Report on the investigation of

the collision between

mt Saetta and mt Conger

on completion of a ship to ship transfer

9.5 miles south east of Southwold, UK

on 10 August 2009

Marine Accident Investigation Branch

Mountbatten House
Grosvenor Square
Southampton
United Kingdom
SO15 2JU
Report No 3/2010
March 2010
 Extract from

The United Kingdom Merchant Shipping

(Accident Reporting and Investigation)

Regulations 2005 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping
(Accident Reporting and Investigation) Regulations 2005 shall be the prevention of
future accidents through the ascertainment of its causes and circumstances. It shall
not be the purpose of an investigation to determine liability nor, except so far as is
necessary to achieve its objective, to apportion blame.”

NOTE

This report is not written with litigation in mind and, pursuant to Regulation 13(9) of
the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005,
shall be inadmissible in any judicial proceedings whose purpose, or one of whose
purposes is to attribute or apportion liability or blame.

Further printed copies can be obtained via our postal address, or alternatively by:
Email: maib@dft.gsi.gov.uk
Tel: 023 8039 5500
Fax: 023 8023 2459
All reports can also be found on our website:
www.maib.gov.uk
 CONTENTS
Page
GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS

SYNOPSIS 1

SECTION 1 - FACTUAL INFORMATION 2

1.1 Particulars of vessels and accident 2
1.2 Background 4
1.3 Narrative 5
1.3.1 Events preceding the STS transfer 5
1.3.2 Securing and cargo operations 5
1.3.3 Preparations for sailing and unmooring 7
1.3.4 The collision 9
1.3.5 Post accident actions 10
1.4 Environmental conditions 12
1.5 Main engine 12
1.6 Bridge organisation 13
1.6.1 Saetta 13
1.6.2 Conger 13
1.7 STS superintendent 15
1.7.1 Experience, qualifications and training 15
1.7.2 Employment with FCM 16
1.7.3 Hours of rest 16
1.8 The STS service provider 16
1.8.1 General 16
1.8.2 Operations manual 17
1.8.3 Risk assessment 17
1.8.4 Vetting 18
1.9 Vessel safety management 19
1.9.1 Saetta 19
1.9.2 Conger 19
1.10 Vessel vetting 20
1.11 Charter requirements 21
1.11.1 Voyage clearance 21
1.11.2 Practical considerations 22
1.12 Training requirements 22
1.13 Regulation 23
1.13.1 Background 23
1.13.2 Current arrangements 23
1.13.3 Proposed legislation 23
1.14 Similar accidents 24
1.14.1 Southwold 24
1.14.2 Accident statistics 25
SECTION 2 - ANALYSIS 26
2.1 Aim 26
2.2 Engine failure 26
2.3 Communications 26
2.4 Decision-making 27
2.5 Planning and briefing 28
2.6 The service provider 28
2.7 Role of the superintendent 29
2.8 Occupational standards 30
2.9 Industry best practice 30

SECTION 3 - CONCLUSIONS 31
3.1 Safety issues identified during the investigation which have been
addressed 31

SECTION 4 - ACTION TAKEN 32

4.1 The Oil Companies International Marine Forum and International
Chamber of Shipping 32
4.2 Cardiff Marine Inc 32
4.3 Prime Marine Management 32
4.4 Fender Care Marine 33

SECTION 5 - RECOMMENDATIONS 34

Figure 1 - Extract of chart BA 1543

Figure 2 - AIS tracks of vessels (underway and manoeuvring)

Figure 3 - AIS tracks of vessels (as moorings slipped)

Figure 4 - AIS tracks of vessels (collision)

Figure 5 - Damage to Saetta’s starboard lifeboat

Figure 6 - Damage to Saetta’s starboard lifeboat davit arm

Figure 7 - Scratches to Conger’s paintwork

Figure 8 - Saetta’s bridge

Figure 9 - View from Conger’s port bridge wing

Figure 10 - Conger’s bridge

Annex A - Notification of STS transfer

Annex B - Extract of FCM’s Standards of Care - STS superintendent

Annex C - MARPOL Amendment

Table 1 - Summary of FCM’s risk assessment

GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS
AIS - Automatic Identification System

BP - British Petroleum

BST - British Summer Time

EEZ - Exclusive Economic Zone

FCM - Fender Care Marine

GMDSS - Global Maritime Distress Safety System

ICS - International Chamber of Shipping

ILO - International Labour Organisation

kts - knots

kW - kilowatt

m - metre

MARPOL - International Convention for the Prevention of Pollution from Ships

MCA - Maritime and Coastguard Agency

MCR - Machinery control room

OCIMF - Oil Companies International Marine Forum

OOW - Officer of the Watch

QMS - Quality Management System

rpm - revolutions per minute

SBE - Stand By Engines

SHA - Statutory Harbour Authority

SIRE - Ship Inspection and Report Programme

SMS - Safety Management System

SOG - Speed over ground

STCW - International Convention on Standards of Training, Certification
and Watchkeeping for Seafarers 1978, as amended

STS - ship to ship

t - tonnes

UTC - Universal co-ordinated time

USA - United States of America

VDR - Voyage data recorder

VHF - Very high frequency

VLCC - Very Large Crude Carrier

Aframax - Term used to describe a tanker between 80,000 and 120,000

tonnes deadweight

Times: All times used in this report are BST (UTC+1) unless otherwise stated
mt Saetta

mt Conger
SYNOPSIS
On 10 August 2009, the Greek registered tanker Saetta and
the Marshall Islands’ registered tanker Conger collided when
completing a ship to ship (STS) transfer operation off Southwold,
Suffolk. Saetta’s starboard lifeboat and davit were damaged.
Conger was undamaged and there were no injuries and no
pollution.

The collision occurred at very slow speed, and resulted from the
failure of Conger’s main engine to start as the vessels separated.
Both manoeuvred to try and avoid a collision, but they were very
close when the engine failed and the action taken was not effective. The response to
the engine failure, and poor communications, were also contributory factors.

The number of STS operations off Southwold had increased considerably in 2009
and this was the third collision between ships involved in transfers in the area within a
6-week period. A further two collisions have occurred since. Although STS operations
worldwide are reported to have a good safety record and the accidents off Southwold
have been relatively minor, their frequency is cause for concern.

The Oil Companies International Marine Forum (OCIMF) has initiated the development
of operational standards for STS service providers and occupational standards for
STS superintendents, which will be published by mid 2010. In co-operation with the
International Chamber of Shipping, OCIMF also intends to revise the STS Transfer
Guide, to include operations between gas and chemical tankers, and advice on
risk assessment and manpower requirements. In view of this action and the action
taken by Fender Care Marine (FCM) and the operators of Saetta and Conger, no
recommendations are considered necessary.

1
SECTION 1 - FACTUAL INFORMATION
1.1 PARTICULARS OF VESSELS AND ACCIDENT
 Saetta

Registered owner : Nautica Shipmanagement S.A.

