Marine Safety Investigation Unit
MARINE SAFETY INVESTIGATION REPORT
Safety investigation into the rollover of a commercial vehicle
on board the Maltese registered passenger / car ferry
GAUDOS
while underway between Ċirkewwa Terminal, Malta
and Mġarr Harbour, Gozo
on 30 January 2015
201501/041
MARINE SAFETY INVESTIGATION REPORT NO. 12/2015
FINAL
ii
Investigations into marine casualties are conducted under the provisions of the Merchant
Shipping (Accident and Incident Safety Investigation) Regulations, 2011 and therefore in
accordance with Regulation XI-I/6 of the International Convention for the Safety of Life at
Sea (SOLAS), and Directive 2009/18/EC of the European Parliament and of the Council of 23
April 2009, establishing the fundamental principles governing the investigation of accidents
in the maritime transport sector and amending Council Directive 1999/35/EC and Directive
2002/59/EC of the European Parliament and of the Council.
This safety investigation report is not written, in terms of content and style, with litigation in
mind and pursuant to Regulation 13(7) of the Merchant Shipping (Accident and Incident
Safety Investigation) Regulations, 2011, shall be inadmissible in any judicial proceedings
whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless,
under prescribed conditions, a Court determines otherwise.
The objective of this safety investigation report is precautionary and seeks to avoid a repeat
occurrence through an understanding of the events of 30 January 2015. Its sole purpose is
confined to the promulgation of safety lessons and therefore may be misleading if used for
other purposes.
The findings of the safety investigation are not binding on any party and the conclusions
reached and recommendations made shall in no case create a presumption of liability
(criminal and/or civil) or blame. It should be therefore noted that the content of this safety
investigation report does not constitute legal advice in any way and should not be construed
as such.
© Copyright TM, 2015.
This document/publication (excluding the logos) may be re-used free of charge in any format
or medium for education purposes. It may be only re-used accurately and not in a misleading
context. The material must be acknowledged as TM copyright.
The document/publication shall be cited and properly referenced. Where the MSIU would
have identified any third party copyright, permission must be obtained from the copyright
holders concerned.
MARINE SAFETY INVESTIGATION UNIT
Malta Transport Centre
Marsa MRS 1917
Malta
iii
CONTENTS
LIST OF REFERENCES AND SOURCES OF INFORMATION .......................................... iv
GLOSSARY OF TERMS AND ABBREVIATIONS .............................................................. vi
EMERGING SAFETY CONCERNS .........................................................................................x
SUMMARY ............................................................................................................................ xii
1 FACTUAL INFORMATION ................................................................................................1
1.1 Vessel, Voyage and Marine Casualty Particulars ..........................................................1
1.2 Description of Vessel .....................................................................................................2
1.3 Gozo Channel Co Ltd ....................................................................................................3
1.4 Crew Members ..............................................................................................................4
1.5 The Terminals in Malta and Gozo .................................................................................5
1.6 The Commercial Vehicle and its Driver ........................................................................6
1.7 Location of the Accident and Prevailing Weather Conditions ......................................8
1.8 Narrative ........................................................................................................................9
1.8.1 Cargo loaded on the truck .......................................................................................9
1.8.2 Loading of the truck on board Gaudos ...................................................................9
1.8.3 The lashing and the securing of the truck .............................................................12
1.8.4 The trip between Ċirkewwa Terminal and Mġarr Harbour ..................................12
1.9 Reported Damages .......................................................................................................14
2 ANALYSIS .........................................................................................................................17
2.1 Purpose ........................................................................................................................17
2.2 The Truck ....................................................................................................................17
2.2.1 Chassis and securing points ..................................................................................17
2.2.2 The loading of cargo on the truck .........................................................................18
2.2.3 The restraining of the cargo on the truck ..............................................................19
2.2.3.1 Web lashing and prevailing weather conditions ...........................................23
2.3 The Decision to Load the Truck on Board ..................................................................24
2.3.1 Goal conflicts ........................................................................................................25
2.4 Lashing of Vehicles on Board and Lashing Equipment ..............................................26
2.4.1 Lack of lashing points on the truck as a principle source of danger .....................26
2.4.2 Available lashing equipment on board .................................................................28
2.4.3 The lashing procedure ..........................................................................................28
2.5 Actions by the Master ..................................................................................................32
2.5.1 The route taken .....................................................................................................32
2.5.2 Recognition-primed decision making ...................................................................34
2.6 Passengers inside the Vehicle Cargo Space when the Vessel is Underway ................36
2.7 Reporting of the Accident ............................................................................................37
3 CONCLUSIONS .................................................................................................................40
3.1 Immediate Safety Factor ..............................................................................................40
3.2 Latent Conditions and Other Safety Factors ................................................................40
3.3 Other Findings .............................................................................................................42
4 ACTIONS TAKEN .............................................................................................................43
4.1 Safety Actions Taken During the Course of the Safety Investigation .........................43
5 RECOMMENDATIONS ....................................................................................................44
LIST OF ANNEXES ................................................................................................................45
iv
LIST OF REFERENCES AND SOURCES OF INFORMATION
Cacciabue, P. C., Fujita, Y., Furuta, K., & Hollnagel, E. (2000). The rational choice of
"error". Cognition, Technology & Work, 2(4), 179-181
Dekker, S., & Hollnagel, E. (2004). Human factors and folk models. Cognition,
Technology & Work, 6(2), 79-86
Department of Transport. (2002). Code of practice. Safety of loads on vehicles
(3rd
Ed.). London: Author
Derret, D. R. (2001). Ship stability for masters and mates (5th
Ed.). Woburn:
Butterworth-Heinemann
Dörner, D. (1989). The logic of failure: recognizing and avoiding error in complex
situations. Cambridge: Perseus Books
European Commission [EC]. (1994). Council Resolution of 22 December 1994 on the
safety of roll-on/roll-off passenger ferries (94/C 379/05). Brussels: Author
EC Directive 1999/35/EC on a system of mandatory surveys for the safe operation of
regular ro-ro ferry and high-speed passenger craft services, as amended
EC Directive 2009/45/EC on safety rules and standards for passenger ships
EC. (2014). European best practice guidelines on cargo securing for road transport.
Brussels: Author
Flin, R., O'Connor, P., & Crichton, M. (2008). Safety at the sharp end: a guide to
non-technical skills. Aldershot: Ashgate Publishing Limited
Gozo Channel Co. Ltd - Safety Management System Manual and Statutory
documentation
Gozo Ferries Co. Ltd - CCTV footage
International Maritime Organization [IMO]. (1997). Amendments to the guidelines
for securing arrangements for the transport of road vehicles on ro-ro ships
(Resolution A.581(14)) and the code of safe practice for cargo stowage and
securing (Resolution A.714(17)). London: Author
IMO. (2009). International convention for the safety of life at sea, 1974 (Consolidated
ed.). London: Author
IMO. (2011). Code of safe practice for cargo stowage and securing. London: Author
IMO. (2011). International Convention on Standards of Training, Certification and
Watchkeeping for Seafarers, 1978, as amended. London: Author
IMO. (2014a). Amendments to the Code of safe practice for cargo stowage and
securing (MSC.1/Circ.1352/Rev.1). London: Author
v
IMO. (2014b). IMO/ILO/UN ECE guidelines for packing of cargo transport units
(CTUs). MSC.1/Circ.1497. London: Author
International Organization for Standardization [ISO]. (1989). Lashing and securing
arrangements on road vehicles for sea transportation on Ro-Ro ships – General
requirements - Part 1: Commercial vehicles and combinations of vehicles, semi-
trailers excluded. ISO Standard 9367-1. Geneva: Author
Managers, master and crew, MV Gaudos
Merchant Shipping Act, 1973 as amended and relevant Subsidiary Legislation
Merchant Shipping Directorate – Transport Malta
Motor Vehicles (Weights, Dimensions and Equipment) Regulations, 2004 (Subsidiary
Legislation 65.21)
Pace & Mercieca Ltd –driver and company documentation
Ports & Yachting Directorate – Transport Malta
Reason, J. (1997). Managing the risks of organizational accidents. Aldershot:
Ashgate Publishing Limited
Simpson, P. A. (2001). Naturalistic decision making in aviation environments, DSTO-
GD-0279. Victoria: Defence Science & Technology Organisation-Aeronautic
and Maritime Research Laboratory
Viner, D. (2015). Occupational risk control. Predicting and preventing the unwanted.
Surrey: Gower Publishing Limited
Weick, K. (1993). The collapse of sensemaking in organizations: the Mann Gulch
disaster. Administrative Science Quarterly, 38(4), 628-652
Woods, D., & Cook, R. I. (1999). Perspectives on human error: hindsight biases and
local rationality. In F. T. Durso, R. S. Nickerson, R. W. Schvaneveldt, S. T.
