REPUBLIC
OF CYPRUS
MARINE ACCIDENT AND INCIDENT
INVESTIGATION COMMITTEE
[Investigation Report No: 5E / 2015]
Very Serious Marine Casualty
Crew member fatality due to fall into the sea,
from the Container Ship “CHOPIN” on the 10th of
January 2015
Foreward
The sole objective of the safety investigation under the Marine Accidents and Incidents
Investigation Law N. 94 (I)/2012, in investigating an accident, is to determine its causes
and circumstances, with the aim of improving the safety of life at sea and the avoidance
of accidents in the future.
It is not the purpose to apportion blame or liability.
Under Section 17-(2) of the Law N. 94 (I)/2012 a person is required to provide witness to
investigators truthfully. If the contents of this statement were subsequently submitted as
evidence in court proceedings, then this would contradict the principle that a person
cannot be required to give evidence against themselves.
Therefore, the Marine Accidents and Incidents Investigation Committee, makes this
report available to interested parties, on the strict understanding that, it will not be used
in any court proceedings anywhere in the world.
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GLOSSARY OF ABBREVIATIONS AND ACRONYMS
AB - Able Bodied Seaman, an experienced and qualified member of the deck crew
APT – After Peak Tank
BA - Breathing Apparatus
CC - Cargo Compartment (Cargo Hold)
C/O – Chief Officer
CoC - Certificate of Competency
CYCOSWP – Cyprus Code of Safe Working Practices for Merchant Seamen
CPR – Cardiopulmonary resuscitation
DPA - Designated Person Ashore
EOSP - End Of Sea Passage
ISM Code - International Management Code for the Safe Operation of Ships
Knots – Speed in nautical miles per hour
ETA - Estimated Time of Arrival
IMO - International Maritime Organization
ILO - International Labour Organization
LT - Local Time
m - metre
MT - Metric Ton
OOW - Officer of the Watch
OS – Ordinary Seaman
PTW - Permit to Work
RA - Risk Assessment
Second Officer (2/O)
SMC - ISM Code Safety Management Certificate
SMS - Safety Management System
SOLAS - The International Convention for the Safety of Life at Sea 1974 (as amended)
STCW - The International Convention on the Standards of Training, Certification and
Watchkeeping for Seafarers 1978 (as amended
VHF – Very High Frequency Hand Held Radio (Walky Talky)
UTC - Universal Time Co-ordinated
ZT - Zone Time
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Contents
Glossary of Abbreviations
List of Figures
List of Annexes
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4
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1. Summary
5
2. Factual Information
6
2.1. Ship particulars
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2.2. Voyage particulars
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2.3. Marine casualty or incident information
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2.4. Shore authority involvement and emergency response
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3. Narrative
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1. Summary
A fatality was investigated in which a sailor washed into the sea from the Gangway’s
lower platform while arranging combination ladder for pilot’s boarding on a
Containership at Flushing, Netherlands.
In conducting its investigation, the Marine Accident Investigation Committee (MAIC)
reviewed events surrounding the accident, interviewed on board the ship the Master, the
Bosun and an Ordinary Seaman, reviewed documents provided by the Master and the
vessel’s ’s Management Company and performed analyses to determine the causal factors
that contributed to the accident, including any management system deficiencies.
Accident Description
The sea was very rough, with strong wind. When the Bosun and the two O.S. went to rearrange the combination ladder from the port side to the stbd side, the ship was turning,
so at the moment of the accident, the weather was almost astern, closer to the stbd
quarter. The Bosun and his team put their helmets aside. They unsecured the Gangway
and before it turned horizontal they adjusted the Gangway’s lower platform and put the
stanchions. Then they turned the Gangway horizontal and hoisted the stanchions of the
Gangway’s upper platform. After they lowered a little bit, about 1½ metres and hoisted
up the Gangway’s railings. Then they dropped the pilot ladder, about 1½ metres over the
water. After they lowered the Gangway a little bit more, made adjustment again. The
O.S.2 was securing the pilot ladder on the deck with a rope. The O.S.1 who was secured
with a life-line went down on the Gangway, to secure the pilot ladder to the Gangway’s
lower platform with a small rope (there was horizontal distance between them of about
10-20 cm). The life-line was secured on the deck railing. When the O.S.1 was standing
on the lower platform trying to pull the pilot ladder close to the Gangway, one wave
washed him into the sea. The life-line was about 10 metres. The freeboard was smaller
than the length of the life-line.
