PRIDE OF TELEMARK - Danish Maritime Authority

MARINE ACCIDENT REPORT
DIVISION FOR INVESTIGATION OF MARITIME ACCIDENTS
PRIDE OF TELEMARK
D a m a g e b y c oPage
n t1 a c t / i n g r e s s o f w a t e r
11 September 2007
Marine accident report
Division for Investigation of Maritime Accidents. Danish Maritime Authority,
Vermundsgade 38 C, DK 2100 Copenhagen
Phone: +45 39 17 44 00, Fax: +45 39 17 44 16 CVR-nr.: 29 83 16 10
E-Mail: oke@dma.dk - www.sofartsstyrelsen.dk
The casualty report has been issued on 13 August 2008
Paragraph 7 “Re-opening of the investigation” has been inserted 29 October 2008
Case: 200711593 and 200809756
The picture on the front page shows PRIDE OF TELEMARK in Hirtshals Harbour after
the accident. (By courtesy of Theo Koch & Co.)
The casualty report is available on our homepage: www.dma.dk.
The Division for Investigation of Maritime Accidents
The Division for Investigation of Maritime Accidents is responsible for investigating accidents and serious occupational accidents on Danish merchant and fishing vessels.
The Division also investigates accidents at sea on foreign ships in Danish waters.
Purpose
The purpose of the investigation is to clarify the actual sequence of events leading to
the accident. With this information in hand, others can take measures to prevent similar
accidents in the future.
The aim of the investigations is not to establish legal or economic liability.
The Division’s work is separated from other functions and activities of the Danish Maritime Authority.
Reporting obligation
When a Danish merchant or fishing vessel has been involved in a serious accident at
sea, the Division for Investigation of Maritime Accidents must be informed immediately.
Phone: 39 17 44 00
Fax: 39 17 44 16
E-mail: oke@dma.dk
Cell-phone: +45 2334 2301 (24 hours a day).
Marine accident report
Page 2
Contents
1
2
3
4
5
Summary ................................................................................................................ 4
Conclusion .............................................................................................................. 4
Recommendations .................................................................................................. 5
The investigation..................................................................................................... 6
Factual Information ................................................................................................. 6
5.1
Accident data .................................................................................................. 6
5.2
Navigation Data .............................................................................................. 6
5.3
Ship data......................................................................................................... 6
5.4
Weather data .................................................................................................. 7
5.5
The Crew ........................................................................................................ 7
5.6
Narratives........................................................................................................ 8
5.7
Hirtshals .......................................................................................................... 9
5.8
The contact with the foundation of the pier ..................................................... 9
5.9
The Crew / Bridge watch............................................................................... 10
5.10 Recruitment................................................................................................... 10
5.11 The voyage plan and navigation ................................................................... 10
5.12 Navigation conditions Hirtshals..................................................................... 11
5.13 Watertight doors............................................................................................ 11
5.14 The bulkheads .............................................................................................. 12
5.15 Collecting of data – AIS – Data..................................................................... 13
5.16 Collecting of data – VDR - Data.................................................................... 13
5.17 The bilge system........................................................................................... 15
5.18 Survey........................................................................................................... 15
5.19 Salvage operation/evacuation....................................................................... 15
5.20 Consequences .............................................................................................. 15
6
Analysis ................................................................................................................ 17
6.1
Bridge watch ................................................................................................. 17
6.2
Current and drift of the ship .......................................................................... 17
6.3
The ingress of water ..................................................................................... 17
6.4
Black out – bilge and emergency bilge system out of order ......................... 19
6.5
VDR – Data................................................................................................... 20
7
Re-opening of the investigation ............................................................................ 20
7.1
Statements concerning the watertight doors................................................. 20
7.2
The ingress of water ..................................................................................... 21
8
Appendixes ........................................................................................................... 22
Appendix 1 - Positions of damage to the hull and the water filling. ........................ 23
Appendix 2 - Water filled heeling tanks and void spaces in the double bottom. ..... 24
Appendix 3 - Water filled compartments on the first deck. ..................................... 25
Appendix 4 - Water filled compartments on the second deck................................. 26
Appendix 5 - Water filling on the car deck. ............................................................. 27
Marine accident report
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1 Summary
PRIDE OF TELEMARK departed from Langesund in Norway in the evening of 10 September 2007 at 0705 pm. Expected time of arrival in Hirtshals, Denmark, was 11 September at 0000.
On board the ferry was a crew of 64, a number of passenger of 150 and 54 lorries and
49 cars.
When approaching Hirtshals, the ferry had a contact with the foundation of the western
pier at the entrance to Hirtshals Harbour. The contact caused three penetrations in the
hull below the waterline which subsequently lead to a number of compartments being
filled with seawater.
Shortly after the contact with the foundation the ferry experienced a blackout. After an
hour it was moored alongside with assistance from tugs. At 0211 all passenger were
disembarked.
