirements on the anchor gear. These include specifications of the required anchor mass and the length, size and strength of the anchor chains. In addition, the size of the anchor gear has to be consistent with the mass of the anchor and the anchor chain so that these can be hauled in (weighed) and to pull free an anchor that has become deeply embedded in the seabed. The anchor gear is generally driven by an electric motor, and the anchor windlass is designed so that it can be operated by one person.

IACS stipulates that an anchor must be constructed in such a way that it is suitable to anchor a ship temporarily in ‘moderate’ ambient conditions. The anchor gear is not designed to stop a ship.44

Conclusion:The anchor gear is not designed to stop a ship.

The anchor winch on board the Planet V was fitted with a brake which is tightened manually on a steel drum by means of a brake control lever (see Figure 12). The port side anchor was used to slow down the ship. This anchor was used approximately once every two weeks. A technical examination of the anchor gear and the strap brake did not reveal any defects.

44 IACS A1 – Equipment. “...The anchoring equipment required herewith is intended for temporary mooring of a vessel within a harbour or sheltered area when the vessel is awaiting berth, tide, etc. The equipment is therefore not designed to hold a ship off fully exposed coasts in rough weather or to stop a ship which is moving or drifting. In this condition the loads on the anchoring equipment increase to such a degree that its components may be damaged or lost owing to the high energy forces generated, particularly in large ships...”

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Strap brake

Brake control lever

Strap brake

Figure 12: Port anchor gear and opened

winch brake of the Planet V.

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The last link of the anchor chain was secured in the chain locker with a steel pin, known as the securing pin. The space between the pin and the anvil was approximately five centimetres (see Figure 13). This is approximately the thickness of the anchor chain links. The pin was visibly damaged after the accident. Given that usually an anchor chain is not fully used and the securing pin is almost never stressed (except when the anchor is let out fully via the winch), the damage was probably caused when the entire chain ran out uncontrollably and broke loose.

Anvil

Securing pin

Securing pin

Damage

Figure 13: Securing of the anchor chain in the chain locker.

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3.4.2 Analysis of the emergency manoeuvre and the use of the anchorSeven seconds after the first bridge alarms, the captain instructed the crew on deck, the AB and a seaman, to prepare the anchor. These sailors who were involved in preparing the pilot ladder went to the forecastle as quickly as possible. In order to let the anchor drop freely, they removed the chain stopper.45

At 17.49:34 the captain ordered the anchor to be dropped by VHF (‘let go anchor’). After that, the crew detached the strap brake by hand. The captain did not order beforehand how many shackles had to be let into the water. At 17.49:43 the running out of the chain could be heard on the SVDR. It was stated that while the anchor chain was running, the AB informed the captain about how far it had ran out. Seventeen seconds after the order to drop the anchor, the captain issued the order to secure the anchor (‘fast’). The captain repeated his order five seconds later (‘fast, fast’). In interviews it was stated that the anchor chain had then ran out for approximately two shackles (50 metres).

Despite the attempts by the AB to secure the winch brake, the anchor chain continued to run out. Interviews with the crew on the forecastle revealed that the AB then took the initiative to step from the deck onto the electric motor of the anchor windlass to exert more force on the lever of the brake. However, it was impossible to stop the rest of the chain from running out. Photos of the anchor windlass after the accident show that the paint is burned over the entire surface. These photos show that, despite the considerable friction of the brake, the chain continued to run out at a relatively high speed. After the last length of chain had broken loose from the chain locker, the AB was hit and fatally injured. It is not known why the AB did not leave his position when it appeared that the chain continued to run out and attempts to stop were insufficient.

The fact that the AB was standing on the electric motor meant that he was exactly standing over the spurling pipe through which the anchor chain ran out from the chain locker to the deck. It was in this position that the AB was hit by the flying anchor chain. He died on the forecastle from his injuries.

Conclusion:The AB stood in a position where he could be hit by the flying anchor chain. The chain fatally injured the AB.

The research facility MARIN also investigated the forces which were exerted on the anchor gear and the ship during use of the anchor at the relatively high speed of approximately 9 knots.

45 The chain stopper is an extra safeguard to remove force from the anchor windlass and prevent the undesirable running out of the chain.

