The document described below is the final report by the Marine Safety Investigation Unit of Transport Malta which explains how a relatively new bulk carrier was able to sail into an island in the middle of the ocean, causing great harm to the natural environment and the loss of the vessel and cargo.
It is a cautionary tale for anyone counting on effective sea transport.
A copy of this report can be downloaded or read on-line at the bottom of this post.
A copy can also be found in the FILES archive of the Tristan da Cunha e-mail group at <http://groups.yahoo.com/group/tristan-da-cunha/files/> — to become a member of that group, send a blank e-mail to <firstname.lastname@example.org>
Below are excerpts from the report and additional information from blogs and web sites about the wreck:
Finally! Why the M/S Oliva ran into Nightingale Island at 14 knots
>From the official Tristan website:
MS Oliva ran aground at 04.30 on 16th March 2011 at Spinners Point, the far north-west promontory of Nightingale Island.
Following a Malta Marine Safety Investigation Report we now know how the accident occurred and lessons to be learned
Why MS Oliva ran aground and lessons to be learned
Compiled by Newsletter Editor Richard Grundy from a Malta Marine Safety Investigation Report
Context of the report
MS Oliva Marine Safety Investigation Report was published by Malta’s Marine Safety Investigation Unit. The detailed and professional report was produced following International and European regulations and directives. Its sole purpose is confined to the dissemination of safety lessons and therefore may be misleading if used for other purposes. The report `shall be inadmissible in any judicial proceedings whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless, under prescribed conditions, a Court determines otherwise.’
The Full Document
The full PDF document of 51 pages can be obtained direct from the Malta Government Ministry for Infrastructure, Transport and Communications Website by using this link: https://mitc.gov.mt/mediacenter
The report contains: A Summary of Events, Factual Information (1.) about the ship and a detailed Analysis (2.) of the causes of the grounding and events following. As this is a technical report intended to inform future marine safety there is a danger that any précis may be misleading. Nevertheless it makes fascinating reading for those who have followed the whole MS Oliva wreck saga.
We publish below in full the report’s Conclusions (3.), Safety Actions Taken (4.) and Recommendations (5.) which clearly identify the cause of the grounding, other findings, safety actions taken subsequently by TMS Bulkers Ltd and recommendations.
We will not here make any comments (although it would be tempting so to do), but leave visitors to draw their own conclusions, perhaps after consulting the full report. The February 2013 Tristan da Cunha Newsletter will contain an article including part of the report and an update on the Tristan Conservation and Fisheries Department monitoring.
Findings and safety factors are not listed in any order of priority.
3.1 Immediate Safety Factors
3.1.1 Oliva ran aground because the planned course the vessel was following on the plotting sheet was found to have taken the vessel directly over Nightingale Island.
3.1.2 Although the bridge team was aware that the vessel would be passing close to some islands, it was not aware as to when that event would take place.
3.1.3 Although the vessel did not have BA (British Admiralty) Chart 1769, other appropriate available charts covering the area had not been used.
3.1.4 Both the second mate and chief mate were not aware that the vessel was heading towards Nightingale Island. This was because there was no indication on the plotting chart to alert them of the dangers ahead.
3.1.5 Both the second mate and chief mate saw some echoes on the radar screen, but did not investigate them and dismissed them as rain clouds.
3.1.6 There was no suitable mark placed across the ship’s track to indicate the need to change to a hydrographic chart.
3.1.7 Neither officer had consulted BA Chart 4022. Although this chart was of an unsatisfactory scale, it could have prompted them to adopt a precautionary approach when radar echoes were sighted on the radar.
3.1.8 The combination of the cold, the medication, lack of sleep, the time of the day and reaction to the vessel’s grounding suggests that the chief mate was probably not fit to stand a navigational watch.
3.1.9 Although the company had provided comprehensive guidance and procedures in its SMS (Safety Management System) to prevent this accident, these were not followed on board.
3.2 Latent Conditions and other Safety Factors
3.2.1 The passage plan did not comply with the company’s instructions of clearing distances when a vessel was in open waters.
3.2.2 The master made no reference to the passing of Islands in his night orders. Reference to the Islands, could have alerted the second mate and chief mate to the significance of radar echoes.
3.2.3 The handing over checklist required the chief mate to establish the proximity of any hazards to the vessel. This appears not to have happened and he relied on the brief hand-over he received from the second mate.
3.2.4 The chief officer did not check the position which the AB (Able Bodied Seaman) plotted on the chart.
3.3 Other Findings
3.3.1 The company had adopted the concept of bridge team management to address performance variability. However, in this case it appears that the crew members’ interaction was not effective and they did not identify and eliminate the factors that resulted in the grounding.
3.3.2 The lifeboat was lowered soon after daylight as a precautionary measure, but was lost when the painters parted. Had the fishing vessel not been in the near vicinity, given the remoteness of the area, the crew of Oliva would have found themselves in a difficult position without a lifeboat.
3.3.3 Although the master had saved the VDR (Voyage Data Recorder) data, he was unable to retrieve it as he abandoned the vessel.