Pumping assistance was arranged from ashore, but the ingress of water was faster
then the discharge capacity. At 1000 the ingress of water was under control.
At a point before 1000 the fore ship grounded in the harbour.
There were neither injuries nor any pollution.
Since the accident the ferry has been in repair.
2 Conclusion
The causes that led to the contact with the foundation of the pier and succeeding ingress of water was the following:
-
Lack of experience of the master as far as entering Hirtshals harbour is concerned (6.1).
-
Nye Kystlink AS appointed a master on the route from Langesund to Hirtshals
without sufficient induction training (6.1)
-
Misjudgment of the current and the drift of the ship. (6.2)
-
Navigational error. (6.2)
-
Bulkheads with penetrations. (6.3)
-
Not tight watertight doors. (6.3)
-
The bilge system was out of order shortly after the leakage (6.4)
-
The automatic shutters in the air pipes failed to work (6.3)
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3 Recommendations
To the shipping company
1. Nye Kyst Link AS is recommended to evaluate and revise their quality management system to ensure sufficient induction training of newly appointed officers before taking part in a navigational watch.
2. Nye Kystlink AS is recommended to establish procedures ensuring regular control of watertight doors, penetrations in the bulkheads, scuppers and shutters in
air pipes.
3. Nye Kystlink is recommended to ensure the proper functioning of the emergency bilge system to avoid malfunction as experienced.
To Kongsberg Marine
1. Kongsberg Marine is recommended to examine and find the courses of the malfunction of VDR systems similar to the one on PRIDE OF TELEMARK.
2. Kongsberg Marine is recommended to ensure a more thorough control of VDR
systems on board ships.
To maritime authorities and classification societies
Maritime authorities and classification societies are recommended to draw special attention to the control of watertight doors, penetrations in bulkheads, scuppers and shutters in air pipes.
Marine accident report
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4 The investigation
The Investigation Division went on board PRIDE OF TELEMARK in Hirtshals on 11 and
18 September 2007 and interviewed the crew.
A sea inquiry was held in Hjørring on 18 September 2007.
The Investigation Division has received statements and other information from the
Norwegian Maritime Directorate and the Maritime Investigator in Oslo.
The Investigation Division has from Nye Kystlink AS received a report about the
grounding close to the western pier of PRIDE OF TELEMARK while approaching Hirtshals 11 September 2007.
5 Factual Information
5.1 Accident data
Type of accident (the incident in details)
Time and date of the accident
Position of the accident
Area of accident
Injured persons
Ship abandoned (usage of either rescue
boat or fleet)
IMO Casualty Class
Contact damage / ingress of water
11 September 2007 at 0002
57°35.87’ N - 009°57.77’ E
Danish Harbours
None
The passengers was evacuated after
berthing in Hirtshals
Serious
5.2 Navigation Data
Stage of navigation
Port of arrival
Date and time of arrival
Depth of the time of the accident
Pilot on board
Arrival
Hirtshals
11 September 2007 at 0059
Draft on even keel 6.55 m
No
5.3 Ship data
Name
Home port
Call sign
IMO No
Flag State
Construction year
Type of ship
Tonnage
Classification Society
Length
Engine power
Hull construction
PRIDE OF TELEMARK
Langesund
LNTC
7907257
Norway
1980
Ro-Ro Passenger ship
28569 BT
Lloyd’s Register
156.20 m
6490
Steel – Double bottom
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5.4 Weather data
Wind – direction and speed
Sea
Visibility
Light/dark
NE 14-15 m/s
3.5 m
Good visibility
Dark
5.5 The Crew
Number of crewmembers
64
Number of crewmembers certified to act as 4
bridge watch
Watch on the bridge
3 shift
Occupation on board the ship at the time of Age, Certificate of Competency, other
the accident (crewmembers relevant to the certificates, training, sailing time.
accident)
Master
Master, age 67 years. Educated as a
navigator in 1961 and holder of Norwegian certificate as “Deck Officer Class,
Master Mariner” without any limitations
(STCW – II/2). Is also holder of certificate
in accordance with the High Speed Craft
Code.
It was his first trip as master on the voyage Langesund – Hirtshals. Prior to this
he had been on board on two trips as supernumerary. Prior to this he has worked
as a pilot for 30 years until 2005. In the
period 2005 – 2007 he was employed on
a passenger ship with a tonnage of approximately 5000 BT. He has been employed in Nye Kystlink AS since 7 September 2007.
Chief officer
Chief Officer, age 50 years. He is the
holder of Norwegian certificate as “Deck
Officer Class2” without any limitations as
chief officer (STCW – II/2 –VI/1-VI/2.1VI/3-V/4).
He has been going to sea since 1973.
Has experience from passenger vessels
since 1980. Has been on board PRIDE
OF TELEMARK since June 2005. In the
beginning as 1st officer and for the last
year as chief officer. Obtained his present
certificate in 2001.
