1.

INTRODUCTION
1.1 On 7th August 2010, MV.’MSC Chitra’ and MV. ‘Khalijia 3’ collided
in the approach channel of Mumbai Port. At the time of the collision
‘MSC Chitra’ was outbound from JawaharLal Nehru Port Trust (JNPT)
while ‘Khalijia 3’ was inbound to Mumbai Port Trust (MbPT), from W-I
anchorage of Mumbai Harbour. Consequent to the collision, both vessels
sustained severe damage. ‘MSC Chitra’ immediately began taking in
water as her hull was breached on the port side. She veered off
northwards and finally ran aground just outside the approach channel.
M.V.’Khalija 3’ sustained damages to her fo’c’sle and bulbous bow, but
remained stable and eventually berthed alongside at BPX jetty of Mumbai
Port. There were no injuries to any persons, neither on the two vessels
nor on any other water craft.

1.2 A preliminary inquiry was conducted by the Mercantile Marine

Department, Mumbai, under the provision of Section 359 of Merchant
Shipping Act. A copy of the Preliminary Inquiry report was subsequently
forwarded to the Ministry of Shipping on 26th October 2010.

1.3 Ministry of Shipping, vide letter No… SR-13014/13/2010-MG

dated 8.12.2010, constituted a committee under the chairmanship of the
Capt. P. V. K. Mohan, Chairman, NSB, to examine the recommendations
given in the Preliminary Inquiry report. Ministry’s letter regarding the
constitution of the committee is at Annexure 1.

The committee has been tasked with following :

a] To propose a clear set of corrective actions to be taken by Mumbai
Port and JNPT.
b] To propose general instructions to be given to all ports.
c] To propose a set of policy initiatives to be taken by the Ministry of
Shipping.
1
2. BRIEF NARRATIVE OF THE INCIDENT

2.1 MV ‘MSC Chitra’, a 31 year old, 2,314 TEU cellular container

vessel, un-berthed from JNPT at 0818 hrs on 7th August 2010, to head
for the port of Mundra (Gujarat). The JNPT Pilot disembarked from the
Vessel at about 0914 hrs in a position about 1.5 miles inwards of the
foul weather pilot disembarking area. The Master then took the con and
continued on a south-westerly course in the channel to exit the harbour.

2.2 M.V. ‘Khalijia 3’ which was anchored at W-1 anchorage in Mumbai

Harbour, weighed anchor at 0912 hrs to proceed to the BPX berth at
Mumbai Port. M.V. ‘Khalijia 3’, after weighing anchor turned to a
southerly course and made her way into the channel by crossing the
outbound traffic lane and then turning north-eastwards to join inbound
lane. She had two tugs in attendance but was maneuvering under her
own power towards Pilot boarding ground at the ‘foul weather
embarkation point’, which is about 2.5 miles inside the regular Pilot
embarkation area marked on the chart. However, while maneuvering
into the channel, she collided with the out-bound ‘MSC Chitra’ at about
0937 hrs.

2.3 ‘MSC Chitra’ sustained heavy damage to her hull on the port side,
possibly in way of Nos. 2 & 3 holds. The complete extent of the damage is
yet to be determined. In any case, the hull was breached below the
waterline and she started listing rapidly to port. The Master of ‘MSC
Chitra’ swung the vessel north-westwards out of the channel but the
Vessel lost power due to the heavy list that she had developed. Shortly
thereafter the Vessel grounded about 2 miles south-east of Prong’s Reef
Lighthouse, and lay there with a port list increased to almost 75 deg.
The Master evacuated the non essential crew on to one of ‘Khalijia 3’s
tugs M.T. ‘Vamsee 3’ and a coast guard vessel ‘Kamla Devi’ that was
2
outward bound from Mumbai. Subsequently, bunker oil escaped from
her ruptured fuel tanks and the progressively increasing Port list caused
many of the containers on deck to topple into the water.

2.4 M.V.’Khalijia 3’ sustained substantial damage in the fo’c’sle area

and the bulbous bow, but remained maneuverable under her own power.
Pilot eventually boarded the vessel at about 1010 Hrs and berthed her at
the BPX jetty.