4. Safety Actions Taken
4.1 Safety actions taken during the course of the safety investigation
TMS Bulkers Ltd has carried out its own internal investigation, which has resulted in a review of its procedures. These include:
instructions on the use of plotting sheets during ocean navigation;
requiring all officers on board to complete computer based training in voyage planning and bridge team management.
TMS Bulkers Ltd. also intends to increase the frequency of internal navigational audits so as to identify any potential problems of a similar nature within its fleet.
In view of the conclusions and taking into consideration the safety actions taken during the course of the safety investigation, TMS Bulkers Ltd. are recommended to:
14/2012_R1 Consider holding unscheduled navigational audits at sea, so as to verify compliance of its operational procedures while the vessel is underway;
14/2012_R2 Ensure that emergency checklists are amended in order to include the need to save the VDR data.
Copied sections of the report are:
©Copyright TM, 2012
Marine Safety Investigation Unit
Malta Transport Centre
Marsa MRS 1917
St Helena Online
South Atlantic news, in association with The St Helena Independent
Revealed: blunders that caused Tristan da Cunha wreck disaster
Posted on 29 November, 2012 by Simon Pipe
Last year’s shipwreck disaster on Tristan da Cunha was caused by a drowsy officer who thought Nightingale Island was a rain cloud, an investigation has revealed.
The chief mate of the MS Oliva failed to change course when Tristan’s sister island showed up on radar, and the ship ploughed on to rocks.
People on Tristan spent weeks trying to save the lives of rockhopper penguins that were plucked from rocks after the cargo ship broke up in heavy swell.
Last month the entire 260-strong community was awarded a medal by the Royal Society for the Protection of Birds (RSPB).
It took a week for salvage crews to make the 1,700-mile voyage across the South Atlantic to the wreck, while the captain and crew were sheltered in homes.
The 75,300-tonne Oliva was wrecked on uninhabited Nightingale in the early hours of 16 March 2011.
Now a report by the Marine Safety Investigation Unit in Malta, where the ship was registered, has revealed a succession of human failures.
The ship’s officers knew they would pass close to some islands on their voyage from South America to Singapore, but not when. They failed to follow their route properly on charts, relying mainly on a satellite navigation system.
Just after four in the morning, the ship passed only 3.25 nautical miles from Inaccessible Island – a World Heritage Site that was later polluted by escaped oil.
The second mate saw its radar echo but “assumed it was either rain clouds or an iceberg”, says the report.
Soon after 0500, the chief mate “noticed a large echo on the radar screen, very close ahead. He assumed it was a heavy storm cloud and thereafter, he felt the vessel’s impact of running aground.
“The vibration of the vessel running aground and the change in the main engine noise woke up most of the crew, including the master.”
The ship slid on the sea bottom as conditions worsened and at about 0300 the next day, a rock pierced one of the holds. The engine room flooded and an oil slick appeared.
The unnamed Greek captain and the Filippino crew were taken off by a trawler and boats from a cruise ship.
Nearly 48 hours after the collision, Oliva broke in two in heavy swells, spilling 1,500 tonnes of oil into the sea, and most of its cargo of soya beans.
The investigation report says the chief mate had been unable to sleep until five hours before he was due on night watch, because of a cold, and had taken medicine.
“He required two wake-up calls before he arrived on the bridge to take over his watch.
“The combination of the cold, medication, lack of sleep, the time of the day and reaction to the ship’s grounding suggested that the chief mate was probably not fit to stand a navigational watch.”
The report also says that bridge management systems were not followed. Charts were not marked with a “no go” area around the islands, and a plotting error meant that the ship’s projected route took it straight over the mile-wide Nightingale Island.
The RSPB has praised the Tristanians for a “phenomenal” response to the resulting ecological disaster.
The fishing vessel Edinburgh transported 3,718 penguins to Tristan da Cunha, where 80 islanders worked for three months to clean and feed the birds. Conservation workers arrived from South Africa to help, bringing medicines.
A works shed was transformed into a penguin hospital, and recovering birds took over the island’s swimming pool.
Chief islander Ian Lavarello said: “Many of us are descendants of shipwrecked sailors who settled on Tristan, so it was natural for us to shelter the rescued men from the Oliva and at the same time, turn to saving as many of the affected penguins as possible.”
But only 12 per cent of those taken to the main island survived to be released into the sea. It is thought most of Nightingale’s penguins had already left the island after breeding when the ship broke up.
Dr Ross Wanless of Birdlife South Africa, who called the outcome “an unmitigated disaster”, criticised insurers for delay in sending bird experts to join the clean-up.
Months after the incident, scientists found rotting soya beans had killed sea creatures and caused severe damage to the lobster fishery that provides islanders with most of their income.
Seventeen months after the incident, the Nightingale fishery remained closed and the quota at Inaccessible Island had been halved.
In September 2012, the ship’s owners agreed to pay compensation to the islanders.
About Simon Pipe
Former print and BBC journalist, running St Helena Online news website about British territories in the South Atlantic at www.sthelenaonline.org and blogging occasionally on other sites.