Chief engineer
Chief Engineer. Age 59 years. Has been
sailing since 1964 holding different positions in the engine room. Has been working as chief engineer for the last 13 years,
the last 10 years on cruise liners. Has
been employed in Nye Kystlink AS for the
last 5 years and has been on board
PRIDE OF TELEMARK since January
2007.
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Ship’s assistant – Helmsman
Able bodied seaman, age 49 years. Has
been employed on board Norwegian
ships for 9 years including passenger
ships. For the last 6 month he has been
the regular helmsman on board PRIDE
OF TELEMARK. Has steered in and out
of Hirtshals many times.
5.6 Narratives
PRIDE OF TELEMARK is a Ro-Ro Passenger ship in regular service between Langesund in Norway and Hirtshals in Denmark. On 10 September at 1906 the ship departed
from Langesund with a draft of 6.66 m forward and 6.43 m aft. Calculations done by the
crew showed that draft, trim and stability were OK. It was normal, that the ship had a
trim forward on departure.
The number of crew was 64, the total number of passengers was 150, and the ship
was carrying 54 lorries and 49 cars.
At 2315 the master arrived at the bridge. At that time, the wind was NE 12-13 m/s and
the sea was moderate. The ship was heading the planned course, and every thing
seemed normal. In a distance of approximately 2 nm from the western pier at the entrance to Hirtshals the master took command of the ship and reduced the speed to 1415 knots.
At 2330 the watch keeping officer started filling 200 m3 of seawater in the after peak
tank to bring the ship to even keel on arrival. This was a normal procedure.
When the master took over command the ship was positioned west of the planned
course when approaching Hirtshals. The master kept the ship west of the red leading
light as he expected the ship to have a drift to the east due to current. As the ship approached the entrance to the harbour, the master realized that the ship drifted to the
west. At that point there was no time to make alterations to the course before the ship
would pass the western pier.
At 0002 on the 11 September the ship touched the foundation of the western pier with
its starboard side. When the ship touched the foundation the speed was approximately
10 knots. The ship continued and passed shortly after the eastern pier in the entrance
to the harbour and began the normal procedure to berth.
At 0007 the ship had a blackout. The speed was approximately 2 knots, and the ship
drifted hereafter slowly towards ferry berth number 2. A list to starboard was observed.
Mooring lines were fastened and a tugboat ordered. The ship was hauled to Color
Lines pier and moored at 0059. Subsequently disembarkation of the passengers
started. At 0211 all passengers were ashore.
Approximately 10 minutes after the contact with the foundation several crewmembers
saw water filling the separator room. At a point before 1000 the ships rested on the
bottom of the harbour with the fore ship due to filling of water.
The ingress of water was under control at 1000 meaning that more water was pumped
out of the ship than water ingressing.
At 2200 water was observed in the main engine room.
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5.7 Hirtshals
When approaching Hirtshals the chief officer was in charge of the navigational watch.
The master arrived on the bridge at 2315. There had been no technical or navigational
problems during the voyage. The ship was cruising at 19 knots. This speed was gradually reduced in order to keep a speed of 12 knots when entering Hirtshals Harbour.
An hour prior to arrival the chief officer contacted Hirtshals Havnevagt to receive information about the weather. He was informed that the wind was NE 14-15 m/s decreasing and that the wave height was 3.5 m. The visibility was good. This information was
passed on to the master.
At 2330 the steering was switched to manual by the helms man.
At 2350, in a distance of approximately 2 nm from the western pier at the entrance to
Hirtshals, the master took over command. At the change of watch the chief officer informed the master, that the ship was steering the planned course of 176° and that the
ship was positioned in the leading lights to Hirtshals. The course in the red leading
lights is 166°
From numerous seafarers, the master had been told; that ships approaching Hirtshals
would have a drift to the east and that the current sometimes would have a speed of up
to 5 knots. At the two approaches as supernumerary the master had experienced, that
the current had given the ship a drift to the east.
Expecting the ship to drift to the east due to current the master kept the ship west of
the leading line to compensate for expected current.
ECDIS was used for navigation as well as two GPS-receivers. Two radars were operational. With this equipment the master was able to determine the drift of the ship.
The master had his focus on visual navigation, and did not use the navigational instrument much during approach.
After shifting to manual steering the helmsman noticed, that the ship seemed to be
closer to the western pier than usual. Approximately 5 minutes before arriving at the
entrance to the harbour he notified the master, that the ship was “heavy” to steer. The
master ordered an alteration of 5° of the course to port.
When approaching the entrance to the harbour the master realized that the ship did not
drift as expected, but still was moving to west. The master did not have any time to
make alterations of the course before the ship passed the western pier at a close distance and hit the foundation of the pier.
5.8 The contact with the foundation of the pier
When passing the western pier at the entrance to Hirtshals Harbour it seemed as there
briefly was a slight resistance to the ships movement forward and noises were heard. A
few minutes after contact with the foundation of the western pier the ship got a list to
starboard.
