casualty investigation report - amp.gob.pa de... · off” and get dinner. he was told to start...

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16 th June 2006 File No. 26206 This Report has been presented without prejudice and with the exercise of due care and diligence. In accepting this report of Certificate, it is agreed that the extent of the obligation of this firm with respect thereto is limited to furnishing a Surveyor believed to be competent, and in making this Report or Certificate, the Surveyor is acting on behalf of the person requesting the same, and no liability shall attach to this Firm for the accuracy, errors and omissions thereof. CASUALTY INVESTIGATION REPORT ( Investigation of Death @ Sea ) M.v. “ NYK SPRINGTIDE ” Voyage :- 32E17 YIT Terminal @ Los Angeles, California 12 th May to 7 th June 2006

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Page 1: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas

16th June 2006 File No. 26206

This Report has been presented without prejudice and with the exercise of due care and diligence. In accepting this report of Certificate, it is agreed that the extent of the obligation of this firm with respect thereto is limited to furnishing a Surveyor believed to be competent, and in making this Report or Certificate, the Surveyor is acting on behalf of the person requesting the same, and no liability shall attach to this

Firm for the accuracy, errors and omissions thereof.

CASUALTY INVESTIGATION REPORT

( Investigation of Death @ Sea )

M.v. “ NYK SPRINGTIDE ” Voyage :- 32E17

YIT Terminal @ Los Angeles, California

12th May to 7th June 2006

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Ship Particulars 1.1 General Data

Name: M.v. NYK Springtide Owners: Ulala Maritime S.A. Panama, R.P. IMO Number: 9017044 Port of Registry: Panama Call Sign: H O C Z Type of Ship: Container Carrier (Capacity: 3054 TEU) Deadweight Tonnage: 39404 (MT) Length overall: 253.38 m Breadth (Moulded): 21.20 m

Extreme Draft: 11.50 m

Means of Propulsion: Diesel Engine Power: 45,000 PS

Service Speed: 23.4 knots Delivery: 30 June 1992 Radio: SAT “F” 764118236, SAT “C” 435312610 Electronic Positioning: GPS

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2 Documents To Be Produced a) Statement of Master; b) Statement of Chief Officer; c) Copies of Official Log Book pages d) Copies of Deck Log Book pages (3 May, 3 May Retard Day, 4 May); e) Copy of Master’s Night Orders from 5/3/06; f) Copy of Panama Seaman’s Document for Jai Kumar Shah; g) Copy of Master’s Certificate for Capt. Peter Damian Misquitta; h) Copy of Ship Registry & most recent Tax Payments to Panama

Maritime Authority; i) Marine Note of Protest; j) Crew List & Ship’s Particulars; k) Copies of Nautical Chart 4522 used during incident; l) Copies of four (4) pages of parallel search pattern; m) Copies of weather and position log pages; n) Weather Charts received on the vessel; o) Weather Reports received on the vessel; p) GMDSS Radio Log Summary; q) Daily Record Summary of all communications; r) Copy of Distress messages sent via GMDSS; s) Copy of list of satellite phone call records; & t) Copy of Heavy Weather Navigation Checklist.

3 Particulars of Voyage The NYK Springtide was on an eastbound transpacific passage between the port of Sendai, China, and Los Angeles, CA on Voyage 32E17, and nearing the International Dateline at the time of the incident. The date at which Cadet Shah was last seen was May 3rd 2006. In the morning when he was discovered missing, was again May 3rd in what is sometimes knows as Dateline Day or Repeated Day. The Master reports that the vessel sailed from the port of Sendai with a full load of containers, and a GM of 0.97m. 4 Particulars of Personnel Involved in Incident

Master: Capt. Peter D. Misquitta Chief Officer: Mr. Vikram Yadav Third Officer: Mr. Ankush Chowdhury Bosun: Mr. Rodolfo E. Rosal FMA: Mr. Eljube T. Lunggakit

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5 Particulars of Sea State, Weather and Tide During the night of the incident, the vessel was passing to the south of a low pressure system which was moving to the NNE. The proximity of the low pressure center was causing strong winds from the SSE which moved to the South during the night. Seas were described in the log book as “high sea and swell.” During the night in which Cadet Shah went missing, and the following day when the search started the visibility was at least two miles at all times. The logbook describes conditions as follows:

Time Wind Force Swell 2100 SSE 7 S 3 m 2200 SSE 7 S 3 m 2300 SSE 7 S 3 m Midnight SSE 7 S 3 m 0100 S’ly 8 S 3 m Retard Day 0200 S’ly 8 S 3 m 0300 S’ly 8 S 3 m 0400 S’ly 7 S 3 m 0500 SSW 7 S 3 m 0600 SSW 7 S 3 m 0700 S 7 S 3 m 0800 S 7 S 3 m 0900 S 7 S 3 m

1000 S 7 S 3/4 m 1100 S 7 S 3 m Noon S 7 S 3 m 1300 SW 7 S 4 m 1400 SW 6 S 4 m 1500 SW 6 S 4 m 1600 SW 6 S 4 m 1700 SW 5 S 4 m 1800 WSW 6 S 4 m 1900 WSW 5 S 4 m

Following this time darkness set in. Wind and sea conditions remained similar through the next night and day with the wind gradually coming around to the West.

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6.1 Type of Incident Marine Casualty: the death of a person that is caused by, or in connection with, the operations of a ship. 6.2 Date, Time and Place of Incident The incident (apparent loss of a person over the side) took place at sometime between the hours of 03/1000Z (when Mr. Shah was last seen) and 03/2030Z (when it was discovered that he was missing). 6.3 Details of Incident and of the Events Leading Up To It and Following It During the last day that Cadet Jai Shah was seen on the vessel, he worked (under the direction of the Chief Officer) with the Bosun cleaning in cargo hold bilges. Following that work he was assigned by the Chief Officer to monitor the ballasting of a tank in the Ballast Control Room as the tank filled by gravity. He reportedly stopped the operations below the tank top level. He reportedly informed the Chief Officer (via ships telephone to the Bridge) when this was completed at approximately 03/1730 LT (03/0630Z). He was told by the Chief Officer to “knock off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas of the ship. Following his fire round, Cadet Shah reportedly came to the Bridge to make a telephone call to India. This happened at approximately 2045 (LT). During this time period, ships clocks were being moved forward 20 minutes per watch. The Third Officer was on the Bridge at this time. Another Crewmember was using the phone at the time. Cadet Shah reportedly told the Third Officer that he would go below for a few minutes and come back when the phone was free. Cadet Shah reportedly came back to the Bridge and made his phone call to a family friend in India. The ships phone records show that this call was made at 03/2136Z. This would have been at approximately 03/2100 LT. The Third Officer reports that he did not overhear any noticeably loud or stressed conversation during the phone call. He reported that Cadet Shah came onto the Bridge (from behind the blackout curtain) and wished the Third Officer a good night. When the Third Officer returned good night wishes, Cadet Shah left the Bridge. According to internal interviews with all crewmembers by the Master and Chief Officer (and confirmed by the Investigator), that was the last time that anyone on the ship saw Cadet Jai Kumar Shah.

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During the night, the records do not indicate any incidents. The Chief Officer reports that all crewmembers (including Cadet Shah) were warned about heavy weather, and told not to go out on deck. There is a notation in the deck logbook that “Checklist for navigating in heavy weather completed with rough seas and swell.” A copy of this checklist is included in this report. It is noteworthy that there is no requirement for the posting of signs on all internal doors warning about not going on deck during heavy weather. On the following morning, the first official notice of Cadet Shah being missing is in the statement of the Chief Officer. He states that he was informed at 0815 hours by the Bosun that the Cadet had not reported for work. The Bosun stated that he had called the cabin of the Cadet (10-15 rings) with no reply. The Chief Officer then went to the cabin. He found the door open, went inside, but did not find the Cadet there. The Chief Officer then went to ask the crew directly if they had seen the Cadet. At 0830 the Chief Officer informed the Bridge (and the Master) that the Cadet was missing. At that time, a search was begun with the Chief Officer, Bosun and deck gang. When the Cadet was not found at 0900 the General Alarm was raised, the crew mustered, and a head count showed the Cadet as still missing. A full-scale intensive search of the vessel from bow to stern was then launched with all hands. This was the first of four such searches during that day. At 1028 the vessel was turned to a reciprocal course to head back towards the last position when the cadet had been seen. The ocean search for the missing Cadet Jai Kumar Shah took place over the next 33 hours. Communications took place with Company officials, and with the USCG providing SAR assistance. The details of the ocean search follow with times in UTC:

• 03/2110 Phoned NYK Cell Manager Mr. Chadha to inform of the incident • 03/2200 Completed physical search of vessel • 03/2226 Received call from Capt. Nakaya of NYK who told to reverse

course • 03/2228 Reversed to reciprocal course to return to last known position • 03/2230-2400 Conducted a second search of vessel for missing Cadet • 04/0100 Commenced third search of vessel for missing cadet • 04/0100 Received phone call from Mr. Richards of USCG RCC Honolulu.

