CASUALTY REPORT Date: 3 June 2004

Case 199934861
File 01.40.01
DIVISION FOR INVESTIGATION OF

MARITIME ACCIDENTS

DANISH MARITIME AUTHORITY

Vermundsgade 38 C
DK-2100 Copenhagen Ø

Tel. +45 39 17 44 00
Fax +45 39 17 44 16
CVR-no. 29 83 16 10
oke@dma.dk

Collision between TOSTE (Danish registered) and www.dma.dk

ZERAN (Maltese registered) in the fairway off Esbjerg

North on 26th April 2003 MINISTRY OF ECONOMIC AND BUSINESS

AFFAIRS

The purpose of investigating accidents at sea is to obtain information about the actual circumstances of the accident and to clarify
the causes and the sequence of events that led to the accident in order that the Danish Maritime Authority or others can take
measures to reduce the risk of recurrences. The aim of such investigations is not to take a position on the aspects of criminal
liability or liability for damages in connection with the accident.
 1. Preface
A concerted investigation has been carried out by the Danish Division for Investigation of
Maritime Accidents (Investigation Division) in co-operation with the Malta Maritime
Authority, Merchant Shipping Directorate, in accordance with IMO Resolution A. 849 (20)
adopted on 27 November 1997.

In addition to the comments to factual information in the report, which has been amended,
the Malta Maritime Authority has presented additional comments. These comments have
been submitted under section 12 – enclosures.

This report is a translation of the authentic report in Danish language.

2
 2. The Casualty
Type of casualty: Collision
Location of casualty: Port of Esbjerg – the area off buoy 19
Date and time: April 26, 2003 at approx. 13.54 local time
Injuries: Slight injury to one crew member aboard TOSTE

3. Ship Particulars
Name of ship: TOSTE ZERAN

Official No: D3491 5374

Home Port: Esbjerg Valletta, Malta

IMO No: 9042087 8302272

Type of ship: Dredger (sand) RO/RO Cargo Ship

Construction year: 1992 1987

Tonnage: 556 GRT 15685 GRT

Length/breadth/draft: 44.2/10.5/3.50 130.41/ 23.51/ 14.91 m

(LOA: 45.70) (LOA: 147.45 m)
Max draft: 3.0 m 7.05 m
(Draft in ballast) (2.2 m)
Engine Power: 242 kW 2 x 3000 kW

Crew: 3 20

Others aboard: - 1 passenger

Pilot
Owner: Coastal Inspectorate Levant Chartering Limited,
Valletta, Malta
Classification Bureau Veritas Polski Rejestr Statkow
Society:

3
 4. Information received
The Division for Investigation of Maritime Accidents has received the following:

28th April 2003:

Extract from logbook of Port of Esbjerg, Maritime Divn.

29th April 2003:

Oral statement from the pilot aboard the ZERAN.

Oral statement from the master of the ZERAN, extract of logbook, course printout,
provisional inspection report from DNV, etc.

Written report from the master and account of events from the AB aboard the TOSTE, both
dated 29th April 2003. The reports were submitted at an inspection aboard the vessel that
same day.
During the inspection aboard the TOSTE, the Investigation Division was given a PC with
data from the vessel’s electronic chart.

12th May 2003:

Statements in Polish from the master and four crewmembers on the ZERAN, dated 26th and
27th April 2003.

5. The Crew
ZERAN
The crew consisted of 20 Poles and the vessel was manned in accordance with the
Safe Manning Certificate issued by the flag State Administration. All the crewmembers on
board were in possession of valid certificates of competence. In addition all, the officers on
board were in possession of either valid endorsements attesting recognition, issued by the
flag State or had documentary proof that an application for an endorsement had been
submitted to the Administration as prescribed in Regulation I/10 of the STCW 1978
Convention as amended.
The duty watch on the bridge on departure consisted of the master and a helmsman. There
were lookouts fore and aft. Because of the restricted visibility, the master had also called the
pilot.
The master had called at Esbjerg regularly during the preceding two years. He knew the
pilot who was aboard on the day concerned from previous pilotage duties to and from
Esbjerg and knew the area in and around the port well.

TOSTE
The crew consisted of three men and the vessel was manned in accordance with the Safe
Manning Certificate issued by the Danish Maritime Authority.
The duty watch on the bridge consisted of the master and an AB (lookout). The AB had
been employed on the vessel since it’s acquisition in 1992, and the master since mid-1993
(as master). Both had many years of experience in the Port of Esbjerg and surrounding areas.

4
 6. Summary
ZERAN departed from the Trafikhavn (Commercial Harbour) in Esbjerg on 26th April at
13.45 hrs. with the pilot aboard.

Meanwhile, the TOSTE had finished discharging (dumping) operations at Mejlsand close to
the western edge of the fairway off Esbjerg North.

There was thick fog in the area of the port with visibility of 100-200 m.

Having discharged, TOSTE sailed towards Dokhavn to lay up for the weekend. The
TOSTE’s passage would bring the vessel past the area off the Trafikhavn.

TOSTE’s intention was to pass along the outer edge of the fairway to starboard (inbound).
During the passage between Buoys 17 and 19, TOSTE was set into the fairway.

ZERAN was on her way out past the pier heads in the Trafikhavn.

Aboard both vessels, they became aware of each other’s presence on radar.

