; Analysis of eee MSC Chitra - Khalijia 3 Collision i i i Report and Recommendations of Committee Constituted to examine MSC Chitra - Khalija 3 Collision1, INTRODUCTION "MSC Chitra’ and MV. ‘Khalijia 3’ collided +. At the time of the collision al Nehru Port Trust (JNPT) 1.1 On 7 August 2010, MV. in the approach channel of Mumbai Port ‘MSC Chitra’ was outbound from Jawaharl. was inbound to Mumbai Port Trust (MbPT), from W-I while ‘Khalijia 3’ ‘0 the collision, both vessels anchorage of Mumbai Harbour. Consequent t ‘MSC Chitra’ immediately began taking in sustained severe damage. She veered off water as her hull was breached on the port side. northwards and finally ran aground just outside the ap) sustained damages to her fo’e’sle and bulbous bow, but ry of Mumbai proach channel. M.V.’Khalija 3” remained stable and eventually berthed alongside at BPX jett two vessels Port, There were no injuries to any persons, neither on the nor on any other water craft 1.2. A preliminary inquiry was conducted by the Mercantile Marine Department, Mumbai, under the provision of Section 359 of Merchant ‘A copy of the Preliminary Inquiry report was subsequently Shipping Act. Ministry of Shipping on 26! October 2010. forwarded to the 1.3. Ministry of Shipping, vide letter No... SR-13014/13/2010-MG dated 8.12.2010, constituted a committee under the chairmanship of the Capt. P. V. K. Mohan, Chairman, NSB, to examine the recommendations given in the Preliminary Inquiry report. Ministry's letter regarding the constitution of the committee is at Annexure 1. ‘The committee has been tasked with following : a] To propose a clear set of corrective actions to be taken by Mumbai Port and JNPT. b] To propose general instructions to be & 1 ven to all ports.c] To propose a set of policy initiatives to be taken by the Ministry of Shipping 2. BRIEF NARRATIVE OF THE INCIDENT 21 MV ‘MSC Chitra’, a 31 year old, 2,314 TEU cellular container 4 from JNPT at 0818 hrs on 7% August 2010, to head dra (Gujarat). The JNPT Pilot disembarked from the .s inwards of the vessel, un-berthe for the port of Mun Vessel at about 0914 hrs in a position about LS mile barking area. The Master then took the con and foul weather pilot disem! hhannel to exit the harbour. continued on a south-westerly course in the cl h was anchored ‘at W-1 anchorage Mumbai 2.2 MV. ‘Khalijia 3’ whi PX berth at at 0912 hrs to proceed to the BI Harbour, weighed anchor after weighing anchor turned to @ Mumbai Port. M.V. ‘Khalijia 3’, ner way into the channel by crossing the va turning north-eastwards to join inbound x her southerly course and made b outbound traffic lane and ther lane, She had two tags in attendance Dut was maneuvering unde power towards Pilot boarding ground at the ‘foul weather own 2.5 miles inside the regular Pilot embarkation’ point’, which is about embarkation area marked on the chart However, while maneuvering the channel, she collided with the out-bound ‘MSC Chitra’ at about 4 into 0937 hrs. 2.3. ‘MSC Chitra’ sustained heavy damage to her hull on the port side, bly in way of Nos. 2 & 3 holds. The complete extent of the damage 1s possi et to be determined. In any case, the and she started listing rapidly to port. t of the channel but the chad developed. Shortly Vessel lost pi thereafter the Vessel grounded about 2 miles south-east of Prong’s Reef 2 hull was breached below the ye waterline ‘The Master of MSC Chitra’ swung the vessel north-westwards ow ower due to the heavy list that shLighthouse, and lay there with @ port list increased to almost 75 deg. ww on to one of ‘Khalijia 3's tugs M.T. ‘Vamsee 3’ and a coast guard vessel ‘Kamla Devi’ that was Subsequently, bunker oil escaped from increasing Port list caused The Master evacuated the non essential cre’ outward bound from Mumbai, tured fuel tanks and the progressively i the water. her rup\ many of the containers on deck to topple into ¢ sustained substantial damage in the fo’e’sle area her own power: 2.4 M.V.’Khalijia 3° nained maneuverable under and the bulbous bow, but ren nd berthed her at Pilot eventually boarded the vessel at about 1010 Hrs au the BPX jetty. ssels were without Pilot at the time of the incident, 2.5 While both ve oring VHF they were in VHF contact with VIS Mumbai and were monit Channels 12 and 13. However the situation leading f© the collision developed within a span of 3 to § minutes during