Technical operator : Cardiff Marine Inc

Port of registry : Piraeus

Flag : Greece

Type : Oil carrier, double hull

Built : 2008 Shanghai, China

IMO number 9384069

Classification society : American Bureau of Shipping

Construction : Steel, double hull

Length overall : 243.8m

Gross tonnage : 58418t

Engine power and type : 18420kW at 105rpm. B & W

Service speed : 15.5kts

Persons on board : 24

Injuries/fatalities : None

Damage : Impact damage to starboard lifeboat and

davit arms

2
 Conger
Registered owner : Conger Shipping Inc

Technical operator : Prime Marine Management

Port of registry : Majuro

Flag : Marshall Islands

Type : Oil / chemical tanker, double hull

Built : 1999 Korea

IMO number 9198771

Classification society : Lloyd’s Register

Construction : Steel, double hull

Length overall : 228.6m

Gross tonnage : 44067t

Engine power and type : 16386kW at 99.5rpm. Sulzer 5 cylinder slow

speed diesel

Service speed : 14.5kts

Persons on board : 23

Injuries/fatalities : None

Damage : None

Accident

Time and date : 1241 UTC 10 August 2009

Location of incident : 52° 12.15’N 001° 51.8’E 9.5miles south east

of Southwold

3
1.2 BACKGROUND
Ship to ship (STS) lightering operations began in the late 1960’s as a result of
the inability of very large crude carriers (VLCC) to safely navigate the shallow
rivers leading to oil terminals in several ports in the Gulf of Mexico. The use of
smaller vessels to transfer cargo to local terminals was efficient and cost effective,
and the number of operations increased rapidly with the lightering tankers either
operated by the oil majors1 or by dedicated lightering companies.

In 1975, the Oil Companies International Marine Forum (OCIMF) and the
International Chamber of Shipping (ICS) published the Ship to Ship Transfer
Guide (Petroleum) which reflects industry best practice for vessels engaged in
STS operations. The guide has been updated periodically and defines an STS
operation as:
‘an operation where crude oil or petroleum products are transferred
between seagoing ships moored alongside each other. Such operations
may take place when one ship is at anchor or when both are underway. In
general, the expression includes approach manoeuvre, berthing, mooring,
hose connection, safe procedures for cargo transfer, hose disconnecting,
unmooring and departure manoeuvre.’

The guide also strongly recommends that a superintendent be employed if

masters are unfamiliar with STS operations, and defines a superintendent as:
‘A person who may be designated to assist a ship’s master in the mooring
and unmooring of the ships, and to co-ordinate and supervise the entire
ship to ship transfer operation. He may also be known as the lightering
master or mooring master’.

STS operations now occur worldwide and, in addition to the lightering of crude oil,
they are also used to transfer oil products for onward transportation or for storage.
The number of transfers conducted off Southwold, UK increased considerably
during 2009 prompted by market conditions. At the time of this accident there
were approximately 30 Aframax size vessels lying at anchor off Southwold either
storing, waiting to transfer, or waiting for orders.

During the STS operation between Saetta and Conger, Conger was the
‘manoeuvring ship2’ transferring 27,000 cubic meters of jet fuel cargo to Saetta,
the ‘constant heading ship3’.

1 The world's largest oil companies which include: ExxonMobil (XOM), Royal Dutch Shell (RDS), BP (BP),
Chevron Corporation (CVX), ConocoPhillips (COP), Total S.A. (TOT)
2 The ship that approaches the constant heading ship.

3 The ship that maintains course and speed to allow the manoeuvring ship to approach and moor alongside.

4
1.3 NARRATIVE
1.3.1 Events preceding the STS transfer
Fender Care Marine Limited (FCM) was appointed by British Petroleum (BP)
Shipping as the STS service provider4 to co-ordinate and facilitate the STS
transfer between Saetta and Conger off Southwold. The company provided
both vessels with information and instructions by e-mail to aid the planning
and the execution of the proposed transfer. It also requested that its Checklist
1-Petroleum be completed and returned. On 4 August 2009, completed
checklists were received from both vessels and FCM notified the Maritime and
Coastguard Agency (MCA) of its intention to conduct the transfer (Annex A).
The MCA advised that it would inspect Conger prior to the transfer. This was
completed on 6 August, shortly after the vessel anchored off Southwold.

On 7 August 2009, checklist number one from the STS Transfer Guide; ‘pre
fixture information’, was completed by both vessels. The following day, Saetta
carried out an STS transfer with the tanker New Challenge under the advisory
control of a superintendent provided by FCM. The transfer was completed the
next morning, and the vessels had separated by 1300.

At 1430, Conger rendezvoused with the tug Flying Spindrift approximately

4.5 miles south south east of Lowestoft (Figure 1). The superintendent, who
had been on board New Challenge, and the fenders required for the STS
operation, were then transferred from the tug to Conger. Under the control
of the superintendent, the fenders were secured on the vessel’s port side.
On completion, the superintendent met with the deck officers to discuss the
impending transfer. Conger then headed to the south-east and rendezvoused
with Saetta. Communications between the superintendent on board Conger and
Saetta was by VHF radio, channel 73.

1.3.2 Securing and cargo operations

Both tankers completed checklists 2 and 3 of the transfer guide, ‘before
operations commence’ and ‘before run-in and mooring’ at 1710. Conger then
closed the starboard side of Saetta, which was maintaining a steady course
and speed. By 1848, Conger had secured to the starboard side of Saetta using
6 headlines, two forward springs, two aft springs and four stern lines. As the
vessels prepared for the cargo transfer, the superintendent ordered Saetta to
manoeuvre toward the agreed STS transfer position and anchor 1 mile clear of
other shipping. At 1954, Saetta’s port anchor was dropped in position 52° 11.8’N
001° 58.0’E (Figure 1), and brought up with 7 shackles on deck. Checklist 4 of
the transfer guide, ‘before cargo transfer’, was then completed on both vessels.
Cargo transfer operations commenced at 2012 and were completed at 0948 the
following morning. Following the transfer of the cargo, Saetta had a freeboard of
9m, and Conger had a freeboard of 14m.

4 A service provider is a shore-based company employed to facilitate an STS operation

5
6
Approximate boundary
of United Kingdom
territorial waters

R/V position
Conger and
support vessel
the Controller of HMSO and the UK Hydrographic Office

5 miles
Reproduced from Admiralty Chart BA 1543 by permission of

MCA approved
R/V position

Position of
accident

STS
transfer
position
Figure 1

Extract of chart BA 1543

1.3.3 Preparations for sailing and unmooring
Shortly after cargo operations had finished, the superintendent passed a note
to Saetta’s master apologising for the poor communications during the transfer
with New Challenge. The note also explained his intentions for slipping the lines
between Conger and Saetta, which were later reaffirmed during a face to face
conversation over the bridge wings.

At 1215, a cargo surveyor on board Saetta called the superintendent and

confirmed that the cargo operation was finished. Two minutes later, the
superintendent advised Saetta that Conger was preparing her engines and that
the unmooring operation would commence when her engines were ready. At
1235, Saetta reported that her engine would be on standby in 1 minute, but was
requested to wait 15 minutes. The superintendent also advised that he would
let the master of Saetta know when to send his crew fore and aft to attend the
moorings.

At 1243, Conger’s main engine was tested ahead from the MCR and dead
slow astern using the bridge telegraph. The engine started as intended on
both occasions. Shortly afterwards, the superintendent briefed Conger’s deck
officers on the intended sequence of events for slipping. On completion, Saetta
commenced heaving in her anchor. This was completed at 1306.

The superintendent’s plan was to manoeuvre from the anchorage and head in
a north westerly direction, putting the wind on the port beam to help the vessels
separate once all lines had been slipped.

