AS Dampskibsselskabet TORM

Marine Accident Report

GOTLAND CAROLINA
IMO 9328132
COLLISION REPORT CONFIDENTIAL
19TH APRIL 2008 Final Report
 A/S Dampskibsselskabet TORM – SQE Department

SQE Department – A/S Dampskibsselskabet TORM

Tuborg Havnevej 18, DK 2900 Hellerup, Denmark
Phone +45 39 17 92 00, Fax +45 39 17 92 98
E-mail: safety@torm.com - www.torm.com

Incident report issued May 5, 2008. Report: GOTLCA20080501

Reg. Collision Gotland Carolina and MV Conti Harmony

Safety and Quality Department – Investigation of Maritime Accidents

Accidents or incidents or legal disputes involving a vessel or an employee are amongst the many risks
inherent in the Company's business and our success in solving such disputes depend almost entirely on the
availability of contemporaneous evidence from our vessels.
Reporting and investigating incidents is consequently considered as an important part of the Company's
occupational health and safety program as it helps the identification and the control of potential health and
safety hazards.

Investigation:
The main purpose is for the Company and / or the Safety & Quality Department to be able to identify the root
causes of an incident in order that the appropriate controls can be initiated and put in place to prevent further
occurrences.

The main aim of the incident investigation shall be to prevent similar incidents recurring in the future; to
identify any new hazards, identifying and implementing suitable controls.

It is important that any investigation occurs as soon as possible. The less time between incidents occurring
and the investigation being conducted, the more accurate is the information that can be obtained. As
concern for an injured seafarer shall take precedence over property damage or any other damage when
incidents involving injury or illness occurs, an early investigation is essential.

It shall be ensured that causes and results of any incident are being examined objectively and that the
investigator conducting it at all times begins the investigation with an open mind, asking open-ended
questions and avoid putting words into the mouth of any witnesses involved. No assumptions must be made
and any judgment shall be based on information that is known to be full and accurate.

Contents

1. Summary
2. Factual Information
3. Conclusion
4. Root Causes
5. Corrective action fleet wide
6. Corrective action Gotland Carolina
7. Preventive action
8. Events and information following the collision

Collision report Gotland Carolina IMO 9328132

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 A/S Dampskibsselskabet TORM – SQE Department

1 Summary
Gotland Carolina loaded 21.687 MT Jet A1 in Mina Abdullah on 13th April and 19.861 MT Jet A1 in Shuaiba
on 17th April for Avonmouth, UK.

The vessel left Shuaiba at 1245 LMT on the 17th April and at 0925 LMT on the 19th April the Gotland Carolina
collided with the MV Conti Harmony IMO 9137894 in position 25o 25’.3 N, 057o 21’.7 E.

The Gotland Carolina was damaged on the aft starboard quarter and returned to Fujairah anchorage for
repairs. No injuries or oil spill occurred.

Temporary repairs were completed on 23rd April and the vessel continued her voyage on 24th April at 1815
LMT.

2 Factual Information

General
Type of accident / incident Collision
Character of the accident Serious
Time and date of the accident / incident 19.04.2008 - 0925 LMT - 0625 UTC.
o o
Place / position of the accident / incident Position 25 25’.3 N, 057 21’.7 E.
Injured persons None
Damage to vessel Starboard aft poop deck damaged
Class reporting Yes – CC 1 – DNV ID 25952 issued. Due date 22.06.2008.
Flag State Reporting Yes
Investigator Capt. J.Loney – Capt.S.Nair – SQE Manager B.Groenhoej
Investigation started 20.04.2008
Methods of investigation Onboard presence
Methods of obtaining information Interviews and data collection.
Investigation completed 21.04.2008

Ship data
Name Gotland Carolina
Home port Copenhagen
Call sign OXFI2
IMO number 9328132
Flag State Danish International Register
Construction year 2006
Type of ship Tanker – ICE 1A1
Tonnage 53160 GT
Classification Society DNV
Length overall 183.00 meter
Engine power 11340 kW x 124 RPM
Hull construction Steel – double hull

Crew
Crewmembers 24
nd rd
Crewmembers certified to act as bridge watch Master, Chief Officer, 2 and 3 Officer
nd rd
Bridge Team Management Master, Chief Officer – 2 and 3 Officer – 3 shift

Collision report Gotland Carolina IMO 9328132

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 A/S Dampskibsselskabet TORM – SQE Department