which time effective wuld not be accomplished. At the time of the VHF communication cot with the salvors the ‘Khalijia 3’ was under the ‘LOF” incident, but for the shifting from W-1 M/s SMIT International, anchorage to the BPX jetty, it was agreed that the Master would have the con. - 2.6 Inthe aftermath of the collision, the channel, which is common to both Mumbai and JNPT ports was closed due to the possible navigational hazard posed by fallen containers fr either sunk in the channel or wert om the vessel ‘MSC Chitra which had ¢ floating in the port waters. The channel was eventually cleared with the assistance of the Indian Navy, and opened for navigation in five days 2.7 Oil from the ‘MSC Chitra’ that had been escaping from the ruptured fuel tanks eventually found its way to the coastline around 3Mumbai harbour. Various agencies were involved in the clean-up efforts. ‘The operators of ‘MSC Chitra’ engaged the services of M/s SMIT International for salving the Vessel and its cargo. 3. Analysis and Synthesis 3.1 Based on the findings of the Committee, the primary cause of collision between the two Vessels and its aftermath is attributed ‘Human Factor’, while there were several contributing factors. 3.2 James Reason’s ‘Swiss Cheese’ model of human error (1990) lends itself well as a tool for analysis of the human factors. As per the model, in any operational ‘situation, hazards are prevented from resulting into accidents by the various safety barriers in place. These barriers are in the form of design/manufacture, rules/regulations, standard operating training, procedures, management & supervision, maintenance, qualification of personnel, and so on. 3.3. However, weaknesses in these barriers, if aligned in a manner that allows the hazard to penetrate all the barriers, will likely result in an accident. In this collision incident, the weakness of the safety barriers in the form of active and latent failures, are examined using the Human Factors Analysis and Classification System (HFACS) (Shappell and Wiegmann, 1997}. HFACS places ‘Organizational Influences’ at the root of latent failures, which lead’ to ‘Unsafe Supervision’ that sets up the stage for accidents (‘Pre-conditions for Unsafe Acts’). Finally, active failures or “Unsafe Acts’ directly culminate in an accident.3.4 An analysi 3.4.1 Active Failures - Decision Errors 3411 ‘MSC Chitra Skill-based Errors Did not discuss passage plan with Pilot prior hauling out of the berth of the MSC Chitra and Khalijia 3 collision follows Unsafe Acts | Khalijia 3 ‘Did not sight MSC Chitra earlier due to ‘attention being given to from the incoming vessels starboard side Gave priority to overtaking the Did not have a proper passage plan for the anchorage to berth transit communication effectively (Ch. 12, 13, and 16) 4 Dredger instead of monitoring incoming vessels \ Failed to Tnonitor ~~ VHF | Improper qnancuvering ~ could not contrél the swing of the vessel to Port after she had turned to head into the channel Maneuvered the vessel improperly after close quarters situation had developed (increase in speed ; rudder movements) Feared that Vessel was heading into shallow waters on the south side of the channel, although the high tide provided sufficient under- keel clearance (handicapped by non-funetional Echo-sounder)Decision-based Errors: 3.4.1.2 MSC Chitra Khalijia 3 jnareased speed after dropping Pilot though vessel was not clear of jncreased speed during the turn to port, thereby increasing the rate of channel/ traffic tum Overtook the Dredger on its| Cast off Tugs and did not use Tug starboard side without proper | assistance for turning planning and consideration for | _| incoming traffic Did not reduce speed when close id not take the way off early enough when close quarters quarters situation had developed and collision seemed imminent. Risk Management was not carried out before the decision was taken to transit the pilotage waters and the channel _—pilet____| Decision to disembark,was taken without information on incoming traffic from pilot or VTS any situation had developed Risk Management was not carried out before the decision was taken to weigh anchor and proceed for berthing 3.4.1.3 Perceptual Errors: ‘MSC Chitra a Could not judge its position in the channel, and had strayed into the southern side of the channel while overtaking and turning at the