Safety Study from the DIVISION FOR INVESTIGATION OF MARITIME ACCIDENTS

Transcription

1 from the DIVISION FOR INVESTIGATION OF MARITIME ACCIDENTS Mooring Accidents on board merchant ships

2 Divsion for Investigation of Maritime Accidents. Danish Maritime Authority, Vermundsgade 38 C, DK 2100 Copenhagen Phone: , Fax: CVR-nr.: f The safety study has been issued on 1 December 2006 The safety study is available on our homepage: The Division for Investigation of Maritime Accidents The Division for Investigation of Maritime Accidents is responsible for investigating accidents and serious occupational accidents on Danish merchant- and fishing ships. The Division also investigates accidents at sea on foreign ships in Danish waters. Purpose The purpose of the investigations is to clarify the actual sequence of events leading to the accident. With this information in hand, others can take measures to prevent similar accidents in the future. The aim of the investigations is not to establish legal or economic liability. The Division s work is separated from other functions and activities of the Danish Maritime Authority. Reporting obligation When a Danish merchant- or fishing ship has been involved in a serious accident at sea, the Division for Investigation of Maritime Accidents must be informed immediately. Phone: Fax: oke@dma.dk Cell-phone: (24 hours a day). 2

3 Contents 1 Foreword Issue Summary Investigations of the Division for Investigation of Maritime Accidents in Denmark Number of accidents at mooring/anchoring Summary of accidents Reports from the Division for Investigation Maritime Accidents in Denmark Reports and lessons learned from investigation branches outside Denmark IMO Lessons learned Foreword At the Flag State Implementation (FSI) meeting in IMO in June 2006 you could read in one of the submitted papers about four seamen, who were killed and one seaman, who was seriously injured in accidents at mooring arrangements. At the meeting a former master stated, that in spite of recurrence of serious accidents at mooring arrangements, not much has been done the last 100 years to develop of the mooring operation. Whether this is entirely correct or not, it raises the question: Is it possible to improve the mooring arrangement and the construction of winches in order to improve the safety of the crew? The Danish Maritime Authority has from 1997 to 2005 registered 80 accidents on passenger ships and 193 accidents on cargo ships during mooring/anchoring. The Danish investigation division has collected information about 16 of these mooring accidents on Danish vessels and about one accident on a foreign flag vessel. The purpose of this safety study is to present factual information about accidents at mooring arrangements investigated by the Danish investigation division. It is not our intention to suggest how mooring arrangements can be improved and how the mooring can be performed safely, but it is our hope; That this safety study has formed an improved factual basis for the Danish maritime industry to discuss how mooring accidents can be prevented. That maritime investigation branches in other countries will publish their information on mooring accidents, so a good factual foundation is created, when improving of safety in this area is done on an international level. 2 Issue Why do accidents occur at mooring arrangements? Strong forces are often present on a mooring deck and these forces are often very difficult to control. It could be stopping a ship moving forward with a spring line. It could be strong gust of wind. It could be winches with great power. 3

4 Strong forces on a mooring deck are neither seldom nor unforeseeable. It is the normal situation. Therefore, there is always a latent risk for the crew of being hit by a line or caught in a winch at arrival, shifting and departure. The mooring deck is fully or partly a risk zone- an area of danger. Both ashore and on board ships, persons are as far as possible removed from risk zones. Otherwise engines and running parts are shielded. The question is, if it possible to do something similar on a mooring deck. Is it possible to avoid working in the risk zone by improving the mooring arrangement? Can the risk zone be minimised? Is it possible to get the crew out of the risk zone and into safe heavens before it gets dangerous? Is it possible to construct winches, so the crew does not have to pull and lead lines, when the winch is running? We do not intend to clarify all these issues in this safety study. We merely have the intention to put forward information on accidents, proving the necessity to consider the problem. The safety study goes through 17 accidents on which the Danish investigation division has collected information. For each accident are factors relevant to the accident considered: Factors concerning arrangement and construction Human factors Technical and factors External factors (e.g. the weather) 3 Summary Normal or unusual work situation Out of 15 of the 17 accidents the work situation was normal and the work was done in the usual way. In one case, the work situation was unusual because of loading trailers in the mooring area. In another case the ship had more speed ahead at arrival than normal. Work situation Arrival 6 Departure 3 Shifting 3 Making fast tug wire 2 Other 3 Total 17 Accident type Hit by broken line/wire/rope 8 Hit by snap-back line 4 Caught in winch/capstan 3 Other 2 I alt 17 4

