Collision between a fishing vessel and a bulk carrier

Transcription

1 Collision between a fishing vessel and a bulk carrier North Sea, 29 April 2010 Datum 6 december 2010 Status Definitive

2 Colofon Uitgegeven door The Netherlands Shipping Inspectorate Informatie Informationcentre Transport and Water Management Inspectorate Telefoon +31 (0) Fax Uitgevoerd door Evert van Leeuwen Opmaak Datum 6 December 2010 Status Definitive Versienummer 3 Pagina 2 van 20

3 Inhoud 1 Summary 4 2 Introduction Aim of the Investigation The Investigation Andries de Vries UK Kaliakra 6 3 Data Provided by the Coastguard and the UK Coastguard radar and AIS data Sound recordings made by the Coastguard UK 143 fish plotter data 9 4 Information Provided by the Crew Members UK Kaliakra 11 5 Damage UK Kaliakra 13 6 Other Findings UK Lighting on the UK Crew of the UK Kaliakra Ship manager s investigation Comments from the Ship manager s on the draft report of the Inspectorate 15 7 Relevant Legislation General Applicable to every vessel Obligation to give way Lights and shapes Sound signals Stationing a lookout on the bridge 16 8 Analysis Data analysis On board the UK On board the Kaliakra 18 Damage 18 9 Conclusions, Lessons and action taken by the Inspectorate Conclusions Lessons Actions to be taken by the Inspectorate 20 Pagina 3 van 20

4 1 Summary On Monday afternoon, 26 April, the fishing cutter UK 143 ( Andries de Vries ) left its home port of Urk and headed out to sea to go fishing. A few days later this fishing trip had a near fatal end for the ship and its crew. While fishing some 19 nautical miles to the west of Den Helder, the vessel s course crossed that of the 180 meter long Maltese bulk carrier Kaliakra. The Kaliakra was obliged to give right of way, but failed to meet this obligation and continued on its course without taking any action whatsoever. The UK 143 s skipper had the watch while the crew were on deck processing a catch of fish. The skipper underestimated the risk of collision and failed to keep an adequate lookout. He thus became aware too late that the Kaliakra was on a collision course and was not giving way. He radioed the Kaliakra but was not answered. The skipper steered hard to port to try to prevent a collision, while the bulk carrier was by now very close. One of the crew members gave a shout as he saw the bow of the carrier bearing down on him. It was too late to prevent a collision and the UK 143 was nearly run over by the Kaliakra. The fishing vessel heeled over nearly flat on its side. One crew member fell overboard while the others escaped to safety from the wave of seawater washing in. Happily the cutter did not sink and righted itself again. Thanks to the nets on the sea floor and the collision with the ship, the cutter came to a standstill and the man overboard was able to swim to the vessel and grab a rope, after which other crew members were able to haul him aboard. Despite the clear indications that a (near) collision had occurred, the Maltese bulk carrier continued on its course and took no action. Important lessons learned are to maintain a proper look-out and never to assume that a give-way vessel will actually give way. Pagina 4 van 20

5 2 Introduction 2.1 Aim of the Investigation The Transport and Water Management Shipping Inspectorate (Inspectie Verkeer en Waterstaat Scheepvaart, hereinafter the Inspectorate ) investigates accidents and incidents concerning shipping. The aim of the Inspectorate s investigations is to prevent accidents and incidents happening. To this end it is necessary to determine the direct causes and where possible the indirect factors that have lead to, or have played a role in, an accident or incident. The conclusions, lessons and recommendations that follow from an investigation are used to improve the Inspectorate s monitoring activities and to make shipping in general safer where possible. 2.2 The Investigation The Netherlands Coastguard and the fishing vessel concerned have made information available for the investigation. The skipper submitted a captain s Protest and inspectors from the Inspectorate carried out a technical investigation on board the fishing vessel. The ship manager and the maritime investigative authority on Malta assisted with information on the Maltese bulk carrier. This information consisted of statements and photographs as well as the ship manager s report and subsequent actions. A concept report of the Inspectorate s investigation was submitted to the involved parties. The comments on the concept have been included in the present report where applicable. The report is available in Dutch and English. The Dutch version is leading. 2.3 Andries de Vries UK 143 The Andries de Vries (hereinafter the UK 143 ) is a Dutch trawler. The ship was built in 1991 and is registered with the Transport and Water Management Inspectorate. The minimum required crew complement is six persons. This vessel is authorised to sail with an unmanned engine room. The vessel s bridge is fitted with an ARPA and a monitor with electronic nautical chart on which the received AIS data is displayed. Vessel name Andries de Vries Vessel type Fishing vessel Fishing registration number UK 143 Call sign PHZU IMO number Keel laid on Length overall meters Gross Tonnage 419 Propulsion Stork 6SW kw Flag The Netherlands Pagina 5 van 20

