1. science
2. weather

Marine Safety Investigation Unit
SAFETY INVESTIGATION REPORT
201401/030
The Merchant Shipping
(Accident and Incident Safety
Investigation) Regulations,
2011 prescribe that the sole
objective of marine safety
investigations carried out in
accordance with the
regulations, including analysis,
conclusions, and
recommendations, which either
result from them or are part of
the process thereof, shall be
the prevention of future marine
accidents and incidents
through the ascertainment of
causes, contributing factors
and circumstances.
Moreover, it is not the purpose
of marine safety investigations
carried out in accordance with
these regulations to apportion
blame or determine civil and
criminal liabilities.
NOTE
This report is not written with
litigation in mind and pursuant
to Regulation 13(7) of the
Merchant Shipping (Accident
and Incident Safety
Investigation) Regulations,
2011, 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 report may therefore be
misleading if used for purposes
other than the promulgation of
safety lessons.
© Copyright TM, 2015.
This document/publication
(excluding the logos) may be
re-used free of charge in any
format or medium for education
purposes. It may be only reused accurately and not in a
misleading context. The
material must be
acknowledged as TM
copyright.
REPORT NO.: 03/2015
January 2015
MV SATIGNY
Water ingress
while on passage in the North Sea
24 January 2014
SUMMARY
At about 0400 (UTC+2) on 24
January 2014, the bulk carrier
Satigny started experiencing
heavy
weather
conditions,
shipping green seas on the main
deck.
For several hours, the crew
members were unable to inspect
the forward area of the ship
because of the prevailing bad
weather.
Following
the
necessary
inspections, the crew members
reported flooding in the forward
spaces and also in cargo hold
no. 1. The vessel deviated from
her intended voyage and
proceeded to Rotterdam to carry
out the necessary repairs.
Satigny arrived safely alongside
on 31 January.
It was concluded that flooding
occurred as a result of a breach
of the weathertight integrity of
the vessel due to the
encountered extreme weather
conditions, exacerbated by the
inadequate condition of critical
hull closures.
The MSIU has issued two
recommendations
to
the
Company designed to ensure
that the necessary pre-sailing
checks are carried out and
weather routing advice is taken
by the master.
MV Satigny
The document/publication shall
be cited and properly
referenced. Where the MSIU
would have identified any third
party copyright, permission
must be obtained from the
copyright holders concerned.
MV Satigny
1
201401/030
FACTUAL INFORMATION
Weather forecasts
Violent storms were forecast for the initial
segment of the Satigny‟s route from Ålesund
to Tongue Anchorage in the Thames Estuary.
For the day of 23 January, the MetArea 1,
Norwegian Basin area, forecast the
following:
Vessel
Satigny, a 5087gt bulk carrier was built in
2009 and is registered in Valletta. She is
owned by Massatlantic (Malta) Ltd. At the
time of the accident, the vessel was managed
by V. Ships USA LLC. The vessel‟s length
overall is 112.80 m and her loaded draught is
6.90 m. Satigny has three cargo holds with
folding hatch covers.
“…[wind] in area west of longitude 05° east,
southerly or southeasterly, (Beaufort) 5 to 7 at
first in far west and far east, otherwise gale 8
to storm 10. Occasionally violent storm force
11 later in central southern areas. [sea] High
occasionally very rough at first. [weather]
Occasional rain, but sleet in far east.
[Visibility] Moderate or good becoming poor
later.
Propulsive power is provided by an 8cylinder Daihatsu 8DKM-28, medium speed
diesel engine, producing 2500 kW at
750 rpm. This drives a single fixed pitch
propeller through a reduction gearbox. The
service speed is 12.0 knots.
Outlook for following 24 hours:
Violent storms expected in east northern
section, west central section, and Norwegian
basin...”
Crew complement
The vessel was manned by a crew
complement of 18, with Eastern European
officers and South American ratings. Most
of the ratings had been on board for
approximately four months whilst the Master
had just signed on a few days prior to the
vessel‟s departure from Ålesund, on 22
January. The master, who was 58 years old
at the time of the accident, was new to
Satigny; this being his first contract with the
vessel‟s Company. However, he had 20
years of experience as master in his 35 year
sea-going career.