With the vessels now underway on a heading of 031°, the superintendent

ordered Saetta to put her helm hard to port and her engine to dead slow ahead.
He then explained to Saetta’s master over the radio that he intended to ‘single
up as before’ referring to the recent separation from New Challenge, and
advising that the last lines to be slipped would be two headlines from Conger
and two stern lines from Saetta.

The vessels slowly turned to port, with their headings passing through 012° at
1313 when speed through the water had increased to 2.3 knots (Figure 2). The
superintendent called Saetta and suggested that the time for completing transfer
guide checklist 5 ‘before unmooring’ be recorded as 1310. This checklist
included ‘The method of unberthing and of letting go moorings has been agreed
with the other ship’.

At 1316, Saetta’s heading was passing through 341° when the superintendent
requested that she steady on a course of 330°. The unmooring operation
commenced 2 minutes later.

At 1319, Saetta’s engine was stopped and 6 minutes later her master reported
that he had lost steerage with the ship’s head at 310°. More exchanges
between the superintendent and the master of Saetta followed concerning which
lines to slacken and slip. At 1327, the superintendent ordered Saetta ‘dead slow
ahead’ and ‘steady’.

7
 Figure 2

AIS tracks of vessels (underway and manoeuvring)

The number of mooring lines had now been reduced to two headlines and two
stern lines and, at 1333, the superintendent ordered Saetta to ‘stop engines’ and
‘wheel amidships’. Seconds later he ordered all lines fore and aft to be slipped
simultaneously; the ships were on a heading of 303° at a speed of 2.4 knots
(Figure 3).
Figure 3

AIS tracks of vessels (as moorings slipped)

8
1.3.4 The collision
After the last lines had been slipped, the superintendent ordered Conger
‘starboard 5°’ and for the main engine to be put to ‘dead slow ahead’. Seconds
later the engine was ordered to ‘stop’ and the helm increased to ‘starboard 10°’.
Conger’s bow started to swing slowly to starboard, causing her stern to close
towards Saetta.

To check this movement, at 1336 the superintendent ordered the engine to

‘dead slow ahead’, and the helm to ‘amidships’, quickly followed by ‘port 5°’.
The officer of the watch (OOW) placed the telegraph to dead slow ahead, and
seconds later saw and heard the main engine alarm. He informed the chief
engineer in the machinery control room (MCR) by telephone that the main
engine alarm was sounding and that the engine had failed to start. He then
shouted to the master on the bridge wing to inform him of the situation. The
ship’s officers spoke Ukrainian during these exchanges.

The master quickly went inside the bridge and discussed the situation with the
OOW. Meanwhile, the superintendent was aware that Conger was starting to
fall astern of Saetta, and ordered ‘port 10°’ and the main engine to ‘slow ahead’.
The helmsman applied the helm as ordered, but when the OOW placed the
telegraph to slow ahead, the engine again did not start. The master returned to
the bridge wing and advised the superintendent that ‘the engine not starting’.

At the chief engineer’s request, the OOW put the engine telegraph to ‘stop’
followed by ‘dead slow ahead’. The main engine again failed to start. The
telegraph was returned to ‘stop’ and the master ordered the OOW not to touch
it. He also instructed the forward mooring team to leave the forecastle.

At 1337, the superintendent ordered Saetta ‘dead slow ahead’ and ‘easy to
starboard’ to try and increase the lateral distance between the sterns of the
vessels. In response, Saetta’s master used varying amounts of helm up to
30°. The superintendent also ordered Conger’s helm to ‘amidships’ to arrest
the continuing slow swing to port. Seconds later, the superintendent broadcast
on VHF radio ‘lost our engines we have lost our engines’. There were no ship
names given before or after the message, and the bridge team on Saetta did
not hear it. The superintendent then repeated his order for Saetta to proceed at
‘dead slow ahead’ and ‘easy starboard’.

At 1338, the master asked the OOW what had happened to the engine. The
OOW again telephoned the chief engineer in the MCR and was informed that
the problem was being investigated. One minute later, the chief engineer called
the bridge and asked for permission to test the engine. This was refused by the
master.

Conger’s bow continued to swing extremely slowly towards Saetta and, at 1340,
the superintendent ordered ‘dead slow astern’. The engine telegraph was
moved as instructed and the engine started. The superintendent immediately

9
 ordered ‘emergency full astern’, quickly followed by ‘stop’ ‘hard to starboard’
and ‘full ahead’. The OOW missed the final order, but immediately advised the
superintendent ‘engine stopped’. The superintendent then ordered ‘slow ahead’
‘full ahead’ ‘hard to starboard’ ‘stop’ and ‘full astern’ in less than 1 minute.
Seconds later, at 1342, Conger’s port anchor struck the starboard lifeboat of
Saetta, and her port bulwark hit the lifeboat davit arm. At impact, Conger’s
heading was 289° and her speed was estimated to be less than 1 knot (Figure
4). The superintendent quickly moved inside Conger’s bridge and ordered the
main engine to ‘stop’ and the helm to ‘amidships’.
Figure 4

AIS tracks of vessels (collision)

Just prior to the collision, the superintendent had assessed that Saetta’s pivot
point was forward of Conger’s bow, and ordered Saetta to ‘full ahead’ and ‘hard
to starboard’ in an attempt to manoeuvre her clear. Saetta’s master remained
unaware of Conger’s engine problems and had started to issue his own helm
and engine orders to try and avoid a collision, but he had not informed the
superintendent of his actions.

1.3.5 Post accident actions

The vessels soon separated and anchored close to the position of the collision.
The superintendent reported the collision to Yarmouth coastguard.

Saetta suffered structural damage to her starboard lifeboat (Figure 5) and the
lifeboat davit arm (Figure 6). Conger suffered only scratches to her paintwork
(Figure 7).

10
 Figure 5

Damage to Saetta’s starboard lifeboat

Figure 6

Damage to Saetta’s starboard lifeboat davit arm

11
 Figure 7

Scratches to Conger’s paintwork

Conger received approval from the Marshall Islands administration and Lloyd’s
Register to proceed to her next port, and she departed UK territorial waters
at about 1900 on the day of the accident. Following approval from the Greek
administration to temporarily use additional liferafts in lieu of the damaged
lifeboat, Saetta remained off Southwold in readiness for further STS operations.

1.4 ENVIRONMENTAL CONDITIONS

The wind was south westerly 6 to 9 knots. The sea state was smooth and
visibility was good. The predicted tidal stream was setting south west at 1.1
knots and there was at least 30m of water under the vessels’ keels.

1.5 MAIN ENGINE

Conger was fitted with a five cylinder slow speed reversing engine. Similar to
many slow speed diesel engines, the engine had to be stopped before engaging
ahead or astern, and was connected to a fixed pitch propeller.

When Conger arrived at Piraeus, Greece, 10 days after the accident, an

electronic systems engineer inspected the engine control system. The
inspection found that the system was functioning correctly.

12
 A Wartsilla service engineer attended the vessel 4 days later in Tutunchiflick,
Turkey, and inspected the main engine starting system. The engine started
successfully and all valves and indicators showed the system was functioning
correctly. However, after air pilot valves mounted on the main air start valves for
each cylinder were removed and tested, the valve on number three cylinder was
found to be defective. The valve was replaced and a successful main engine
function check was carried out both ahead and astern. The maintenance of the
pilot valve prior to its failure had been in accordance with the manufacturer’s
instructions.