2.5 While both vessels were without Pilot at the time of the incident,
they were in VHF contact with VTS Mumbai and were monitoring VHF
Channels 12 and 13. However the situation leading to the collision
developed within a span of 3 to 5 minutes during which time effective
VHF communication could not be accomplished. At the time of the
incident, the ‘Khalijia 3’ was under the ‘LOF’ with the salvors
navigational M/s SMIT International, but for the shifting from W-1
anchorage to the BPX jetty, it was agreed that the Master would have the
con.

2.6 In the aftermath of the collision, the channel, which is common to

both Mumbai and JNPT ports was closed due to the possible navigational
hazard posed by fallen containers from the vessel ‘MSC Chitra which had
either sunk in the channel or were floating in the port waters. The
channel was eventually cleared with the assistance of the Indian Navy,
and opened for navigation in five days.

2.7 Oil from the ‘MSC Chitra’ that had been escaping from the
ruptured fuel tanks eventually found its way to the coastline around
Mumbai harbour. Various agencies were involved in the clean-up efforts.
The operators of ‘MSC Chitra’ engaged the services of M/s SMIT
International for salving the Vessel and its cargo.
3
3. Analysis and Synthesis

3.1 Based on the findings of the Committee, the primary cause of

collision between the two Vessels and its aftermath is attributed ‘Human
Factor’, while there were several contributing factors.

3.2 James Reason’s ‘Swiss Cheese’ model of human error (1990) lends
itself well as a tool for analysis of the human factors. As per the model, in
any operational situation, hazards are prevented from resulting into
accidents by the various safety barriers in place. These barriers are in
the form of design/manufacture, rules/regulations, standard operating
procedures, management & supervision, maintenance, training,
qualification of personnel, and so on.

3.3 However, weaknesses in these barriers, if aligned in a manner that

allows the hazard to penetrate all the barriers, will likely result in an
accident. In this collision incident, the weakness of the safety barriers in
the form of active and latent failures, are examined using the Human
Factors Analysis and Classification System (HFACS) {Shappell and
Wiegmann, 1997}. HFACS places ‘Organizational Influences’ at the root of
latent failures, which lead to ‘Unsafe Supervision’ that sets up the stage
for accidents (‘Pre-conditions for Unsafe Acts’). Finally, active failures or
‘Unsafe Acts’ directly culminate in an accident.

4
3.4 An analysis of the MSC Chitra and Khalijia 3 collision follows :
3.4.1 Active Failures - Unsafe Acts

3.4.1.1 Skill-based Errors :

MSC Chitra Khalijia 3
Did not discuss passage plan with Did not sight MSC Chitra earlier
Pilot prior hauling out of the berth due to attention being given to
incoming vessels from the
starboard side
Gave priority to overtaking the Did not have a proper passage plan
Dredger instead of monitoring for the anchorage to berth transit
incoming vessels
Failed to monitor VHF Improper maneuvering – could not
communication effectively (Ch. 12, control the swing of the vessel to
13, and 16) Port after she had turned to head
into the channel
Maneuvered the vessel improperly Feared that Vessel was heading
after close quarters situation had into shallow waters on the south
developed side of the channel, although the
(Increase in speed ; rudder high tide provided sufficient under-
movements) keel clearance (handicapped by
non-functional Echo-sounder)

5
3.4.1.2 Decision-based Errors:
MSC Chitra Khalijia 3
Increased speed after dropping Increased speed during the turn to
Pilot though vessel was not clear of port, thereby increasing the rate of
channel/traffic turn
Overtook the Dredger on its Cast off Tugs and did not use Tug
starboard side without proper assistance for turning
planning and consideration for
incoming traffic
Did not reduce speed when close Did not take the way off early
quarters situation had developed enough when close quarters
and collision seemed imminent. situation had developed
Risk Management was not carried Risk Management was not carried
out before the decision was taken out before the decision was taken
to transit the pilotage waters and to weigh anchor and proceed for
the channel berthing
Decision to disembark was taken
without any information on
incoming traffic from pilot or VTS