The pilot on ZERAN and the master of TOSTE were in direct communication on VHF
channel 12.

Subsequent manoeuvring did not enable the vessels to clear each other and the vessels
collided at approx. 13.54 hrs.

TOSTE

5
 7. Narratives:
This description is based on written statements dated 29 April 2003 from the master
and the AB of the TOSTE.

Dredging works in the Port of Esbjerg on 26 April started at 06.00 hrs. The first load was
dredged in the Søndre Havn (S. Harbour) and discharged on the rising tide at dumping
ground F, south of the fairway into the Port. Dredging continued until high water at about
12.00 hrs with dredging in the Trafikhavn and discharge at dumping ground F. There were
seven discharges in all.

After high tide, dredging continued in the “Trafikhavn”, with discharge at dumping ground
E, southwest of the Mejlsand channel. They discharged there three times in total (cf. map of
p.13).

After the final load at about 13.30 hrs, on passage to dumping ground E, the Port Control
duty officer reported that there was an inbound vessel in the fairway and that ZERAN was
about to sail. The master of TOSTE told the Port Control that he would keep clear of the
inbound vessel and that after discharge at dumping ground E, he would keep to the starboard
side of the channel inbound. The AB who was also on the bridge heard the call between the
pilot of the ZERAN and the Port Control. The pilot reported that the mooring ropes had been
cast off and that the vessel was underway. Port Control warned that TOSTE was on her way
out to discharge at dumping ground E.

The final discharge was made within the limits of the dumping ground approximately 0.1
nm from Buoy 17.

The final discharge was at 13.45 hrs and TOSTE then sailed towards Dokhavn to lay up for
the weekend. This was reported to the Port Control.

At 13.45 hrs, the visibility was approximately 200 m, the wind SW 5 m/s.

No fog signals were sounded during passage towards the harbour.

Radar range was set to 0.75 nm.

Two VHF sets were operating, one set to channel 16 and the other to channel 12.
Communication between the vessel and the Port Control was on channel 12.

Buoy 17 was passed to starboard1 and course altered for Buoy 19 which was passed close to
starboard. Navigation was assisted by electronic charts and depth sounder.

The AB did not see any buoys (visually).

At a position between the two buoys, a large target was observed approximately 10o to port
at an estimated distance of 0.4 - 0.5 nm. There were no range rings on the radar screen.
The master thought that this had to be the ZERAN. The target was not plotted and there was
no check on changes to the bearing.

1
The master subsequently explained that the buoy was passed astarboard and not as he had stated in his report, aport.
6
According to the AB, the pilot called the TOSTE. The AB heard the pilot say that ZERAN
was leaving the “Trafikhavn” and heard the master state that TOSTE would keep to the
Fanoe side of the fairway.

En route, the TOSTE was set to port. According to the master, he was called by the pilot. It
was discovered that TOSTE had got to approximately 50 m from the south-western edge of
the fairway, theoretically still in the red sector of the beacon lines from Fovrfelt N.
According to the master, he warned the pilot that he had turned to starboard. At the same
time as altering course, the master saw the ZERAN ahead at a distance of about 200 m. They
were making about 5 knots through the water.

The TOSTE gave no manoeuvring signals.

Between 1-3 minutes after overhearing the conversation on the VHF, the AB saw a large
vessel dead ahead. He saw the starboard side of the vessel. His impression was that a
collision was unavoidable. He saw the bow wave of the ZERAN and his impression was that
ZERAN was making good way.

The master also saw the bow wave of the ZERAN and switched over to manual control, both
levers being set to “Full Astern” and the bow thruster to “Full Starboard”.

The thruster was partly out all the water since the vessel was in ballast. As a result of this,
and because the effect was further reduced by the speed of the vessel, the thruster was
ineffective.

The collision occurred at approx. 13.55 hrs.

Both engines were working full astern.

The TOSTE was struck on the port bow (according to the AB, on practically reciprocal
courses) and the vessel was pushed across and slid around the bow of the ZERAN and then
pushed clear on the ZERAN's starboard side.

The master contacted the pilot aboard the ZERAN and told him that the ZERAN had been
holed in the bow.

The AB was ordered forward to inspect the damage on the TOSTE. No leaks could be
immediately detected on the TOSTE. Shortly after the AB had reported this to the master,
the AB noted water pouring in from a leak below decks in the pump room.

The master asked Port Control for assistance in pumping from Falck and stated that TOSTE
would sail to the Dokhavn.

The TOSTE arrived in the Dokhavn at 14.30 hrs.

After rigging four pumps, a diver inspected the hull externally and reported a leak between
the hull plating and thruster housing on the port side. The leak was partly stopped and the
pump room almost emptied.
At 16.30 hrs, the water level was reduced to a few centimetres of water in the pump room.
The water level could then be kept down by the vessel's own pumps until being slipped on
27 April at about 10.00 hrs.

7
The following section is based on an oral statement by the pilot of the ZERAN
submitted to the Investigation Division of 29 April in Esbjerg.

The pilot knew the master of the ZERAN from previous pilotage duties. The ZERAN visited
Esbjerg approximately once a week.

The pilot reported that the ZERAN handled well with its twin variable pitch propellers and
bow thruster. However, because of the size of the vessel and the windage of its large
superstructure, it was relatively difficult to manoeuvre out of the narrow channel outside the
pier heads.