5 Ship type Passenger ships 6 Container ships 3 Tankers 3 Bulk carriers 2 Others 3 Total 17 Ship size 13 of the accidents occurred on ships over 10,000 GT. One accident occurred on a ship between 3,000 and 10,000 GT. Only 3 of the accidents occurred on ships under 3,000 GT. Consequences 3 crewmembers were killed and 14 crewmembers were injured. Factors concerning arrangement and construction At all accidents, the crewmembers worked in an area, where there was a latent risk In 2 accidents, a complicated operation of a winch was a contribution factor In 3 accidents, lack of overview on the mooring deck was a contributing factor 5

6 In one accident, a high level of noise (and because of that, lack of communication) was a contributing factor In 2 accidents, the winch handle did not return automatically to stop. In one accident, it was a contributing factor In 2 accidents, it was a contributing factor that the line ran wrong on the drum during pulling In one accident, it was a contributing factor that the line was jammed on a drum end Human factors The age of the injured crewmembers. Under Over 54 No information Rank of the injured. Boatswain 2 AB 11 Deck officer 4 I alt 17 The experiences of the injured crewmembers are only known partly. In one accident, the limited experience of the crewmember may have been a contributing factor In 4 accidents, lack of communication was a contributing factor In 2 accidents, wrong operation of winches was a contributing factor 6

7 In one accident, it was a contributing factor that an overload device by mistake was switched off In 6 accidents, it was a contributing factor that a crewmember worked close to the line while the winch was running In 2 accidents, the mooring arrangement was used in another way, than it was constructed for Technical and factors In 8 accidents, the line/wire/rope broke In 2 accidents, the frayed or chafed lines were a contributing factor In one accident, the stop pawls on a capstan failed. It was a contributing factor that the capstan was not maintained in a proper way In one accident, it was a contributing factor that the marking of a danger area was painted over In one accident, it was a contributing factor that a welding on a fair leader was not made in a proper way In one accident, a piece of metal was torn off a drum end and it hit a crewmember In 14 of the 17 accidents, there were no technical failures besides the broken lines/wires/ropes External factors In one accident an unexpected manoeuvre of a tugboat was a contributing factor. Weather: In 2 accidents, swell in the harbour was a contributing factor In one accident, strong wind was possibly a contributing factor In one accident, the current was possibly a contributing factor In 13 of the 17 accidents, wind or sea state were not contributing factors 4 Investigations of the Division for Investigation of Maritime Accidents in Denmark The Danish investigation division has collected information about 17 accidents at mooring arrangements from 1997 to of the accidents occurred on board Danish ships and one occurred on board a foreign flag ship in a Danish port. 7

8 The Danish investigation division has published 4 marine accidents reports and one report about these types of accidents. On the other accidents there is comprehensive material in the Division s database. Ship Skip type GT Year Fatalities Injured Ship 1 Passenger ship 34, Ship 2 Passenger ship 12, Ship 3 Reefer ship 7, Ship 4 Bulk carrier 18, Ship 5 Container ship 11, Ship 6 Supply ship 1, Ship 7 Container ship 51, Ship 8 Oiltanker 2, Ship 9 Cargo ship Ship 10 Passenger ship 20, Ship 11 Container ship 92, Ship 12 Passenger ship 17, Ship 13 Oiltaner 29, Ship 14 Passenger ship 17, Ship 15 Bulk carrier 18, Ship 16 Chemical tanker 30, Ship 17 Passenger ship 109, Number of accidents at mooring/anchoring The accidents investigated by the Danish investigation division are only a small part of the accidents, which actually occur at mooring arrangements on board Danish ships. From 1997 to 2005 the Danish Maritime Authority has registered the following number of accidents on board Danish passenger ships and cargo ships. Passenger ships Accidents at mooring/anchoring Total Cargo ships Accidents at mooring/anchoring Total Summary of accidents Ship 1 Accident data November 1997, at 1705 hours. Ship data Ro-Ro Passenger ship, 34,000 GT, built Crew data The injured crewmember was AB, Danish, 54 years. 8