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The MARIN simulations show that the shortest braking distance is achieved if the braking capacity of the winch brake is only partly used (25%). The brake on the ship will then optimally absorb the maximum retaining power of anchor and anchor chain on the seabed to slow down the ship. The anchor will then just about hold. This means that slowing down the Planet V using the anchor at a speed of approximately 8 to 9 knots will result in a theoretical stopping distance of 330 metres from the moment the anchor takes hold. This is longer than the available and prescribed chain length on board (approximately 250 metres).46 The chain will therefore extend completely and be lost before the ship is stopped.

If the maximum braking force of the strap brake is used, the retaining power of the anchor in the seabed of the Westerschelde is insufficient, as a result of which the ship will drag the anchor and the anchor chain over the seabed. This will result in a longer braking distance. Further tightening the strap brake will therefore not have any positive effect on the ship’s braking distance.

The execution of such a manoeuvre in practice is highly complex. This is because the crew has no insight into the actual retaining power of the anchor and the chain on or in the seabed and cannot therefore adjust the braking force accordingly.

Conclusion: A ship that uses its anchor to stop at a relatively high speed will most likely lose its chain or suffer other damage to the anchor windlass, anchor hawse or chain locker.

Safety when anchoring in exceptional conditionsRisk matrices are available on board which can be used to define hazardous work. In order to ensure that these risk matrices actually reflect the situation on board, they are completed by the crew members themselves. The Detailed Risk Assessment for anchoring (see Annex 4) provides an insight into the presumed risks associated with this activity. Anchoring is designated as a potentially very dangerous manoeuvre which can result in (fatal) injury. The safety measures prescribed by the shipping company state that crew members must wear personal protective equipment, that a crew member must be assisted when anchoring and that relevant instructions and training must be given.

The AB on board the Planet V was wearing his prescribed personal protective equipment. The AB was also assisted by a seaman on the foredeck. It could not be established whether, and if so how, the crew received any additional anchoring instructions. The proposed safety measures were insufficient to protect the crew against the hazards which can routinely occur during an anchor manoeuvre, let alone in an emergency situation.

46 The chain length on board the Planet V is based on international standards that apply to all ships built in accordance with the IACS rules.

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For example, personal protective equipment provides insufficient protection against a flying anchor chain, the second crew member on the foredeck was unable to prevent the accident and the potential risks which could occur during an (emergency) anchor manoeuvre had never been discussed.

Conclusion:The proposed safety measures of the shipping company for a standard anchor manoeuvre were insufficient to protect the crew against the high risks which occur during an (emergency) anchor manoeuvre.

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4 CONCLUSIONS

4�1 The engine failure, blackout and the ship’s manoeuvre

The emergency situation on board the Planet V, during which a decision was taken to anchor, was caused by a main engine failure, followed by a blackout. The main engine failure was caused by a defective regulator.

The high rate of turn of the Planet V after the blackout can only have been caused by the rudder suddenly turning to port. The blackout meant that the crew could no longer correct the turn to port in due time, as a result of which the Planet V collided with the pontoon.

The blackout could have been avoided by running on both auxiliary generators. However, the auxiliary generators were switched off to save fuel and maintenance. As a consequence, the main engine failure directly resulted in a blackout. If the auxiliary generators had been switched on, the ship potentially would have remained (partially) manoeuvrable after the main engine failure and the collision could have been avoided without using the anchor.

4�2 Use of the anchor

The anchor gear on board the Planet V, as applies to all merchant vessels, was not designed to slow down the ship. The anchor was nevertheless dropped from the Planet V, despite its high speed, which caused considerable forces to be exerted on the anchor gear that led to the chain breaking loose and one crew member being fatally injured as a consequence of the flying chain.

The crew on board the Planet V were not aware of the considerable risks of emergency anchoring at high speed, as a result of which this manoeuvre was executed without any safety measures. In addition, the anchor manoeuvre turned out to be ineffective: it did not contribute to the prevention of the collision or the mitigation of its consequences.

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5 LESSONS FROM THE ACCIDENT

The investigation into the accident on board the Planet V on 26 May 2012 has produced two important safety lessons for the shipping industry in general. These lessons are important in particular for shipowners, crews, the Pilotage Service, training institutions, shipyards and ship designers.

1. The need for uninterrupted power supply when sailing in narrow waters

Sailing in narrow waters entails more risks due to the smaller margins available for correcting a ship’s course and the increased risk of the ship colliding or grounding. Therefore, prior to commencing a passage in narrow waters, a risk analysis should be carried out as part of the SMS in order to verify that back-up systems are instantly available. For example, uninterrupted power supply is essential in order to guarantee a ship’s manoeuvrability.