Dumais, D. S. Lindsay & M. T. H. Chi (Eds.), Handbook of applied cognition
(1st ed., pp. 141-171). New York: John Wiley & Sons Ltd
vi
GLOSSARY OF TERMS AND ABBREVIATIONS
AB Able Seaman
cc Cubic Centimetres
Circ. Circular
Co Company
CSM Cargo Securing Manual – a Manual which is approved by the flag
State Administration and covers all relevant aspects of cargo
stowage and securing. It is required on all types of ships engaged
in the carriage of all cargoes, other than solid and liquid bulk
cargoes. The Manual is required in accordance with the
International Convention for the Safety of Life at Sea, 1974
chapters VI and VII, and the Code of Safe Practice for Cargo
Stowage and Securing. Cargo units, including containers, shall
be stowed and secured throughout the voyage in accordance with
the specifications in the Manual
CSS Code Code of Safe Practice for Cargo Stowage and Securing, adopted
by IMO Resolution A.714(17), as amended by IMO circulars
MSC/Circ.664, MSC/Circ.691, MSC/Circ.740, MSC/Circ.812,
MSC/Circ.1026 and MSC.1/Circ.1352/Rev.1
DOC Document of Compliance – a document issued to a Company
which complies with the requirements of the International Safety
Management Code
DPA Designated Person Ashore – appointed in terms of the
International Safety Management Code to serve as a link between
the Company and the crew members. The responsibility and
authority of the DPA includes monitoring the safety and pollution
prevention aspects of the operation of each ship and ensuring that
adequate resources and shore-based support are applied, as
required
DWT Deadweight – the difference in metric tonnes between the
displacement of a ship in water of specific gravity of 1.025 at the
load waterline corresponding to the assigned summer freeboard
and the lightweight of the ship
E East
(G) Gyro Course
GCCL Gozo Channel Co Ltd
GM Metacentric height - the vertical distance between the vessel’s
centre of gravity ‘G’ and the vessel’s metacentre ‘M’
GMT Greenwich Mean Time
vii
GPH General Purpose Hand
GT Gross Tonnage – a tonnage determined under the 1969 Tonnage
Convention. It is a function of the moulded volume of all
enclosed spaces of the ship. Gross tonnage is the basis for
manning regulations, safety rules, registration fees and port dues
GVW Gross Vehicle Weight – the road weight specified by the
manufacturer as being the maximum design weight capacity for
the vehicle, such weight being the combined weight of the
vehicle, maximum specified load, driver and a full fuel tank
IMO International Maritime Organization – the United Nations
specialised agency responsible for the safety and security of
shipping and the prevention of marine pollution by ships
ISM Code International Safety Management Code – the International
Management Code for the safe operation of ships and for
pollution prevention, as adopted by the IMO Assembly
iwo In way of
Kgs Kilogrammes
Kmhr-1
Kilometre per hour
kW Kilowatt
Lat Latitude
LOA Length overall
Long Longitude
LT Local time
Ltd Limited
m metres
mm millimetres
mt Metric tonnes
MSC Maritime Safety Committee
MSIU Marine Safety Investigation Unit
MSL Maximum Securing Load - the allowable load capacity for a
device used to secure cargo to a ship. Safe working load may be
substituted for maximum securing load for securing purposes,
provided that this is equal to or exceeds the strength defined by
the maximum securing load
viii
MSM Minimum Safe Manning – the number of qualified and
experienced seafarers necessary for the safety of the ship, crew,
passengers, cargo and property and for the protection of the
marine environment
MV Motor vessel
N North
NE’ly Northeasterly
NNW’ly North Northwesterly
NT Net Tonnage
NW’ly Northwesterly
OOW Navigational officer of the watch
PA Public Address
PFC Parallel flanged channels
PFRB Proficiency in Fast Rescue Boat
Ro-Ro Roll on, Roll off
RPM Revolutions per minute
SE’ly Southeasterly
S.L. Subsidiary Legislation
SMC Safety Management Certificate – a document issued to a ship
which signifies that the Company and its shipboard management
operate in accordance with an approved safety management
system
SMS Safety Management System – a structured and documented
system enabling Company personnel to implement effectively the
Company safety and environmental protection policy
SOLAS International Convention on the Safety of Life at Sea, 1974, as
amended
SSW South Southwest
STCW International Convention on Standards of Training, Certification
and Watchkeeping for Seafarers, 1978, as amended
SW’ly Southwesterly
(T) True Course
Tare Weight The weight of a vehicle without cargo and passengers on board
TM Transport Malta
ix
V Volts
VTS Vessel Traffic Service
W’ly Westerly
x
EMERGING SAFETY CONCERNS
Most of the safety investigations carried out by the Marine Safety Investigation Unit
(MSIU) are into casualties which would have resulted in either ‘very serious’ or
‘serious’ consequences, as defined in the relevant regulations of Subsidiary
Legislation 234.49. Although this particular accident has been classified as ‘less
serious’, the preliminary assessment of the evidence indicated that the occurrence
should be investigated. The decision to investigate was based on three main factors:
1. Safety concern on ro-ro passenger ferries. Over the years, safety on ro-ro
passenger ferries has been at the top of the agenda of the International Maritime
Organization and other maritime fora. This safety investigation report clearly
highlights the concerns which the MSIU has on the presence of passengers inside
the vehicle cargo spaces when the vessels are underway;
2. The potential of the findings of the safety investigation. The findings in this safety
investigation report have the potential to prevent future similar accidents. Typical
of safety investigations, the MSIU queries and investigates what is responsible
rather than who is responsible. This approach is adopted on the basis of the
philosophy that the crew members’ assessments, decisions and actions make sense
only when the critical features of the context in which they operate are understood.
The MSIU believes that the actions (or inactions) of Gozo Channel Co Ltd
employees should not be considered to be random but systemically connected to
features of their tools and tasks. The safety investigation report is targeting these
features because the potential for learning, change and eventual improvement is
contained therein.
Cultures evolve gradually in response to, inter alia, local conditions and past
events. These conditions may come with error-provoking characteristics and the
potential to ‘attract’ people into ‘unsafe acts’. This is very typical of safety critical
domains and has been observed by the MSIU in other accidents involving other
companies and types of ships. Therefore, Gozo Channel Co Ltd is neither unique
nor immune; and
3. Common safety issues. Gaudos and the other two sister ships provide a lifeline to
Malta and Gozo. The vessels and the services offered by the Company are crucial
xi
to both islands in terms of social and economic activities. The three vessels, which
carry thousands of passengers and vehicles every year, are operated under the same
safety management system. Therefore, safety issues identified on Gaudos apply to
the other two Company ships.
The purpose of this safety investigation report is to demonstrate the influence of the
prevailing context on the dynamics of the events and to make a number of
recommendations to enhance safety on board.
xii
SUMMARY
On 30 January 2015, at about 09001, the Marine Safety Investigation Unit (MSIU)
learnt from one of the local electronic media sites, that at about 0800, a commercial
vehicle rolled over on its side on the passenger / car ferry Gaudos. At the time, the
vessel was on her 0730 trip from Ċirkewwa Terminal, Malta to Mġarr Harbour, Gozo.
Gozo Channel Co Ltd, the managers of the ferry Gaudos, were immediately contacted
for more information. The MSIU also notified officials from the Ports & Yachting
Directorate and the Merchant Shipping Directorate within Transport Malta. Transport
Malta dispatched its officials to inspect the vessel. The MSIU also deployed one of
its representatives and launched a safety investigation into the occurrence.
Preliminary information collected from the accident site indicated that while Gaudos
was underway in strong Westerly to Southwesterly winds and moderate
Southwesterly swell, a commercial vehicle loaded mainly with a cargo of melamine
and other chipboard sheets, rolled over in the vehicle cargo space at 0755. At the
time, the vessel was approaching the entrance to Mġarr Harbour.
No injuries and pollution were reported. Moreover, there were no damages to other
vehicles inside the vessel’s vehicle cargo space. The vessel’s equipment sustained
minor damage, mainly to a nearby sliding passenger door, which leads from the
vehicle cargo space to the passenger spaces on the upper decks.
The safety investigation concluded that the immediate cause of the accident was the
improper loading and restraining of the cargo on the commercial vehicle and the
improper lashing of the vehicle to the deck.
The MSIU has made a number of recommendations to the managers of Gaudos and
the owners of the commercial vehicle, with the scope of enhancing safety in the
vehicle cargo spaces when Company vessels are underway.
1 Unless otherwise stated, all times in this safety investigation report are Local Time.
1
1 FACTUAL INFORMATION
1.1 Vessel, Voyage and Marine Casualty Particulars
Name Gaudos
Flag Malta
Classification Society DNV GL
IMO Number 9176319
Type Passenger / Car Ferry
Registered Owner Gozo Ferries Co. Ltd
Managers Gozo Channel Co. Ltd
Construction Steel (Double bottom)
Length overall 85.40 m
Registered Length 80.60 m
Gross Tonnage 4893
Minimum Safe Manning 11 with 500 passengers or less
15 with excess of 500 passengers
Authorised Cargo Ro-Ro
Port of Departure Ċirkewwa Terminal, Malta
Port of Arrival Mġarr Harbour, Gozo
Type of Voyage Coastal
Cargo Information 61 vehicles
Manning 15
Date and Time 30 January 2015 at 0755
Type of Marine Casualty Less Serious Marine Casualty
Place on Board Ship – vehicle cargo space
Injuries/Fatalities None reported
Damage/Environmental Impact Minor damage to the sliding door opening
mechanism and damages to the commercial
vehicle
Ship Operation Normal Service – In passage
Voyage Segment Arrival
External & Internal Environment Good visibility with strong Southwesterly winds
Force 5 to 6 and Southwesterly moderate swell
Persons on Board 171
2
1.2 Description of Vessel
The Maltese registered Gaudos (Figure 1) is a car / passenger ferry, built in 2001 at
Malta Shipbuilding Co Ltd, Malta. She is owned by Gozo Ferries Co Ltd and
managed by Gozo Channel Co Ltd (GCCL). The vessel has a Gross and Net Tonnage
of 4893 and 1468, respectively.
