REPORT General Cargo Vessel DALARNA - P3JD7 - Grounding on December 22nd, 2002 2003-04-10
REPORT General Cargo Vessel DALARNA - P3JD7 - Grounding on December 22nd, 2002 Our reference: 080202-03-15022 Maritime Casualty Jörgen Zachau Investigation Division: Phone: +46 11 19 12 73 Photo by Frivilliga Flygkåren Reprint permitted provided stating of source SJÖFARTSVERKET SE-601 78 NORRKÖPING Sweden Phone: +46 (0)11-19 10 00 Fax: +46 (0)11-23 99 34
Table of Contents Summary...1 Account of facts...1 The vessel...1 The weather...2 Course of events...2 Master's description...3 Pilot's description...4 Analysis...6 Pilot's description...6 Wrong radar position...6 Wrong course...7 Measures after the grounding...8 Conclusions...8 Miscellaneous...8 Causes...9 Remarks...9 Result of the Investigation...9 General Recommendations...10 Damages...10 Enclosures: Excerpt from nautical charts
Summary After finishing the unloading in the morning of Sunday December 22 nd, 2002, the Dalarna left Norrsundet heading for the pilot station off Gävle in order to land the accompanying pilot. About 1045 hours the pilot asked the master, so far inactive in the navigation process, to assist in finding the buoy Utgrund, which was anticipated to be on the port side. On the occasion the sun was low, intensely shining from almost straight ahead. At 1052 hours the Dalarna grounded in position N 060 54,95 E 017 20,18. In this connection the buoy appeared close on the starboard side, burdened with ice and partly hidden under the surface of the water. The ship was not stuck on the ground but proceeded to a safe anchorage after relevant measures had been taken on board. Account of facts The vessel Name: DALARNA IMO No.: 916 50 85 Call sign: P3JD7 Port of registry: Limassol, Cyprus Gross tonnage: 3796 Length over all: 100.7 meters Breadth: 16.2 meters Draught: Fore 2.4 m, aft 4.0 m Classification society: Germanischer Lloyd Year built: 1996 Construction material: Steel Propulsion power: 1600 kw Crew: 9 + pilot Page 1
The Dalarna was a general cargo vessel of conventional type with a cargo hold covered with hydraulically managed hatch covers. No equipment was blocking the view, such as cranes or similar. Astern of the cargo hold was the machinery room and above that was the deck house with crew areas and navigation bridge. The vessel had one propeller and a main engine of make SKL Motoren 8VDS29/24-AL2. On the bridge was i.a. automatic steering, GPS, gyro-compass and two radar units. The only radar used on the occasion got input from the GPS as well as from the gyro-compass. The vessel had earlier had a severe breakdown, when a damage to engine and propeller together with lost helm had caused a stay at a shipyard in the winter of 1998. The vessel had not been subject to a registered detention before the grounding. The weather On the occasion the wind was about WNW, just below 10 m/s and the sea state abt. 2 m. The sun was low in bearing 170-175. Course of events At 1000 hours on Sunday December 22 nd the Dalarna left Norrsundet after finishing the unloading. The vessel had a pilot on board and was going inside the skerries to the pilot station off Gävle to land him there. The pilot handled the navigation, the master being inactive on the bridge. Both had comprehensive and thorough knowledge of their assignments. The Dalarna passed the buoys Välkomst and Förstugrund, at which time the course was changed to 148 and the automatic steering was engaged. At this moment the chief officer, who had acted helmsman, left the bridge. A radar position from Skärmarbergsudden (bearing 330, distance 3.5 M [nautical mile, 1852 metres]) was set and was laid on the chart. Since the vessel was slightly too far to port the course was altered to 155. Page 2
The pilot set the distance ring of the radar at 0.7 M, which was a safe distance for passing Iggöskaten. Next the pilot was looking for the Utgrund buoy without success. He passed this information to the master, who then assisted in searching for the buoy. The sun was low and from straight ahead, which made the situation more difficult. At about 1052 hours the vessel bumped the bottom. Almost simultaneously the buoy was caught sight of 20-25 metres to starboard, partly invisible and weighed down by ice. The vessel was not stuck, but slid off the ground. The engines were stopped and actions taken to check for damages. In order to avoid drifting onto other grounds the engines were started and the vessel was taken to a safe anchorage off Gävle. The coast guard vessel KBV 289 and an attendant from the Swedish Maritime Inspectorate arrived there later. Master's description The pilot was more or less continuously at the steering stand, which was located close to the centre line of the vessel. There was not enough space to stand between the stand and the screens. The pilot looked for the Utgrund buoy, and then went over to the radar for some adjustments. He then mentioned to the master that normal distance for passing Iggöskaten was 0.7 M. The master started to look for the Utgrund buoy when the pilot could not find it. The master cannot remember whether the pilot at any time was at the chart or not. The master does not know what course was set when grounding. Since the automatic steering was used also after the grounding, the actual settings at the grounding have been changed. The automatic steering was connected to the gyro-compass, and there had been no problems with any of these equipments earlier. According to the master the vessel had drifted easterly (port) since she was in ballast condition. The only radar in use on the occasion was utilized by the pilot. There was no radar shadow astern. There was no ice at Iggöskaten that interfered with Page 3
