VTSD REPORT ON THE SINKING OF THE SV BEZHIN
VEIID TRANSIT SAFETY DEPARTMENT
MARINE INCIDENT REPORT
BULK CARRIER SV BEZHIN CAPSIZING AND SINKING 60 NAUTICAL MILES WEST OF DECLAV, MADJAR, NOV 27, 2208
1Report No: 2. Gov Accession No:
NSD/NOV-2208/02 No. JD09-951242
3. Report Date: 4 Performing Organization:
January 27, 2209 Veiid Transit Safety Department
5 Abstract:
Around 1730 hours on November 27, 2208, the 123-meter Bulk Carrier SV BEZHIN capsized and sank during a cyclone approximately 60 nautical miles west of Declav, Madjar. Twenty-two persons were aboard. One person survived the incident, and the bodies of two were recovered. The other 19 persons are missing and presumed dead. The location of the SV BEZHIN and its current condition are unknown. The wreck is believed to be located in the Bashir Trench at an estimated depth of 5,000 meters; Its estimated value, including cargo, was $10 million.
The Veiid Transit Safety Department determines the probable cause of the capsizing and sinking of the bulk carrier SV BEZHIN was the flooding of several forward compartments as a result of a structural failure after encountering abnormal weather conditions, combined with poor hull design. Contributing to the loss of life was a lack of personnel training and clear instruction to minimize the impact of unexpected catastrophic conditions.
INVESTIGATION
Events preceding the accident.
About 1245 on November 26, 2208, the 123-meter-long bulk carrier SV BEZHIN (see figure 1) departed Declav, Madjar with around 14,000 Metric Tons of lump iron ore for the United States of Central Kafrica. Twenty-three persons were onboard the vessel, including a Madjar pilot, the chief engineer, the chief mate, the second mate, the 8 to 12 third mate, the 12 to 4 third mate, the assistant engineer, the 8 to 12 third assistant engineer, and the 12 to 4 third assistant engineer. The chief mate testified that the entire ship, including the hatch covers, was secured for sea as the SV BEZHIN proceeded out of the harbor. Due to a predicted storm, the chief mate ordered the boatswain (bos'n) and deck Utility Man, "to put all the dogs that they could get on around the hatches." The Utility Man [later] testified:
"Usually, I'd only been told to put a few dogs on the coamings of the hatches, because the hatches are so heavy that when the jacks used to keep them up are released, they rest in a groove, so they're pretty secure just with the weight of the hatch. Most of the time it's not necessary to dog all the way around."
About 1400 November 26, the pilot disembarked, and the ship headed to sea. Due to rough conditions, the master ordered the ship speed be reduced from 80 RPM (around 12 knots in calm water) to 60RPM (Around 7 knots in calm water) The Utility Man testified that around this time the winds were from the north east at a force of 7/(22 to 27 knots), the seas were from the northeast and 7 to 9 meters high, and green seas were coming over the port bow. He said the seas were breaking near the anchor windlass on the forecastle, but "the vessel was shedding water properly and getting rid of it without issue, the ride was generally smooth."
At 1532 SV BEZHINS master reported "I've (sic) having problems with the GPS in this water -weather." At 1540, he reported being on a course of 335° making 5 knots over the ground. At 1632, the master of the SV BEZHIN said, "I'll set a course for Staplijs to avoid this weather; we're in the midst of a very serious squall here," which would have been a course of about 210°; however, at 1641, the master of the SV BEZHIN reported:
"I don't think I can hold that course - Something has gone wrong with [unclear]- We're taking water, green water over - over my port side all, all the way across the deck at this heading."
DCG requested that SV BEZHIN continue on the course of 210° to make rendezvous with the coast guard icebreaker DCG ELOO (estimated at 1745), however, at 1650, the master of the SV BEZHIN reported. "I have to return to my original heading." The DCG ELOO radioed the SV BEZHIN, "Unable to rendezvous at that heading." The DCG ELOO would return to its original heading, bound for Rainjas.
THE INCIDENT
At approximately 1655, the chief mate observed what he believed to be movement of the No.4 hatch cover and sent the AB assigned to the 4 to 8 watch to investigate the dogging. While the AB was transiting the main deck, he was struck by a section of railing that broke loose, incapacitating him. He was escorted to the aft crew quarters by the bos'n. With no other relief immediately available, the master directed the Utility Man (hereinafter referred to as "UM") to assume the AB's watch.