Artificial respiration and cardiopulmonary resuscitation was provided by the crew but
without positive results. Declaration of death issued after examination by the Search and
Rescue (SAR) Medical Officer, physician in the Royal Netherlands Navy.
5. Conclusions
The Direct Cause of the casualty (death) was wash by sea waves into the sea and impact
with the vessel’s side shell.
The Immediate Cause of the accident which led to the fall of the AB into the sea:
There were no eyewitnesses to the accident and the exact nature of the ABs fall is not
known. It is assumed to have been washed by sea waves when he attempted to secure
with a rope the pilot’s ladder on the Gangway’s lower platform.
The Contributing Causes of the accident were:
It is assumed that Inattention was a contributing factor to the accident.
Failure / Inappropriate to use defenses (barriers) i.e. Safety Harness (Personal Protective
Equipment). The life-line was about 10 metres. The freeboard was smaller than the
length of the life-line.
6. Recommendations
Management Company by way of a circular or other means, to educate its crews, on Risk
Assessment and Work Permit System, with particular emphasis on crew responsibility for
carrying out the work and taking safety measures as described on the Work Permit.
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2. Factual Information
2.1.
Ship particulars
IMO: 9449120
Name of ship: CHOPIN
Call sign: 5BEJ4
MMSI number: 229488000
Flag State: CYPRUS
Type of ship: Container
Gross tonnage: 38364
Length overall: 239.63 m
Classification society: DNV-GL
Registered ship owner: MS “CHOPIN” Schiffahrtsgesellschaft GmbH &Co.KG
Ship’s Company: Ocean Shipmanagement CmbH - Zurich Haus, Domstrasse, 17, 20095
Hamburg, Germany
Year of build: 2012
Deadweight: 73235MT
Hull material: Steel
Hull construction: Single Hull
Propulsion type: Internal Combustion Engine, Hyundai-B&W 7K90MC-C
Type of bunkers: HFO & MDO
Number of crew on ship’s certificate: 13
2.2. Voyage particulars
Port of departure: Hamburg
Port of Destination: Antwerp
Type of voyage: International
Cargo information: Containers (16452 MT general cargo in containers)
Manning: 20
Draft: Fwd= 8.70m Aft=9.60m
2.3. Marine casualty or incident information
Type of marine casualty/incident: Very Serious Marine Casualty
Date and time:
10/01/2015 @ 01:55 LT
Position:
Lat.: 51-10.10 N - Long.: 003-11.16 E
Location:
Coastal (Antwerp approaches)
External and internal environment: Wind Force & Direction : WNW 8/9, Sea state:WNW 6/7,
Weather: Clear, Night, Vis. good
Ship operation and voyage segment: Displacement mode – Arrival (Antwerp approaches)
Place on board:
Gangway
Human factors:
Yes/ Human Error /Decision
Consequences
Death: 1
2.4. Shore authority involvement and emergency response
Artificial respiration and cardiopulmonary resuscitation provided by crew. Rescue-Boat with
Rescue Team and a SAR helicopter with two Doctors responded. Declaration of death issued
after examination by the SAR Medical Officer, Physician in the Royal Netherlands Navy.
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3. Narrative
Sequence of Events:
1. Before sailing from Hamburg, received on board weather forecast for the intended
voyage. Forecasted prevailing weather conditions: Very Rough Sea WNW-8B
with gusts up to 9B. Required procedures according to SMS were carried out:
Risk Assessment dated 8/1/2015 “Detailed Risk Assessment” – company form
F111 and SMS Procedure 8.4.11 “Heavy Weather Navigation”. ” The procedure
had been implemented using the company forms F134 “Check List for
Navigation” in Heavy Weather and company form F130 “Working on Deck in
Heavy Weather”.
2. On 08/01/2015 at 23:04 hrs LT the M/V “CHOPIN”, departed from Hamburg –
Germany, bound for Antwerp - Belgium. ETA Antwerp (at berth) 10/01/2015 at
06:00 hrs LT.