Gaudos has a length overall (LOA) of 85.40 m and a maximum beam of 18.30 m.
The vessel's summer deadweight (DWT) is 1100 mt at a draught of 4.10 m. The
vessel is certified to carry 900 passengers and 138 cars. She is classed by DNV GL
with a Class Notation 1A1 R3 (mlt) Car Ferry A DG-P E02.
Figure 1: MV Gaudos
2 Class notations are assigned by classification societies (in this case, it is DNV GL) in order to
determine applicable rule requirements for assignment and retention of class. Class notations cover
mandatory and optional requirements. Gaudos class notations were assigned as follows:
The construction symbol is assigned to ships built under the supervision of a recognised
classification society and later assigned class with DNV GL.
The notation 1A1 is assigned to ships with hull, machinery, systems and equipment found to be in
compliance with applicable rule requirements.
The service area notation R3 is assigned to ships with certain modifications to arrangement,
equipment or scantlings, in relation to ships built for unrestricted trade. With an area notation R3,
the vessel has a service area restriction of 20 nautical miles (winter seasonal zone),
50 nautical miles (summer seasonal zone) and 100 nautical miles (tropical seasonal zone).
Gaudos is limited to trade in Maltese coastal waters and the maximum distance from coast is
12 nautical miles; she is therefore given the Register Notation (mlt).
The main ship type class notation Car Ferry A is assigned to ro-ro ships (car ferries) designed for
regular transport of passengers and cars (cars on enclosed decks).
The DG-P is an optional class notation related to cargo. Vessels with this notation are arranged for
the carriage of dangerous goods in packaged form.
The E0 is an optional notation related to equipment and systems. Vessels with this notation are
fitted with instrumentation and automation to allow for unattended machinery spaces.
3
Gaudos is a double-ended vessel and has forward and aft bridges with change-over
commands. The use of either bridge depends on whether the ship is leaving
Ċirkewwa Terminal or Mġarr Harbour. This configuration minimises on turnaround
time, reduces fuel consumption and minimises risks during berthing and unberthing
operations.
Propulsive power is diesel electric, provided by four 6-cylinder Normo KRGB-6, high
speed diesel engines, each producing 1325 kW at 900 rpm. Each engine is coupled to
a generator, rated at 1200 kW (440 V). Each generator powers an EaUlstein Bergen
azimuth thruster, giving a total power of 5300 kW and a service speed of 13 knots3.
1.3 Gozo Channel Co Ltd
GCCL, the only ferry operator between the islands of Malta and Gozo, employs
around 200 people and operates three open-ended sister ships, i.e., Gaudos, Malita
and Ta’ Pinu. The three ferries complete about 20,000 trips annually, ferrying around
4.1 million passengers and 1.2 million vehicles, mainly between Ċirkewwa Terminal,
located at the Northern part of Malta, and Mġarr Harbour in Gozo. Cargo trips are
also performed regularly between Sa Maison (which is located on the Northern side of
the Valletta Peninsula) in Malta, and Mġarr Harbour.
The Company operates three schedules, i.e., the Winter Schedule (November to May),
the Summer Schedule (May to September) and the Mid-Season Schedule (September
to November). In all three schedules, trips are carried out around the clock, weather
permitting. At the time of the accident, Gaudos and Malita were operating on the
Winter Schedule, while Ta’ Pinu was in dry-docks at Palumbo Malta Shipyards Ltd.
The Company implements a mandatory Safety Management System (SMS). As part
of its SMS, Company SMS Manuals are available on board and at the Company’s
offices. These manuals provide Company instructions and procedures in compliance
with the International Safety Management (ISM) Code. The manuals also include
detailed job descriptions for all officers and ratings, the safe operation of Comapny
vessels and procedures on how the Company responds to unplanned events and
emergencies. The Company and its vessels are certified under the ISM Code. Copies
3 One knot is equal to 1.852 kmhr
-1.
4
of Gaudos’ Safety Management Certificate (SMC) and of GCCL’s Document of
Compliance (DOC) are annexed to this safety investigation report [Annex A].
1.4 Crew Members
At the time of the accident, Gaudos had 15 crew members on board, all Maltese
nationals. The complement included a master, a chief mate, one engineer, an assistant
engineer and eleven General Purpose Hands (GPHs), including the bosun. All crew
members on the crew list, bar for the bosun, were assigned a number from 1 to 10.
Each GPH had his own specific duties (to be affected when the vessel was at sea and
alongside); the duties being assigned in accordance with the GPH number on the crew
list. A number of GPHs were assigned to the Catering Department.
The crew compliment was in accordance with the Minimum Safe Manning (MSM)
Document [Annex B], issued by Transport Malta (TM)’s Ports & Yachting
Directorate. The MSM Document was issued on 01 October 2014 and is valid until
12 April 2019.
According to the Company’s SMS, the master’s duty station is always on the bridge,
responsible for the overall safety of the vessel while the chief mate’s duty station is on
the bridge when the vessel is at sea and in the vehicle cargo space when the vessel is
alongside. The bosun is responsible for the GPHs and in addition to other duties, he
monitors the loading of passengers and vehicles.
The master, who was 34 years old at the time of the accident, had been working for
the Company for 13 years, five years of which as a chief mate and as a master for the
last seven years. His Certificate of Competency was issued in Malta on 19 September
2014, under the provisions of regulation II/2 of the International Convention on
Standards of Training, Certification and Watchkeeping for Seafarers, 1978, as
amended (STCW) Convention.
The chief mate was 40 years old and had been employed by the Company for 10 years
in the rank of chief mate. His Certificate of Competency was issued on 01 November
2000, under the provisions of regulation II/1 of the STCW Convention.
5
The bosun, who was of 57 years old, had been working for the Company for 25 years.
Besides his Able Seaman (AB) Certificate, which was issued in 1995, he also held
certificates for basic training, including Crowd Management, Crisis Management and
Human Behaviour, Proficiency in Fast Rescue Boat (PFRB) and Marine Outboard
Engine Operator.
All of the other GPHs had a significant number of years of experience with the
Company. They all held a GPH Certificate, in addition to certificates in Crowd
Management, Crisis Management and Human Behaviour, PFRB and Marine Outboard
Engine Operator.
1.5 The Terminals in Malta and Gozo
Mġarr Harbour (Figure 2) is protected by a breakwater extending to the Northeast
(NE) and another arm extending to the South Southwest (SSW) from the shore to
form an ‘E’ facing entrance.
Figure 2: Mġarr Harbour
Although the Harbour itself is well protected, entering and leaving the Harbour
becomes more challenging when the weather is blowing strongly from the West (W)
and Southwest (SW). Ċirkewwa Terminal, which is situated at the Northernmost tip
6
of the island of Malta, was reconstructed in 2010 and now has three quays, which are
well protected from W’ly weather by means of a breakwater extending to the
Northeast (NE). The Terminal also has a marshalling area for the vehicles and a
passenger terminal.
1.6 The Commercial Vehicle and its Driver
The commercial vehicle (Figure 3) was an Isuzu ‘Forward Truck’ (truck) with a
Maltese registration. The truck was manufactured in 2003, imported second hand and
first registered in Malta in 2008 by Pace & Mercieca Ltd. The aft axle was fitted with
double-wheels. The truck had a registered engine capacity of 7160 cc, a Gross
Vehicle Weight (GVW) of 7960 kgs, a Tare Weight of 3710 kgs and a payload of
4150 kgs4, at a loading height of 970 mm.
Figure 3: The truck after the accident
The truck had a cargo wooden flatbed, measuring 5200 mm in length and 2250 mm in
width. The sideboards (dropsides), which were made of aluminium, had a height of
400 mm each. The headboard was made of steel and had a height of 1500 mm (up to
the top of the driver’s cabin).
4 The payload value was extracted from the specifications document, supplied by the owner. A
payload of 4350 kgs was stamped on the tailboard of the truck.
Left Sideboard
(dropside)
Headboard
Tailboard
7
The truck’s cargo wooden flatbed was constructed of two wooden beams running
along the two steel Parallel Flanged Channels (PFC) that form part of the chassis.
The wooden beams and the steel PFCs were made fast together using a number of
‘D’ shackles and ‘V’ plates (Figures 4a and 4b). Attached to these two ‘wooden
chassis beams’ were a number of transverse wooden stiffeners (90 mm by 60 mm),
fitted at intervals of 340 mm.
The flatbed was constructed on these transverse wooden stiffeners, using a number of
wooden boards running longitudinally. The hooks for the web lashings were fitted to
the transverse wooden stiffeners (Figure 4b).
Figures 4a and 4b: Steel chassis, wooden beam, the ‘D’ shackle (left picture) and ‘V’ plate (right
picture). Hooks for the web lashing are also marked in the right picture
The driver, who was 67 years old, was very experienced and had been working for
Pace & Mercieca Ltd for 18 years. His duties included the loading of the vehicle and
delivering hardware around Malta and Gozo.
8
1.7 Location of the Accident and Prevailing Weather Conditions
The accident happened in the Gozo Channel, in proximity to Mġarr Harbour entrance,
approximately in position 36° 01.51’ N 14° 18.22’ E (Figure 5).