The pilot went aboard the ZERAN on 26 April at 13.35 hrs.

The pilot had already obtained information about the wind, weather and currents in the area.
There was a slight south-westerly wind, thick fog with visibility of 150-170 m. The tide was
ebbing at 0.8-1.2 knots. High water had been (theoretically) at 12.25 hrs.

The draft of the vessel was notified to the Port Control on VHF channel 12. All subsequent
communication was then, as usual, on channel 12 and in Danish.

The Port Control reported the current traffic situation outside the Port of Esbjerg, adding that
the S/P TOSTE was in the area and that a pleasure craft was inbound from the Hjerting
channel.

The pilot was in communication with the pleasure craft on VHF channel 12, which reported
that it would stay outside the buoyed fairway on the Fanoe side.

On the bridge, in addition to the pilot there were the master of the vessel, a helmsman and
another crew member whom the pilot thought was the First Officer.

Both the vessels radar was operational. The radar set used by the pilot was set to a range of
0.75 nm. When making any changes to the settings of equipment of the bridge, including
radar settings, the pilot always asked the crew to make the changes.

On the radar was a simple chart, an outline on the piers, etc., and a marked line from the
northern pier head. The pilot did not know whether this line was in accordance with the
soundings or something else on the chart (Chart 95). The pilot did not feel that the lines
were of great significance for the navigation.

The ZERAN departed from the quay (Berth 117) at 13.45 hrs (by the pilot's watch).

At 13.50 hrs, the ZERAN passed the pier heads.

The vessel was clear of the pier heads at 13.52 hrs and altered hard astarboard.

The port engine was slow ahead, the starboard engine slow astern.

8
While the vessel was turning towards north, the pilot noted an echo on the radar. The pilot
was initially in doubt as to whether it was the pleasure craft with which he had spoken over
the VHF or whether it was the TOSTE. It subsequently turned out to be the TOSTE. The
pilot made contact with the TOSTE and it was agreed that they would pass each other port to
port.

The master of the TOSTE reported that he had proceeded too far into the fairway and he was
on the way over to the Fanoe side.

The ZERAN continued her turn onto a course of 3300.

The events from the beginning of the turn and subsequent observations and communication
between the vessels until the vessels struck each other occurred within 2-3 minutes. The
pilot emphasised that the fact that the ZERAN was turning made it difficult for him to detect
the vessels’ relative motion on the radar.

On course 3300, the pilot saw the TOSTE approaching and he saw that the bearing was not
changing. The pilot gave the order "Hard astarboard".

The pilot heard a gasp from the ZERAN's master and he saw what had to be the TOSTE's
forward jacking leg practically dead ahead. On passage, the jacking leg sticks high above the
TOSTE's superstructure (see picture on p. 5).

The pilot gave the order for both engines to go full astern; the vessel was making 5-6 knots.
The pilot was not sure whether the order to go full astern was carried out immediately, or if
it had been, whether it had had any effect.

Immediately after the collision, the pilot reported what had happened to Port Control at
approximately 13.54 hrs

ZERAN struck the TOSTE's stem on the port side at an angle of about 140o between the
vessels. The TOSTE's course was approximately SSW.

The collision forced the TOSTE round on the ZERAN's starboard side and she cleared the
ZERAN just aft of the forecastle.

When the collision occurred, ZERAN was on a course of approximately 345o and after the
collision, the vessel ended up on a course of approximately North.

The pilot felt the effect of the collision as a tremor.

The TOSTE reported that nobody aboard had been injured and that the damage was above
the water line.

ZERAN return to the Trafikhavn, berth 112.

The pilot reported that he had not attached special importance to the information about the
TOSTE's presence since the TOSTE normally kept clear of the fairway.

9
The following is an extract from the Port Control duty officer involved at the Port of
Esbjerg, Maritime Divn., Traffic Divn.

The entries in the duty log were made by the duty officer at the time of the collision.
The extract is repeated in its entirety. The Investigation Division has, however, omitted
some sensitive personal data.

Extract begins:
Collision:
At 13.54 hours, the ZERAN (outbound) collided with S/P TOSTE (inbound) off Buoy 19.
Both vessels damaged in the collision. ZERAN holed above the water line. More details
when available. Height of tide: + 1.31, falling. Wind 233, 5 m/s. Visibility approx. 100 m.

The following traffic was in the fairway, all notified about movements:
ZERAN, sailed 15.45 hrs from berth 117.
Pleasure craft (name unknown) in fairway from Hjerting Løb 13.50 hrs.
S/P TOSTE at Mejsand 13.45 hrs.
HEIMDAL - STEVNS TENDER and TJALFE from the Nordsøkaj (North Sea Quay),
ordered to remain in the Fiskerihavn (Fishing Harbour) until ZERAN was clear of the
Trafikhavn.
SBS CIRRUS arrived at Berth 303 at 14.10 hrs, at Sønderhavn when the collision occurred.
NORTH CHALLENGER departed Berth 302 at 13.55 hrs, ordered to remain south of Buoy
20 until ZERAN had turned and entered Trafikhavn again.