When UM assumed the lookout watch on the starboard bridge wing, the SV BEZHIN was on a course of 330°, the seas were 6-8 meters high, and the ship's bow was "riding a little down." UM stated the bow "looked to be down a little bit." At 1700, the chief mate and the master were on the bridge, and "I think the chief mate and the helmsmen were discussing what to do about the bow a bit."
At 1715, the chief mate went to the master's room, woke him, and informed him of the situation with the bow. UM testified the chief mate said, "I think she's settling the head," before going below to get the chief engineer and returning to the bridge.
At 1723, the master called DCG Station Soljka on VHF-FM Channel 16. The transmission as received and logged by DCG Station Soljka was:
"This is the bulk carrier SV Bezhin; assistance is needed immediately. Mayday, we're [unintelligible]"
UM testified that the master continued, "taking on water, someone needs to come help us. The situation is unclear, but we are in bad shape," but the transmission was not received in full. UM stated, "The radio set stopped working, something happened, and it just cut out."
At approximately 1725, the master ordered the bridge crew to sound the alarm to muster at the lifeboats; however, UM testified he wanted to put his immersion suit on before leaving the bridge due to severe conditions, quote "in waters near Illishira, you know how cold it gets. I wanted to put my suit on first." However, it was noted that no emergency alarm was sounded, so the crew below deck was not made aware of the situation. As UM was putting his immersion suit on, he reported, "I looked out the bridge and saw a huge wave that, by his estimation, was '30 meters tall, ' hit the bow of the ship, reportedly resulting in a severe list to port. Meanwhile, the master was attempting to activate the EPIRB (Emergency Position Indicating Radio Beacon) on the bridge. UM stated, "he was trying to get the EPIRB to go off, and it wasn't working. I tried telling him to leave the bridge, but he just kept trying to get the EPIRB going."
When UM exited the bridge, he noted the ship was listed 10°. When he reached the lifeboat, it was still hanging from the davits, and two crew members were trying to pull the boat closer to the rail. UM attempted to help bring the boat in, but at 1730, the SV BEZHIN capsized to port, throwing UM and others into the water.
RESCUE EFFORTS
At 1725, the DCG rescue command at DCG Station Solkjka instructed the DCG ELOO to go to the aid of the SV BEZHIN. At 1731, the nearby oiler THEOASA reported it was 25NM east of the last reported position of the SV BEZHIN and was proceeding at 17 knots on a course of 255° to assist. The THEOASA attempted to radio the nearby cargo ship ELO GÏERHKEME, which was located 4NM ahead of it; however, no response to correspondence was noted. The ELO GÏERHKEME's whereabouts and operational status during the incident could not be confirmed during this investigation. At 1835, DCG Air Station Gannet dispatched a DCG HC-12 tail number CJ14252. About 1900, the oiler THEOASA and DCG CJ14252 reached the last reported location of the SV BEZHIN. CJ14252 located one individual at the last known AIS location of the SV BEZHIN and directed the THEOASA to the location of the survivor. Crewman of the THEOASA attempted rescue efforts at 1920; however, due to rough seas, the individual was knocked from the liferaft and could not be located. At around 1940, the DCG ELOO arrived at the location, at which time the THEOASA was released.
The DCG cutter PORT STEFAN arrived at 0452 to aid in search-and-rescue efforts. The DCG ELOO and DCG CJ14252 would continue search operations until 0630 November 28, when CJ14252 was returned to DCG Air Station Gannet. DCG HC-12 Tail number CJ24217 was dispatched and resumed search operations at 0700. At 0742, the DCG ELOO located one victim in the water and performed recovery operations. At 0815, a life raft was located 7 NM south of the last reported location of the SV BEZHIN by the DCG PORT STEFAN. One crewmember was found onboard. A victim was found floating nearby. The survivor was loaded into DCG ZH-2M, Tail Number CH1272, and departed the scene at around 0915. At 0936, the survivor was transferred to an ambulance and taken to Saba General Hospital.
INJURIES CREW OTHERS TOTAL
Fatal 21 0 21
Serious 0 0 0
Minor 1 0 1
Total 22 0 22
DAMAGE TO VESSEL
The SV BEZHIN sank an estimated 5,000 meters and is believed to rest in the base of the Bashir Trench. Attempts to locate the wreck were performed by DCG vessels; however, results were inconclusive. The value of the SV BEZHIN was estimated at $7.5 million, and the ore at $2.5 million.