Figure 5: Approximate position of the accident, just outside Mġarr Harbour
The Gozo Channel is the short stretch of sea separating the small island of Gozo from
the main island of Malta. The distance is just under three nautical miles. The Gozo
Channel is a busy channel, especially during the summer months, with regular and
frequent ferry service offered by GCCL. This stretch of sea is well sheltered from the
Northwesterly (NW’ly) weather, which is the prevailing weather over the Maltese
island; but not so much from the W’ly and Southwesterly (SW’ly) weather.
The weather forecast for 30 January 2015 was windy with strong W’ly to SW’ly wind
Force 6 to 7, locally Force 7 to 8. The sea was rough becoming very rough and the
NW’ly swell was low, becoming W’ly and then SW’ly.
© 2015 Google
9
1.8 Narrative
On Friday, 30 January 2015, at 0430, a scheduled crew change was carried out on
board Gaudos. The relieving crew members manned the 0500 trip from Mġarr
Harbour, the 0545 trip from Ċirkewwa Terminal, and then the 0645 trip from Mġarr
Harbour. All the trips were uneventful.
1.8.1 Cargo loaded on the truck
Early on Friday, the truck loaded the cargo from a warehouse at Mrieħel, Malta. The
driver drove to Ċirkewwa Terminal to catch the 0730 ferry trip to Gozo. These
deliveries were made on a regular basis to Gozo and this was not the first time that
this particular truck driver delivered similar cargoes to Gozo.
Evidence indicated that the cargo consisted of 159 sheets of melamine and other
chipboard sheets, measuring 2440 mm by 1220 mm of various thickness (16, 18 and
19 mm). 12 pieces of wooden planks, (eight of 25 mm and four of 40 mm in
thickness) were also loaded on the truck. The sheets were stowed in two piles with
spacers placed between the different types of chipboard sheets. The planks were
loosely stowed in between the piles and the truck sideboards. The two piles of
chipboard sheets were lashed in place by six webbing straps and made fast to the
vehicle’s lashing hooks located on the outside and underneath the sideboards.
The truck arrived at Ċirkewwa Terminal just before 0730. No particular issues were
reported by the driver, who joined the queue of vehicles waiting in the marshalling
area of the Terminal.
1.8.2 Loading of the truck on board Gaudos
Gaudos arrived at Ċirkewwa Terminal at about 0715 and made fast alongside Quay
No. 2. The master remained on the bridge while the chief mate proceeded to the
vehicle cargo space in order to coordinate and supervise the unloading and loading of
the vehicles. In line with their designated duties, three GPHs and the bosun were also
stationed in the vehicle cargo space during the cargo operation. Once the ramp was
lowered, the unloading of vehicles commenced immediately.
The loading operation commenced soon after the unloading was completed. The first
to be loaded was a commercial vehicle carrying marble slabs. The vehicle, which had
10
four hydraulic outrigger jacks, was directed towards the forward end of the vehicle
cargo space. The outrigger jacks were lowered and two chains were used to lash the
vehicle to the deck. The rest of the cars were then loaded.
When the last few cars were being loaded, the truck was stopped and the driver was
requested to wait on the side on the shore linkspan. Following the loading of all the
cars, the truck driver was authorised by the chief mate to proceed on board, where he
parked inside the inboard starboard lane close to the stern ramp (Figure 6). A total of
61 vehicles were loaded. By this time, it was already 0730 and the chief mate
proceeded immediately to the bridge while the GPHs were sent off to their mooring
stations by the bosun. The bosun made his way to the ramp control panel (in the
vehicle cargo space) to close the ramp and then to lash down the truck.
Four chains were used, two on each side of the truck. Two chains were secured at the
rear corners and two just behind the driver’s cabin. Once the chains were in place and
tightened by the chain tension levers, the bosun reported back to the bridge. Due to
the cargo lashing operation, the vessel’s departure was delayed by about seven
minutes.
11
Figure 6: The truck’s position in the vehicle cargo space (not to scale)
12
1.8.3 The lashing and the securing of the truck
For the lashing of commercial vehicles, Gaudos is equipped with 100 pieces of chain
of 2000 mm in length. Each chain is complete with a hook, an elephant foot and a
chain tension lever, all with a breaking load of 15 tonnes. For the lashing of cars, the
vessel has 50 web lashings, complete with hooks and elephant feet5. The breaking
load is 12 tonnes. The vehicle cargo space has 117 star inserts for the fitting of the
elephant feet (Figure 7).
Figure 7: Lashing chains, tension levers and a star insert
1.8.4 The trip between Ċirkewwa Terminal and Mġarr Harbour
Gaudos left Ċirkewwa Terminal Quay No. 2 at 0737, with three generators
synchronised on the switchboard. The use of three generators (and motors) was in
line with the Company’s normal standard procedure on all three ferries. As soon as
the ferry cleared the Ċirkewwa breakwater and turned to a more North Northwesterly
(NNW’ly) course, she started rolling due to the effects of the prevailing strong W’ly
weather. At this time, the master noticed that the weather conditions had worsened
since the previous trip.
5 For this trip, the web lashings were not used.
Lashing chain
Tension lever
Star insert
13
At 0746, the GPH assigned to watch the vehicle cargo space, reported to the bridge
that the cargo of melamine and other sheets on the truck was shifting due to the
vessel’s movement. Immediately, the master altered the vessel’s course further to
port in order to reduce the rolling by bringing the W’ly wind and swell closer on the
port bow. The master also ordered the fourth generator to be started and have it
synchronised on the switchboard to have maximum power on all four thrusters. The
master had also considered to turn the vessel back to Ċirkewwa Terminal but
eventually decided that this manoeuvre would have been too dangerous. Nonetheless,
after the master’s actions, it was noted that Gaudos was riding the waves more
comfortably.
In the meantime, the master and the chief mate adjusted the two CCTV monitors on
the garage camera so that they could continuously monitor the truck from the bridge
(Figure 8). However, only the truck’s cabin could be captured by the CCTV camera.
Figure 8: CCTV monitors on the bridge console
In the meantime, as soon as the GPH raised the alarm, the bosun and one other GPH
went down to the vehicle cargo space to assist. The driver was also called on the
vessel’s Public Address (PA) system and requested to proceed to the vehicle cargo
space. The bosun checked the lashings and at one point he also re-tightened one of
the chains. Since a number of passengers had remained in their cars in the vehicle
14
cargo space, the bosun also ensured that no passengers came in close proximity of the
truck at any time. As the vessel was approaching the entrance to Mġarr Harbour, the
GPHs returned to their mooring stations and only the bosun remained in the vehicle
cargo space, together with the truck driver.
At the approach to Mġarr Harbour entrance, the master had to perform a bold
alteration of course to port in order to bring the vessel on a W’ly course. With this
alteration of course, Gaudos’ port was temporarily exposed to the full force of the
W’ly wind and swell. The vessel rolled heavy to starboard and consequently, the
truck rolled over. The truck came to rest on its right side next to the starboard
bulkhead of the vehicle cargo space (Figure 9).
Figure 9: The truck on its right side after rolling over
1.9 Reported Damages
Soon after Gaudos was safe alongside, both the master and chief mate proceeded
immediately down to the vehicle cargo space. The master also informed the Duty
Terminal Manager of the accident. As a safety precaution, as soon as the master
arrived in the vehicle cargo space, he disconnected the truck’s batteries and rigged a
number of fire hoses.
No one was injured and no damages were reported to other vehicles. However, as the
truck and it’s load came to rest against the bulkhead in the vehicle cargo space
15
(Figure 9), a nearby passenger sliding door was slightly damaged (Figures 10 to 12).
The truck sustained significant damages, especially to its cabin (Figure 13).
Figure 10: The cargo load carried by the truck
Figure 11: The truck’s cabin against the damaged passenger sliding door
16
Figure 12: Damaged passenger sliding door on the vehicle cargo space
Figure 13: Damages to the truck’s cabin
17
2 ANALYSIS
2.1 Purpose
The purpose of a marine safety investigation is to determine the circumstances and
safety factors of the accident as a basis for making recommendations, to prevent
further marine casualties or incidents from occurring in the future.
2.2 The Truck
2.2.1 Chassis and securing points
Evidence indicated that no ferry securing points6 were fitted on this truck. IMO
Assembly Resolution A.581(14) – Guidelines for Securing Arrangements for the
Transport of Road Vehicles on Ro-Ro Ships, as amended by MSC/Circ.812
[Annex C] recommends that commercial vehicles, which are meant to use sea
transport, should be fitted with ‘securing points’; in this case, four securing points
(two points on each side) were required7.
Amongst other things, it is recommended that:
securing points should be marked in a clear visible colour;
are so located to ensure effective restraint of the vehicle by the lashings;
are so located that the lashings can be readily and safely attached; and
be capable of transferring directly the forces from the lashings to the chassis of
the vehicle.
Since the truck was not equipped with adequate ‘securing points’, the crew members
did not have the possibility to lash the truck adequately to the deck.
The MSIU is unaware of the number of commercial vehicles which are loaded daily
on board the three vessels managed by GCCL and which are not provided with an
adequate number of accessible ferry securing points of sufficient strength to ensure an
6 Ferry securing points are designed to allow the securing of road vehicles to ships’ decks.
7 Safety of ro-ro ferries and IMO Assembly Resolution A.581(14) had been also referred to in
Council Resolution of 22 December 1994 on the safety of roll-on/roll-off passenger ferries
(94/C 379/05), which was published in the wake of the MV Estonia disaster.
