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Release Final Report of the Occurrence Investigation of Cargo Vessel GODSPEED and Pilot Boat Yonghua No. 6


Publication Date 2021-09-15
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Publication Date 2021-09-15

On March 9, 2020, a Hong Kong registered dry cargo vessel GODSPEED, owned by Creativity Dragon Holding Limited and managed by Fujian Xinan Shipping Co., Ltd, International Maritime Organization number 9426738, gross tonnage 5272, with 1 captain and 19 crew members totally 20 people on board, departed from Taichung Port for Taipei Port at 1420. While entering the breakwater of Taipei Port, the GODSPEED collided with pilot boat Yonghua No. 6 (hereafter referred to as the Yonghua), owned by Shun Fa Motorboat, at 2024, causing the Yonghua to capsize and sink with loss of two lives.

Pursuant to the Republic of China’s Transportation Occurrences Investigation Act and the International Maritime Organization’s Casualty Investigation Code, the Taiwan Transportation Safety Board (hereafter referred to as the TTSB), an independent transportation occurrence investigation agency, was responsible for investigating this transportation occurrence. Organizations or agencies been invited to participate in the investigation included the Ministry of Transportation and Communications, the Maritime and Port Bureau of the Ministry of Transportation and Communications, Taiwan International Ports Corporation (hereafter referred to as the TIPC), the Coast Guard Administration of the Ocean Affairs Council, the Taipei Port Pilot Office, Shun Fa Motorboat, and Fujian Xinan Shipping Co., Ltd. This investigation report was released on September 15, 2021, after been reviewed and approved by the TTSB 30th Board meeting.

 

Findings related to Probable Causes:

  1. After the pilot boarded the GODSPEED, the Yonghua did not comply with the rule to cruise at a reduced speed, and shall not sail alongside or overtake other ships, or obstruct the navigation of other ships. In the dark night, the Yonghua approached the GODSPEED’s course and overtook it. After the pilot had boarded, the GODSPEED accelerated and heading turned to the port side. As a result, the distance between the two ships reduced gradually and crossing the tracking vectors. The controller of vessel traffic service failed to monitor the dynamic status of both ships at that time and issued an early warning in time.
  2. The on-duty crew on the bridge of the GODSPEED did not keep proper look-out, and failed to use radar or electronic chart systems to maintain awareness of their surrounding situation. At least 10 seconds before the collision, as the chief officer of the GODSPEED noticed that the Yonghua was approaching the GODSPEED, the navigator of the Yonghua should also have noticed the GODSPEED approaching from the starboard side. However, neither the GODSPEED nor the Yonghua had sufficient time to react, resulting in the Yonghua colliding with the GODSPEED and subsequently capsizing.

 

Findings related to risks:

  1. The pilot involved in the occurrence did not adhere to the guide to Taipei Port entry, which were to exit the harbor and wait outside the breakwater to guide the GODSPEED into port. The pilot also failed to follow the controller’s operation manual of Taipei Port, which were to instruct the GODSPEED to place a pilot ladder on the leeward side (in this case, starboard) which might increase the risks to safe navigation within the harbor. The Taipei Port controllers did not comply with the procedures as specified in the manual to remind the pilot to exit the harbor and board the GODSPEED from the leeward side to conduct pilotage operation.
  2. The Taipei Port Branch Office uses the term “safety speeds” without speed limit in its controller’s operation manual to regulate ship navigation within the harbor, which may affect ship’s safe navigation within the harbor.
  3. On the day of the occurrence, as the GODSPEED was entering Taipei Port, the pilot joined the crew on the bridge of the GODSPEED, the operations of bridge crew wholly showed a failure to keep proper look-out and use various techniques, knowledge, experience, and available resources to maintain awareness of their position and movements and those of surrounding vessels, and communicate effectively with the pilot to identify possible risks of collision. The processes showed the lack of literacy of GODSPEED on duty bridge crew in bridge resource management.
  4. Since the implementation of the "Separation of Government from Enterprises" policy in year 2012, the Vessel Traffic Service (VTS) system was operated and managed by the TIPC. At this stage, domestic commercial ports do not have consistent operating standards. Controllers also have no consistent standard professional training and certification. Regarding the port arrival and departure of ships, it is unable to provide effective safety services to ships with the current powers, responsibilities and operational functions of VTS. For reasons of public safety, the operation and responsibilities of VTS should be the responsibility of a publicly-powered maritime administration agency.