CREW INFORMATION
The DCG Certificate of Inspection for the SV BEZHIN required a crew of 17, including a master, a chief mate, a second mate, a third mate, a radio officer, four able seamen, two ordinary seamen, a chief engineer, a first assistant engineer, a second assistant engineer, a third assistant engineer, and two oilers or enginemen. At the time of the accident, in addition to the required crew, the following crewmembers were onboard: an additional third mate, an additional third assistant engineer, a bosun, a utility man, and an engine cadet.
The master, 62, had held a valid DCG License as master since 2176. He first went to sea in 2164, received his third mate's license in 2166, his second mate's license in 2168, and his chief mate's license in 2169. He had been employed by SHIPPING VARIETY since June of 2170 and had served in the capacity of chief mate or master on tankships or bulk carriers of comparable size to SV BEZHIN.
The Chief mate, 59, had held a valid DCG license as unlimited master since 2189, although he had never sailed as master of a ship. He received his original third mate's license in 2170, his second mate's license in 2172, and his chief mate's license in 2175. From 2176 to 2181, he sailed for a company that operated ore-carrying bulk carriers; from 2182 to 2199, he served on various types of ships, and in 2200, he became the permanent chief mate on SV BEZHIN.
The Chief Engineer, 59, had held a valid DCG license as chief engineer, steam and motor vessels of any horsepower since 2180, and had held the position of chief engineer on the SV BEZHIN since 2194. He received his license as third assistant engineer of steam vessels in 2173, his license as second assistant engineer of steam vessels in 2175, and his license as first assistant engineer of steam vessels in 2179. The Chief Engineer served concurrently in the capacity of port engineer for SHIPPING VARIETY while serving as chief engineer, and during his 6-month shore time vacation each year. As a port engineer, he was responsible for approving all repair requests from the master, the chief mate, or the engine department.
VESSEL INFORMATION
General The SV BEZHIN was owned by Shipping Variety and operated by Jurkom Co, a Subsidiary of the Coastal Consolidated Shipping Company of Ulkam, Fortis. The ship was built in 2151 by Freetown Shipyards and was named ARCADIA SUMMER. Built to the specifications of the Laythi Transport Co K3 tankship, the ship was 118 meters long. It was outfitted with a raised forecastle deck, amidship house, and raised aft deck.
In 2172, the ship was converted to a bulk carrier by Fortis Heavy Industries as part of the Novobrod shipping program, along with 16 of her sisters.The ship was outfitted with a 103-meter midbody. The new midbody section, which met DCG construction standards for building and classing steel vessels, overcame common K3 tankship design issues by incorporating a riveted deck and bottom crack arrestors. The main deck of the new midbody was the same height as the forecastle deck and the aft deck, which became a part of the new main deck. The former main deck was redesigned as the secondary deck. The converted ship was 123 meters long.
The stern section contained an aft deckhouse and the machinery compartment. The midship house was moved from amidships to the aft deck and placed on the original aft deckhouse. The new midship section contained four cargo holds and four lower wing ballast tanks, port and starboard. Steel hatch covers on 1.25-meter coamings protected each cargo hold. The original bow section contained a small dry cargo space with a non-weathertight hatch on the second deck. Various storerooms, the forepeak tank, and the port and starboard fuel oil bunkers. A hinged steel watertight hatch cover on a 0.75-meter coaming on the main deck protected the dry cargo area.
Equipment: The SV BEZHIN was equipped with single-pull steel hatch covers. Each cover consisted of a number of panels designed to be stowed clear of the hatch opening when in the open position. The hatch covers consisted of six panels. The forward and aft panels were of similar construction and scantlings. The forward panel was 2 meters wide, and the aft panel was 2.3 meters wide. The four intermediate panels between were identical, each being 2.1 meters wide. When the hatch cover was in place, the panels were connected structurally at the seams between panels. All panels were equipped with traveling wheels to permit rolling of panels into place on the hatch coaming. Weathertightness was achieved by lowering the wheels into recesses in the coaming, releasing the hydraulic jack system, allowing the weight of the cover to rest on a gasket. Setting quick-acting dogs around the periphery of the hatch and installing cross-joint wedges between panels completed the hatch-closing arrangement.
