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