Chain of events:
At 13.40 hrs, the pilot (name extracted) reported that the ZERAN was ready to depart from
Berth 117. The pilot was informed about TOSTE and the inbound pleasure craft. At 13.45
hrs, the head of the mooring crew reported that the ZERAN was underway. I immediately
called the S/P TOSTE and notified him of the departure of the ZERAN and that the
HEIMDAL, STEVN TENDER and TJALFE would enter the Trafikhavn after ZERAN had
left. TOSTE responded that they had finished their duties for the day and would return to the
Dokhavn “to moor up” and he furthermore stated that he was aware of the traffic and would
keep to the Fanoe side. At approximately 13.50 hrs, I heard ZERAN report that the vessel
(TOSTE) had come to far out in the fairway but that he would immediately move over to the
Fanoe side.

At 13.54 hrs., I heard a crash and immediately afterwards the pilot reported that he had had a
collision. He could not say what had happened to the other vessel. I then asked TOSTE
whether they needed assistance. He did not think this was necessary and reported that there
was a hole in ZERAN's bow. Shortly after, ZERAN requested a berth in the Trafikhavn.

At 14.13 hrs, TOSTE asked me to call Falck and request pumping assistance since water
was entering forward in the vessel. This was overheard by b/b Diver Master who
immediately offered assistance which was accepted. At the same time, the b/b Storesund
offered assistance; the Storesund was requested to stand by.
At 14.35 hrs, the b/b Diver Master requested assistance from Storesund. The Storesund
departed from Berth 303 immediately afterwards.
At 15.05, the TOSTE reported that the hole had been mostly blocked and they were
pumping at full speed. The danger of sinking was averted.
Extract concludes.

10
The following section is based on an oral statement from the master of ZERAN,
submitted to the Investigation Division of 29 April in Esbjerg, together with statements
from the master, First Officer, Second Officer, Chief Engineer and helmsman the 26/27
April 2003 and an extract from the log.
The statements and extract from the log have been translated from Polish into Danish.

The ZERAN arrived at Berth 117, Esbjerg, with a pilot aboard on 26th April at 09.30 hrs.
On arrival, the wind was easterly, Force 5.
Loading started at 10.00 hrs. The estimated time of departure (ETD) was 14.00 hrs. At
approximately 12.40 hrs, the master remarked that visibility had deteriorated and he ordered
a pilot via the ship's agent.
Before departure, the master was on the bridge and he checked the settings of the vessel's
radar sets.
Before departure, the master used the radar to scan at ranges of 0.5 nm to 3 nm and noted no
movements in the area outside the harbour.

The pilot came aboard at 13.36 hrs and was on the bridge at about 13.38 hrs. The master
reported that the ships´ draught was 5.40 m fore and 6.15 m aft.

The pilot reported that ZERAN had permission for departure from Esbjerg Port Control and
that apart from a pleasure craft, no other vessels were reported in the area. The master had
noticed a dredging vessel in the area outside the harbour on arrival that same morning. The
pilot stated that the vessel was outside the fairway. The master asked the pilot whether the
fog signals should be sounded. The pilot replied that it should not because radio contact had
been established.

The ramp was closed and secured at 13.44 hrs.

The master took command for departure and gave orders to let go the moorings at 13.45 hrs.
The master manoeuvred the vessel from the port side bridge wing. The pilot was on the
bridge talking on the VHF, after which he moved to the port side bridge wing. Visibility was
approx. 150 m ahead.
After departure, the master ordered the crew to remain fore and aft so as to report the
distance from the quayside underway. The first mate was on the starboard side of the stern;
the third mate on the port side aft, and the second mate on the forecastle, all carrying VHF
radios. The second mate was told by the master to keep him informed of the distance to the
pier heads on both sides. Apart from the master and the pilot, there was a helmsman on the
bridge. When the vessel was clear of the quayside, the pilot went inside the bridge to the
radar, from where he gave orders to the helmsman. When the harbour buoy was abeam the
port bow, the master went in and operated the power levers from the bridge controls. The
port engine was stopped, and the starboard engine was set to Dead Slow Ahead. When the
vessel was about 50 m from the entrance, the second mate could not see the pier heads from
the forecastle. The master went to the 3 cm radar and completed the turn to port. Shortly
afterwards, the second mate reported that he could see the pier heads. The bow was over
towards the green (starboard) side. The master stood to by the power levers. The pilot then
gave the order for Dead Slow Ahead for both engines. The second mate reported that the
ship was then centrally between the pier heads. The master checked the radar and passed the
message to the pilot.
The mates aft reported to the master that the stern was passing the pier heads, first the third
mate on the port side and shortly after, the first mate on the starboard side.

11
The first mate reported the distance at 25 m and noted the time as 13.52 hrs. Shortly
afterwards the first mate went to the bridge. The pilot was at that time on the port bridge
wing. When the stern was clear of the pier head to port, the pilot ordered "Hard astarboard",
"Full starboard bow thruster", "Slow ahead both (engines)". When the orders had been
carried out, the master and the pilot saw a large echo on the radar. The master asked the pilot
what he knew about the echo they had seen, to which he replied that it was a dredger. The
master immediately asked whether they should pass port to port, which the pilot confirmed.
The pilot ordered "Stop bow thruster","Helm amidships", and "Steady on 320o". The pilot
had not previously notified the master about traffic in the fairway and all communication
had been on channel 12 in a language which the master assumed was Danish.
The master immediately stopped the bow thruster and told the pilot that they needed to come
further starboard. The pilot ordered "Starboard 20". At the same moment, the master
received a report from the bow that there was a vessel ahead and immediately afterwards
that there was the danger of collision. The master immediately assumed command. The
master ordered "Hard astarboard" and ran to the power levers to stop the propellers. The
master noted a slight vibration in the vessel as he was reversing the propellers. The bow of
the ZERAN struck the port side of the bow of the dredger, which turned out to be the
TOSTE, on a course of 294o. The collision occurred at 13.54 hrs. The first mate came to the
bridge and the TOSTE passed alongside the ship.
The first mate was ordered by the master to plot the vessel's position and note the position of
the dredger in accordance with the procedure "PR 14-22”, and the GPS position 55028,34' N,
008024,71' E, was entered on the chart at 13.55 hours.