When the ship was converted in 2172, the DCG permitted SHIPPING VARIETY to retain the ship's original sheath screw lifeboat davits with rope falls and lifeboats. The original lifeboats, though also retained, were subsequently replaced. The port lifeboat was built in 2177, and the starboard lifeboat in 2174. Both lifeboats were of steel construction and located on and boarded from the main deck. The SV BEZHIN was also equipped with two DCG-approved inflatable liferafts. One was manufactured in 2199, and the other was manufactured in 2203. The vessel was equipped with an SHREPCO Harpoon FB2-CW Emergency Position Indicator Radio beacon (EPIRB), which was last inspected by the DCG on June 2, 2206. Onboard the vessel were also carried, although not required by law, 23 survival suits that met DCG 2205 revisions for naval mariner safety codes, which were last inspected by the DCG on June 3, 2206.
The radio room, located one deck below the navigation deck, was equipped with a main transmitter and receiver, an emergency transmitter and receiver, and a single-sideband radio transceiver. Although the radio equipment did not meet current DCG naval standards, the ship was exempt under DCG-TRF-2199STR(a) guidelines.
Bilge and ballast system. The Upper and lower ballast tanks in each hold were connected by two vertical risers, port and starboard, without valves. The upper ballast tanks were filled by pumping through the port and starboard ballast manifolds into the lower ballast tanks until they were filled, and then the water rose through the vertical risers until the upper ballast tanks were full. Water was discharged from the ballast tanks through the piping in the lower ballast tanks using suction valves in the ballast manifolds. The three original K3 Cargo pumps were used as ballast pumps. New bilge and ballast valve manifolds were installed in the aft pumproom. Each wing ballast tank was serviced via a single 2-decimeter pipe, and each cargo hold bilge via a single 1.5-decimeter pipe. The Port pump serviced the port-side ballast tanks, and the starboard side pump serviced the starboard-side ballast tank, although pumps could be cross-connected. The center pump normally serviced the cargo hold bilges; however, while the SV BEZHIN was in the ore trade, the cargo hold bilge wells were covered with steel plates, rendering the system inoperative.
Stability and Loading. - Because the SV BEZHIN was a cargo ship, it was not required by VBS or DCG, or any international convention, to meet any subdivision or damage stability standards. The ship's collision bulkhead was located about 20 meters aft of the forward perpendicular (FP). (Before conversion, the collision bulkhead was located about 12 meters aft of the FP.) The SV BEZHIN had a DCG-approved trim, stability, and loading manual dated May 1 2199. In addition, a SHIPPING VARIETY port captain developed some standard loading conditions in 2201 for use by the master. The temporary master testified that when he had been carrying grain between Desovo and Shive, he would calculate the metacentric height (GM), which ranged from 1-1.2 meters, and the stress numeral, which ranged from 95 to 98, for the loaded portion of the voyage. However, after a while, he was instructed to stop performing the GM and stress numerical calculations because they carried the same load each voyage, and it was difficult to estimate the residual grain that remained onboard after discharging. To reduce the turnaround time of the ship, some grain was left in the holds upon completion of discharge.
Inspections and repairs. - From November 8 to November 27, 2206, the SV BEZHIN was at Sunway Mariners for drydocking and routine repairs. During this time, a VBS surveyor conducted a drydocking survey, an intermediate hull survey, a tailshaft survey, and a port and starboard boiler survey; commenced a special survey of machinery; and witnessed hull gaugings which were later credited towards the special survey of the hull. A Shipping Variety engineer took additional hull gaugings, and DCG inspectors conducted a drydock inspection.
While in the shipyard, doubler plates were installed on the sloping bulkheads of port and starboard upper wing tanks. The lower wing tanks were found to be satisfactory; however, both the VBS surveyor and DCG inspector issued a requirement that the upper wing tanks be retested at a later time after leaks, which were found in the welds at the doubler plates, were repaired.
The original bow section was examined internally and found satisfactory by the VBS surveyor; however, the DCG inspector required that doubler plates be installed on the upper fore bulkhead due to significant wastage that exceeded the maximum allowable limit. In total, ninety-three doubler plates were installed on panels of all five hatch covers, wasted sections of the hatch coaming, and the deck. Over seventy hatch hold-down bolt clips had to be replaced on all five hatches. The hatch covers were inspected and found to be satisfactory by the VBS surveyor. Although the new doubler plates on the hatches were hose tested as required by the VBS surveyor, the DCG inspector did not test the hatches to DCG standards as the repairs were done following his inspection.