bend in the channel Khalijia 3 Tost situational awareness while turning into the channel, resulting, in a wide turn and continued swing to port (assisted by wind catching the Port quarter) Gould not appreciate the ‘closing in ‘speed of the two vessels, thus avoiding action not taken earlier Could not appreciate the ‘closing: in’ speed of the two vessels, thus avoiding action not taken earlier3.4.1.4 Violations: MSC Chitra Khalijia 3 7 Routine Violation: Bridge | Routine Violation : Bridge ~ Pilot} manning level required in this procedures viz Master situation was not complied with. interchange not done properly There was no dedicated lookout on the Bridge. Routine Violation : Safe. speed requirement was not observed outine Violation : Sound signals Routine Violation : Sound signals for maneuvering were not given for maneuvering were not given [Exceptional Violation : Steering | Exceptional Violation : Steering and Sailing rules as per Colregs "72 and Sailing rules as per Colregs."72 for Vessels meeting end-on oF for navigation ina Narrow Channel, and action to avoid collision by | crossing were not followed. | Stand-on Vessel, were not followed. | ‘The required alteration of course to starboard was not effected which resulted in vessel coming to southern edge of the channel. 3.4.2. Latent Failures - Pre-Conditions for Unsafe Acts S RECONDITION: FOR UNSAFE ACTS ibstandard ‘Adverse ‘Mental ‘States ‘Physical Mental samnagement Limitations ern3.4.24 Adverse Mental States MSC Chitra” Khalijia 3 ‘Being the larger, faster Vessel, a sense of complacency prevailed on the Bridge, that may have led to a belief that other vessels in the channel will generally keep clear overtaking the Task fixation Dredger) may have resulted in a awareness VHF loss of _ situational especially: with regard to communication Unchallenged acceptance of Pilot’s disembarking _ prict request for reaching the usual disembarking point. of the events “during thé In vie preceding month, (Grounding, flooding, abandonment, salvage], Master likely and the was to be mentally fatigued under psychological pressure. e — Vessel had fallen behind on the Pilot boarding time and was prompted to - increase speed by the Pilot in order to complete the berthing on high tide Bima acceptance of Pilot’s advice | off Tugs, without for casting consideration of consequence. to reduce the | Predisposition alertness level on the Bridge once the Pilot has been dropped synonymous with commencement < of sea passage Distraction during maneuvering by Pilot’s request to switch VHF channel and, subsequent communication (regarding breakfast readiness) 3.4.2.2 No significant findings. No o medical or physiological condition: pers onnel on both Vessels noted from the records availabl Adverse Physiological States : jective evidence of any abnormal s, including fatigue, ic and sighted. amongst the3.4.2.3 Physical / Mental Limitations : No significant findings. There is no reason to believe that there was any visual or physical limitation, or incompatible ifitelligence or aptitude existing among the persons involved, which could have any bearing on the accident, 3.4.2.4 Crew Resource Mis-management : |Khaiijia 3 | between | Bridge resources under-utilized — fase Chitra Lack of coordination members of the Bridge team. | senior navigating officer (Ch. Off) Inspite of additional _officer | was not on the Bridge. available on the bridge, VHF communication was not effectively monitored. Inadequate support from the Bridge | Although 3/08 did the position: | team lo the Master ~ insufficient | fixing, the Master had inadequate | information given about Ship’s| Bridge team support, the con, the and was position in the channel, overtaking | handling of the Dredger on the starboard | communications, and lookout duty side, approaching turn point, etc. _ | by himself 3.4.2.5. Personal Readiness : No significant findings. There is no evidence ssels were physically or mentally to believe that any of the involved persons on the two ve: unprepared for duty.3.4.3 Latent Failures - Unsafe Supervision UNSAIE | SUPERVISION Planned Inappropriate Teadequate Supeeviston It I While the causal factors listed in above relate to the Vessels 3.4.3.1 and their crews, the causal chain of events are strongly linked to the supervisory chain of command, involving a number of parties, Latent failures of the