Extract from ship’s log No. 61, p. 88

13.54: Collision with dredger S/P OSTE, General alarm sounded for crew and passengers.
Started PR 14-22.
13.55: Ship's position noted as 55028,34' N, 008024,71' E. On the recommendation of the
Captain, the pilot contacted the S/P TOSTE with an offer of assistance. Chief Engineer
notified.
14.00: Power, rudder and steering checked. Visual inspection reported no oil leaks
overboard. Ship turned to port.
14.06: Turn completed. Pilot passed permission to berth in the harbour.
14.17: Stern passed ESBJERG pier heads
14.20: Chief engineer reported that well, pumps, hydraulics room forward and the small
storeroom in the bows not damaged.
14.30: Bow and stern springs passed. LB all fast alongside ESBJERG, Berth No. 112.
Td (draft forward)= 5.60, Tr (draft aft) 6.05. Cancellation of PR 09-33. Procedure PR 14-01
initiated.
14.35: Course plotter/echo sounder stopped. Control of propellers passed to CMK (Chief
Engineer).
15.00: Condition of fuel tanks B/Z. All ballast tanks, holds and coffer dams sounded.
15.50: Sounding of FP indicated water rising in FP to level of water alongside.
16.00: Chief Engineer reported sounding of engine room tanks showed no change.
17.25: Inspectors P and 1 MR (names deleted) aboard.
18.00: All ballast tanks, holds and coffer dams sounded, no change. Check for accident
stability. PR 14-22 cancelled.

12
 8. Supplementary Information
Graphical review base on statements and Investigation Division chart measurements

TOSTEs approx.
position during
discharge within
the limits of the
dumping ground
approximately 0.1
nm from Buoy 17.

Extract from Chart 95 Grådyb and chart of Port

ZERAN's approximate position was plotted on the chart at 13.55 (as stated in the ship's
logbook). The position shows that ZERAN was theoretically on the border of the green and
white sectors of Fovrfelt N.
ZERAN left the Trafikhavn, berth 117, where the vessel had been moored with the bow
pointing North, measured as 348o on the chart. After the collision, the ZERAN returned to
the Trafikhavn, Berth 112, on a course of 144o measured on the chart.
The shortest distance between the pier heads on entering the Trafikhavn and ZERAN's
approximate position at 13.55 hrs is measured 0.50 nm on the chart.

13
According to the statement, TOSTE passed Buoy 17 close to starboard shortly after 13.45
hrs and altered course for Buoy 19. According to the chart, Buoy 19 is 0.43 nm on a bearing
of 143o from Buoy 17.
According to the statement, TOSTE was about 50 m from the border between the two buoys
but still theoretically in the red sector of the beacon lines from Fovrfelt N. TOSTE's master
subsequently stated that the distance was probably more like 60-70 m.
TOSTE was on her way to Dokhavn (see chart extract lower right corner) and would thus
pass the Trafikhavn.

Extract of course diagram - ZERAN

ZERAN's course along the quay before departure from Berth 117 and after the vessel's
arrival at Berth 112 has in this diagram been compared to measurements on the chart (see
chart extract). The distances on the diagram and physical checks agree, taking into account
the uncertainties of comparison. Some reservations should be considered as to the accuracy

14
of the timings given on the readings from the vertical axis depending on how the timer was
set at the beginning; it is here stated as 13.00 hrs.
It is uncertain whether the diagram in the copy provided is correct.
The diagram shows meanwhile precise changes in course and gives an indication of the rate
of turns.
The diagram shows that when ZERAN departed she was on a course of approximately 348o
and turned to approximately 270o, after which she turned sharply starboard. It also shows
that ZERAN ended up on a course of 005o before the course was altered to port

Communications between the vessels and Port Control

Summary of events
Local Port of Esbjerg ZERAN ZERAN TOSTE Course plot
time Control Pilot Master ZERAN
13.30 Port Control Course
reports ZERAN’s approx.348o
departure
13.40 Pilot reports Course approx.
ZERAN ready to 348o
leave Berth 117.
Pilot informed of
TOSTE and
inbound pleasure
craft.
13.45 Berthing crew ZERAN departs Gives order to cast Reports that
reports ZERAN’s Berth 117 off moorings. TOSTE sailing
departure. TOSTE after discharge
informed. TOSTE close to Buoy 17
aware of traffic, towards Dokhavn.
would keep to According to AB,
Fanoe side. Port Office reports
TOSTE on way to
dumping ground.
13.50 TOSTE notifies ZERAN’s bows
ZERAN that they pass pier heads.
are too far over in
the fairway and (1-3 minutes
will immediately before he sees
move towards ZERAN visually,
Fanoe. the AB hears
13.52 Clear of pier heads, First Officer master telling Course approx.
sharp turn to reports stern clear pilot that he would 270o then rapid
starboard. Echo of pier head to keep to Fanoe turn starboard
noted while port, in the turn side) (via N). Timing
turning. Pilot in Master notes echo added as a
doubt whether it is on radar. remark.
TOSTE.
13.54 Heard crash. ZERAN on course Collision with Master notifies Collision on
of approx. 345o. TOSTE on course pilot of starboard course of 292o,
Collision with of 294o. turn, in turn sees added as
TOSTE on course ZERAN 200 m remark
of approx. SSW. dead ahead.