2. The use of the anchor to slow down the ship in an emergency

Anchors are designed to moor a ship in a harbour or sheltered area. An anchor is expressly not designed to slow down a ship. Anchoring at high speed is an extremely risky operation that may result in fatal injuries to crew members and serious damage to the ship. This is why such a manoeuvre should only be considered in an extreme emergency. In such a case the captain, in consultation with the bridge team, should assess whether the potential benefits of an effective manoeuvre outweigh the substantial risks for his crew and ship.

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ANNEx 1

INVESTIGATION DETAILS

Reason for the investigation

The accident took place in Dutch territorial waters. According to the Casualty Investigation Code of the International Maritime Organization (IMO) and EU Directive 2009/18/EC the accident was a very serious casualty and, as a coastal state, the Netherlands is required to ensure that an investigation is carried out. This duty to investigate is laid down in the Dutch Safety Board Decree [Besluit Onderzoeksraad voor Veiligheid]. The Netherlands has acted as lead-investigative state. Antigua & Barbuda has participated in the investigation as substantially interested state in accordance with the IMO Casualty Investigation Code.

Objective of the investigation

The objective of this investigation is to identify the causes of the accident in order to learn lessons that will help prevent similar incidents from occurring in the future and/or minimise their consequences. The Dutch Safety Board also wants the investigation to provide the shipping industry with insight into the forces exerted on a ship when an anchor is used at high speed, and the associated risks for the crew and the ship.

To this end the following questions were formulated:

1. Why did the failure of the Planet V’s propulsion system result in the ship becoming unmanoeuvrable and experiencing an undesirable course change? How did the parties involved manage the risks of the undesirable consequences of failure of the propulsion and electricity systems?

2. What were the risks of the emergency manoeuvre with the anchor for the Planet V and its crew? How did the parties involved manage these risks?

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Investigation method

On the morning after the accident, investigators from the Dutch Safety Board travelled to the accident site to conduct initial interviews with crew members and to safeguard (electronic) data. In the period after the accident, information was obtained via additional interviews.

To make an reconstruction of the accident, the following sources were used:

• Simplified Voyage Data Recorder (SVDR) from the Planet V• Automatic Identification System (AIS) from the Planet V and the MTS Vantage• Electronic Chart System (ECS) from the Planet V and the MTS Vantage• Radar images and communication data from the Scheldt Coordination Centre (SCC)

The AIS data from the two ships was recorded and made available by the Netherlands Coastguard Centre . During the blackout on board the Planet V the SVDR was unable to record the position, course, speed and radar images for several minutes. However, the communication during the blackout was recorded.

Use of expertise

To answer the research questions an investigation was carried out, in addition to the investigation by the Dutch Safety Board, by external experts from the Maritime Research Institute Netherlands (MARIN).47 This investigation provided insight into:

• the cause of the Rate of Turn of the vessel after the blackout and what could have prevented this Rate of Turn;

• the magnitude of the loads on the anchor gear and the vessel when a vessel is stopped by the anchor, the main parameters and what loads can be expected for various scenarios.

During the investigation information was used from the Royal Netherlands Navy (or Navy Command), the flag state, the shipping company and various classification societies.

Although communication was recorded by the SVDR during the blackout, the recorded audio quality is limited at certain points in time. The Naval Maintenance and Sustainment Agency of the Navy Command [Marinebedrijf van het Commando Zeestrijdkrachten] was commissioned by the Dutch Safety Board to process the recording using different audio techniques to improve the audio quality during the period between the first alarms on the bridge and the collision. Even after the use of various audio techniques, audio quality issues rendered some parts of the recording during this period of time ‘unusable’.48

47 The MARIN-reports are available on www.safetyboard.nl.48 The recorded audio quality was determined using the National Transportation Safety Board Cockpit Voice

Recorder Quality Rating Scale. ‘Unusable’ means the following: “Crew conversations may be discerned, but neither ordinary nor extraordinary means made it possible to develop a meaningful transcript of the conversations”. Source: NTSB Cockpit Voice Recorder Handbook for Aviation Accident Investigations.

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The Navy Command concluded that the limited audio quality was caused by noise pollution and distortion. The Navy Command also established that setting standards and imposing functional requirements on the system may improve the quality and audibility of recorded data. The possibilities for improvement listed include the improved positioning of microphones and the use of an Automatic Level Controller,49 possibly in combination with a Compressor/Limiter function.