supervisory role are categorized as follows : 3.4.3.2 Inadequate Supervision a. Lack of oversight by the operators of MSC Chitra to ensure that Bridge procedures are sirictly followed. Ref: passage planning, Master Pilot exchange, Pre-departure briefing, and risk management as per ISM Code. b, Failure of the operators of Khalijia 3 to provide resource management training to the ship’s staff, and monitor compliance with Bridge procedures, and ensure risk management practices are followed as per IMS Code. c. Failure of the part of the Pilot of the out-bound MSC Chitra to provide detailed guidance to the Master for safe navigation till the Vessel exited the channeld. Neither the Pilot of the inbound Khalijia 3, nor the VTS operator, gave proper guidance to the Vessel for her inbound passage, especially with regard to the out-going trafic. f. Though the VTS did track the two vessels, the status of ‘Pilot on Board’ the MSC Chitra was not known at all times to the VTS, (nor to the Khalijia 3) g VTS operators were not sufficiently trained to appreciate the movements of vessels and detect hazardous situations developing, 3.4.3.3. Planned Inappropriate Operations : a. Due to multi-party communication - VTS (MbPT), VTS (JNPT), MbPT Pilot, and JNPT Pilot and the two Vessels ~ and the use of two different channels (MbPT on Ch-12; JNPT on Ch. 13}, there was loss of data/information ledding to incomplete understanding of the situation by the different parties. b. Planning of Pilot boarding by MbPT did not provide for exigencies. ‘The Pilot nominated to bring Khalijia 3 was first assigned to take anottier Vessel outwards from the anchorage. Delayed departure of the Pilot Launch from the Pilot station, and delayed ETA of the Khalijia 3 at the Pilot boarding ground, affected the entire operation. c. Similarly, scheduling of Pilot duties by JNPT for outward-bound and inward-bound transits is subject to vulnerabilities. Outbound Pilot on MSC Chitra disembarked earlier than usual in order to board an incoming Vessel which was already in the line-up. idé. Change in the Pilot boarding area from the mouth of the channel (half a mile south of the Prongs SE’ red can buoy} to the ‘foul weather boarding area’ (about 2.5 mile inside the channel) escalates the hazards for the Vessels approach not marked on the chart, ing the ports. The foul weather boarding point is although approaching Vessels are advised by ark, In the Admiralty List of Lights Vol. 6(4), VHF where the Pilot will emb: as 18:51N, 072:49B, with a remark :“In Pilot boarding position is given monsoon conditions Pilot board inside the channel” For safe Pilot transfers, Vessels are required to provide a lee. Given e. evailing direction of wind/waves the direction on the channel and the pri during monsoons, an outbound Vessel making a Ice will turn southwards, thus interfering with the passage. of incoming traffic. incoming Vessels will turn northwards, ‘causing obstruction to outgoing .d. To prevent this, Conversely, traffic. Thus a potentially dangerous condition is create the outbound Pilot may prefer to disembark further up the channel, lowever, (his causes where the making of a lee may not be necessary. Hi ic without the the Vessel to negotiate the rest of the channel and the traffi benefit of a Pilot, or radio/radar assistance from the VTS. f, There is’ no formal ‘Decision Support System’ for both ports MbPT JNPT to deal with movements of Vessels known to be in a less-than- and ‘The recent history of Khalijia 3, optimum condition for navigation. ther with her current state of bottom damage and being under the toget care of Salvors, warranted extreme care in her transit from anchorage to berth, However, baring the precaution of nominating the senior-most pilot on duty that day, no other safeguards were initiated &.. The handling of the post-collision oil pollution from MSC Chitra was not effecti handling capabilit vely controlled partly because of the Ports’ poltution y was limited, although they are expected to be able to rehandle Tier 1 pollution incidents. Further, the Indian Coast Guard, 7 2 & 3 pollution cases, was which has the responsibility'to deal with Tie in shallow and tidal waters. not properly equipped to handle oil pollution i 3.4.2.4 Failure to Correct Known Problems : a. The Operators of Khalijia 3 did not rectify the faulty Bridge equipment on the