9 Narrative Arrangement/ construction Human factor Technical/ External factor The 2 nd officer, 3 Abs and an apprentice were on the mooring deck aft at departure. When pulling on a mooring line the eye of the line got stock. Thereby a horn on a fair leader broke off. The line snapped away and hit an AB in the stomach. The AB sustained internal injuries. The winch was operated from a place, where the operator did not have full overview. All crewmembers worked in the risk zone. The horn on the fair leader was used in another way, than it was constructed for. The horn on the fair leader was not welded in a proper manner on the ship building yard. Dark. Wind and sea state are not registered as contributing factors. Ship 2 Accident data September 1998, at 1032 hours. Ship data Ro-Ro Passenger ship, 12,000 GT, built Crew data The deceased was 2 nd deck officer, Danish, 25 years. Narrative A deck officer and two ABs were on the mooring deck aft at arrival. A breast line from the port mooring winch was lead through a hawse-hole to a bollard ashore. The winch should be shifted to tension operation. In order to get the tension operation, the load on the line should be inside adjusted limits, which in the actual situation were 5 to 10 tons. The AB at the winch estimated, that the load on the line was lower. Therefore he pulled the line which broke. The deck officer was in the same moment passing the line. He was hit by the line and died later. Arrangement/ It was not possible to control the actual load on the line before shifting to tension construction operation of the winch. The crewmembers worked in a risk zone. 9

10 Human factor Technical/ External factor An overload device was by mistake switched off. Because of that the pull of the winch was 19 tons instead of 13 tons. The winch was operated while the officer was passing the line. The line was frayed and the tensile strength was considerable lowered. Wind 3 m/s. Daylight. Wind and sea state had no influence on the accident. Ship 3 Accident data November 1998, at 0815 hours. Ship data Reefer ship, 7900 GT, built Crew data The injured crewmember was boatswain, Philippine, 44 years. Narrative The ship was going to be shifted aft without use of engine. A deck officer, a boatswain, 2 ABs and an aspirant were on the forecastle. When the ship was shifted 30 meters, the ship was going to be stopped in order to replace the lines on the bollards ashore. The ship should be stopped by use of the two head lines, which were placed on a drum winch. The brake of the winch was activated. One of the head lines tightened before the other. Because the brake was activated, it was not possible to ease off quickly. The load on the fore line became too high and the line broke. The line hit the boatswain and one AB. The boatswain fell and got a fracture of the skull. Other There were written instruction about mooring on board, but only in Danish. information 10

11 Arrangement/ construction Human factor Technical/ External factor All crewmembers worked in the risk zone during the shifting. The brake of the winch should not have been activated. The ship s safety board concluded after the accident, that both the working environment and the working situation were normal. The line broke. There were no technical failures or lack of. Dusk. Wind and sea state are not registered as contributing factors. Ship 4 Accident data February 1999, at 0715 hours. Ship data Bulk carrier, 18,000 GT, built Crew data The injured crewmember was AB, Danish, 28 years. He had been on board the ship twice 11 months totally. Narrative The ship was moored alongside and should be shifted aft. The ship was shifted only by use of the winches. The chief officer and 3 ABs were on the forecastle. There was a breast line forward. The breast line was placed on a drum. Just before the shifting started, the brake of the drum was released. The breast line was not used during the shifting. When the ship moved aft, the breast line tightened because the brake was not released sufficiently. The officer shouted to the AB to release the brake further. The AB was pulling a spring placed on a 11