Years with Years in 1 rank Years on Years on all types of

Qualification Years in Rank
Operator below tankers tankers
Master 6 2,5 4 8,3 9,3
Chief Officer 1,5 3,5 3 6 6
2.Officer 10 0,9 3 3 3
3.Officer 0,3 0,4 NA 6 6
Chief Engineer 6 2 5 3 3
1.Engineer 3 1 2 1 1,5
2.Engineer 8 1 NA 4 5
3.Engineer 0 0 NA 0,5 1

Inspections
th
Last external ISM Audit 12 May 2007
NCR issued Nil
rd
Last Internal ISM Audit 3 April 2008
NCR issued 7
th
Last onboard inspection report 6 March 2007
th
Last vetting 11 April 2008 - Vela
Observations 2
Remarks None of the observations and NCR can be related to this accident.

Line of events in LMT

The following is based on investigation carried out onboard, with interviews of the Master, the Chief Officer,
the 3rd Officer, the dual cadet and the crew.

On 19th April at 0800 the Gotland Carolina is in the middle of the SE bound TSS lane of Ra’s al Kuh on
course 139° with speed 13.5 knots. The visibility is good and SW wind, force 2.

The 3rd Officer has just taken over the watch from the Chief Officer in accordance with Company Procedure
‘Checklist for Change of Watch Deck Officers’ Form 120-013. The radars are set to 6 nm and 12 nm range
with north up and on relative motion with 30% off center. Plotting was on manual.

The traffic in the TSS is light and two targets are being plotted on the ARPA. One vessel on the port bow,
which had overtaken the Gotland Carolina and one vessel on the port beam, which had been overtaken by
the Gotland Carolina. Both targets are discussed between the Chief Officer and the 3rd Officer. The Chief
Officer uses 3-minute trails on the ARPA, but it is uncertain weather the 3rd Officer continued to have this
function activated.

The ECDIS is in use, but the radar overlayer is out of order. However, all targets which are being plotted on
the radar will appear on the ECDIS. The AIS is activated.

One steering gear is in use and the lookout had been dismissed at 0445. Both VHF’s are monitoring
Channel 16, with the sound reception system (fully enclosed bridge) off.

The 3rd Officer begins to prepare his resthours sheet. He is standing between the starboard radar and the
ECDIS – facing ahead.

Position of the 3rd Officer

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Gotland Carolina leaves the Ra’s al Kuh TSS at 0830 and a GPS position is plotted in the chart. Another
GPS position is plotted in at 0900. The vessel is on track. Until 0925 the 3rd Officer is occupied with his
overtime sheet and pays no specific attention to the radars, neither does he conducts a visual lookout.

The dual cadet is inside the officer’s smoking room at 0900 and observes a large container vessel on the
starboard quarter. He estimates the distance to be 4-5 nm. This container vessel is later identified to be the
Conti Harmony. The dual cadet leaves the officer’s smoking room and goes to the swimming pool to start
cleaning it. A few minutes later he observes the Conti Harmony, now at an estimated distance of 1.5 nm and
in the same direction. He continues his work, but monitors the Conti Harmony. Within an additional few
minutes he realizes that a collision is imminent and he rushes to the bridge.

MV Conti Harmony

On the bridge the 3rd Officer is still completing his overtime sheet when the dual cadet rushes in. The time is
now 0924 and the 3rd Officer is warned against the approaching Conti Harmony. Consequently he turns the
auto-pilot full to port. At the same time the dual cadet jumps to the helm and changes over to manual
steering turning the wheel hard to port.

In the following seconds the Gotland Carolina turns hard to port and the Conti Harmony hard to starboard,
but a collision is unavoidable. Point of impact on the Conti Harmony is approximately 150 meters from the
stern on port side of the hull. Point of impact on the Gotland Carolina is starboard quarter.

Following the collision the internal emergency procedures were engaged and both vessels remained in the
area and exchanged information about damages sustained. No risk of pollution or injury to ship staff reported
on either vessels.

It was reported that the MV Conti Harmony has large port side shell damage in way of life boat
approximately 5 meters above water line.

Gotland Carolina suffered a large damage on the starboard side poop deck in way of the chemical locker.

Damage on Gotland Carolina

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 A/S Dampskibsselskabet TORM – SQE Department

Investigation data
The Master has been employed by DS Torm since 2002 and he has an excellent record of service.

The Chief Officer has been employed since 2006 and he has an excellent record of service.