3. On 09/01/2015 at 22:00 hrs LT pre – arrival checks completed using check-list.
4. On 09/01/2015 at 22:30 hrs LT End Of Sea Passage (EOSP). One hour notice to
E/R. Master took-over command of the Bridge. Vessel was scheduled to take on
board two Sea Pilots at about 23:30 hrs LT.
5. On 09/01/2015 at 22:40 hrs LT Master was informed by “Steen Bank Traffic” that
pilotage operations were suspended due to weather conditions, until improvement.
He was advised to either drop anchor or drift.
6. On 09/01/2015 at 22:55 hrs LT Master was advised by “Steen Bank Traffic” that
pilotage was re-scheduled for 10/01/2015 at 01:00 hrs LT. Received instructions
from “Steen Bank Traffic” to arrange combination ladder on port side, gangway
platform 7m over sea level and pilot ladder 3,5m over sea level.
7. Master decided not to drop anchor or drift, but to proceed with slow steaming to
Pilot Station.
8. On 10/01/2015 at 00:42 hrs LT combination ladder was in place at the port side. It
was placed by the Bosun and two Ordinary Seamen (OS) – OS1 & OS2.
9. On 10/01/2015 at 01:00 hrs LT vessel arrived at Pilot Station.
10. On 10/01/2015 at 01:26 hrs LT two Sea Pilots boarded.
11. When the Sea Pilots went on the bridge, the Captain ordered the Bosun to prepare
the anchor for emergency. Bosun went forward to prepare the port side anchor
according to the Captain´s order. Sea Pilots advised that exchange for Berth Pilot
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will be carried out at Flushing from the ship’s starboard (stbd) side. Rearrangement of combination ladder was necessary for the pilot exchange 1-2
hours later at Flushing.
12. The two O.S. remained on the Main Deck, close to the combination ladder at port
side. The Bosun reported that the anchor is prepared and returned back and met
the two O.S..
13. Then, the Bosun asked the Captain what to do, if the port side ladder will remain
hanged. The Captain replied after 3-5min and said to secure the port side ladder.
The Bosun and the two O.S. did the job and reported to the Captain that the
securing of the port side combination ladder was done. The Captain said “OK,
Thank you”. Then on their way to the accommodation, the Captain ordered to rig
the combination ladder on the starboard side for the next pilot i.e. the Berth Pilot
who will be boarded at Flushing Pilot Station.
14. The sea was very rough, with strong wind. When the Bosun and the two O.S.
went to re-arrange the combination ladder from the port side to the stbd side, the
ship was turning, so at the moment of the accident, the weather was almost astern,
closer to the stbd quarter. The Bosun and his team put their helmets aside. They
unsecured the Gangway and before it turned horizontal they adjusted the
Gangway’s lower platform and put the stanchions. Then they turned the
Gangway horizontal and hoisted the stanchions of the Gangway’s upper platform.
After they lowered a little bit, about 1½ metres and hoisted up the Gangway’s
railings. Then they dropped the pilot ladder, about 1½ metres over the water.
After they lowered the Gangway a little bit more, made adjustment again. The
O.S.2 was securing the pilot ladder on the deck with a rope. The O.S.1 who was
secured with a lif-line went down on the Gangway, to secure the pilot ladder to
the Gangway’s lower platform with a small rope (there was horizontal distance
between them of about 10-20 cm). The life-line was secured on the deck railing.
When the O.S.1 was standing on the lower platform trying to pull the pilot ladder
close to the Gangway, one wave washed him into the sea. The life-line was about
10 metres. The freeboard was smaller than the length of the life-line. The Bosun
said that “I did not notice that the life-line was very long because I was busy
working to fix the gangway. The O.S.1 may have noticed that the life-line was
very long but he still went down”.
15. O.S.2 heard the “bang” when the Gangway hit the ship´s side. He looked down
(over the ship’s stbd side) and saw the O.S.1, hanging. He didn´t see him on the
platform because he was already washed away. When the wave was going down
the OS1was hanging, but when the wave was going up he was in the water.
16. According to the O.S.2, he realised that the life- line is too long, when the
accident happened. The life-line can be adjusted. He was on board only 3-4 days.
He was told that he will not be going down to secure the Gangway to the pilot
ladder. They were doing this job always the same way. They were using the
same life-line.