Consultation

A draft version of this report has been sent to all the parties involved, in accordance with the Dutch Safety Board Act [Rijkswet Onderzoeksraad voor Veiligheid]. These parties were asked to check the report for mistakes, omissions and inaccuracies and to provide comments where necessary. The Dutch Safety Board is obliged to include the views of parties that differ from the views of the Dutch Safety Board in its report, along with reasons. See Annex 2 of the report.

Guidance Committee

The Dutch Safety Board set up a guidance committee for the investigation into the accident with the Planet V. The members of this committee were external individuals with expertise relevant to the investigation, and the committee was chaired by a board member of the Dutch Safety Board. The external individuals sat on the guidance committee in a private capacity. During the investigation the committee met three times to exchange ideas with the board member and the project team regarding the investigation process and results. The committee fulfilled an advisory role during the investigation. The Safety Board has final responsibility for the report and any recommendations or lessons learned from the investigation. The committee consisted of the following members:

Guidance Committee

E.R. Muller (chairman) Dutch Safety Board

C. Herfst Captain of merchant vessel

E. Hietbrink STC-Group – Chairman of the board

J.J. Hopman Delft University of Technology – Maritime Engineering

M. Torpstra Holland Shipbuilding Association, former pilot

49 An Automatic Level Controller (ALC) makes it possible to automatically set an optimal signal level during a recording. Rapid signal peaks can be managed in combination with a Compressor/Limiter function. This assigns optimal signal/noise distance to the signal and can prevent distortion.

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Project team

Project team

H. van Duijn Investigation manager

A.J. Timmers Project leader/investigator

N. Smit Analyst

P.H. Verheijen Investigator

M. Vlag Investigator

A.A.J. van der Zee Investigator

The following people made significant contributions

M.J. Schuurman Investigator

L.P. Sluijs Investigator

H.J.A. Zieverink Investigator

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ANNEx 2

RESPONSES RECEIVED FOLLOWING REVIEW OF THE REPORT

In accordance with the Dutch Safety Board Act, a draft version of this report was submitted to the parties involved for review. The parties were requested to check the report for any errors and ambiguities. The draft version of this report was submitted to the following parties for review:

• Reedereigesellschaft MS “PLANET” Henry Gerdau KG (GmbH & Co.)• Captain Planet V• Pilot Planet V• Marine & Towage Services Group Ltd• Captain MTS Vantage• Pilot MTS Vantage• Antigua & Barbuda (Antigua and Barbuda Department of Marine Services and

Merchant Shipping, ADOMS)

All parties availed themselves of the opportunity to respond. The responses received were grouped into the following two categories:

• The Safety Board has incorporated corrections of factual inaccuracies, additional details as well as editorial comments, where relevant. The relevant passages were amended accordingly in the final report. These responses have not been separately included;

• The Safety Board replied to the responses that were not included in the report. These responses are set out in the following table. In addition to the verbatim content of the responses, the table also provides the following information: the section relevant to the response, the party providing the response and the Safety Board’s reply.

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Comments from Paragraph Argumentation for / substantiation of your response

Response

Antigua and Barbuda 1.1 There is one thing our office thinks should be included, namely a statement that the casualty investigation was executed as a joint with the Netherlands in the lead.

The text in the report has been adapted in part. “...the Netherlands has acted as lead-investigative state. Antigua&Barbuda has participated in the investigation as substantially interested state in accordance with the IMO Casualty Investigation Code…” The flag state provided relevant information on request.

Pilot MTS Vantage 3.3 I know from practical experience that in the event of a blackout it is ESPECIALLY difficult to stay on course with pitchprop-driven vessels. Experience has taught me that during a blackout, even with a fully functional becker rudder the ship’s initial turn caused by the propulsion blackout cannot be compensated. In my view it is caused by the loss of pressure that occurs when the (pitch) propulsion fails. According to MARIN the turn must have been caused by a 45-degree rudder angle. Also note that the ship was on automatic pilot during the blackout. I find it hard to believe that an automatic pilot could cause a 45-degree rudder angle. I have never seen this happen.