The 3rd Officer graduated in 1996 from the University of the Visayas, Philippines. He has served as a 3rd
Officer since April 2001 in Hanseatic Shipping and Net Ship Management before he joined DS Torm in
September 2007. His first trip was onboard Nordic Lisbeth, where he served for 3 months. His Performance
and Appraisal Report dated 15th December 2007 is above average and he was recommended for promotion.
He was transferred to Gotland Carolina on 17th December 2007 and signed off on 22nd April. The Master of
the Gotland Carolina completed his Performance and Appraisal Report with ‘average’ – but no
recommendation for promotion. However, the Master notes that he still has his recommendation for further
employment.

The bridge was manned in accordance with legislations and company requirements.

The bridge layout includes blind sectors in between the windows of the wheelhouse and from the position
from where the 3rd Officer was located at the time of the collision the abeam starboard blind sector is
approximately 8° - 12°.

Rest Hour Management for the Master and all deck officers has not been violated.

The Master conducted a Drug & Alcohol Test of all crewmembers at 1045 LMT and nobody was tested
positive.

All navigation equipment was fully operational except of the ECDIS radar overlayer, only showing those
targets that had been plotted.

Data from the course recorder, rudder indicator and the main engine pitch recorder confirms the line of
events.

All Safety Checklists, Emergency Drills, Safety Committee Meetings, Navigational Audits and Master’s
Standing Orders have been completed correct and the Passage Plan was being followed accordingly with
the required intervals of position plots.

The 3rd Officer had not been instructed to complete his overtime sheet nor other non-navigational duties on
his watch. The Master and Chief Officer were unaware of the fact that he was doing so.

A Kelvin Hughes technician arrived onboard on 20th April to retrieve the various data from the VDR and
ECDIS. Data from the ECDIS only shows own vessel track (Kelvin Hughes ECDIS). The ECDIS data
confirms the line of events. The VDR hard disc was removed and the Kelvin Hughes technician tried to
replay the data onboard, however this was not possible due to a corrupted file. The hard disc was send to
Kelvin Huges in London for data-recovery, however this was not possible and according to the service report
from Kelvin Hughes the hard disc is empty or corrupted.

ECDIS data retrieved from Torm Sofia – IMO 9295086 – at anchor of Fujairah at the time of the collision
confirms the line of events and in addition provides these data about the MV Conti Harmony:

0600
25-54.9N, 056-57.8E;course 151° speed 21.2 knots (Gotland Carolina 7 miles astern of Conti Harmony)

0623
25-47.9N, 057-02.4E;course 180° speed 21.2 knots (Gotland Carolina 12.8 miles astern of Conti Harmony)

0745
25-27.8N, 057-09.2E;course 220° almost stopped.

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 A/S Dampskibsselskabet TORM – SQE Department

0810
25-27.2N, 057-08.7E; course 360°speed 4.7 knots (Conti Harmony 11 miles starboard bow of Gotland
Carolina)

0850
25-27.2N, 057-08.8E;course 100 speed 12.4 knots (Conti Harmony 7.5 miles starboard quarter of Gotland
Carolina)

0910
25-26.2N, 057-15.3E;course 098 speed 19.6 knots (Conti Harmony 3.7 miles starboard quarter of Gotland
Carolina). Signal disappear from ECDIS.

0926
Collision. Signal appeared back on ECDIS.

Last ECDIS capture from Torm Sofia approximately 10 minutes before the collision.

3 Conclusion
Rule 5 of the International Regulations for Preventing Collisions at Sea 1972 regarding proper lookout has
been violated.

The 3rd Officer was occupied with non-navigational work and did not pay the required attention to his duty as
a watchkeeping officer.

Rule 7 of the International Regulations for Preventing Collisions at Sea 1972 regarding risk of collision has
been violated.

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 A/S Dampskibsselskabet TORM – SQE Department

The 3rd Officer didn’t use the ARPA Radars as required and he didn’t plot the MV Conti Harmony as she was
approaching.

Rule 10(f) of the International Regulations for Preventing Collisions at Sea 1972 regarding safe navigating in
areas near the terminations of traffic separation schemes has been violated.

The 3rd Officer didn’t conduct the required particular caution while navigating in the area of the Ra’s al Kuh
TSS.

As the data is sparse about the exact bearing of the MV Conti Harmony and since no plotting was conducted
it is not possible to determine, whether the MV Conti Harmony was a crossing or an overtaking vessel.
However, the available data and the witness declaration of the dual cadet indicates that the MV Conti
Harmony approached the Gotland Carolina with an angle of more than 22.5° abaft her beam.