12 Arrangement/ construction Human factor Technical/ External factor drum end. He did not hear the officer. A moment later the breast line broke and hit the AB. He got a fracture of the skull. The AB and the other crewmembers worked in an area, where they were in danger in case a line broke. It was difficult to hear orders because of high noise level. The handle of the winch did not return automatically to stop. Therefore, the AB worked alone at the drum end. All lines had to be controlled during the shifting. The control of the breast line (brake) failed. The AB should also control the spring and he did not hear the officer s order. Safety helmets were not used. The line broke. There were no technical failures and the line was relatively new. Dark. Current 3 knots. The current may have been a contributing factor. Ship 5 Accident data January 2000, at 1130 hours. Ship data Container ship, 11,000 GT, built Crew data The injured crewmember was AB, Philippine, 37 years. Narrative At departure the lines should be taken on board. The 3 rd officer and an AB were on the aft deck. The ship was kept alongside by use of the thrusters, and the lines were eased. A stern line got stucked on a bollard ashore, because another ship used the same bollard. The stern line sat on a drum end. When trying to ease out more on the line, the line was jammed on the drum end. Therefore, the line was pulled the wrong way around on the drum end. The AB tried to clear the line, while the winch was running. He stood between the drum end and the hawser hole. The line broke, when it tightened and the line hit the AB in the stomach, so he fell. The line was chafed, possibly during the stay in the harbour. Arrangement/ The line was jammed on the drum end. The AB was working in a risk zone. construction Human factor The winch was not stopped, when the AB tried to clear the line. Technical/ The line had been chafed during the stay in the port. External factor Daylight. Wind and sea state are not registered as contributing factors. Ship 6 Accident data May 2001, at 1205 hours. Ship data Supply ship, 1,700 BT, built Crew data The deceased crewmember was AB, Nigerian, 26 years. According to his documentation he had been at sea 9 months totally. Narrative At arrival 2 ABs were working fore. One of the ABs was alone on the forecastle pulling a line on a capstan. The other AB was handling the spring line further aft and he was not able to see the AB at the capstan. The AB at the capstan was caught between the line and the capstan. He could not reach the hand wheel to operate the capstan. The other AB arrived quickly, because he heard shouting. He stopped the capstan and released the AB, who was already unconscious. Other There were written instructions about mooring on board. information Arrangement/ The work was done by pulling the line, while standing in a risk zone close to the construction capstan. The capstan was running when it was set in motion, without holding the hand wheel. Human factor The AB was alone on the forecastle, while pulling the line on the capstan. The 12

13 Technical/ External factor AB had limited experience. There were no technical failures or lack of. Daylight. Wind and sea state are not registered as contributing factors. Ship 7 Accident data November 2001, at 1940 hours. Ship data Container ship, GT, built Crew data The injured crewmember was AB, 35 years. Narrative A tugboat should be connected forward at arrival. The messenger line to the tug wire was put on a drum end and the winch operator started to pull. Before the eye of the wire was put on the bitts, the messenger line broke and hit the operator in the head. He sustained a serious flesh wound in the face and lost several teeth. Arrangement/ The winch operator and the other crewmembers worked in a risk zone, while construction there was a heavy load on the messenger line. The safety depended on how good the operator was to estimate the load on the line and his ability to ease out the line, before the load became too high. Thereby there was a latent risk during the work. Human factor The work situation was normal. Neither before nor after the accident, the risk factors of the work were not sufficiently realised on board. The accident was seen on board as an extraordinary occurrence, where the operator had failed, because he had not eased out the line, before it broke. Technical/ The guy line broke. There were no technical failures or lack of. External factor Dark. Wind and sea state are not registered as contributing factors. 13