1.6 BRIDGE ORGANISATION

1.6.1  Saetta
This was the Greek master’s second STS transfer in command. His first transfer
as master had been with New Challenge the previous day, but he had been
involved in STS operations as a chief officer. During the vessel’s separation,
the master stood mainly on the starboard side of the bridge, but occasionally
moved to the bridge wing to gauge the distance between the vessels. The
master had the con and operated the engine room telegraph when on the
bridge. He also carried a hand-held VHF radio to communicate with his crew.

The Filipino OOW had previously participated in STS transfers and was
primarily stationed at the port radar display (Figure 8) adjacent to a fixed
VHF radio. He was responsible for collision avoidance, external VHF
communications, and monitoring the application of helm orders. He also
operated the engine telegraph when the master was on the bridge wing. The
vessel was operating in manual steering, and a Filipino AB was stationed at the
helm.

1.6.2 Conger
The superintendent had the con and was stationed at the extremity of the
port bridge wing (Figure 9). He passed engine and helm orders to Conger’s
Ukrainian OOW and helmsman verbally, and to Saetta via a hand-held VHF
radio. The superintendent communicated to both vessels in English.

The Ukrainian master accompanied the superintendent on the bridge wing and
carried a hand-held VHF radio to communicate with his mooring teams. The
master had carried out approximately 10 previous STS transfers as a master.

The OOW was positioned on the starboard side of the bridge (Figure 10), next
to the engine telegraph and close to VHF radios monitoring both the channels in
use for internal and external communications. He had previously been involved
in a number of STS transfers as an OOW. The vessel was also operating in
manual steering, with an AB at the helm.

13
 Figure 8

Saetta’s bridge
Figure 9

View from Conger’s port bridge wing

14
 Figure 10

Conger’s bridge

1.7 STS SUPERINTENDENT

1.7.1 Experience, qualifications and training
The superintendent on board Conger was Swedish and had 47 years
experience of oil and chemical tanker operations. He had been employed by oil
majors throughout his seagoing career, and had been an STS superintendent
since the mid 1980’s. He was approved by Chevron for all lightering operations
and had been involved in over 1500 STS operations worldwide.

15
 The superintendent held an STCW II/2 certificate of competency issued by the
Swedish administration, and had completed a number of additional training
courses including bridge simulator, and mooring master training. In September
2006, he attended and passed a simulator based ship handling / ship to ship
lightering course in Trondheim, Norway. The superintendent did not hold a
dangerous goods endorsement.

1.7.2 Employment with FCM

The superintendent was first employed by FCM in May 2007. Up to May 2009
he had carried out 23 STS operations for the company as superintendent and
8 operations as mooring master. None of these transfers were conducted off
Southwold. The superintendent had commenced his latest contract with FCM on
22 July 2009, during which he had completed seven consecutive transfers as
superintendent off Southwold prior to the accident.

The superintendent’s duties and responsibilities were outlined in FCM’s

operations manual: Standards of Care – STS Superintendent (Annex B),
which he had read and understood. The superintendent’s performance was not
periodically assessed by FCM during his contracts, and no further training had
been provided or required by the company.

1.7.3 Hours of rest

The superintendent kept a record of his general movements between vessels
and the shore, but did not record his hours of work or rest. He had two periods
of rest in a hotel ashore when operating off Southwold. The first lasted for 20
hours and the second, 7 days later, lasted for 29 hours. The superintendent
had insisted on the second period, which was completed 56 hours before the
accident, because he felt fatigued. He estimated that he had achieved one
period of rest lasting between 2.5 and 3 hours each night of the 8 and 9 August.
The superintendent reported that he did not feel tired at the time of the accident.

1.8 THE STS SERVICE PROVIDER

1.8.1 General
Fender Care Marine (FCM) was formed in the 1980’s with its headquarters in
the UK. Since the mid 1990’s it has also operated regional bases in Singapore
and Nigeria. FCM was sold to James Fisher plc in 2005. The company has ISO
9001:2000 accreditation for its quality system, and ISO 14001 accreditation for
its environmental management system.

FCM is one of the five largest global providers of STS services and conducted
2688 operations in 2008. During 2009, it had completed 2260 operations up to
31 August.

16
 Within the UK, the company facilitates STS transfers alongside in Sullom Voe, at
anchor in Scapa Flow, and offshore at Southwold, using 25 superintendents on a
self-employed basis, most of whom work exclusively for FCM.

1.8.2 Operations manual

FCM had developed a comprehensive operations manual to underpin its
STS operations. The manual was revised in March 2009 and was issued
to all its superintendents. Its objective was to ensure that ‘all STS transfers
are co-ordinated in accordance with the ICS / OCIMF STS Transfer Guide
(Petroleum)……’. The manual specified:
• The overall co-ordination of an STS operation should be in the hands of
the STS superintendent, who would ensure that both vessels’ crews were
familiar with all phases of the operation during the pre-planning meeting.
• Masters retained their statutory responsibilities and overall authority
for the safety of the vessel and crew. They remained in charge of the
berthing operation, and it was normally the role of the superintendent
to offer guidance and advice leading to a safe berthing. However,
responsibilities were to be agreed at the pre-operation conference.
• Superintendents were required to ensure they took adequate rest periods
during their time on board, and comply with STCW Code A-V111.1. In
the event of multiple STS transfers, it was the duty of the superintendent,
masters of the vessels and the FCM operations co-ordinators to manage
the periods of duty in a safe and structured manner, calling for assistance
if required.
• The emergency signal of seven or more short blasts on the whistle must
be understood by all personnel, and also recognise that emergency
situations can arise during mooring and unmooring operations. During
such emergencies the master, together with the superintendent, was
responsible for deciding the best course of action.

1.8.3 Risk assessment

A risk assessment had been carried out by FCM for its STS operations off
Southwold. The assessment identified 25 hazards, the consequences of four of
which were collision or ship damage. The assessment is summarised in Table 1

17
 Hazard Consequence Mitigation Applicable Recommendations Resultant
Regulations risk

Experience Risk of collision Only use Selection criteria Only employ experienced 1D
of STS between vessels, experienced in FCM operations STS superintendents that
superinten ship damage and superintendents manual meet FCM standards. Very
dent pollution, injuries FCM to conduct regular unlikely
to personnel. assessments of STS
superintendents skills and
abilities. Minor

Acceptable

Experience Risk of collision STS superintendent COSWOP STS superintendent and 2D

of STS between vessels, to provide a STS masters to carry out pre
vessels ship damage, operation plan and Vetting information cargo transfer meeting to Unlikely
crew pollution, injuries communicate to all safeguarding agree procedures during
to personnel vessels masters and against sub STS operations to ensure
crew. they are conducted in a Minor
standard ships
Superintendent to safe manner. Any single
view vessels risk party deem that conditions
assessments before are unsafe then operations
operation are to be suspended until Acceptable
commences. conditions are improved.