Informed that 2 aircraft had been dispatched (from Honolulu and Alaska) • 04/0155 Informed by RCC Honolulu that C-130 aircraft would search the

area starting around 04/0600

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• 04/0500 Received call from NYK Captains A Singh and Joshi asking for telephone numbers for cadet.

• 04/0518 Informed by RCC Honolulu (Lt. Taylor) that SAR aircraft would be over the area and stay on site for approximately one hour

• 04/0600 Commenced fourth physical search of the vessel • 04/0730 Darkness setting in. Search suspended. Proceeded to position of last

sighting to resume search at daybreak • 04/0900 Informed passing vessel MV TANGO of missing crewmember and

asked to keep sharp lookout • 04/1015 Informed by RCC Honolulu that due to fuel constraints, aircraft

were returning to their home stations • 04/1740 Resumed search for missing cadet in position 38-333.5N 171 38.9E

in parallel search pattern • 05/0145 Informed by USCG RCC Honolulu that they were suspending

search • 05/0730 As darkness fell, suspended the search for missing crewmember

Cadet Jai Kumar Shah, and resumed voyage to Los Angeles, CA 6.4 Details of the Performance of Relevant Equipment There is no evidence of any equipment failures relevant to the incident. However, it will be noted in another section of this report that a chain link rail was not in place over the port bunker rail (located just aft of the Accommodation House), and the chain over the starboard bunker rail did not have proper tension, and added little height to the rail at that position. 6.5 Persons on Bridge During the time period in which the incident apparently took place, the Bridge was manned by a Watch Officer (3rd Officer, 2nd Officer and Chief Officer) and a lookout. 6.6 Persons in Engine Room During the time period in which the incident apparently took place, the engine room was in UMS condition and unmanned. Security rounds were made periodically of the area, but Cadet Shah was not seen in the Engine Room.

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6.7 Whereabouts of the Master The Master was not on the Bridge when Cadet Jai Shah was last seen. He later came to the Bridge to write Master’s Night Orders at 2300 LT, and then retired to his quarters for the remainder of the evening. The Master was notified that Mr. Shah was missing at approximately 03/0830 LT after he failed to report to the Chief Officer. 6.8 Extracts from all Relevant Documents The documents which were required to be produced are listed in Section 2 of this report. Where the contents of these documents are deemed relevant, quotations are inserted at points where they are relevant. 6.9 Details of Communications Made Between Vessel and Radio Stations The details of all communications between the vessel and radio stations are noted in the “details of the incident” section of this report. Copies of radio logbook entries and other documents are attached. 6.10 Details of Any Injuries/Fatalities There were no injuries noted as a result of this casualty. As to fatalities, the subject of this report is the status of the missing crewmember, Cadet Jai Kumar Shah. Mr. Shah is missing and believed to be deceased. 7 Assistance After the Incident The Master received assistance after the discovery of the missing crewmember from the following:

• Mr. Chadha – NYK Shipmanagement Cell Manager • Capt. Nakhaya – NYK Shipmanagement Casualty Response Center • Mr. Richards - USCG RCC Honolulu (for SAR advice) • Lt. Taylor – USCG RCC Honolulu (arranging for dispatch of two rescue

aircraft) • Passing vessel M.V. EVER ULTRA • Passing vessel M.V. TANGO (LAPN-5) • Capt. Anuraj Singh – NYK Shipmanagement • Capt. Joshi – NYK Shipmanagement

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• LES Santa Paula (land radio station) • CAMSPAC Station (MF/HF DSC Urgency Messages) • AMVER positions reported

8 Authentication of Documents All of the documents listed in this report, and attached to the report were reviewed by the investigating officer with the Master of the NYK Springtide. Captain Peter Damian Misquitta verified the copies as having been directly copied from various ship records. The investigating officer reviewed the chart which was in use at the time of the incident, and also reviewed the original copies of many of the documents to ensure their authenticity. 9 Interviews (Crew or Witness)

