The German Bureau of Maritime Casualty Investigation published the accident report of the multi-purpose vessel ELSE, which sailed into a lock gate at Kiel Holtenau on the Kiel Canal (NOK), on 29 August 2020.
The incident
The ELSE passed the navigational chart position of the pilot boarding point abeam at about 0453 but continued her voyage without making any significant course or speed alterations and without reporting in to VTS NOK or the pilot station.
The ship then began to leave her aforementioned general course at about 0457 and turned purposefully towards the Kiel-Holtenau lock entrance, maintaining a speed of just under 6 kts. It was not possible to verify whether this course alteration was carried out by a helmsman – as claimed on the ship – or the chief mate personally. However, the sources of information evaluated by the BSU indicate that the master was not on the bridge at that time.

At 0505, VTS NOK (here: NOK IV = the chief lockmaster in the Kiel-Holtenau lock control station)19, whose area of responsibility the ELSE had reached at about 0458, called the vessel in English on VHF channel 12. Still nearing the approach to the lock chamber continuously and purposefully without reducing her speed, the ELSE was requested to proceed to the Holtenau roadstead:
Please proceed to Holtenau Roads
VTS NOK IV also clearly stated in the radio message that the ship was not in the waiting area but rather already in the lock’s approach channel. The chief lockmaster also stated loudly and clearly that the gate was reportedly closed:
This is not the waiting area! You are in entrance of the locks right now and the gate is closed!
Since there was no immediate response from ELSE, the chief lockmaster asked a few seconds later whether his message had been understood. The ELSE’s chief mate then confirmed this, but only with a brief and hesitant “Yes” in a very insecure tone of voice.
VTS NOK then clearly repeated the request that the ship return to the roadstead at Holtenau:
Then please go back to Holtenau Roads!
The officer on watch’s reply was once more extremely brief and restricted to a very doubtful sounding: “Holtenau Pilot”.
Immediately after this radio contact, the Kiel-Holtenau pilot station called the ELSE on channel 12 at 0506. The chief mate answered promptly this time and seamlessly stated the following:
My position enter to channel
The watchkeeper at the pilot station then immediately requested that the officer on watch turn around and proceed to the pilot position. He forcefully stated that the ship was reportedly not permitted to enter the lock without a pilot:
Turn back to the pilot position please! You have no permission to enter the lock without pilot! Turn back!
The ELSE did not respond to this request. Instead, she continued her voyage towards the lock gate, which was still closed, and the inevitable allision occurred at 0507.
Probable cause
The analysis of the AIS track and the radio traffic, the results of the ELSE’s technical assessment and the examination of the extremely contradictory statements of the ship’s crew members involved in the accident lead to the conclusion that the main cause of the accident was probably that the officer on watch had reached the limits of his competence when carrying out his duties on the last section in fairway mode.
Given the situation at hand, it must be assumed that the master had not properly informed the officer on watch (at least with regard to important questions of detail), who had no experience with transiting the NOK, about the procedure to be followed for engaging a pilot and entry into the NOK lock, as well as about the time for waking the master or that there had been significant linguistic or other misunderstandings in this respect.
There is no other explanation for the fact that the officer on watch sailed the ship past the pilot boarding point without slowing down and then purposefully set a course for the approach to the lock chamber.
By contrast, that a technical malfunction was responsible for the disastrous final course of the ship’s voyage, which has been proven beyond doubt, is completely absurd. On the one hand, the results of the technical assessment of the machinery and steering gear oppose this theory.
On the other hand, and in particular, this does not come close to explaining why one could have purposefully set a course for the lock in such an outof-control ship and without any distress call after sailing past the pilot boarding point without slowing down due to an alleged malfunction.
The assumption or assertion in the meantime that the master had reportedly taken over the ship’s command at (or at least shortly before or after) the pilot boarding point is not consistent with the course of the accident, either. In contrast to his officer on watch, the master was familiar with the NOK’s specific circumstances and requirements.
That or why he nevertheless steered the ship towards the closed lock gate cannot be plausibly explained. The entire course of events and fact that – if at all – an emergency stop manoeuvre was initiated only a few seconds before the allision suggests that the master only entered the bridge when the allision was imminent.

One material factor that may have played a major role in the officer on watch’s decision to simply pass the pilot boarding point and then steer for the lock was the ‘time error’ on board the ELSE. In all communications with the pilot station, the officer on watch assumed the time was one hour ahead of local time.
Accordingly, at 0342 (CEST) he stated that 0600 was the ETA at the pilot boarding point, even though he would obviously reach and actually did reach it in less than 90 minutes, i.e. at about 0500 (or even a little earlier based on German local time).
In this context, the question as to whether the officer on watch was actually aware that the (agreed) boarding point for the NOK pilot was on the southern edge of the Holtenau roadstead went unanswered.
Although he could have recognised this at the latest by taking a careful look at the navigational chart, where the position in question is marked with the standardised symbol, it cannot be ruled out that the officer on watch assumed the pilot would not embark until they were in the lock (either because of a basic lack of knowledge or because the pilot was not at the boarding point at 0600 (ship time) in accordance with the officer on watch’s presumed agreement).
The investigation team found it difficult to comprehend how neither the red lights of the signal installations nor the red warning signals mounted on the lock gate, which were visible from afar and clearly indicated the gate was closed, prevented the officer on watch from approaching the lock chamber.
It must be assumed that he was not aware of the meaning of the signals. On the other hand, he may have assumed that the conspicuous red warning signals on the lock gate indicated the rear end of the open lock chamber.