Vessels Pollution, ship Adequate ship 2D

main damage, injuries vetting information
engine to personnel from from traders and Unlikely
failure steel to steel tanker owners
contact.
Minor

Acceptable

Collision Injury, ship Experienced STS Application to port Operation to follow FCM 2D
between damage and superintendent to be authorities to procedures by
STS pollution appointed. English include experienced STS Unlikely
tankers language to be used communications superintendent.
during run in and information and
mooring. manoeuvring Minor
arrangements.
Acceptable

Table 1: Summary of FCM’s risk assessment for its operations off Southwold showing
the hazards with consequences resulting in collision
Table 1. Summary of FCM’s risk assessment for its operations off
Southwold showing the hazards with consequences resulting in
1.8.4 collision
Vetting
FCM has been vetted by each of the oil majors it provided with STS services.
The requirements of each of the majors differed to varying degrees, and the
information gathered during each vetting process was not shared.

BP Shipping last vetted FCM (UK) on 9 June 2005. The assessment consisted
of a desktop review of relevant documentation, interviews and discussions with
key personnel. The assessment did not provide any evidence of practices or
procedures which precluded FCM from being contracted as an STS service
provider to the BP Group.

18
1.9 VESSEL SAFETY MANAGEMENT
1.9.1  Saetta
The vessel’s safety management system (SMS) categorised an STS transfer
as a critical operation and stated that the recommendations and guidelines laid
down in the ICS / OCIMF Ship to Ship Transfer Guide (Petroleum) should be
followed, including the completion of the operational checklists contained in the
guide.

The SMS advised that a mooring master and an assistant would be assigned
by the lightering company, with the mooring master advising the master of the
lightering vessel, and the assistant advising the master and deck officers of the
ship to be lightened. The master was to comply with all instructions given by
the mooring master, and was to ensure that the proposed operation was well
understood. In the event that radio communication failed, five short blasts were
to be sounded on the ship’s aft whistle.

A generic risk assessment for ‘Mooring, STS Operations’ was incorporated into
the SMS. The assessment covered the period from the production of the pre-
arrival checklist, to when both vessels were made fast and the hoses connected.
It identified 14 hazards with the potential to result in collision during an STS
transfer.

An onboard risk assessment of the proposed transfer was conducted by the

vessel’s deck officers on 7 August, which highlighted the lack of a company
instruction or procedure regarding the use of a common working language. The
assessment summary provided a series of generic recommendations to be
followed prior to the commencement of the operation, including the study of the
procedures provided in the STS guide. The completed onboard risk assessment
was signed by the master on completion. No assessment of the risks of
unmooring or separating was undertaken.

In accordance with the control measures that had been identified, the master
and chief officer had familiarised the deck crew with the equipment and
procedures to be used in the operation, and the chief officer and the boatswain
had checked the condition of the equipment to be used.

1.9.2  Conger
The SMS on board Conger stated that: ‘The guidance contained in the ICS
publication ‘Ship to Ship Transfer Guide’ is adopted as company procedure’. It
also required the checklists contained in the guide to be used throughout the
operation, and for the master to establish several criteria before commencing a
transfer operation. These included:

19
 • The characteristics and compatibility of the other vessel.
• The person in overall charge of the operation.
• The common language to be used during the operation, which would
normally be English. Any failure to communicate with personnel on the
other vessel should result in the operation being suspended.
• Methods of communicating between ships at various stages of the
operation.
• Navigation procedures to be adopted during the operation.

A generic risk assessment for an STS transfer operation was incorporated into
the company’s SMS that identified the hazard of a contact between vessels.
Additional control measures to those contained in the company’s SMS and the
ICS / OCIMF checklists, included:
• Before approaching, satisfactory communication should be agreed
externally bridge to bridge, and internally between bridge and fore and aft
stations.
• Verification of the correct positioning of the fenders.
• Communicating the mooring plan to the crew involved.
• Adequate training for the crew involved.
• List and trim should be kept to a minimum.
• A responsible officer from both ships to board the other vessel at agreed
intervals.

The risk assessment was prepared by the chief officer and signed by the master
on 8 August.

1.10 VESSEL VETTING

The Ship Inspection and Report Programme (SIRE) was launched by OCIMF
in 1993 to address concerns about sub-standard shipping. The programme
is unique to the tanker industry and provides a database of up-to-date
information on ships for use by charterers, ship operators, terminal operators
and government bodies concerned with ship safety. The information contained
on the database is a valuable asset for those engaged in operational risk
assessments.

Chapter 8 of the SIRE report ‘Cargo and ballast systems – Petroleum’ contains
a section titled ‘Ship to Ship transfer operations supplement – petroleum’ which
lists five questions specific to offshore STS operations:

20
 • 8.86 Are operators’ procedures provided for ship to ship operations?
• 8.87 Have senior deck officers had open water ship to ship transfer
experience within the last 12 months?
• 8.88 Are sufficient closed fairleads and mooring bitts provided?
• 8.89 Are ship to ship transfer checklists completed?
• 8.90 If an STS operation was in progress during the inspection, was
it conducted in accordance with the recommendations of the OCIMF /
ICS STS transfer guide?

The last SIRE inspections carried out on both vessels prior to the accident were,
coincidentally, conducted by the same surveyor. The answer to questions 8.86
and 8.88 on both reports was ‘yes’; the remaining questions were marked not
applicable because the vessels were not engaged in an STS operation at the
time of the inspection.

1.11 CHARTER REQUIREMENTS

1.11.1 Voyage clearance
Saetta was under charter to BP. The voyage clearance details specified that the
vessel would be engaged in STS loading and transfer operations off Southwold.

The clearance required that:

• The operation complied with the requirements of the ICS / OCIMF Ship to
Ship Transfer Guide (Petroleum).
• Both vessels had BP shipping vetting approval for STS operations.
• Only a BP shipping approved STS service provider be contracted for the
provision of advice, fenders, hoses and associated resources.
• The STS operation complied with applicable local laws and regulations.
• The service provider liaised with the MCA and obtained approval on a
case by case basis.
• A transfer would not commence, or would be terminated, when pre-
defined weather or sea conditions were experienced.

The clearance explained the need of the service provider to submit a

contingency plan and risk assessment for the operation to the MCA and,
provided detailed instructions for the BP casualty emergency notification. It also
noted that the area off Southwold is exposed to winds from all directions and
little protection is afforded by the coastline.

21
1.11.2 Practical considerations
The suitability of the vessels chosen to undertake STS transfers was based
upon satisfactory results obtained from the SIRE report programme and the
vessel’s ability to safely carry the designated cargo.

The responsibility for ensuring that the two vessels were compatible for STS
operations was left to the service provider.

The location of the transfer was driven by the need to use an approved site.
There was no instruction for the transfer to be carried out either inside or outside
of United Kingdom territorial waters.

1.12 TRAINING REQUIREMENTS

Tanker crews must complete a Tanker Awareness Course, the syllabus of
which includes loading and discharge procedures during STS operations.
However, there are no STCW requirements for the qualification or training of
superintendents engaged in STS operations.

The STS transfer guide advises that the service provider supplies trained and
experienced superintendents, taking the following into consideration:
• Possession of an appropriate management level deck licence, including
necessary STCW requirements and dangerous cargo endorsement.

• Possession of valid medical certification.

• How much experience as a senior deck officer?

• Has the superintendent completed a suitable number of supervised

operations?

• Has the superintendent undergone a supervised apprentice training

programme?

• Has the superintendent satisfactorily completed a recognised ship-

handling course?

• Has the superintendent had STS operational experience within the

preceding 4 months?

• Has he been subject to a performance assessment on an annual basis?