Weather routeing
The vessel was provided with weather
routeing advice. A first message was sent on
the evening of 22 January. Confirming the
MetArea forecast, the subject line included
the words “heavy weather” in capitals. The
same message forecast what weather lay
ahead (Figure 1):
Evidence indicated that the previous master
reported no significant anomalies or
deficiencies during his hand-over to the
relieving master.
Figure 1: Forecast weather
Environmental conditions
North Sea weather and climate in January
Winter storms (and their fronts) contribute to
most of the strong winds and gales along the
North Sea coasts. Gales are frequent and
extreme winds, highs seas and swell are
commonly reported.
MV Satigny
The forecast also indicated that
late on the 24th / early on the 25th, a broad
area of Bf 10-11 winds and ≥7 m waves were
expected to be unavoidable along the
Southwest coast of Norway. During that time
exposure to the Bf 10-11 winds and ≥7 m
2
201401/030
waves is expected to be unavoidable along all
the route options passing the coast of Norway.
continued until 29 January in the evening. At
this point, however, the vessel was already en
route to Rotterdam.
Subsequent messages forecast that storm and
gale conditions would continue until 27
January; the forecast noting for the 26/1454
that “heavy conditions expected to ease after
27/12Z.”
The master stated that it was possible to
inspect the forward part of the vessel
between 0940 and 1020 on 26 January. The
inspection revealed that the rope hatch on the
forecastle was open, bulwark rails on the
after part were either deformed or damaged,
and the space beneath, which was utilised for
rope storage, was partially flooded.
Narrative
At the time of the accident, Satigny was
chartered to load a cargo of salt in jumbo
bags from Ålesund, Norway for discharge at
the port of Bay Roberts in Newfoundland,
Canada. The passage plan required the
vessel to steam Southwards through the
North Sea and English Channel, deviating to
the Tongue anchorage (Thames estuary) for
bunkers and MF radio antenna repairs before
continuing her passage across the North
Atlantic.
The forecastle head was entered and the
doors to the forward rope store, compressor
room on the starboard side and the access
hatch to the emergency fire pump space were
all found unsecured. All openings were resecured, following which, the Company was
informed of the situation.
The forward areas were once again inspected
during the morning on 29 January. The rope
hatch on the forecastle was still closed,
however, the forecastle head was once again
“...full of water.” Although the inner doors
were found closed, it was noted that water
was escaping from the door seams.”
The cargo loading operation was completed
on 22 January at 1940(LT) and preparations
were made for departure. At 2345 of that
same day, the pilot boarded the vessel,
departing at 0055 of 23 January. Full Away
on Passage (FAOP) was recorded in the
logbook five minutes later, i.e. at 0100 hours.
The doors were not reopened as this was
considered to be too dangerous. During the
inspection, cargo hold no.1 was accessed via
the access hatch on the aft starboard side.
Water was noted to be present inside. The
sounding indicated that there was about 3 m
of water. The master informed the Company
accordingly and the order was given to
proceed to either Rotterdam or Dunkirk for
repairs.
On reaching open waters, heavy weather was
encountered with winds from the South
Beaufort force 7 and 4 m seas from the
Southeast recorded at 0800. Logbook entries
at this time were: “Vessel pitching and
rolling heavily, seawater washing main deck
and hatches.”
Thereon, wind and sea
conditions deteriorated progressively, as
predicted.
On the morning of 30 January, a submersible
pump was lowered and rigged in cargo hold
no. 1 to pump out the water. The process
was continued until the vessel‟s arrival in
Rotterdam.
Satigny was safely moored
alongside a floating dock in a shipyard in
Rotterdam on 31 January at 0215.
On 25 January, the bilge alarm for the
forward spaces activated. However, the crew
members could neither go forward nor pump
out the spaces.