3.4.1.3 Perceptual Errors:

MSC Chitra Khalijia 3
Could not judge its position in the Lost situational awareness while
channel, and had strayed into the turning into the channel, resulting
southern side of the channel while in a wide turn and continued swing
overtaking and turning at the bend to port (assisted by wind catching
in the channel the Port quarter)
Could not appreciate the ‘closing in Could not appreciate the ‘closing-
‘speed of the two vessels, thus in’ speed of the two vessels, thus
avoiding action not taken earlier avoiding action not taken earlier

6
3.4.1.4 Violations:
MSC Chitra Khalijia 3
Routine Violation : Bridge Routine Violation : Bridge
procedures viz Master – Pilot manning level required in this
interchange not done properly situation was not complied with.
There was no dedicated lookout on
the Bridge.
Routine Violation : Safe speed
requirement was not observed
Routine Violation : Sound signals Routine Violation : Sound signals
for maneuvering were not given for maneuvering were not given
Exceptional Violation : Steering Exceptional Violation : Steering
and Sailing rules as per Colregs ’72 and Sailing rules as per Colregs ’72
for navigation in a Narrow Channel, for Vessels meeting end-on or
and action to avoid collision by crossing were not followed.
Stand-on Vessel, were not followed.
The required alteration of course to
starboard was not effected which
resulted in vessel coming to
southern edge of the channel.

3.4.2 Latent Failures - Pre-Conditions for Unsafe Acts

7
3.4.2.1 Adverse Mental States :

MSC Chitra Khalijia 3

Being the larger, faster Vessel, a In view of the events during the
sense of complacency prevailed on preceding month, (Grounding,
the Bridge, that may have led to a flooding, abandonment, salvage),
belief that other vessels in the the Master was likely to be
channel will generally keep clear mentally fatigued and under
psychological pressure.
Task fixation (overtaking the Making haste – Vessel had fallen
Dredger) may have resulted in a behind on the Pilot boarding time
loss of situational awareness and was prompted to increase
especially with regard to VHF speed by the Pilot in order to
communication complete the berthing on high tide
Unchallenged acceptance of Pilot’s Blind acceptance of Pilot’s advice
request for disembarking prior for casting off Tugs, without
reaching the usual disembarking consideration of consequence.
point.
Predisposition to reduce the Distraction during maneuvering by
alertness level on the Bridge once Pilot’s request to switch VHF
the Pilot has been dropped – channel and subsequent
synonymous with commencement communication (regarding
of sea passage breakfast readiness)

3.4.2.2 Adverse Physiological States :

No significant findings. No objective evidence of any abnormal
medical or physiological conditions, including fatigue, amongst the
personnel on both Vessels noted from the records available and sighted.

8
3.4.2.3 Physical / Mental Limitations :
No significant findings. There is no reason to believe that there was
any visual or physical limitation, or incompatible intelligence or aptitude
existing among the persons involved, which could have any bearing on
the accident.

3.4.2.4 Crew Resource Mis-management :

MSC Chitra Khalijia 3

Lack of coordination between Bridge resources under-utilized –
members of the Bridge team. senior navigating officer (Ch. Off.)
Inspite of additional officer was not on the Bridge.
available on the bridge, VHF
communication was not effectively
monitored.
Inadequate support from the Bridge Although 3/Off did the position-
team to the Master – insufficient fixing, the Master had inadequate
information given about Ship’s Bridge team support, and was
position in the channel, overtaking handling the con, the
of the Dredger on the starboard communications, and lookout duty
side, approaching turn point, etc. by himself

3.4.2.5 Personal Readiness :

No significant findings. There is no evidence to believe that any of
the involved persons on the two vessels were physically or mentally
unprepared for duty.