FCM required its superintendents who had not completed a recognised ship-
handling course, to attend an STS simulator course and a bridge resource
management course at a nautical college in the UK. The simulator course was
developed by the college and tailored to meet FCM’s requirements.

22
 The training provided by FCM to its superintendents was determined by
individual needs and experience, and superintendents were only authorised
to carry out operations unsupervised after successfully completing two,
formally evaluated transfer operations under the supervision of an authorised
superintendent. The company required its superintendents to have a dangerous
cargo endorsement and a GMDSS certificate.

1.13 REGULATION
1.13.1 Background
STS transfers have been carried out in UK territorial waters for many years.
Lord Donaldson’s 1994 report, ‘Cleaner Ships, Safer Seas’, recognised that
STS operations should ‘take place at recognised safe anchorages and under
close supervision’, and that regulations already drafted by the Department
of Transport to contain STS operations within SHA limits would achieve this
goal. His report recommended that the inshore boundary of the specified
transhipment area in Lyme bay should be located at least 9 miles away from
land. Lyme bay and Southwold were for some time the preferred areas, but
following environmental lobbying over several years Southwold has since
been identified by the MCA as the UK’s only offshore STS transfer area. No
environmental impact assessment has been carried out with respect to STS
operations in this area.

1.13.2 Current arrangements

There is currently no regulation controlling STS operations inside UK territorial
waters. However, non-voluntary arrangments have been established between
the MCA and the STS service providers. Under these arrangements offshore
STS transfers are only conducted in an identified area spanning both the UK’s
territorial waters and Exclusive Economic Zone (EEZ) off Southwold (Figure 1),
and the service providers will notify the MCA at least 72 hours in advance of any
intended transfer (Annex A).

STS operations in Scapa Flow are conducted inside a Statutory Harbour

Authority (SHA) area of responsibility and are regulated by the Orkney Islands
Council, Department of Harbours.

1.13.3 Proposed legislation

National
In 2008, the Government issued a public consultation on proposed legislation
to regulate STS operations carried out in UK territorial seas. The proposed
regulations prohibit STS transfers in UK territorial waters unless conducted
within an area controlled by a Statutory Harbour Authority (SHA). SHA’s will
be required to operate under licence subject to environmental and habitat
assessments, and adequate contingency measures being in place. A second
consultation on the proposed legislation commenced on 8 February 2010.

23
 International
International regulation for the ‘Prevention of Pollution during Transfer of Oil
Cargo between Oil Tankers At Sea’ will come into force on 1 January 2011 via
an amendment to the International Convention for the Prevention of Pollution
from Ships (MARPOL) (Annex C). The amendment provides general rules
on safety and environmental protection, including the requirement for any oil
tanker involved in STS operations to carry on board an STS plan approved by
the vessel’s administration. The plan is to be developed using industry best
practice, which the regulation identifies to be the OCIMF / ICS STS Transfer
Guide.

The forthcoming regulation also places responsibility on vessels to notify

coastal states when it is intended to carry out a ship to ship transfer within
territorial waters, or EEZ at least 48 hours before the operation is scheduled to
commence.

1.14 SIMILAR ACCIDENTS

1.14.1 Southwold
The MAIB is aware of four other collisions that occurred off Southwold between
3 July and 1 December 2009:

On 3 July, a bunkering vessel had completed its operation with a tanker, and
was unmooring when her starboard quarter struck the port wing ballast tank of
the tanker, causing an indentation.

On 25 July, two tankers similar in size to Saetta and Conger were preparing to
come alongside for an STS transfer within UK territorial waters. As the vessels
closed, the manoeuvring vessel had difficulty maintaining a parallel heading,
and the approach was aborted. During a second approach, the helmsman of
the manoeuvring vessel had difficulty in maintaining the ordered heading as the
vessels closed; the manoeuvring vessel started to swing towards the constant
heading vessel despite the use of full opposite rudder. The superintendent was
not made aware of the steering difficulties, but took action to try and avoid a
collision, including manoeuvring the constant heading vessel. The vessels
collided, with the port bow of the manoeuvring vessel striking and penetrating
number 3 starboard ballast tank of the constant heading vessel.

Contributory factors identified included: the master’s lack of STS experience,

the probable effects of interaction, poor communications on the bridge of the
manoeuvring vessel, the lack of a risk assessment, the lack of a pilot card, poor
line of sight between the bridge wing gyro repeater and bridge instrumentation,
and an inability to secure a forward secondary fender at deck level.

24
 On 27 August, an STS transfer involving a VLCC (constant heading vessel) and
an Aframax tanker (manoeuvring vessel) resulted in a collision just outside UK
territorial waters during the final stages of the approach. The superintendent
ordered the constant heading vessel to reduce to dead slow ahead. Seconds
later, the stern of the manoeuvring vessel started to close the stern of the
VLCC. The superintendent ordered the helm hard to port and the main engine
slow ahead. He was informed that the engine was operating dead slow astern.
Before any action could be taken to recover the situation, the vessels collided.
The hull of the VLCC suffered a 6m dent on the starboard side, and the hull of
the manoeuvring vessel suffered 12 sq m of deck plate buckling, considerable
damage to stiffeners below the deck, and damaged railings and davits.

Contributory factors included poor communications, and the inability to secure

the aft secondary fender accurately in a position to protect the vessel in line with
the guidance provided in the ICS / OCIMF guide. The superintendent in control
of the transfer was also in control of the operation conducted on 25 July, and
has been recommended for refresher training.

On 1 December 2009, a collision occurred when two vessels were in the final
stages of their approach. The helmsman, who had been on the wheel for
approximately 1.5 hours, was given an order to apply starboard helm to counter
the manoeuvring vessel’s swing to port. The vessel continued her swing, and
it was only moments before impact that it became apparent that port helm
had mistakenly been applied. Contributory factors to the accident were: the
operation had been delayed and was conducted in the hours of darkness using
a bridge wing rudder indictor that was not visible from the superintendent’s
conning position; the OOW was not monitoring the helmsman’s actions; and
the superintendent was too pre-occupied with other aspects of the operation to
recognise that his orders had not been complied with.

1.14.2 Accident statistics

Accident data provided by FCM showed that of its 2688 STS operations
carried out worldwide in 2008, there were 6 collisions and 5 near misses
reported. In 2009, up until the end of August, of its 2260 STS operations
carried out worldwide, 6 collisions and 6 near misses were reported. Through
its membership of Intertanko, FCM, along with the oil majors, attempted to
establish a global database of accidents during STS transfers. However, the
database was not populated by other service providers, and was discontinued.

25
SECTION 2 - ANALYSIS
2.1 AIM
The purpose of the analysis is to determine the contributory causes and
circumstances of the accident as a basis for making recommendations to
prevent similar accidents occurring in the future.

2.2 ENGINE FAILURE

The sequence of events leading to the collision between Conger and Saetta
was triggered by the failure of Conger’s main engine to start as the vessels
separated. Subsequent investigation identified that an air start pilot valve on the
engine’s number three cylinder was not working correctly.

Following the initial ahead movement used to separate the bows after the
vessels had unmoored, it is almost certain that the engine had been stopped in
the position in which the number three cylinder was the first cylinder to fire when
the engine was next ordered ahead. As a result, when dead slow ahead was
ordered, air was unable to pass through the defective pilot valve and the engine
did not start.