6 2.4 Kaliakra The bulk carrier Kaliakra sails under the flag of Malta and is owned and managed by Cosmos Shipping AD from Bulgaria. The ship was manned by a crew of 25, of which the majority had the Bulgarian nationality. There were also Ukrainian and Indian nationals among the crew. The captain and the officer of the watch at the time of the incident were both Bulgarian. The ship s bridge is fitted with an APRA and a simplified Voyage Date Recorder (s- VDR). Vessel name Kaliakra Vessel type Bulk carrier Call sign 9HVU8 IMO number Keel laid on 1983 Length overall meters Gross Tonnage GT DWT tonnes Propulsion B&W Diesel 8352 kw Flag Malta Ship manager Cosmos Shipping AD Class Russian Maritime Register of Shipping Pagina 6 van 20

7 3 Data Provided by the Coastguard and the UK 143 The area where the collision took place is monitored by the Netherlands Coastguard. The Radar, AIS (Automatic Identification System) 1 and sound recordings have been made available to the Inspectorate for this investigation. The material includes the data received by the AIS transponder combined with radar data from the Kaliakra, the radar images of the UK 143 and Kaliakra and the sound recordings of various Marine VHF channels. 3.1 Coastguard radar and AIS data The situation prior to the collision is described below using screen-prints. CPA data situation 04:46:54 LT The Kaliakra is at the bottom of the screen and the UK 143 is above it (indicated by nr 7698). The Kaliakra data comes from the Kaliakra s AIS transponder and the UK 143 data comes from the radar receptions. The UK 143 is sailing a course along the Traffic Separation System (TSS) and the Kaliakra is sailing towards the entry to the TSS. The UK 143 s calculated heading and speed is 104 degrees at 4.5 knots. The data transmitted by the Kaliakra gives a heading of 030 degrees and a speed of 16.5 knots. The CPA 2 of 0.39 nautical miles is calculated on the basis of these data. 1 AIS transponders automatically transmit information from a vessel, such as position, heading and speed, which can be received by other stations with an AIS transponder. 2 CPA: Closest Point of Approach Pagina 7 van 20

8 04:48:14 LT 04:49:11 LT A few minutes later there are some small variations in the UK 143 s headings, ranging from 100 to 110 degrees. The UK 143 s speed increases a little to 6 knots. The ships are now on a near collision course. The CPA calculated on the screen shots is 0.03 and 0.01 nautical miles during 13:47 and 11:49 minutes respectively. 04:53:18 LT 04:58:34 LT The near collision course remains unchanged. At 04:58:34 the computer generates another number (4304) for the UK 143 because its echo briefly disappeared from the screen. Distance between vessels 0,39M CPA data 05:00:00 LT Pagina 8 van 20

9 Just before the collision. The UK 143 s heading has changed slightly to 094 degrees and the speed has increased slightly to 7.0 knots 3. The distance between the ships at this point is approximately 4 cables (0.39 nautical miles). The CPA is close to zero. The Kaliakra s heading and speed are more or less unchanged. The ships have now been on a near collision course for 15 minutes. Neither of the ships has corrected their heading or speed to ensure a safe passing distance. A few seconds later the UK 143 s echo vanishes from the screen, and then reappears after the collision. The collision takes place shortly after 05:00. 05:17:24 Fifteen minutes after the collision, the Kaliakra s heading and speed remain unchanged. The ship continues on its course, even though it has just nearly run over the UK Sound recordings made by the Coastguard The sound recordings are the Marine VHF transmissions received by the Coastguard station. At 05:00:01 we hear the UK 143 radio the Kaliakra on channel 16 (the compulsory International Distress, Safety and Calling channel): Kaliakra this is the fishing vessel on your port bow over!. The UK 143 radioes the Coastguard at 05:06:09 to report the collision. The UK 143 reports the position of the collision as N and E. The Coastguard takes immediate action by sending a nearby ship to the location and coordinates the further assistance. The UK 143 further reports that a man overboard was safely retrieved and they give a short description of the damage and inform the Coastguard that the propulsion system is still working. The Kaliakra is radioed by the Coastguard on channel 16 at 05:15:44 and the Kaliakra answers immediately. When asked if the Kaliakra might have been involved in a collision they answer in the negative: No no possible!. The Hr. Ms. De Ruyter provides assistance to the UK 143 and then heads for the Kaliakra to ascertain any damages. 3.3 UK 143 fish plotter data 3 This is calculated by the computer on the basis of the UK 143 s echo and can thus deviate from the actual heading and speed. Pagina 9 van 20