During a sea trial in 1994 the Planet V appeared to be a course-stable ship (as shown, for example, by a zigzag test, a crash-stop test and a pull-out test). During the crash-stop test in 1994, the course of the ship hardly changed. MARIN confirmed this in simulations. The captain stated that in practice, in the event of a fast reduction in the pitch (for example in a blackout situation) the Planet V makes a limited turn to port. The speed of the turn to port at the time of the accident (rate of turn of up to 57 degrees per minute) is out of proportion to the turn indicated by the captain. In order to achieve such a rate of turn, a substantial lateral force is required. The lateral forces resulting from the interaction with the tug and the pontoon and the reducing propellor and current and wind are insufficient to have been able to cause the rate of turn that was observed.

Pilot Planet V 2.2 Speed over ground lower due to head current

Unless stated otherwise, all speeds mentioned in this report are ‘speeds over ground’. See also footnote 20.

Pilot Planet V 2.4 I believe the anchor already hit the seabed north of the 20 m line. A 10-metre difference influences / may influence the forces exerted on the anchor gear.

Partly adapted in the main text. The depth of the water influences the force exerted on the ship by the anchor. MARIN performed its calculations using its database, which includes details of the area and bathymetric data. MARIN used a water depth of 27 m for its calculations.

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Response

Pilot Planet V 3.3 In my opinion, this explains that the rudder was hard to starboard. After all, the autopilot measures the difference between the actual course and the set course, but due to eddies around the rudder caused by the failure of the main engine there was no pressure on the rudder (no lift).

The Planet V initiated a very sharp turn to port (rate of turn of 57 degrees / minute). This turn could only have been caused by a port rudder angle. The crew stated that during the blackout the pitch reduced to 50% while the propellor gradually slowed down. This results in a sufficient flow of water past the rudder to achieve the observed rate of turn. The investigation failed to provide an explanation for the difference between the declared position of the helm indicator on the bridge and the actual position of the rudder vane which was required for the actual change in course to port.

Pilot Planet V 3.3 I totally disagree!!! With all due respect, I think MARIN is just theorising here. I think that in this context more value should be attached to practice. Ask nautical experts about their experiences with pitch propellers and fast reducing…

See previous response to this item.

Pilot Planet V 4.1 From my practical perspective, I totally disagree. This is very premature; a ship with a pitch that is declining fast can become completely “not in command”, irrespective of the rudder deflection. The conclusion is premature!

See previous response to this item.

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Response

Reedereigesellschaft MS “PLANET” Henry Gerdau KG

3.3 The captain stated that when he switched the rudder control from autopilot to manual control and tried to put the rudder to starboard, the rudder indicator was moving to starboard. I cannot judge this finally, but power was reported to be restored in less than 10 seconds (later blackout tests showed the same). So maybe continous power supply would not have led to prevention of the port side turn.

The captain and the pilot declared to the Dutch Safety Board that the rudder was not operated directly after the blackout. This is because the indicator already indicated a (desired) starboard rudder angle. In section 3.3.5, the Dutch Safety Board states that if the electicity systems had not failed, the crew would still have been able to operate the rudder directly after the main engine failure. If that had been the case, the rudder would have become less effective however due to the ship’s deceasing speed and the limited flow of the water against the rudder.

Reedereigesellschaft MS “PLANET” Henry Gerdau KG

General On ‘Planet V’ we had a case on river Elbe, were both generators stopped due to a earth fould in the 24 V system, causing blackout and ME stop. That time the vessel was sailing with slow speed, so nothing happened, but that is why I do not generally agree that auxiliary engine power supply is more safe than shaft generator. I consider the main engine as the most reliable source of power on board. In this case it it obvious though, that the power supply of the auxiliary engines would not have failed. And generally I also agree that the failure of 2 engines at the same time is not as likely as the failure of 1 engine.

No substantive comments.

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ANNEx 3

REFERENCE FRAMEWORK

Introduction

This chapter contains the reference framework which the Dutch Safety Board uses to assess its findings. The basis used by the Dutch Safety Board in this context are current legislation as well as other relevant standards and guidelines. The Safety Board also applies a reference framework to determine how the parties involved fulfil their safety management responsibilities.

Laws and regulations - international

International Convention for the Safety of Life at Sea (SOLAS)The SOLAS convention is an international convention on safety at sea. The convention was drawn up in 1914, after the Titanic disaster, and has been the responsibility, since 1960, of the International Maritime Organization (IMO). Since then the convention has been supplemented several times and has imposed requirements on seagoing vessels in relation to construction, safety resources, (communication) equipment and crew.