18
effective restraint of the vehicle by the ship’s lashing. Further to this lack of data, the
MSIU is concerned that a number of cargo owners may neither be necessarily aware,
nor appreciate the generated forces acting on cargo units when the vessel is navigating
in adverse weather conditions.
2.2.2 The loading of cargo on the truck
As described in sub-section 1.6 of this safety investigation report, the steel headboard
had a height of 1500 mm, up to the top of the driver’s cabin. The aluminium side and
tailboards had a height of 400 mm. The permissible load was 4150 kgs, at a height of
970 mm. The hooks for the web lashings were fitted to the transverse wooden
stiffeners.
At the warehouse, the truck was loaded with a cargo of 159 melamine and chipboard
sheets, and a number of wooden planks8. Taking into account the thickness of the
chipboard sheets, the height of these piles, including the wooden spacers, would have
reached more than 1500 mm.
Although the exact height cannot be verified, the photographs available provide a
clear indication that the piles were even higher than the headboard, which had a height
of 1500 mm (Figure 14). This exceeded the recommended payload height of 970 mm.
It was estimated that the centre of gravity of the cargo was around 750 mm (or even
more) above the flatbed of the truck.
With each chipboard sheet weighing about 30 kgs, the total weight of the 159 sheets
would have been 4770 kgs. Adding the weight of the loose wooden planks and the
wooden spacers, the total weight of the cargo on the truck amounted to around
4850 kgs, which was more than the permissible payload of the truck (4150 kgs).
Once the cargo had shifted to one side, the truck would have become less stable under
the influence of the accelerating forces generated by the vessel in the adverse weather
conditions. The alteration of course to port to enter Mġarr Harbour resulted in a
lateral force which would have been in excess of the roll stability threshold of the
commercial vehicle. The high centre of gravity of the cargo (which shifted away from
the truck’s centre line when the cargo shifted), would have also contributed to the
8 This information was provided to the MSIU by the truck’s Company.
19
truck’s rollover. It was evident that whilst the restraint system used in the warehouse
was suitable for the road journey to Ċirkewwa Terminal, it was inadequate for the sea
passage, where the cargo was subjected to significant dynamic accelerations.
Figure 14: Piles of chipboard sheets higher than the truck’s headboard
2.2.3 The restraining of the cargo on the truck
The two piles of chipboard sheets were lashed down using the over-top lashing
system9. The over-top lashing system is a securing method, where the lashings are
positioned over the top of the goods to prevent the cargo from either tipping or sliding
9 IMO documents refer to this system as ‘over-top lashing’ whereas European Union Commission
documents refer to the system as ‘top-over lashing’.
20
by pressing the cargo against the load platform. The system may be used in parallel
with other systems, e.g. transverse spring lashing (Figure 15).
Figure 15: Over-top lashing (top) in parallel with another restraining system (bottom)
Cargo lashing is not necessarily the only restraining method which can be applied.
Dunnage, shoring or battens may also be used to block cargo from shifting in cases
where there is excessive clearance on the sides (Figure 16).
Figure 16: Typical cargo blocking arrangements Adopted: MSC.1/Circ.1497.
21
Erection of side stanchions (Figure 17), fitted to reach the height of the cargo, is also
another method applied to restraint the movement of cargo on trucks10
.
Figure 17: Side stanchions reaching the height of the cargo Adopted: Code of Practice. Safety of Loads on Vehicles
© Crown Copyright, 2002
In this particular case, the two piles of chipboard sheets were placed at the centre of
the truck’s flatbed. Since the sheets had a width of 1220 mm and the width of the
flatbed was 2250 mm, there was a gap of around 500 mm on each side between the
piles and the sideboards.
Six fairly equally spaced web lashings, complete with a ratchet system, were used.
These web lashings were positioned over the top of the piles of chipboard sheets and
made fast to the trucks hooks, which were located outside and underneath the
sideboards (Figure 18).
10
Note that the truck in Figure 17 has no sideboards and would therefore allow a more effective over-
top lashing.
22
Figure 18: Web lashings used to secure the cargo on the truck
Positioning the load centrally rather than to one side of the truck was the better option
since longer restraints would have been required if the latter position had been
selected11
. However, although the over-top lashing is a recognising restraining
system, unless the cargo is blocked at the sides (e.g. by the use of dunnage as
indicated in Figure 16), cargo could still move during the transportation. Friction is
the force which prevents cargo from sliding and the friction coefficient is an important
factor in the equation; nonetheless, laminated boards are known to slide if not
properly secured. The coefficient of friction is independent of the weight of the cargo
and therefore heavy cargo would still shift, irrespective of its weight. Moreover,
vibrations, shocks and external forces can also cause cargo to shift.
11
With a load close to one side of the truck, any movement (towards the centre of the truck) would
have led to a loss of tension in the webbing, even if initially tight.
23
Notwithstanding that the six web lashings used were tightened down using the ratchet
mechanism, these lashings proved to be ineffective when the ship was experiencing
transverse accelerations during the sea passage and the alteration of course.
The MSIU identified the following contributing factors related to the securing of the
cargo on the truck:
the web lashings went over the truck’s sideboards (Figures 14 and 18), rather
than directly from the flatbed to the top of the piles (Figures 15 and 17);
the truck may have not necessarily been the ideal vehicle for the carriage of
this cargo, given that there was no other option for the web lashings but to pass
over the sideboards (this would have affected the tension on the web lashing);
the web-lashings was the only restraining method applied on the truck;
the gap of 500 mm between each sideboard and the piles of chipboard was not
neutralised (Figure 16);
some of the chipboard sheets were of the melamine type, with a very low
friction coefficient; and
the near vertical web lashing (in excess of 60° from the horizontal) provided
resistance to the cargo’s tendency to tip but on its own, it was unable to resist
the sliding forces acting on the cargo units as a result of the ship’s forces
arising mainly from rolling, swaying and pitching.
2.2.3.1 Web lashing and prevailing weather conditions
Further to the contributing factors identified above, the decision of the shipper to
apply six web lashing to the cargo was also analysed. Evidence available to the
MSIU did not indicate that the weather conditions were taken into consideration by
the shipper.
Although weather forecasts are locally available on line at no costs, GCCL website
provides minimal details on the weather - limited only to its condition and the air
temperature. Shippers do not have the necessary (live) details of the sea conditions
(waves and swell) and whether additional lashings should be applied before the cargo
leaves the warehouses and eventually loaded on the ferry.
24
2.3 The Decision to Load the Truck on Board
The crew members, who started their shift on board Gaudos at 0430 on 30 January
2015, were experienced with many years of service. They had been serving on this
ferry and performing the crossings many times over. They have been through all
types of weather conditions, including weather conditions similar to those experienced
on the day of the accident. Over the years, they have assisted in the loading and
unloading of thousands of vehicles. They also got to recognise all the commercial
vehicles that made the crossings on a regular basis and the types of cargo carried.
It was normal practice that during bad weather, both the master and the chief mate
would decide together which commercial vehicles were to be refused boarding by
spotting them from the bridge as the ferry was berthing, both at Ċirkewwa Terminal
and at Mġarr Harbour; although mainly at Ċirkewwa Terminal, from where most of
the laden vehicles were loaded to Gozo.
When Gaudos arrived at Ċirkewwa Terminal, the truck had not yet arrived at the
marshalling area since neither the master nor the chief mate noticed it from the bridge
while the vessel was coming alongside. After the berthing operation was completed
and the vessel safely moored alongside, the master remained on the bridge preparing
the changeover of the bridge and the next trip. The chief mate proceeded to the
vehicle cargo space to supervise the loading of the vehicles.
As a result of the bad weather, the vessel had arrived late at Ċirkewwa Terminal and
the crew were under pressure to unload and load the vehicles as quickly as possible so
that the ferry could depart on the scheduled time of 0730. There was a significant
number of vehicles waiting in the marshalling area. A total of 61 vehicles were
loaded, which, however, only took a few minutes to load on board.
The chief mate had seen the truck with similar cargo during previous voyages. The
truck had always been allowed on board without being inspected and had never been
involved in an accident. Moreover, the chief mate had to proceed immediately back
to the bridge as the time to depart was due; in fact, by this time all the deck GPHs
who were stationed in the vehicle cargo space, had gone to their respective mooring
stations, leaving the bosun on his own in the vehicle cargo space.
25
As a result of the situation and notwithstanding the condition of the cargo on the
truck, the driver was granted permission to board without the cargo units being
inspected, analysed and rectified as necessary.
2.3.1 Goal conflicts
The MSIU believes that the chief mate (and other crew members) had to deal with
organisational goal conflicts, which were clearly manifested on board. Typical of
safety critical domains12
, organisational goal conflicts are normally transmitted to the
individual practitioner, be it a Company employee on the quay or a crew member on
board. It is very clear that the Company is expected to provide trips which are safe,
punctual and where customers find value for money.
Studies in safety science have shown that in principle, it is rarely possible to achieve
the three expectations simultaneously and this accident was clear evidence of this13
.
These incompatible goals had to be negotiated and decided upon by the crew
members on board, including the chief mate as the crew member in charge of the
cargo operation.
This situation was such that pressure put on the organisation (GCCL) was being
transmitted to the crew members serving on board the Company ships. This was the
point where external pressure (the three expectations referred to above) was being
internalised and propagated vertically and horizontally within the Company’s
management and operational structures. The more the evidence was analysed and
studied, the clearer it became that in this particular occasion, the crew members had to
negotiate between safety and efficiency.