Vessel. ‘The Echo Sounder and Course recorder were out of order, and doubt has been raised about the proper. functioning of the VDR. (Data from the VDR has not been made available to date apparently the manufacturers’ service agents have not been able to retrieve any data from the ship's VDR so far) b. inadequacy of navigational aids, especially buoys, at the harbour ance and at the alteration points of the channel has been reported by entr s a difficult port to make. visiting shipmasters terming port of Mumbai & marking the bend in the channel near which the collision Lack of buoys, took place, makes itdifficult for Vessels to judge their relative position in the channel. c. * The VTS radar situated at Colaba is reported ta be non-functional, along with the VHF DF. The VTS Radar's range discrimination capability is poor, due to which the operator may not be able to distinguish between two vessels passing close to each other. d. The number of VTS operators are insufficient and it is reported that on occasion, only one of the two VIS consoles is manned Sanctioned strength at MbPT VTS is 17, but current strength is 10 operators. VTS Operators’ training and certification is also reported to be unsatisfactory. 13ec. VTS recording capacity is limited to .the channels they are monitoring (Ch 16, 12, and’ 13) each other) in the course of the du for various reasons. Such communi ). Pilots communication with vessels (or ties may switch to different channels cation is then not monitored or recorded at the VTS. Cluttering of VHF Channels by fishing vessels, especially the f directly impacts the communication working channels of the ports, processes which are vital for safe operations. Reporting protocols between Pilots and VIS are not striclly & s not have real-time observed, resulting in situations where the VTS doe: information about a Vessels ‘Pilot-on-board’ status. ‘The availability of the MbPT Pilot Launch is reportedly often pilots reporting on duty at 0800 Hrs are 5 Hrs. The delay h, delayed by 30° to 45 ints, thy able to depart from the Pilot station at about 084 resulting in the Vessels only throws the Pilot boarding schedules out of gear, having to hold positions in tricky’waters, 3.4.2.5" | Supervisory Violations + No willful disregard of rules and regulations was noted at the supervisory level. However, cértain undesirable practices as mentioned above are being tolerated and it is not evident that any disciplinary measures have been initiated against the erring parties 43.4.2 Organizational Influences [ Resource | | orn | Organizational ‘Management ‘Climate Process, 3.4.2.1 Resource Management : a. Lack of adequate manpower 1¢ conspicuous when it comes to the availability of experienced, well-trained Pilots, especially for JNPT. In view of the increasing traffic in this port, the outcome is obvious -a negative impact oni the safety goals of the Port. b. Similarly, the manpower availability at the VTS stations is less than adequate. and competencies of the existing VIS operators avs. not properly matched to the functional requirement of the job. c. The Pilot Launches provided by the Ports may be suitable for Pilot transfers in good weather, but in the foul weather conditions, which occur every year during monsoons, the Pilot Launch is unsafe. On occasion, use of Tugs for Pilot transfers has been reported by JNPT, but although safer than the Pilot Launch, the Tugs are not as agile as a high- powered and stable Pilot Launch, fit for purpose d. The lack of navigational aids in the Port approaches and the channel has been pointed out earlier. It is understood that the deployment of buoys to mark the channel has not been taken up as it is felt that they may obstruct anchorages alongside the channel. (though it is not clear how). 15e. Equipment is said to have been provided to the Ports for handling Tier 1 oil pollution incidents (Upto 700 Tons oil discharge). However, the capability of the Ports personnel to use the said equipment appears to have been limited. The suitability of the pollution equipment has not been put to test under the monsoon conditions and tidal currents. {The Indian Coast Guard which has the responsibility. of handling ‘Tier 2 and Tier 3 pollution incidents, seems to be lacking modern pollution gear. Purthermore, it does not have sufficient manpower trained to use the pollution equipment. 