International Safety Management (ISM) CodeThe ISM Code is an international standard for safety management on board ships. Shipping companies and ships are required to implement a safety management system which contains, among other things, the procedures for operations on board, training, maintenance, evacuation, reporting incidents, (internal) audits and reviews. It also has to include the responsibilities and tasks of the shipping company and crew.

The SOLAS convention stipulates that both the shipping company and its ships have to fulfil the requirements of the ISM Code. Periodical audits have to be carried out to verify whether this is the case. A shipping company must possess a Document of Compliance (DoC). This document is valid for maximum five years and states that the shipping company fulfils the obligations of the ISM Code. Every ship that has to fulfil the obligations must have a Safety Management Certificate (SMC) on board. This certificate is also valid for maximum five years and is issued if the safety management system on board fulfils the code’s standard. At least one intermediate audit is required between the certificate’s second and third anniversaries. The audits are carried out by the flag state or by a organisation which is recognised by the flag state. In the latter case the flag state remains responsible for verification which is recognised by the flag state.

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The ISM Code has been applicable for passenger ships and tankers since 1997. Since 2002 the ISM Code has been obligatory for all merchant ships larger than 500 GT. Fishing vessels and cargo vessels including tugs under 500 GT do not need to comply with the ISM Code requirements.

International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW)The STCW convention was adopted by the IMO in 1978 and entered into force in 1984. The STCW stipulates minimal requirements that training courses and certificates have to fulfil. The convention also contains rules and recommendations as to how and in which conditions seafarers should carry out their tasks on board. For example, it contains rules regarding working hours, time off and medical examinations but also tasks which have to be carried out during the watch duties. The convention was revised in 1995, 2010 and 2012. The latest version will enter into force in 2013.

There is a connection between the STCW convention and the ISM code. For example, the ISM Code states that the safety management system must comply with the codes, guidelines and standards described by the IMO – including the STCW convention. Antigua and Barbuda and the Netherlands – the flag states of the two vessels – ratified the SOLAS convention and the STCW convention. This means that ships that sail under the flags of these countries have to comply with the obligations ensuing from these conventions.

International Regulations for Preventing Collisions at SeaThe COLREGS are the international ‘rules of the road’ that apply at sea. The COLREGS were drawn up by the IMO. The COLREGS convention sets rules on how ships should behave when near each other. The convention also specifies ships’ responsibilities, in addition to the rules of manoeuvre for ships in the vicinity of another ship. Specific mention is made of the fact that nothing (...) shall exonerate any vessel, or the owner, master or crew thereof, from the consequences of any neglect to comply with these Rules or of the neglect of any precaution which may be required by the ordinary practice of seamen, or by the special circumstances of the case.

The COLREGS convention and the SOLAS convention impose rules regarding safe navigation. These conventions have been incorporated into Dutch legislation.

Laws and regulations - national

Shipping Traffic Act (SVW)The SVW contains general rules for the safe and smooth passage of shipping traffic and implements the COLREGS in national legislation.

Among other things, the SVW regulates the safety and flow of shipping traffic, the upkeep and maintenance of waterways, the prevention or limitation of damage by shipping traffic to banks, dykes, bridges and the like and the prevention or limitation of pollution due to shipping.

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Westerschelde Shipping Regulations [Scheepvaartreglement Westerschelde] (SRW)The SRW is the elaboration of the SVW (and the COLREGS convention), concerning the Westerschelde region. The SRW contains the traffic rules for the Westerschelde and its estuaries. It relates to matters such as the ordinary practice of seamen, the use of radar or VHF and the rules governing priority and avoidance on the water, taking account of the specific environmental conditions on the Westerschelde.

Schelde Regulations [Scheldereglement] Compulsory pilotage applies in the region of the accident pursuant to Article 9 of the Scheldt Regulations. Regulations also exist regarding a number of categories of ships that are exempt from compulsory pilotage. The tug MTS Vantage is exempted from compulsory pilotage.50

Guidelines and best practices

Anchor gear regulationsThe regulations concerning anchors on board seagoing vessels were drawn up by the classification societies. The Planet V was constructed according to Germanischer Lloyd’s classification rules.51 The rules for the anchor gear are based on standardised usage. Germanischer Lloyd defines this as: ‘…The anchoring equipment required (...) is intended of temporary mooring of a vessel within a harbour or sheltered area when the vessel is awaiting berth, tide, etc....’ and ‘...the equipment is, therefore, not designed to hold a ship off fully exposed coasts in rough weather or to stop a ship which is moving or drifting...’.52 Germanischer Lloyd also indicates that the following parameters are normative: a maximum current of 4.85 knots and maximum wind force of 10 Bft with a chain length to water depth ratio of between 6 and 10.