The MSIU believes that this phenomenon was not unique to this particular day when
the accident happened. Adherence to the schedule is an ongoing expectation because
the ferry service is considered to be a lifeline to Malta and Gozo. Thus, while the
three expectations are not necessarily possible to be achieved simultaneously, the
pressure on the Company in general leads its employees to pursue them; and
12
This phenomenon is not only observed in transportation domains but also in industries which do not
offer transportation services. Goal conflict is therefore not exclusive to GCCL and its ships.
13 Dörner (1989) raises an interesting discussion on goal conflicts and in so doing, he introduces the
concept of documentary integration of incompatibilities.
26
negotiating successfully these expectations is seen (internally and externally) as a sign
of competence.
2.4 Lashing of Vehicles on Board and Lashing Equipment
2.4.1 Lack of lashing points on the truck as a principle source of danger
The truck driver had made this trip to Gozo many times before. In the warehouse, the
driver had assisted with the loading and the restraining of the cargo on the truck. He
clarified that he had no role in the quantity of cargo that had been loaded. The driver
was responsible for the vehicle and the cargo it carried on the way to Ċirkewwa
Terminal. Accordingly, he clarified that he was not involved in any way with the
lashing of his truck on board Gaudos.
After the truck was loaded, the bosun had to first close the ship’s stern ramp and then
proceed to lash down the truck. He had informed the bridge to wait until the truck
was properly lashed down. The bosun then proceeded to apply four chains, one at
each corner of the truck, and engage each of the elephant’s feet to the nearest star
inserts on the deck of the vehicle cargo space. According to the bosun, he proceeded
to hook these chains to the truck’s chassis with the help of the truck driver.
The MSIU had conflicting evidence as to who had actually hooked which of the
chains to the truck’s chassis. However, irrespective of who has actually hooked the
chains to the truck, it had been deduced that the only way these chains could be
hooked to the truck was to the lower edge of the chassis’ two PFCs. Once hooked,
these chains were tightened using the chain tension levers. This meant that the
chains’ open hooks were engaged upside-down to the bottom edge of the chassis’
PFCs.
From the information gathered, including detailed inspections of the truck after the
accident at the truck’s company warehouse, it resulted that the four chains used had
neither failed nor were damaged prior to or as a result of the accident. Therefore, it
may be submitted that the two chains on the left side of the truck must have, at one
point, come free / loose from their hooked position.
27
It was also noticed that the two aft chains were most probably hooked to the
‘D’ shackles, in way of the bottom edge of the chassis’ PFCs (Figure 19).
The ‘D’ shackle, which held the wooden beam to the chassis’ PFC, and which was
located at the rear of the truck on the left-hand side, was found completely damaged
and the wooden beam on top of the chassis had structurally failed.
The ‘D’ shackle located at the rear on the right-hand side was noticed to have shifted
from its original position (Figure 20). The problem which the bosun and / or the
driver had in order to lash the truck to the deck emanated from the fact that, as
indicated in sub-section 2.2.1, the truck was not provided with the recommended ferry
securing points in compliance with the guidelines provided in the ISO 9367-1
Standard14
. The MSIU considered this to be a principle source of danger.
Figure 19: The chassis’ rear left side and the damage iwo the ‘D’ shackle
Figure 20: The truck’s chassis rear right side and the ‘D’ shackle shifted out of position
14
ISO Standard 9367-1: Lashing and securing arrangements on road vehicles for sea transportation on
Ro-Ro ships – General requirements - Part 1: Commercial vehicles and combinations of vehicles,
semi-trailers excluded.
28
2.4.2 Available lashing equipment on board
It is crucial that the chassis of loaded trucks is kept static as much as possible when
the vessel is at sea. This would be possible if deflections in the leaf spring systems of
the suspension are prevented15
.
In order to prevent the lashing from becoming slack because of leaf spring deflections
when the vessel is underway, two practical ways may be applied:
either by securing the vehicle to the deck as tightly as the lashing equipment
allows (say, with the use of bottle screws), and / or
by jacking up the vehicle chassis and take the weight off the leaf spring system
prior to securing the vehicle to the deck.
The solution, however, was not necessarily straight forward for the crew members.
Whereas there was a potential issue within the Company with respect to the lashing
procedure16
, the Company’s vessels were never equipped with bottle screws, trestles
and / or long, medium and short cargo jacks.
2.4.3 The lashing procedure
The lashing procedure on board the vessels was discussed in detail with all the crew
members and other Company personnel. All the crew members that were interviewed
by the MSIU referred to the collective agreement signed between the Union and the
Company. They claimed that since they were not paid for the lashing of the vehicles,
it was the drivers’ responsibility to lash down their vehicles, especially the hooking up
of the chains to the vehicles.
The crew members stated that they would not be held liable for any damages done to
any vehicle and / or its fittings17
. The crew members further stated that in practice,
they would still end up doing the lashing themselves, especially if drivers were not
conversant with the lashing equipment. The crew members also acknowledged,
however, that it was their responsibility to make sure that the lashings were tight.
15
It is also usual that ro-ro vessels are equipped with wheel chocks to supplement the vehicle
lashings.
16 The Company’s lashing procedure will be discussed in sub-section 2.4.3.
17 This was suggestive that this particular truck was not the only commercial vehicle to be loaded on
board and not fitted with ferry securing points.
29
A copy of the crew members’ collective agreement, which was made available to the
MSIU, made reference to the Code of Practice for Safety of Commercial Vessels
Regulations, 2002 (Code) and the relevant health and safety legislation. Section
29.5.1 of the Code (11th
Edition) stipulates that “[w]hen a vessel is engaged in
carrying cargo, all such cargo should be stowed and secured in a manner which will
not adversely affect the safe operation of the vessel.”
As expected, the Code does not specify as to who should lash the cargo, given that
this falls within the remit of the management of the (commercial) vessels to determine
this role within the relevant job descriptions. However, it is understood that whoever
secures the cargo and uses lashing equipment should be well trained and aware of the
instructions prescribed in the Company’s Cargo Securing Manual (CSM). On the
basis of this school of thought, drivers are definitely not the appropriate persons to use
the vessel’s lashing equipment.
When this issue was raised with the Company, the MSIU was referred to the
Company’s SMS Manuals and the ship’s CSM. The SMS Manual, Volume II,
Chapter 3, stipulated that one of the main duties and responsibilities of the chief mate
was to be responsible to the master for the planning and undertaking of the
loading/discharging operations.
The bosun and the GPHs were responsible to:
monitor the boarding of passengers and vehicles;
ensure that all are in possessions of a valid ticket or boarding pass; and
to monitor the number of vehicles loaded.
The SMS Manual also stipulated that the main role of the GPHs was “[t]o be
responsible for the boarding of passengers and the stowage of wheeled freight under
the direction of the bosun, ensuring a safe stowage and maximum space utilization.”
Hence, the SMS Manual did not stipulate in a clear and unequivocal manner the duties
and responsibilities of the crew members with respect to the actual lashing of ro-ro
cargo.
30
Furthermore, the SMS Manual, Volume III, Chapter 7.4, determined that the securing
of vehicles on board shall be made in accordance with the vessel’s CSM18
. It also
required that when accepting vehicles for loading, the chief mate had to ensure that
there were adequate lashing points on the vehicle to enable it to be lashed in
accordance with the CSM and that the cargo on the vehicle itself is properly stowed
and secured to the vehicle. It is also stated that “…[s]towing and securing should be
properly supervised during loading and lashings should be regularly inspected during
the voyage.”19
Notwithstanding the above, it has already been explained in the previous sub-sections
of this safety investigation report that in the case of this truck, the above requirements
were not met. The context was also explained to give a meaning as to why the crew
members would have been challenged to meet these requirements.
The lashing procedure was not the only issue which the MSIU considered. During the
course of the safety investigation, it transpired that four chains were used for the
lashing of the truck. The lashings were applied at a time when the chief mate was not
in the vehicle cargo space. Although IMO Resolution A.581(14), as amended,
recommended a minimum of four securing points on a vehicle of the size of the truck,
the crew members were unaware of this. This is so because they were neither aware
of the IMO Assembly Resolution nor was the truck fitted with securing points.
The MSIU did not calculate the minimum number of lashing which should have been
applied because it was more of an interest to determine how the figure (four chains)
was actually reached. The analysis made by the MSIU sought to identify whether the
following factors were taken into consideration before the chains were applied:
the position of the vehicle in the vehicle cargo space20
;
conditions expected during the voyage;
18
This is also a requirement in the International Convention on the Safety of Life at Sea, 1974, as
amended (SOLAS), regulation VI/5 and VII/5, which stipulate that cargo units and cargo transport
units shall be loaded, stowed and secured throughout the voyage in accordance with the approved
CSM, which shall be drawn up to a standard at least equivalent to the guidelines developed by the
Organization.
19 SMS Manual, Volume III, Section 7.
20 The vehicle was loaded towards the aft end of the vessel (vide Figure 6) where it would have been
exposed to significant forces. Largest forces are experienced towards the furthest forward and aft
parts of the vessel and the highest positions on either side of the ship.
31
(specific) nature of the commercial vehicle;
weight and centres of gravity21
;
factors which may reduce the coefficient of friction between surfaces;
the holding power of the lashings22
; and
vessel’s metacentric height (GM)23
;
Evidence indicated that in all probability, it was only the weather conditions which
had been taken into consideration and the number of chains applied was based on a
(subjective) decision taken by the bosun and / or driver24
.