9
3.4.3 Latent Failures – Unsafe Supervision

3.4.3.1 While the causal factors listed in above relate to the Vessels
and their crews, the causal chain of events are strongly linked to the
supervisory chain of command, involving a number of parties. Latent
failures of the supervisory role are categorized as follows :

3.4.3.2 Inadequate Supervision

a. Lack of oversight by the operators of MSC Chitra to ensure that
Bridge procedures are strictly followed. Ref: passage planning, Master-
Pilot exchange, Pre-departure briefing, and risk management as per ISM
Code.

b. Failure of the operators of Khalijia 3 to provide resource

management training to the ship’s staff, and monitor compliance with
Bridge procedures, and ensure risk management practices are followed
as per IMS Code.

c. Failure of the part of the Pilot of the out-bound MSC Chitra to

provide detailed guidance to the Master for safe navigation till the Vessel
exited the channel

10
d. Neither the Pilot of the inbound Khalijia 3, nor the VTS operator,
gave proper guidance to the Vessel for her inbound passage, especially
with regard to the out-going traffic.

f. Though the VTS did track the two vessels, the status of ‘Pilot on
Board’ the MSC Chitra was not known at all times to the VTS, (nor to
the Khalijia 3)

g. VTS operators were not sufficiently trained to appreciate the

movements of vessels and detect hazardous situations developing.

3.4.3.3 Planned Inappropriate Operations :

a. Due to multi-party communication – VTS (MbPT), VTS (JNPT),

MbPT Pilot, and JNPT Pilot and the two Vessels – and the use of two
different channels (MbPT on Ch 12 ; JNPT on Ch. 13), there was loss of
data/information leading to incomplete understanding of the situation by
the different parties.

b. Planning of Pilot boarding by MbPT did not provide for exigencies.

The Pilot nominated to bring Khalijia 3 was first assigned to take another
Vessel outwards from the anchorage. Delayed departure of the Pilot
Launch from the Pilot station, and delayed ETA of the Khalijia 3 at the
Pilot boarding ground, affected the entire operation.

c. Similarly, scheduling of Pilot duties by JNPT for outward-bound

and inward-bound transits is subject to vulnerabilities. Outbound Pilot
on MSC Chitra disembarked earlier than usual in order to board an
incoming Vessel which was already in the line-up.

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d. Change in the Pilot boarding area from the mouth of the channel
(half a mile south of the ‘Prongs SE’ red can buoy) to the ‘foul weather
boarding area’ (about 2.5 mile inside the channel) escalates the hazards
for the Vessels approaching the ports. The foul weather boarding point is
not marked on the chart, although approaching Vessels are advised by
VHF where the Pilot will embark. In the Admiralty List of Lights Vol. 6(4),
Pilot boarding position is given as 18:51N, 072:49E, with a remark :“In
monsoon conditions Pilot board inside the channel”.

e. For safe Pilot transfers, Vessels are required to provide a lee. Given
the direction on the channel and the prevailing direction of wind/waves
during monsoons, an outbound Vessel making a lee will turn southwards,
thus interfering with the passage of incoming traffic. Conversely,
incoming Vessels will turn northwards, causing obstruction to outgoing
traffic. Thus a potentially dangerous condition is created. To prevent this,
the outbound Pilot may prefer to disembark further up the channel,
where the making of a lee may not be necessary. However, this causes
the Vessel to negotiate the rest of the channel and the traffic without the
benefit of a Pilot, or radio/radar assistance from the VTS.

f. There is no formal ‘Decision Support System’ for both ports MbPT

and JNPT to deal with movements of Vessels known to be in a less-than-
optimum condition for navigation. The recent history of Khalijia 3,
together with her current state of bottom damage and being under the
care of Salvors, warranted extreme care in her transit from anchorage to
berth. However, barring the precaution of nominating the senior-most
pilot on duty that day, no other safeguards were initiated.

g. The handling of the post-collision oil pollution from MSC Chitra

was not effectively controlled partly because of the Ports’ pollution
handling capability was limited, although they are expected to be able to
12
handle Tier 1 pollution incidents. Further, the Indian Coast Guard,
which has the responsibility to deal with Tier 2 & 3 pollution cases, was
not properly equipped to handle oil pollution in shallow and tidal waters.