After departing the shipyard, the SV BEZHIN transported grain between Desovo and Shive until December 2207. On May 9 2207, the upper wing ballast tanks were satisfactorily tested in the presence of a DCG inspector. During May 2207, SV structural engineers drew up preliminary specifications for work to be performed on the SV BEZHIN. The specifications included steel renewals as required by DCG regulations and additional structural renewals, including extensive plate renewals to the transverse bulkheads in the midship cargo area and twenty additional doubler plates along the port and starboard wing tanks.
The SV BEZHIN was in the Sunway Mariners shipyard from December 1st, 2207, to March 27th, 2208, and was on dry dock during the period from January 18 to January 23, 2208. The structural renewals, as required, and the additional doubler plates per DCG regulations were accomplished. A VBS surveyor completed a drydocking survey, an annual classification survey, an annual load line inspection, and a special survey of the hull. Additional gauging was taken of the hull and main decking, and a requirement for twenty-seven additional doubler plates was put into place.
The SV BEZHIN was attempted to be re-entered service on April 3rd, 2208, as a bulk ore carrier; however, DCG inspectors found the condition of the vessel unsatisfactory and denied it without a further thirty-two doubler plates. Shipping Variety applied for a deferment of the required work until December of 2208, which was granted.
A review of Shipping Variety records indicates that, during the ship's last drydocking in December 2207, until its sinking in 2208, numerous repairs had been made to the cargo holds and wing tanks as a result of damage incurred during the offloading of cargo. Shipping Variety considered the repairs temporary and did not report them to DCG inspectors or shipyard surveyors. A temporary master who had been serving on the SV BEZHIN testified that even though the ship's hatch covers had some defective dogs, gaskets that needed repair, and panels with temporary patches, the hatch covers were weathertight when he had been to sea. The only exception was after the panel of the No. 4 hatch cover, where the master had specifically requested that some holes not be patched, so the Shipping Variety marine superintendent could observe the degraded condition of the hatch covers when he attended to the ship. Shipping Variety records indicated that following the drydocking 2207, the permanent chief mate reported he believed the hatch covers were not weathertight due to damaged gaskets and significant wastage on the hatch plating.
Survival Aspects
After entering the water, the Utility Man (UM) swam on his back until he came across two other persons floating near the aft liferaft, which had successfully deployed. He testified as follows:
"Im not sure when I noticed that they weren't holding onto the liferaft. I don't know how long I was holding onto the liferaft before I noticed the only one there with me was the chief engineer. I could hear the radio operator saying he was cold and he couldn't swim, he kept saying "i'm cold, i'm cold, help," but I couldn't see him. I noticed the chief engineer they (sic) was starting to get cold real fast, because he didn't have his suit on just a [life] vest. I climbed into the raft and tried pulling him [chief engineer] into the raft. He didn't have any strength. I was doing as much as I could, but it was so cold. When it gets cold, you lose all your strength and freeze up, you know. I saw the plane fly overhead a few times, and when I looked back, I turned to tell [chief engineer] that rescue was here and [he] wasn't near the liferaft anymore. It was just me."
When DCG CJ14252 arrived on-site around 1900, the crew reported seeing "A singular light in the water that was attached to a liferaft." Shortly thereafter, the THEOASA arrived and began search and rescue operations. The THEOASA located the liferaft and was able to verify one person onboard. Crewmen from the THEOASA climbed down netting in an attempt to rescue the survivor on board; however, due to rough seas, the liferaft was pushed into the port side of the THEOASA and tipped over, ejecting the survivor from the liferaft. CJ14252 was called to assist in locating the survivor; however, he could not be located despite continued efforts. At 1940, the DCG ELOO arrived on scene, and the THEOASA was released from continued search and rescue efforts. CJ14252 would continue to search until 0630 on November 28th, and was replaced by CJ24217 at 0700.
The DCG cutter PORT STEFAN arrived at 0452 on November 28th to assist the DCG ELOO in search and rescue efforts. DCG PORT STEFAN deployed two RHIBS (rigid hull inflatable boats) to increase the search area. At 0742, the DCG ELOO would locate one victim floating in the water equipped with a 2180s era floatation vest, but no survival suit, and perform recovery operations 3NM south south east of the last estimate location of the SV BEZHIN. At 0815, one of these RHIBs would locate a liferaft 7NM south of the last known AIS location of the SV BEZHIN. One survivor was located in the raft wearing a survival suit, and a second victim was located approximately 400 meters west. Crewmembers rescued the survivor from the liferaft and performed recovery operations on the deceased, also wearing a 2180s flotation vest without a survival suit. At 0845, the PORT STEFANs #2 RIB returned and loaded the survivor onto DCG CH1272, which departed at 0915. The PORT STEFAN continued searching for survivors throughout the night until the morning of 0600 Dec 1. On December 3, a final helicopter search was conducted between 0724 and 1030. The active search was suspended at 1600 when the DCG ELOO departed the scene.