Table 1 tabulates entries, extracted from the
deck logbook, and which record the wind and
sea observations.
Heavy weather with
Easterly force 8 wind, as well as high seas,
MV Satigny
The Netherlands port State control officers
attended on board later during the day and
3
201401/030
noted
a
total
of
16
deficiencies.
The vessel was consequently detained and
remained alongside for 43 days until the
cleaning and repairs were completed.
Table 1: Deck logbook extracts
Date
Jan.
Time
Wind
Direction
Bf
Sea
Direction
H in
m
23
1200
S
8
SSE
4
“Vsl pitching and rolling. Hatch covers awashed by water
continuously.”
23
2400
S
8
SSE
6
“Vsl rolling and pitching. Sea water awashed cargo hold.”
24
0415
24
1200
SSE
9
SSE
6
“Bilges of holds (1, 2, 3) pump out every 6 hrs”
“Rolling and pitching. Hatch covers awashed by sea water.”
N/N distance 104 nm, av.sp. 4.3 kn
24
2100
SSE
10
SSE
6
“Due to severe storm weather, to avoid damage of the vsl and
cargo proceeded for shelter closer to the coast. A/C 160°
true.”
25
Master stated that “at about 0700 the alarm of the water level detection system sounded for the forward spaces. Due
to the heavy weather is was not feasible and dangerous to attend forward.” The chief officer added: “It was tried to
start pumping on the forecastle space, but obviously this was not possible due to a (maybe) closed valve
somewhere.”
25
1200
25
Master stated that “at about 1900 the bilge level alarm on cargo hold no. 1 on the water level detection panel on the
bridge was triggered. The engine room was requested to pump on the bilge with the fire pump and ejector system.
Noted that small quantities of water were discharged but suction was lost after a few minutes.” The chief officer
added: “After several attempts the master instructed the pumping should be done at a 6 hourly interval.”
25
2000
SSE
11
SSE
8
“Vsl rolling and pitching heavily, sea water washing main
deck and hatch covers.”
26
1200
SSE
8
SSE
5
“Bilges of holds (1, 2, 3) pump out every 6 hrs”
“Vsl pitching and rolling. Hatch covers awashed by sea
water.”
N/N distance 81 nm, av.sp. 3.4 kn
27
1200
E
9
E
6
“Bilges of holds (1, 2, 3) pump out every 6 hrs”
“Snowing. Vsl pitching and rolling. Hatch covers awashed
by sea water.”
N/N distance 69 nm, av.sp. 2.9 kn
28
1200
SE
8
SE
5
“Bilges of holds (1, 2, 3)...pump out every 6 hrs”
Vsl pitching and rolling. Seawater awashed deck and cargo
holds.”
N/N distance 164 nm, av.sp. 6.8 kn
MV Satigny
Remarks
“To avoid damages to the vsl due to heavy weather reduced
RPM till 150.”
SSE
11
SSE
8
“Bilges of holds (1, 2, 3).pump out every 6 hrs”
“Vsl pitching and rolling. Hatch covers awashed by sea
water.”
N/N distance 34 nm, av.sp. 1.4 kn
4
201401/030
Furthermore, the PSC report indicated that
there were traces of seawater leakage from
the gaskets of the cargo hatches on cargo
hold no. 2.
Observed damages
On 31 January 2014, the master noted
protest. In his letter, the following apparent
damages were listed:
1.
Opened hatch on the forecastle and
flooding of all forward spaces;
2.
Damaged and partly torn off railings
on the forecastle;
ANALYSIS
3.
Damaged light on the forward mast;
4.
Damaged equipment in the forward
spaces due to exposure to sea water;
5.
Water ingress in cargo hold no. 1
resulting in partial damage to the
cargo;
Aim
The purpose of a marine safety investigation
is to determine the circumstances and safety
factors of the accident as a basis for making
recommendations, and to prevent further
marine casualties or incidents from occurring
in the future.
6.
Several fire boxes and fire hoses
washed overboard; and
7.