15
TOSTE – electronic chart

The master of TOSTE was thrown forwards in the collision and hit the screen/display of the
electronic chart, which was damaged and “went blank”. The display showed "alt-control-
delete".
A subsequent attempt to restart the system by a representative of the ship’s owner was
successful. The day's tracks had, however, been lost and could not be restored. Traditional
charts were not used aboard. It has not been possible to obtain exact positions and courses
from the vessel.
On an inspection aboard, the representative of the ship owner agreed that the Investigation
Division could retain the vessel’s navigation system, a PC with associated software.
The Investigations Division has reviewed the content of the PC for relevant data without
positive results.

Rules of Navigation

The rules laid down by the Danish Maritime Authority for passage, etc., in certain Danish
waters (Order No. 779 of 18th August 2000) apply to passage within the sea area around the
Port.

“Port of Esbjerg: The rule in § 11 is changed thus the outbound vessel must postpone its
departure from the port. A vessel is to be considered inbound when it has given the notice of
being inbound on VHF channel 12”.

Position Reporting System

For safety reasons there is established a position reporting system between the Graadyb Bar
and the Port of Esbjerg. This is done to ensure that vessels navigating within that reach are
informed about other vessels movements.

The reporting system is operating with following checkpoints:

1. Passing lightbuoy No. 1, Graadyb Bar.
2. Passing lightbuoys Nos. 13 and 14.
3. Port of Esbjerg.

Following rules apply:

1. All vessels of 100 GT and above, which are equipped with VHF, must report. The
positions are reported on VHF channel 12.
2. 15 minutes prior to departure vessels lying in the Port shall keep watch on VHF channel
12 and on the same channel the information about departure shall be reported to the Port
Control as well. All vessels shall keep watch on VHF channel 12, when navigating between
Graadyb Bar and the Port of Esbjerg.
3. When passing lightbuoy No. 1 inbound a vessel shall report following information:
vessel's name, position, draught and the name of the master. When departing from the port
the afore mentioned information and the number of the berth shall be reported.
4. When a vessel going in the opposite direction receives a report given according to item 3
it shall, in order to make the two vessels pass each other safely, acknowledge the report by
identifying itself by name, sailing direction (inbound or outbound), position and draught.
5. For the sake of foreign vessels navigating within the reach the language of
communication should be English.

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 9. Analyses
Information regarding where the collision occurred and courses

It is not possible for the Division for Investigation of Maritime Accidents to determine
precisely where the collision occurred. The statements that the Investigation Division has
received do not reconcile.

TOSTEs exact course at the time of the collision is not known.

The master of ZERAN has in his statement and on the course diagram concluded that when
the collision occurred, ZERANs course was 294º and 292º respectively.
The statements made by the master and the pilot concerning ZERANs course at the time of
the collision do not reconcile.

The communication

The pilot on ZERAN, the master of TOSTE and the Port Control were all informed about
the ships presence and intentions. It is possible, however, that a misunderstanding arose over
TOSTEs movements at the time of ZERANs departure at approximately 1345 hours.

The master of ZERAN was, according to his statement, not informed about TOSTEs
presence.

The pilot considered TOSTEs presence in the area to be rather insignificant because TOSTE
normally keeps clear of the fairway. This may have contributed to the fact that the ships did
not communicate directly until late in the proceedings.

According to his statement, the pilot did not realise that TOSTE was in the fairway until he
had initiated the starboard (northerly) turn.

According to the Port Control, TOSTE informed ZERAN, at approximately 1350 hours, that
TOSTE had come too far into the fairway.

According to the AB, the pilot called TOSTE. The AB heard that the pilot informed TOSTE
that ZERAN had left the inner port area. The AB also heard the master of TOSTE informing
ZERAN that he would keep clear at the “Fanoe-side” of the fairway.
1-3 minutes later, the AB saw ZERAN visually - straight ahead.

According to the master of TOSTE, the pilot was informed that TOSTE was going to turn to
starboard. While turning, the master of TOSTE saw ZERAN visually.

The communication between the two ships began at a late stage and in a stressful situation.
This may have caused some misunderstandings. The Investigation Division is of the opinion
that it is necessary to have certain reservations concerning the inaccuracies in and
discrepancies between the statements. The Division is, however, of the opinion that some
time passed from TOSTEs master spoke with the pilot and until he began the starboard turn

17
It was agreed to pass each other port-to-port. On the basis of the statements regarding the
communication, the Investigation Division is of the opinion that the “agreement” was
unclear. The ships did not inform each other of their intentions regarding course and speed.