As the radar overlay to the ECDIS was inoperational it was not possible to see any vessels or objects not
being plotted on the radars.

The bridge layout with its blind sectors prevented the 3rd Officer from his position to see the MV Conti
Harmony in due time. However, the MV Conti Harmony has appeared in the visible sectors prior the collision,
but not observed.

4 Root Causes
Lack of bridge discipline.

• No proper lookout
• Incorrect use of radar
• Conducting non-navigational duties during watchkeeping

5 Corrective action all Torm Vessels

A circular letter was issued on 24th April and forwarded to all vessels in the Torm fleet with the following
content:

1. The Company requires that a proper lookout is being maintained on the Navigation Bridge at all
times during normal operational conditions and in compliance with Rule 5 of the International
Regulations for Preventing Collisions at Sea 1972;
2. Other that watch-keeping and navigational related duties no other kind of work must be allowed to
take place on the Navigational Bridge by the watch-keeping officer;
3. Any kind of distracting equipment such as Laptops, CD players, Games installed on Bridge
Computer, FM/AM Radios, private mobile phones etc. must not be allowed on the bridge;
4. Un-authorised crewmembers or visitors must not be allowed on the navigation bridge during normal
navigational operations;
5. The watchman (look-out) is only allowed to undertake work such as cleaning and maintenance in the
close vicinity of the navigation bridge;
6. The watchman must at all times maintain means of communication (Walkie-Talkie) to the OOW on
the bridge. The walkie-talkie must be switched on and must be used to notify the watch-keeping
officer of any dangerous or suddenly occurring situation in the vicinity of the vessel;
7. The Master must assess the needed lookout requirements for each and every watch and ensure that
this requirement is being executed in the required and agreed manner;
8. ARPA functions – especially the Guard Rings with auto detection – must be fully utilized at all times
where traffic is expected.
9. ARPA off-centre motion function must take overtaking and stern passing traffic into consideration.

In order to ensure above listed requirements are being complied with the Master is required to assess this
CIRCULAR LETTER with each individual deck officer and ensure that Master and Deck Officer by a note in

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 A/S Dampskibsselskabet TORM – SQE Department

made in the Deck Log Book certify fully understanding and compliance with the given requirements, e.g.
“Torm CIRCULAR LETTER 2008-03 read and understood by: (name/rank of Officer).

6 Corrective actions Gotland Carolina

The 3rd Officer will be dismissed with immediately effect.

7 Preventive action
Company procedures will be reviewed with respect to the Circular Letter 2008-03.

As a consequence of these incidents the Company will initiate actions for improving our navigational skills on
board our vessels. The first initiative will be the implementation of a 2-day navigational course, where
navigational incidents will be reviewed and discussed. A program will be set up and intention is to capture all
deck officers within a 6 months period. The 2-day navigational course will also be included in our OTP
(Onboard Training Program) conducted by our SQE Teams.

One of the elements in this 2-day navigational course is ideas of navigation-improvements as indicated by all
our Masters and deck officers. A fleet wide survey has been initiated to collect a wide range of navigational
improvements – beginning with onboard BTM meetings, followed by Officer Seminar talks and individually
contact with each Master.

A fleet wide survey of all navigational equipment in order to obtain operational status and to ensure
immediately and urgently repairs if needed.

With immediate effect all Masters signing on must be summoned in our offices for a briefing about this
incident and the Company policy about Safe Navigation.

A VDR and ECDIS survey will be completed – listing all types of VDR / ECDIS in the Company – testing of
playback and data recovery functions. A Company VDR / ECDIS handbook with these guidelines will be
prepared in order to ensure immediate and correct data recovery.

8 Events and information following the collision

DNV attended the vessel at Fujairah anchorage on the 20th April. As the vessels watertight integrity had been
breached a permanent repair was requested. However, being fully laden, DS Torm was granted a temporary
repair and voyage to discharge port – Avonmouth ETA 12th May – and European repair yard basis the
following conditions:

1. Sealing off the chemical store.

2. Trim, stability and longitudinal strength calculations within acceptable limits.
3. Watertight door to steering gear room to be sealed.
4. Drainage facility from chemical store to be arranged.
5. Damaged piping necessary for the safe operation of the vessel to be restored.
6. Extreme weather condition to be avoided at Master’s discretion.

DNV issued a Condition of Class (CC1) with number 25952 on 23rd April after the temporary repairs were
completed. The Condition of Class is due 22nd June 2008.

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