10 Screen-prints from the fish plotter show the UK 143 s heading. The fishing vessel first heads North and then at approximately 04:45 it turns East to follow the TSS. This course is followed for nearly 9 minutes. There is a slight deviation to port and then the Eastern course is continued until the UK 143 steers hard to port at approximately 05:01:36. The headings then become varied. The culmination of these varied headings is that the UK 143 turns almost 90 degrees to port. This is about when the collision took place. The cutter then moves in a northerly direction for approximately 100 meters. Drawing in of nets completed Slight deviation to port Location of collision Figure 1: Fish plotter screen-print UK 143 steers hard to port Figure 2: Fish plotter screen print - enlargement of collision location Pagina 10 van 20

11 4 Information Provided by the Crew Members 4.1 UK 143 The UK 143 departed from Harlingen on Monday afternoon, 26 April. The weather had been beautiful for several days. The duty skipper had been called at 04:30 on Thursday morning to take over the watch after which the nets were drawn in. The nets were lowered to the sea floor again at approximately 04:50. An easterly course was plotted on the automatic pilot and the crew remained on deck to process the catch. The skipper saw the AIS data on the Kaliakra, which was sailing approximately 3 nautical miles away, on the monitor. He thought first that the Kaliakra would pass before his bow, but when this later proved not to be the case he radioed the Kaliakra on Marine VHF channel 16. When the Kaliakra did not reply he made a hard turn to port. Crew members simultaneously shouted to him that they saw the Kaliakra's bow bearing down on them, upon which he put the vessel into full reverse as well. A collision then occurred. The ship was heeled so far over to its port side by the impact that the bridge was partially submerged. The crew under the forecastle saw the wall bearing down on them and they had to swim under the forecastle to save themselves due to the cutter being on its side. One crew member fell overboard. This crew member was able to swim back to the ship and grab onto a rope. He was not wearing a life vest or harness. He was helped back on board with the aid of a hawser. The ship remained afloat and the nets were able to be drawn in. The UK 143 then set a course for Stellendam. 4.2 Kaliakra On board the Kaliakra the First Mate stood watch with a seaman on the lookout. They too mention that the weather was fine with good visibility. They were sailing with the current, some 2 knots. In their own statement they refer to a small dim light that was seen at 05:00 to port which suddenly turned on fishing lights. The fishing vessel s starboard passed very close to the Kaliakra s port side. The helmsman declared that he did not see the fishing vessel on the AIS screen. The captain afterwards came to the bridge to drink a coffee with the helmsman. After a few minutes the Coastguard s call came in. The following was discovered later following questions by the Maltese investigator: The helmsman and lookout stood on the bridge together. All equipment was working correctly. The cutter was observed at less than a cable s distance, seconds before the collision. The cutter s deck lights were burning. No action was taken aboard the Kaliakra and a period of about 5 sec. of shock condition was reported after noticing the very strong light nearby the port bow. The Kaliakra passed extremely close to the side of the cutter which was on the same course and was rolling heavily. The cutter was then left behind in the ship s wake. The following sketches were drawn by the Maltese investigator on the basis of the information supplied by the Kaliakra s first mate and lookout. Pagina 11 van 20

12 See below: diagram No. 1 elaborated as per instruction of the C/O Explanation: Red colour = Maltese vessel (033 true heading) Green colour = Other vessel Position 1: Very strong deck lights. No navigational lights had been observed. The stbd. side of the vessel was observed. Position 2: It was observed by the C/O that the other ship was passing by very, very fast with her stbd. side too close to the Maltese vessel s port side with the bow in the same direction as the course of the Maltese ship, heavily rolling. After that, the other vessel had been observed straight astern with easterly heading in a distance of about 1 cable and with a speed of about 1-2 knots. See below: diagram No. 2 elaborated as per instruction of the C/O Appearance of the other vessel to C/O (in line with position 1): man on deck observed superstructure (aft) Pagina 12 van 20