The communication between the ships and the Port Control was in Danish language. This is
not in the accordance with the rules of the Port of Esbjerg and this has influenced the
sequence of events leading to the collision considerably.
The Investigation Division is of the opinion that the master did not have the same
comprehension of the situation as the pilot had, because he (the master) was informed
belated. Especially when TOSTE was observed unexpectedly on the radar, the master
neither had the time nor the possibility to estimate the developing situation.

Risk of collision

It is the opinion of the Division for Investigation of Maritime Accidents that is was
predictable that the ships would pass each other relatively close in the fairway. They would
also have done so if TOSTE had not been set (“off tracked”). The passage would have been
unsafe in any case. This is based on the following facts:

• ZERANS size
• The conditions with restricted visibility.
‘
ZERANS length (LOA) is illustrated by the two figures in the extract below.

Coordinate system: Geographical (gr. min) related to WGS84. Units: metres

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COLREG (Convention on the International Regulations for preventing Collisions at sea)
Rule 7(b) prescribes, that proper use shall be made of radar equipment if fitted an
operational “ including long-range scanning to obtain early warning of risk of collision and
radar plotting or equivalent systematic observation of detected objects” and rule 7(c)
prescribes: “ Assumptions shall not be made on the basis of scanty information, especially
scanty radar information”.

According to the statements, the radars were set to 0.75 nautical miles range on both ships.
The master of ZERAN had, according to his own statement, performed a scanning on the
3 nautical miles range before departure. At that time, there were no movements in the
fairway.

TOSTE was, however, not observed on the radar until ZERAN was leaving the inner port
area.

On TOSTE, it was not efficiently determined whether the risk of collision actually existed.
It is the opinion of the Investigation Division that the pilot and TOSTEs master, who both
had been informed about the presence of the other ship by the Port Control, immediately
should have located the other ship on the radar. Having done that, they would have had more
time to take action to avoid the collision.

Conduct of vessels in restricted visibility

ZERAN and TOSTE agreed on VHF channel 12 that they were going to pass each other
port-to-port and thus they intended to navigate themselves out of the developing close-
quaters situation. This was done, while ZERAN was in a starboard turn making it difficult to
monitor the effect of the manoeuvres.
After the planned turn, ZERAN was steadying on the course before turning to starboard
once more.
According to TOSTEs master, TOSTE was in a starboard turn immediately before the
collision occurred.
The Investigation Division believes that the pilot and the master of TOSTE misjudged the
situation and thus the manoeuvres did not have the intended effect or were performed too
late.

Watch keeping principles

TOSTE was set outwards in the fairway during the passage between buoy No. 17 and buoy
No. 19. The ship was navigated by means of electronic sea chart and echo sounder.
It is the opinion of the Investigation Divisions that the available navigational facilities were
not used appropriately.
Taking the area into consideration, the radar should have been used to establish the exact
position. By using e.g. parallel index, the master would immediately have discovered that
the ship was being set.

According to the pilot, he did not know whether the marked line from Northern pier head
(on the radar) was in accordance with the soundings or something else on the chart. The fact
that the pilot was not aware of the meaning of the line in the chart and the fact that he was
communicating on the VHF in the Danish language, indicates that the bridge crew and the
pilot were not acting as one team.

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Sound signals in restricted visibility

There is nothing, in accordance with neither Danish legislation nor in the rules of Port of
Esbjerg that exempt power-driven vessels from sounding fog signals, in accordance with
COLREG – in this case rule 35(a).

10. Conclusion

Causes

The ships involved did not realise that a close-quarters situation was developing until late in
the course of events.
This in spite of the fact that the ships involved reported their positions and intentions to the
Port Control, and they all knew the area well.

It is the opinion of the Investigation Division that the reasons are the following
(not in any order of priority):

• None of the ships involved used the radar appropriately

• The pilots judgement was influenced by the assumption that TOSTE normally keeps
clear of the fairway
• The fact that TOSTE was in the fairway due to a navigation error – this in
contradiction to the ships reported intention to stay close to the outer limit of the
fairway
• Possible misapprehensions between the ships – especially regarding information
about TOSTEs movements
• Lack in direct communication between the ships at an early stage
• Lack in or belated communication to the master of ZERAN caused by the fact that
the communication was established in Danish language

TOSTE and ZERAN collided. They did that in spite of the fact that the ships had
detected each other on the radar in a distance of 0.4 – 0.5 nautical miles. The ships had
furthermore been in direct contact on the VHF where it was ascertained that TOSTE was
in the fairway.

It is the opinion of the Investigation Division that the reasons are the following:

• Insufficient communication - especially regarding the ships´ intentions

• The pilot and TOSTEs master misjudged the situation and thus the manoeuvres
performed were not effective or they were carried out too late

Contributing causes

• None of the ships gave fog signals

• It was difficult to monitor the effect of the manoeuvres because ZERAN was turning

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 11. Actions and Recommendations

Installation of radar and AIS at the Port of Esbjerg

The Port of Esbjerg, Maritime Divn. has stated to the Investigation Division that since
February 2004 it has been equipped with a radar system with, inter alia, ARPA functionality
and that an Automatic Identification System (AIS) linked to the radar has been installed.
The Port Control is now able to monitor vessels' movements in the reporting area to ensure
identification of and detailed information from vessels equipped with AIS. They also have
the possibility of detecting the presence of vessels to which the Port's position reporting
system does not apply.

