Collision and explosion kills nine

The Nautical Institute has issued Mars Report referring to a fatal accident  in which several elements, each of them unremarkable, combined to create a disastrous collision and explosion at sea. Distraction on the bridge, lack of clarity about intentions, an unjustified assumption and excessive speed all played their part.

The Incident

Several vessels, including Ship A and Ship C, were in a traffic lane heading about 130 degrees true. Ship B was in the process of crossing this traffic lane in order to integrate the opposite-bound lane. Visibility was good and seas were light.

On the crossing vessel, Ship B, the 3rd officer was OOW. The Chief Officer (CO) and the 2nd officer were present on the bridge too, as was a helmsman. The CO was plotting targets on the ARPA radar to assist the OOW. The Master was also on the bridge from time to time monitoring the traffic. Initially, the 2nd officer was setting up the GPS units, but afterwards he was chatting and joking with the OOW and CO in addition to catching up with some work on the chart table. The 2nd officer’s presence appears to have been a source of distraction to the OOW and the CO.The OOW on Ship B stated they would allow Ship A to pass ahead. The OOW on Ship A expressed surprise at this, as he had initially expected Ship B to alter course to port to join the traffic lane. When Ship B’s OOW then declared their intention to alter course to starboard, Ship A’s OOW considered this as an acceptable course of action for a crossing situation.

Later, the OOW of Ship A had identified that a close quarters situation was continuing to develop with Ship B. He expressed concern on the VHF radio several times; a bigger alteration of course to starboard by Ship B was urgently required.At 20.45, the CO on ship B informed the OOW that one of the targets was a false echo. This was an incorrect assumption and could easily have been clarified by visual observation. In fact, the bridge team had mistaken Ship C, also in the traffic lane, for Ship A, and assumed the actual echo of Ship A was a false echo. In the final minutes before the collision, the team on Ship B also mistakenly identified a fourth ship as Ship A. At 20.52 a collision occurred between Ship A and Ship B; Ship B was at about 11kt (full ahead manoeuvring) and Ship A was at 13.5kt (full ahead sea speed).

A massive explosion occurred on Ship A as a cargo tank ruptured and naphtha was spilt and ignited. The ignited spill engulfed the sea surrounding the two vessels. On Ship A, nine crew members were killed and other crew members injured. Three crew members were injured on board Ship B. Both vessels incurred substantial fire and structural damage as a result of the collision. Shockingly, of the many vessels in the vicinity at the time of the accident only one stopped to assist.

 Findings 

• This collision highlights the importance of effective, well-managed lookout techniques with correct implementation of the COLREGs in as bold and timely a manner as possible.
• This case also highlights the importance for vessels to avoid becoming severely restricted by other vessels so as to limit their ability to comply with the COLREGs. Adequate contingency room should always be left to provide an escape route should other vessels appear not to be complying.
• The bridge team on vessel B were continually distracted from their lookout duties by laughing and joking on the bridge among themselves and also with other crew members on the bridge.
• Ship A was considered to be a false echo by the Ship B team, who also mistook Ship C for Ship A. Greater emphasis on comparing ships observed visually against the information presented by the electronic navigation aids was required. l Small and arbitrary alterations of course were made by Ship B without knowing what effect the actions would have.
• There was no use of the ‘Trial Manoeuvre’ function on the radar of Ship B. The team proceeded with indications of low CPAs and without realising the steady compass bearings with Ship A.

Source: The Nautical Institute/ Mars Reports