The Taiwan Transportation Safety Board (hereafter referred to as the TTSB)：Major Transportation Occurrence Investigation Report on Collision of Roll-on–Roll-off Passenger ship COSCO STAR with Tugboat TIPM No. 15001 at Taichung Port.

On November 27, 2019, a Hong Kong registered RO/RO passenger vessel COSCO STAR, owned by Cosco Shipping (Xiamen) Co.,Ltd., International Maritime Organization number 9073440, gross tonnage 26847, departed from Wharf 19A of the Taichung Port to the Xiamen Port in Fujian, China,. At 2111:19, COSCO STAR collided with a Kaohsiung Port registered tugboat TIPM No. 15001, owned by TIPC Marine Corporation, Ltd., gross tonnage 496, near the North Turning Basin. At the time of the collision, TIPM No. 15001 was returning to the tugboat basin. The collision resulted in a dent in the port bow of COSCO STAR and a hole in the starboard bow, deformed funnel, and crooked masts for TIPM No. 15001. No personnel injury or oil pollution in this occurrence.

Pursuant to the Republic of China’s Transportation Occurrences Investigation Act and the International Maritime Organization’s Casualty Investigation Code. 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, The TIPC Marine Corporation, the Taichung Port Pilot Office, Cosco Shipping (Xiamen) Co.,Ltd. and Acme Shipping Agency Co., Ltd. the Marine Department of the Hong Kong Special Administrative Region is authorized representative. This investigation report was released on January 7, 2022, after been reviewed and approved by the TTSB 34th Board meeting.

The investigation findings:

1. The crew members aboard TIPM No. 15001 did not turn on the electronic navigation system to assist in navigational watch during night navigation. The tugboat also did not follow the legal requirement to navigate at a reduced speed in the Port or the requirement of the Guide to Taichung Port Entry to remain tuned into the port’s radio channel at all times.
2. COSCO STAR’s bridge team used the naked eye rather than the electronic navigation system for navigational watch, which prevented early identification of the collision with TIPM No. 15001. Although it navigated at a safe speed in the Port, it did not perform the required check of the surrounding conditions to determine the safety of navigation.
3. The handbook for operators at the Port’s vessel traffic service (VTS) center does not specify the operational procedures for monitoring, analyzing, and evaluating the status of vessels in the Port in real time. This prevents VTS warnings from being issued in real time and can lead to accidents.
4. The pilot in question stopped their service and disembarked earlier than the scheduled time at the Port’s Inner Channel. They also did not disembark at the designated location. The VTS operator did not report the pilot’s disembarkation, which was considered implicit acceptance of the pilot’s action. The pilot disembarked against the Port’s rule of compulsory pilotage within a port area as per Pilotage Law.
5. The certificates of COSCO STAR, TIPM No. 15001, and all personnel onboard were valid. The rest records of the pilots and crew members of the two vessels before the boats were moored at the Port and the accident occurred indicated compliance with regulations; therefore, fatigue was ruled out as a cause.
6. At the time of the accident, the Port had a wind force of 5 and visibility of 7 nautical miles, which constitute normal weather conditions. Therefore, weather conditions were ruled out as a cause.
7. All navigation instruments onboard COSCO STAR and TIPM No. 15001 functioned normally; equipment malfunction was ruled out as a cause.
8. At the time of the collision, the bridge team members’ vision was not affected by the lighting onshore for both vessels.

Transportation Safety Recommendations

Please refer to the Taiwan Transportation Safety Board’s recommendations for amendments to provisions related to pilot disembarkation in the Guide to Taichung Port Entry in a previous investigation, the Major Transportation Investigation Report on Bulk Carrier「ANSAC CHRISTINE NANCY」.

To the Ministry of Transportation and Communications

• Amend provisions related to pilot disembarkation in the Guide to Taichung Port Entry in accordance with pilotage management regulations and international definitions of the role of pilots (TTSB-MSR-21-09-005).

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

• Ensure full adherence to Articles 4 and 5 of the Pilotage Law, establish pilotage districts, stipulate the division of these districts, and identify designated points of embarkation and disembarkation for pilots to ensure safe navigation in ports (TTSB-MSR-21-09-006).

These recommendations will remain in the watch list and shall not be included in the board’s recommendations for this case.

To the Cosco Shipping (Xiamen) Co.,Ltd.

1. Review the bridge team’s training outcomes regarding resource management, convey the importance of navigational watch to crew members, and require officers of the watch to use the electronic navigation system in accordance with conventions and bylaws related to navigational safety.

To the TIPC Marine Corporation

1. Improve crew training, mandate the use of the electronic navigation system during navigation, require crew members to keep watch diligently, ensure boats remain tuned into port radio channels, and ensure compliance with the navigational guidelines of each port and that crew members are aware of their surroundings and can navigate safely in ports.
2. Ensure compliance with Article 31 of the Commercial Port Law and Article 9 of the Regulations on Port Services at Commercial Ports, which prescribe that when navigating within a port, ships must navigate at a reduced speed and not overtake ships in narrow channels or prevent other ships from navigating safely.

To the Taichung Port Pilot Office

1. Collaborate with the Maritime and Port Bureau of the Ministry of Transportation and Communications to establish guidelines that improve the operational environment of ships, mandate that pilotage service end within designated disembarkation areas, and increase the quality of pilotage service to implement compulsory pilotage and ensure safe navigation through the channels of Taiwan’s international ports.

To Taiwan International Ports Corporation, Ltd.

1. Amend the Guide to Taichung Port Entry’s provisions for the disembarkation of pilots, ensure safe navigation upon departure and arrival, follow the suggestions of the Maritime and Port Bureau of the Ministry of Transportation and Communications and those of pilots, and ensure compliance with the Regulations for Administrating Pilots.
2. Provide training to signal tower operators at ports to strengthen their abilities to collect, analyze, and respond quickly to data from automatic identification systems and radar and ensure port safety.
3. Clearly delineate the responsibilities and duties of VTS operators at each port to ensure that they thoroughly monitor vessels in ports and that they provide messages to vessels in real time and establish standard operating procedures based on the standards of international ports.

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

1. Supervise the Port’s Pilot Office as it establishes operational guidelines to improve operational environment on ships, mandate that pilots navigate ships in compulsory pilotage districts as per Article 16 of the Pilotage Law, and improve pilotage service for implementation of compulsory pilotage and ensure navigational safety in the channels of Taiwan’s international ports.
2. Improve the planning, execution, and supervision of pilotage service, ensure full adherence to the pilot embarkation and disembarkation regulations and the rule that a pilot must be present on board in compulsory districts, provide administrative operation guidelines, and raise pilotage service to international standards to ensure navigational safety in port channels.

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

Vivi Yang, Secretariat Office
Tel: +886-2-7727-6217
E-mail: viviy2314@ttsb.gov.tw