 

Other Findings

  1. The Captain and crew of the GODSPEED had valid certificates issued by the flag state of the GODSPEED, and the pilot and crew of the Yonghua had valid certificates issued by the Maritime and Port Bureau of the Republic of China. On the day of the occurrence, at 20:00, the weather and sea state at Taipei Port met the standard for the GODSPEED to enter harbor.
  2. After the occurrence, the pilot and the Captain, chief officer, third officer, and on-duty crew of the GODSPEED tested negative for blood alcohol concentration. No evidence indicated that alcohol was a factor affecting the crew on the bridge of the GODSPEED in their ability to navigate the vessel. The forensic report by the Ministry of Justice indicated that no factors related to alcohol or drugs influenced the Captain or crew of the Yonghua in their control of the vessel.
  3. Before the occurrence, the maintenance record of the Yonghua contained no abnormalities, and after the occurrence, the engine operation and power test results were normal. In accordance with the Yonghua’s refueling record and the amount of fuel in the service tank, the possibility that the Yonghua lost power because of insufficient fuel or engine failure was eliminated.
  4. The night of the occurrence, when the wreckage of the Yonghua was recovered from the water, the propeller and shaft were not entangled by fishing nets. The fishing nets that fell from the deck were originally stored in and fell out of the stern cabin. The possibility that the propellers were entangled in a fishing net, thereby causing the Yonghua’s engine to become temporarily stalled, was eliminated.

 

Transportation Safety Recommendations

To Shun Fa Motorboat

  1. Conduct fleet training to ensure that vessels proceed slowly within the harbor, that vessels may not cruise alongside other vessels or overtake other vessels, and that when navigating through the same channel, smaller vessels should not interfere with the safe navigation of larger vessels.

To Fujian Xinan Shipping Co., Ltd.

  1. Disseminate the importance of keeping proper look-out during navigation and conduct resource management training for bridge crew members, requiring them to, in compliance with STCW conventions, use various techniques, knowledge, experience, and available resources such as electronic chart systems while navigating to maintain awareness of their surroundings, their movements, and the possible risk of collisions in a timely manner.

To the Ministry of Transportation and Communications

  1. Supervise the Maritime and Port Bureau and the TIPC to review and strengthen the supervision and management mechanism of the vessel traffic service system.

To the Maritime and Port Bureau of the Ministry of Transportation and Communications

  1. Call TIPC and the Taipei Port Pilot Office together to negotiate and formulate standards of "heavy weather conditions" and "exceptional conditions" to be followed by pilots for unable to exit the harbor to piloting ships, and the associated notification procedures and emergency plans to ensure the safety of navigation.
  2. Engage in diligent assessments and planning with TIPC to review and strengthen the supervision and management mechanism of the vessel traffic service system.

To Taiwan International Ports Corporation, Ltd.

  1. Request all ports under TIPC authority to enforce regulations in the guide to Taipei Port entry related to pilot operations under normal circumstances, pilots shall board and disembark ships on the outside sea by using a pilot ladder on the leeward side.
  2. Plan and discuss “safety speeds” standards, and conditions for the safe navigation of vessels in all ports under the TIPC’s jurisdiction to be followed by VTS controllers and pilots.
  3. Strengthen the professional training of VTS controllers at each port, confirm that the controllers are familiar with the functions of the VTS system, based on the collected ship data from dynamic monitoring to assess and take correct action in real time to ensure the safety of ships entering and exiting the harbor.
  4. Engage in diligent assessment and planning with the Maritime and Port Bureau to review and strengthen the supervision and management mechanism of the vessel traffic service system.

To the Taipei Port Pilot Office

  1. Enforce adherence to operating procedures for pilots to board and disembark ships on the outside sea by using a pilot ladder on the leeward side.
  2. In response to the development of emerging technologies of ship types and on-board equipment, strengthen pilot professional training, and certified pilot professional and technical capabilities to be competent in the piloting duties of the designated pilot zone.
  3. Reinforce advocacy that pilots, while piloting ships, shall exchange information and procedures related to vessels entering or exiting the harbor with ship Captain.

 

Full final report is in Chinese only and available for download at website: https://www.ttsb.gov.tw

 

Vivi Yang, Executive Officer

Tel: +886-2-7727-6217

E-mail:viviy2314@ttsb.gov.tw

Last updated 2021-09-15
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