Emergency anchoringIn order to limit the forces on the ship and the anchor gear, it is essential to run out the anchor in a controlled manner until it reaches the seabed after which it will be dragged slowly forwards, thereby building up retaining force, until the ship actually starts to slow down. In such instances it is even possible to use both anchors. Such a manoeuvre requires time, preparation and expertise, mainly because momentum can be built up as a consequence of the ship size and anchor gear which crew members are no longer able to control.53 Such a manoeuvre should only be initiated, therefore, in a ‘controlled’ emergency situation, such as slowly drifting towards a coastal area at low speed, with ample time to execute the manoeuvre.

50 This is regulated in the Scheldt Regulations on the Compulsory Pilotage Exemption Decision [Besluit vrijstelling loodsplicht Scheldereglement]: Seagoing vessels with lengths over all of 80 metres or less and draughts of 5.5 metres or less, if they sail the estuaries of the Scheldt from the Magne buoy, via the Oostgat, the Galgeput, the Sardijngeul and Flushingroads to the harbours of East Flushing.

51 GL Class GL 100 A5 E ‘Container Vessel’.52 The MARIN-reports are available on www.safetyboard.nl.53 A Master’s guide to Berthing, 2nd edition, The Standard P&I Club.

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Navigating using the shaft generatorAt the time that the ship was constructed (1994), no guidelines were imposed relating to the use of a shaft generator instead of stand-alone generators in narrow waters. The International Association of Classification Societies (IACS), of which the Germanischer Lloyd classification society is also a member, has since stipulated that, subject to certain conditions, a shaft generator may be used as a main source of electricity.54 Vessels constructed after 1 July 1998 therefore have to be equipped in such a way that, in the event of the failure of one or more generator(s), the power supply can be maintained or is immediately (preferably within thirty seconds but in any case not more than 45 seconds) restored so that the ship retains its propulsive and steering capacities.55, 56

In addition, sailing in narrow waters on two generators connected in parallel each having sufficient power to supply the ship’s electrical systems can be regarded as the ordinary practice of seamen. A malfunction in one of the generators will then not immediately result in a blackout, since the other generator is capable of delivering sufficient power.

Dutch Safety Board - Safety Management

In the past, the structure and implementation of safety management systems have proven to play a crucial role in the management and continuous improvement of safety. This applies to all organisations, both private and public, which are either actively or more remotely involved in activities which may expose Dutch citizens to risks.

In principle, the way an organisation complies with its responsibility to ensure safety is reviewed and evaluated from different perspectives. This means that no universal handbook for all situations exists. Therefore Safety Board has selected five areas of focus, which can be used for assessment purposes. These areas are selected by the Safety Board based on national and international laws and regulations and a large number of widely accepted and implemented standards.

54 IACS Unified Interpretation SC1, rev. 1 June 2002 of SOLAS Regulation II-1/41.1.3 Generators and generator systems, having the ship’s main propulsion machinery as their prime mover, may be

accepted as part of the ship’s main source of electrical power, provided they are to be capable of operating under all weather conditions during sailing and during manoeuvring, also when the vessel is stopped, within the specified limits for the voltage variation in IEC 60092 - 301 and the frequency variation in UR E5.

55 IACS Unified Interpretation SC 157, rev 1 Feb 2005 of Solas Regulation II -1/41-5.1.1 2.1 - Where the electrical power is normally supplied by more than one generator set simultaneously in parallel

operation, provision of protection, including automatic disconnection of sufficient non-essential services and if necessary secondary essential services and those provided for habitability, should be made to ensure that, in case of loss of any of these generating sets, the remaining ones are kept in operation to permit propulsion and steering and to ensure safety.

2.2 - Where the electrical power is normally supplied by one generator provision shall be made, upon loss of power, for automatic starting and connecting to the main switchboard of stand-by generator(s) of sufficient capacity with automatic restarting of the essential auxiliaries, in sequential operation if required. Starting and connection to the main switchboard of the stand-by generator is to be preferably within 30 seconds, but in any case not more than 45 seconds, after loss of power. Where prime movers with longer starting time are used, this starting and connection time may be exceeded upon approval from the society.

56 These rules apply to ships with unmanned machinery rooms only.

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Based on international and national legislation and regulations, and a large number of broadly accepted and implemented norms, the Safety Board has defined a number of focal issues in the area of safety, which the safety management system of the organisations concerned must address.