After the contact the chief officer contacted the engine room and ordered sounding of
the tanks and check for ingress of water. The response was that ingress of water on
deck 1 was observed by camera (CCTV) in watertight compartment 6. (W.T. COMP 6).
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5.9 The Crew / Bridge watch
The bridge watch team consisted of the master, the chief officer, the first mate and a
helmsman.
The master had been employed in Kyst Link A/S since 7 September and was on his
first signing on on PRIDE OF TELEMARK. It was his third voyage from Langesund to
Hirtshals. On his first two voyages he had been supernumerary.
The chief officer had been on board the ship since 2005. In the beginning as 1st officer,
but for the last year as chief officer. On prior occasions the chief officer had been in
charge when approaching Hirtshals under supervision of the master and in good
weather conditions.
The first officer was on the bridge, but had his attention on planning the discharging of
the ship. He did not notice what was happening on the bridge before the contact with
the foundation of the pier.
5.10 Recruitment
Nye Kystlink AS has informed the Division for Investigation of Marine Accidents that the
master was recruited through their channels, that reference checks was done, that
evaluation was done by Marine/QA/ISM/HR-manager and finally Managing Director as
per the company’s written procedures. The new master’s past long experience in a
commanding role as pilot and master in difficult waters and handling og car-carriers
gave the company confidence.
The master had been requested to have a period of hand over on board with the off
going master until the off going master was satisfied with his performance and in particular the port of Hirtshals before taking over the command of the PRIDE OF TELEMARK.
The company had no negative feedback or doubts about the newly recruited master’s
experience and skills. The off going master reported that he was confident that the new
master would have no problem in handling the vessel.
The new master also confirmed very strongly that he was confident in his role and that
he was ready to take command.
Previous relieving masters have been recruited and introduced to the trade in exactly
the same way before assigned command of any company vessel.
5.11 The voyage plan and navigation
The voyage from Langesund to Hirtshals followed a schedule that included waypoints,
courses and distances. The transit time was roughly 5 hours.
When approaching Hirtshals the helmsman arrived on the bridge approximately half an
hour before the steering was switched from the autopilot to manual steering. The reason for this was to get accustomed to the darkness and the actual weather conditions.
The steering was switched to manual steering 20 minutes before reaching the buoys at
the entrance to the harbour.
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5.12 Navigation conditions Hirtshals
Information under existing conditions regarding wind-, wave- and water level can be
obtained from Hirtshals Harbour on VHF channel 16. Ships are advised to contact
Hirtshals Harbour to obtain this information.
On Hirtshals Harbour’s homepage following information can be obtained relating to
current.
Beam current at the entrance to the harbour are characterized by the wind. Most of the
time the current runs from west to east, and may under special circumstances have a
speed of 3 knots. Normative is:
Wind from directions between 020° and 180° results in a westerly current
Wind from directions between 200° and 360° results in an easterly current
Hirtshals Harbour does not give information on VHF concerning the current and there
are no current meter at Hirtshals.
On the night of 11 September 2007 the wind was coming from NE, which should result
in a westerly current.
5.13 Watertight doors
According to the ships ISM, all watertight doors have to be closed on arrival and departure. This is stated on the Damage Control Plan with the wording: “Watertight doors
shall be kept closed whilst the ship is at sea, except when they are required to be
opened for the operation of the ship. When open, every door shall be kept free from
obstruction which might prevent its rapid closure.”
The control of whether the doors were closed or not, were carried out in the following
manner. On the first and second deck the watch keeping engineer carried out the control by physically inspecting the doors. As for the passenger compartment on the second deck the inspection was carried out by the passenger crew. The closing of the
watertight doors were being verified by the watch keeping officer on the bridge and in
the engine room on indicator panels on the bridge and in the engine control room.
The ship had a total of 15 watertight doors, 7 on the first deck and 8 on the second
deck. The doors could be operated in three ways:
-
hydraulically – locally at the door on both sides of the bulkhead,
-
remotely from the bridge
-
emergency closing of the watertight doors in the watertight door station.
Opening and closing of the watertight doors was ordered from the bridge.
The closing of the watertight doors on arrival were verified by the chief officer on the
indicator panel on the bridge. A remark of this is entered in the ship’s logbook at 2353.
Marine accident report
Page 11
Besides this control of whether the
doors were closed or not, the watch
keeping engineer inspected physical
the doors on the first and second
deck. As for the passenger compartment on the second deck the
inspection was carried out by the
passenger crew.
When observing ingress of water on
the CCTV the chief officer ordered
the engine room crew not to open
any watertight doors.
On the evening on 11 September
water was observed passing
through watertight door number 9
which was closed. At the time of the
observation the water was at a
height of approximately 3.5 meter in
the adjacent compartment. The
doors are not kept watertight by
packings. The tightness is obtained
steel by steel when the doors are
closed. Other watertight doors may
have leaked in a similar manner.
