Malta Marine Safety Investigation Unit Report
MS Oliva ran aground at 04.30 on 16th March 2011 at Spinners Point, the far north-west promontory of Nightingale Island. Following a Malta Marine Safety Investigation Report we now know how the accident occurred and lessons to be learned
Why MS Oliva ran aground and lessons to be learned
Compiled by Newsletter Editor Richard Grundy from a Malta Marine Safety Investigation Report
Context of the report
MS Oliva Marine Safety Investigation Report was published by Malta’s Marine Safety Investigation Unit. The detailed and professional report was produced following International and European regulations and directives. Its sole purpose is confined to the dissemination of safety lessons and therefore may be misleading if used for other purposes. The report ‘shall be inadmissible in any judicial proceedings whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless, under prescribed conditions, a Court determines otherwise.’
The Full Document
The full PDF document of 51 pages can be obtained direct from the Malta Government Ministry for Infrastructure, Transport and Communications Website by using this link: https://mitc.gov.mt/mediacenter
The report contains: A Summary of Events, Factual Information (1.) about the ship and a detailed Analysis (2.) of the causes of the grounding and events following. As this is a technical report intended to inform future marine safety there is a danger that any précis may be misleading. Nevertheless it makes fascinating reading for those who have followed the whole MS Oliva wreck saga.
We publish below in full the report’s Conclusions (3.), Safety Actions Taken (4.) and Recommendations (5.) which clearly identify the cause of the grounding, other findings, safety actions taken subsequently by TMS Bulkers Ltd and recommendations.
We will not here make any comments (although it would be tempting so to do), but leave visitors to draw their own conclusions, perhaps after consulting the full report. The February 2013 Tristan da Cunha Newsletter will contain an article including part of the report and an update on the Tristan Conservation and Fisheries Department monitoring.
Findings and safety factors are not listed in any order of priority.
3.1 Immediate Safety Factors
3.1.1 Oliva ran aground because the planned course the vessel was following on the plotting sheet was found to have taken the vessel directly over Nightingale Island.
3.1.2 Although the bridge team was aware that the vessel would be passing close to some islands, it was not aware as to when that event would take place.
3.1.3 Although the vessel did not have BA (British Admiralty) Chart 1769, other appropriate available charts covering the area had not been used.
3.1.4 Both the second mate and chief mate were not aware that the vessel was heading towards Nightingale Island. This was because there was no indication on the plotting chart to alert them of the dangers ahead.
3.1.5 Both the second mate and chief mate saw some echoes on the radar screen, but did not investigate them and dismissed them as rain clouds.
3.1.6 There was no suitable mark placed across the ship’s track to indicate the need to change to a hydrographic chart.
3.1.7 Neither officer had consulted BA Chart 4022. Although this chart was of an unsatisfactory scale, it could have prompted them to adopt a precautionary approach when radar echoes were sighted on the radar.
3.1.8 The combination of the cold, the medication, lack of sleep, the time of the day and reaction to the vessel’s grounding suggests that the chief mate was probably not fit to stand a navigational watch.
3.1.9 Although the company had provided comprehensive guidance and procedures in its SMS (Safety Management System) to prevent this accident, these were not followed on board.
3.2 Latent Conditions and other Safety Factors
3.2.1 The passage plan did not comply with the company’s instructions of clearing distances when a vessel was in open waters.
3.2.2 The master made no reference to the passing of Islands in his night orders. Reference to the Islands, could have alerted the second mate and chief mate to the significance of radar echoes.
3.2.3 The handing over checklist required the chief mate to establish the proximity of any hazards to the vessel. This appears not to have happened and he relied on the brief hand-over he received from the second mate.
3.2.4 The chief officer did not check the position which the AB (Able Bodied Seaman) plotted on the chart.
3.3 Other Findings
3.3.1 The company had adopted the concept of bridge team management to address performance variability. However, in this case it appears that the crew members’ interaction was not effective and they did not identify and eliminate the factors that resulted in the grounding.
3.3.2 The lifeboat was lowered soon after daylight as a precautionary measure, but was lost when the painters parted. Had the fishing vessel not been in the near vicinity, given the remoteness of the area, the crew of Oliva would have found themselves in a difficult position without a lifeboat.
3.3.3 Although the master had saved the VDR (Voyage Data Recorder) data, he was unable to retrieve it as he abandoned the vessel.
4. Safety Actions Taken
4.1 Safety actions taken during the course of the safety investigation
TMS Bulkers Ltd has carried out its own internal investigation, which has resulted in a review of its procedures. These include:
• instructions on the use of plotting sheets during ocean navigation;
• requiring all officers on board to complete computer based training in voyage planning and bridge team management.
TMS Bulkers Ltd. also intends to increase the frequency of internal navigational audits so as to identify any potential problems of a similar nature within its fleet.
In view of the conclusions and taking into consideration the safety actions taken during the course of the safety investigation, TMS Bulkers Ltd. are recommended to:
14/2012_R1 Consider holding unscheduled navigational audits at sea, so as to verify compliance of its operational procedures while the vessel is underway;
14/2012_R2 Ensure that emergency checklists are amended in order to include the need to save the VDR data.
Copied sections of the report are: