Communiqués

TSB # M 09/2000

(Halifax, Nova Scotia, 08 June 2000) - The Transportation Safety Board of Canada (TSB) has concluded that a combination of rough weather, existing fatigue fissure damage in the deck plating, and inappropriate ballasting eventually led to the break-up and sinking of the bulk carrier "FLARE" on the morning of 16 January 1998. The loss of life was probably exacerbated by the lack of information from the vessel regarding the location of the distress situation; the MAYDAY was short, incomplete and difficult to understand, and the Emergency Position Indicating Radio Beacon (EPIRB) did not provide any information.

The Board has identified safety deficiencies related to the accessibility and stowage of the EPIRB, the carriage of immersion suits on vessels operating in waters where hypothermia can reduce the survival time of persons in the water, the effect of high frequency stress loads induced by vessel pounding in association with inadequate ballasting and the need for stricter adherence to approved loading manuals. The Board has made five marine safety recommendations to address a number of the safety deficiencies uncovered in the investigation and to alert the international maritime community to changes that need to be made to reduce the risks to human life.

The vessel was en route from Rotterdam to Montreal in severe weather conditions, and was approximately 45 miles southwest of the islands of Saint-Pierre-et-Miquelon when she broke in two. The stern section sank within 30 minutes. An extensive search and rescue (SAR) operation was undertaken in very difficult conditions. There were 25 crew members on board; four survived. The bow section sank four days later off Nova Scotia, on the western side of Banquereau Bank.

In order to better understand why the vessel broke up, the TSB, in July 1998, undertook a dive operation in 100 metres of water using a remotely operated vehicle (ROV) to videotape the sunken bow section. Preliminary analysis using the aerial photographs and the underwater survey of the vessel indicated that fatigue fissure damage in the main deck plating adjacent to grain-loading ports near the mid-length of the "FLARE" may have existed prior to the hull failure. The TSB identified 14 vessels of similar age and built to the same plans that were believed to be still in service and that could be subject to similar defects. Consequently, in September 1998, the TSB apprised all involved Flag States of the fissure damage found on the "FLARE", in order that such damage on similar vessels under their administration might be located in a timely manner, and appropriate remedial action taken.

The TSB also informed Transport Canada (TC) of its concerns, in order that its Port State Control inspectors could take any necessary action during their inspection of similar vessels or of the 14 vessels identified by the TSB. Two of the vessels arrived in Canada and were inspected by TC Marine Safety. Both were detained; one with structural defects similar to those of the "FLARE" and the other for defective life-saving equipment, navigation equipment and tank remote shut-offs. Both were released after these deficiencies were rectified.

Recovery, by the SAR technicians (SAR TECHs) on board the rescue helicopters, of the survivors and of the bodies of the ship's crew was complicated by the oil slick caused by fuel oil escaping from the sunken stern section and the water temperature of 2°C. SAR TECHs have now been provided with dry suits to ward off the chill from the cold water and full face masks to protect against fumes from the oil. Furthermore, communication devices have been acquired to enable the SAR TECHs to communicate during future rescue missions.

The Marine Communications and Traffic Services (MCTS) at Stephenville, Newfoundland, received a MAYDAY distress alert, later determined to have originated from the "FLARE", but the transmission was indistinct and incomplete. The EPIRB reportedly carried on the "FLARE" either did not float free or did not self-activate as intended, and therefore failed to alert the SAR system of the distress or its location. Consequently, the actual position of the sinking was not determined for some time. The fact that no signal was received from the EPIRB contributed to the severity of the consequences in this occurrence.

In severe climatic conditions, such as those encountered by the "FLARE", it is essential that shore-based facilities be able to respond without delay. In most accidents involving bulk carriers, since the early 1990s, the absence of any distress messages would indicate their loss was sudden and most likely due to structural failure, rapid flooding and loss of buoyancy/stability. As in this occurrence, most involved ships were at least 15 years old, and a high proportion were lost or had the potential to be lost through structural damage and/or heavy weather. Worldwide between 1990 and 1997, a total of 99 bulk carriers sank, with an associated loss of 654 lives.

Canadian SAR agencies expended substantial time and resources in attempting to save the lives of "FLARE" crew members. Valuable time was lost when SAR resources were misdirected to various estimated MAYDAY positions. Notwithstanding the substantial resources allocated to the "FLARE" SAR operation, it took six hours before the first survivors were spotted. (Airborne resources searched an area of 4,371 square nautical miles, over 90 flying hours including the time spent in transit. Marine resources searched an area of 1,702 square nautical miles, for close to 200 ship hours.) Had the "FLARE" managed to deploy her EPIRB and had it operated, it is likely that the early identification of an accurate position would have decreased the search time, thereby increasing the crew's chances of survival.

The Board is concerned that ship management personnel, ships' officers and crews may not be aware of the severe consequences of improper stowage and installation of EPIRBs, thereby exposing themselves to undue risk in emergency situations. Furthermore, in view of the inherent weakness of relying on distress calls during an emergency and the loss of lives associated with delayed SAR operations, as demonstrated in this occurrence, the Board has recommended that:

• The Department of Transport, working through the appropriate agencies, advocate increased international measures aimed at ensuring that Emergency Position Indicating Radio Beacons are properly installed and deployable on vessels so that their distress signals are transmitted without delay in distress situations.[M00-01]

The North Atlantic Ocean is one of the most hostile environments in the world. Average mid-winter sea surface temperatures off the eastern seaboard range from 0°C to 2°C, and in mid-summer, they range from 8°C to 16°C. In such harsh marine conditions, the survival time for a person immersed in water is often measured in minutes, while for a person wearing an immersion suit, survival time can run to several hours. People clad in such suits have been rescued following 18 hours of immersion in cold water.