Water passing through water tight door number 9
5.14 The bulkheads
An inspection of the bulkhead after the accident carried out by the Norwegian Maritime
Directorate revealed the following:
-
Bulkhead at frame 80 between W.T. COMP 8 and 9 dividing the main engine
room and auxiliary engine and boiler room. In the afternoon 11 Septembers ingress of water was observed through watertight door number 9 in this bulkhead.
At the time of the observation the height of water in the auxiliary engine and
boiler room was approximately 3 m.
-
Bulkhead at frame 99 between W.T. COMP 7 and 8 dividing the main engine
room and auxiliary engine and the work shop. No remarks.
-
Bulkhead at frame 117 between W.T. COMP 6 and 7 dividing the work
shop/bunker room on the first deck and accommodation and engine control
room on the second deck. In the engine room area an old penetration about
one inch in width was found.
-
Bulkhead at frame 133 between W.T. COMP 5 and 6 dividing the bunker room
and W.T. COMP 5 on the first deck and two accommodation sections on the
second deck. On the first deck no remarks. On the second deck a circular penetration about 1” in diameter was found.
-
Bulkhead at frame 147 between W.T. COMP 4, sewage plan/emergency bilge
pump, and W.T. COMP 5 on the first deck, and fore accommodation on the
second deck. No remarks to this bulkhead.
-
Bulkhead at frame 165 between W.T. COMP 3 & 4, sewage plant room and
bow thrusters room. No remarks.
Marine accident report
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5.15 Collecting of data – AIS – Data
From the Danish Maritime Safety Administration the Investigation Division has received
AIS-data regarding the incident.
AIS plot showing PRIDE OF TELEMARK passing the western pier
5.16 Collecting of data – VDR - Data
The ship was equipped with a KONGSBERG Voyage Data Recorder. A recording from
the system covering the period from 2343 on 10 September to 0130 on 11 September
was obtained from Kyst Link A/S.
An Annual Survey Procedure for Maritime Black Box (MBB) including performance test
dated 20 August 2007 was received from Kongsberg Maritime.
The Voyage Data Recorder from Kongsberg Maritime A/S was model Full VRD, serial
number 137.
An Annual Survey Procedure including inspection details was carried out 20 August
2007 in Langesund.
The performance test revealed that that the system:
-
Was unable to record the speed of the ship due to a serial line not working
properly.
-
Was unable to record the water depth due to broken censor.
-
Did not hold log data from 2006 and 2007. Last data was logged in 2005.
Apart from above mentioned, no malfunctions or defects were found during the inspection.
A certificate documenting the annual survey was issued 20 August 2007 and expired
20 November 2007.
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Page 13
A recording covering the period from 2343 on 10 September to 0130 on 11 September
was available to the Investigation Division. Replay software (RU_SW 1.3.4 and
REU_SW 1.3.5) was also available.
After having examined the recording from the VDR system indications were found indicating that the VDR / MBB had been unstable.
-
Ref. survey item 2.1.8 Interfaces: Operation an recording:
14) Watertight and fire door
status – At the survey on 20
August 2007 it was
observed: “all mandatory
status information displayed
on bridge”.
Kongsberg Maritime (KM)
have informed, that watertight and fire door status is
only hard wired to digital
input modules and not as
serial lines, (NMEA). These
items are monitored as
digital input signals.
Figure 1
During the annual inspection of the VDR system, KM did spot check of digital
inputs. This was about 5+10% of the total signals. The way to test if the input is
corresponding with the indication on the VDR system is to open one door and
see, if it causes a correct input on the VDR system.
Figure 1 shows the status of the
watertight doors at the time of the
contact with the foundation of the
pier and figure 2 shows the status
one hour later.
According to several statements
and indications on panels on the
bridge and engine control room
these doors were closed.
The Division for Investigation of
Maritime Accidents finds there is
every probability that the watertight
doors were closed and that the
VDR data concerning the watertight doors are unreliable. KM is
unable to establish the reason for
this.
Figure 2
Indications of open watertight doors after the contact with the foundation with the pier
may be due to signal errors. The equipment controlling the doors and giving indications
on whether the doors were open or closed are in no way waterproof.
Marine accident report
Page 14
Radar picture unstable.
During replay of VDR data the radar picture is unstable and it not recorded during the last hours prior to – during and after – accident.
Kongsberg Maritime was on board the ship after the accident, and found the
logging and displaying of radar pictures normal indicating that the VRD system
has been working as specified all time. KM is not able to explain why the radar
picture was down during the hours around the accident.
5.17 The bilge system
The ship was equipped with a remote controlled ballast and bilge system, which could
be operated from the engine control room and the damage control centre. This system
was in an early stage of the ingress of water out of order due to flooding of the work
shop in W.T. COMP 6 where the control panels to booster pumps and transfer pumps,
which supplies both main and auxiliary engine with fuel oil, is placed. The emergency
bilge pump was started but had no capacity to keep in step with the ingress of water.
