Poor decision making led to the Cemfjord’s capsizing reveals MAIB investigation report

The report into MAIB’s investigation of the capsize and sinking of the cement carrier Cemfjord in the Pentland Firth, Scotland with the loss of 8 lives on 2-3 January 2015 has been published.

At 1316 on 2 January 2015, the Cyprus registered cement carrier Cemfjord capsized while transiting the Pentland Firth, Scotland; no distress message was transmitted. Twenty-five hours later, the alarm was raised when its upturned hull was sighted by a passing ferry. An extensive search followed but none of Cemfjord’s eight crew were found and they are all assumed to have perished. The vessel sank late in the evening on 3 January 2015.

The investigation found that Cemfjord capsized in extraordinarily violent sea conditions caused by gale force winds and a strong, opposing tidal stream. Such conditions are commonly experienced within the Pentland Firth, were predictable and could have been avoided by effective passage planning. The master’s decision to take Cemfjord into the Pentland Firth at that time was probably influenced by actual or perceived commercial pressures and his personal determination to succeed. While it is likely that he had underestimated the environmental conditions, his decision to press on would almost certainly have been influenced by his recent experience of a dangerous cargo shift while attempting to abort an approach to the Firth in heavy seas.

In his statement to the media, Steve Clinch, The Chief Inspector of Marine Accidents stated:
“The MAIB investigation found that Cemfjord capsized in extraordinarily violent sea conditions; a fatal hazard that was predictable and could have been avoided. The decision to enter the Pentland Firth, rather than seek shelter, was almost certainly a result of poor passage planning, an underestimation of the severity of the conditions and perceived or actual commercial pressure to press ahead with the voyage. Critically, this decision will also have been underpinned by an unwillingness to alter course across the heavy seas after the experience of a cement cargo shift in similar circumstances about 3 months before the accident. The appalling conditions and rapid nature of the capsize denied the crew an opportunity to issue a distress message or to escape from their ship. Although not a causal factor of the accident, it was also established that Cemfjord was only at sea because of Flag State approved exemptions from safety regulations. This tragic accident is a stark reminder of the hazards faced by mariners at sea and the factors that can influence decision making in such treacherous circumstances.”

The investigation also established that Cemfjord was at sea with significant safety deficiencies relating to its rescue boat launching arrangements and bilge pumping system in the void spaces beneath the cement cargo holds. Both shortcomings were subject to Flag State approved exemptions from safety regulations; however, the exemption regarding the rescue boat was not applicable to the equipment on board. This resulted from misunderstandings caused by the imprecise nature of the communication between the vessel’s managers, the Flag State and the Flag State’s recognised organisation. The Flag State’s process for managing requests for exemptions from international safety regulations was also found to lack rigour. Additionally, Flag State inspections of the vessel over many years in Poland were ineffective and did not deliver the intended levels of assurance.

Since the accident, Cemfjord’s managing company, Brise Bereederungs GmbH, has implemented several changes and initiatives aimed at improving the safe operation of its cement carrying vessels and the safety culture of its crews. The changes include enhancements to its vessels’ stability management and weather forecasting capabilities in order to aid passage planning. The Department of Merchant Shipping for the Republic of Cyprus has introduced a new process for managing requests from shipping companies for Flag State exemptions from international safety regulations. Det Norske VeritasGermanischer Lloyd has appointed designated Flag State liaison officers to improve dialogue and enhance mutual understanding between itself and Flag States.

The report in full: MAIB Cemfjord Report

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