3.4.2.4 Failure to Correct Known Problems :

a. The Operators of Khalijia 3 did not rectify the faulty Bridge

equipment on the Vessel. The Echo Sounder and Course recorder were
out of order, and doubt has been raised about the proper functioning of
the VDR. (Data from the VDR has not been made available to date –
apparently the manufacturers’ service agents have not been able to
retrieve any data from the ship’s VDR so far).

b. Inadequacy of navigational aids, especially buoys, at the harbour

entrance and at the alteration points of the channel has been reported by
visiting shipmasters terming port of Mumbai as a difficult port to make.
Lack of buoys, marking the bend in the channel near which the collision
took place, makes if difficult for Vessels to judge their relative position in
the channel.

c. The VTS radar situated at Colaba is reported to be non-functional,

along with the VHF DF. The VTS Radar’s range discrimination capability
is poor, due to which the operator may not be able to distinguish
between two vessels passing close to each other.

d. The number of VTS operators are insufficient and it is reported

that on occasion, only one of the two VTS consoles is manned.
Sanctioned strength at MbPT VTS is 17, but current strength is 10
operators. VTS Operators’ training and certification is also reported to be
unsatisfactory.

13
e. VTS recording capacity is limited to the channels they are
monitoring (Ch 16, 12, and 13). Pilots communication with vessels (or
each other) in the course of the duties may switch to different channels
for various reasons. Such communication is then not monitored or
recorded at the VTS.

f. Cluttering of VHF Channels by fishing vessels, especially the

working channels of the ports, directly impacts the communication
processes which are vital for safe operations.

g. Reporting protocols between Pilots and VTS are not strictly

observed, resulting in situations where the VTS does not have real-time
information about a Vessels ‘Pilot-on-board status.

h. The availability of the MbPT Pilot Launch is reportedly often

delayed by 30 to 45 mts, thus pilots reporting on duty at 0800 Hrs are
only able to depart from the Pilot station at about 0845 Hrs. The delay
throws the Pilot boarding schedules out of gear, resulting in the Vessels
having to hold positions in tricky waters.

3.4.2.5 Supervisory Violations :

No willful disregard of rules and regulations was noted at the
supervisory level. However, certain undesirable practices as mentioned
above are being tolerated and it is not evident that any disciplinary
measures have been initiated against the erring parties.

14
3.4.2 Organizational Influences

3.4.2.1 Resource Management :

a. Lack of adequate manpower in conspicuous when it comes to the

availability of experienced, well-trained Pilots, especially for JNPT. In
view of the increasing traffic in this port, the outcome is obvious –a
negative impact on the safety goals of the Port.

b. Similarly, the manpower availability at the VTS stations is less

than adequate, and competencies of the existing VTS operators and not
properly matched to the functional requirement of the job.

c. The Pilot Launches provided by the Ports may be suitable for Pilot
transfers in good weather, but in the foul weather conditions, which
occur every year during monsoons, the Pilot Launch is unsafe. On
occasion, use of Tugs for Pilot transfers has been reported by JNPT, but
although safer than the Pilot Launch, the Tugs are not as agile as a high-
powered and stable Pilot Launch, fit for purpose.

d. The lack of navigational aids in the Port approaches and the

channel has been pointed out earlier. It is understood that the
deployment of buoys to mark the channel has not been taken up as it is
felt that they may obstruct anchorages alongside the channel. (though it
is not clear how).

15
e. Equipment is said to have been provided to the Ports for handling
Tier 1 oil pollution incidents (Upto 700 Tons oil discharge). However, the
capability of the Ports personnel to use the said equipment appears to
have been limited. The suitability of the pollution equipment has not
been put to test under the monsoon conditions and tidal currents.

f. The Indian Coast Guard which has the responsibility of handling

Tier 2 and Tier 3 pollution incidents, seems to be lacking modern
pollution gear. Furthermore, it does not have sufficient manpower
trained to use the pollution equipment.

3.4.3 Organizational Climate :

a. The organizational structure of the two Ports directly impact the

safety of navigation in the port areas. The rigid dividing lines between the
Traffic and Marine departments act as communication barriers. The
traffic department’s concerns for berth occupancy, productivity, turn-
around of vessels etc., may be in conflict with the operational safety of
vessel movements in and out of the ports. As a result, there is no check
on the seaworthiness of a Vessel when it is ordered to sail out or move to
anchorage. Khalijia 3 was ordered to haul out of the BPX berth to an
exposed anchorage even though her cargo of steel coils in the No 4. Hold
was un-secured.

b. With regard to Pilotage services, the chain of command and control

is weakened by the existence of two separate entities using the same
approaches and channel. Accountability for the Pilots’ actions (or lack
thereof) tends to fall through between the gap in the two chains. Neither
of the Pilots briefed the Master of their respective ships about the
movements of the other, resulting in disastrous consequences.