17. On 10/01/2015 at 01:55 hrs LT the Bosun informed the Master on his VHF, that
there was a man overboard (MOB). At 01:56 hrs LT MOB Procedure was
implemented: The Master sent the Second Officer to see what happened, sounded
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the General Alarm, made announcement “Manoverboard” and stopped the Main
Engine. One Sea Pilot informed “Steenbank Traffic” about the MOB incident.
18. At 01:57 hrs LT the Second Officer went from the Bridge to the Main Deck and
informed the Master on his VHF that O.S.1 fell overboard but he was hanging on
a life-line attached to his safety harness. (The other end of the life-line was
secured on the railings of the Main Deck). A ring-buoy with line was thrown
towards the O.S.1. The Bosun and the O.S.2, could not heave up the O.S.1
because he was very heavy. The Helmsman was sent from the Bridge to assist.
Additional crew members arrived to assist.
19. At 02:00 hrs LT the Master maneuvered the vessel in order to make a lee and the
crew members be able to lower the Gangway, so as from its platform to pick-up
the O.S.1.
20. On 10/01/2015 at 02:05 O.S.1was recovered from the sea onto the Gangway’s
lower platform. The crew member who took the O.S.1 from the water, reported
that he was unconscious and that he could feel slight pulse and breathing.
21. On 10/01/2015 at 02:08 hrs LT i.e. within about 15 minutes, the O.S.1 was
recovered and was placed on the Main Deck.
22. When the O.S.1 was placed on the Main Deck, the Chief Officer reported that he
could not feel pulse and breathing.
23. Artificial respiration mouth to mouth and chest compression was provided whilst
on Main Deck.
24. On 10/01/2015 at 02:15 hrs LT i.e. a few minutes later, the O.S.1 was transferred
from the Main Deck in the Accommodation, where his wet clothing was removed
and was covered with warm, dry blankets. Artificial respiration and chest
compressions continued.
25. On 10/01/2015 at 02:30 hrs LT at the request of a Sea Pilot, AED equipment
(Defibrillator) was brought on board from the Pilot - Boat and applied to the
O.S.1.
26. On 10/01/2015 at 02:48 hrs LT the Sea Pilot informed that a Rescue Helicopter
with a Doctor will arrive in 27 minutes and that the vessel should proceed to
North direction, to meet the Helicopter. Vessel directed to north direction.
27. On 10/01/2015 at about 03:00 hrs LT the Sea Pilot informed the Master that the
Helicopter will arrive later but that a Rescue - Boat with a Medical Team, will
arrive shortly.
28. Deck crew was ordered to arrange at the vessel’s port side a combination ladder
for Medical Team’s embarkation.
29. On 10/01/2015 at 03:15 hrs LT port side combination ladder was arranged.
Rescue - Boat arrived.
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30. On 10/01/2015 at 03:25 hrs LT Rescue -Team (two men) boarded and proceeded
to the O.S.1.
31. On 10/01/2015 at 03:55 hrs LT the Helicopter arrived.
32. On 10/01/2015 at 04:00 hrs LT two Doctors from the Helicopter, boarded on the
vessel.
33. On 10/01/2015 at 04:10 hrs LT the Doctors advised to stop artificial respiration. A
“Declaration of Death” was issued.
34. The body of the deceased O.S.1 was transferred in the vessel´s hospital.
35. On 10/01/2015 at 04:20 hrs LT the vessel’s Local Agent “EMS” and OSM Q/S
were informed by tel. and e-mail.
36. Vessel resumed her passage to Antwerp.
37. On 10/01/2015 at 06:58 hrs LT the Rescue Team and the two Doctors left from
the vessel by Rescue-Boat.
38. On 10/01/2015 at 07:00 hrs LT Pilots exchange. River Pilot boarded. The two Sea
Pilots left at 07:10 hrs LT.
39. On 10/01/2015 at 11:42 hrs LT the vessel was berthed in the port of Antwerp.
40. On 10/01/2015 at 16:36 hrs LT the body of the deceased O.S. was taken ashore to
the Belgium´s Coroner. CORONER’S REPORT MISSING
41. The deceased OS’s personal belongings were recorded on board and along with
his documents, were delivered to the ship’s Local Agent “EMS” in order to be
sent to his family. After that, the ship´s hospital was disinfected according to the
“Ship´s Medical Guide”.
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