'Lysblink Seaways' Report - a Summary

The following is very largely taken, with some editing, from the Marine Accident Investigation Branch report, published on 20th November 2015 link here.

Drunk:

The MAIB report states that the prime cause of the accident was that the chief officer, as Officer of the Watch (OOW) at the time of the accident, was drunk.  At 0520, some three hours after the ship grounded, his breath alcohol reading was 2.71mg/l, the UK limit for mariners being 0.35mg/l. The reason for the OOW's state was that, before going on watch, he had, "made a private telephone call which caused him anxiety, after which he consumed about 0.5 litre of rum."

DFDL's employees are not allowed to consume or possess alcohol while at work. The company says it has a Zero Tolerance alcohol policy in place. Yet the MAIB investigation found that the owner’s policy was often flouted by crew members. Further, the inventory of the vessel’s bonded store records that it was regularly replenished with spirits, wine and beer. This evidence of significant alcohol consumption by the crew should have alerted the owner to the likelihood that its alcohol policy was not being observed.

The MAIB report says, "Had the company’s zero alcohol policy been effectively administered and monitored, it might have prevented the development of a culture in which the chief officer considered it acceptable to consume alcohol before his bridge watch."

Alone on the Bridge:

Before going on watch, the chief officer informed the AB who was scheduled to keep the 0000-0600 watch with him that he should remain in the deck office for his watch, as the 1800-2400 duty AB had also done. The UK's Maritime and Coastguard Agency's Marine Guidance Notes state that it considers it dangerous and irresponsible for the OOW to act as sole look-out during periods of darkness. The owner’s Safety Management System includes a requirement that a lookout should be on the bridge when a vessel is navigating in close waterways with reduced visibility under two nautical miles, though there is no definition of a 'close waterway'.

Navigation Systems Switched Off:

The bridge navigational watch alarm system (BNWAS), which could have alerted the crew to the officer’s incapacity, had not been switched on, and an off-track alarm on the Electronic Chart System (ECS) had been silenced. Although a radar watch alarm had sounded every 6 minutes, the OOW was able to reset the alarm without leaving his chair. Although it was company policy to do so, no positions were plotted onto the vessel’s charts after midnight.

Events Leading to the Grounding:

At 0211 the Lysblink Seaways’ track, for the second time that night, passed outside the 0.2nm cross track limit set on the ECS. Had the ECS been on, this would have triggered an alarm. At 0212 the radar watch alarm sounded and was reset, but an alteration of course onto a new heading of 315°, which should have been made at that time, was not executed. At 0222 the Lysblink Seaways, still heading 324°, passed the wrong side of the New Rocks buoy, narrowly missing the rocks.  At 0231, shortly after the radar watch alarm had again sounded and been reset, the steering mode was changed from autopilot to manual and the helm placed hard-a-port. By that time the vessel was 0.1nm (about 200m) from the shoreline and making a speed of 13.3 knots. The ship hit the rocks by Mingary Pier at 0232.

Events After the Grounding:

At 0234 the master arrived on the bridge and put the propeller pitch to zero. He asked the chief officer if he had been asleep or drinking, and if the AB had been on watch. He also suggested that someone should “check for leakage”. The emergency checklist for grounding was not consulted.

At 0240 the chief engineer reported that a double bottom sludge tank in the engine room had been breached and was filling with water. At 0241 the master attempted to call the owner’s Designated Person Ashore by telephone, with no response.

At 0253 - 20 minutes after grounding - the master informed the coastguard at the Maritime Rescue Co-ordination Centre (MRCC) Stornoway via VHF radio that the vessel was aground, and gave its position. At 0259 MRCC Stornoway contacted the vessel to obtain the number of persons and quantity of fuel on board, and asked if the vessel had been damaged. The master advised that the vessel was not damaged and that there was no pollution or injuries.

At 0400 - over an hour after it was informed of the grounding - MRCC Stornoway requested the Tobermory lifeboat to launch and standby the Lysblink Seaways. At 0512 - nearly three hours after it was known that a tank had been breached - an owner’s representative contacted MRCC Stornoway and advised that two of the vessel’s fuel oil tanks had been breached and that the vessel had 273 tonnes of marine gas oil fuel on board at the time of the accident. In the hours after the accident, 25 tonnes leaked into the Sound of Mull.

The Report:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of such an investigation
to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”

Recommendations:

The MAIB report says that DFDS has since carried out a full inspection and audit of Lysblink Seaways’ sister vessels resulting in the removal of the bonded stores, a verification of the owner’s random alcohol testing regime, the issuing of instructions regarding the posting of lookouts, a verification of Electronic Chart Display and Information System training for officers, a revision of the management structure of the sister vessels, and a review of, and new training in Bridge Resource Management in narrow navigational waters for its vessels.

As a result, the MAIB report says that it has no recommendations to make.

Much of this is extracted from Crown Copyright Marine Accident Investigation Branch publication, 20th November 2015, 'Grounding of Lysblink Seaways Kilchoan, West Scotland, 18 February 2015' - link here.