3.4.3 Organizational Climate : ‘The organizational structure of the two Ports directly impact the a. he safety of navigation in the port areas. The rigid dividing lines between 0 ‘Traffic and Marine departments act as communication barriers. The traffic department's concerns for berth occupancy, productivity, turn around of vessels etc., may be in conflict with the operational safety of vessel movements in and out of the ports. As a result, there is no check on the seaworthiness of a Vessel when it is ordered to sail out or move to anchorage. Khalijia 3 was ordered to haul out of the BPX berth to an exposed anchorage even though her cargo of steel coils in the No 4 Hold was un-secured. b. With regard to Pilotage services, the chain of command and control is weakened by the existence of two separate entities using the same approaches and channel. Accountability for the Pilots’ actions (or lack thereof) tends to fall through between the gap in the two chains. Neither of the Pilots briefed the Master of their respective ships about the movements of the other, resulting in disastrous consequences. 16c. Similarly, the VTS services are affected by lack of supervisory control, as the Dock Master in-charge has other duties also to attend to. Further, the VPS operation, not being seamless due to the use of different channels by MbPT and JNPT VTS, is susceptible to lack of coordination. The VTS is perceived to be outside of the mainstream operations of the ports, and thus it is not yet fully integrated with the rest of the ports’ organization. Although an agreement exists between MbPT and JNPT since 1989, d t day demands, when JNPT traffic has it does not cater to presen! increased many-fold. The complexities of issues related to jurisdiction, and accountability come to light in mishaps, such as in the case of MSC Chitra, a JNPT caller, whose collision, grounding, and consequent effects took place in MbPT waters. Coordination between the Port authorities and the Maritime ‘Administration (D.G. Shipping / MMD) has scope for improvement. The Khalijia 3’s anchor dragging incident did not trigger any alarms in the maritime administration, which only stepped in after the subsequent flooding and abandonment of the Vessel. f. The Indian Coast Guard has the mandat operations. Issues related to priority berth allocation to Coast Guard te for pollution combating vessels, storage space of pollution equipment, etc. are matter of concern for the Coast Guard as against the commercial and operational constraints for the port. 3.4.4, Organizational Process a. Standard Operating Procedures (SOPs) for Pilotage and VTS operations at both the Ports are either absent or inadequate to handle contingency situations 0b. Risk Management does not seem to feature as an essential part of the decision-making with respect to Vessel movernents in the approaches and Port areas. Navigating a deep-drafted Container Vessel which has stricted visibility from the Bridge due to Container stacks, through a 360 mtr wide channel which has heavy two-way traffic during a tidal window is a risky operation. So is bringing in a loaded Bulk Carrier which has a history of disablement and a damaged bottom. Masters of both Vessels although Indian nationals, were first time callers at this port (though this may not have been known to the Pilots/Dock Master). In both cases, risk management was not exercised by the Port authorities. ¢. The shifting of the Pilot boarding point in foul weather is governed by fixed dates (26% May to 31st August) though this is ‘not formally notified internationally. In any case, the criteria for ‘foul weather’ is Wind force § and above, which may occur outside of the declared dates, d. Salvage operations on the MSC Chitra were hindered by the Customs procedures which delayed the clearance of essential salvage equipment being imported by the Salvors. Loss of time has made the salvage operation more complicated than it would have been otherwise. Special equipment had to be procured by owners of the MSC Chitra and their contractors, ITOPF and OSR. However, this equipment could not be arranged expeditiously due to customs procedural issues of assessment of duty ete. Further the Containers that fell off the Vessel drifted to different points of the coast, and thus under different Customs Commissioners, complicating the retrieval process. 18