The Taiwan Transportation Safety Board (TTSB) published the Final Report on the investigation of ORIENTAL CHILAN Contact with pier in Kaohsiung Port in Kaohsiung Port.

On July 24th 2020, a Panama registered reefer cargo vessel ORIENTAL CHILAN (hereinafter referred to as GAO SHENG) owned by the Taiwan Navigation Company, International Maritime Organization no. 8301723, gross tonnage of 2113. At local time of 1246:09, the ship struck pier no. 48, while maneuvering toward its assigned berth at the Port of Kaohsiung, which resulted in material damage to the infrastructure of the port. There was no personnel injury or oil pollution from this occurrence.

In accordance with the Transportation Occurrences Investigation Act, R.O.C., and IMO CI Code, the Taiwan Transportation Safety Board was the independent agency in charge of investigating the marine casualty. The agencies (institutions) invited to participate in the investigation include the Maritime and Port Bureau, MOTC, Go-Rising Trading Ltd., and Pilot Office of Kaohsiung Port. This final report was reviewed and approved by the 49th TTSB Board meeting on April 7, 2023.

Findings

Findings related to probable causes

1. The causal factors of the GAO SHENG contacted with the pier are a combination of factors, including: failure of the main engine, which caused the malfunction of astern, insufficient exchange of information between the captain and the pilot, and inaccurate preparations before arriving at the destination port.
2. The direct cause of the failure of the main engine was that the intake valve base of the 4th cylinder head was fractured, and the cooling water seeped into the combustion chamber from the cylinder head, causing it to fail to re-start after stopping the main engine. The root cause was that the planned maintenance program for the engine room has not been implemented.

(1)The seaman in the engine room did not monitor the quality of the cooling water, resulting in uneven heating of the cylinder heads, then rupture of the cylinder head of the 4th cylinder due to thermal stress.

(2)After the cylinder head of the 4th cylinder of the main engine was ruptured, the cooling water penetrated into the combustion chamber from the crack of the intake valve base of the cylinder head, which made the combustion and explosion process of the combustion chamber abnormal, so that it could be restarted after stopping the main engine.

Findings related to risk

1. The GAO SHENG is 38 years old, a high-risk sub-standard ship. On July 2012, the port authority of Taiwan contacted Port State Control for inspection. Until the occurrence, the GAO SHENG was categorized as a standard risk ship by the port authority of Taiwan.
2. The information exchange between the captain and the pilot was insufficient, and the possible failure of the main engine of the old ship was not properly assessed, which did not comply with the safety information exchange recommendations in IMO Resolution A.960 (23), and increased the risk of pilotage in the port area.
3. The GAO SHENG did not actually perform the "pre-arrival/pre-departure tests" and filled the checklist tables, to ensure that the relevant equipment entered the port in good condition.
4. The GAO SHENG did not implement the planned maintenance program, and many maintenance items were not implemented as planned.
5. During the occurrence voyage, the bell speed indicator and rudder angle indicator on the right side of the bridge are not returning to zero, which would affect the pilot's effective grasp of the ship's status, and easily lead to the risk of ship maneuvering.
6. The national New Inspection Regime (NIR) system has not synchronized with the Tokyo MOU, and the flag state blacklist and recognized organizations have not been unified and have not shared the information of sub-standard ships with relevant agencies, which may affect the effectiveness of Taiwan’s port state control inspection.

Other findings

1. The manning scale of the GAO SHENG, includes: a Vietnamese captain, a ship-owner representative, and 14 foreign crew members. The captain and 13 crew members of the GAO SHENG had valid certificates issued by the flag state of the GAO SHENG. The certificate of competency held by an Able Seaman (AB) at the helm has expired.
2. During the occurrence, the officers of the watch on the bridge consisted of the captain and 2 ABs, 2 ABs were respectively responsible for steering and controlling the bell, and a representative of the ship-owner who was responsible for conveying the pilot's order and rudder order to the captain and the 2 ABs.
3. The water hardness and pH value of the cooling water of the main engine of the GAO SHENG have not been kept in written records.
4. There are only nine Port State Control (PSC) inspectors at the Southern Maritime Affairs Center of the Maritime and Port Bureau, MOTC, who hold the certificate of competency, and the ship inspection rate is about 2.2%, and the nine inspectors also conduct other businesses.

Safety Recommendations

To Go-Rising Trading Ltd.

1. RContinue to strengthen the ship safety management mechanism, including bridge operations, ship equipment maintenance, and emergency drill procedures.
   （TTSB-MSR-23-04-010）

To Pilot Office of Kaohsiung Port.

1. Referring to the IMO Resolution A.960(23), effective Master Pilot Information Exchange (MP-X) at the start of the pilotage, strengthen the regular recurrent training (not more than 5 years) and on-the-job training courses of the pilot, and ensure the professional ability under the pilot and safe navigation of the pilot’s responsibility.
   （TTSB-MSR-23-04-011）

To Maritime and Port Bureau, MOTC

1. Referring to the IMO Resolution A.960 (23), supervise the regional pilot offices to strengthen the regular recurrent training (not more than 5 years) and on-the-job training courses of pilots to ensure the professional ability and safe navigation of the pilot’s responsibilities.
   （TTSB-MSR-23-04-012）
2. Review the scoring criteria of the national New Inspection Regime (NIR) System, and include the flag state black/gray list, performance of recognized organizations in the Tokyo MOU annual report as a priority in Taiwan’s NIR system, so as to facilitate appropriate Port State Control (PSC) measures. （TTSB-MSR-23-04-013）
3. Check the manpower of Port State Control (PSC) inspectors in Taiwan, to strengthen the inspection mechanism, and ensure ongoing training of dedicated and competent inspectors.（TTSB-MSR-23-04-014）

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