Stage

• On Scene
• Factual Collection
• Analysis
• Final Draft
• Closure

At 0432 hours on June 3^rd, 2023, a Taiwanese-registered passenger ship "Taima Star”, IMO number 9684938, with a gross tonnage of 4982, lost propulsion at approximately 34 nautical miles southeast of Nangan Island, Lienchiang County. The ship carried 22 crew members and 385 passengers, 407 people totally on board. At around 1500 hours on the same day, the tugboat "Dong Yan No.1" successfully towed the "Taima Star" to Fuao Port, Lienchiang County. No casualties or environmental pollution resulted from this occurrence.

Investigation Found

About Possible Causes
• 1. Before "Taima Star" departed from Port of Keelung, the ship's fuel oil purifier failed to purify the heavy fuel oil due to a malfunction of the electric-actuated steam control valve. Additionally, no engineer assisted the chief engineer in verifying the fuel level in the heavy fuel oil service tank. The chief engineer estimated the tank's fuel level only by checking the fuel level on the engine room monitoring system. However, due to an incorrect estimation of the fuel level in the heavy fuel oil service tank, the "Taima Star" experienced a fuel shortage in the heavy fuel oil service tank during the voyage.
  2. Due to insufficient fuel in the heavy fuel oil service tank, a series of alarms were continuously triggered before the generator and main engine stopped. The duty third engineer did not understand the cause of these continuous alarms and failed to switch the fuel supply from heavy fuel oil to diesel oil in time when the alarms occurred. Consequently, the "Taima Star" lost both electrical power and propulsion due to the lack of fuel supply to the generator and main engine.

About Risk
• 1. The duty engineer switched the fuel supply from heavy fuel oil to diesel oil after the "Taima Star" lost power and propulsion, and the generator returned to normal operation. However, the electrical power and propulsion were still unable to recover because the crew of the engine department was not familiar with the reset procedure and reinstallation steps for the main switchboard air circuit breakers.
  2. During the voyage of the "Taima Star", the second engineer noticed a low fuel level in the heavy fuel oil service tank at a shift handover. However, the actual fuel level situation and alarm information were not verified, and the second engineer neither immediately reported to the chief engineer nor took any appropriate measures, thus missing the opportunity to prevent the loss of power.
  3. After the third engineer completed the shift handover with the second engineer, the third engineer did not verify the fuel level in the service oil tank as reminded by the second engineer.
  4. There were no equipment operation and emergency procedure documents placed near the main switchboard and related devices, which affected the timing of the emergency response.
  5. The interim verification conducted before the departure of “Taima Star” did not identify the risk of the ship's seaworthiness and crew competent.
  6. Following the occurrences of the "Taima Star", the port authority convened multiple meetings to review deficiencies, track progress, and discuss ship return-to-service plans. These meetings included several notes regarding the ship management company and the "Taima Star", highlighting systemic deficiencies in crew familiarization training, ship equipment, and safety management procedures.
  7. The "Taima Star" and the ship management company lacked effective systemic implementation of safety management capabilities before the occurrences. If the port authority could develop effective audit criteria and scope, especially for the new management company and newly hired crew, it would help identify risks early and discover systemic issues related to the ship. This proactive approach could reduce risk, enhance the operational safety of the ship, improve crew equipment familiarity, and mitigate accident risk.
  8. Current procedures for delivering the "Taima Star" focus on inventorying the ship's condition and belongings of the ship, rather than ensuring the receiving ship management company is familiar with the operations of the "Taima Star". If Matsu Lienchiang Marine Co., Ltd. could supervise or assist the ship management company during the handover period, ensuring their familiarity with the operation of "Taima Star’s" equipment and emergency procedures, it would reduce the risk of accidents related to unfamiliarity with equipment operation.

Other
• 1. The rudder, main engine, and navigation equipment of the "Taima Star" were all functioning normally.
  2. The captain and duty crew of the "Taima Star" hold valid certificates issued by the competent authority of our country.