Master: Capt. Peter D. Misquitta Chief Officer: Mr. Vikram Yadav Third Officer: Mr. Ankush Chowdhury Bosun: Mr. Rodolfo E. Rosal FMA: Mr. Eljube T. Lunggakit

10 Analysis and Conclusions 10.1 Human Element 10.1.1 People Factors Cadet Jai Kumar Shah was reportedly on his first ship after graduating from maritime college. He had been on the ship for almost 5 months before the incident. It is noted that the Chief Officer apparently took great care not to assign Mr. Shah to any hazardous areas of work, and duly noted his relative lack of experience. All persons interviewed indicate that they find it difficult to believe that Cadet Shah would venture outside of the Accommodations House in a storm. An email from the brother of Cadet Shah indicates that the he was looking forward with great anticipation seeing his brother again after more than a year apart. There is no other indication of any suicidal impulses by Cadet Shah. Several interviews indicate that Mr. Shah was well-liked by the crew. It is noteworthy that the person who is presumed to be the best friend of Cadet Shah on board (FMA Eljube Lunggakit) shared memories of the two friends singing songs from their respective countries. There is no indication of any likelihood of foul play. 10.1.2 Organization on Board

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It appears that Cadet Shah was well-supervised on board by the Chief Officer and persons assigned by the Chief Officer. While cadets often are well-supervised during their working hours, they are normally left alone to work, study and sleep in their individual cabins during off-duty hours. 10.1.3 Working and Living Conditions As noted, the deck cadet on the NYK Springtide is assigned to a single cabin on D Deck. The cabin was found to be clean, with no indications of any unusual activities. It is noted that when the Investigator looked at the cabin, it had already been inspected by USCG officials. It is believed that the USCG investigators left the room in a somewhat messy condition. The national makeup of the crew was typical for this NYK Shipmanagement with officers coming from India, and ratings/junior officers from the Philippines. There is no indication of any racial tension or other issues on the ship. 10.1.4 Ship Factors While the ship obviously is operating well, and in most respects has no apparent problems, the following issues were noted by the Investigator:

• The chain over the top of the rounded bunker station rail on the Starboard side was sagging, and provided little extra protection from falling over-the-side from the main deck. The top rounded rail is approximately 25-30 cm lower than the top rail around the remainder of the Main Deck.

• The chain over the top of the Port Bunker rail was missing, and was reportedly not in place at the time of the incident.

• The ship does not routinely place signs on the inside of doors leading out of the ship during heavy weather.

Recommendations to address these issues will be provided in the following section of this report. 10.1.5 Shore Side Management It is noted that the “Heavy Weather Navigation Checklist” which apparently came from the Company ISM Manual does not contain a requirement for placing signs on interior doors warning not to go out on deck during heavy weather. 10.1.6 External, Influences and Environment

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The strong winds and large seas during the time that Cadet Shah went missing made it extremely unlikely that Cadet Shah would be found if not one actually saw him go over the side. It is virtually certain that the only other person outside during this time period would have been the lookout on the Bridge wing. The fact that the wing is 20 meters above the main deck and 30 meters above the ocean; combined with the noise of the wind would make it virtually impossible for any outcry from a person going over the side would be heard on the ship. 11 Recommendations It is apparent that all crewmembers on the NYK Springtide are devastated from the loss of a friend and fellow crewmember. It is also apparent that Cadet Shah was well-supervised during his working hours on the ship. There is no reasonable way that any crewmember (even a young and inexperienced one such as Cadet Shah) can be watched and supervised 24 hours a day. However, it is the opinion of the Investigator that the two Ship Factors noted in the previous section should be addressed. His recommendations follows:

• Chain rails over the rounded bunker rail should always be replaced before a vessel leaves port. These chains should be stretched tightly over this space so that the effect is to have a rail at the same height as the rest of the railing on the main deck.

The Company should institute a requirement that all interior doors which lead to the outside (at all decks) should have warning signs placed on them during periods of heavy weather. The placement of these warning signs should be a requirement of the “Heavy Weather Navigation Checklist.”