In it’s report to the Investigation Division, the Port emphasised that they do not operate an
actual traffic monitoring or traffic service system as in VTS. The system is a supplement to
the position reporting system which purpose is to ensure that the vessels in the area are
informed of other vessels´ movements.

Position reporting system

The Port's regulations for the position reporting system state as follows:

For the sake of foreign vessels navigating within the reach, the language of communication
should be English.

In this instance, the communication on the dedicated channel was fully or partly in Danish.

The Investigation Division recommends the Port of Esbjerg, that their staff is more stringent
with respect to the users of the reporting system if they detect that this rule is not being
complied with, or alternatively that the Port staff ensures that relevant information is passed
on in English.

Thomas Rekvad
Ship Surveyor

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 12. Enclosure
Additional comments of the Malta Maritime Authority.

After dumping the dredged sediment the TOSTE was in ballast condition. In this condition,
part of the vessel's thrusters were out of the water. This restricted the speed and
manoeuvrability of the TOSTE in its passage to its berth and in collision avoidance
manoeuvres. This extreme ballasted condition of the TOSTE hampered the vessel in being
able to carry out any required actions effectively and in time. As such, this condition may
also have indirectly contributed to the casualty.

At the time the pilot gave the order 'full astern' the vessel was making 5-6 knots. A speed of
5-6 knots in the port limits and in dense fog conditions raises concern of the ship was
proceeding at a safe speed.

The discussion on VHF between the master of the TOSTE and the pilot onboard the ZERAN
revealed that the TOSTE was about to make a turn to starboard. The TOSTE had informed
the ZERAN that it had entered too far into the fairway and was thus making this manoeuvre
to avoid the ZERAN.

The AB onboard the TOSTE recalled a hard over rudder to starboard about 1 to 3 minutes
after this VHF conversation. This delayed action in the starboard turn of the TOSTE
prevented the dredger from clearing the fairway in adequate time. The delayed manoeuvre
meant that the ZERAN was between 150m to 450m further ahead (and closer to the
TOSTE).

From the narrative it appears that the both vessels first saw each other on their respective
radars when the vessels were 0.5nm away, notwithstanding that the radars of the vessels was
set at 0.75nm range. Radar plotting was not utilised by either vessel and each vessel simply
resorted to verbal communication by VHF to resolve the situation.

In addition, onboard the ZERAN, there were two radars, both operational. However, one
was being observed by the pilot on a range of 0.75nm and the other being used by the master
was on a range of 0.5nm. Notwithstanding the fact that these ranges are normal within port
areas, these small ranges did not permit the ZERAN in observing the TOSTE until at a close
quarters situation.

Taking into consideration the Rules of Navigation in the Port of Esbjerg § 11 - outbound
vessels must postpone its departure from the port. Taking into consideration the conditions
of restricted visibility at the time when the ZERAN was leaving port, and the fact that the
TOSTE was 'inbound', the port authorities may have considered delaying the departure of
the ZERAN from Esbjerg.

The TOSTE is a local dredger that operates frequently in the area. Due to the frequency of
the dredger's operations in the area in the vicinity of Esbjerg, the port control were familiar
with its operations and normal passage plan. To this extent, it may be possible that the port
control assumed that the TOSTE would not interfere with other traffic in the strait and
allowed it to proceed with its operations without conducting a risk assessment of the
unfolding situation.

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The bridge team onboard the ZERAN consisted of the master, in control of the ship's
thrusters and one radar, the helmsman on the wheel and a pilot on the VHF and observing
the other radar. In addition, there where two other members of the crew at the bow, two
crewmembers at the starboard quarter and the chief officer at the port quarter. The lookouts
at the bow and both quarters were positioned by the master to ensure that in the conditions
of restricted visibility, adequate vessel positioning could be made by visual means in
addition to the vessel's position on GPS and radar. The complete composition and duties of
the crew on leaving the port of Esbjerg, however, left the bridge undermanned. In fact,
during the departure from the port, no position fixing was made on the chart. Furthermore,
the master was occupied with the operation of the vessel's thrusters and could only
momentarily refer to the radar console.
As soon as the vessel had cleared the port head piers, the chief officer started to make his
way towards the bridge to join the bridge team. Had there been a member of the crew
dedicated to continuously observe the radars both on a short and long range, the
identification of the TOSTE inside the fairway may have been noted earlier.

In addition, due to the conditions of restricted visibility at the time, the use of the lookouts at
the bow and at the vessel's port and starboard quarter were of limited usefulness although a
common practice. With visibility of approximately 150-200m, any observations from the
lookouts would not have been acted on quickly enough by the bridge team to be of any real
assistance.

The pilot onboard the ZERAN was communicating with the port control and with the master
of the TOSTE in the Danish language. The crew of the ZERAN, did not understand
Danish. The working language onboard the vessel while the pilot was onboard was
English. The port control of Esbjerg also requires that all communication on VHF should be
carried out in the English language. The fact that the pilot did not communicate on the VHF
in a language understood by the bridge team, caused an element of confusion onboard the
ZERAN. In particular, the master was not in a position to immediately evaluate the
evolving situation with the TOSTE, since the information he received was only the
conclusion of any conversation that had already taken place. Thus, although the master had
the con, he was placed in a passive role by the pilot and was not able to make informed
decisions but simply carry out instructions given by the pilot.

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