16
c. Similarly, the VTS services are affected by lack of supervisory
control, as the Dock Master in-charge has other duties also to attend to.
Further, the VTS operation, not being seamless due to the use of
different channels by MbPT and JNPT VTS, is susceptible to lack of
coordination. The VTS is perceived to be outside of the mainstream
operations of the ports, and thus it is not yet fully integrated with the
rest of the ports’ organization.

d. Although an agreement exists between MbPT and JNPT since 1989,

it does not cater to present day demands, when JNPT traffic has
increased many-fold. The complexities of issues related to jurisdiction,
and accountability come to light in mishaps, such as in the case of MSC
Chitra, a JNPT caller, whose collision, grounding, and consequent effects
took place in MbPT waters.

e. Coordination between the Port authorities and the Maritime

Administration (D.G. Shipping / MMD) has scope for improvement. The
Khalijia 3’s anchor dragging incident did not trigger any alarms in the
maritime administration, which only stepped in after the subsequent
flooding and abandonment of the Vessel.

f. The Indian Coast Guard has the mandate for pollution combating
operations. Issues related to priority berth allocation to Coast Guard
vessels, storage space of pollution equipment, etc. are matter of concern
for the Coast Guard as against the commercial and operational
constraints for the port.

3.4.4. Organizational Process

a. Standard Operating Procedures (SOP’s) for Pilotage and VTS
operations at both the Ports are either absent or inadequate to handle
contingency situations.
17
b. Risk Management does not seem to feature as an essential part of
the decision-making with respect to Vessel movements in the approaches
and Port areas. Navigating a deep-drafted Container Vessel which has
restricted visibility from the Bridge due to Container stacks, through a
360 mtr wide channel which has heavy two-way traffic during a tidal
window is a risky operation. So is bringing in a loaded Bulk Carrier
which has a history of disablement and a damaged bottom. Masters of
both Vessel, although Indian nationals, were first time callers at this port
(though this may not have been known to the Pilots/Dock Master). In
both cases, risk management was not exercised by the Port authorities.

c. The shifting of the Pilot boarding point in foul weather is governed

by fixed dates 26th May to 31st August) though this is not formally
notified internationally. In any case, the criteria for ‘foul weather’ is Wind
force 5 and above, which may occur outside of the declared dates.

d. Salvage operations on the MSC Chitra were hindered by the

Customs procedures which delayed the clearance of essential salvage
equipment being imported by the Salvors. Loss of time has made the
salvage operation more complicated than it would have been otherwise.
Special equipment had to be procured by owners of the MSC
Chitra and their contractors, ITOPF and OSR. However, this equipment
could not be arranged expeditiously due to customs procedural issues of
assessment of duty etc.
Further the Containers that fell off the Vessel drifted to different
points of the coast, and thus under different Customs Commissioners,
complicating the retrieval process.

e. Disposal of scrap i.e. recovered containers and their contents, is

mired in legalities as there are export cargoes and import / transit

18
cargoes among the recovered Containers. The law does not have
adequate provisions to handle such an eventuality.

4. Conclusion
4.1 The primary cause of collision between MV MSC Chitra and MV
Khalijia-3 is lack of professional competence demonstrated by both the
Masters in navigation of their vessels in narrow waters. During the
crucial time when the close quarter situation had developed, MV Khalijia
3 was the ‘give-way’ vessel and MSC Chitra was the ‘stand – on vessel’.
Both vessels had their responsibilities clearly outlined in the
International Regulation for Preventing Collision at sea, 1972,
(COLREGS) as amended. Both vessels could have avoided this collision
through their actions alone, if taken in ample time.