Summary Casualty Investigation of M/V NYK Springtide The container vessel M/V Springtide suffered the loss and presumed death at sea of a crewmember during the evening of May 3rd, 2006. May 3rd was a repeated day on the vessel as it transited Eastbound across the Pacific and the International Date Line. The vessel was enroute from Sendai, China to Los Angeles, CA on Voyage 32E17 and approaching the International Date Line at position 38 42.0N 176 26.0E at 0830 LT (03/2030Z) when it was discovered that Cadet Jai Kumar Shah had not reported for duty. After an unsuccessful physical search of the vessel and consultation with Company and other officials, at 1028 LT (03/2228Z) the Master ordered the ship to be turned

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around to go back over the course traveled during the previous night and begin an ocean search of the waters traveled. A total of four complete physical searches of the entire vessel were conducted over the course of the day. The ocean search of the waters traveled, and a parallel ocean search under the direction of the USCG Search and Rescue (SAR) unit was conducted until searching was abandoned as darkness fell on the second search day on 4 May 2006 at 1930 LT (05/0730Z). Interviews with the Master and a number of crewmembers indicate that the last time anyone saw Cadet Shah on the ship was at approximately 02/2100 LT (03/2140Z) on the bridge where he had made a ship-to-shore phone call to a friend in India. Thus, there was a period of more than 11 hours in which his whereabouts were unknown. The vessel was in relatively heavy weather during the night of the disappearance, with winds from the SE at force 7 increasing to force 8 from the south during the night. A log book entry during the 00-04 watch indicates that the vessel completed the checklist for maneuvering in heavy weather. There are no other log book entries as to heavy weather procedures; however the Master and Chief Officer indicate that verbal warnings were given to crewmembers not to go on deck during the night. The ship apparently does not use warning signs on the doors to attempt to prevent anyone from going out on deck. During the investigation, we reviewed all relevant documents, charts, and records, and conducted a thorough inspection of the ship from the Navigation Bridge (where Mr. Shah was last seen), to Mr. Shah’s cabin, inside and around the outside of the Accommodation House of the vessel, around the Main Deck, and through the entire system of port and starboard tunnels. We also conducted interviews with the Master, Chief Officer, 3rd Officer, Bosun, and the FMA (Fitter Assistant) who was known to be the best friend of Mr. Shah on board. There are four possible conclusions to draw from a person missing on a ship at sea:

• The person committed suicide (planned or unplanned) • The person was the victim of foul play • The person was hidden away on board, not found, and managed to leave the

ship un-noticed when it reached port • The person met with an accident while out on deck and was washed (or fell)

over the side It is the conclusion of this investigation that Mr. Shah is missing and presumed deceased. The most likely occurrence of the four possibilities listed above is that Cadet Jai Kumar Shah mistakenly went out on deck and accidentally went over the side where he perished.

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During the time period when the whereabouts of Mr. Shah became unknown, the deck officer on the bridge was operating inside the wheelhouse. The lookout was on the wing of the bridge, but due to the noise of the wind and the distance above the water, the chances of the lookout hearing any shout from a person going over the side would be highly unlikely. The exact cause which led Mr. Shah to leave his cabin at night to go out onto a dark and windy deck in the dark will likely never be known. The temperature of the water at the time is this incident was listed in the ship logbook as 15 degrees Celsius. All of the survival gear on the ship was reported to be in place by the Master and ships officers. Given this situation, the amount of time that a person could be expected to survive in the sea would certainly be less than 2 hours, and would likely be measured in minutes. The sea was also quite rough during this time period. The Master conducted a search of the waters where Mr. Shah could most likely be expected to be found for approximately 33 hours, and with consultation with SAR officials, it appears to have been a reasonable decision to abandon the ocean search, and reach the inescapable conclusion that Mr. Jai Kumar Shah had perished at sea. USED ABBREVIATIONS AIS Automatic Information System ARPA Automatic Radar Plotting Aid COG Course Over Ground GPS Global Positioning System IMO International Maritime Organization ISM International Safety Management (Code) OOW Officer on Watch SAR Search and Rescue SOLAS Safety of Life at Sea UTC Universal Coordinated Time (also known as Z)

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FOREWORD The Panama Maritime Authority Directorate General of Merchant Marine, Department of Navigation and Maritime Safety appointed the firm of K Fitter & Associates to investigate the accident on May 12, 2006. The on-board investigation took place on the vessel NYK Springtide at the YIT Terminal in Los Angeles CA beginning at 1100 hours (LT) 5/12/2006.