The engine started when dead slow astern was ordered because in this direction
number three cylinder would not have been the first cylinder to fire, and the pilot
valves of all other cylinders were functioning correctly. Engine failure had been
identified as a hazard by FCM in its risk assessment of STS operations (Table
1), and had relied on the effective vetting of vessels as its control measure.
However, as the pilot valves had been maintained in accordance with the
manufacturer’s instructions, the engine had been tested before unmooring was
commenced, and there had been no previous indication of the fault, the defect
was difficult to foresee, and had possibly been latent for some time.

However, the actions taken by the OOW, master and chief engineer following the
failure did not follow a predefined procedure. This resulted in a 4.5 minute delay
in restoring propulsion, which occurred by chance when the superintendent
ordered ‘slow astern’. It is likely that, had a breakdown procedure been available
and followed, the main engine would have been started sooner.

2.3 COMMUNICATIONS
Conger’s main engine failed to start when the superintendent was attempting
to arrest the movement of the vessel’s stern towards Saetta. This was a
critical time, but prompt and effective action was hindered by two significant
breakdowns in communications.

First, although the failure was quickly seen by Conger’s OOW, it was reported to
the master in Ukrainian and the superintendent was not informed until about 1
minute later.

26
 Second, Saetta’s master was never aware of the engine failure prior to the
collision because: the superintendent did not follow basic voice procedures
when broadcasting his message on VHF radio; Saetta’s bridge team did not
hear the superintendent’s transmission; and no emergency signal was sounded.

Co-ordinating the movements of two vessels underway in very close proximity

requires clear and concise communications between all parties, but this accident
and the accidents summarised in paragraph 1.14 indicate that this is not always
achieved. The need for good communications is particularly relevant when
the persons involved are working in a second language. As in this case, the
possibility of messages being missed or misunderstood and persons forgetting
protocols or reverting to their native language when under pressure is inevitably
increased. It is therefore essential that during STS operations, account is taken
of the language and communication channels to be used, and the roles of the
persons involved, when determining the composition and organisation of bridge
teams.

2.4 DECISION-MAKING
The departure manoeuvre had gone as planned, until the engine failure, but
by the time the superintendent had been informed of the problem, Conger
had started to turn very slowly back towards Saetta, which was increasing
speed and moving ahead. The superintendent was very experienced in STS
operations, but with the vessels probably no more than 30m apart, he was
placed in a very difficult situation, which he was unable to control.

The very slow turn to port had been initiated by the use of the rudder and was
possibly assisted by the wind acting on the vessel’s port side accommodation,
and by the forces of interaction acting between the vessels. However, although
the helm had been ordered to ‘amidships’ shortly before the engine failure,
no counter helm was applied to check the movement towards Saetta until the
engine had been started.

Once the engine was started, the superintendent issued a series of orders in
rapid succession, one of which was missed by the OOW and others which were
not given sufficient time to have an effect. This resulted in the vessel continuing
to make slow headway. Given Conger’s slow speed at impact, it is highly likely
that, had Conger’s engine been kept running continuously astern since it had
restarted, the collision might have been avoided. Although Saetta’s master acted
independently to try and avoid collision, this action was taken too late to have
any effect.

This was the superintendent’s eighth and final STS transfer within a 20 day
period. Notwithstanding two periods of rest ashore, this had been an arduous
period of employment, with rest periods dictated by operational requirements
and prevailing weather conditions. This had led to disrupted sleep patterns over

27
 the course of his contract and a lack of sleep during the 48 hours before the
collision. However, although the superintendent reported that he did not feel
tired, it was inevitable that he was suffering from the effects of fatigue; it is not
possible to determine to what extent, if any, this affected his behaviour under
pressure, his judgment, or his manoeuvring of the vessels.

2.5 PLANNING AND BRIEFING

In preparation for unmooring, the superintendent briefed Conger’s master and
OOW in person. His briefing to Saetta’s master was by a note indicating that it
would be conducted in a similar way to the STS transfer with New Challenge,
followed up by a face to face conversation over the bridge wings. No information
was passed regarding the times to have main engines ready, or weigh anchor,
and there were no details provided regarding the intended unmooring and
departure manoeuvres. Therefore, given Saetta’s master’s inexperience in
command during STS operations, it was not surprising that the superintendent
had to repeat his instructions, or that the master had to request clarification.

The risks involved when two vessels unmoor and separate while underway are
potentially the same as when coming together and mooring. Therefore, it is
important that both mooring and unmooring operations be planned in detail, and
that all aspects of these operations be briefed. However, this does not appear to
have been identified in the risk assessments undertaken by the service provider
or the vessels. In this case, the superintendent appears to have directed the
unmooring operation and departure manoeuvre as events unfolded rather than
following a specific plan. In addition, the absence of a comprehensive briefing to
both masters indicates that the superintendent was largely content to rely on the
completion of checklist 5 –‘before unmooring’ to signify that both vessels were
ready. The absence of a comprehensive brief was also an opportunity missed
to clarify the actions to be taken in the event of an engine or steering failure on
either vessel, including the signal to be sounded on the vessel’s whistle.

Although the checklists in the ICS / OCIMF guide are a useful ‘aide mémoire’ to
ships’ crews, robust operational risk assessments are also required to determine
the depth and detail of the actions required. Moreover, when checklists are
used frequently, a ‘tick-box’ mentality can develop, which seriously undermines
their effectiveness. This possibly explains why neither master was aware of the
emergency signal to be used, and the master of Saetta signed the unmooring
checklist as completed, even though he had not been fully briefed.

2.6 THE SERVICE PROVIDER

FCM’s operations manual was comprehensive and was largely in accordance
with guidance in the STS transfer guide. The company had also been proactive
in designing ship-handling simulator training for its superintendents. However, a
number of shortcomings identified indicate that its safety management system
would benefit from some revision.

28
 In particular, the operations manual placed the onus on its superintendents to
ensure they were sufficiently rested; the service provider had not taken any
steps to monitor the hours of work and rest of its superintendents as advised in
the ICS / OCIMF Guide. The potential for the superintendent to become fatigued
would have been considerably decreased had the superintendent’s hours of
work and rest also been monitored by the service provider in accordance with
the guidance in the ICS / OCIMF Guide, and designated rest periods planned
into his work schedule.

In addition, the superintendent’s performance had not been assessed annually

as suggested in the STS transfer guide. Such assessments help to monitor
competence and compliance with operational procedures. Importantly, they also
help to identify if additional training is required.

FCM had been vetted by the oil majors it provided with STS services. In the
absence of any global operational standards for service providers, each oil
major vetted the company against its own criteria, and did not share the results
of the vetting. Inevitably, this required FCM to meet differing requirements
demanded by each oil major. It is almost certain that the provision of operational
standards for service providers within the STS guide would not only help to
simplify the vetting process for the majors, but it would also provide service
providers with a benchmark standard to reach and maintain.

2.7 ROLE OF THE SUPERINTENDENT

The growth of STS operations worldwide, and the diversity of the products
transferred, have resulted in the participation of many crews who are
not experienced in this activity. In turn, this has led to the reliance on
superintendents to assist inexperienced masters. However, although the
employment of superintendents in these circumstances is advised in the ICS /
OCIMF guide, this does not absolve any master from his responsibility for the
safety of his vessel. In this respect, the decision of Saetta’s master to take
action to try and avoid a collision was appropriate.