The emergency bilge pump was immediately started but went shortly out of order due
to short-circuit in the switch board controlling the emergency bilge pump and the pump
to the sprinkler system. It is suspected that the short-circuit is caused by start of the
pump to the sprinkler system. It is not known, why the pump to the sprinkler system
was started.
5.18 Survey
PRIDE OF TELEMARK was last inspected by the Swedish Authorities in Strømstad in
Sweden on 14 December 2006. No deficiencies were found.
5.19 Salvage operation/evacuation
After the contact with the foundation and the black out, the ship was by help of tugs
hauled to ferry berth number 2 where all passenger were evacuated during the night.
After the berthing of the ship, The Danish Emergency Management Agency (Beredskabsstyrelsen) supplied the ship with pumping material. At 0520 the pumping of water
from PRIDE OF TELEMARK began. The maximum pumping capacity was approximately 6000 m3/hour. It has been estimated, that the maximum ingress of water was
3200 m3/hour. At 1000 more water was pumped out of the ship than water ingressing.
5.20 Consequences
Due to the contact with the foundation of the pier there were three penetrations in the
hull below the waterline.
When the ship touched the ground at the western pier on arrival it received damage to
the starboard side as follows:
Marine accident report
Page 15
-
At frames 95-96 ripping a hole in a dry tank/void space. This tank goes across
of the breadth of the ship and consists of a bottom tank and two deep tanks.
This caused an increase in the draught.
-
At frames 106-107 ripping a hole in the fore heeling tank / trim tank. At the time
of contact with the foundation of the pier this tank was empty as all water in the
heeling tank was pumped to port side. This caused an increase in the draught
and a list to starboard.
-
Between frames 120-124 ripping a hole in W.T. COMP 6. This compartment
contains among other things fuel oil and booster -pumps for main and auxiliary
engines. The compartment also contains accommodation. This contributed to
the increase in draught and the list to starboard.
Due to the ingress of water there was extensive damage to electrical and electronic
installations as well to machinery.
4 cars were partly damaged by water.
The ship has been in casualty since the incident.
Water pouring out of the penetrations in the hull after the ship was dry docked
Marine accident report
Page 16
6 Analysis
6.1 Bridge watch
It was the master’s first voyage on PRIDE OF TELEMARK not being supernumerary.
He had been supernumerary on two voyages, and as such he was inexperienced.
It is a normal procedure, that the master is notified one hour prior to arrival and then
taking over the watch before entering the harbour. On 10 September the master took
over command at 2350.
The chief officer was also on the bridge. He was very experienced on the line from
Langesund to Hirtshals, as he had been on board PRIDE OF TELEMARK for more
than two years.
The chief officer did not take active part in the navigation as the ship was approaching
Hirtshals.
6.2 Current and drift of the ship
From numerous seafarers, the master had been told; that ships approaching Hirtshals
would have a drift to the east and that the current sometimes would have a speed of up
to 5 knots. At the two approaches as supernumerary the master had experienced, that
the current had given the ship a drift to the east. At these approaches the wind came
from a westerly direction.
On the homepage of Hirtshals Harbour the following information about current is found.
Normative is:
Wind from directions between 020° and 180° results in a westerly current
Wind from directions between 200° and 360° results in an easterly current
On approach 10 September the wind was coming from NE, which should give a westerly current.
ECDIS was used for navigation as well as two GPS-receivers. With this equipment the
master would have been able to determine the drift of the ship. But he master had his
focus on visual navigation, and did not use the ECDIS much during approach.
Relying on his limited knowledge and what he had heard from other seafarer and failing
to use information from the ECDIS-system, the master expected the current to be easterly.
The misjudgment of the current caused the master to approach Hirtshals at a course to
much to the west.
6.3 The ingress of water
An inspection of the watertight bulkheads revealed only minor penetrations which cannot explain the large quantity of seawater that filled major part of the ship after the contact with the foundation of the pier. An explanation could be that watertight doors had
leaked in a similar manner as watertight door number 9.
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The damage at frames 95-96 caused immediate filling of a double bottom tank and two
heeling tanks.
The damage at frames 106-107 caused filling of the fore heeling tank / trim tank. At the
contact with the foundation of the pier the starboard tank was empty.
The damage between frames 120-124 into W.T. COMT 6 was the primary source of
the water ingress. From W.T. COMT 6 the water then spread to W.T. COMP 3, 4, 5, 7,
8, and 9 through penetrations in the bulkheads, staircases and watertight doors.
The most likely way of the seawater entering the ships is as follows:
Immediately after the contact with
the foundation of the pier W.T.
COMP 6 on the first deck was filled
with water. As the switch boards to
booster pumps and transfer pumps,
which supplies both main and
auxiliary engine with fuel oil, is
placed in this compartment the ship
had a blackout few minutes after
the contact. An emergency generator was then started. Trough a
staircase the water found its way to
the second deck containing accommodation.