SMS checklists
Departures and adverse weather conditions
were addressed in the Company‟s SMS
Manual; Document NAV 07 – Departure
checklist and Document NAV 09 – Adverse
conditions checklist.
Both checklists
included checks to ensure that the watertight
integrity of the vessel was confirmed. The
checks were accordingly signed as done and,
in the case of the Departure checklist, the
form was countersigned by the master.
1
Inflated forward liferaft .
The MSIU‟s inspection of cargo hold no. 1
was limited but it could not be excluded that
water had entered the cargo hold via the
hatch covers, during the periods of heavy
weather on the way from Ålesund to
Rotterdam.
1
During MSIU‟s visit on board, the following
additional damages were noted:
Ingress of water in the cargo holds
It was clear that the vessel had suffered from
loss of watertight integrity and subsequent
flooding of a number of compartments.
Although the vessel had encountered heavy
weather, the MSIU remained sceptic as to
whether the vessel was adequately prepared
to undertake a voyage, where known extreme
conditions were likely to have been
encountered.
Forecastle:
1. Bulwark rails torn off and bent in aft
direction;
2. Watertight boxes mounted on the foremast
and enclosing electrical switches were found
with their access panels either missing or
damaged;
3. Lifebuoy light missing and bracket damaged;
4. Tarpaulins covering the spurling pipes were
found loose or missing, allowing water to
enter the chain lockers.
Forecastle head:
5. A large amount of debris was observed in the
rope store that was contaminated with oil;
6. The chain locker doors were both missing
and were located amongst the debris;
7. Presence of oily-water in the emergency fire
pump space;
8. A large amount of debris and oil was
observed in other spaces.
MV Satigny
Documentary evidence confirmed that the
vessel was in class and all Statutory
certificates were valid. It was also noted that
the cargo hatch covers had been hose tested
during the last dry-docking period in
December 2013. It was however, difficult to
reconcile that hatch covers were certified
tight in the beginning of December, when
5
201401/030
stating that “all hold bilges pumped out every
six hours.”
traces of expansion foam (used to seal
leaking hatch covers) were found along the
hatch cover seams, just under two months
later (Figure 2).
Ingress of water in the forecastle head
With regards to the flooding of the forecastle
head, the high water level alarm sounded on
25 January at 0700. It was stated that no
pumping out was done at this time “as local
operation was not possible” and “…(maybe)
closed valve somewhere.”
The MSIU had no evidence which would
have suggested that ingress of water into
cargo hold no. 1 had happened from adjacent
ballast tanks, void spaces and / or fresh water
tanks.
It was reported that the rope hatch cover on
the forecastle was observed to be partly open
during an inspection on 26 January at sea and
in heavy weather. The securing bolts were
found loose and the hatch cover moving
freely despite the wire and turnbuckle
securing it from inside the forecastle head
rope store.
Figure 2: Missing cross-joint wedge and expansion
foam on hatch cover
An analysis of the compiled PSC inspection
report dated 31 January, seemed to confirm
that the weathertight integrity of the cargo
holds was also compromised by an
inadequate sealing mechanism.
The
following remarks were made:
The forecastle head door was observed to be
still padlocked but all the internal doors were
found open. The chief mate stated that there
were about 0.60 m of water inside the space
and some 0.40 m of water in the emergency
fire pump space. The bosun also commented
that after opening (the forecastle head door),
water was noted to be present up to the door
sill.
“Inside cargo hold no. 2 also traces of
seawater leakage from the gaskets of the
cargo hatches. Found wedges on top of cargo
hatch covers of all holds to be loose by hand.
Three wedges missing, one cleat on hold no 1.
One wedge missing on hold no 2. Some cleats
have weak tension.
All cargo hatches,
hatches and doors of forecastle to be proved
seaworthy and to be rectified by Class before
departure.”
Available evidence pointed to the poor
condition of the rope hatch cover due to
corrosion and lack of maintenance as a
contributory factor to the flooding. The
hatch could be closed by means of three
nuts/bolts. These nut/bolt arrangements were
provided with one or more extra ring washers
and/or bolts (Figure 3).