the radar image. The radar was of daylight type and connected to both the gyro-compass and the GPS. (The second radar of the vessel had only "head-up" setting). The chart was clean, i.e. no positions were marked. Permanent course lines were used, but old notes were erased for future voyages. The vessel had not been at Norrsundet after the grounding, so that chart had not been used after the grounding. Thus the chart was not cleaned from old notes. Supplementary information from the master The master was asked by the investigator to look at the chart for notes, if any. After a while the master returned with the following message: "On the Swedish chart 533 I have found: 3 crosses (without comments, probably made by pilot), remark 'missing' (stick) and position at 1120." Pilot's description The pilot had been on duty from December 18 th and his working period would end on December 22 nd. This is called "disposition days" at which work is scheduled to 14-15 hours per 24 hours. As far as he could remember he had been working from 0300 hours this morning and returned home at about 1800 hours in the evening. This may be tough, especially before Christmas. However, he had got his sleeping hours the day and night before the grounding. The vessel was not more than 4-5 years old, but the equipment on the bridge was rather simple. The steering gear was located so that it was possible to stand in front of it. The course was set by means of a turning device. The compass card was read in a small display just forward of the device. The steering gear was probably older than the vessel itself. There was no ECS (electronic chart) or course recorder. The pilot is not certain whether both radars were in operation, but the one which was on was set at North up and the scale 3 or 6 M - one does normally alternate between the scales. At the buoy Förstugrund, maybe somewhat earlier, one changed to automatic steering. The helmsman then went down, leaving the master and the pilot alone on the bridge. The pilot could not remember if one or two steering gears were in operation, but he thought that, as a matter of routine, Page 4
one was shut off when changing to automatic steering. After having set the vessel on course at the buoy he laid a radar position in the chart. Up till this change of course the vessel kept the planned course without drift of any note. According to the position the vessel was about two cables port of the intended heading line. He then adjusted with another change of course 7-8 degrees to starboard in order to reach a safe distance to Utgrundet. He reckoned upon that this would compensate also for the drift caused by the wind that came in from starboard. He did not stand forward of the steering desk when setting this change of course. Normally he needs glasses to read the compass, but he cannot say for sure that he had them on at the time. However, he is certain that he did not turn the knob in the wrong direction. He did probably not pay attention to the yaw by reading the rudder indicator but means that it would have felt unnatural to have turned the knob the wrong way. According to the pilot he always checks that the vessel gets into the right course, since this is not always the case. He prefers to stand behind the steering stand when setting the course. At this point the master was informed that the vessel had rounded the buoy Förstugrund. The pilot then routinely kept the officer in command informed about the progress of the navigation. The master followed the navigation rather passively. There was general small talk since the two of them were slightly acquainted as the pilot had worked with this master many times earlier. The master seemed by the way to be of the careful type. This was the pilot's conclusion from having seen the general operations on the bridge. The master was in the process of getting a fairway permit for the route in question. The pilot considered this pilotage to be mere routine. The pilot set the distance ring of the radar at a distance of 0.7 M. This would give a safe distance for passing the point of Iggöskaten. This was the distance that he generally used himself. Everything was in order. The radar was not continuously checked. He then looked for the buoy to port (Utgrunden). Possibly he also scanned to starboard. There was ice and he was not sure he would catch sight of it. Also the master was searching actively. The sun was low, shining practically from straight ahead. Page 5
In the meantime the vessel must have left the course line. The pilot estimated the time to approx. 10 minutes after the latest change of course. The grounding took place before the buoy was discovered 20 metres to starboard. He considered the drift to have been greater than estimated. However, in his opinion the drift had not been great enough to cause such a deviation. Possibly the position he had set might be misplaced - that he had misread the triangular protractor or something similar. The draught of the vessel was abt. 4 metres, possibly slightly more. She was without cargo, hence more sensible to drift than she would have been if loaded. On the occasion the water level was 70 cm below mean water level. If the level had been on the mean level the vessel would have passed. The speed of the vessel was 12 knots. Analysis Pilot's description The conclusion of the pilot's description reads that the vessel, after having passed the buoy Välkommen, was laid at course 130. The course was later changed to 148 after passing the buoy Förstugrundet close to starboard. Then a radar position was taken from Skärmarbergsudden, which was also laid in the chart (bearing 330 and distance 3.5 M), after which the course was further increased, to 155, in order to ascertain a safe distance to the buoy Utgrundet. Furthermore, a distance ring of 0.7 M was laid on the radar, which offered a safe distance for passing Iggöskaten. If this description reflects the reality, the vessel would have been exposed to a drift of 12-13. The vessel was indeed without cargo, and indeed there was a slight wind from star board, but it is hard to believe that the drift would have been that exceptional. Wrong radar position If the radar position in reality was Skärmarbergsudden in bearing 320 in stead of 330, but with the same distance, this may explain the course of events. In that case the vessel was so far to the east that the course 155 Page 6