It is evident from Annex B that the responsibilities of a superintendent in STS

operations are wide-ranging, time-consuming, and demanding. With regard
to manoeuvring, his role is similar to that of a harbour pilot, particularly when
embarked on a tanker approaching or separating from a vessel at anchor. It is
even more demanding when neither vessel is at anchor.

When such operations are conducted by two vessels underway, a

superintendent is expected to provide direction and advice to the masters of
both vessels. Potentially this can be a challenging task which can be influenced
by: the experience and training of the superintendent; the opportunities to
rest; the experience of the vessels’ masters in STS operations; the ability and
performance of the bridge teams; and potential language or communications
difficulties. In this case it was made far more difficult when one vessel had an
emergency which seriously affected her manoeuvrability.

29
 The high workload and the responsibilities placed upon superintendents creates
a severe risk that they may become overloaded, a situation made worse when
emergency situations are encountered. In some circumstances the risk of
overload could be reduced by the provision of a second superintendent or an
assistant, as indicated in Saetta’s SMS, but this precaution is not considered in
the ICS / OCIMF.

2.8 OCCUPATIONAL STANDARDS

The ability of a superintendent to meet the demands placed upon him, is
largely dependent on his competency, measured by his qualifications, training
and performance. In this case, apart from not having a dangerous cargo
endorsement which was not contributory to the collision, the superintendent was
suitably qualified and trained. Nevertheless, the guidance for the qualifications
and training of superintendents provided in the STS transfer guide (paragraph
1.12) is ambiguous and open to a great deal of interpretation by service
providers.

Similarly, the guide does not specify the criteria a master should have met
before being considered suitable to control an STS transfer. This is significant
in view of the training areas suggested for superintendents, even when they are
qualified as a master.

2.9 INDUSTRY BEST PRACTICE

It is evident from FCM’s operations manual and transfer notification (Annex A),
the SMS on board Saetta and Conger, and the requirements of the charter party,
that the ICS / OCIMF Transfer Guide (petroleum) and its checklists is the main
reference used by the shipping industry’s tanker sector for the conduct of STS
operations. However, over the 25 years in which the guide has been developed,
STS operations now also include the transfer of gas and chemicals, and have
become a global phenomenon which has changed in several ways.

First, transfers are no longer limited to traditional lightering operations; smaller

vessels now frequently transfer oil products to larger vessels. Second, many
transfer areas are determined by market conditions, and therefore can be short-
lived. Third, crews without significant STS experience are being exposed to
the operation. Finally, outside the traditional transfer areas, most transfers are
facilitated by a service provider and controlled by superintendents.

STS operations have a reputation for being safe, which is testament to the
usefulness and effectiveness of the transfer guide to date. However, the collision
between Saetta and Conger, and the accidents and near misses identified in
paragraph 1.14.1, although minor, happened in quick succession and are cause
for concern. Given the transfer guide’s significance to international law from 1
January 2011, it is important that the publication is reviewed and amended to
fully reflect the changes to the operation and the lessons learned from these
accidents, providing greater detail where appropriate.

30
SECTION 3 - CONCLUSIONS
3.1 SAFETY ISSUES IDENTIFIED DURING THE INVESTIGATION WHICH
HAVE BEEN ADDRESSED
1. When Conger’s main engine failed to start when ordered ahead, there was
no procedure in place for the crew to follow. This possibly led to the engine
remaining stopped for about 4.5 minutes. [2.2]
2. Prompt and effective action following the loss of Conger’s main engine
was hindered by two significant breakdowns in communications. It is
essential during STS operations, that account is taken of the language and
communication channels to be used and the roles of the persons involved
when determining the composition and organisation of bridge teams. [2.3]
3. The unmooring operation and departure manoeuvre was not properly
planned or briefed, and there was an over-reliance on checklists. [2.5]
4. The provision of operational standards for service providers would help to
simplify the vetting process for the oil majors and would provide service
providers with a benchmark. [2.6]
5. The service provider had not taken any steps to monitor the hours of
work and rest of its superintendents, or assessed the superintendent’s
performance annually as suggested in the STS transfer guide. [2.6]

6. The responsibilities of a superintendent in STS operations are wide-ranging,

time-consuming, and demanding, and vary according to the type of transfer
conducted. The risk of overload could be reduced by the provision of a
second superintendent or an assistant. [2.7]
7. There are no occupational standards defined for superintendents or masters
in control of STS operations. [2.8]
8. It is important that the ICS / OCIMF STS Transfer Guide (Petroleum) is
reviewed and amended to fully reflect current operations worldwide and to
take into account the lessons learned from this and other recent accidents.
[2.9]

31
SECTION 4 - ACTION TAKEN
4.1 THE OIL COMPANIES INTERNATIONAL MARINE FORUM AND
INTERNATIONAL CHAMBER OF SHIPPING
In early 2009, OCIMF initiated the development of ‘A Guide for Service Providers
and Assessment of Suitability’. The publication is expected to be completed by
mid 2010 and will provide operating standards for STS service providers, and
standards for STS superintendents’ qualifications, experience, and workload
(including rest periods).

In addition, OCIMF and ICS intend to revise the STS Transfer Guide to
include guidance on chemical and gas tanker operations, and advice on risk
assessments and manpower requirements. Work on the revision is planned to
start during the first quarter of 2010 and is anticipated to be complete by the end
of 2011.

4.2 CARDIFF MARINE INC

Saetta’s operator carried out an investigation into the accident, the report of
which identified poor communications as a contributory factor. The company
has revised its STS operations procedures to include the requirement for an
additional officer to be present on the bridge. The officer will be in charge of
the communications between the bridge team and the superintendent while the
vessel is manoeuvring during STS operations.

4.3 PRIME MARINE MANAGEMENT

Conger’s operator has reviewed its risk assessment for STS operations.
Additional control measures now include:
• Defined STS weather parameters above which the operation should be
aborted.
• Ensuring crew and the mooring master (aka superintendent) have
adequate rest prior to the mooring and unmooring.
• Mooring master orders must be assessed and evaluated before they are
followed by the master.
• Mooring masters’ qualifications and physical condition to be verified prior
to commencement of the operation.
• Mooring and unmooring operations should be carried out underway if a
tug is not available.

A contingency plan for the loss of propulsion during an STS transfer has been
forwarded to its fleet. The plan includes the standard actions in the event of an
engine failure and the need for good communications arrangements between
masters and mooring masters.

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 Revised STS instructions now prohibit vessels from manoeuvring or berthing
operations after sunset, and recognise that tug assistance may be required. A
‘lessons learnt’ memorandum has been circulated to its fleet.

4.4 FENDER CARE MARINE

FCM has developed and implemented a timesheet for superintendents to record
rest periods during STS operations. This information is then entered onto a
database that allows a superintendent’s rest periods to be monitored. The
operations manual has been revised to reflect that it is the superintendent’s duty
to comply with STCW requirements and to record rest periods on the revised
timesheet.

The company’s marine department has now been expanded to include:

• An STS manager who is responsible for the regular auditing of all
superintendents and global bases to ensure FCM’s standards of care are
being complied with.
• A marine superintendent to provide marine support to the operations
team, including advising on the suitability of vessels to conduct a transfer.

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SECTION 5 - RECOMMENDATIONS

In view of the actions taken, no recommendations are considered necessary.

Marine Accident Investigation Branch

March 2010

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