13 5 Damage 5.1 UK 143 The UK 143 suffered considerable damage to starboard above the waterline. The place of impact can be seen on the photos with the rounded impression of the Kaliakra s bulbous bow. The ship was heeled so far over by the collision that water was found in the side lights. The forecastle was partly destroyed and there was damage to the bridge and the bridge equipment, the fish hold and the rigging. Figure 3: Damage to the UK Kaliakra The Kaliakra was photographed by the Hr. Ms. Ruyter shortly after the collision. Green paint marks are visible on the ships port and on the bulbous bow. The bulbous bow has small dents and traces of fishing tackle can be seen. Figure 4: Paint marks On the port side Figure 5: Damage to the bow Pagina 13 van 20

14 6 Other Findings 6.1 UK Lighting on the UK 143 If the UK 143 had not been fishing it would have had to give way. It is thus very important to determine whether the fishing lights were indeed turned on so that the navigator on the Kaliakra could have ascertained that the fishing vessel had right of way. Photos taken by the Royal Netherlands Sea Rescue Institution (Koninklijke Nederlandse Reddings Maatschappij - KNRM) reveal that the fishing lights were on when they arrived at the site after the collision. As there were crew working on the deck, the deck lights were also turned on. Green White Figure 6: Fishing lights on the UK 143 (Source: KNRM) Crew of the UK 143 The minimum required crew is six persons. There were five persons on board. The same infringement was discovered on board the UK 143 earlier in the year. The skipper on the watch required a navigation license (vaarbevoegdheidsbewijs - vbb) for skipper <45 meters. He did not hold this license, but he did possess the requisite documents for obtaining this license. This infringement is being considered by the National Police Services Agency (KLPD). 6.2 Kaliakra The data on the incident is stored on the s-vdr. Only the radar linked to the s-vdr was not activated. The other data was inspected by the Maltese authorities. The Inspectorate has not received a report of sound or other recordings Ship manager s investigation The ship manager opened an investigation into the incident and carried out an audit on board. On the basis of the findings, the watch keeping officer was dismissed. The administrative body responsible for issuing this helmsman s national navigation license has been informed by the ship manager. The administrative body has been asked to withdraw the license pending additional training and testing of the required Pagina 14 van 20

15 competences of the person in question. The ship manager has not yet had a reply from this administrative body. The findings of the investigation have provided the ship manager with several lessons pertaining to the safety management system in relation to the crew and familiarity with navigation equipment and navigation procedures Comments from the Ship manager s on the draft report of the Inspectorate The Ship manager s investigation was based on the collision position drawn up on board of the Kaliakra. There the position was inside the Traffic Seperation Scheme. There do different rules apply with regard to giving-way and the rights to fishingvessels. The Inspectorate s investigation was based on the Coastguard data, which is an independent registration of ship s positions at the moment of, and before the collision and those positions were outside of the Traffic Seperation Scheme. Pagina 15 van 20