4.2 Mumbai Port Trust has the responsibility to ensure that the
approach channel is well marked, competent pilotage service is provided
to vessel movements in its waters and the vessels are assisted by Vessel
Traffic System (VTS). Jawaharlal Nehru Port Trust (JNPT) has similar
responsibility for ensuring safe pilotage is provided to all ships in/out of
JN port. Additionally, JNPT has the responsibilities for ensuring the
adequacy and upkeep of the navigational aids in their part of the channel.
The VTS is to be manned by trained and qualified operators and
supervised by experienced master mariners.

The analysis of the contributory causes to the collision, clearly

indicate that the navigational aids in the approach channel are
inadequate. To cite an example, it is a standard practice in all ports
around the world that a ‘Fairway buoy’ is placed at the mouth of the
approach channel, however there is none at MbPT approach channel.

19
 The ‘pilot boarding area’ is common to both MbPT and JNPT. The
marked area on the chart is ‘congested’ for the quantum of the traffic
that the two ports handle. Further, there is no official notification with
regard to ‘shifting of pilot boarding point’ inwards during the monsoon
season. This, when seen through the fact that the VTS in Mumbai port is
manned by inadequate number of operators who are neither trained nor
have seafaring experience and with no dedicated supervisor, leaves the
Master with no local assistance to navigate within the port waters,
particularly for the passage up-to the inwards shifted ‘pilot boarding
area’ during monsoon.

Due to shortage of pilots in JNPT, there is unhealthy commercial

stress on the existing pilots to rush through their ship movements and in
particular, disembark from the out bout bound pilot at a location earlier
than marked on the chart so as not to keep the in bound traffic, waiting.

4.3 Consequent to the collision, and while dealing with the post
collision issues, it has clearly emerged that there is an imperative need
for a single authority which is empowered with decision making
power to over ride established Rule based approach of concerned
agencies such as Customs, Port, Pollution Board, Coast Guard, Police
and other connected agencies, so as to ensure expeditious disposal of
impediments for the over all objective of expeditiously ensuring the
restoration of functionality of the concerned port.

4.4 While enquiring into the state of seaworthiness of MV Khalijia,

prior to the collision, it has emerged that the vessel was involved in an
emergency situation earlier on 19th July 2010 when the crew of the
vessel had to be evacuated due to reported ingress of water in her holds.
Post collision, a safety inspection carried out under Port State Control
20
Regime, revealed 37 number of deficiencies, several of which were in the
category of ‘detainable deficiencies’.

Therefore, it emerges that the vessel Khalijia -3 was a sub-

standard vessel and for which its technical managers are to equally held
accountable, alongwith the ship’s crew.

Considering that the technical managers, M/s Quadrant Maritime

Pvt. Ltd, Mumbai have been earlier issued a Document of Compliance, in
recognition of their having satisfactorily demonstrated their ‘Safety
Management System’ for operating ‘bulk carriers’, and noting the prima-
facia evidence of their unseaworthy ship,

4.5 Merchant Shipping Act under part XII deals with the subject of
‘Casualties and Investigations’. Through these provisions, a shipping
casualty is defined and the conduct of preliminary and formal
investigation has been mandated by the central govt. Central Govt.
through Gazette notification has delegated the authority to conduct
preliminary Inquiry to Principal Officers of Mercantile Marine
Department , generally for casualties occurring at sea and to Dy.
Conservators of ports for accidents occurring in their ports when such
ships are in control of their pilots. The Gazette notification is pre-
independence era, though new ports have been added through several
amendments subsequently.

The present delegation for conduct of casualty inquiries to the DG

Shipping (Mercantile Marine Departments being subordinate offices of
DGS) needs amendment in light of the fact that DG Shipping is
empowered to regulate Indian shipping through the provisions of
Merchant Shipping Act.