14 Ship 8 Accident data June 2002, at 0605 hours. Ship data Oiltanker, 2,800 GT, built Crew data The injured crewmember was AB, 50 years. He had been at sea for 27 years. It was the second time he was on board the ship. Narrative The ship arrived at the harbour and was manoeuvred alongside. A head line and a fore spring were made fast. The engine was running dead slow ahead on order to keep the ship alongside. An AB on the forecastle was setting an extra fore spring. A swell lifted the ship and pushed it forward. The spring line broke and hit the leg of the AB. The leg was later amputated. Other There was written instruction about mooring on board telling about the risk information during mooring operations. Arrangement/ The crewmembers had to work in the risk zone setting extra lines, after the first construction lines were made fast. Human factor The working procedure at the time of the accident was normal. Technical/ The line broke. There were no technical failures. The line was relatively new. External factor Wind 5 m/s. Dark. There were swell in the harbour. This resulted suddenly in a heavy load on the spring. Slip 9 Accident data November 2002, at 0200 hours. Ship data Coaster, 400 GT, built Crew data The deceased crewmember was AB, Polish, 34 years. Han had been on board the vessel for approx. 5 years. Narrative The ship was moored alongside in bad weather. Because of tide slack on the stern line should be pulled in. The ship was equipped with an old capstan operated manually by a handle. The AB operated the handle. Stop pawls near the foundation of the capstan should prevent the capstan from running backwards. The ship rolled because of the swell and the line tightened. The stop pawls broke off and the capstan was pulled in the opposite direction. The handle thereby also turned in opposite direction and hit the AB in the head. He was dead when the ambulance arrived 5 minutes later. Arrangement/ The capstan was of old design and manually operated using a handle. The construction handle was placed on the capstan. Human factor Technical/ External factor Neither the master nor the owner recognized before the accident that the pawl system on the capstan could be a risk factor. There was no system for the capstan. The capstan was not well maintained. One pawl was missing before the accident. The pins holding the pawls were corroded and should have been replaced. Wind 17 m/s. Dark. Bad weather and swell in the harbour. The swell caused a large load on the mooring line. 14

15 Ship 10 Accident data November 2002, at 0630 hours. Ship data Ro-Ro Passenger ship, 20,000 GT, built Crew data The injured crewmember was deck officer, Danish, 48 years. Narrative At arrival a fore spring wire was put on a bollard ashore, while the ship still was moving ahead. The ship had more speed ahead at arrival than usual. The wire tightened and before the wire was eased out, it broke. A deck officer jumped down in order to avoid getting hit by the wire and he was injured. The winch operation was designed in a way requiring 4 steps going from 0 (stop) to 4 (max). When the winch was overloaded it eased out in jerks. This was possibly misunderstood by the winch operator, and instead he put the handle on 0, whereby the winch brake was activated. Arrangement/ The winch operation was designed in a way, which complicated quickly easing construction out on the wire. The crew worked in a risk zone after the wire was put on the 15

16 Other information Human factor Technical/ External factor bollard ashore. The ship had more speed ahead at arrival than normal. The crewmembers on the forecastle did not notice that the ship had more speed than normal. The crewmembers were not told that the ship had more speed than normal. The winch was probably operated wrongly. The wire broke. There were no technical failures or lack of. Dark. Wind and sea state are not registered as contributing factors. Ship 11 Accident data April 2003, at 1350 hours. Ship data Container ship, 92,000 GT, built Crew data The injured crewmember was AB, Danish, 49 years. Narrative At departure the tug wire should be put on the bitts. The wire eye was pulled by a messenger line to the bitts. The messenger line was put 6 times around the drum end. The messenger line suddenly eased off on the drum end, because an unexpected manoeuvre of the tugboat resulted in extra load on the line. An AB, who was going to put the wire eye on the bitts, was hit and he injured his hand. Arrangement/ The messenger line eased off on the drum end, when a sudden load came on construction the line. If it had eased off, it may have broken. In the procedure there is a latent risk of something going wrong. The AB should grab the wire eye with his hands to put the eye on the bitts. He thereby had to work in the risk zone. The safety of the AB depended on the ability of the messenger line to keep the wire eye in position. Human factor The procedure used at the accident was normal. Technical/ There were no technical failures or lack of. External factor Wind 18 m/s. Daylight. The tugboat did an unpredicted manoeuvre. Ship 12 Accident data November 2003, at 1515 hours. Ship data Ro-Ro Passenger ship, 17,000 GT, built Crew data The injured crewmember was AB, Polish, 33 years. Narrative During loading of trailers on open deck aft, some lines had to be replaced in order to give more space to the trailers. The lines were going to be replaced in positions for which the mooring arrangement was not constructed. An AB placed in starboard side should operate two winches in port side by use of a remote control. He only had partly overview to the winches and the lines. A deck officer who had full overview should signal to the AB. Because of mistake or misunderstanding the lines were tightened in wrong order, so one line pulled another line off a fair lead. The line snapped and hit an AB standing next to the line. The AB sustained internal injuries and was brought to hospital. Arrangement/ The deck area for mooring and the deck area for cargo overlapped. This meant construction that overview on the mooring deck was partly hindered by trailers. This also meant that the mooring arrangement was used in a way, for which it was not constructed. Human factor Mistake and/or misunderstanding when signalling and operating the winch were a contributing factor. The injured AB was not out of the danger zone, when they pulled the lines. 16