The DCG Chief of search and rescue operations for this mission testified that the primary factor behind locating survivors was the significant difficulty in determining the SV BEZHIN's actual position. He also testified that the DCG Guideline for dispatching ready helicopters, which is 45 minutes, was exceeded in this case, because the pilot of the ready helicopter believed that, after reviewing severe on-scene weather, the helicopter on station was not fit to navigate or perform search and rescue operations. When questioned concerning the delayed response, the pilot stated that he had talked with DCG Naval weather operators for some time and that he ultimately decided the on-station ZH-2M Helicopter would be unable to handle the significant reported windspeed.
Tests and Research
Stability. - The DCG Marine technical and Hazardous Materials division in Castasus Desovo performed intact and damage stability calculations to determine the SV BEZHINS intact stability when it departed Declav, Madjar, November 26, 2208, and to investigate certain assumed flooding conditions on November 27, 2208. The intact stability calculations showed that SV BEZHIN departed with a GM of 1M and a positive stability of up to 73° of heel, assuming no flooding and a 40-knot beam wind, resulting in a 0.5° heel. The DCG requires a minimum GM of 0.5M. For calculating the SV BEZHINS intact condition, the depth of the ship at bow was assumed to be 17M. To determine the righting movement at any given angle of heel, the righting arm was multiplied by the displacement of the vessel, or 32500 long tons. The ship's estimated natural roll period was 13 seconds.
To perform the damage stability calculation, the DCG considered 22 cases of assumed flooding. The cases were examined to prove logical combinations of assumed flooding, which analytically presented the lists and trims observed by the eyewitness. The forward pumproom was not included because it was not common with shell plating. Cases 2 through 19 represented hull damage, and cases 20 to 22 represented flooding through the hatch covers. Permeabilities of 0.98 and 0.95 were assumed for ballast tanks and the compartments forward of the collision bulkhead, respectively. The permeability of the holds loaded with ore was determined by laboratory tests conducted by the Desovan Maritime testing and engineering department using ore similar to that transported by the SV BEZHIN. The permeability of the hold was determined to be 0.4, and the angle of repose of the ore was 25°.
During tests 20 and 22, it was determined that significant water intrusion via hatch covers No.1 and No.2 or hatch covers No. 1 and No.4 would result in a GM of only 20 centimeters. Water protrusion into the fore dry cargo bay was determined to hold a GM of 25 centimeters if flooding breached the fore bulkhead, which was noted to be in significant disrepair.
Full details on this testing are available in Appendix B.
Capsizing
When the Utility Man who survived the accident relieved the watch of the 4 to 8 AB at 1700, the SV BEZHIN was hove to heading into 6- to 8-meter seas. At that time, the Utility Man did notice a 6° to 9° trim by the bow, and 2-2.5m of water was flooding the deck near the No.1 hatch cover. Based on survivor testimony and DCG records, around 1725, the SV BEZHIN developed a 10° list to port, which rapidly increased until it capsized about 5 minutes later. Trim and stability calculations performed following the accident indicated that to develop a 6° to 9°trim by the bow would have required, at least, flooding the Nos. 1 and 2 cargo holds and most of the spaces forward of the collision bulkhead. A 10° port list would have required flooding both Nos 1 and 2 port wing tanks, as well as the port oil bunker. A 40-knot beam wind would have produced a list of about 0.5. Flooding the No.1 Port wing ballast tank alone would have resulted in a 3.0° heel, flooding of the port oil bunker would result in a 1.5° and flooding Nos. 1 and 2 Port wing tanks would have resulted in a 7.5°heel angle.