Staircase between first and second deck.
Before the leakage in W.T. COMP 6 could be tightened, which took about 22 hours, the
water spread to W.T. COMP 7 containing the workshop on first deck and engine control
room on second deck. Further to W.T. COMP 8 containing the auxiliary engine and
boiler room, and finally to W.T.COMP 9, the main engine room. From W.T. COMP 6
the water also spread to W.T. COMP 5, 4 and 3. The way the water spread from W.T.
COMP 6 to W.T. COMP 7, 8, 9, 5, 4 and 3 are not known in details, but several penetrations were found in the bulkheads as well in the deck dividing first and second deck.
It was also observed, that
watertight doors was leaking,
allowing substantial amount of
water to pass. A large quantity of
water found it way through
staircases between first and second deck.
Water pouring from the boiler room through a
bulkhead to the passage between the auxiliary
engine rooms
At 0146 water was observed on
the car deck. The water on the car
deck came through the scuppers
on the fore part, that normally
drains water from the car deck. As
the ship immersed and had a list
to starboard the waterline on the
starboard side was above the car
deck and water ingressed through
the scuppers.
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An inspection has shown that the scupper valves were not tight due to fouling with
mussels. In addition water was flowing from not tight covers to water ballast tank number 2. The filling of water on the car deck was limited to the fore part due to a transverse bulkhead. A limited quantity of water came from the air pipes to the starboard
heeling tank.
Water ballast tank no. 2 in
W. T. COMP 2 was filled
through the air-escape
valves placed on the car
deck.
Due to a heavy list to
starboard, there was more
water in this side of the
ship. At the most the list to
starboard was approximately 15 – 17°
Summing up it can be
concluded, that the water
spread to numerous room
in the ship not being
Water finding its way through penetrations in a bulkhead
penetrated when the ship
had a contact with the foundation by:
-
Not tight watertight doors.
-
Penetrations in the bulkheads.
-
Water finding its way through air pipes to tanks.
-
Staircases.
-
Scuppers with not tight valves.
-
Not tight covers to water ballast tank number 2.
-
Air pipes to the heeling tank.
6.4 Black out – bilge and emergency bilge system out of order
Immediately after the contact with the foundation of the pier W.T. COMP 6 on the first
deck was filled with water. As the switch boards to booster pumps and transfer pumps,
which supplies both main and auxiliary engine with fuel oil, is placed in this compartment the ship had a blackout few minutes after the contact.
After the black out the ballast and bilge system was out of order.
The emergency bilge pump was started shortly after the black out. Due to a shortcircuit in the switch board that supplies the pump with energy, the emergency bilge
pump was only in operation for a short while.
The rapid breakdown of the ballast and bilge system and shortly after the emergency
bilge system resulted in that the ship was unable to discharge ingressing water by its
own effort.
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6.5 VDR – Data
A recording covering the period from 2343 on 10 September to 0130 on 11 September
was available to the Investigation Division. Replay software (RU_SW 1.3.4 and
REU_SW 1.3.5) was also available.
After having examined the recording from the VDR system indications were found
showing that the VDR / MBB had been unstable.
There is every probability that the VDR data concerning the watertight doors are unreliable. There were discrepancies between the statements given by the crew, the readings of the control panels for the water tight doors and the VDR data. Kongsberg Marine is unable to explain the reason for this.
Indications of open watertight doors after the contact with the foundation of the pier
may be caused by signal errors. The equipment controlling the doors and giving indications on whether the doors were open or closed are in no way waterproof.
During replay of VDR data the radar picture was unstable and was not recorded during
the last hours prior to – during and after – accident.
Kongsberg Maritime was on board the ship after the accident, and found the logging
and displaying of radar pictures normal indicating that the VRD system has been working as specified all time. KM is not able to explain why the radar picture was down during the hours around the accident.
7 Re-opening of the investigation
After publishing of the Marine Accident Report, it has come to the knowledge of the
Division for Investigation of Maritime Accident, that a watertight might have been
opened by a lorry driver after the contact with the foundation of the western pier at the
entrance to Hirtshals Harbour.
Viewed in the light of this information the Division decided to re-open the investigation.
7.1 Statements concerning the watertight doors
At the time of the accident only two crewmembers had quarters in cabins on deck 2.
On this particular voyage, no passengers were assigned cabins on this deck. One
crewmember, a receptionist, was in her cabin at the time of the accident. When the
main engines stopped, she immediately left her cabin by a staircase close to her cabin.
She passed no watertight doors on her way out, and observed no open watertight
doors.
The other crewmember, a contractor, was sleeping in his cabin at the time of the accident. He woke up, when the ingressing water in his cabin reached his bed. The water
was filling his cabin at a swift rate, and he left the cabin as fast as possible. After opening the cabin door, he had to swim through the corridors to a nearby staircase by which
he left deck 2. He passed no watertight on his way out, and observed no open watertight doors.