21
 The subject of conduct of casualty investigation has been over the
years, extensively deliberated in the IMO, the outcome of which is the
amendment to International Convention for Safety of Life at Sea (SOLAS)
and coming into force of IMO Code of Casualty Investigation. This Code,
under the chapter ‘Principles of Investigation’ states that
Quote
16.1 A marine safety investigation should be unbiased to ensure the free
flow of information to it.
In order to achieve the outcome in paragraph 16.1, the
investigator(s) carrying out a marine safety investigation should have
functional independence from;
.1 the parties involved in the marine casualty or marine incident;
.2 anyone who may make a decision to take administrative or
disciplinary action against an individual or organization involved in a
marine casualty or marine incident; and
.3 judicial proceedings.
Unquote
The underlying principle of investigation is that in order to bring
out the cause of accident, the investigation should be undertaken by an
agency which is independent of a regulatory body which has powers to
initiate punitive actions.

4.6 Considering that both the vessels were very old (MSC Chitra being
31 yrs and MV Khalijia being 25 yrs old), it is recommended to ban entry
of over 25 yrs old ships into Indian ports unless such ships are certified
under classification societies which are members of IACS.

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5. Recommendations
5.1 Corrective actions to be taken by Directorate General of
Shipping
a. Certificate of Competency of both Masters should be suspended,
for a specified period, to be decided by the Chief Examiner of Master of
Mates, as per the provisions of the MS (Cancellation or Suspension of
Certificate) Rules, 2003.

b. the DOC issued to technical managers be forthwith suspended /

withdrawn.

c. Flow of information between Ports and the regulatory authority for

safety i.e. Directorate General of shipping should be further streamlined
so that cases of unseaworthy ships are well reported to DGS by the ports,
whose pilots are the first person who board the incoming vessel into their
port.

5.2 Corrective actions to be taken by MbPt and JNPT

a. the on-going proposal of JNPT and MbPT for widening of pilot
boarding area is to be expedited.

b. Additional navigational aids such as Fairway buoy, transit lights,

navigational buoys (with racons) at every turn of the channel should be
installed.

c. Manning, training and qualification of operators and supervisors of

VTS should be as per the international norms.

d. VTS equipment should be upgraded to better technology which has

features such as ‘guard range’ etc so that audible and visual alarms
could alert the VTS operator for impending collision.
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e. A VTS authority under the MbPT should be formed which will
provide pilot service for the entire length of approach channel i.e the
MbPt and also the JNPT stretch, to ensure the seamless flow of
information under one authority.

5.3 General instructions for all ports

a. A voluntary review of navigational safety in all ports should be
undertaken by the NSPC.

b. A review of contingency planning reflected in Crisis Management

Plan of all ports should be undertaken in reference to lessons learnt in
handling post collision issues.

5.4 Policy initiatives to be taken by Ministry of Shipping

a. The scope of existing Navigational Safety Committee in Ports
(NSPC) should be extended to include all major ports, as well, so that
navigational safety of both MbPT and JNPT is audited by an external
oversight body.

b. Govt. should identify such person / authority and make

appropriate amendments in the legislative instruments. In UK, such
authority is vested with ‘Secretary of State’s Representative (SOSREP).

c. There is a need to restructure the decision making hierarchy in the

port organizational structure to include a person of seafaring background
with domain knowledge of cargo, navigation and safety issues so as to
serve as as bridge between the traffic depart and the marine department.
This could be best achieved by including the said
experience/qualifications as desirable qualifications of Dy. Chairman of
the port.

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d. An independent casualty investigation agency be formed which
should be staffed with 4-6 permanent officers and with provision for co-
opting industry experts on job specific requirements. This agency should
directly report to Ministry of Shipping. Subsequent to Mangalore air
disaster, similar system is being formed by DGCA.

e. Considering that both the vessels were very old (MSC Chitra being
31 yrs and MV Khalijia being 25 yrs old), it is recommended to ban entry
of over 25 yrs old ships into Indian ports unless such ships are certified
under classification societies which are members of IACS.

6. Disclaimer
This report has been prepared with the sole aim of ascertaining the
primary cause and the possible contributory causes, to the extent
possible, for the sole purpose of suggesting to Govt. certain measures
which may prevent similar accidents. Therefore, it would not be proper to
use the contents of this report for settling or apportioning responsibilities
among various interested parties in any legal proceedings.

Capt. Y. Sharma Mr. Raghuramaiah

Member Member

Capt. P.V.K Mohan

Chairman

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