17 Technical/ External factor There were no technical failures or lack of. Day light. The mooring lines should be replaced because of a loading operation. Wind and sea state are not registered as contributing factors. Ship 13 Accident data February 2004, at 0830 hours. Ship data Oiltanker, 29,000 GT, built Crew data The injured crewmember was AB, Philippine, 27 years. Narritive During replacement of lines an AB was hit by a piece of metal, which had been torn off a drum end. The AB injured his foot. The line had been trapped between the drum end and the brake. They tried to release the line by running the winch in the opposite direction. In the drum there was a hole for making fast a wire. When the line pushed at the edge of the drum, a piece broke off the drum end at the hole. The AB standing 3 meters away was hit. Other There was written instruction about mooring on board. information Arrangement/ The drum end had a weak point at the hole. It was possible for the line to get construction trapped between the drum end and the brake. Human factor The crewmembers were not sufficiently aware that they were working in a danger zone, while they were trying to release the line. Technical/ A part of a drum end broke off. 17

18 External factor Calm. Daylight. Wind and sea state were not contributing factors. Ship 14 Accident data August 2005, at 1700 hours. Ship data Ro-Ro Passenger ship, 17,000 GT, built Crew data The injured crewmember was AB, Polish, 42 years. He had been 3 months on board the ship. The boatswain was Polish, 31 years. He had been 6 years in the company. Narrative At departure the master and the chief officer were on the bridge, a deck officer and two ABs were on the aft deck and the boatswain and an AB were on the forecastle. From the bridge, order was given by radio to let go the lines fore and aft. From the bridge, there was a very limited view over the forecastle. The boatswain stood in the starboard side operating the winches using a remote control. He pulled on a winch in the port side, which he could not see. The AB stood at the port winch leading the line on to the drum. The sleeve of the AB s boiler suit was caught by the line, and he was pulled around the drum 2 or 3 times before he fell down on the deck. Other informs. There were written risk assessment and instruction about mooring on board. Arrangement/ The overview conditions on the forecastle were bad. The line jammed on the construction drum when pulling. Therefore a crewmember stood in the danger zone close to the drum in order to guide the line. Human factor The procedures used at the time of the accident were normal. The crewmembers were not sufficiently aware of the risk of the work. Safety instructions about only operating the winch, when the winch operator could see the winch, were not followed. Technical/ The marking of the danger area was painted over. There were no technical 18

19 External factor failures. Wind 5 m/s. Daylight. Wind and sea state were not contributing factors. Ship 15 Accident data January 2006, at 0800 hours. Ship data Bulk carrier, 18,000 GT, built Crew data The injured crewmember was 3 rd officer, Polish, 36 years old. Narrative A Danish cargo ship shifted loading position alongside a quay. The 3 rd officer took control of the crew at the forecastle, the master took control of the crew aft and the chief officer controlled the whole operation from the central main deck. All officers had radios. The ship was moved slowly forward for approx. 5 minutes when the forward breast line became too tight. The breast line was not part of the shifting. The 3rd officer tried to ease off the breast line from the bitts. The line eased off in a snatchy way. The 3rd officer's hand got caught between the bitt and the line. The hand became seriously injured. Other informs. Work place instructions were placed in each mess room. Arrangement/ It was necessary to release the line manually (by hands) from the bitts, while construction there was a heavy load on the line. The officer was exposed to a latent risk by doing this work, because there was a heavy load on the line. Human factor The procedure at the shifting of the ship was normal. The officer was not sufficiently aware of the risk, when he tried to ease off the line. There was no communication and the movement ahead of the ship was not stopped, before he tried to ease out the line. Maybe the line was put through a wrong hawser hole. Technical/ There were no technical failures or lack of. External factor Wind and sea state are not registered as contributing factors. 19

