The Taiwan Transportation Safety Board (TTSB) published the final report on the investigation of Hong Kong flag bulk carrier “KOOMBANA BAY ” made contact with the south breakwater when departing from the first entrance of Kaohsiung Port.

At about 0750 local time on 9th December, 2022, a Hong Kong flag bulk carrier, KOOMBANA BAY, IMO No. 9515735, was sailing outbound from Kaohsiung Port first entrance, the vessel made contact with the pier’s underwater construction extension. There was no crew injured and environmental pollution was involved in this event.

In accordance with the Transportation Occurrences Investigation Act, and the relevant content of the Casualty Investigation Code of the International Maritime Organization, the TTSB is an independent transportation occurrence investigation agency, and responsible for conducting the investigation. The investigation team also included members from the Ministry of Transportation and Communications, Maritime and Port Bureau, MOTC, Taiwan International Ports Corporation Ltd., Kaohsiung Harbor Pilot Association and Pacific Basin Shipping Ltd.

On the basis of comprehensive factual information and analyses, TTSB proposes the following 7 findings from the final report, and 8 safety recommendations issued to the related organizations. This final report was reviewed and approved by the 54th TTSB Board Committee Meeting on September 12, 2023.

Findings

Findings related to probable causes

1. When the pilot was performing the duties of pilotage for the departure of KOOMBANA BAY from the port, the vessel was not navigated to a safe position. Despite objections from the ship's captain, the pilot disembarked within the narrow channel of the port, violating port compulsory pilotage regulations and international practices regarding the disembarkation of pilots. After the pilot disembarked, the KOOMBANA BAY was unfavorably positioned within the narrow channel that was not conducive to safe passage through the narrow channel. The captain of KOOMBANA BAY did not promptly correct the ship’s heading and adjusted its position to the middle of the narrow channel, resulting in the KOOMBANA BAY's hull under the waterline making contact with the south breakwater of the narrow channel.

Findings related to risk

1. During the pilotage process for the departure of the KOOMBANA BAY, the captain of KOOMBANA BAY failed to promptly remind the pilot that the ship's position had deviated from the channel, as per the voyage plan in the port.
2. The nautical chart of Kaohsiung Port does not indicate the pilot's disembarkation point within the port, resulting in a lack of transparency in the information regarding pilotage regulations on the chart. Additionally, the locations of disembarkation points for different pilots within the first entrance are inconsistent.
3. The Kaohsiung Vessel Traffic Service (VTS) was unable to effectively utilize its equipment before the incident to monitor vessel dynamics and identify potential risks, and promptly offer suggestions or warnings.

Other findings

1. The pilot regarded Article 39 of the Regulations for administrating pilots as a valid basis for disembarking within the port, resulting in the captain of KOOMBANA BAY taking over the navigation within the port independently. This increased the risk of traffic accidents in the port area.
2. If the pilot disembarks from the vessel early within the compulsory pilotage area of the port, except with the consent of the captain, for the sake of overall vessel traffic safety in the port, they should apply for early disembarkation from the Vessel Traffic Service (VTS). If the pilot disembarks early within the port's compulsory pilotage area without reporting to VTS permission. The VTS must have an appropriate traffic management mechanism.
3. Our country’s pilots have not yet established and implemented a safety management system. The maritime authority should consider establishing an independent safety management and supervision system. This system is fundamental to port internationalization and can effectively mitigate risks and accidents associated with pilotage.

Safety Recommendations

To Ministry of Transportation and Communications

1. To enhance navigation safety within the port area and facilitate captains who are unfamiliar with our commercial ports in easily obtaining relevant traffic information, we shall follow the provisions of Articles 4 and 5 of the Pilotage Law. This involves formulating and announcing pilotage areas, pilot boarding procedures, and specifying the locations of boarding and disembarkation points. It will also provide information to relevant units for revision and publication on the nautical chart.
2. To mitigate pilotage risks and accidents, it should supervise the Maritime Port Bureau, MOTC as it assists each port pilot office in establishing a safety management system and implementing an independent safety management supervision system.

To Maritime Port Bureau, MOTC

1. Amend the Regulations for administrating pilots. When performing pilotage operations, pilots shall not disembark from the vessel midway within the compulsory pilotage port area, except for weather-related factors.
2. To ensure traffic safety in the Taiwan International Commercial Port, supervise the pilot offices of each port and ensure that pilots perform the task of piloting ships throughout the compulsory pilotage area, thereby achieving the purpose of compulsory pilotage.
3. To mitigate pilotage risks and accidents, assist each port pilot office in establishing a safety management system and implementing an independent safety management supervision system.

To Taiwan International Ports Corporation Ltd.

1. To ensure the safety of navigation within the port area, an assessment of the establishment of relevant regulations and a clear definition of the reporting mechanism for pilots should be conducted before the completion of pilotage operations.

To Kaohsiung Harbor Pilot Association

1. Develop operating policies to improve the operating environment and ensure that pilots carry out their vessel piloting duties throughout the compulsory pilotage area. This is to achieve the purpose and ensure traffic safety within the Taiwan International Commercial Port.
2. When the pilot is required to terminate pilotage early within the compulsory pilotage area, he must promptly report to the Vessel Traffic Service (VTS). The pilotage operation can be terminated only after receiving confirmation from the VTS.

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

Wei-Chung Chen, Investigator-In-Charge
Marine Occurrence Investigation Division

Tel: +886-2-7727-6246

E-mail: willis@ttsb.gov.tw