The Utility Man and 4 to 8 AB should have been able to note a 1° to 2° port or starboard permanent list, even though the ship may have been rolling, since the bridge was equipped with a transverse inclinometer. However, a bow trim of up to 3°would not have been as apparent because of the pitching motion of the ship. The Ultity man recalled overhearing at 1630 to 1700 that Nos. 1 and 2 port ballast tanks were being pumped out. The Safety Department concludes that the engineers were pumping the Nos. 1 and 2 port wing tanks; however, it could not determine, based on the survivors' statements, that both tanks, in fact, had flooded. The 10° list at 1725 was probably the result of flooding of the Nos. 1 and 2 port wing tanks, as well as the port oil bunker. As the bow went deeper into the water, the SV BEZHIN lost her seakeeping ability, resulting in significant flooding; however, the asymmetrical flooding would only have increased the list rather than cause the ship to capsize. The sudden capsizing at 1730 was the result of the loss of all positive stability as the bow went deeper underwater, and not further asymmetrical flooding of the wing tanks.
Flooding
Based on the limited available evidence and testimony, the Safety Department could not determine the cause of the flooding in SV BEZHIN's forward compartments; however, there are several possible causes, including hatch cover failure, damage caused by the anchor, and hull structural failure. Each possible cause is discussed separately in Appendix C
Older Ships
The SV BEZHIN, which was built in 2151 and converted in 2172, is the second Desovan registered ship built during the post-Imperial Reclamation war boom, which has been lost during the last three years. In December 2206, the TI FAIRSEAS disappeared in the Illishiran seas about 50 NM north of Rainjas during a severe storm. The TI FAIRSEAS was converted in 2171, also by Fortis Heavy Industries, from a K2 Tankship to a bulk carrier. Approximately 23 percent of the Desovan seagoing fleet is over 30 years old. Although the Safety Department in the last 3 years also investigated the total loss of three other major vessels less than 10 years old, these losses did not raise any questions about the structural integrity of the vessels. The loss of the TI FAIRSEAS and the SV BEZHIN, on the other hand, may have involved these factors and raised the possibility that owners, operators, the VBS, and the DCG should subject older vessels to more comprehensive inspections. Although the VBS survey requirements increase their scope and depth at every succeeding special survey up to special survey No. 6 (24 to 30 years after construction), there are no additional requirements for vessels over 30 years of age. DCG inspection regulations do not include any special accommodation or have any special requirements based upon vessel age, and the DCG has not issued any standard policy or written guidance for its inspectors to follow when conducting inspections of older vessels.
The records and testimony of the VBS surveyor and DCG inspector who attended the 2206 drydocking of the SV BEZHIN showed that a comprehensive VBS special survey No. 8 and DCG drydocking inspection were conducted and that extensive structural renewals were required as a result. The cargo hatch covers, however, were not hose tested or otherwise tested for weathertightness as required by VBS special survey No. 8. The records and testimony of SHIPPING VARIETY representatives indicated that "regular' repairs had been performed on SV BEZHINS cargo hatch covers and bulk cargo holds (to correct damages caused by unloading equipment) and the main deck between hatch coamings. The 2206 gaugings indicated that extensive plate and stiffener renewals were required for the hull structure to meet the required standards. The structural calculations performed after the accident, which indicated that stresses were within design standards, used average wastage values in determining the longitudinal hull strength of the SV BEZHIN. However, some local areas of wastage may have developed during the 2-year period since the last gaugings were taken, which, in the sea conditions of November 26 and 27 2208, could have led to a local structural failure. The Safety Department believes that the SV BEZHIN's continuous need for structural repairs of the hatch covers, main deck, and cargo holds (which it does not view as "regular" repairs) also indicates that a parallel deterioration of structural strength of the vessel must have been in progress over the preceding 2 years due to the wasting of underwater hull plating. The next extensive gaugings would not have been required until 2210. The Safety Department believes that the VBS and DCG should require extensive gauging of all older vessels every 2 years during the biennial drydocking rather than every 4 to 5 years at special surveys. If such gaugings are performed during regular drydock periods, the added cost to the owner should be minimal. The Department also believes that the DCG should publish additional specific guidelines for DCG inspectors who conduct inspections of such older vessels.
Conclusions
Findings
On November 27, 2208, the SV BEZHIN capsized and sank after its forward compartments flooded.
The SV BEZHIN had sufficient intact stability before flooding to withstand the wind and sea conditions it experienced on November 26 and 27, 2208.
The SV BEZHIN's No. 1 hatch cover failed, but not until some other structural failings had occurred, causing a significant trim by the bow due to flooding.
The SV BEZHIN was loaded correctly when it departed Declav, Madjar, November 26, 2208.
The blocking of the bilge sections in cargo holds with steel plates did not contribute to the accident.