Doubts over the weathertight integrity of the
hatch covers were augmented by the (deck)
logbook entries. It was implied by the master
that cargo hold no. 1 bilge was pumped out
for the first time after the alarm sounded on
the 25 January at 1900. However, it was
difficult to rationalise this with prior daily
logbook entries commencing on 24 January
Figure 3: Rope hatch cover securing bolt
MV Satigny
6
201401/030
The tightening nuts and thread of the bolts
were noted to be heavily corroded and could
not be turned and appeared to be frozen. It
seemed that the closing of this hatch was
only done by forcing the arrangement in
place. Moreover, the bolts on the cleats of
the hatch of the rope store on forecastle deck
were seized.
Ingress of water through the spurling
pipes and chain lockers into the forecastle
head
The MSIU could not ascertain whether water
was actually pumped out from the forward
spaces during the first inspection by the crew
on 26 January. However, an increase in the
water level inside the forward spaces was
evident during the second inspection on 29
January.
Evidence indicated that when the forecastle
head door was opened, significant amounts
of water flowed out of the space and
although the internal doors were still shut,
water escaped from the seams of the inner
doors (Figure 4).
Figure 4: Flooded forecastle store after the
accident
The MSIU had doubts on whether the
spurling pipes were adequately sealed when
the vessel was prepared for sea at Ålesund.
Good practice would have required that
besides a cement plug, i.e. filling the space
between the chain and pipe with cement, it
was also necessary to fit a steel or wood
spurling pipe cover followed by a canvas
cover, that is tied around the spurling pipe
and anchor chain.
During the second inspection, it was
observed that the rope hatch cover was still
secured shut (after extra lashings were
previously applied). It was therefore highly
probable that further ingress of water
occurred through the spurling pipes and the
chain lockers. The chain locker doors were
both missing, although they were later
retrieved damaged, when the vessel was
alongside in Rotterdam.
On Satigny, the spurling pipes were closed
by tarpaulins, secured by means of ropes
around the chain and the collar of the
spurling pipe. No additional cement or foam
had been applied (Figures 4 and 5)2.
2
MV Satigny
7
There is adequate literature on spurling pipes and
water ingress. For instance, UK‟s Merchant
Shipping Notice No. 622 „Miscellaneous openings
in freeboard and superstructure decks - spurling
pipes‟ is clear that the mere fitting of canvas
around spurling pipes is considered to be
insufficient.
201401/030
regularly undertake transoceanic passages.
However, it would appear that a decision had
been taken to navigate a small vessel in a
region which was well noted for its winter
storms, without a contingency plan to
proceed to a safe anchorage or port of refuge
being considered and included in the passage
plan.
Planning errors and decision-making
Considering the experience which the master
had, the initial orientation and goal
elaboration must have been very important
for him during the voyage planning process.
It was unclear, however, whether sufficient
time was spent in analysing the weather
forecast, the voyage plan and eventually
decide on how to safely reach the discharge
port.
Figure 4: Port anchor spurling pipe
It was not excluded that being his first
voyage with the Company, there was lack of
attention to the balancing of contradicting
goals – delivering the cargo and doing it
safely in adverse weather conditions. It has
to be stated, however, that in order to sail, a
decision had been made by the master on the
understanding that the vessel was in all
aspects prepared for the voyage.
It is also a common experience in safetycritical domains where planning may not
necessarily be driven by the actual goals, but
the effects of one‟s actions/inactions, i.e., for
instance, delaying the departure at a time
when in any case bad weather was expected
to prevail in that period of year.
Figure 5: Starboard anchor spurling pipe
Passage planning
The passage plan as prepared by the vessel
did not include detailed information, except
for the minimum necessary. The document
was generic with the usual comments /
remarks in the general information section:
"keep sharp look out for fishing boat; watch
out for crossing vessel; watch out no go area
w/ passing distance on charts…”
Planning is a cognitive process where the
person responsible for it combines pieces of
information (including information retrieved
from memory).