Shortly after the accident all passengers and crewmembers where counted to make
sure, that everybody was safe. By a mistake the contractor, who lived on deck 2, were
Marine accident report
Page 20
reported to be in the control room, thus nobody was believed to be in the cabins on
deck 2.
At the time of the contact with the foundation a motor man was in the main engine
room. To examine what had happened he moved aft in the ship passing watertight
doors number 9 and number 8. He found the two doors closed, and he opened and
closed the doors while passing through. This was observed on the indication panel on
the bridge. In the workshop the motorman discovered, that watertight door number 7
leading to WT COMP 6 not was properly closed. It was open by approximately 5 cm,
and water in limited quantities was pouring into WT COMP 7 from WT COMP 6. The
motorman closed this door immediately and observed that water now only was dripping
at the door casing.
An hour after the contact with the foundation, the control panels showing the status of
the watertight doors started to flash on and off in a random way. To make sure that this
did not indicate open watertight doors a crewmember was ordered to the damage control centre on deck 4 to close all watertight doors just to be on the safe side.
When the ship subsequently was
drained for water section by section,
all watertight doors was found closed
except watertight door number 2. It
has not been possible to establish
why this door was open, but an
inspection on 2 September 2008
showed, that the handle to open and
close this door not was functioning in
a proper manner. After being
activated to open the door handle did
not go back to a neutral downright
position but remained in the position
to open the door. This explains why it
was impossible to close the door
from the damage control centre. The
Figure showing the instructions of
same malfunction was furthermore
how to operate the watertight door
observed on a couple of the watertight
doors in the fore part of the ship. These doors were found closed when the ship was
drained.
On the VDR-sound recordings it appeared that watertight doors were allowed to be
opened and closed for passage in the efforts to examine and limit the consequences of
the accident. This has been confirmed by the master. At 0030 an order was issued not
to open any watertight doors under no circumstances.
7.2 The ingress of water
An hour after the damage WT COMP 7 had to be abandoned due to the ingress of water. In addition to ingress of water through penetrations in the bulkhead to comp 6, limited quantities of water found its way through small cracks in a cofferdam in WT COMP
7.
The water filling of WT COMP 8 (Auxiliary engine and boiler room) happened after
some time. Not until 22 hours after the contact with the foundation water was observed
in WT COMP 9.
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At 0146 water was observed on the car deck. At first only in limited quantities coming
from the air pipes in the starboard side leading to the heeling tanks. Not until some
hours later water came through the scuppers on the fore part. The scuppers normally
drain water from the car deck. As the ship immersed and had a list to starboard and an
increasing draft forward the waterline on the starboard side was above the car deck
and water ingressed through the scuppers. At a time in the morning before 10 a.m. the
fore ship rested on the seabed in Hirtshals Harbour.
Based on the facts that came to light after re-opening the investigation, the Investigation Division adhere to the conclusions and recommendations given in this report
It is further recommended that handles operating watertight doors on PRIDE OF
TELEMARK and sister ships are controlled and repaired where necessary.
8 Appendixes
Appendix 1. Positions of damage to the hull.
Appendix 2. Water filled tanks and void spaces in the double bottom.
Appendix 3. Water filled compartments on the first deck.
Appendix 4. Water filled compartments on the second deck.
Appendix 5. Water filling on the car deck.
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Appendix 1 - Positions of damage to the hull and the water filling.
K
*
1
2
3
1. At frames 95-96 ripping a hole in a dry tank/void space
2. At frames 106-107 ripping a hole in the fore heeling tank/trim tank
3. Between frames 120-124 ripping a hole in W.T. COMP 6
* The blue line represents the waterline on starboard side when the fore ship rested on the seabed in the harbour.
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Appendix 2 - Water filled heeling tanks and void spaces in the double bottom.
W.T. 13
W.T. 12
W.T. 11
W.T. 10
W.T. 9
W.T. 8
W.T. 7
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W.T. 6
W.T. 5
W.T. 4
W.T. 3
W.T. 2
W.T 1
Appendix 3 - Water filled compartments on the first deck.
W.T. 13
W.T. 12
W.T. 11
W.T. 10
W.T. 9
W.T. 8
W.T. 7
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W.T. 6
W.T. 5
W.T. 4
W.T. 3
W.T. 2
W.T 1
Appendix 4 - Water filled compartments on the second deck.
W.T. 13
W.T. 12
W.T. 11
W.T. 10
W.T. 9
W.T. 8
W.T. 7
W.T. 6
W.T. 5
Note:
The compartments in the port side of the ship are only partly filled with seawater due the list to starboard.
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W.T. 4
W.T. 3
W.T. 2
W.T 1
Appendix 5 - Water filling on the car deck.
W.T. 13
W.T. 12
W.T. 11
W.T. 10
W.T. 9
W.T. 8
W.T. 7
Marine accident report
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W.T. 6
W.T. 5
W.T. 4
W.T. 3
W.T. 2
W.T 1