Further to the potential issues mentioned above, the MSIU’s concern is that the same
approach is adopted in other similar situations. Drivers are expected to lash their
vehicles even if they are not familiar with the vessel’s CSM, and they neither have the
technical skill nor the competence to decide on matters related to cargo operations. In
the meantime, the role of the GPHs is limited / reduced to ensure that the chains are
tight and that passengers have valid tickets for the intended trip.
21
High centres of gravity can increase the load on the lashings and additional lashings may be
necessary.
22 Holding power refers to the Maximum Securing Load (MSL).
23 A high GM value would result in a stiff ship, i.e. difficult to incline but one which returns rapidly to
the upright position, creating excessive acceleration stresses on the lashings. A tender ship has a
small GM value and therefore it will incline with ease but returns slowly to the upright.
Acceleration forces are therefore limited but the inclining angles may lead to gravitational effects
which also create excessive stresses on the lashings.
24 The MSIU is aware that the problem related to the adequacy of lashing vs. the actual forces on the
cargo in adverse weather conditions is complex. Nonetheless, it has been addressed by a number of
major companies which operate ro-ro ferry services in the UK, The Netherlands, and New Zealand.
These companies invested in a ‘Decision Support System’ and (class) approved procedures that are
designed to assist the master to decide on the adequacy of the required lashing for each voyage. A
motion monitoring system is fitted on board to measure and display real-time and historical motions
of the vessel. The system calculates the actual forces on the vessel, lashing and cargo and compares
it to the maximum allowable forces. Trends and historical data on the vessel’s motion are stored in
the system to allow future planning.
There are also other tools available which calculate accelerations and balance of forces in semi- and
non-standardised lashing arrangements and which can be used to provide acceleration tables for
various GM values either to be inserted into the CSM or to prepare standard lashing arrangements
for road vehicles, depending on their weight.
32
This does not reflect the obligations imposed on qualified persons, which stems from
section 7 of the ISM Code25
.
2.5 Actions by the Master
2.5.1 The route taken
The MSIU believes that when the master departed from Ċirkewwa Terminal at about
0737, he was not fully aware that the weather conditions had deteriorated further.
This explained why he proceeded to take the usual and most direct course to Mġarr
Harbour. On leaving the shelter of the Ċirkewwa breakwater and turning to a
NNW’ly course, Gaudos immediately started rolling. It was only then that the master
realised that the weather had deteriorated further.
When the GPH, who was in charge of the vehicle cargo space watch, had reached the
point where the truck was parked, he immediately noticed that the cargo of chipboard
sheets was shifting due to the vessel’s motion. The problem was reported to the
bridge at 0746. It is the MSIU’s opinion that the master took immediate steps to ease
the rolling by altering course further to port, i.e. to a more NW’ly course. He also
requested the engine-room for more power.
The request for more power was important and it indicated that the master was
contemplating various possibilities in order to try and contain the problem. In fact,
the weather had deteriorated so much that the master had considered turning the
vessel back, by either altering course or by a change-over of the bridge, or take the
longer route round the island of Comino. He eventually decided that at that stage
these options were too dangerous and continued with the planned direct route.
Applying the principle of local rationality, it has to be acknowledged that the actions
taken by the master were the result of an assessment which he made under those
complex prevailing (local) conditions. It is therefore the MSIU’s opinion that his
25
The MSIU considers cargo loading and discharge as key shipboard operations. Section 7 of the
ISM Code specifies that,
[t]he company should establish procedures for the preparation of plans and instructions, including
checklists as appropriate, for key shipboard operations concerning the safety of the ship and the
prevention of pollution. The various tasks involved should be defined and assigned to qualified
personnel.
33
decision was influenced by the data which he was receiving from one of his crew
members, the weather and sea conditions.
The ‘direct route’, however, became more of a zigzag route (Figure 21). On this
route, the master had to first sail on a NW’ly course, thereby reducing the rolling by
bringing the wind and swell closer to the port bow and then turn the vessel to a NE’ly
course whereby the weather was brought on the starboard quarter. However, on the
last leg of this route, the master had to make a broad alteration to port and approach
the entrance to Mġarr Harbour on a W’ly course.
Figure 21: Approximate courses taken from Ċirkewwa Terminal to Mġarr Harbour
Not to be used for Navigation
Heading 1: 320°(T)
Heading 2: 290°(T)
Heading 3: 023°(T)
Heading 4: 282°(T)
© Crown Copyright and/or database rights. Reproduced by permission of the
Controller of Her Majesty’s Stationery Office and the UK Hydrographic Office
(www.ukho.gov.uk)
1
3
4
2
34
This meant temporarily exposing the vessel’s port side to the full force of the W’ly
weather, a situation which at that stage could not have been avoided. That was a point
of no return and it was at this time that the vessel rolled heavily to starboard side and
the truck rolled over.
It is to be noted that there were no specific written Company guidelines as to when a
master had to change from the direct to the longer route around the island of Comino.
However, the longer route around the island of Comino is normally taken when there
is strong W’ly wind and swell. The decision to change the route is normally either
discussed and agreed between the two masters on the two ferries on duty at the time,
or by the master on duty when only one ferry is operating. This procedure is in
accordance with SMS Manual, Volume III, Chapter 3, whereby, the master is given an
overriding authority to choose the best course and speed to reduce the vessel’s
rolling26
.
It is clear that once the ferry takes the longer route around the island of Comino, the
whole schedule is disrupted and therefore, masters always decide on the longer route
as a very last resort.
2.5.2 Recognition-primed decision making
Contemporary academic research in naturalistic decision making suggests that
decision making in a dynamic context of, inter alia, time pressures, cannot be
analysed by applying rational and normative decision theories. The selected decision
making strategy depends on the characteristics of the problem, the environment (the
context), and the characteristics of the decision maker. Therefore, the MSIU analysed
the master’s decision (to select a particular route rather than another), taking into
consideration an evolving situation where, information on the context may have been
either inaccurate or incomplete, with a significant amount of uncertainty and where
the consequences of the decision were high.
A decision under these circumstances is critical and is based on a very important
assessment of the situation, followed by the application of the course of action. The
assessment of the situation was therefore crucial and it may have been influenced by
26
The master’s overriding authority is an acceptable and recognised international norm in terms of the
ISM Code. This is important because the master is best placed to decide in terms of safety and
pollution prevention; not even commercial considerations may interfere with this authority.
35
previously encountered weather conditions. It is normal that these events and
circumstances, which become stored mental models, are recalled from memory during
pattern matching in order to facilitate the situation awareness process.
The decision to take a different route would have only been triggered when the
contextual information which the master would have been receiving suggested a
mismatch with previous experience – a stage known as ‘problem recognition’.
It is not uncommon that a partial assessment is carried out (in comparison with a full
risk assessment) – even because of the dynamic environment and the available short,
critical time. It is at this stage of the decision making process where heuristics may be
experienced, e.g. by considering only partial data and ignoring other parts27
. All these
factors would have influenced the diagnosis of the situation.
Problem recognition relies heavily on the first stage, i.e. the accuracy of the situation
assessment carried out during the first stage. Given the experience which the master
had, even in similar weather conditions, the MSIU is of the view that the master
adopted a recognition-primed decision making process. This mode of decision
making is based on recalling previous experience / situation of the same type.
This cognitive model has the advantage of being rapid; requiring little conscious
thoughts and which can be used under situations similar to the ones experienced by
the master. The main disadvantage, however, is that evidence which does not support
the mental model may be ‘discarded’ and may also lead to confirmation bias.
The recognition-primed decision making may have also been the adopted (cognitive)
process by the master given that, as indicated above, standard procedures were not
included in the Company’s SMS28
.
27
The MSIU did not engage in a speculative exercise in trying to establish whether or not other
options should have been taken by the master. That would have been beyond the scope of the
safety investigation.
28 Decisions based on the Company’s SMS Manual would be classified as rule-based decision
making, which is also referred to as procedure-based decision making. The application of rule-
based decision making is not necessarily a guarantee of an accident-free activity. Rather,
procedures which are too prescriptive may inhibit resilience and contribute to even more
complexity.
36
2.6 Passengers inside the Vehicle Cargo Space when the Vessel is Underway
Passengers who regularly travel between the two islands are aware that in
contravention to the Company’s instructions posted in the vessels’ vehicle cargo
spaces, a significant number of passengers remain inside their vehicles while the
vessels are underway. A large electronic display at Mġarr Harbour (Figure 22) also
cautions passengers that they are not allowed to remain inside the vehicle cargo space
when the vessels are underway. Several notices are also posted inside the vehicle
cargo spaces (Figure 23).
Figure 22: Electronic display at Mġarr Harbour
Figure 23: Two of the safety notices posted inside the vehicle cargo space
37
The matter was discussed with the crew members during the course of the safety
investigation since it was immediately evident that this accident could have had
serious consequences had the truck rolled over a private car with passengers inside.
The crew members clarified that the issue was beyond their control and they were
unable to enforce this policy. This does not only contravenes the Company’s safety
policy but also the job description of the relevant crew members.