One common mistake,
which typically happens in complex systems
is the lack of consideration of side (and
long)-term effects. Such lack of analysis
may be the result of limited understanding of
the current system status / future status.
However, it may also be „a strategy‟ to
actually avoid prolonged considerations,
There was no evidence that the passage plan
took into account the advice contained in the
Admiralty Sailing Directions and the
monthly routeing charts.
It has to be
acknowledged that vessels of this size
MV Satigny
8
201401/030
where the planner may actually risk falling in
a vicious circle of planning.
5. The weather routeing advice to
remain close to the port of Ålesund
until conditions improved were not
adhered to;
The above would be happening, of course, in
a situation where at least one of the goals
would have already been set – in this case,
the delivery of the cargo from the loading
port to the discharge port.
6. A contingency plan to proceed to a
safe anchorage or port of refuge had
not been considered and included in
the passage plan;
The decision of the master to depart in the
prevailing weather conditions had a
significant „dead-time‟, i.e. the failure /
success would not have been immediately
visible – at least not before the ship would
have left her berth and proceed out to open
sea.
7. It was not excluded that there was
lack of attention to the balancing of
contradicting goals – delivering the
cargo and doing it safely in adverse
weather conditions;
However, it did not seem that any of the
other crew members had discussed and
voiced their concerns, if any. This could
have been a missed opportunity for the
master to self-reflect on his decision and its
appropriateness. A situation had thus been
created, which was fertile for error-prone
thinking and decision-making.
9. A situation existed, which was fertile
for error-prone thinking and decisionmaking.
8. It did not seem that any of the other
crew members had discussed and
voiced their concerns, if any;
RECOMMENDATIONS3
V. Ships USA LLC. is recommended to
ensure that:
CONCLUSIONS
1. Progressive
flooding
occurred
through openings that were not made
weathertight prior to departure,
namely, the forecastle rope hatch
cover, the spurling pipes and the
cargo hatch covers;
03/2015_R1 in accordance with the SMS
Manual, crew members carry out all the
necessary procedures and checks prior to
departure from port, including adequate
prevention of flooding through the
spurling pipes.
2. The weather tightness of the cargo
hatch covers and the rope hatch cover
securing arrangements was doubtful;
03/2015_R2 masters discuss and wherever
possible, take the advice from the
provided weather routing service and the
reasons for deviating from the
recommended track is immediately
communicated
to
the
routing
organisation and the Company.
3. It was highly probable that further
ingress of water occurred through the
spurling pipes and the chain lockers;
4. There was no evidence that the
passage plan took into account the
advice contained in the Admiralty
Sailing Directions and the monthly
routeing charts;
MV Satigny
3
9
Recommendations should not create a presumption
of blame and / or liability.
201401/030
SHIP PARTICULARS
Vessel Name:
Satigny
Flag:
Malta
Classification Society:
Bureau Veritas
IMO Number:
9522738
Type:
Bulk Carrier
Registered Owner:
Massatlantic (Malta) Limited
Managers:
V. Ships USA LLC
Construction:
Steel
Length Overall:
113.0 m
Registered Length:
106.17 m
Gross Tonnage:
5087
Minimum Safe Manning:
14
Authorised Cargo:
Solid bulk
VOYAGE PARTICULARS
Port of Departure:
Ålesund, Norway
Port of Arrival:
Bay Roberts, Newfoundland, Canada
Type of Voyage:
International
Cargo Information:
Salt in jumbo bags
Manning:
18
MARINE OCCURRENCE INFORMATION
Date and Time:
24 January 2014 at 0400
Classification of Occurrence:
Less Serious Marine Casualty
Location of Occurrence:
North Sea
Place on Board
Forecastle deck and cargo holds
Injuries / Fatalities:
None reported
Damage / Environmental Impact:
None reported
Ship Operation:
In passage
Voyage Segment:
Transit
External & Internal Environment:
Wind: South Southeast Beaufort force 10
Sea state: High
Visibility: good
Persons on board:
18
MV Satigny
10
201401/030