The SV BEZHIN's hatch covers were probably weathertight when the ship left Declav, Madjar, November 26, 2208.
The Veiid Bureau of Shipping did not test the weathertightness of the SV BEZHIN's hatch covers at the last special survey in November 2206 as required by VBS guidelines.
The Veiid Bureau of Shipping annual survey in November 2206 did not detect the extensive wastage which existed on the SV BEZHIN's hatch covers at that time.
The Desovan Coast Guard does not provide its inspectors with adequate guidance on their responsibility for inspection of items, such as the weathertightness of hatch covers, covered by the Load Line Regulations, which are administered by the VBS.
The Desovan Coast Guard does not provide its inspectors with adequate written guidance for the inspection of vessels over 20 years of age.
Although they do not require more frequent gaugings for older vessels, the VBS rules for special surveys generally provide for stricter inspections on older vessels.
The Desovan Coast Guard and the Veiid Bureau of shipping could enhance the safety of older vessels by requiring gauging of vessels over 20 years of age at more frequent intervals.
The crew of the SV BEZHIN was not provided with adequate training for abandoning ships on short notice, which contributed to the death of 19 persons.
The crew of the SV BEZHIN was not provided with adequate training for utilizing protective equipment for abandoning ship in a cold environment, which contributed to the death of 2 persons from hypothermia.
The boarding ladders and hand grabs on the DCG-approved liferafts were not adequate for their intended function and prevented several crewmembers from successfully boarding a liferaft.
Although the earlier arrival of a Desovan Coast Guard rescue helicopter probably would have saved some lives, the Coast Guard responded reasonably and in a timely manner under the severe weather conditions. The additional time required to launch the ready helicopter was used to evaluate the severe weather conditions to verify the capacity of the helicopter.
The Federal Communications Bureau needs to take further actions to ensure the reliability of SHREPCO Harpoon FB2-CW EPIRB.
RECOMMENDATIONS
While the investigation of this accident was in progress, the Veiid Transit Safety Department made the following recommendations:
--to the Desovan Coast Guard:
Conduct a design study to determine the adequacy of existing boarding systems of Coast guard-approved inflatable liferafts regarding the marking of the location and ease of rigging of the boarding ladders or equivalent, and the ability of persons in the water, including those wearing exposure suits, to use the boarding ladder and hand holds or equivalent, and require design changes encompassing both new and existing liferafts found to have inadequate boarding systems.
Status: No response
Reevaluate the water temperature analysis underlying the Coast Guard's proposal to exempt vessels operating in southern waters from having to carry exposure suits as standard, and modify the proposal to an appropriate limit to vessels operating where the water is over 15 degrees year-round.
Status: No response.
Require that exposure suits and adequate training in their use be provided for each crewmember, scientific personnel, or industrial personnel on tank vessels, passenger vessels, cargo and miscellaneous vessels, mobile offshore drilling units, offshore supply vessels, small passenger vessels, and oceanographic vessels that operate in areas where water temperature is below 15 degrees.
Status: No response.
-- To Shipping Variety:
Provide additional evacuation training for each person on board all its vessels that operate in waters where hypothermia can greatly reduce an individual's survival time.
Status: Open - Acceptable action.
--To Desovan Coast Guard Standards Board
Provide written guidance to Desovan Coast Guard inspectors regarding the inspection of vessels over 20 years of age, including specific structural gauging, equipment renewal, and testing requirements.
Require that structural gaugings of vessels be conducted at a 2-year interval after a vessel reaches 20 years of age.
Provide written guidance to Coast Guard inspectors further specifying their responsibility of inspecting items, such as weathertightness of hatch covers, that have been delegated to the Veiid Bureau of Shipping under the Load Line Regulations.
Evaluate the design of the bilge pump systems in cargo holds of Desovan-flag bulk carriers similar to the SV BEZHIN to determine if the systems are compatible with the cargo and require modifications if necessary to those vessels that do not comply with Coast Guard regulations.
Status: No response
--to the Veiid Bureau of Shipping
require that structural gauging of vessels be conducted at 2-year intervals after a vessel reaches 20 years of age.
Status: Open - Acceptable action.
To the Federal Communications Bureau
Require a design change to the SHREPCO Harpoon FB2-CW Emergency Position Indicator Radio Beacon to improve its maintainability and operation.
Status: No Response.
BY VEIID TRANSIT SAFETY DEPARTMENT