Panama Maritime investigation authorities acted in accordance to the IMO Resolution A.849(20) concerning accident investigation as the leading party of the investigation.

Capt. Allan R. Breese representing K Fitter & Associates to conduct the on-board investigation. All interviews, inspections and other actions by Capt. Breese took place in the presence of Mr. Anuraj Singh (Senior Personnel Manager Crewing Department), Mr. Erich P. Wise (an attorney representing the Company), and either the Master or Chief Officer. At the insistence of Company officials the brother of the missing Cadet and his fiancé were also present.

Statements Concerning the Investigation Report

In accordance with IMO Resolution A.849(20) concerning investigations of marine casualties and incidents, this report is submitted to the Panama Maritime Authority Directorate General of Merchant Marine. The statements from the Master and Chief Officer have been noticed in this text. All received statements, documents and records are attached.

Issued without prejudice,

CAPT. KHUSH FITTER K .P. Fitter & Associates, Inc. California U.S.A. Office

KPF-LB/ KPF-CAPT. ALLAN BREESE-LB

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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Photographs;

Resume of the Investigator;

Statement of Master;

Statement of Chief Officer;

Copies of Official Log Book pages;

Copies of Deck Log Book pages; (3 May, 3 May Retard Day, 4 May);

Copy of Master’s Night Orders from 5/3/06;

Copy of Panama Seaman’s Document for Jai Kumar Shah;

Copy of Master’s Certificate for Capt. Peter Damian Misquitta;

Copy of Ship Registry & most recent Tax Payments to Panama Maritime Authority;

Marine Note of Protest;

Crew List & Ship’s Particulars;

Copies of Nautical Chart 4522 used during incident;

Copies of four (4) pages of parallel search pattern;

Copies of weather and position log pages;

Weather Charts received on the vessel;

Weather Reports received on the vessel;

GMDSS Radio Log Summary;

Daily Record Summary of all communications;

Copy of Distress messages sent via GMDSS;

Copy of list of satellite phone call records; &

Copy of Heavy Weather Navigation Checklist.

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PHOTOGRAPHS

M.v. NYK Springtide

Voyage No :- 32E17

Vessel Alongside YIT Terminal @ Los Angeles - California.

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PHOTO 1: Stateroom of Cadet Jai Kumar Shah (5/12/06)

PHOTO 2: Desk of Cadet Jai Kumar Shah

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PHOTO 3: Notebook Found In Room of Cadet Jai Kumar Shah ( Only Routine Note From Cadet Studies Found )

PHOTO 4: Last Page of Notes Found in Notebook

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PHOTO 5: Email From Brother: Sharn Kumar Shah Asking About Next Meeting Date

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PHOTO 6: Mobile Phone Found in Cabin

PHOTO 7: Cash Found in Cabin Desk Drawer

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PHOTO 8: Wallet Found in Desk Drawer

PHOTO 9: Cash Found in Wallet

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PHOTO 10: Lifejacket/PFD Found in Cabin

PHOTO 11: Cadet Cabin is Close to Door to Outside Ladderway

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PHOTO 12: Satellite Phone on Bridge Last Place Where the Cadet was Seen

PHOTO 13: Starboard Ladderwell and Window of Cadet Stateroom at Bottom of Photo

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PHOTO 14: Starboard Ladderwell as Seen From Main Deck Below

PHOTO 15: Chain Over Starboard Bunker Station Does Not Stretch Tightly Across Opening

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PHOTO 16: Bunker Station Rail on Port Side Does Not Have a Chain Stretched Across top to Provide Protection from Accidental Fall

PHOTO 17: Vessel @ Dock Demonstrates the Height on the Main Deck Area Above the Water. The Height of the Bridge Wing