16 7 Relevant Legislation 7.1 General The International Regulations for Prevention of Collisions at Sea, 1972 (COLREGS) are the applicable navigation rules at sea. According to these regulations, the UK 143 was a vessel engaged in fishing. Both ships were power-driven vessels. Both ships were underway. Both ships were crossing each other. Visibility was not limited and the ships were sailing in sight of one another. The collision took place in an area at the limit of a Traffic Separation System. Ships sailing in such an area are required to do so with exceptional caution Applicable to every vessel Every vessel must at all times keep a proper lookout by sight, hearing and all available means 5. Every vessel must use all available means in order to judge if a risk of collision exists. In cases of uncertainty, such a risk is deemed to exist. Radar equipment must be properly used, including plots or equivalent systematic observations 6. Actions taken to avoid collision must be positive and taken in ample time Obligation to give way Rule 18a prescribes that the Kaliakra should have given way to the UK 143 because the UK 143 was engaged in fishing. The give-way vessel must take early and substantial action to keep well clear 8 and the stand-on vessel must maintain its heading and speed 9. The stand-on vessel may only take action to avoid collision if it becomes clear that the give-way vessel is not taking appropriate action Lights and shapes A vessel engaged in trawling must display, alongside standard navigation lights, two all-round lights in a vertical line, the upper being green and the lower white. 7.5 Sound signals If a vessel is in doubt whether the other vessel is taking appropriate action to avoid collision, this vessel must immediately signal this by giving at least five short blasts on the ship s whistle Stationing a lookout on the bridge The Standards of Training, Certification and Watchkeeping (STCW) prescribe that a lookout must be stationed on the bridge alongside the watch officer during the hours of darkness. Fishing vessels are exempted from this rule in the STCW convention. According to Dutch law, a fishing vessel may suffice with only an officer of the watch on the bridge if it is using an automatic pilot f: A vessel sailing in areas at the limits of traffic separation systems must do so with exceptional caution. 5 Regulation 5: Lookout 6 Regulation 7: Risk of collision 7 Regulation 8: Action to avoid collision 8 Regulation 16: Action by the give-way vessel 9 Regulation 17a: Action by the stand-on vessel 10 Regulation 17b: Action by the stand-on vessel 11 Regulation 34d: Manoeuvring and warning signals 12 Decree on seagoing fishing vessel crews (Besluit zeevisvaartbemanning), article 76 Pagina 16 van 20

17 8 Analysis 8.1 Data analysis Both ships were on a near-collision course with one another for approximately fifteen minutes. Neither vessel widened the passing distance. The skipper of the UK 143 radioed the Kaliakra shortly before the collision when he realised there was a risk of collision. The Kaliakra did not respond. The Kaliakra also failed to react following the collision and maintained its heading and speed. A call on channel 16 to the Kaliakra by the Coastguard later on was answered. This means that the VHF radios on both vessels were working correctly. 8.2 On board the UK 143 It was early Thursday morning and dark outside. The weather and visibility were good. The crew was on the deck and the skipper had just taken over the watch. The fishing and deck lights were all on. The nets were emptied and then lowered again and the vessel then headed East while engaged in fishing. The skipper saw that the Kaliakra was crossing their heading at 3 nautical miles distance according to the AIS data. He took no action because he assumed the Kaliakra would cross ahead of them. The Kaliakra had the obligation to give way so the UK 143 was supposed to hold its heading and speed. This did not relieve it of the obligation to keep a proper lookout, using all available means, and to assess the risk of collision. Moreover, it is prescribed that exceptional caution is required at the limits of a TSS. Had the skipper displayed such caution he would have taken action sooner instead of radioing the other vessel shortly before the collision. The radio call, in which the skipper mentions the other vessel s name, indicates that the skipper was alert to the AIS data. Had this not been the case he could not have known the other vessel s name. Under these conditions, with a vessel at 3 nautical miles distance, just crossing ahead, the situation should obviously have been monitored carefully. It is also important that the available information is interpreted correctly. The position data supplied by an AIS is sourced from the GPS s antenna position. This is almost always located on the bridge. In the Kaliakra s case, at least 150 meters separate the GPS from the bow. This means that a correction of almost one cable was required to correctly judge the passing distance. Had the Kaliakra replied to the radio call, the chance that the collision could have been averted was small. Shortly before the collision, the UK 143 turned to port and went into reverse. Unfortunately, the skipper had waited too long and his actions could not prevent the collision. He failed to use the ship s whistle to give a warning signal. Because they were sailing with the deck lights on it was more difficult to see the lights of other ships. A visual lookout can best be kept with the deck lights off. With the deck lights on, the vessel is dependent on radar. The UK 143 was undermanned, with five instead of six crew members. The skipper did not have a navigation license but did have the requisite other documents for Pagina 17 van 20