20 Ship 16 Accident data July 2006, at 0800 hours. Ship data Chemical tanker, 30,000 GT, built Crew data Injured person: 2 nd officer, Danish, born Three years in the company as officer on board oiltankers. Narrative During mooring at arrival the 2nd officer, the boatswain, a voyage cleaner and 2 deck hands were on the forecastle. A mooring headline piled up in approx. three layers against the side of the storage drum. The winch was stopped. An officer pushed to the line, which was tight, to put it in right position. When it fell into right position the line jumped and hit the officer on the wrist. The officer broke his wrist. Other informs. Arrangement/ construction Human factor Technical/ External factor Risk assessment/instruction on mooring operation was written. The officer had not read it. It is possible for the mooring line to pile up in a wrong way. Because of this, a person is placed in front of the drum occasionally. This person is occasionally in physical contact with the mooring line. The officer pulled to the mooring line, which was tight. There were no technical failures or lack of. Calm. Daylight. Wind and sea state were not a contributing factor. 20

21 Foreign flag ship Ship 17 Accident data May 2006, Copenhagen. Ship data Passenger ship, 108,977 GT, built Crew data Injured crewmember: AB, Portuguese Narrative An AB got injured under a mooring operation as a result of a parted mooring rope. The AB sustained hip fracture. Arrangement/ The AB was in a risk zone. construction Human factor No information Technical/ A mooring line broke. External factor Wind and sea state are not registered as contributing factors. 21

22 7 Reports from the Division for Investigation Maritime Accidents in Denmark The reports on mooring accidents published by the Danish investigation division can be downloaded from under Ulykkesopklaring Rapporter om ulykker på handelsskibe - Arbejdsulykker One report from 2005 has been translated to English and can be down loaded from the English home page of the Danish Maritime Authority under Casualty Investigation Accidents on merchant ships. Ship name Accident date Language JENS KOFOED 14 September 1998 Danish MÆRSK TACKLER 6 May 2001 Danish DITTE THERESA 23 June 2002 Danish DUCHESS OF SCANDINAVIA 1 November 2003 Danish DUCHESS OF SCANDINAVIA 11 August 2005 Danish/English 8 Reports and lessons learned from investigation branches outside Denmark Mooring accidents investigated by Investigation Branches outside Denmark MAIB - Marine Accident Investigation Branch in United Kingdom Marine Accident Report DART 8 published MAIB Safety Digest 2/2000, page 20. MAIB Safety Digest 2/2003, page 42. MAIB Safety Digest 3/2003, page 26. MAIB Safety Digest 1/2004, page 14. MAIB Safety Digest 1/2004, page 21. MAIB Safety Digest 1/2006, page 25. The reports/safety digest can be downloaded from the homepage under Publications. BSU Federal Bureau of Maritime Casualty Investigation in Germany Investigation Report 350/03 MV AUTO ATLAS published The report can be downloaded from the homepage under Publications. Maritime Casualty Investigation Unit Swedish Maritime Authority Rapport TOR SCANDIA 2000 (in Swedish language). 22

23 The report can be downloaded from the homepage under Sjöfartsinspektionen Olycker & tilbud. 9 IMO Lessons learned At a meeting in IMO in June 2006 (FSI 14 - Session on Flag State Implementation) a paper with lessons learned was submitted. Five of the lessons learned were about mooring accidents. The lessons learned are written by the IMO correspondence group on casualty analysis and the lessons learned are based upon reports submitted to IMO by the member states. Reports of the Correspondence Group on Casualty Analysis to the IMO sub-committee on flag state FSI 14/5, dated 3 March 2006, submitted by United Kingdom. Annex 2 Overview of lessons learned 23

24 Annex 3 Draft text of lessons learned for presentation to seafarers 24

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