1. Identification of risks as the basis of the safety regime The starting point for achieving the required level of safety is an analysis of the system, followed by an assessment of the associated risks. Based on these elements, it is decided which risks need to be managed, and which preventive and curative measures are required.

2. Concrete and realistic safety regimeIn order to prevent and control undesirable events, a realistic and practically applicable approach to safety or safety policy, including the associated basic principles, must be documented. This approach to safety, or safety regime, must be decided upon and controlled at management level. This safety regime is based on:

• relevant valid legislation and regulations;• existing norms, guidelines, and ‘best practices’ in the sector; • the organisation’s in-house expertise and experience, and specific safety

objectives that have been drawn up for the organisation.

3. Implementation and enforcement of the safety regime Execution and enforcement of the safety regime, and control of the identified risks are achieved through:

• a description of the way in which the chosen safety regime is to be implemented, with a strong focus on concrete objectives and plans, including the resulting preventive and curative measures;

• transparent and clear assignment of responsibilities on the work floor with regard to implementation and enforcement of safety plans and measures. This information must be accessible to everybody;

• clear documentation with regard to the required deployment of personnel and expertise for the different tasks;

• clear and active centralised coordination of the safety activities.

4. Further upgrading of the safety regime The safety regime should be continually upgraded based on:

• periodical and, in the event of changes to the basic principles, incidental performance of (risk) analyses, observations, inspections, and audits (proactive approach);

• a system for monitoring and investigating incidents, near-accidents and accidents, as well as expert analysis (reactive approach);

• based on the above, evaluation takes place and the safety regime is adapted by management if required. Improvement actions are also revealed by the above, allowing focused management action.

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5. Management control, involvement, and communication The management of the involved parties/organisation should:

• internally set clear and realistic targets in terms of the safety strategy, create a climate of continuous improvement to safety on the work floor by setting a good example at all times and, finally, make adequate manpower and resources available for this;

• externally clearly communicate the general working practices, assessment method, procedures when errors occur, etc. based on clear and documented agreements with the involved parties.

The Safety Board acknowledges that the assessment of the way in which organisations actually comply with their responsibility with regard to safety is very much dependent on the organisations themselves. Aspects such as the nature of the organisation and its size can be important considerations and should therefore be included in the assessment. Although the final assessment may be different from case to case, the logical processes are identical.

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ANNEx 4

DETAILED RISK ASSESSMENT BY PLANET V SHIPPING COMPANY

3.1.14 Detailed Risk AssessmentShip’s Name: M/V “PD SAMPLE”IMO number: 9000000Assessment No. 0020 Person(s) at Risk All crew

Location/Activity Anchoring

Date : 16-11-2011 Assessor C/O

Hazard(s):1 Unsafe moving objects2 Moving objects not under control or Moving in adverse local conditions or overstrain3 Slips/falls on the level or Falls from a height4 Dangerous surfaces5 Noise > 80 dB

Consequences1 Fatal injuries2 Injuries3 injuries4 Injuries5 Injuries

Protective Measures1 Personal Protective Equipment (PPE)2 Personal Protective Equipment (PPE)3 Personal Protective Equipment (PPE)4 Personal Protective Equipment (PPE)5 Ear protection

Risk Assessment

Hazard numberHazard Severity (A) Likelihood of Occurrence (B) Risk

Factor1 2 3 1 2 3 (AxB)

Hazard No. 1 x x 9Hazard No. 2 x x 6Hazard No. 3 x x 4Hazard No. 4 x x 4Hazard No. 5 x x 2

Additional Protective Measures if Risk Factor is Moderate or High1 Integrity of protective equipment to be checked2 Assistance during working from other crew3 Instruction and training before performing this type of jobs4 5 Signed Date: 16-11-2011 Review Date: 16-11-2013

Likelihood of Occurrence (B)Hazard Severity (A)

1 = Slightly Harmful 2 = Harmful 3 = Extremely Harmful1 = Highly Unlikely Very Low (1) Acceptable (2) Moderate Risk (3)2 = Unlikely Acceptable (2) Moderate Risk (4) High (6)3 = Likely Moderate Risk (3) High (6) High (9)

Version: 2.0 Page 1 of 1 Released: 16.12.2011

DUTCHSAFETY BOARD

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Postal Address PO Box 95404 2509 CK The Hague

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