would lead straight onto the ground. The setting of the distance ring that the pilot made on the radar did not clearly show how close the vessel would pass Iggöskaten due to the fact that the ring was centred to the vessel, which might explain why the faulty position was not observed. It would have been easier to see that something was wrong if the distance ring had been centred on Iggöskaten, since the heading line with the actual course would then not touch the distance ring, as it would have done if everything was correct. The pilot does not exclude a faulty set position. However, the information from the pilot saying that the buoy Förstugrund was passed close to starboard contradicts what is said above. Should the vessel have been further to the east than assumed by the pilot, the buoy would have been passed at quite a distance (0.6-0.7 M). This is not likely to have happened without reaction from anybody. Wrong course An alternative course of events, which would also have led the vessel straight onto the ground, is that the pilot would have yawed the wrong way at the latest change of course before the grounding. In stead of turning the knob clockwise, hence initiating a change of course to starboard, the corresponding change anti-clockwise would have set the vessel on course 135. This could be excused by the fact that the figures 135 could easily be mistaken for 155, especially if one in such situations is dependent on glasses, as is the case with the pilot, on his own statement. In addition, the pilot does not exclude the possibility that he was standing at the side or askew of the automatic steering desk, not right behind, which may cause such a mistake to be made unawares. Contradictory to this, however, is the fact that the sun more or less was shining from straight ahead. Intuitively the people on the bridge would then have reacted to the fact that the sun was "on the wrong side". Furthermore, the distance to Iggöskaten would have been so great that with a quick glance one would have noted that something was wrong. Moreover, it is the pilot's firm opinion that a faulty change of course such as described has not taken place. All these facts put together contradict that a faulty change of course should be the reason for the grounding. Page 7
Measures after the grounding The measures taken on board seem to have been the relevant things to do. Conclusions It has not been possible to find an obvious explanation opposing the pilot's description in any way. However, most likely the margins have been stretched as regards the navigation and also as regards the follow-up of the ship's driving from a safety point of view. When passing the buoy Förstugrund automatic steering was applied. Then the pilot set the vessel on course and laid a position. Later on he changed the course and searched visually for the buoy Utgrund. This course of events has most probably taken quite some time, which has caused the vessel to get further to the east than intended. In combination with the drifting the vessel has come too close to the ground. In this situation the pilot unsuspectingly searched with the sun in his eyes for a buoy that he was not sure to be able to see and that later on turned out to be burdened with ice and partly invisible. He has not used safer methods, such as additional position check by means of radar or GPS. The master has remained passive and trusted in the pilot up to the point when the latter said he could not find the buoy Utgrund. When the two of them had looked for the buoy to port in the intense sunlight it is likely already to have been straight ahead or close to starboard. Then the vessel has gone straight towards the ground and, since the water was rather low at the time, she touched the bottom. Miscellaneous When one has done the same thing many times, hence getting into a kind of routine, one can be subjected to what is termed "complacency". This is not unusual, neither onboard ships nor elsewhere. Complacency preferably occurs under generally favourable external circumstances: good visibility, no wind, no interfering traffic. One may then enter a routine state, thinking oneself to be in complete control of the situation. This may tempt to relaxation and failing attention. Especially Page 8
subjected groups are pilots and ferry officers and other persons who frequently use the same routes. Complacency can be prevented if one is observant of the complex of problems. Causes The immediate reason for the grounding was the pilot's failing follow-up of the position. This may be explained by the fact that the pilot executed his mission by routine. A contributing cause was the master's passivity by totally leaving the driving of the vessel to the pilot. Also the intense sunlight was contributing, as well as the fact that the buoy Utgrund due to icing partly was under the surface, factors which both made the buoy more difficult to find. Remarks It is notable that the pilot did not use an additional navigation method to check his position, particularly since he was not sure whether he would be able to see the buoy or not. It is also notable that the master completely left the navigation to the pilot. Result of the Investigation The Dalarna was a well-managed vessel. Both the pilot and the master were experienced and competent and had been in the fairway many times before. The navigation was carried out by the pilot. The master was passive during the navigation until the pilot informed him that he could not find the buoy. Page 9
The buoy was pressed down by ice and partly invisible under the surface of the water. The navigational means of the vessel were not optimally used. The depth of the water was below normal. The weather was nice with low sun from almost straight ahead and wind, just below 10 m/s, in from starboard. General Recommendations The inattention that may occur in cases of complacency can be provided against by the following way of working: To effectively use available resources (such as a look-out or an additional navigator). To navigate after two systems as a minimum. To aim at a good working discipline, i.a. by always following the existing routines and check-lists. Damages Five bottom tanks were damaged, however without causing leakage. The rudder as well as the rudder post were damaged. The vessel was docked in a shipyard in Poland after the event. Page 10