It has to be highlighted that Directive 2009/45/EC of the European Parliament and of
the Council of 06 May 2009 on Safety Rules and Standards for Passenger Ships,
stipulates in Chapter II-1, Part B, article 17-2 that “…without the expressed consent of
the master or the designated officer, no passengers are allowed access to an enclosed
ro-ro deck when the ship is under way.” 29
Directive 2009/45/EC has been transposed into national law and its requirements are
made mandatory in the Code of Practice for the Safety of Commercial Vessels, issued
in terms of the Commercial Vessels Regulations, 2002. Therefore, passengers
remaining in the vehicle cargo space are not only contravening Company
requirements but also national law.
Aside from the legal aspect, the MSIU is equally concerned that passengers neither
seem to be aware of the risks involved when they remain in the vehicle cargo spaces,
nor are these risks being brought to their attention.
2.7 Reporting of the Accident
It has already been established that when the truck rolled over, Gaudos was
approaching the entrance to Mġarr Harbour under difficult weather conditions. As
expected, the master had to focus on manoeuvring the vessel safely into the Harbour.
The chief mate, whose main duty on the bridge was to communicate and coordinate
with the other crew members using the hand-held radio, was in contact with the bosun
who had remained in the vehicle cargo space. Once close to the berth, the chief mate
was in radio contact with other crew members at their mooring stations.
As soon as the vessel was safely berthed alongside, the master informed the Duty
Terminal Manager of the accident, as stipulated in the Company’s SMS Manual,
29
This article regulates the access to ro-ro decks on all ro-ro passenger ships.
38
Volume V, Chapter 2. The Duty Terminal Manager relayed the message to the
Designated Person Ashore (DPA), the Police and the Chairman of the Company. The
master, however, did not inform the local authorities of the accident30
; neither did the
DPA nor the Duty Terminal Manager.
In accordance with national legislation, the master and / or owners were to
immediately inform the local authorities of the accident31
. When the Company’s DPA
who, at the time was on board Ta’ Pinu at Palumbo Malta Shipyards Ltd, received the
call from the Duty Terminal Manager, he immediately called the master to establish
the facts. He also dispatched the Company’s electronic engineer to proceed to
Ċirkewwa Terminal, to investigate the accident and inspect the damages sustained by
the ship, mainly, the passenger sliding door.
After evaluating the accident on the basis of the information given, the DPA felt that
he neither had to go personally on board Gaudos to investigate the accident, nor to
immediately inform the local authorities of the accident.
Although the accident had not been notified to the MSIU, it was not considered that
this affected in any way the course of the safety investigation. However, the MSIU
has to highlight the obligations which the master and the Company have to report
occurrences to, inter alia, the MSIU, irrespective of the nature, severity, or perceived
severity of the occurrence32
.
30
Informing local authorities could have been done by a VHF call to the Valletta Vessel Traffic
Service (VTS).
31 Masters (or the owners) are required to notify local authorities of accidents in terms of:
Merchant Shipping Act 1973 (CAP. 234), section 307;
Merchant Shipping (Accident and Incident Safety Investigation) Regulations (S.L. 234.49),
regulation 6;
Commercial Vessels Regulations (S.L.499.23), regulation 56.1; and
Code of Practice for the Safety of Commercial Vessels, section 31.8.
32 In its submissions during the Consultation Period, GCCL remarked that although Valletta VTS was
not informed of the accident, the MSIU’s accident notification forms were completed and all the
requested information transmitted to the accident investigation body in good time. The Company
wished to highlight that its personnel had to resolve the issue on board in the shortest possible time
given that as a result of the accident, the Ċirkewwa – Mġarr ferry service was being operated with
one ship only. GCCL also confirmed that the Police had been informed of the accident and Police
officers were present on the quay upon arrival of the vessel at Mġarr.
39
THE FOLLOWING CONCLUSIONS, SAFETY
ACTIONS AND RECOMMENDATIONS SHALL IN NO
CASE CREATE A PRESUMPTION OF BLAME OR
LIABILITY. NEITHER ARE THEY BINDING NOR
LISTED IN ANY ORDER OF PRIORITY.
40
3 CONCLUSIONS
Findings and safety factors are not listed in any order of priority.
3.1 Immediate Safety Factor
The immediate cause of the accident was the improper loading and restraining of the
cargo on the truck and the improper lashing of the truck on board Gaudos.
3.2 Latent Conditions and Other Safety Factors
.1 The piles of cargo were higher than the headboard of the truck. This meant
that the centre of gravity of the cargo was around 750 mm (or more) above the
wooden flatbed of the truck, contributing to the truck’s rollover;
.2 The total weight of the cargo on the truck amounted to around 4850 kgs,
which was more than the permissible payload of the truck;
.3 Once the cargo had shifted to one side, the truck became less stable under the
influence of accelerating forces generated by the vessel in adverse weather
conditions;
.4 The cargo restraining system used in the warehouse was inadequate for the sea
passage, where the cargo was subjected to significant dynamic accelerations;
.5 The following contributing factors related to the inadequate securing of the
cargo on the truck were identified:
the web lashings went over the truck’s sideboards (rather than directly
from the flatbed to the top of the piles);
the truck may have not necessarily been the ideal vehicle for the carriage
of this cargo;
restraining by web-lashings was the only cargo securing method applied
on the truck;
the gap of 500 mm between each sideboard and the piles of chipboard
was not neutralised with battens / shores;
some of the chipboard sheets were of the melamine type, with a very low
coefficient of friction; and
41
the near vertical web lashing (in excess of 60° from the horizontal)
provided resistance to the cargo’s tendency to tip but on its own, it was
unable to resist the sliding forces acting on the cargo units as a result of
the ship’s forces arising mainly from rolling, swaying and pitching;
.6 The weather conditions were not taken into consideration by the shipper
before restraining the cargo on the truck;
.7 Notwithstanding the cargo condition on the truck, the crew members did not
deny permission to board;
.8 The problem which the bosun and / or the driver had to lash the truck to the
deck emanated from the fact that the truck was not provided with the
recommended ferry securing points;
.9 Company vessels were never equipped with bottle screws, trestles and / or
long, medium and short cargo jacks;
.10 The lashing of the truck to the deck was not carried out in accordance with
Company’s procedures and instructions;
.11 Once on board, it was only the weather conditions which had been taken into
consideration when determining the number of chains to secure the truck to the
deck;
.12 When the master departed from Ċirkewwa Terminal, he was not fully aware
that the weather conditions had deteriorated further;
.13 When Gaudos was turning to enter Mġarr Harbour, her port side was
temporarily exposed to the full force of the W’ly weather, a situation which at
that stage could not have been avoided. It was at this time that the vessel
rolled heavily to starboard side and the truck rolled over.
42
3.3 Other Findings
.1 A number of cargo owners may neither be necessarily aware, nor appreciate
the generated forces which cargo units are subjected to when the vessel is
navigating in adverse weather conditions;
.2 Positioning the load centrally rather than to one side of the truck was the better
option;
.3 GCCL website provides minimal details on the weather, which is limited to
the condition and the air temperature;
.4 The four chains used to secure the truck to the deck had neither failed nor were
they damaged prior to or as a result of the accident;
.5 The drivers are expected to lash their vehicles even if they are not familiar
with the vessel’s CSM, and may neither have the technical skill nor the
competence to decide on matters related to cargo operations;
.6 After receiving the report that cargo was shifting, the master took immediate
steps to ease the rolling by altering course further to port, i.e. to a more NW’ly
course. He also requested the engine-room for more power. This is
considered to be an adequate action;
.7 Notwithstanding national legislation and Company requirements, which
prohibit access to cargo spaces when the vessel is underway, a significant
number of passengers remain inside their vehicles during the crossing.
43
4 ACTIONS TAKEN
4.1 Safety Actions Taken During the Course of the Safety Investigation
During the course of the safety investigation, GCCL informed the MSIU that as a
result of the accident:
its SMS will be amended in order to address better the master’s reporting
obligations to Valletta VTS. The amendments will also require the DPA to
confirm that the reporting would have been made;
the current situation on the lashing of vehicles on board Company vessels will
be discussed during the next scheduled Safety Management Review Meeting
and the outcome communicated to the Company’s Board of Directors;
Police officers will be called on board to carry out random inspections of the
enclosed vehicle cargo spaces when the vessels are underway to ensure that no
passengers remain inside their vehicles;
consideration will be given to the purchase of additional lashing equipment,
which will be used in adverse weather conditions;
vehicles will be inspected more thoroughly prior to boarding. Vehicles which
are not properly and safely loaded will be denied boarding.
44
5 RECOMMENDATIONS
In view of the conclusions reached and taking into consideration the safety actions
taken during the course of the safety investigation,
Gozo Channel Co. Ltd is recommended to:
12/2015_R1 provide more detailed information on its website on the weather and
sea conditions;
Pace & Mercieca Ltd is recommended to ensure that Company’s trucks:
12/2015_R2 used for the transportation of cargo to Gozo are fitted with ferry
securing points;
12/2015_R3 leaving its warehouse are loaded in accordance with the truck
manufacturer’s instructions and adequately lashed, taking into consideration
the additional forces acting on the cargo units during the transit.
45
LIST OF ANNEXES
Annex A GCCL’s DOC and Gaudos SMC
Annex B Vessel’s MSM Document
Annex C IMO Assembly Resolution A.581(14), as amended
46
Annex A GCCL’s DOC
47
Gaudos SMC
48
Annex B Vessel’s MSM Document33
33
This document is a copy of the MSM Document kept on board.
49
Annex C IMO Assembly Resolution A.581(14), as amended
50
51
52
53
54