In accordance with the minimum requirements of the International Convention for the Safety of Life at Sea (SOLAS), the "FLARE" was equipped with 6 immersion suits and 27 thermal protective aids; the latter items stowed in the lifeboats. These thermal protective aids were intended for those persons, in open lifeboats, for whom immersion suits were not provided.

All four surviving crew members of the "FLARE", wearing lifejackets, were found to have been severely hypothermic and could barely move their limbs during their rescue, rendering the rescue operation difficult and subjecting SAR personnel to undue risks. Two other crew members, who had clung to the same lifeboat, remained alive for some time but succumbed to hypothermia before the survivors were spotted.

A sea survival model indicated that the use of immersion suits would have increased survival times to between 12 and 14 hours, depending on the clothing worn. The model also indicated that, in seawater of 2°C, the best-clothed survivor would lose consciousness within 6.4 hours while the other survivors would reach this state in 2.0 to 2.3 hours. The Board believes that, under such conditions, crew survival largely depends on adequate thermal protection. Therefore, the Board has recommended that:

• The Department of Transport advocate international measures requiring that an adequate immersion suit be provided for each person on board vessels operating in waters where hypothermia can greatly reduce anindividual's survival time. [M00-02]

In rapidly developing distress situations such as those involving bulk carriers, it is critical that life-saving equipment, such as immersion suits, be readily accessible and rapidly retrievable without confusion. During this occurrence, the survivors of the "FLARE" indicated that they were unaware of where the suits were stowed, nor had they time to locate any of the immersion suits. In view of the frequency of occurrences involving bulk carriers that have suddenly sunk, often leaving crews insufficient time to avail themselves of on-board life-saving equipment, the Board further recommended that:

• The Department of Transport advocate international measures to help ensure that critical life-saving equipment, such as immersion suits and thermal protective aids, are stowed so that they are readily retrievable, without confusion, and that all crew members are familiar with their use and their stowage location. [M00-03]

The investigation found that the shallow forward draught, upon departure from Rotterdam as well as during the Atlantic crossing, made the vessel highly vulnerable to repeated pounding and slamming throughout the stormy voyage. "Slamming," or the impact of the bow on the water during a large downward pitch, causes "vibratory stresses" or "slamming stresses." Slamming forces increase with increasing wave height and ship speed. The investigation concluded that the resulting severe whipping and flexing of the hull of the "FLARE" caused the sudden brittle fracture of the main deck and upper side shell plating.

The light ballast loading condition of the "FLARE", and the draughts recorded in Rotterdam prior to departure, confirm that the vessel sailed with a relatively shallow forward draught. The forward draught and the total quantity of water ballast on board were lower than those shown for the light ballast departure condition in the Loading Manual of the "FLARE", which was provided for the guidance of the master. In addition to the light ballast loading condition, the vessel's Loading Manual also included a full or deep ballast condition suitable for longer and more exposed ocean passages such as this Atlantic crossing. Again, while the vessel was making a winter crossing of the North Atlantic, the No. 4 hold/deep tank was not filled with ballast as indicated in the deep ballast loading condition of the vessel's Loading Manual. The total weight of ballast on board was significantly less than that stipulated for any of the ballasted conditions in the vessel's Loading Manual.

The International Convention on Load Lines, 1966 (LL1966), requires that the master of every ship be supplied with sufficient information to enable him to arrange for the loading and ballasting of the ship in such a way as to avoid any unacceptable stresses in the ship's structure. Loading manuals provide masters with guidelines to assist them in ensuring that their vessels are safely ballasted and trimmed throughout a voyage, to maintain adequate structural integrity in various operating conditions.

In addition to the vessel's Loading Manual, the Lloyd's Rules and Regulations for the Construction and Classification of Steel Ships that were applicable at the time the vessel was built make reference to the minimum forward draughts. According to these rules, the "FLARE" should have had a minimum forward draught of 4.6 m in order to avoid excessive forefoot exposure in rough seas. However, the vessel's actual forward draught of 3.35 m, reported to the Eastern Canada Traffic System (ECAREG) three days before the occurrence, was substantially less. Increasing the draught results in a decrease in both the slamming stress and the speed range in which slamming occurs. Had the instructions pertaining to ballasting and minimum draughts been followed, the vulnerability of the "FLARE" to pounding and slamming would have been markedly reduced, and the negative effects of dynamic stresses could have been avoided. However, the investigation was unable to determine why the instructions in the Loading Manual were not followed.

Notwithstanding the existing guidelines and requirements of LL1966 and the International Maritime Organization (IMO) Code of Practice for the Safe Loading and Unloading of Bulk Carriers, it appears that structural failure of bulk carriers due to inappropriate loading and/or distribution of ballast continues to occur. The Board is concerned that mariners may not fully appreciate that deviation from approved loading manuals may overstress the structure and lead to failures. In particular, the Board is concerned that mariners may not fully appreciate the adverse consequences of dynamic loadings on the hull caused by slamming and bow flare impacts due to inadequate forward draughts. Therefore, the Board has recommended that:

• The Department of Transport promote increased awareness and understanding in the international maritime community of potential structural failure associated with high frequency stresses on the hull due to slamming and pounding as a result of inadequate draughts of vessels operating in ballast conditions. [M00-04]

and that:

• The Department of Transport, in coordination with international agencies (including the International Maritime Organization and the International Association of Classification Societies), bring the need for stricter adherence to approved loading manuals to the attention of shipowners, ship operators and ship masters in order to avoid undue structural stresses in bulk carriers. [M00-05]

The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

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