Above the Water Estimated More Than 30 Meters

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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Resume

of the

Investigator

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Resume of the Investigator

Name: Captain Allan R. Breese Career Summary During his time as a deck officer and ship master, Capt. Breese transited every ocean in the world, making port calls in Asia, Africa, Europe and North America. His primary focus was in the Pacific Basin, with dozens of trans-Pacific crossings. His time as Master was spent on large containerships, but he has also sailed as a deck officer on Crude Carriers, Product Carriers, Bulk Carriers, Break Bulk ships, and Passenger Vessels out of all major ports on the U.S. West Coast and to Japan, Taiwan, Korea, the Philippines, and Singapore. As Master he made more than 100 transits of the treacherous Straits of Malacca. As a safety, quality, environmental and security auditor of merchant ships, Capt. Breese has evaluated the working practices of seafarers from around the world. He has participated in dozens of ride-along audits where he has been able to consult and advise captains, mates and engineers on the latest and best practices of seafarers. His primary focus has been on bridge-team management, and operation of an effective bridge. He has evaluated maintenance programs, including computerized preventive maintenance programs, and has evaluated the operation of cargo, ballast, and stability systems on all of the ships he has visited. He has also trained hundreds of mariners in the principles of safety and quality operations, and the use of management systems to improve shipboard life. Management of projects has been his focus for the past 4 years. His recent work includes a security gap analysis for the country of Jordan, and the development of security processes for Exxon Mobil for their FPSO fleet. He is a certified lead auditor in ISM, ISO 9001 and ISO 14001, and has developed safety management systems for maritime terminals and ships. He has extensive experience with Oil Spill Cleanup exercises and plans, have my 40 hours hazmat certification, and fully trained in ICS. Capt. Breese has a bachelor’s degree in Broadcast Journalism. This has assisted him in his writing, training, and his ability to speak in front of large groups. Capt. Breese is married, with two grown children. He lives with his wife in Fountain Valley, California.

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Investigator/ Assessor Captain Breese was a Subject Matter Expert as part of a team that developed a Port Security Assessment Tool for the USCG shortly after 9/11/2001. Following development of the tool, he participated in security assessments at the ports of Philadelphia, San Diego, and Portland, OR. Capt. Breese has conducted safety and security assessments on ships and at facilities around the world. Capt. Breese developed methodology for vulnerability and risk assessments of U.S. flag and international vessels, as well as ports and port facilities. He either led teams, or participated in investigations and audits for the following:

• Matson Navigation vessels • Matson Navigation Hawaii Port Facilities • Alaska Tankers Fleet • Louis Dreyfus fleet vessels • Offshore Marine Service Association vessels (more than 200) • Exxon Mobile’s Kizomba A FPSO • Port of Gothenburg • Port of Aqaba, Jordan • Ports of Oman • Ports of Nigeria • Victoria Ship Management vessels • Penn Terminals, Philadelphia, PA • Chemoil Terminals, Long Beach, CA

Capt. Breese has conducted dozens of audits of port, port facility, and vessel security plans around the world, and has trained more than a thousand persons to become SSO/VSO, CSO, and PFSO under the requirements of the IPSPS Code. Representative: K . P. Fitter & Associates, Inc

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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Statement of Master;

&

Statement of Chief Officer;

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Page 31: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Copies of

Official Log Book

pages;

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Page 37: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 38: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 39: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 40: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 41: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Copies of

Deck Log Book

pages;

( 3 May, 3 May Retard Day, 4 May );

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Page 45: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 46: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 47: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 48: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Copy 0f Master’s

Night Orders

5/3/06;

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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Copy of Panama Seaman’s Document for

Jai Kumar Shah;

&

Copy of Master’s Certificate for

Capt. Peter Damian Misquitta;

Page 53: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 54: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 55: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Copy of Ship Registry

&

most recent Tax Payments to

Panama Maritime Authority;

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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Marine

Note of Protest;

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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Crew List

&

Ship’s Particulars;

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Page 63: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Copies of Nautical Chart 4522 used during incident;

Copies of four (4) pages of parallel search

pattern;

Copies of weather and position log pages;

&

Weather Charts received on the vessel;

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Page 67: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 68: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 69: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 70: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 71: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 72: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 73: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 74: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 75: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Weather Reports received

on the vessel;

&

GMDSS Radio Log Summary;

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Page 79: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 80: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 81: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 82: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 83: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 84: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 85: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 86: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 87: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 88: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 89: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 90: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 91: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
Page 92: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Daily Record Summary

of all communications;

&

Copy of Distress messages sent via GMDSS;

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Page 96: CASUALTY INVESTIGATION REPORT - amp.gob.pa DE... · off” and get dinner. He was told to start work again in approximately two hours (1940) to make a fire round of the interior areas
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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Copy of list

of satellite phone call

records;

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ATTACHMENTS

Attached to this report and made part of hereto are the following:

Copy of

Heavy Weather

Navigation Checklist.

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