18 keeping watch on the bridge and skippering the vessel. No causal connection has been demonstrated between sailing undermanned and the collision. The UK 143 heeled over to such a degree that one of the crew members fell overboard. Because the vessel practically came to a standstill due to the collision, and with a lot of luck, the man overboard was able to swim back to the ship and could be helped on board. He was not wearing a life vest or harness and thus the chances of being found in the dark had been very small. 8.3 On board the Kaliakra The bridge was manned by a helmsman and a lookout. A radio call shortly before the collision, including mention of the vessel s name, was not answered. In contrast to what the crew had written in their statements, the Maltese investigator has discovered that the collision was in fact noticed on board. Shortly after the collision the captain came on the bridge for a cup of coffee. The investigation revealed that the collision caused shocks to be felt through the vessel. This could be an explanation for the captain joining the officer of watch on the bridge just after 05:00 for a cup of coffee. The captain answered the Coastguard s radio call and denied that a collision had occurred. The Kaliakra s officer of watch tried to find the cutter s AIS data on his equipment without success. This is unsurprising, because the UK 143 had no AIS, nor is this equipment required. Possibly, the navigator did not take sufficient account of vessels that sail without AIS and can only be sighted visually and on the radar. The Kaliakra, too, was supposed to display exceptional caution at the limits of a TSS, alongside the standard proper lookout. If a proper lookout had been kept, the UK 143 would have been seen, both visually and on the radar. It was clear that it was a vessel engaged in fishing due to the fishing and deck lights. In this case the Kaliakra was obliged to give way. No one kept a proper lookout so that the UK 143 went unobserved until the moment of the collision. The Kaliakra maintained its heading and speed. The obligation to give way was not obeyed, no action was taken to assess the risk of collision and no action was taken to prevent the collision. To make matters worse, the Kaliakra deliberately continued on its way, even after strong indications of a (near) collision, without enquiring after the situation aboard the UK Damage The impact took place on the starboard side of the UK 143 just behind the bow, where the impression of the Kaliakra s bulbous bow can be seen. The dent runs from the rear of the vessel towards the bow. Green paint marks and dents were found on the Kaliakra s bulbous bow and port. It is quite a miracle that the cutter was not run over by the much larger and heavier Kaliakra. This has happened before in the past, with the loss of crew members lives as a result. This may well have happened in this case if the place of impact had been slightly more to the rear of the UK 143. If the track angles in the data are compared with the dent, the dent should have been more at right angles to the side of the vessel. This does not take into account that the UK 143 was probably lying somewhat more to starboard because of the current coming in from the starboard. It is possible that the actions of the skipper of the UK Pagina 18 van 20

19 143 prevented a much worse incident by steering to port and reversing the engines The KLPD is carrying out an additional investigation to determine whether this is the case. This investigation proved of minor relevance for determining the final lessons and recommendations of the present investigation. Pagina 19 van 20

20 9 Conclusions, Lessons and action taken by the Inspectorate 9.1 Conclusions The collision occurred because both ships, to different degrees, failed to obey the COLREGS. The Kaliakra had an obligation to give way and failed to meet this obligation. The watch on the bridge of the Kaliakra failed in the following respects: listening watch and lookout were inadequate, no assessment of the collision risk was made and no action was taken to prevent a collision. The information that the collision was in fact noticed on board supports the assumption that the watch officer of the Kaliakra deliberately continued on his course without enquiring after the situation on board the UK 143. On the UK 143 the lookout was inadequate and the collision risk was inadequately assessed. When the risk was finally perceived, the vessel failed to warn the other ship with its ship s whistle. The UK 143 met its obligation to maintain heading and speed, but the obligatory actions to prevent a collision were taken too late. The use or interpretation of AIS data lead to a false impression of safety on both vessels. On the UK 143 a CPA was inadequately interpreted and on the Kaliakra, as far as could be ascertained, no account was taken of vessels without AIS on board. If the place of collision had been slightly more to the rear the cutter could have been run over. The UK 143 thus narrowly avoided a much greater disaster. 9.2 Lessons Never automatically assume that a give-way vessel will actually give way or increase the passing distance. When interpreting CPA, always take account of the error margins of the equipment that provides the information. For example, the distance from the bow to the antenna position of an AIS transponder. When sailing in the dark with deck lights on, visibility is impeded and extra caution must be taken. A proper lookout involves a visual lookout alongside monitoring of the radar and other information such as plots and the use of spacer and bearing line (EBL). Use sound signals to warn other vessels when necessary. Trying to radio another vessel can cost too much time when time is limited. Not all vessels carry an AIS and a navigator must thus take account of vessels that are only visible visually and on radar. Assessing collision risk with all available means is an obligation for all navigators, including those on stand-on vessels. 9.3 Actions to be taken by the Inspectorate Make this report known to seagoing crews to gain extra attention for the above mentioned lessons. Pagina 20 van 20