Report 2014/03
Marine report 2014/03
In the morning of 3 July 2012 the workboat Maria, with two people on board, was at a fish farm in Store Kufjord on the island of Seiland. A group of six people and four dogs were on their way home from walking in the mountains. The group was taken on board the Maria to be transported to Altneset. Immediately prior to the accident, the passengers' inflatable boat, which was being towed, had broken loose. It was retrieved and lifted on board the Maria using the crane. During an attempt to manoeuvre the inflatable boat onto the aft deck with the keel down, the Maria capsized. The entrance to the wheelhouse was under water after the vessel capsized. The hatch to the engine room was open, which probably caused the stern of the vessel to sink faster than it would otherwise have done, making it difficult to escape from the wheelhouse. Maria sank with two passengers and four dogs on board.
AIBN concludes that the dynamic forces created by strong gusts of wind in the area affected the vessel and the suspended inflatable boat, and that this caused the vessel to capsize. In the AIBN's opinion, the decision to take the inflatable boat on board using the crane on this type of vessel in extremely poor weather conditions, and with passengers on board, falls outside the limits of what can be deemed to constitute normal and safe operation. The AIBN believes, however, that the accident was made possible by a combination of several contributing factors. These factors are also related to the day-to-day operation of the vessel.
In the AIBN's opinion, inadequate competence and risk control were among the contributing factors of this accident. The crew lacked sufficient competence in the safe operation of the vessel and crane in relation to stability and weather conditions. Among other things, the crew was unaware of the instructions concerning topping up the ballast tank before using the crane.
AIBN believes that the crew had not received adequate training in the use of the workboat, including operational limitations and crane use. This was, in turn, related to the fact that the aquaculture company had failed to carry out risk assessments and prepare operating instructions for the use of the workboat and crane. Following the accident, the company has implemented relevant measures in accordance with the orders issued by the Norwegian Labour Inspection Authority after inspection. At the same time, the AIBN points to the lack of more formal requirements of competence for crews on this type of workboat with a length of less than 15 metres, since they may carry out complex and demanding operations involving a lot of technical equipment.
The investigation also found that there had been insufficient communication between the shipyard where the Maria was built and the aquaculture company as the responsible owner, about the vessel and crane's operational limitations. The aquaculture company was also unaware of the requirements to which it, as the owner, is subject when using workboats to transport passengers.
The circumstances under which the accident occurred cannot be considered a normal work situation. However small vessels in the aquaculture industry often have varying crane loads and deck cargoes, and this can affect the vessel's stability and wind-exposed surfaces. In the AIBN's opinion, this has not been taken sufficiently into account in connection with the certification and operation of such vessels. It is likely to happen that crane operations are carried out on workboats where the stability reserve may be uncertain, despite the crane being certified for use on board the vessel.
The AIBN promotes three safety recommendations as a result of this investigation.
Illustration: GMV AS adapted by AIBN
Safety recommendation
Safety recommendation MARINE No 2014/02T
Inadequate competence and risk control contributed to the accident on 3 July 2012 involving the workboat Maria. At present, few requirements apply to the competence of crews on this type of vessel with a length less than 15 metres, even though they sometimes carry out complex and demanding operations involving a lot of technical equipment.
The Accident Investigation Board Norway recommends that the Norwegian Maritime Directorate implement measures to ensure that crews on workboats of less than 15 metres have adequate competence for the operations they carry out.
Safety recommendation MARINE No 2014/03T
The investigation of the accident on 3 July 2012 in which the Maria capsized has shown that the aquaculture company was unaware of the requirements to which it, as the owner, is subject when using workboats to transport passenger. According to the Norwegian Labour Inspection Authority, the regulatory requirements concerning passenger transport are generally not known in the aquaculture industry. It is therefore the AIBN's opinion that several companies in the industry fail to comply with important framework factors in the Norwegian Regulations relating to the operation of small passenger vessels, such as certificate requirements that apply to the vessel's master and requirements relating to safety management and risk assessment.
The Accident Investigation Board Norway recommends that the Norwegian Maritime Directorate, in cooperation with the Norwegian Labour Inspection Authority, implement measures to ensure that the aquaculture industry's use of workboats complies with the applicable regulations as regards passenger transport.
Safety recommendation MARINE No 2014/04T
The investigation of the accident on 3 July 2012 in which the Maria capsized has shown that there are deficiencies in the Nordic Boat Standard NBS 1990 relating to the determination of maximum crane moment in that the test is limited to one set of defined condition and only concerns the maximum heel angle. As a consequence, the dynamic stability reserve during crane lifts, particularly in combination with deck cargo, can be uncertain and significantly lower than the intentions of the regulations.
The Accident Investigation Board Norway recommends that the Norwegian Maritime Directorate ensure that residual dynamic stability is included as a criterion in the determination of maximum crane moment for all relevant load conditions when the new regulations for small cargo ships are drawn up. The minimum requirements for residual stability should reflect that the vessel shall be capable of withstanding relevant dynamic weather forces considering how the wind-exposed surface increases during crane lifts.
Facts
| Location | Sore Kufjord, north of Alta |
| Occurrence date | 03.07.2012 |
| Accident category | Capsize |
| Area | Norwegian Territorial Waters |
| IMO number | 5236222 |
| Name of vessel | Maria |
| Accident type | Fatal Accident, Capsize |
| Vessel type | Misc. Ship |
| Register | The Norwegian Ship Register |